Our Lady of Peace Nursing Care Residence
December 12, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.25(e)(1)-(3):BOWEL/BLADDER INCONTINENCE, CATHETER, UTI

REGULATION: §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2018
Corrected date: February 8, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 12/12/18, the facility did not ensure that a resident, with an indwelling catheter (Foley - tube inserted into the bladder to drain urine), received the appropriate care and services to prevent urinary tract infections (UTI's) to the extent possible. Specifically, one (Resident #219) of two residents reviewed for urinary catheter had issues that involved improper handling of the urinary catheter tubing and urinary collection bag. The finding is: 1. Resident #219 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS - a resident assessment tool) dated 11/20/18 documented the resident has severe cognitive impairment and has an indwelling urinary catheter. The facility policy and procedure entitled Catheter Care, Urinary revised 12/2017 included the following: The purpose of this procedure is to prevent catheter-associated UTI's. Be sure the catheter tubing and drainage (collection) bag are kept off the floor. The Medication Record For 8/2018 included the following: - [MEDICATION NAME] (antibiotic) 500 mg (milligram) tablet every eight hours x five days for UTI signed as given on 8/14/18, 8/15/18, and 8/16/18. - [MEDICATION NAME] (antibiotic) 600 mg tablet every 12 hours x five days for UTI [MEDICAL CONDITION] ([MEDICAL CONDITION] - an antibiotic resistant bacteria) and VRE ([MEDICATION NAME] resistant [MEDICATION NAME] - an antibiotic resistant bacteria) in urine signed as given on 8/17/18, 8/18/18, 8/19/18, 8/20/18, and 8/21/18. The Medication Record For 9/2018 included [MEDICATION NAME] (antibiotic) 200 mg tablet every 12 hours for UTI signed as given on 9/21/18, 9/22/18, 9/23/18, 9/24/18, and 9/25/18. Intermittent resident observations revealed the following: - 12/6/18 at 11:07 AM resident in front of the nurse's station seated in a wheelchair (w/c) with the catheter tubing touching the floor. At 11:17 AM resident at a table in the unit dining room in a w/c with the catheter tubing touching the floor. At 11:48 AM resident in the dining room seated in a w/c at a table moving the w/c back and forth with the catheter tubing touching the floor and the left front wheel of the w/c. - 12/11/18 8:01 AM resident in the dining room seated in the w/c at a table with the catheter tubing touching the floor. During observation of care on 12/11/18 at 9:42 AM, Certified Nurse Aide (CNA) #1 removed the urinary collection bag from the privacy bag attached to the lower rear of the w/c; she placed the urinary collection bag with attached tubing onto the floor then pushed the urinary collection bag and tubing on the floor to the front of the w/c. During an interview on 12/11/18 at 9:49 AM, CNA #1 stated, I try to make sure it (the tubing) doesn't tug, I took it (collection bag and tubing) out of the privacy bag and slid it (collection bag and tubing) under the chair. It's odd the privacy bag is in the back of the w/c and not the front. During an interview on 12/11/18 at 9:53 AM, CNA #2 stated, The bag and tubing should never touch the floor. It's infection control, anything could happen. During an interview on 12/11/18 at 9:53 AM, Licensed Practical Nurse (LPN) #1 stated, If the tubing or bag touches the ground it's contaminated and we would have to get a whole new bag and tubing. During an interview on 12/11/18 at 9:55 AM, the Registered Nurse (RN) Assistant Director of Nursing stated, We don't want the tubing to drag on the floor for infection control reasons and it could pull the catheter out. During an interview on 12/12/18 at 7:35 AM, the RN Director of Nursing stated, I would not slide the bag and tubing on the floor because of infection control. 415.12(d)(1)

Plan of Correction: ApprovedJanuary 3, 2019

Corrective Action Taken for the Affected Resident:
- Resident #219 had his foley tubing and collection bag replaced by his nurse on 12/11/18. Immediate re-education of the staff involved was provided by the Asst. Director of Nursing on 12/11/18.
Identification of Other Affected Residents and Corrective Action:
? All residents with a foley catheter are determined to be at risk.
? A foley catheter placement audit will be conducted on all residents with a foley catheter by the Unit Manager no later than (MONTH) 25, 2019.
Measures or Systematic Changes to Prevent Recurrence:
? A hook has been placed on all stand-lifts to assure there is a place to hang the foley collection bag and tubing during transfers.
? All Nursing Staff will be reeducated on the Foley Catheter Care Policy by the Education Dept.
? All Residents who have a foley catheter will be evaluated for use of a leg bag while out of bed (if appropriate) by the Unit Manager.
How Corrective Action is Monitored and Person Responsible:
? The Foley Catheter Placement Audit will be randomly conducted weekly to assure all residents with a foley catheter are audited each month through (MONTH) 31, 2019. Audits will be turned into Asst Director of Nursing on a weekly basis. Ongoing audit needs will be determined by the QAPI Committee.
? The Asst. Director of Nursing or designee will compile statistical data on a monthly basis. Trend analysis data will be presented monthly to the Quality Assurance & Process Improvement Committee by the Asst. Director of Nursing, or designee, for evaluation and recommendations for improvements as needed.
The responsibility of attaining and maintaining compliance is assigned to the Asst. Director of Nursing.

FF11 483.45(c)(3)(e)(1)-(5):FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2018
Corrected date: February 8, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 12/12/18 the facility did not ensure that a resident's drug regimen was free from unnecessary [MEDICAL CONDITION] medications for one (Resident #27) of five residents reviewed for usage of [MEDICAL CONDITION] medications. Specifically, the issue involved the lack of specific targeted behaviors and lack of documented evidence of behaviors to support the continued use of antipsychotic medication. The finding is: 1. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS- a resident assessment tool) dated 4/26/18, 7/19/18, and 9/11/18 documented the resident had severe cognitive impairment, received antipsychotic medication on a routine basis, had no behavioral symptoms, and no rejection of care. The facility policy entitled [MEDICAL CONDITION] Medication dated 9/2018 documented [MEDICAL CONDITION] medications shall generally be used only for the following [DIAGNOSES REDACTED]. in addition to the following conditions: behavioral symptoms present a danger to the resident/ others and symptoms are due [MEDICAL CONDITIONS] or behavioral interventions have been attempted and included in the plan of care. [MEDICAL CONDITION] medications will not be used if the only symptoms are one or more of the following: wandering, restlessness, mild anxiety, fidgeting, nervousness, or uncooperativeness. physician's orders [REDACTED]. The Care Plan documented mood state related to depression dated 4/20/18. There were no specific targeted behaviors documented related to mood. Behavior problem dated 12/6/18. There were no behaviors currently and the resident had a history of [REDACTED]. [MEDICAL CONDITION] drug use dated 4/27/18. There were no specific targeted behaviors documented for use of [MEDICAL CONDITION] medications. Gradual Dose Reduction (GDR) dated 11/7/18 documented a GDR was clinically contraindicated at that time as it may cause a decompensation of symptoms and pose a risk to the resident's well-being and quality of life. Comments documented the resident calls out and attempts to self-transfer at times and 1:1 (one on one support) given with some effect. During an observation of morning care on 12/10/18 at 11:00 AM the resident displayed no agitation or other behavioral problems. The resident was cooperative during care. Interdisciplinary Notes dated 7/1/18 through 12/10/18 documented a nurse's note dated 9/2/18 that the resident was calling out, attempting to self-ambulate, toileted, food given and 1:1 with little effect. Also, a Social Work (SW) note dated 9/17/18 documented that the resident continues to utilize [MEDICATION NAME] (medication used to improve resident's mental status) for dementia, [MEDICATION NAME] (antidepressant) for depression, and anxiety at this time. Resident calls out and attempts to self-transfer. 1:1 given with some effect. There was no other documentation of any resident behavioral symptoms. During an interview on 12/11/18 at 9:00 AM the Registered Nurse (RN) #1 Unit Manager revealed he did not know what the resident's [DIAGNOSES REDACTED]. The resident was reviewed for a GDR on 11/7/18 but it was contraindicated for her condition because she calls out and attempts to self-transfer at times. He did not know how often she did this because he has not seen these behaviors however, he would expect staff to document if the resident had these behaviors. He added, the Physician or Nurse Practitioner decide if a GDR is contraindicated and would base it on staff observations and documentation. During an interview on 12/11/18 at 9:48 AM, the SW stated, the resident had a history of [REDACTED]. When asked if these behaviors were a threat to the resident or others the SW stated, no. During an interview on 12/11/18 at 1:42 PM, the Physician stated the [DIAGNOSES REDACTED]. He tries to reduce resident's medication when he sees them, polypharmacy is a big issue and that a GDR would not be contraindicated for this resident. During a telephone interview on 12/12/18 at 8:55 AM, the Consultant Pharmacist stated, typically nursing homes use [MEDICAL CONDITION] medications for dementia with behavioral associated disorders but these medications are indicated for [MEDICAL CONDITION] and [MEDICAL CONDITION] disorders. Regardless of diagnosis, if used in a nursing home there has to be some behaviors causing distress to him/herself or causing danger to self or others. During an interview on 12/12/18 at 9:58 AM, the Director of Nursing (DON) when asked what the resident's targeted behaviors are stated, obviously the doctor thought the medication was warranted for her, we're not the prescribers. After review of the care plan the DON stated, she's care planned for depression and mood state so they would look for signs of depression, periods of anxiety and calling out at times. The DON added, her behaviors are not a threat to herself or others but we look for therapeutic effects on people, so they (residents) can enjoy the things in life. 415.12 (l)(2)

Plan of Correction: ApprovedJanuary 3, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action Taken for the Affected Resident:
- Resident #27 had a medication review conducted by the consultant Pharmacist who made the recommendation to the attending physician for a gradual dose reduction. The attending physician reduced the [MEDICATION NAME] from 0.5 mg bid to 0.25 mg bid on [DATE], (YEAR). Behavior charting was
initiated for 14 days to monitor condition during reduction of medication and individual approaches were implemented. Future reviews are scheduled for the Behavior Modifying and Review Committee to continue gradual dose attempts. Specific targeted behaviors have been identified and the Interdisciplinary Team are monitoring for and documenting if behaviors are exhibited. These behaviors and individual approaches have been careplanned.
Identification of Other Affected Residents and Corrective Action:
? All residents receiving [MEDICAL CONDITION] medications have the potential to be affected by untimely gradual dose reductions. The facility will identify those residents through a [MEDICAL CONDITION] drug
regimen review conducted by the Behavior Modifying and Review Committee on (MONTH) 16, 2019. The Committee will review [MEDICAL CONDITION] medication dose, [DIAGNOSES REDACTED]. MD orders will be obtained and the resident will be monitored during any gradual dose reduction. Careplans will be adjusted accordingly by the Social Worker to include individual approaches.
? Future Behavior Modifying and Review Committee dates will be assigned to each resident to assure gradual dose reductions are evaluated timely, include specific targeted behaviors for the medication and that consistent documentation is present to support the evaluation.
Measures or Systematic Changes to Prevent Recurrence:
? Behavior charting with specific targeted behaviors will be implemented for all residents to reviewed at Behavior Modifying and Review Committee one week prior to the meeting to assure specific targeted behavior are present or absent and the effectiveness of individual approaches.
? All Unit Managers and Social Work staff will be re-educated on the (1) Antipsychotic
Medication and (2) Behavioral Assessment, Intervention and Monitoring Policy and Procedures by the
Administrator. All Nurses will be inserviced on the (1) Antipsychotic Medication and (2)
Behavioral Assessment, Intervention and Monitoring Policy by the Education Dept.
? A [MEDICAL CONDITION] drug regimen review audit to include specific targeted behaviors and individualized approaches will be added to the Care Plan Review Audit with each resident's scheduled Annual/Quarterly/Significant Change assessments with recommendations provided to the attending physician.
How Corrective Action is Monitored and Person Responsible:
? The [MEDICAL CONDITION] drug regimen review audits/Care Plan Review Audits will be completed on all residents at least quarterly and turned into Director of Social Work on a weekly basis through our next Annual Recertification Survey.
? The Director of Social Work or designee will compile statistical data on a monthly basis. Trend analysis data will be presented monthly to the Quality Assurance & Process Improvement Committee by the Director of Social Work, or designee, for evaluation and recommendations for improvements as needed.
The responsibility of attaining and maintaining compliance is assigned to the Director of Social Work.

FF11 483.25(b)(1)(i)(ii):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER

REGULATION: §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 12, 2018
Corrected date: February 8, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 12/12/18, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing for one (Resident #105) of three residents reviewed for pressure ulcers. Specifically, the pressure ulcer treatment was not completed as planned. Additionally, the physician's orders [REDACTED]. The finding is: 1. Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS- a resident assessment tool) dated 12/3/18 documented the resident was cognitively intake, understood, understands and had an unstageable pressure ulcer upon admission with slough and or/ eschar (dead tissue). The facility policy and procedure entitled Wound Care/ Dressing Change dated 12/2017 documented the purpose of the procedure was to provide guidelines for dressing changes of wounds to promote healing. Additionally, review and verify physician's orders [REDACTED]. Care Plan dated 11/26/18 documented the resident had an unstageable pressure injury of the right gluteal fold/ ischium (lower part of hip bone) with interventions to complete treatments as indicated, and to see the physician order [REDACTED]. Skin assessment sheet dated 12/10/18 documented an unstageable full thickness pressure injury to the right gluteal fold that measured 4 centimeters (cm) in length x 1.5 cm in width x 1 cm in depth. Slough tissue present with bloody sanguineous (mixture of serum and blood) drainage. Treatment plan is Santyl (sterile ointment to remove dead skin tissue) and a dry clean dressing. physician's orders [REDACTED]. Opti foam to sacral slit (indentation/ intact skin) topically two times a week for [MEDICATION NAME]. During an observation of pressure ulcer care on 12/11/18 at 8:47 AM, Registered Nurse (RN) #2 was assisted by Licensed Practical Nurse (LPN) #2. The resident was rolled onto her left side toward LPN #2 who reached over the resident and removed two dressings. The sacral foam dressing was loose and had no drainage. The right gluteal foam dressing was removed and had a large amount of serous (pale yellow, transparent body fluid) drainage. The right gluteal pressure ulcer was open, the sides of the ulcer were red and moist, the base was unable to be visualized. RN #2 cleansed the sacral slit area with wound cleanser, applied Skin Prep to the peri wound, applied Santyl to the sacral slit area and covered the area with a foam adhesive dressing. RN #2 then cleansed the right gluteal unstageable ulcer with wound cleanser, and began to apply an adhesive foam dressing (without Santyl) over the pressure ulcer. At this time the surveyor asked the nurse to stop and verify the treatments. LPN #2 left the room to obtain additional supplies and the treatments were completed as planned by RN #2. During an interview on 12/11/18 at 9:07 AM, LPN #2 stated the treatment was done incorrectly. Santyl should have been applied to the right gluteal ulcer not the sacral area. During an interview on 12/11/18 at 9:12 AM, RN #2 stated she had never completed this resident's treatment before. Normally, she would check the computer to review the order prior to completing the treatment, but today she did not. RN #2 further stated she should have applied Santyl to the right gluteal ulcer, not the sacral slit. During an interview on 12/11/18 at 9:39 AM, RN #3 (covering the unit) stated RN #2 should have checked the order prior to doing the treatment. During an interview on 12/11/18 at 3:43 PM, the Director of Nursing stated the nurse should have checked the order prior to doing the treatment. 415.12 (c)(2)

Plan of Correction: ApprovedJanuary 3, 2019

Corrective Action Taken for the Affected Resident:
- Resident #105 had the Treatment Order clarified with the MD and the Treatment was applied according to the MD order. Immediate re-education of the RN #2 and LPN #2 was provided by the Director of Quality on 12/11/18.
Identification of Other Affected Residents and Corrective Action:
? All residents with Treatment Orders are identified as at risk.
? A Treatment Audit will be conducted on all residents with a Treatment Order by the Unit Manager. The audit will be completed by (MONTH) 31, 2019 to assure the orders are specific and the correct treatment is on per the MD order. Any necessary order clarifications will be obtained from the MD.
Measures or Systematic Changes to Prevent Recurrence:
? All Nurses will be reeducated on the Wound Care/Dressing Change Policy by the Education Dept. to include checking the Treatment Order prior to completion of any dressing change.
? All Nurses will be reeducated wound care treatment product types and their specific application by the Education Dept.

How Corrective Action is Monitored and Person Responsible:
? The Treatment Order Audit will be randomly conducted on 12 treatments weekly by the Unit Managers through (MONTH) 31, 2019. Any requiring remediation will be completed immediately. Completed audits will be turned into Director of Nursing on a weekly basis. Ongoing audits will be performed based on recommendations of the QAPI Committee.
? The Director of Nursing or designee will compile statistical data on a monthly basis. Trend analysis data will be presented monthly to the Quality Assurance & Process Improvement Committee by the Director of Nursing, or designee, for evaluation and recommendations for improvements as needed.
The responsibility of attaining and maintaining compliance is assigned to the Director of Nursing.