Horizon Care Center
May 17, 2018 Certification Survey

Standard Health Citations

FF11 483.21(b)(2)(i)-(iii):CARE PLAN TIMING AND REVISION

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: July 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during the recertification survey, the facility did not ensure that the comprehensive care plan (CCP) was reviewed and revised by an interdisciplinary team to meet the needs of each resident. This was evident for one (Resident #63) of five residents reviewed for Accidents. Specifically, Resident #63 fell from his wheel chair on 2/7/18, and was sent to the hospital for evaluation. The Comprehensive Care Plan (CCP) for falls lacked documented evidence that the CCP was reviewed and revised to reflect the fall, and no new goals and interventions were implemented to prevent further incidents of falls. The finding is: Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 15, which indicated intact cognition. The resident required extensive assist of one staff member for transfers, does not ambulate, and had no behavior symptoms. The resident had no falls prior to this assessment. A Nursing progress note dated 2/7/18 documented the resident was found lying on the floor in front of his room door in prone position. The Supervisor was notified. The resident was asked what happened and stated that he could not remember but complained of nausea and vomiting. A Resident Accident/Incident (A/I) Report dated 2/7/18 documented the resident was found lying on the floor in prone position and that the fall was unwitnessed. The resident statement documented the resident verbalized that he could not remember what had happened. The Physician section of the A/I documented the resident was sent to the emergency room (ER) for [MEDICAL CONDITION], Nausea and Fall. A Falls Risk assessment dated [DATE] documented a score of (6) which indicated that the resident was a high risk for falls. A CCP dated 6/7/16 for falls documented the resident has potential for falls due to right upper extremity weakness, the use of assistive device/rolling walker, the use of cardiac medication related to [MEDICAL CONDITION], an Antidepressant and early mild cataract. Interventions include to observe the resident for unpredictable, involuntary movements secondary to poor cognition and to provide and encourage the use of assistive device. A review of the Monitoring and evaluation section of the CCP revealed on 2/26/18 the care plan was updated and documented the resident had no recent falls reported at this time and to continue the plan of care. During an interview with the Director of Nursing Services (DNS) on 5/10/18 at 3:33 PM, she stated the Nursing Care Coordinator (NCC) was responsible for updating the CCP. The DNS further stated that the NCC resigned on 5/4/18. During an interview conducted with the Assistant Director of Nursing Services (ADNS) on 5/14/18 at 11:15 AM, she stated that it the responsibility of the NCC to initiate and to update the CCP to reflect any episodes of a fall. A review of the CCP was conducted with the ADNS which revealed the CCP was not reviewed or revised to reflect the fall, and with new goals and interventions to prevent further episodes of falls. The ADNS stated the CCP for falls should have been updated and a CCP initiated for [MEDICAL CONDITION]. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedJune 11, 2018

F 657- 483.21(B)(2)(i)-(iii) CARE PLAN TIMING AND REVISION -
Resident # 63

I. IMMEDIATE CORRECTIVE ACTIONS
1. An ad hoc Comprehensive Care Plan (CCP) meeting was held to review the resident?s fall history and update goals and interventions as clinically necessary to prevent or minimize further incidents of falls.
2. The Certified Nursing Assistant/Nurse Instructions was revised to include all new interventions developed from the ad hoc CCP meeting.
3. The Director of Nursing identified the Nurse responsible for completing the Comprehensive Care Plan for this resident and respectively reports that she is no longer employed by this facility.

II. IDENTIFICATION OF OTHER RESIDENTS
1. The Director of Nursing (DNS) directed the Risk Manager Assistant Director of Nursing to populate a list of all residents who experienced an Accident/Incident in the last ninety days.
2. The list was utilized by the DNS/designee and the Clinical Team to identify any resident(s) who did not have an updated Comprehensive Care Plan after experiencing and Accident/Incident.
a. Care plans identified with quality issues will have an immediate Clinical Team meeting scheduled for care plan goal(s)/interventions update/revision and Nurse Instructions for the Certified Nursing Assistant revised to include any new interventions.

III. SYSTEMIC CHANGES
1. The Director of Nursing and Administrator reviewed and revised the facility Policy and Procedure on Care Planning.
2. All Registered Professional Nurses will be re-educated on the policy by the Nurse Educator.
3. Lesson Plan will concentrate on:
a. Review of F 657 and facility policies
b. Timely updating of Care Plans after an Accident/Incident.
c. Nursing?s responsibility and clinical accountability for ensuring that the Comprehensive Care Plans are accurate and complete.
d.Quarterly and Annual Care Plan meetings will review resident(s) Comprehensive Care Plan as it pertains to Accident/Incidents.
4. A copy of the Lesson Plan and attendance sheets will be filed for reference and validation.

IV. QUALITY ASSURANCE MONITORING
1. The Director of Nursing and Administrator developed an audit tool to monitor/track and review all Accident and Incidents for timely updates/revision of Comprehensive Care Plans.
2. The MDS Coordinator/designee was delegated the clinical responsibility to monitor and track each MDS for accurate documentation of resident?s falls prior to federal submission.
3. Audits will be performed by the Risk Manager Assistant Director of Nursing/designee weekly for six months, monthly for six months and then quarterly thereafter to ensure and maintain 100% compliance.
4. Audits with negative findings will have immediate corrective actions included but not limited to resident assessment, evaluation and care planning, with subsequent re-education and progressive disciplinary action of clinical staff member(s) involved.
a. Accident and Incident documentation will also be reviewed at each Morning Quality Assurance Meeting and at quarterly Safety Risk Management Meetings.
5. Audit findings will be presented to the Quality Assurance and Performance Improvement (QAPI) Committee at least quarterly for needed revisions to action plan, improvement of our delivery services and resident outcomes.
6. The Lesson Plan for this Plan of Correction will be included in the facility?s Orientation Program for all licensed nurses.
V. DATE OF CORRECTION: 7/13/2018

Responsible Parties?Risk Manager Assistant Director of Nursing, Director of Nursing,& MDS Coordinator.

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: July 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during the recertification survey, the facility did not ensure that a person centered care plan with measurable objectives and timeframes was implemented. This was identified for one (Resident #63) of one resident reviewed for [MEDICAL CONDITION]. Specifically, Resident #63 was observed with bilateral lower extremity [MEDICAL CONDITION], was receiving Diuretic therapy and there was no documented evidence in the medical record that a Comprehensive Care Plan (CCP) was developed to reflect the lower extremity [MEDICAL CONDITION] and the use of a Diuretic. The finding is: Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 15, which indicated intact cognition. The resident required extensive assist of one staff member for transfer and does not ambulate. During an initial observation conducted on 5/10/18 at 11:35 AM Resident #63 was observed with bilateral lower extremity swelling. A physician's orders [REDACTED]. Apply in AM and remove at HS for [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the resident's electronic Comprehensive Care Plan (CCP) revealed no documented evidence that a CCP was developed for [MEDICAL CONDITION] or the use of [MEDICATION NAME]. During an interview conducted with the Director of Nursing (DNS) on 5/10/18 at 3:33 PM, she stated that the Nursing Care Coordinators (NCC) were responsible for initiating and updating the CCP. The DNS further stated the NCC resigned on 5/4/18. During an interview conducted with the Assistant Director of Nursing Services (ADNS) on 5/14/18 at 11:15 AM, she stated that it the responsibility of the NCC to initiate and to update the CCP to reflect the resident current status. 415.11(c)(1)

Plan of Correction: ApprovedJune 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 656 ? 483.21 (b)(1) DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN.

Resident # 63
I.IMMEDIATE CORRECTIVE ACTIONS
1. The resident was evaluated and assessed by a Registered Professional Nurse and the Primary Care Physician/Nurse Practitioner.
2. All clinical assessments are documented in the resident?s clinical record SIGMA-Matrix EMR).
3. A Comprehensive Care Plan (CCP) was developed and implemented for the [DIAGNOSES REDACTED].

4. The Certified Nursing Assistant Accountability Record/Nurse Instructions was revised to include all new interventions developed from the implemented Care Plan
5. The Director of Nursing identified the Registered Professional Nurse responsible for completing the Care Plan on 4/11/2018 and 5/13/18.
6. The facility respectfully reports that the responsible Registered Professional Nurse is no longer employed with the facility.

II. IDENTIFICATION OF OTHER RESIDENTS
1. The Director of Nursing (DNS) directed the Clinical Assistant Director of Nursing to populate a list from the Electronic Medical Records (SIGMA/Matrix) of all residents diagnosed with [REDACTED].?s orders for [MEDICATION NAME] as a treatment modality.
2. The list was utilized by the Director of Nursing/designee and the Clinical Team to review the Medical Records of the residents for current Comprehensive Care Plans documenting evidence of goals and interventions for [MEDICAL CONDITION] and the use of [MEDICATION NAME].
a. Medical records identified without Comprehensive Care Plans for [MEDICAL CONDITION] and the use of [MEDICATION NAME] were immediately corrected and/or revised.
III. SYSTEMIC CHANGES
1. The Director of Nursing and Administrator reviewed and revised the facility Policy and Procedure on Care Plan Development and Implementation.
2. All nursing staff inclusive of the MDS Department, will be re-educated on the revised policy by the Nurse Educator/Assistant Director of Nursing.
a. Lesson Plan will concentrate on:
i. Review of F 656 and facility policy
ii. Timely development and implementation of clinical care plans.
iii. Nursing?s responsibility and accountability for ensuring that clinical
interventions for medical [DIAGNOSES REDACTED].
timely manner.
iv. Comprehensive Care Plan development and implementation is the responsibility
of the Registered Professional Nurse assessing any resident upon any new
order for [MEDICATION NAME] from the provider.
v. The importance of Comprehensive Care Plan meetings which are consistent with
resident clinical [DIAGNOSES REDACTED].
3. A copy of the Lesson Plan and attendance sheets will be filed for reference and validation.
IV. QUALITY ASSURANCE MONITORING
1. The Director of Nursing developed an audit tool to randomly monitor and review Comprehensive Care Plans for residents diagnosed with [REDACTED].?s care.
2. The Assistant Director of Nursing/designee was delegated the clinical responsibility to monitor the Electronic Medical Records (EMR) dashboard daily to review if Care Plans were developed and implemented for all residents on the 24hr report who are newly diagnosed with [REDACTED].
a. Deficiencies will be corrected immediately
b. Clinical staff members involved will be re-educated and/or disciplined.
3. The MDS Coordinator will review Comprehensive Care Plan development and implementation at each Quarterly and Annual Assessment for corresponding Comprehensive Care Plans.
4. Audits will be performed by the Clinical Assistant Director of Nursing/designee weekly for six months, monthly for six months and quarterly thereafter to ensure and maintain 100% compliance.
5. Audits with negative findings will have immediate corrective actions included but not limited to resident assessment, evaluation and comprehensive care planning, in conjunction with re-education and progressive disciplinary action of clinical staff member (s) involved.
6. Audit findings will be presented to the Quality Assurance and Performance Improvement (QAPI) Committee at least quarterly for need revisions to action plan, improvement of our delivery services and resident outcomes.
7. The Lesson Plan for this Plan of Correction will be included in the facility?s Orientation Program for all Licensed Nurses.

V. DATE OF CORRECTION: 7/13/2018

Responsible Parties? Clinical Assistant Director of Nursing, Director of Nursing, & MDS Coordinator.

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: May 17, 2018
Corrected date: July 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that residents who use [MEDICAL CONDITION] drugs have clinical indication for the use of the medication and receive gradual dose reductions unless clinically contraindicated. This was evident for one (Resident #244) of seven residents reviewed for unnecessary medication. Specifically, on 4/16/18 the resident was started [MEDICATION NAME] (an antipsychotic medication) 0.25 milligram (mg) twice daily without a proper indication for its use, and continued the medication after a Psychiatrist recommendation on 4/27/18 to discontinue the [MEDICATION NAME]. The finding is: Resident #244 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 10 which indicate moderate cognitive impairment. The resident had trouble concentrating on things, and had behavioral symptoms not directed toward others occurring 1 to 3 days in the past 7 days. The resident required supervision to extensive assist of one staff for all areas of Activities of Daily Living (ADL). The resident received Antipsychotic medication 5 of 7 days and received Antidepressant medication 2 of 7 days prior to this assessment. A Comprehensive Care Plan dated 2/1/17 documented the resident uses [MEDICAL CONDITION] medication. The goal is that the resident will be maintained on lowest possible dose of [MEDICAL CONDITION] medication. The interventions included to review medications to determine that all ordered medication is needed to control the resident's symptoms and monthly reviews of medications by pharmacy consultants. A Psychiatry Consult dated 4/13/18 at 2:56 PM documented the resident has impulse control by touching all staff and patients. The resident had no history of physical or sexual abuse. His mood was neutral, affects was appropriate, had no hallucinations but had some delusions. The resident was oriented to person only and impulse control was fair. The resident was diagnosed with [REDACTED]. The recommendation and treatment plan was to discontinue [MEDICATION NAME] and give [MEDICATION NAME] 0.25 mg po twice daily. The consult also documented no change in medications. A Psychology Consult dated 4/14/18 at 2:02 PM documented the resident was seen for individual session. The resident was alert and oriented times two. The resident indicated periods of Anxiety and depressed mood. He expressed frustrated mood and stated I don't think they want to help me. Cognitive behavioral therapy and supportive therapy treatment was administered. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Nurse's note dated 4/16/18 at 2:51 PM documented the resident was alert and responsive. Discontinue [MEDICATION NAME] 20 mg. Day 1 of 21. No behavior problems noted. Review of the Progress notes dated 4/1/18 to 4/29/18 lacked documented evidence of behaviors that warranted the start of [MEDICATION NAME], and there was no documented evidence of non-pharmacological interventions that was attempted prior to the start of [MEDICATION NAME]. A Psychiatry Consult dated 4/27/18 at 3:44 PM documented the resident is doing well, no side effects, and no hallucination. The resident had no history of physical or sexual abuse. His mood was neutral, affects was appropriate, had no hallucinations but had some delusions. The resident was oriented to person only and impulse control was fair. The resident was diagnosed with [REDACTED]. Gradual Dose Reduction and Medication Management is to discontinue [MEDICATION NAME]. The consult further documented dose reduction can be attempted, GRD will not impair patient's function, and no change in medications. A Pharmacy medication review dated 4/30/18 documented that a Psychiatric Consult dated 4/13/18 documented a [DIAGNOSES REDACTED]. The Black Box Warning: [MEDICATION NAME] is not approved for Dementia Related [MEDICAL CONDITION] and there is an increase mortality risk in elderly Dementia patients on conventional or atypical Antipsychotics. Most deaths are due to cardiovascular or infectious events. Please evaluate the risk and benefit and Gradual Dose Reduction (GDR). During an interview conducted on 5/16/18 at 2:30 PM with the day shift Certified Nursing Assistant (CNA), she stated that she cared for the resident for approximately one year. The CNA stated sometimes the resident will say no to care but has never attempted to hit or verbally abuse her. The CNA stated that at times the resident will speak in a loud voice saying, I don't want to get up or I don't want to get changed. The CNA stated she usually re-reapproachs the resident and most time re-approaching works. During an interview conducted on 5/16/18 at 3:15 PM with the 3:00 PM to 11:00 PM CNA, she stated that she cared for the resident for the past ten years which includes the period when the resident resided on the 4th floor. The CNA stated that the resident has never exhibited aggressive behavior towards her or other residents. The CNA stated that the resident is showered on her shift and has not attempted to touch her inappropriately. During an interview conducted on 5/16/18 at 2:32 PM with the 7:00 AM to 3:00 PM 5th floor Licensed Practical Nurse (LPN/#7) Charge, she stated that she cared for the resident for the past 2 years. The LPN stated that the resident is very friendly and loves to greet others (staff and peers). The LPN stated that the resident does not exhibit any behaviors that puts himself and others in danger. The LPN stated that the resident likes to sleep and stays in bed mostly. She stated that with encouragement the resident comes out for meals and will attend activities in the dining room. The LPN stated after consultation the Psychiatrist will discuss the care of the resident with her if there are new recommendations, however, when the resident was started on the [MEDICATION NAME], it was not discussed with her. The LPN further stated that she was not aware of the recommendation from the Psychiatrist to discontinue the [MEDICATION NAME]. During an interview conducted on 5/17/18 at 12:37 PM with the per diem LPN (#8) that worked on 4/27/18 on the 3:00 PM to 11:00 PM, she stated that the Registered Nurses (RN) are usually responsible for reviewing the consults and to follow up with the Physicians if there are recommendations. However, the LPN in charge also reviews consults and follow ups with the RN and the Physician if there are recommendations. The LPN stated that she did not recall the Psychiatrist being there or him discussing the care of the resident with her. She stated that it was the start of the shift and she was busy with narcotic count and getting items ready for her shift. The LPN further stated that the protocol is that she reviews the consult for any recommendations and reports to the RN Supervisor and the Physician. The LPN further stated that the RN Supervisor should have followed up on the recommendations. The LPN could not recall if the RN was made aware of the Psychiatrist consultation of the resident. During an interview conducted on 5/17/18 at 1:13 PM with the 3:00 PM to 11:00 PM RN Supervisor, she stated that if she is notified a consult was done and needed to be reviewed, she would follow up. The RN stated when there is a consult with recommendations to be reviewed, the unit nurse is responsibility for informing the RN. The RN stated that she was only made aware on 5/17/18. She stated that if she was made aware she would have notified the Physician regarding the Psychiatrist's recommendation and obtained a telephone order to discontinue the [MEDICATION NAME] after the resident's family was made aware. During an interview conducted on 5/17/18 at 2:02 PM with the Medical Director (MD), he stated that he discusses the care of the resident with the Psychiatrist, however, as the Psychiatrist are experts in their field, they follow the Psychiatrist's recommendations. The MD further stated after the Psychiatrist sees the resident, if there are recommendations that need to be addressed, the Psychiatrist should contact the Supervisor or the unit charge nurse and inform them of the new recommendations. During an interview conducted on 5/17/18 at 11:40 AM with the Psychiatrist, he stated that when a resident is started on an Antipsychotic medication, usually there are clear indications documented in the recommendation section of the consult. The Psychiatrist stated that he did not order [MEDICATION NAME] for the resident, but when he saw the resident on 4/27/18 he recommended to discontinue the [MEDICATION NAME]. Additionally, the Psychiatrist stated that there should have been clear documentation in the nurse's note of the exhibited behaviors and the non-pharmacological interventions that were attempted. In a subsequent interview conducted with the Psychiatrist on 5/17/18 at 4:06 PM, he stated the facility protocol is after seeing a resident the unit nurse is informed if there are recommendations to be addressed. He stated if he was unable to locate the unit nurse he discusses the changes in the resident's care with the Nurse Manager or Supervisor. When asked about the recommendation to discontinue the [MEDICATION NAME], he stated that his practice is to inform staff of any change in the resident plan of care. During an interview conducted on 5/17/18 at 3:50 PM with the Director of Nursing Services (DNS), she stated that non-pharmacological intervention should be attempted prior to the start of any [MEDICAL CONDITION] medication and clearly documented in the progress notes. The DNS stated that the unit nurse reviews the consult and reports to the RN if there are recommendations to be address. 415.12(l)(2)(i)

Plan of Correction: ApprovedJune 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 758 483.25(c)(3)(e)(1)-(5) FREE FROM UNNECESSARY [MEDICAL CONDITION] MEDS/PRN USE

Resident #244

I. IMMEDIATE CORRECTIVE ACTIONS:
1. The attending physician was contacted and a follow-up Psychiatry consult was ordered.
2. The resident was assessed and evaluated by the Psychiatrist.
3. All resident assessments and outcomes are documented in the resident?s clinical record.
4. The Medical Director identified the consulting psychiatrist who ordered the [MEDICATION NAME] on 4/13/18.
5. The Medical Director/Administrator provided educational counselling to the consulting psychiatrist.
a. Lesson plan concentrated on
i. F 758
ii. Collaborating with the nursing staff to ascertain non-pharmacological
interventions prior to prescribing [MEDICAL CONDITION] medications.
iii. Accuracy of progress note/consulting notes
6. The Director of Nursing identified the license nurse who reviewed the psychiatrist evaluation and transcribed the order for [MEDICATION NAME].
7. The facility respectfully acknowledges that the responsible nurse is no longer employed at the facility.
II. IDENTIFICATION OF OTHER RESIDENTS
1. The Medical Director and the Director of Nursing compiled a list of all residents with current orders for [MEDICAL CONDITION] medications.
2. This list was used by the Medical Director, Pharmacy Consultant and Director of Nursing to perform comprehensive chart reviews to ensure that each resident?s drug regimen met the requirements for F 758.
3. Quality issues from this review will warrant immediate corrective actions by the Medical Director and the Director of Nursing including
a. Resident re-evaluation by the primary care physician and or psychiatry
b. Educational counselling for any physician and nurses involved
c. Disciplinary actions as warranted
4. The Medical Director and Director of Nursing will maintain the list of medical records identified with quality issues and corrective actions for validation and reference.

III. SYSTEMIC CHANGES
1. The Medical Director, Director of Nursing and Administrator reviewed the facility policy and procedure on Quality of Care: Use of [MEDICAL CONDITION] Medications. Modifications were made to re-enforce compliance with current regulatory guidelines.
2. The Nurse Educator will provide in-service to all Clinical staff.
3. The Lesson plan will concentrate on
a. Overview of F758 and revised facility policy
b. Current standards of professional practice as it pertains to [MEDICAL CONDITION] medication administration.
c. Documentation requirements by the physician and clinical staff for residents to be evaluated by the Psychiatrist.
d. The licensed nurses? responsibility to review each consult and collaborate with primary care physician prior to transcribing an order for [REDACTED].
e. Guidelines for dose reduction and documentation of symptoms
f. Use of non-pharmacological interventions prior to [MEDICAL CONDITION] medication initiation.
4. A copy of the Lesson Plans and attendance sheets will be filed for reference and validation

IV. QUALITY ASSURANCE MONITORING

1. The Director of Nursing in collaboration with the Medical Director developed an audit tool to track the appropriate documentation and use of [MEDICAL CONDITION] meds per policy and regulatory guidelines.
2. Audits will be performed by the Medical Director/designee weekly for six months, monthly for six months and quarterly thereafter to ensure and maintain 100% compliance.
3. Audits with negative findings will be referred to the Administrator & Pharmacy Consultant and followed up by the Medical Director for corrective action (s).
4. All findings will be presented to the Quality Assurance and Performance Improvement (QAPI) Committee at least quarterly for needed revisions to action plan, improvement of our delivery services and resident outcomes.
5. The Lesson Plan for this Plan of Correction will be included in the facility?s Orientation Program for all new clinical and will be discussed periodically at Medical Board Meetings.

V. DATE OF CORRECTION: 7/13/2018
Responsible Party ? Medical Director, Director of Nursing, Administrator

FF11 483.30(b)(1)-(3):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDER

REGULATION: §483.30(b) Physician Visits The physician must- §483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; §483.30(b)(2) Write, sign, and date progress notes at each visit; and §483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: July 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey the facility did not ensure that the physician accurately reviewed each resident's total program of care, including medications and treatments, for 1 (Resident #167) of 7 residents reviewed for Unnecessary Medications. Specifically, a Neurologist recommended the medication [MEDICATION NAME] (a medication for movement problems due to [MEDICAL CONDITION]) be started at 0.5 milligrams (mg) three times per day (TID) for Resident #167, with a further recommendation to increase the dosage to 1 mg TID after one week if there were no side effects. Instead, a lower dosage (0.25 mg) was inadvertently ordered and the recommended increase in dosage was not done. The finding is: Res #167 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/20/2018 Significant Change Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident had moderate cognitive impairment. A Neurology consultation request was ordered by the Nurse Practitioner (NP), dated 4/20/2018, due to increased tremors and increased leaning to the left side with a [DIAGNOSES REDACTED]. A Neurology consult dated 4/24/2018 documented the resident had a history of [REDACTED]. The Neurologist recommended continuing the treatment with [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]) and to add [MEDICATION NAME] at 0.5 mg TID, and if no side effects to increase [MEDICATION NAME] to 1 mg TID in one week. This consult was signed by the Attending Physician on 4/25/2018. A nursing progress note dated 4/24/2018 documented that the resident was seen by the Neurologist due to increasing hand tremors, with recommendations to continue [MEDICATION NAME] and add [MEDICATION NAME] 0.5 mg TID. The Primary Medical Doctor was informed and the order was entered. A physician's orders [REDACTED]. A Medical progress note dated 4/29/2018, written by the Attending Physician, documented the resident was seen by a Neurologist who addressed the increasing hand tremors with the recommendation to continue [MEDICATION NAME] and add [MEDICATION NAME] 0.5 mg TID. A Comprehensive Care Plan (CCP) titled Alteration in Neurological Status/[MEDICAL CONDITION], effective 5/10/2018, had an entry dated 5/10/2018 documenting the resident was seen by a Neurologist on 4/24/2018 with recommendations to start [MEDICATION NAME] for [MEDICAL CONDITION] and that medication was to be administered as ordered. On 5/17/2018 at 12:19 PM a Unit Licensed Practical Nurse (LPN) medication nurse was interviewed. She removed the resident's [MEDICATION NAME] blister pack from the cart. The label on the blister pack read: [MEDICATION NAME] ([MEDICATION NAME]) tablet 0.5 mg, take ½ tablet (0.25 mg) by oral route three times per day. The LPN stated this is what the resident was currently receiving. The tablets in the blister pack were already cut in half. On 5/17/2018 at 12:58 PM the Unit Registered Nurse (RN) Supervisor who entered the [MEDICATION NAME] order on 4/24/2018 was interviewed. She reviewed the record and was unable to provide an explanation as to why the [MEDICATION NAME] dosage was ordered at 0.25 mg TID rather than the recommended 0.5 mg TID. On 5/17/2018 at 1:33 PM the NP was interviewed. She stated that when she signed the order on 4/24/2018 she saw 0.5 tablet and thought that was 0.5 mg. On 5/17/2018 at 1:48 PM the Attending Physician was interviewed. He reviewed the record and stated he did not see any documentation as to why the dose was half of what was recommended by the Neurologist or why it was not increased as per the recommendation. On 5/17/2018 at 2:55 PM the Director of Nursing Services (DNS) was interviewed. She stated the RN that entered the order on 4/24/2018 also did the second step, which was completing the order. The order was then reviewed by one other nurse, so only two nurses saw the order. 415.15(b)(2)(iii)

Plan of Correction: ApprovedJune 18, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 711 483.30(b)(1)-(3) PHYSICIAN VISITS- REVIEW CARE/NOTES/ORDERS
Resident #167
I. IMMEDIATE CORRECTIVE ACTIONS:
1. The resident was assessed and evaluated by the Primary Care Physician/Nurse Practitioner to identify any negative clinical effects that may have developed due to the administration of a lower dose of [MEDICATION NAME].

2. No negative clinical effects were identified.

3. All resident assessments and outcomes are documented in the resident?s clinical record.
4. The Director of Nursing identified the nurse who transcribed the order for [MEDICATION NAME] from the Neurologist and the nurse who reviewed the order.
5. Educational counselling was provided to the nurse regarding Physician?s orders, clarification and transcription. Disciplinary counselling was also performed.
6. Educational counseling was provided on accurately reviewing orders prior to sign off to the Nurse Practitioner who signed the order on 4/24/2018. Counseling was provided by the Medical Director.
6. Copies of disciplinary and educational counselling are filed for reference and validation

II. IDENTIFICATION OF OTHER RESIDENTS
1. The Director of Nursing asked the Consults Coordinator to prepare a list of all residents who were seen by a consulting physician in the last 30 days.

2. This list was used by the Medical Director and the Director of Nursing to perform comprehensive chart reviews to ensure that all medication (and other) recommendations were transcribed correctly to the eMAR and followed.
3. Quality issues from this review will warrant immediate corrective actions including resident evaluation and assessment; educational counselling and disciplinary actions for licensed nursing staff involved.
4. All educational counselling and disciplinary actions will be filed for validation and reference

III. SYSTEMIC CHANGES
1. The Director of Nursing and Medical Director reviewed the facility policy and procedure on Physicians Orders and Transcribing Physicians Orders. In addition, the policy and procedure on Consults was also reviewed and revised.
2. The Nurse Educator will provide in-service to the all Clinical staff and the Consults Coordinator regarding facility?s policies and procedures as it pertains to their individual job functions and responsibilities.
3. The Lesson plan will concentrate on
a. Overview of F 711 and facility policies and procedures
b. Accurate transcription of medication orders
4. A copy of the Lesson Plans and attendance sheets will be filed for reference and validation
IV. QUALITY ASSURANCE MONITORING
1. The Director of Nursing in collaboration with the Medical Director developed an audit tool to track consulting physician?s recommendations for resident care.
2. Audits will be performed by the Director of Nursing/designee on random residents who are seen by a consulting physician weekly for six months, monthly for six months, and then quarterly thereafter to ensure and maintain 100% compliance.
3. Audits with negative findings will be corrected immediately with follow up assessment and evaluation of the resident and re-education and/or disciplinary actions for the license nurses involved.
4. All findings will be presented to the Quality Assurance and Performance Improvement (QAPI) Committee at least quarterly for needed revisions to action plan, improvement of our delivery services and resident outcomes.
5.The Lesson Plan for this Plan of Correction will be included in the facility?s Orientation Program for all new clinical staff.
V. DATE OF CORRECTION: 7/13/2018
Responsible Party ? Director of Nursing, Medical Director, Clinical Assistant

FF11 483.21(b)(3)(ii):QUALIFIED PERSONS

REGULATION: §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: July 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey the facility did not ensure that services were provided in accordance with each resident's plan of care for 1 of 7 residents reviewed for Unnecessary Medications. Specifically, Resident #106 had physician's orders [REDACTED]. In (MONTH) (YEAR) and (MONTH) (YEAR) the resident refused to have his Orthostatic blood pressure (BP) checked and there was no documented follow up. Additionally, in (MONTH) (YEAR) the Orthostatic BP exceeded the ordered parameters to call the physician; however, the physician was not contacted. The finding is: Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/7/2018 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was cognitively intact. A Comprehensive Care Plan titled Drug Related Complications, effective 11/29/2017 and last updated 3/13/2018, had an intervention for Orthostatic BP (the difference in blood pressure measured when the resident is lying and sitting or standing) monitoring (lying and sitting) as ordered. A physician's orders [REDACTED]. A drop of 20 millimeters of Mercury (mmHg) or more in the lying and upright position required the Physician be informed. An additional physician's orders [REDACTED]. Notify the Physician of change of systolic (upper number) BP greater than 20 mmHg or change of diastolic (bottom number) BP greater than 10 mmHg. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. There was no Orthostatic BP recorded for the corresponding [MEDICATION NAME] 200 mg order. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the medical record revealed the Physician was not notified of the refusals in (MONTH) (YEAR) and (MONTH) (YEAR) and was not notified on 4/28/2018 for the change of Orthostatic BP. The resident was interviewed on 5/16/2018 at 10:58 AM in her room. The resident stated that she feels dizzy sometimes when she changes positions. The Licensed Practical Nurse (LPN) that documented the refusals in (MONTH) (YEAR) and (MONTH) (YEAR) was interviewed on 5/17/2018 at 6:00 AM. She stated she did not remember the circumstances of the resident refusals. The LPN that documented the Orthostatic BP on 4/28/2018 was interviewed on 5/17/2018 at 8:36 AM. She said she did not recall the circumstances, but with blood pressures like that she should call the doctor. The Assistant Director of Nursing Services (ADNS) was interviewed on 5/17/2018 at 9:12 AM. She stated if the resident refuses the Orthostatic BP, it can be offered later in the day or on another shift, and with the pressure difference indicated on 4/28/2018, she would expect the nurse to call the doctor or Nurse Practitioner. The Director of Nursing Services (DNS) was interviewed on 5/17/2018 at 11:17 AM. She stated the doctor should have been notified on 4/28/2018 to report the change in Orthostatic BP, and regarding the refusals, the Orthostatic BP could have been re-attempted on another shift. The Attending Physician was interviewed on 5/17/2018 at 1:56 PM. He stated the he or his staff should have been notified about the change in blood pressure on 4/28/2018. 415.11(c)(3)(ii)

Plan of Correction: ApprovedJune 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 659 ? 483.21 (b)(3)(ii) QUALIFIED PERSONS.
483.21(b)(3)COMPREHENSIVE CARE PLANS
Resident #106
I.IMMEDIATE CORRECTIVE ACTIONS
1. The resident?s orthostatic blood pressure was assessed by a Licensed Nurse and found to be within acceptable clinical parameters.
2. The resident was evaluated by the Psychologist to assist with determining the resident?s reason for refusing orthostatic blood pressure assessment.
3. All results of clinical assessments and evaluations performed are documented in the resident?s clinical record SIGMA-Matrix EMR.
4. The Director of Nursing identified the Licensed Nurses who were assigned to perform orthostatic blood pressure for the resident in February, (MONTH) and (MONTH) of (YEAR).
5. The Nurses who did not report the refusals were given educational counselling and re-education.
a. Lesson plan will concentrate on:
i. Proper technique for ascertaining orthostatic blood pressure
ii. Protocol to follow if the resident refuses (i.e. re-approach at a later
time, inform physician)
iii. Collaborating/escalating refusals to the Registered Nurse Professional
Supervisor on duty.
6. The Licensed nurse who performed and documented the resident?s orthostatic blood pressure in (MONTH) of (YEAR) was given a disciplinary action as it relates to following the physician?s orders. Re-education was also provided.
a. Lesson plan will concentrate on:
i. Notifying the physician when residents exhibit abnormal clinical parameters
as dictated by the physician?s order.
II. IDENTIFICATION OF OTHER RESIDENTS
1. The Director of Nursing (DNS) directed the Clinical Assistant Director of Nursing to populate a list from the Electronic Medical Records (SIGMA/Matrix) of all residents who had a current order to assess Orthostatic [MEDICAL CONDITION] as part of their treatment modality.
2. The list was utilized by the DNS/designee and the Clinical Team to review the Medical Records eMAR for accurate documentation of orthostatic blood pressure and identify abnormal/normal parameters.

3. No other deficiencies were identified
III. SYSTEMIC CHANGES
1. The Director of Nursing reviewed the facility Policy and Procedure on Physicians Orders and found it to be compliant with current standards of professional practice and regulatory guidelines.
2. All nursing staff will be re-educated on the policy by the Nurse Educator.
a. Lesson Plan will concentrate on:
i. Review of F 659 and facility policy
ii. The licenses nurse?s responsibility and accountability for
a)performing skills as ordered by the physician,
b)reporting abnormal parameters to the physician and
c)escalating resident refusals to the Registered Professional Nurse
Coordinator/Supervisor.
3. A copy of the Lesson Plan and attendance sheets will be filed for reference and validation.

IV. QUALITY ASSURANCE MONITORING
1. The Director of Nursing developed an audit tool to randomly monitor, review and track the Medical Records of residents who have a current order for Orthostatic [MEDICAL CONDITION], to ensure adherence with facility policy and current standards of professional practice.
2. Audits will be performed by the Director of Nursing/designee monthly for six months and then quarterly to ensure and maintain 100% compliance.
3. Audits with negative findings will have immediate corrective actions included but not limited to resident assessment and evaluation, in conjunction with re-education and progressive disciplinary action of clinical staff member(s) involved if non-compliance to facility polices are identified.
4. Audit findings will be presented to the Quality Assurance and Performance Improvement (QAPI) Committee at least quarterly for need revisions to action plan, improvement of our delivery services and resident outcomes.
5. The Lesson Plan for this Plan of Correction will be included in the facility?s Orientation Program for all licensed nurses.

V. DATE OF CORRECTION: 7/13/2018

Responsible Parties? Director of Nursing, Assistant Director of Nursing

FF11 483.10(f)(1)-(3)(8):SELF-DETERMINATION

REGULATION: §483.10(f) Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section. §483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. §483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. §483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility. §483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: July 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the recertification survey the facility did not ensure that each resident had the right to choose schedules consistent with his or her interests for 1 (Resident #123) of 3 residents reviewed for Activities of Daily Living (ADLs). Specifically, Resident #123 refused showers during the day and preferred to have a shower in the evening; however, the shower schedule was not revised to accommodate the resident's preference. The finding is: Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/14/2018 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. The MDS documented the resident required extensive assist of one staff member for personal hygiene, transfers, and dressing, and needed physical help for bathing. A Comprehensive Care Plan (CCP) titled ADLs, Dressing, Personal Hygiene, and Bathing, dated 9/21/2016 and last updated 3/15/2018, documented interventions for as needed (PRN) assessment of personal bathing tasks and showers or whirlpool bi-weekly and PRN. A Social Services CCP for Behavior, effective 9/16/2015 and last updated 3/28/2018, documented the resident was resistant to changing his clothes and showering. An entry on 3/28/2018 documented the resident agreed to a shower today and to see the Social Services progress note, dated 3/28/2018. A Social Work progress note dated 3/28/2018 at 10:55 AM documented the resident refused a morning shower. The resident stated that he prefers to have his shower in the evening and nursing was made aware. A Social Work progress note dated 3/28/2018 at 3:48 PM documented that the resident agreed to a shower this afternoon with prompting and positive reinforcement. The Social Worker that wrote these progress notes is no longer employed at the facility. Resident #123 was observed on 5/8/2018 at 10:02 AM and 5/9/2018 at 9:21 AM in the hallway in his wheelchair. The resident was noted with a body odor. The resident's Certified Nursing Assistant (CNA) was interviewed on 5/9/2018 at 9:24 AM. He stated the resident does not like to shower and the resident is on the 7 AM-3 PM shift schedule for showers. He further stated he was not aware if the resident was receiving showers on other shifts. Review of the nursing directions for the CNA, last dated 5/10/2018, documented the resident's shower was scheduled for Tuesdays and Thursdays during the 7 AM-3 PM shift. The CNA directions were not updated to include the evening shower preference. In addition, the CCP dated 9/21/2016 and last updated 3/15/2018, for Dressing, Personal Hygiene, and Bathing was not updated to include the resident's evening shower preference. Review of the CNA sign-off sheet through (MONTH) 10, (YEAR) documented that bathing was performed by the 7 AM-3 PM shift on (MONTH) 3 and (MONTH) 10, but not performed on (MONTH) 1 or (MONTH) 8. Resident #123 was interviewed on 5/11/2018 at 11:29 AM. He stated that he prefers to shower at night. A unit Licensed Practical Nurse (LPN) familiar with the resident was interviewed on 5/14/2018 at 10:34 AM. She reviewed the 3/28/2018 Social Work note and stated she was not sure who the Social Worker spoke to. The Assistant Director of Nursing (ADNS), who is the covering Registered Nurse (RN) for the unit, was interviewed on 5/14/2018 at 11:07 AM. She stated the former unit RN recently resigned. She stated what would normally happen is the RN on the unit would approach the resident to confirm that he wanted an evening shower, and if that was the case, the shower would be changed on the schedule. She stated she could not confirm what took place. The Director of Nursing Services (DNS) was interviewed on 5/17/2018 at 11:19 AM. She stated the resident should have been re-approached regarding his shower preference and the CNA directions and care plan should have been updated to accommodate the resident's preferences. 415.5(b)(1-3)

Plan of Correction: ApprovedJune 11, 2018

F561 483.10(f)(1)-(3)(8) SELF DETERMINATION
Resident #123

I. IMMEDIATE CORRECTIVE ACTION
1. The Social Worker and Nurse Care Coordinator spoke with the resident and offered a shower to be performed immediately.
2. The residents? shower schedule was revised and updated in the Nurse Instructions for the direct care giver/certified nursing assistant to reflect the resident?s preference.
3. The resident?s Care Plan for Alternate Choice was updated to reflect the
resident?s preference of showers on the 3-11pm shift.
4. The resident will be reminded by Nursing and/or Social Services staff of his shower preference prior to his shower day as well as on the day of.
5.If the resident refuses the scheduled showers he will be offered a bed bath as an alternate choice.

II. IDENTIFICATION OF OTHER RESIDENTS

1. A current list of all residents? in the facility who are able to verbalize there needs and preferences was developed by the Interdisciplinary Team using the last documented BIMS (10-15 score) on the Minimum Data Sets.
2. The list was utilized by the Director of Nursing and the Multi-disciplinary Team to interview a random sample of residents utilizing the Resident Interview & Resident Observation Form (CMS- , 3/2013) section QP234 (Questions 3 & 4) and QP075 (A, B & C), to identify any other residents who might prefer to have their shower schedule changed.
3. No deficiencies were identified.
III. SYSTEMIC CHANGES
1. The Director of Nursing and the Administrator reviewed the facility Policy and Procedure on Quality of Life and found it to be compliant with current standards of professional practice and regulatory guidelines.
2. During Quarterly Assessment Care Plan Meetings, residents will be asked about their shower preferences and any changes/updates will immediately be communicated to the team via:
a. Care Plan updates
b. Clinical Progress note section of the Medical Record
c. Nursing Instructions/Certified Nursing Assistant documentation
3. Resident Council Meetings will be utilized as a forum to inform residents of their right to self-determination.
a. Information will be documented in the Resident Council Meeting minutes which will be filed for reference and validation
4. All staff will be re-educated on the Quality of Life policy by the Nurse Educator.
a. Lesson Plan will concentrate on:
i. Review of F 561 and facility policy
ii. Importance of providing showers as guided by the resident?s preference.
iii. Reporting instances of refusal for additional follow up and planned interventions.
iv. Identifying changes in resident preference under Nursing Instructions
v. Reporting to Nursing or Social Services if they speak with a resident and they verbalized that they would prefer a change in shower schedule
5. A copy of the Lesson Plan and attendance sheets will be filed for reference and validation.
IV. QUALITY ASSURANCE MONITORING

1. The Director of Nursing and Administrator developed an audit tool to randomly monitor that resident?s preferences are honored for showers.
a.This may include attending random care plan meetings, resident council meetings and/or interview of random residents with BIMS of 13-15.
2. Audits will be performed by the Director of Nursing/designee weekly for six months, monthly for six months and quarterly thereafter to ensure 100% complaint with standards of professional practice is maintained.
3. Audits with negative findings will have immediate corrective actions including
a. Changes in Nursing Instructions and Care Plans
b. Re-education and progressive disciplinary action for clinical staff who
were informed by any resident that they preferred a change in shower schedule and
was not honored.
4. Audit findings will be reviewed each morning during Morning Quality Improvement Report for immediate follow-up and resolution.
5. Audit findings will also be presented to the Quality Assurance and Performance Improvement (QAPI) Committee at least quarterly for needed revisions to action plan, improvement of our delivery services and resident outcomes.
6. Quality Assurance Resident Satisfaction Surveys will be performed at Quarterly Care Plan Meetings with each resident.
a. Findings will be discussed at the next Morning Quality Improvement Report
for immediate follow-up.
7. The Lesson Plan for this Plan of Correction will be included in the facility?s Orientation Program for all new employees.
V. DATE OF CORRECTION: 7/13/2018

Responsible Party ? Director of Nursing, Assistant Director of Nursing, Director of Social Services, Director of Recreation Activities & Administrator.

FF11 483.25(g)(4)(5):TUBE FEEDING MGMT/RESTORE EATING SKILLS

REGULATION: §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: July 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review during the recertification survey, the facility did not ensure for one (Resident # 149) of one resident reviewed for tube feeding, the resident was being given the quantity of feedings as ordered by the Nurse Practitioner (NP). Specifically, Resident # 149 was administered three feedings, not four feedings as ordered. The finding is: Resident # 149 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's short and long term memory was impaired and cognition was severely impaired. In addition, the MDS documented in Section K, the resident was being tube fed. The MDS documented the resident's height as 62 inches. The Comprehensive Care Plan dated 3/19/18 documented diet order as per the physician's orders [REDACTED]. The Nutrition assessment dated [DATE] documented the ideal body weight range as 100 to 120 pounds. The Resident's weight documented on 5/9/18 was noted as 81.2 pounds. Physician orders [REDACTED]. The times documented in the physician's orders [REDACTED]. The feedings would provide a total of 2000 ml and 3,000 kilocalories daily. The schedule of the tube feeds was documented on the Medication Administration Record (MAR) as follows: Every day at 7 AM to 3 PM, 3 PM - 11 PM, 11 PM to 7 AM. There were signatures for each nursing shift on the MAR. The timing of each of the bolus feeds was not documented in the schedule. The 7 AM to 3 PM shift Licensed Practical Nurse #1 (LPN) was interviewed on 5/16/18 at 12:00 PM and stated that she provides the resident with two bolus feeds during the day shift, once at 9 AM and once at 1 PM, respectively. The 11 PM to 7 AM LPN #5 was interviewed on 5/16/18 at 1:15 PM and stated she does not bolus feed any resident on the 11 to 7 AM shift. The LPN stated that bolus feeds are not scheduled on the 11 PM to 7 AM shift. She further stated that she works full time on the 11 PM to 7 AM shift on the third floor. The 3 PM to 11 PM shift LPN # 6 was interviewed on 5/16/18 at 3:30 PM and stated he feeds the resident one time during the shift at 5 PM. The 11 PM to 7 AM shift LPN # 4 was interviewed on 5/16/18 at 3:45 PM and stated she does not administer any bolus feedings on the night shift. The Registered Nurse (# 1) Care Coordinator (NCC) was interviewed on 5/17/18 at 10:00 AM and stated the medication nurse oversees the resident's feeding. The NCC further stated although the resident is combative, she has not been informed of any feeding refusals. An interview was held with the Registered Dietitian (RD) on 5/17/18 at 12:00 PM. The RD stated she was attempting to understand why the resident was not gaining weight while planned to receive 3,000 calories per day. The RD further stated she has changed the formula, increased the quantity of the feeds several times, and meets with the weight committee to address weight concerns. The RD further stated she asked nursing whether the resident was receiving the ordered bolus feeds and was told by nursing that she was. In addition, the RD stated that six cans (feedings) of the [MEDICATION NAME];1.5 is more than sufficient to ensure the resident's daily caloric needs are being met. The Nurse Practitioner (NP) who ordered the bolus feeds was interviewed on 5/17/18 at 1:30 PM and stated Nursing would decide which shift of nurses feeds the resident. The NP also stated that she was unaware that the resident was not receiving all four feedings. The Director of Nursing Services (DNS) was interviewed on 5/17/18 at 1:00 PM and stated the Medication Administration Record (MAR) should have documented the specific times of each bolus feeding, not just a shift signature. A second interview was held with the DNS on 05/17/18 02:57 PM. The DNS stated that either the 11 PM to 7 AM or the 7 AM to 3 PM shift would have been able to administer the 7 AM bolus feeding. The DNS stated we have an hour before and an hour after the timed feedings. She further stated the nurses are supposed to be reading the physician orders. The DNS could not comment on the 11 PM to 7 AM signatures of nurses who did not administer the bolus feed. 415.12(g)(2)

Plan of Correction: ApprovedJune 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 693 483.25(g)(4)(5): TUBE FEEDING MGMT./RESTORE EATING SKILLS

Resident #149
I. IMMEDIATE CORRECTIVE ACTION
1. The resident was weighed and a weight of 84.6 lbs. was measured and documented in the clinical chart.
2. A Comprehensive Metabolic Panel was ordered to ensure values were within acceptable clinical parameters.

3. An ad hoc Care Plan Meeting to review and discuss the resident?s weight was completed and documented.
4. All assessments and outcomes are documented in the resident?s medical record.
5. The physician?s order was reviewed and clarified to add actual times of [MEDICATION NAME] administration.
6. The Director of Nursing identified the Licensed nurses who were assigned to administer the bolus [MEDICATION NAME] to the resident.
7. The licensed nurses were given educational counselling and disciplinary actions
a. Lesson plan concentrated on
i. Review of the nine rights of medication administration
ii. The licensed nurse?s responsibility and accountability to clarify a
physician?s order before administering when discrepancies are identified

8. Copies of educational counseling, disciplinary actions and lesson plan are filed for reference and validation.

II. IDENTIFICATION OF OTHER RESIDENTS

1. The Director of Nursing directed the Clinical Assistant Director of Nursing to populate a report from Sigma/Matrix identifying all residents with a current order for bolus and nocturnal/continuous tube feed.
2. This list was used to review each order to ensure its accuracy and compliance with standards of professional practice (i.e. nine rights of medication administration).
3. No deficiencies were identified
III. SYSTEMIC CHANGES
1. The Director of Nursing and Administrator reviewed the facility Policy and Procedure on Medication Administration, Physicians Orders and Tube Feeding Administration and found them to be compliant with current standards of professional practice and regulatory guidelines.
2. The Administrator added a criterion for Weight Meetings to include an evaluation and review of all residents whose weight were below 100lbs and not assessed to be within their ideal body weight and body mass index.

3. All licensed nurses will be re-educated on the policies (Medication Administration, Physician?s orders and Tube Feeding Administration) by the Nurse Educator.
a. Lesson Plan will concentrate on:
i. Review of F 693 and policies
ii. New Weight Meeting criterion
iii. Importance of clarifying physician?s orders prior to administering tube
feeding to residents.
iv. The licenses nurse responsibility and clinical accountability for
ensuring that the physician?s orders are accurate prior to administering tube
feeding and compliance with the nine rights for medication administration.
4. A copy of the Lesson Plan and attendance sheets will be filed for reference and validation.
5. All License Nurses will receive Tube Feeding competencies on orientation and as needed.
a. Copies of Competencies will be filed for reference and validation.

IV. QUALITY ASSURANCE MONITORING
1. The Director of Nursing developed an audit tool to review, monitor and track physician?s orders for bolus tube feeding for accuracy inclusive of administration times.
2. Audits will be performed by the Director of Nursing/designee weekly six months, monthly for six months and quarterly thereafter to ensure physicians orders are 100% complaint with standards of professional practice.
3. Audits with negative findings will have immediate corrective actions included but not limited to resident assessment and evaluation, in conjunction with re-education and progressive disciplinary action of clinical staff member (s) involved if non-compliance is identified.
4. Audit findings will be presented to the Quality Assurance and Performance Improvement (QAPI) Committee at least quarterly for need revisions to action plan, improvement of our delivery services and resident outcomes.
5. The Lesson Plan for this Plan of Correction will be included in the facility?s Orientation Program for all licensed nurses.
6. The new weight meeting criterion will be monitored by the Registered Dietician.

V. DATE OF CORRECTION: 7/13/2018

Responsible Party ? Director of Nursing, Assistant Director of Nursing, Registered Dietician & Administrator.

Standard Life Safety Code Citations

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: July 13, 2018

Citation Details

2012 NFPA 101: 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25: Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 5.2* Inspection. 5.2.1 Sprinklers. 5.2.1.1* Sprinklers shall be inspected from the floor level annually. 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5)*Loading (6) Painting unless painted by the sprinkler manufacturer This requirement is not met as evidenced by: Based on observation, and staff interview during the recertification survey, the facility did not ensure that sprinkler heads that showed signs of corrosion were replaced on 1 of 5 floors. This was noted in the kitchen, in the laundry department and by a loading dock on the 1st floor. Additionally, two sprinkler heads were spaced less than the required 6 ft. apart in a resident common shower room on 1 of 5 floors. The findings are: During the Life Safety Code survey conducted on 05/11/18 between 9:00am and 2:00pm, the following were noted: 1. Pendent type sprinklers that showed signs of corrosion were noted in the following locations: - In the dishwashing area of the main kitchen - In the wash area of the commercial laundry department - By the loading dock outside of the laundry department. 2. Two sprinkler heads were noted installed at approximately 3ft. apart, instead of the required 6ft. distance between pendent sprinklers, in the 5th floor resident common shower room. In an interview on the same day at approximately 12:15pm, the Director of Maintenance stated that he would contact a sprinkler company to address the concerns with the sprinkler heads. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 5.3.1.1.1.6, 5.4.1.4, 5.4.1.4.1 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJune 1, 2018

The following plan of correction is submitted for continued Medicare/Medicaid Certification.

K353
1.No resident was affected by the deficient practice
2.Immediate Correction
A.Licensed Sprinkler Company conducted an inspection of all the sprinkler heads in the facility on 5/25/2018.

A proposal was obtained for the replacement of corroded/damaged heads with escutcheons 5/28/2018.
Permit will be obtained and filed with NYC Buildings.
The Sprinkler heads found to be with signs of corrosion in the area listed below will be replaced:
?dishwashing area of the main kitchen
?wash area of the commercial laundry department
?by the loading dock outside of the laundry department.
All sprinkler heads throughout the facility will be inspected and replaced as needed by Licensed Sprinkler Company.
Licensed Sprinkler Company will sign after installation completed, testing of system is performed and functioning properly as per code.
B.Licensed Sprinkler Company after inspection of all the sprinkler heads in the facility including the resident common shower room on all units will perform work to correct the positioning of the two sprinkler heads in the 5th floor resident common shower room that were found to be not at the required distance apart between pendent sprinklers of 6ft. as per code.
All other units common areas were also inspected for code compliance to the required 6ft. distance between pendent sprinklers and found to be in compliance.

3.The Director of Maintenance will keep a log of the installation date of the new sprinkler heads and will inspect as per code regulations.
4.Documentation will be kept on file in in a binder in the Maintenance Office. The Director will submit a report to the Administrator and the QA committee quarterly.
5.Completion date 7/13/2018
6.The Director of Maintenance will be responsible to ensure implementation of the corrective action.