Heritage Hall South

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About Heritage Hall South

Heritage Hall South is a for profit, 122-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Westfield, Southwick, West Springfield, Chicopee, Holyoke, Agawam, Springfield, Easthampton, Longmeadow, South Hadley, and the other towns in and surrounding Hampden County, Massachusetts.

Heritage Hall South focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Heritage Hall South
65 Cooper Street
Agawam, MA 01001

Phone: (413) 786-8000
Website: http://www.genesishcc.com/HeritageHallSouth

CMS Star Quality Rating

The Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.

As of 2017, Heritage Hall South in Agawam, Massachusetts received a rating of 1 out of 5 stars.

Performance Area Rating
Overall Rating 1 out of 5 (Much Below Average)
State Health Inspections 1 out of 5 (Much Below Average)
Staffing 3 out of 5 (Average)
Quality Measures 3 out of 5 (Average)

Fines Against Heritage Hall South

The Federal Government fined Heritage Hall South $24,310 on February 1st, 2016, $68,445 on June 6th, 2016, and $3,775 on April 6th, 2017 for health and safety violations.

Fines and Penalties

Our Nursing Home Abuse Lawyers inspected government records and discovered heritage hall south committed the following offenses:

Failed to protect each resident from all abuse, physical punishment, and being separated from others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of 4 sampled residents (Resident #1), the facility failed to ensure freedom from abuse, neglect, misappropriation of resident property, and exploitation. On or about 02/12/17, Certified Nurse Aide (CNA) #1 viewed videos of Resident #1, uploaded to what was identified as a Snapchat account belonging to Nursing Assistant (NA) #1. The female voice on the video, identified as consistent in tone and manner of speaking by multiple staff of the Facility, was heard speaking to Resident #1 in what was describe as a harassing, rude, demeaning, and frustrated manner. There also was no documentation that Resident #1 and/or his/her legal representative consented to the video and audio recordings, or to the posting of such recordings on a social media website such as Snapchat. Although Resident #1 could not be interviewed due to cognitive impairment, a reasonable person would suffer mental anguish after being videotaped without consent, and having that video posted on a social media site.

Findings include:

Resident #1 was admitted to the Facility in December 2015, with [DIAGNOSES REDACTED]. Resident #1’s Minimum Data Set, dated dated [DATE], indicated that he/she had severe cognitive impairment. Resident #1’s clinical record did not include a signed authorization by the Administrator and Resident #1 or his/her legal representative, consenting to the photography, video recording, or audio recording of Resident #1, or to the posting of such recordings on a social media website such as Snapchat.

The Facility’s Personal Cell Phones and Handheld Devices: Use of Policy, revised 09/01/16, indicated that staff could not use cell phones, Bluetooth ear pieces, ear buds, headphones, camera phones, digital cameras, video cameras, audio recorders, or any other personal, handheld device, or other forms of personal communication, image, audio, text, and/or computer devices when in resident care areas including resident rooms, dining areas, community rooms, and adjacent hallways, or while attending to in any area of the location. The policy indicated that it was prohibited to take resident photographs for any reason without both Administrator and resident authorization in writing; to take photographs and/or recordings of residents that were demeaning or humiliating; and, to keep, send, post, or distribute resident photographs or recordings of any kind through multimedia messages or on social media networks.

The Facility’s Abuse Prohibition – State of Massachusetts policy, revised 11/28/16, indicated that training would be provided to all employees, through orientation, annually, and ongoing sessions as needed. The policy indicated that sessions included the prohibition of staff from using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and recordings of residents that were demeaning or humiliating. The Facility’s internal investigation indicated that NA #1 completed abuse prevention training on 11/17/16.

The Surveyor interviewed Nurse #1 at 10:17 A.M. on 04/06/17. Nurse #1 said NA #1 had recently completed the Facility’s Nurse Aide training program, and had completed orientation approximately 2 days prior to the alleged incident. Nurse #1 said she was horrified that a staff member videotaped a resident and posted it on social media. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:56 P.M. on 04/06/17. CNA #1 said she and NA #1 completed nurse aide training together, and during the training, had exchanged Snapchat usernames so that they could become friends on the application. CNA #1 said that on a Saturday night towards the beginning of February 2017, she watched videos on NA #1’s Snapchat account, which included videos of Resident #1. CNA #1 said a female voice heard on the videos was consistent with NA #1’s tone of voice and manner of speaking. CNA #1 said that one video showed Resident #1 with his/her hands tucked under the waistband of his/her pants, and NA #1 told Resident #1 to get his/her hand out of his/her pants. CNA #1 said that NA #1’s tone of voice made it sound as if Resident #1’s actions were inappropriate, like he/she was doing something wrong. CNA #1 said that throughout the videos, NA #1’s tone of voice while speaking to Resident #1 was harassing, rude, demeaning, and frustrated.

The Surveyor interviewed the Administrator and the Director of Nurses (DON) at multiple times throughout the date of survey. The Administrator and DON said they were notified by CNA #1 that NA #1 had posed a video of Resident #1 on Snapchat. The Administrator and DON said that they and Nurse #1 were able to view the Snapchat video with the assistance of CNA #3. The Administrator, the DON and Nurse #1 said CNA #3 sent a request to the username provided by NA #1 to CNA #1 as NA #1’s Snapchat username, and the request was accepted. The Administrator, the DON and Nurse #1 said they were then able to view the Snapchat video, which started with a picture of NA #1 before moving to what appeared to be 2 short videos of Resident #1 taken at the Facility. The Administrator, the DON and Nurse #1 said they were able to record a portion of the video onto the Administrator’s cell phone. The Administrator, the DON and Nurse #1 said the backgrounds in the videos of Resident #1 were consistent with areas of the Facility. The Administrator, the DON and Nurse #1 said that the voices heard in the 2 videos were consistent with Resident #1 and NA #1.

At multiple times on the date of survey, the Surveyor, the Administrator and the Director of Nurse (DON) viewed a recording of the video of Resident #1 allegedly posted on Snapchat by NA #1. A username observed in the upper left corner of the video was identified by CNA #1 as consistent with the username NA #1 gave her. CNA #1 said the video viewed by the Surveyor was one of the videos she viewed on NA #1’s Snapchat account. The Administrator and DON said the video they had did not include the first few seconds of the video, which showed a picture of NA #1. The video showed Resident #1 seated at a table in what was identified by the Administrator and the DON as a dining space in the Facility. Audible conversation was heard regarding a frog in an unidentified person’s throat, or words to that effect, between Resident #1 and a voice consistent with NA #1’s, as identified by the Administrator and DON. The video then transitioned to Resident #1 seated in what was identified by the Administrator and DON as a hallway in one of the Facility’s resident care areas. The video showed Resident #1 with his/her hands tucked flat against his/her abdomen, under the waistband of his/her pants to the wrist. The following verbal exchange, or words to the effect of, was heard between a female voice, consistent with NA #1’s voice, and Resident #1: the female voice said, Bad, very bad in a scolding tone; Resident #1 responded yeah?, the female voice replied, yeah in a sarcastic manner, and Resident #1 said, alright; the female voice then said, can you take your hands out your pants? in a scolding manner, and Resident #1 replied, I have to keep my hands on my belly., the female voice replied, why? in a sarcastic tone, and the video ended. It was unclear if the two portions of the video were recorded on the same day.

The Surveyor interviewed CNA #2 at 9:16 A.M. on 04/06/17. CNA #2 said Facility policy was that staff could not use or carry cell phones with them during work hours. CNA # said cell phones were to be used before or after a shift, or during breaks only. The Administrator, DON, Nurse #1 and CNA #1 said Facility policy was that staff could not use or carry cell phones with them during work hours. The DON and Nurse #1 said Facility staff needed permission to photograph and/or record a resident.

Failed to immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to notify the Physician of a change in condition for 2 Residents (#7 and #15) out of a total sample of 15 residents.

Findings include:

Review of the facility’s policy for Skin Integrity Management, dated 11/28/16, indicated the following:

a. Policy: The implementation of an individual patient’s skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for change and implements revisions to the care plan as needed. Review of the facility’s Diabetic Care Protocol, dated 1/2014, indicated to evaluate for and respond to any change in condition.

1. For Resident #7, the facility staff failed to notify the Physician when the resident experienced a change in weight.

Resident #7 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. Review of the NP’s order, dated 6/5/17, indicated an order for [REDACTED]. Review of the daily weights from 6/6/17 thru 6/21/17 indicated the following:
6/7/17: 203 lbs,
6/8/17: 199.3 lbs (a difference of 3.7 lbs),
6/9/17: 202.8 lbs (a difference of 3.5 lbs),
6/10/17: 197.2 lbs (a difference of 5.6 lbs),
6/17/17: 199.8 lbs,
6/18/17: 194.4 lbs (a difference of 5.4 lbs), and
6/19/17 198.7 lbs (a difference of 4.3 lbs).

During an interview on 6/21/17 at 12:20 P.M., the NP said she was never notified of any weight changes for Resident #7.

2. For Resident #15, the facility staff failed to notify the Physician of several missed doses of insulin. Resident #15 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. Review of the physician’s orders [REDACTED]. Review of the 3/2017 Medication Administration Record [REDACTED]. Review of the 4/2017 MAR indicated [REDACTED]. Further review indicated it was not administered at all from 4/16/17 to 4/24/17 and there was no documented reason. Review of the 5/2017 MAR indicated [REDACTED]. During an interview on 6/22/17 at 1:42 P.M., UM #1 said she did not notify the Physician of the missed doses and did not have any evidence that the Physician was notified by someone else.

During interview on 6/21/17 at 8:40 A.M., the Nurse Practitioner (NP) said that all FBS have to be entered into the electronic medical record system, and that despite frequent education, Licensed Nurses do not always do this.

During record review on 6/21/17 at 12:30 P.M., Nurse #2 documented that she obtained a FBS test on Resident #8 at 7:30 A.M. The Surveyor asked Nurse #2 how this was possible, as Resident #8 was at [MEDICAL TREATMENT] during this time, and returned at approximately 9:15 A.M. Nurse #2 said that Resident #8 eats breakfast before he/she leaves for [MEDICAL TREATMENT] at 5:00 A.M. Nurse #2 said that she has an hour leadway in which to obtain the FBS and administer sliding scale coverage. The Surveyor pointed out that Humalog is a fast acting Insulin, and must be administered at least 15 minutes before or after a meal, subsequently, there is no 1 hour leadway. Nurse #2 said, let me check the orders. Nurse #2 checked the orders and said perhaps the 11:00 P.M. – 7:00 A.M. shift should obtain the FBS and administer Insulin, if needed then. The Surveyor asked Nurse #2 who transcribes orders when received by Physicians/NPs. Nurse #2 said that the nurses on the medication carts do, as there is not desk/charge nurse.

During interview on 6/21/17 at 3:55 P.M., Unit Manger (UM) #2 said that FBS and sliding scale coverage is supposed to be documented on the MAR as before meals, three times a day, and with no time identified, especially in circumstances where residents go out early for appointments or [MEDICAL TREATMENT]. UM #2 said that when residents go out to [MEDICAL TREATMENT], such as Resident #8 at 5:00 A.M., not writing the times, but before meals has always been the Facility’s practice (i.e. breakfast, lunch and dinner). UM #2 said that there are several Residents who go out to [MEDICAL TREATMENT] and she would have to go through each record to ensure Residents receive FBS and sliding scale Insulin, if ordered to ensure those other residents records are accurate. UM #2 said there is no leadway to administer Insulin and that education would be provided to Nurse #2. UM #2 said that FBS should be entered into the electronic medical record to ensure accuracy, and is easier for Physicians/NPs to follow and prescribe medication regimes accordingly, based on what is documented.

Review of the blood glucose entries for Resident #8 in the electronic medical record revealed that the FBS were not documented three times a day from 6/8/17 – 6/21/17 in accordance with the Facility’s practice. Please refer to F282 and F514.

2. For Resident #6, admitted to the facility in 9/2015 with [DIAGNOSES REDACTED]. According to the Nursing 2014 Drug Handbook, As with any insulin therapy, [DIAGNOSES REDACTED] (hardening of tissue) may occur at the injection site and delay absorption. Reduce the risk by rotating the injection site with each injection.

Review of the physician’s orders [REDACTED].#6 was to use Toujeo [MEDICATION NAME] (a long-acting insulin used to control blood sugar in adults with diabetes mellitus) Latex free 300 unit/1 milliliter (ml) Insulin pen, and was prescribed 72 units subcutaneously (sc) at bedtime. The Insulin was not administered in accordance with the prescribed regimen on 6/4/17. The Medication was then increased to 80 units sc on 6/6/17, and increased again on 6/12/17 to 84 units sc.

Review of the corresponding MAR indicated that the Toujeo Insulin 84 units was administered. However, Licensed nurses failed to document where the Toujeo Insulin had been injected to ensure the sites were rotated and to ensure proper absorption of the Insulin on 6/12, 6/13, 6/14, 6/15, 6/16, 6/17, 6/18, and 6/19/17. Resident #6 also received sliding scale Insulin three times a day before each meal. The sliding scale Insulin injection sites were not consistently documented, to ensure adequate absorption, as required, in accordance with Nursing Standards of Practice.

During interview on 6/21/17 at 4:20 P.M., UM #2 said that Licensed Nurses are supposed to be documenting where the Insulin is injected each time to ensure the sites are rotated. UM #2 said that this has been an ongoing problem at the Facility. Please refer to F282 and F514.

Failed to provide housekeeping and maintenance services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on Environmental Tour observations and staff interviews, facility staff failed to provide housekeeping and maintenance services necessary for a sanitary, orderly and an environment in good repair for residents on 1 of 2 nursing units (C-Wing, with a bed capacity of 32), and housekeeping services in 1 of 2 Nourishment Kitchen’s refrigerators

Findings include:

Environmental tours on [DATE] at 8:00 A.M., 10:48 A.M. – 11:10 A.M. and on [DATE] at 9:15 A.M. and at 2:10 P.M. with the Maintenance Supervisor and Contracted Housekeeping Supervisor indicated the following unsanitary concerns, and disrepair as follows:

Bathroom for Room 19: This bathroom shared by two residents had a small basket hanging on the wall, just above the open toilet. The basket held an electric toothbrush, three other toothbrushes and tubes of toothpaste, openly stored and unsanitary, as this increased the risk of contamination when the toilet was flushed after use, and splashing onto the openly stored oral hygiene products. In addition, none of the toothbrushes were labeled as to whom they belonged increasing the risk of cross-contamination between the two residents who shared this bathroom. On [DATE] at 2:15 P.M., the Maintenance Supervisor said that the toothbrushes were unsanitary as stored openly above the toilet.

Rooms 20 and 22: The thin laminate covering the bottom of the doors entering Rooms 20 and 22 (occupied by 4 residents) were in disrepair. The laminate was jagged, loose, and the rough edges protruded outward which increased the risk for skin injury. On [DATE] at 2:16 P.M., the Maintenance Supervisor said that both laminate panels would be repaired/replaced. The bathroom, shared by residents in Rooms 20 and 22, had a commode apparatus over the toilet. The open, metal frame surrounding the seat of the commode was rusted and seated with moisture and debris which was unsanitary. There were yellow-colored strips of a stretchy, rubberized material tied around the interior bathroom’s doorknobs to both bathroom doors (for Room 20 and Room 22). The rubberized material had smudges of brownish substances and were unsanitary as they hung loosely from each doorknob in the bathroom. On [DATE] at 2:19 P.M., the Maintenance Supervisor immediately removed the soiled yellow bands, and said that the commode would be replaced with a better one.

Room 29: Bed A stored an Intravenous (IV) pole with a tube feeding pump attached. The pump, IV pole and cross bar support at the bottom of the IV pole had thick, dried on creamy substances. The Surveyor attempted to scrape the dried substance from the cross bar of the IV pole where the build-up was more prominent. This substance was firmly attached to the metal and was unsanitary for Non-sampled Resident #1 who received the [DEVICE] feeding via this apparatus. On [DATE] at 2:22 P.M., the Contracted Housekeeping Supervisor said that it was housekeeping’s job to ensure the IV poles and [DEVICE] machines were cleaned daily, and that both the IV pole and [DEVICE] apparatus were unsanitary.

Room 33: There were two bedpans stored in this bathroom. One of the dark-colored bedpans faced inward and was wedged between the wall surface and towel bar next to the hand washing sink. The second bedpan was stored openly on the floor under the sink. Neither bedpan was labeled as to whom they belonged, and were unsanitary as stored. On [DATE] at 2:30 P.M., both the Maintenance Supervisor and the Contracted Housekeeping Supervisor said that it was unsanitary to store bedpans on a towel bar and on the floor in a shared resident’s bathroom.

Room 34: In the Bathroom, there was a soap dispenser with a dirty, worn toothbrush stored on top of the soap dispenser (on [DATE]). The Bathroom and Room were cleaned by the contracted housekeeping department (sign on Bed B indicated the mattress was cleaned), as the Resident who occupied this room on the previous day had expired. On [DATE], the toothbrush remained on top of the soap dispenser in the bathroom and was unsanitary.

C-Wing Nourishment Kitchen: The Refrigerator had several stored containers including one ,[DATE] gallon plastic pitcher containing an orange liquid, not dated as to when prepared. In the middle of the lid to the pitcher was a gooey and sticky dark-colored substance (like that of old adhesive). One round slice of pizza, was stored on the shelf and was not dated, labeled or identified as to whom it belonged. A unlabeled, rectangular container, which held a thick, red substance was stored in the vegetable keeper of the refrigerator. The container was not labeled to identify the contents, was not dated or labeled as to whom this food belonged to. The shelving of the refrigerator had dried stains and was littered with crumbs.

The Freezer held a large, quart-sized sport bottle on the same shelf as 3 small plastic bowls containing foodstuff. One of the bowls was tilted, had contained an orange substance, and had dripped onto the floor of the freezer. There was a small ice cube tray embedded in the orange substance. The Surveyor touched this substance which was gooey and sticky. The floor of the freezer was also littered with crumbs and was unsanitary. During interview on [DATE] at 2:35 P.M., both the Maintenance Supervisor and Contracted Housekeeping Supervisor said that the Refrigerator and freezer needed to be cleaned. The Contracted Housekeeping Supervisor said that there was no printed schedule to identify when the refrigerator/freezer should be cleaned, or it it had been cleaned, but that both were supposed to be cleaned daily by housekeeping, and were not.

Failed to make sure each resident receives an accurate assessment by a qualified health professional.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, facility staff failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 2 of 15 sampled Residents (#8 and #9).

Findings include:

1. For Resident #8, admitted to the Facility in 5/2017, and had [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED].

During interview on 6/22/17 at 10:00 A.M., the MDS Coordinator said that all pertinent and active [DIAGNOSES REDACTED].#8.

2. For Resident #9, admitted to the facility in 7/2016 with a fractured forearm secondary to a fall and dementia, facility staff failed to ensure falls were accurately coded in Section J1800 and J1900 on the 12/22/16 Quarterly MDS assessment. According to the clinical record, Resident #9 was found on the floor, next to the bed on 9/4/16 and on 9/27/17 was found lying on his/her back on the floor. Neither fall resulted in an injury.

Review of the 12/22/16 Quarterly MDS assessment, Section J was inaccurately coded in Section J1800 as No, indicating the Resident had no falls since the previous assessment (9/1/16). Section J1800 should have been coded as Yes, which would have prompted the next section to be accurately coded as a 2 for J1900 indicating 2 or more falls occurred since the last assessment related to the 9/4 and 9/27/16 falls with no injury. During interview on 6/21/17 at 10:10 A.M., the MDS Coordinator said that Section J1800 and J1900 were inaccurately coded to identify Resident #9 did fall, and fell 2 or more times, once on 9/4 and the second time on 9/27/16 with no injury.

Failed to make sure services provided by the nursing facility meet professional standards of quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews, facility nursing staff failed to provide services in accordance with nursing standards of practice for 2 of 5 applicable residents (#6 and #8) from a total of 15 sampled residents related to Insulin administration (injectable medication used to control blood glucose levels in residents with Diabetes Mellitus.

Findings include:

Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice.

1. For Resident #8, Licensed Nurses failed to: – ensure sliding scale Insulin coverage had been provided prior to a meal, and ensure implementation of the prescribed medical regimen had been followed when Insulin was not administered for elevated blood sugar levels, or immediately before/after a meal, and – ensure rotation of the Insulin injection site. Resident #8 was admitted to the facility in 5/2017. The Resident’s [DIAGNOSES REDACTED]. During interview (on 6/20/17 at 8:15 A.M.), Unit Manager (UM) #2 said that Resident #8 leaves for [MEDICAL TREATMENT] at 5:00 A.M., three times a week, for 4 hours on Mondays, Wednesdays and Fridays, and returns back to the facility at approximately 9:15 – 9:20 A.M. Review of a 6/7/17 Telephone Order (T.O.) indicated that Fasting Blood Sugar (FBS) levels were to be done before meals three times a day.

Review of the corresponding Medication Administration Record (MAR) indicated FBS three times a day before meals. The times were listed as 7:30 A.M., 11:30 A.M. and 4:30 P.M. (This resident leaves the Facility three times a week for [MEDICAL TREATMENT], and eats his/her breakfast meal before 5:00 A.M.). Review of a 6/8/17 T.O., indicated the Physician ordered Humalog Insulin (a fast acting Insulin that must be taken within 15 minutes before or after a meal), with sliding scale coverage to regulate elevated FBS levels three times a day. The sliding scale Insulin coverage was as follows:

– 150 – 199: give 2 units.
– 200 – 250: give 3 units.
– 251 – 300: give 5 units.
– 301 – 350: give 7 units.
-351 – 400: give 9 units.

Review of the corresponding 6/2017 MAR indicated times documented when the FBS and sliding scale Insulin was to be administered for 7:30 A.M., 11:30 A.M. and 4:30 P.M. However, on days when Resident #8 leaves for [MEDICAL TREATMENT] at 5:00 A.M., and returns back to the facility approximately 9:15 – 9:20 A.M. on Monday, Wednesday and Friday, the 7:30 A.M. FBS and sliding scale Insulin, if required, would not be able to be administered, in accordance with the prescribed regimen.

Licensed Nurses did not consistently document whether the sliding scale Insulin coverage had been administered for elevated FBS levels, and did not consistently document rotation of the injection site, when Insulin had been administered. In addition, Resident #8 attended [MEDICAL TREATMENT] on 6/12, 6/14, 6/19 and 6/21/17 (leaving the Facility at 5:00 A.M.). However, FBS had been documented for 7:30 A.M., when Resident #8 was not in the facility at this time according to UM #2.

The following inaccuracies were documented regarding Insulin coverage, such as; no documentation of injection sites to ensure rotation, and dates/times when Insulin coverage had not been administered for elevated FBS as follows:

– 6/9/17: 7:30 A.M., FBS not obtained (Resident at [MEDICAL TREATMENT], and had breakfast on 11:00 P.M.
– 7:00 A.M. shift, prior to leaving for [MEDICAL TREATMENT]).
– 6/10/17: 7:30 A.M., FBS not obtained (a non-[MEDICAL TREATMENT] day); 11:30 A.M., FBS was 150. No Insulin was administered (should have received 2 units); 4:30 P.M., FBS was 152. No Insulin was administered. The Resident should have received 2 units.
– 6/12/17: 4:30 P.M., FBS was 235. No Insulin was administered. Resident should have received 3 units.
– 6/13/17: 7:30 A.M., FBS illegible; 4:30 P.M., FBS was 205 and 5 units of Insulin was administered. There was no documentation of the injection site.
– 6/14/17: 7:30 A.M. FBS was 150 (Resident at [MEDICAL TREATMENT] from 5:00 A.M. – 9:00 A.M.). No Insulin coverage administered. Ordinarily, the Resident would have received 2 units Insulin coverage; 11:30 A.M., FBS was 150. No Insulin coverage administered.
– 6/15/17: 4:30 P.M., FBS was 175. No sliding scale Insulin coverage administered.
– 6/16/17: 11:30 A.M., No FBS obtained; 4:30 P.M. indicated the Resident was not in the Facility.
– 6/17/17: 7:30 A.M., FBS was 162 and received 2 units Humalog. However, there was no documentation as to where the Insulin was injected to ensure rotation of injection sites.
– 6/18/17: 4:30 P.M., FBS was 181. No Insulin was administered. Resident should have received 2 units Insulin.

Failed to provide care by qualified persons according to each resident's written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews, the facility nursing staff failed to provide services in accordance with care plans and/or physician’s orders [REDACTED].#4, #6, #8 and #15).

Findings include:

1. For Resident #8, nursing staff failed to ensure the plan of care/physician’s orders [REDACTED].
a. [MEDICATION NAME] 2 step screening test,
b. Pneumococcal vaccine,
c. Diabetic Foot Care every (Q) night,
d. Sliding scale Insulin administration,
e. Daily weight for 6:00 A.M., and
f. Bilateral Heel treatment.

Resident #8 was admitted to the facility in 5/2017. The Resident’s [DIAGNOSES REDACTED]. During interview on 6/20/17 at 8:15 A.M., Unit Manager (UM) #2 said that Resident #8 leaves for [MEDICAL TREATMENT] at 5:00 A.M., three times a week, on Mondays, Wednesdays and Fridays, and returns back to the facility at approximately 9:15 – 9:20 A.M. She said that the Resident has diabetes, and an ischemic right leg that the Vascular Surgeon wants to amputate, and the Resident has vascular ulcers related to the [MEDICAL CONDITION]. a. Review of the 6/2017 pre-printed physician’s orders [REDACTED]. The orders were signed by the Physician.

Further review of the corresponding Medication Administration Record (MAR) indicated that the 2 STEP [MEDICATION NAME] test (test used to screen residents for [MEDICAL CONDITION]) was not administered, as planned/ordered. During interview on 6/20/17 at 2:30 P.M., UM #2 said that the Facility did not perform this test on residents admitted for short term rehabilitation, or those patients with stays less than 3 months (exception clause from the Centers for Disease Control and Prevention allowing this). UM #2 said the order was on a pre-printed physician’s orders [REDACTED].

b. Review of the 5/2017 – 6/2017 physician’s orders [REDACTED].#8 was to receive a Pneumonia vaccine 0.5 cc Intramuscularly (IM) X 1, if not contraindicated. Review of the Initial Minimum Data Set (MDS) Assessment completed 6/3/17 indicated in the Immunization section that the Pneumococcal vaccine was not offered. Review of the corresponding MAR indicated that Resident #8 was not provided with the Pneumococcal vaccine, as ordered.

During interview on 6/20/17 at 2:30 P.M., UM #2 said that there was no Immunization record completed for Resident #8. She said that the Facility should have checked to see of Resident #8 had already received the vaccine elsewhere, and offered the vaccine, as ordered, if there was no contraindication.

c. Review of the physician’s orders [REDACTED].M. – 11:00 P.M. shift. Review of the corresponding TAR for 6/2017 lacked documentation that diabetic foot care was provided on 6/5 or 6/17/17, as ordered/planned.

d. Review of a T.O., dated 6/8/17, indicated that Resident was to have Fasting Blood Sugar (FBS) levels tested three times a day with Humalog Insulin, according to sliding scale parameters for elevated FBS (from 150 – 400).

Review of the corresponding 6/2017 MAR indicated that although the Resident’s FBS were elevated, Resident #8 did not receive sliding scale Insulin, as ordered for the following dates/times:

– 6/10/17: 11:30 A.M., FBS was 150. No Insulin was administered (should have received 2 units); 4:30 P.M., FBS was 152. No Insulin was administered. The Resident should have received 2 units.
– 6/12/17: 4:30 P.M., FBS was 235. No Insulin was administered. Resident should have received 3 units.
– 6/14/17: 7:30 A.M. FBS was 150. No Insulin coverage administered. Resident should have received 2 units Insulin coverage; 11:30 A.M., FBS was 150. No Insulin coverage administered.
– 6/15/17: 4:30 P.M., FBS was 175. No sliding scale Insulin coverage administered.
– 6/16/17: 11:30 A.M., No FBS obtained, as ordered. The space was blank.
– 6/18/17: 4:30 P.M., FBS was 181. No Insulin was administered. Resident should have received 2 units Insulin.

During record review and interview on 6/21/17 at 12:30 P.M., Nurse #2 said that all FBS should be recorded on the MAR and then entered into the electronic medical record (EMR). Nurse #2 then checked in the EMR, and revealed that not all FBS had been entered, in accordance with the Facility’s protocol. Nurse #2 said that anytime Insulin has to be administered for elevated FBS, that an entry has to be documented on the back of the MAR with the Insulin dose, and the injection site where the Insulin was administered. During interview on 6/21/17 at 3:55 P.M., UM #2 said that FBS are required to be entered into the EMR so that Physician’s/Nurse Practitioners have the information readily available. UM #2 said that nursing staff did not enter FBS in the EMR, three times a day, in accordance with the Facility’s protocol. UM #2 said that Licensed Nurses did not document on the back of the MAR each time Insulin was required for elevated FBS, or the location where the Insulin was injected, as required.

e. Review of a skilled nursing note, dated 5/25/17, indicated the Resident had a scab at the left heel and on 5/27 and 6/3/17, the notes indicated Resident #8 had a pressure area on the left heel. Review of the 6/2017 TAR indicated an entry for bilateral heel skin prep three times a day. The treatment was not applied on 6/5/17 for the 3:00 P.M. – 11:00 P.M. shift, as planned. There was a hand written entry indicating this was rewritten. Review of a T.O., dated 6/6/17, indicated that skin prep was to be applied to the right heel with a dry dressing. There was no direction as to how often the skin prep and dressing were to be applied. This entry was documented on the TAR, but was crossed out, and was not provided, as ordered.

Further review of another entry on the TAR indicated the to apply skin prep to bilateral heels 3 times a day. The treatment was not provided on 6/7, 6/8, 6/13 or 6/17/17 for the 11:00 P.M. – 7:00 A.M. shift; or on 6/17/17 for the 7:00 A.M. – 3:00 P.M. shift, as planned. During interview on 6/21/17 at 9:30 A.M., the Nurse Practitioner (NP) said that the areas on Resident #8’s heels were vascular, and that the skin prep with the dressing to the right heel was supposed to have been discontinued, with an order written [REDACTED]. Please refer to F314 and F514.

2. For Resident #6, admitted to the facility in 9/2015 with [DIAGNOSES REDACTED].
>a. Vitamin B12 ([MEDICATION NAME], which is a vitamin supplement to treat [MEDICAL CONDITION] and the Vitamin B12 deficiency) was not administered as ordered every month.
b. [MEDICATION NAME] was not administered, as ordered to treat the resident’s [MEDICAL CONDITION].
c. Sliding scale Insulin was not administered for elevated FBS, as ordered.
d. [MEDICATION NAME] (a corticosteroid inhalant medication used, and must be used regularly to be effective in treating lung diseases) 0.5 milligrams (mg) Singe Dose Vial (SDV) nebulizer breathing treatment was not administered, as ordered.
e. [MEDICATION NAME] (antipsychotic type of medication used to treat [MEDICAL CONDITION]) was not administered, as ordered. Review of the physician’s orders [REDACTED]. Review of the corresponding MAR for 6/2017 indicated the 15th of the month was crossed out, and the Vitamin B12 was not administered, as ordered. Further review identified another dated box for 6/17/17 was initialed and the initials were circled, indicating the medication was not administered. There was no documentation as to why this medication was not administered, as ordered. During interview on 6/21/17 at 4:00 P.M., UM #2 said that when the nurse was preparing the Vitamin B12, the vial broke, and the medication was lost. She said that there were issues with obtaining another vial of the Vitamin B12, but that the medication should be here, and the medication should have been administered, as ordered. In addition, UM #2 said that the circumstances on why the medication hadn’t been administered should have been documented by the licensed nurse, and was not.

b. Review of a T.O., dated 6/13/17 at 3:50 P.M., indicated an order to increase [MEDICATION NAME] (medication used to remove excess fluid from the tissue/lungs) to 40 mg in the morning and 20 mg in the afternoon. On 6/20/17 at 8:20 A.M. and again on 6/21/17 at 9:00 A.M., the Surveyor observed Resident #6 sitting upright in a wheelchair. The Resident was wearing compression stockings to bilateral legs. On 6/21/17, the Surveyor reviewed the corresponding MAR which indicated the 8:00 A.M. and 2:00 P.M. doses of [MEDICATION NAME] had not been administered on 6/19 or 6/20/17, as ordered.

c. Sliding scale Insulin was not administered for elevated FBS, as ordered. Review of a 6/6/17 T.O. indicated an order to start sliding scale [MEDICATION NAME] Insulin (fast acting Insulin medication) at 11:30 A.M., indicating FBS would be obtained three times a day with sliding scale coverage, instead of twice a day. Review of the corresponding 6/2017 MAR indicated elevated FBS and Insulin coverage was not administered as follows:

– 6/7/17 at 7:30 A.M., the FBS was 291. The Resident should have received 7 Units of [MEDICATION NAME] Insulin. There was no indication this dose was administered.
– 6/8/17 at 11:30 A.M., the FBS was 478. The Resident should have received 13 Units of [MEDICATION NAME] Insulin. There was no indication this dose was administered, as ordered.
– 6/10/17 at 7:30 A.M., the FBS was 183. The Resident should have received 3 Units of [MEDICATION NAME] Insulin. There was no indication this dose was administered, as ordered.
– 6/19/17 at 7:30 A.M., the FBS was 340. The Resident should have received 9 Units of [MEDICATION NAME] Insulin. There was no indication this dose was administered, as ordered. At 11:30 A.M., the FBS was 397. The Resident should have received 11 Units of [MEDICATION NAME] Insulin. There was no indication this dose was administered, as ordered.

d. Review of the 6/2017 physician’s orders [REDACTED].M. and 6:00 P.M. Review of the 6/2017 corresponding MAR indicated the inhalant medication was not administered as follows:

– From 6/1 – 6/19/17, Resident #6 did not receive the 6:00 P.M. dose, as ordered. – 6/2, 6/3 and 6/18/17, Resident #6 did not receive the 6:00 A.M. dose, as ordered. e. [MEDICATION NAME] was not administered, as ordered. Review of the 6/2017 physician’s orders [REDACTED]. Review of the corresponding MAR indicated Resident #8 did not receive the anti-psychotic type medication to treat [MEDICAL CONDITION] on 6/2, 6/3, 6/12 and 6/13/17, as ordered. During interview on 6/21/17 at 4:30 P.M., UM #2 said that the Facility has been using a lot of Pool (Agency) Nurses, and believes this has contributed to the problem with medications not being administered or documented as being administered as well as medication transcription errors. Please refer to F514.

3. For Resident #15, the facility staff failed to ensure the resident’s FBS was checked, as ordered. Resident #15 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. Review of the physician’s orders [REDACTED]. Review of the 3/2017 MAR indicated there was no evidence that the FBS was checked QID on 17 out of 21 days between 3/10/17 and 3/31/17.

Review of the 4/2017 MAR indicated there was no evidence that the FBS was checked QID on 8 out of 9 days from 4/1/17 to 4/9/17.

Review of the physician’s orders [REDACTED]. Further review of the 4/2017 MAR indicated there was no evidence that the FBS was checked once a day at bedtime on 9 out of 21 days from 4/10/17 to 4/30/17. During an interview on 6/22/17 at 1:15 P.M., UM #2 and the Director of Nurses reviewed the March and April MARs and said that they did not have any evidence that the FBS was checked on the dates and shifts where documentation was left blank.

4. For Resident #4, the facility staff failed to follow the physician’s orders [REDACTED]. Resident #4 was admitted to the facility in 11/2014 with a [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 5/31/17, indicated the resident had significant cognitive deficits with a Brief Interview for Mental Status (BIMS) score of 4 out of 15.

Review of the 6/2017 signed physician’s orders [REDACTED]. Observation of the resident on 6/20/17 at 2:05 P.M., indicated the resident was in his/her room in a reclined chair with no tab alarm in place. Observation of the resident on 6/20/17 at 4:20 P.M., indicated the resident was in his/her room in a reclined chair with no tab alarm in place. Observation of the resident on 6/21/17 at 7:45 A.M., indicated the resident was in his/her room asleep on the bed with no tab alarm in place. During an interview on 6/21/17 at 8:20 A.M., Certified Nurses Aide (CNA) #2 said the resident used to wear an alarm, but it was discontinued a few months ago. During an interview on 6/21/17 at 3:00 P.M., UM #1 said the alarm was discontinued a couple of months ago. She said it should not have been on the current Physician orders. She said she was unable to find the physician’s orders [REDACTED]. Please refer to F514.

Failed to give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to provide care and services to prevent the development of pressure ulcers for 1 of 2 applicable Residents (#8) with pressure ulcers, from a total sample of 15 residents.

Findings include:

Review of the facility’s policy for Skin Integrity Management, dated 11/28/16, indicated the following: a. Policy: The implementation of an individual patient’s skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for change and implements revisions to the care plan as needed.

b. Purpose: To provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment .

c. Practice Standards: .Develop comprehensive, interdisciplinary plan of care including prevention .as indicated. Review of the facility’ Diabetic Care Protocol, dated 1/2014, indicated the following:

– Perform skin and extremity assessment .
– Develop a care plan to include:  Daily foot care/skin observations.
– Evaluate for and respond to any change in condition.

For Resident #8, nursing staff failed to ensure necessary treatments, wound care and services to promote healing to a wound, described as being Moisture Associated Skin Damage (MASD), that deteriorated and was later identified as being an unstageable pressure ulcer, located on the left inner buttocks. In addition, pressure ulcers were identified on the Resident’s heels.

Resident #8 was admitted to the Facility in 5/2017. The Resident’s [DIAGNOSES REDACTED]. Review of a 5/17/17 skilled nursing note indicated the Resident had a Braden Scale score of 22 (Braden Scale is a tool used for predicting pressure sore risk). The total score of 22 indicated that Resident #8 was only a mild risk for pressure sores. The note also indicated that Resident #8 had excoriated skin on the left and right buttocks. The 5/18/17 skilled nursing note indicated the excoriated areas on the Resident’s buttocks were MASD, which is a general term for inflammation or skin erosion from a source of moisture, such as urine, stool, sweat etc.

Review a 5/18/17 skilled nursing note indicated a Norton Scale was completed, with a score of 15. The Norton Scale is another tool utilized to determine the level of risk for pressure ulcer development. The score of 15 indicated that Resident #8 was at medium risk for pressure ulcer development. This Norton Scale could not be located for review. Review of the care plan, initiated 5/18/17 related to the potential risk for skin breakdown indicated the Resident had an open area on the left buttock, and a zinc oxide cream (Zguard, provides a protective barrier for skin irritation) was ordered. Review of the Initial MDS assessment, dated 5/23/17, indicated the Resident was alert and oriented with no cognitive impairment, received extensive assist for bed mobility, transfers, toilet use, ambulation, dressing and hygiene, used a walker and a wheelchair as assistive devices for mobility; was dependent on staff for bathing; was on [MEDICAL TREATMENT]; was at risk for pressure ulcer development; had no pressure or vascular ulcers, and pressure relief was provided while in the bed and chair.

Review of a Norton Plus Pressure Ulcer Scale, dated 5/24/17, indicated that the Resident was in good physical condition (not according to admission diagnoses), was alert, ambulant with full mobility (not according to the MDS assessment findings), and was not incontinent (total score was 20). The Norton Plus deductions equaled 5 checks, 5 deducted from 20 indicated the total score was 15 placing the Resident at a medium risk for pressure ulcer development.

Review of a 5/25/17 skilled nursing note indicated Resident #8 had MASD on the buttocks. There was no measurement taken of these areas, nor was there a description of the areas to indicate depth, wound evaluation/status etc. for the buttocks. According to the clinical record, Resident #8 had low blood pressures, complained of pain in the right foot, and was sent to the emergency room (ER) for evaluation on 5/25/17. Resident #8 was admitted to the hospital and returned back to the facility on [DATE]. Review of a T.O., dated 6/12/17, indicated the Resident was to have an [MEDICATION NAME] dressing applied before [MEDICAL TREATMENT] (Mondays – Wednesdays and Fridays at 5:00 A.M.), and instructed the dressing be removed when the Resident returned back to the facility. ([MEDICATION NAME] is either an adhesive or non-adhesive dressing that is highly absorbent, protects wounds, such as pressure injuries, lacerations, abrasions and absorbs moisture or wound drainage etc.). The T.O. did not identify where nursing staff were to apply the [MEDICATION NAME] dressing, whether the left heel, right heel where there were pressure ulcers or the buttocks area.

Further review of a 6/14/17 skilled nursing note indicated the Resident refused to stand to have the dressing applied to the left inner buttock, subsequently, the dressing was not applied, for this Resident with severe [MEDICAL CONDITION], ischemia to the right foot and great toe, right lateral foot fracture, pain, and ulcers to both feet.

Review of a T.O., dated 6/14/17, indicated an order to wash with soap and water twice a day then pat dry. In the morning, apply Zguard and evenings apply [MEDICATION NAME] powder (antifungal powder) for 10 days. The order did not identify where to wash and apply treatment creams/powders for 10 days. Further review of the corresponding TAR indicated this order was transcribed as follows: apply Zguard to the upper buttocks at 8:00 A.M., apply [MEDICATION NAME] Powder at 8:00 P.M. and call the health care provider if the area worsens. This order was discontinued 6/16/17. There was no documentation as to why the treatment was discontinued. There was no documentation to indicate if the area on the buttock had in fact worsened, as there was no description or measurement of the wound in the clinical record or on the TAR.

Review of a T.O., dated 6/16/17, indicated to discontinue previous wound orders and to apply Zguard to buttocks/coccyx every 6 hours and as needed. Review of the corresponding TAR indicated to apply the Zguard at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. Review of the 6/17/17 skilled nursing note indicated that Resident #8 had an open area on the buttock. There was no evidence that this open area was described, measured, evaluated as to the appearance, depth, wound periphery, whether there was drainage, maceration or if the wound had worsened to a pressure ulcer that was previously identified as MASD. Further review of the TAR indicated that the Zguard, ordered to be applied every 6 hours, was not provided to the left buttock wound on 6/17/17 for 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M., as ordered, or on 6/18/17 at 12:00 P.M. Furthermore, there was no description documented on the reverse side of the TAR or outcome related to the ulcer on the TAR or in the clinical record to identify how the area on the left inner buttocks appeared or if the ulcer had been evaluated, or even reported to the Physician/Nurse Practitioner (NP) for appropriate treatment.

During the initial tour of the Resident’s unit on 6/20/17 at 8:00 A.M., UM #2 said that Resident #8 was alert and oriented, could be interviewed regarding care provided, had an ischemic stroke, has vascular disease in the right lower extremity with wounds on the right and left heels, and refused an amputation. UM #2 said that the Resident was a diabetic and went to [MEDICAL TREATMENT] three times a week at 5:00 A.M. At this time, the Surveyor observed Resident #8 in bed, on a pressure reducing mattress, resting on his/her back. The Resident had padded, light blue booties on bilateral feet and was wearing yellow non-skid slipper socks. The left knee was in a flexed position, with the left foot flat on the bed in the bootie, as the right leg was crossed over the left leg pressing the foot into the bed. The head of the bed was slightly elevated at 30 degrees.

During interview on 6/20/17 from 11:15 A.M. – 11:40 A.M., Resident #8 was in bed, resting flat on his/her back with the head of the bed elevated to approximately 40 degrees. The Resident’s right leg was crossed over the left leg. Resident #8 said that he was told he had pressure sores on the heels. He/she asked what is pressure? Resident #8 said nursing staff put these boots on me, took away my sneakers and said I can’t walk. Resident #8 said that he/she had terrible shooting pain in the coccyx area and base of the spine, but it was worse when sitting up for [MEDICAL TREATMENT], three times a week for 4 hours duration in a chair. Resident #8 said they also gave me a cushion in the wheelchair, but it doesn’t help much when at [MEDICAL TREATMENT] as the Resident sits in a recliner, not the wheelchair. The Resident said the doctor increased pain medication due to the pain in the coccyx area and right leg, and it has helped somewhat, but wasn’t sure how long it would last, before it had to be increased again.

During interview on 6/20/17 at 12:30 P.M., Nurse #2 said that she was familiar with and was caring for Resident #8 today. She said that the treatments were not done as of yet, and she would do them later this afternoon, when the Resident returned back from an appointment. Nurse #2 said that she works until 3:00 P.M. The Surveyor requested to observe treatments and wounds when the Resident returns. On 6/20/17 at 1:10 P.M., the Surveyor observed Resident #8 sitting upright in a wheelchair near the Nursing Desk. The Resident said that he/she was still waiting to go to the appointment, and apparently, there was a delay. As of 3:00 P.M., the Surveyor was not summoned to observe the treatments for Resident #8.

During interview on 6/21/17 from 9:10 A.M. – 9:40 A.M., the NP said that she was very familiar with Resident #8 and was assigned to care for the Resident, since being admitted to the Facility. The NP said that Resident #8 was medically compromised and had multiple problems. The NP said the area on the Resident’s buttocks was excoriated and believed Resident #8 had been admitted from the hospital with it in 5/2017. She said that she did order [MEDICATION NAME] to be applied to that area on [MEDICAL TREATMENT] days, then discontinued this and ordered Z-Guard cream instead. The NP said that she had not observed the buttock area, but understood it was just an excoriation.

During observation on 6/21/17 at 5:10 P.M. with UM #2, UM #2 approached Resident #8 with the Surveyor as Resident #8 resting flat on his/her back in bed, with the head of bed slightly elevated. UM #2 asked Resident #8 if UM #2 could look at the buttocks area with the Surveyor to observe where Resident #8 had complained of discomfort. Resident #8 agreed, said that the area was very painful, then turned over onto the right side and pulled down his/her shorts. There were no areas on either left or right outer buttocks. UM #2 washed hands and donned gloves. As she attempted to lift the left buttock up, Resident #8 loudly moaned, and asked that the area not be touched, as it was very painful. The Surveyor observed two areas located on the inner, upper buttock. The distal area was as a shallow crater, while the area above this was smaller and very reddened. The shallow crater was approximately 1 cm long by 0.8 cm wide, and approximately 0.2 cm deep. The inner wound margin had yellow slough. The wound base was pale pink and moist. The outer periphery was inflamed. The area adjacent to the shallow crater was approximately 0.5 cm round and prominently red. Resident #8 said that the pain was like that of a knife driving up and into the spine, especially when sitting up on it. UM #2 said that the areas were pressure sores, not excoriated areas, and that she would clean the ulcers first, then measure them and call the doctor for treatment orders. UM #2 said that wound measurements and staging of the ulcers would be provided to the Surveyors on the following day (6/22/17).

During interview on 6/21/17 at 5:30 P.M. with two Surveyors, the Clinical Nurse Coordinator (CNC) and the Director of Nursing (DON), the Surveyor reviewed findings identified with UM #2 regarding the areas on Resident #8’s inner buttocks, and reviewed clinical record documents. The CNC said that the Facility does not use a Braden Scale tool for pressure ulcer risk assessment, and uses a Norton Scale. The DON said that the Norton Scale is to be done weekly times 4, and that wound measurements and skin assessments were to be done weekly. The DON said that the weekly Norton Scales and weekly skin assessments could not be located after two days searching for this information. The Surveyors requested that measurements and the Facility’s evaluation of the pressure ulcers for Resident #8 be provided when completed, due to the findings upon inspection of the areas on the left inner buttock on 6/21/17 at 5:30 P.M. with UM #2. Measurements, assessment evaluation and condition of other areas identified in the clinical record as pressure will also be completed per UM #2, as required and in accordance with the Facility’s policy/procedure. During interview on 6/22/17, the DON said that the areas on Resident #8’s inner left buttock were measured on 6/21/17 last evening, and that one of the areas was a Stage 1 and the other area was unstageable with 75 percent slough.

Failed to make make sure that residents are safe from serious medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility staff failed to ensure 2 Residents (#7 and #15) out of a total sample of 15 residents were free of any significant medication errors.

Findings include:

1. For Resident #7, the facility staff failed to administer the correct dose of Apixaban (a blood thinner used to prevent blood clots). Resident #7 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. Review of the hospital discharge paperwork, dated 1/6/17, indicated to administer Apixaban 5 milligrams (mg) through the resident’s gastro-intestinal tube ([DEVICE]) 2 times a day. Review of the hand transcribed admission orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the clinical record indicated the resident had a Venous Duplex Ultrasound to the right lower extremity on 1/31/17. The impression of the ultrasound was the resident had a [MEDICAL CONDITION] (blood clot) and a Baker cyst (a fluid filled cyst that develops behind the knee). The resident was transferred to the hospital. Review of the hospital discharge paperwork, dated 2/2/17, indicated the resident did not have a [MEDICAL CONDITION], but a very large Baker cyst. Review of the Event Summary Report, dated 2/2/17, indicated when the resident was admitted to the facility on [DATE], the resident received Apixaban 5 mg 1 time day, instead of the ordered Apixaban 5 mg, 2 times a day because of a transcription error. During an interview on 6/21/17 at 12:10 P.M., the Nurse Practitioner (NP) said the resident was supposed to receive Apixaban 5 mg 2 times a day, and it never should have been given 1 time a day. The NP said the Apixaban was never ordered for 1 time a day and it was a definite medication error. Please refer to F514.

2. For Resident #15, the facility staff failed to ensure the resident was free of significant medication errors in relation to the administration of Insulin. Resident #15 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. Review of the Physician orders [REDACTED]. Review of the 3/2017 MAR indicated [REDACTED]. Review of the 4/2017 MAR indicated [REDACTED]. Further review indicated it was not administered at all from 4/16/17 to 4/24/17 and there was no documented reason. Review of the 5/2017 MAR indicated [REDACTED]. During an interview on 6/22/17 at 1:15 P.M., UM #2 and the Director of Nurses reviewed the March, April and May MARs and said that they did not have any evidence that the Insulin was administered on the dates where documentation was left blank.

Failed to store, cook, and serve food in a safe and clean way

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a Kitchen Tour with the FSS (Food Service Supervisor), Facility staff failed to ensure food was stored and prepared under sanitary conditions.

Findings include:

1. Hand Washing Sink only inches from stored, clean dishware The hand washing sink was located adjacent to a large open storage rack with inverted bowls and dishes. On 6/20/17 at 8:45 A.M., the Surveyor observed Dietary Aide #1 washing her hands in the hand sink. However, there was a large open storage rack only inches away from the hand sink where splashes during hand hygiene splattered on the inverted bowls stored nearby. On 6/21/17 at 11:25 A.M., the Surveyor observed Dietary Aide #2 performing hand hygiene in the hand washing sink, splashing water onto inverted bowls stored on the open rack, only inches away. On 6/21/17 at 11:30 A.M., the Surveyor observed Cook #1 perform hand hygiene at the hand washing sink. The water splashed onto the inverted bowls stored nearby. The Food Service Supervisor (FSS) was standing nearby. The Surveyor pointed out the hand hygiene process and close proximity of the clean dishes/bowls. The FSS said that the rack has to be moved, as it was not sanitary to store clean dishes so close to the hand hygiene sink.

2. Commercial Mixer On 6/20/17 at 8:50 A.M., and again on 6/21/17 at 11:26 A.M., the Surveyor observed a large, commercial mixer, where the beater and paddle attachments connected, had dried creamy substances adhered. The Surveyor pointed this out to the FSS who said that the mixer needed to be cleaned.

3. Air Conditioning (AC) Unit On 6/20 and 6/21/2017, the Surveyor observed a large, rectangular AC unit attached to the ceiling surface, just above the metal food prep table. The AC was running, and condensation was built up around the metal outer framed surface. The condensation dripped and splashed onto the food prep/serving table (on 6/20/17 from 8:50 A.M. – 9:04 A.M. There was no food openly stored or being prepared at this time). On 6/21/17 from 11:25 A.M. – 12:00 P.M. during observation of the tray line, the Surveyor observed the AC was on. Condensation was beginning to form around the outer framed surface of the AC. There were two large bowls of salad on the food prep/service counter that were covered with clear, plastic wrap. After the food had been served, the Surveyor pointed this out to the FSS who was present during observations. The FSS said that he would have the Facility call the Vendor and have the unit checked, as the moisture dripping on the food prep/service table was not sanitary. At this time, the condensation had not yet dripped on the food prep area.

4. Milk refrigerator/chest. On 6/20/17 at 8:47 A.M., the Surveyor observed the small milk cartons were all wet, as stored inside the milk refrigerator. There was ice building up on the interior left side of the chest, and a heavy build-up of frost on the back interior of the chest. The temperature was appropriate at 36 degrees Fahrenheit (F). There was a distinct foul odor emanating from the interior when the chest was opened. On 6/21/17 at 12:00 P.M., the Surveyor observed the milk refrigerator and interior with the FSS. The FSS said that the Vendor has been in to change gaskets, repair holes with metal patches, and fix the milk chest, but the Facility really needs a new one. The FSS said that there was a distinct foul odor emanating from inside the milk refrigerator, despite it being cleaned, and would call the vendor again. The FSS said that the milk chest should not have a thick build-up of ice on the inside, or frost build-up on the back of the chest. Cook #1 said that when she tested the temperature of the milk prior to serving today at 11:24 A.M., that the milk was 30 degrees F. During interview on 6/21/17 at 12:10 P.M., the Facility Administrator said that the Facility needs to purchase a new milk chest, as the unit is old and has been repaired many times.

5. Floor drain near the Ice Machine The floor drain, adjacent to the Ice Machine was discolored black. There was debris surrounding the [MEDICATION NAME]-colored piping that dripped into the drain. The floor surface surrounding the drain was also discolored with a blackened periphery. During interview and observation of the floor drain on 6/21/17 at 11:55 A.M., the FSS said that the floor drain has been an ongoing problem.

Failed to maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility staff failed to label multi dose vials of medication in accordance with currently accepted professional principles on 2 out of 4 medication carts and 1 out of 2 medication rooms.

Findings include:

On [DATE] at 9:00 A.M., during inspection of the C wing back hall medication cart, the surveyor observed;

– 1 vial of Humalog Insulin opened [DATE] and still in use, expired on [DATE]. During an interview on [DATE] at 9:05 A.M., Nurse #1 said the Humalog Insulin is good for 28 days and should have been thrown away. On [DATE] at 9:10 A.M., during inspection of the C wing front hall medication cart, the surveyor observed;

– 1 vial of Lantus Insulin with no date when opened and still in use. During an interview on [DATE] at 9:15 A.M., Nurse #2 said all vials of insulin need to be dated when opened. She was unable to find any date on the vial of Lantus Insulin. On [DATE] at 11:00 A.M., during inspection of the C wing medication room, the surveyor observed 1 vial of Tuberculin purified protein derivative (PPD) with no date when opened. During interview on [DATE] at 11:05 A.M., Nurse #2 said that there was no date on the PPD vial when it was opened and once opened it is good for 30 days.

Failed to keep accurate, complete and organized clinical records on each resident that meet professional standards

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews, facility staff failed to ensure the clinical record was accurately documented and complete for 5 of 15 sampled residents (#1, #6, #7, #8 and #11).

Findings include:

1. For Resident #8, admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. [MEDICATION NAME] screening testing; (b). Fasting Blood Sugar (FBS) testing and sliding scale Insulin administration; (c). Pressure ulcer assessments with measurements, evaluations for staging, descriptions, orders and transcription.

a. Review of the 6/2017 pre-printed physician’s orders [REDACTED]. The orders were signed by the Physician. Further review of the corresponding Medication Administration Record (MAR) indicated that the [MEDICATION NAME] test was not administered. During interview on 6/20/17 at 2:30 P.M., Unit Manager (UM) #2 said that the [MEDICATION NAME] screening test ordered was not accurate, as Resident #8 is at the Facility short term care, and the screening test is not required for residents who’s stay is less than 3 months (exception clause from the Centers for Disease Control and Prevention allowing this). She said that the order automatically appears on pre-printed orders, and it should have been crossed out, before the Physician signed it during editing.

b. Review of a T.O., dated 6/8/17, indicated that Resident #8 was to have a FBS three times a day with Humalog Insulin (fast acting Insulin that must be taken within 15 minutes before or after a meal), according to sliding scale parameters for elevated blood sugars (from 150 – 400).

Review of the corresponding 6/2017 Medication Administration Record (MAR) indicated times were documented when the FBS and sliding scale Insulin doses were to be administered (7:30 A.M., 11:30 A.M. and 4:30 P.M.) according to parameters of FBS test results. However, Resident #8 was identified by UM #2 as leaving for [MEDICAL TREATMENT] at 5:00 A.M. and does not return until sometime after 9:00 A.M. on Monday, Wednesday and Friday. The times documented when the FBS and sliding scale Insulin coverage would be completed at 7:30 A.M Resident #8 would not be in the facility for 7:30 A.M. on those days/times. In addition, the FBS and sliding scale Insulin doses were squeezed together in 3 blocks on the MAR, subsequently, there was no way to tell what particular dose had been administered at any given time for elevated FBS. Five separate doses were transcribed all together (150 – 199: give 2 units; 200 – 250: give 3 units; 251 – 300: give 5 units; 301 – 350: give 7 units and 351 – 400: give 9 units). With the doses documented together, there was no room to document when the Insulin was administered, the dose, the time, or the site where the Insulin was injected to ensure the sites were rotated.

During record review and interview on 6/21/17 (Wednesday) at 12:30 P.M., Nurse #2 said that she documented on the MAR she obtained a FBS at 7:30 A.M. for Resident #8. The Surveyor asked Nurse #2 how this was possible for 7:30 A.M., as Resident #8 was at [MEDICAL TREATMENT] at this time. Nurse #2 said that Resident #8 receives his/her breakfast meal, prior to leaving the facility at 5:00 A.M. for the 11:00 P.M. to 7:00 A.M. shift, and that perhaps that shift should be checking the FBS and administering the sliding scale Insulin on the days Resident #8 is at [MEDICAL TREATMENT]. During interview on 6/21/17 at 3:55 P.M., UM #2 said that the FBS and sliding scale Insulin coverage were not accurately documented for Resident #8. UM #2 said Insulin coverage is supposed to be documented on the MAR as before meals, three times a day, and that the times should not have been documented, especially for Resident #8 who attends [MEDICAL TREATMENT] and is not in the Facility 3 x week at 7:30 A.M. UM #2 said that it is the Facility’s practice to document all doses together in the fashion observed on the MAR during record review, but nursing staff are supposed to document on the back of the MAR, each time when Insulin is administered, and did not, to ensure the clinical record was accurate and complete to ensure Insulin was actually administered.

c. Review of a 5/17/17 skilled nursing note indicated the Resident had excoriated skin on the left and right buttocks. The areas were not measured. The 5/18/17 skilled nursing note indicated the excoriated areas on the Resident’s buttocks were moisture related. The note also indicated the Resident had a scab at the left heel. The areas identified were not measured, evaluated or described to ensure the areas were accurately recorded.

The skilled nursing notes of 5/27 and 6/3/17 indicated Resident #8 had a pressure area on the left heel. There was no measurement, evaluation for staging of this pressure area to the left heel, or description of the skin integrity. Review of a T.O., dated 6/6/17, indicated that skin prep was to be applied to the right heel with a dry dressing. The order did not identify how often the treatment was supposed to be provided, such as daily, three times a day etc.

This entry was documented on the Treatment Administration Record (TAR), but was crossed out, and the treatment was not provided. There was no order to discontinue the 6/6/17 order, to accurately reflect why the treatment was crossed out and not provided. Review of a T.O., dated 6/12/17, indicated the Resident was to have an [MEDICATION NAME] dressing applied before [MEDICAL TREATMENT] (Mondays – Wednesdays and Fridays at 5:00 A.M.), and instructed the dressing be removed when the Resident returned back to the facility. ([MEDICATION NAME] is either an adhesive or non-adhesive dressing that is highly absorbent, protects wounds, such as pressure injuries, lacerations, abrasions and absorbs moisture or wound drainage etc.). The T.O. did not identify accurately where nursing staff were to apply the [MEDICATION NAME] dressing, whether the left heel, right heel or buttocks area.

Review of a T.O., dated 6/14/17, indicated an order to wash with soap and water twice a day then pat dry. In the morning, apply Zguard and evenings apply [MEDICATION NAME] powder (anti-infective powder) for 10 days. The order was not accurately documented to identify where to wash and apply treatment creams/powders for 10 days. Review of the corresponding TAR indicated the 6/14/17 order was transcribed for the treatment to be applied to the Resident’s buttock area. However, according to documentation on the TAR, the treatment was discontinued on 6/16/17 (only 3 days and not 10 days as the order indicated). The TAR was not accurately documented to identify the condition of the wound on the buttocks or a description/evaluation or assessment of the wound, whether it had improved or worsened.

Review of a T.O., dated 6/16/17, indicated to discontinue previous wound orders and to apply Zguard to buttocks/coccyx every 6 hours and as needed. Review of the corresponding TAR indicated to apply the Zguard at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. Review of the 6/17/17 skilled nursing note indicated that Resident #8 had an open area on the buttock. The open area was not documented as to the description, measurements taken, evaluation or assessment whether it had worsened or improved. During interview on 6/21/17 at 9:30 A.M., the Nurse Practitioner (NP) said that the areas on Resident #8’s heels were vascular, not pressure, and she recalled clarifying the left heel dressing versus the right heel dressing, and had discontinued that order and the dressing, which apparently, was not documented. She said that the skin prep was supposed to be applied three times a day, on each shift, for both the left and right heels. The NP said that the area on the Resident’s buttocks was just an excoriation. She said she recalled discontinuing the treatments, and had to clarify several treatments that were not accurately documented.

2. For Resident #6, admitted to the facility in 9/2015 with [DIAGNOSES REDACTED]. inhalant medication ([MEDICATION NAME]) with pre/post Lung Sounds (LS) and (b). Vitamin B12 injection. a. Review of the 6/2017 physician’s orders [REDACTED].M. and 6:00 P.M. Review of the 6/2017 corresponding MAR indicated the inhalant medication was not administered from 6/1 – 6/19/17 for the 6:00 P.M. dose. However, the area where pre and post LS would be documented, if the treatment had been provided for the 6:00 P.M. dose indicated the following: On 6/1, 6/4, 6/8 and 6/9/17, LS were clear and vital signs were documented, the 6:00 P.M. 2. For Resident #6, admitted to the facility in 9/2015 with [DIAGNOSES REDACTED]. inhalant medication ([MEDICATION NAME]) with pre/post Lung Sounds (LS) and (b). Vitamin B12 injection. a. Review of the 6/2017 physician’s orders [REDACTED].M. and 6:00 P.M. Review of the 6/2017 corresponding MAR indicated the inhalant medication was not administered from 6/1 – 6/19/17 for the 6:00 P.M. dose. However, the area where pre and post LS would be documented, if the treatment had been provided for the 6:00 P.M. dose indicated the following: On 6/1, 6/4, 6/8 and 6/9/17, LS were clear and vital signs were documented, the 6:00 P.M. space to document the [MEDICATION NAME] had been administered was blank. During interview on 6/21/17 at 4:30 P.M., UM #2 said that the Facility has been using a lot of Pool (Agency) Nurses, and believes this has contributed to the problem with medications not being administered or documented as being administered, as well as medication transcription errors.

b. Review of the physician’s orders [REDACTED]. Review of the corresponding MAR for 6/2017 indicated the 15th of the month was crossed out, and the Vitamin B12 was not administered. Further review identified another dated box for 6/17/17 was initialed and the initials were circled, indicating the medication was not administered. There was no documentation as to why this medication was not administered, as required. During interview on 6/21/17 at 4:00 P.M., UM #2 said that when the nurse was preparing the Vitamin B12, the vial broke, and the medication was lost. She said that due to the cost, the Pharmacy requested a Prior Authorization to dispense a second vial. Once explained what happened, the Pharmacy agreed to send another vial to be administered free of charge. UM #2 said that the circumstances on why the medication hadn’t been administered should have been documented by the licensed nurse, and was not.

3. For Resident #7, the facility staff failed to correctly transcribe an order for [REDACTED]. Resident #7 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. Review of the hospital discharge paperwork, dated 1/6/17, indicated to administer Apixaban 5 milligrams (mg) through the resident’s gastro-intestinal tube ([DEVICE]) 2 times a day. Review of the hand transcribed admission orders [REDACTED]. Review of the Event Summary Report, dated 2/2/17, indicated when the resident was admitted to the facility on [DATE] the order for Apixaban was incorrectly transcribed to administer Apixaban 5 mg 1 time a day instead of Apixaban 5 mg 2 times a day as ordered. During an interview on 6/21/17 at 12:10 P.M. with the Clinical Nurse Coordinator and the Director of Nurses (DON) the Clinical Nurse Coordinator said that neither of them worked at the facility at the time of the event, but both had reviewed the report that morning and the DON said the order was transcribed incorrectly.

4. For Resident #1, the facility staff failed to maintain an accurate medical record pertaining to non-weight bearing status and the use of an ace wrap (bandage). Resident #1 was admitted to the facility in 5/27/14 with [DIAGNOSES REDACTED]. He/she sustained a non displaced [MEDICAL CONDITION] foot during a fall on 1/8/17. Review of the annual Minimum Data Set assessment, dated 3/29/17, indicated the resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. Review of the record indicated an order dated 3/7/17, to begin use of a weight bearing boot for 2 weeks, then full weight bearing on the right foot. Review of the 6/2017 signed Physician orders [REDACTED]. Further review indicated an order for [REDACTED]. Review of the 4/2017, 5/2017 and 6/2017 TARs indicated interventions for non-weight bearing to right foot and ace wrap to the lower right foot at the base of the fifth metatarsal, both with a start date of 1/31/17. The rows for both interventions were marked discontinued on all three TARs. During an interview on 6/20/17 at 8:41 A.M., Resident #1 said he/she had been ambulating with assistance from staff, and did not need to restrict how much weight was placed on the right foot. The resident also said he/she was no longer required to wear an ace wrap because it had been discontinued a few months ago. During an interview on 6/21/17 at 2:55 P.M., UM #1 said the process for properly discontinuing orders is to get a telephone order from the Physician, and send a copy to the pharmacy so it doesn’t re-occur monthly in the Physician orders [REDACTED]. She said that should have happened for the ace wrap and the non-weight bearing restriction, based on the Physician order [REDACTED].

5. For Resident #11, the facility staff failed to ensure that hospice records were readily available. Resident #11 was admitted to the facility in 3/2014 with [DIAGNOSES REDACTED]. Review of the 6/2017 signed Physician orders [REDACTED]. Review of a hospice Visit Documentation Log indicated recorded visits (date of visit, staff name, discipline) made by the hospice staff members. The log indicated that completed, signed notes, if not left at the time of the visit, were placed in the chart on the next visit by that staff member. Further review of the log indicated the last logged visit was on 5/16/17. Further review of the record indicated there were no copies of hospice notes in the record, other than the visit log and recommendations to the physician, dated 3/3/17, 4/5/17 and 6/12/17. During an interview on 6/21/17 at 2:50 P.M., UM #1 said she was unable to locate any hospice notes for Resident #11, other than the visit log and physician recommendation forms found in the chart. She said hospice notes were sometimes in a binder or sometimes in the record, depending on the company providing hospice. She went on to say she could find neither. The Administrator said she would contact the hospice company to ask where the documentation was usually kept. During an interview on 6/22/17 at 8:00 A.M., the Administrator said the hospice contact person told her they had been on vacation and had fallen behind on bringing in the documentation. The Administrator provided the surveyor with all the hospice documentation from 1/31/17 to 6/12/17. She said the documentation was sent over by the hospice company on 6/22/17, at her request. She also said that hard copies of the documentation from 1/31/17 to 3/31/17 were in the medical record overflow, and that the notes from April, May, and June were what was missing from the medical record.

Failed to make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed, for one of three sampled residents, (Resident #1), the Facility failed to provide supervision to prevent elopement. On 7/1/17, Resident #1, who was cognitively impaired and known to wander, eloped from the Facility to the far end of the driveway. Facility staff were unaware Resident #1 had eloped from the Facility until another resident reported to staff that Resident #1 was outside.

Findings include:

The policy titled Elopement, dated 5/15/14, indicated staff would respond to a sounding alarm. Resident #1 was admitted to the Facility 12/27/16, his/her [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment for Resident #1, dated 6/29/17, indicated a Brief Interview for Mental Status (BIMS) score of 7 out of 15, (score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment), and was able to self propel in his/her wheelchair. A physician’s orders [REDACTED].#1’s right leg. A physician progress notes [REDACTED].#1. A Recreation Quarterly Progress Note, dated 6/28/17, indicated Resident #1 was known to wander.

A Nurse Progress Note, dated 7/1/17, indicated it was reported to staff by another resident that Resident #1 was outside in the driveway, the wanderguard alarm was sounding, and Resident #1 was returned to the Facility. The Surveyor interviewed Nurse #1 at 5:00 P.M. on 10/3/17. Nurse #1 said that on 7/1/17 around 1:30 P.M. she was on the C unit of the Facility when another resident told her Resident #1 was outside in the driveway. Nurse #1 said she found Resident #1 self-propelling in his/her wheelchair, at the far end of the driveway, outside the front entrance of the Facility. Nurse #1 said she could not recall if she heard the wanderguard alarm sounding at the time of Resident #1’s elopement.

The Surveyor interviewed The Managed Minutes Questionnaire (MMQ) Nurse at 11:08 A.M., on 9/8/17. The MMQ Nurse said she and Nurse #1 found Resident #1 outside. The MMQ Nurse said the wanderguard alarm was sounding at the time, but said she could not recall if she noticed it sounding before or after the other resident reported Resident #1’s elopement. On 9/8/17 the Facility provided the Surveyor with a plan of correction which addressed the concerns as evidenced by: Resident #1’s care plan was updated on 7/5/17. The care plan indicated Resident #1 was at risk for elopement, and interventions included check wanderguard placement and functioning every day, and redirection and documentation of any episodes of Resident #1 attempting to leave the Facility. Resident #1 was evaluated for elopement risk on 7/6/17. The elopement evaluation indicated Resident #1 had a history of [REDACTED]. Interventions implemented included checking his/her wanderguard for placement and function daily, and encouraging Resident #1 to attend activities.

The Staff Education Record, dated 7/5/17, indicated staff were re-educated regarding the elopement protocol and response to alarms. The Facility updated the elopement books at each nurses station and at the reception desk. For residents requiring wanderguard’s, the treatment records were updated to include checking placement of wanderguard’s every shift, and function of wanderguard daily. The Facility changed the numerical code required to turn off the alarm for the wanderguard was changed as a result of Resident #1’s elopement, as a precaution to prevent elopement. The missing resident drill records, dated 7/6/17 and 7/8/17 indicated staff followed protocol during elopement drills. The safety committee meeting minutes, dated 8/22/17 indicated Resident #1’s elopement was reviewed, staff were re-educated regarding elopement prevention and protocol, and response to alarms.

 

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Page Last Updated: February 4, 2017

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