New York State Veterans Home at Montrose
February 13, 2017 Certification Survey

Standard Health Citations

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (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: February 13, 2017
Corrected date: April 3, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not ensure for one of five residents reviewed for unnecessary medications (#185) that a care plan with measurable objectives, time frames and interventions was developed to address the use of an antidepressant medication ([MEDICATION NAME]) that was being used to treat anorexia. The findings are: Resident #185 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set; a resident assessment tool) of 7/19/16 indicated the resident was not receiving any antidepressant medication. The Quarterly MDS dated [DATE] indicated the resident was receiving an antidepressant medication during the last seven days of this assessment period. The current physician's orders [REDACTED]. at bedtime was initiated on 10/11/16 and it was increased to 30 mg at bedtime on 12/9/16. The weight record in the Electronic Medical Record indicated that since admission, when the resident's weight was 159 lbs., the resident had experienced a steady decline in his weight. The resident's total weight loss in 7 months was 33.6 lbs. and the most recent weight dated 2/8/16 was 125.4 lbs. The comprehensive care plan was reviewed with the unit Registered Nurse manager (RNM#1) and there was no documented evidence that a care plan was included to address the use of [MEDICATION NAME] for Anorexia. The effectiveness of the medication had not been evaluated. RNM#1 was interviewed on 2/13/17 at 11:15 AM regarding the missing care plan and stated that the use of [MEDICATION NAME] and the reasons for which it was prescribed should have been addressed in a care plan. 415.11(c)(1)

Plan of Correction: ApprovedMarch 2, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** *Immediate action taken for the resident found to have been affected:
Resident #185 was reassessed by the Acting Medical Director. Based on resident?s medical condition, [MEDICATION NAME] was tapered and discontinued on 2/19/17.
The RN Unit Manager #1 reassessed the resident and immediately updated the Care Plan to reflect the use of [MEDICATION NAME] as an appetite stimulant for Anorexia as well as interventions to monitor the effectiveness of the medication and/or lack of effectiveness as well as follow up measures.
RN Unit Manager #1 was counseled for failure to revise and update the Care Plan timely.
*Identification of other residents having the potential to be affected:
A list has been compiled of all residents who are receiving medications for Anorexia including [MEDICATION NAME]. An audit tool was developed by the DON to track, monitor and evaluate residents who are receiving medication for Anorexia including [MEDICATION NAME], and to document effectiveness of the medications as part of the Care Plan, and in the Progress notes. The Acting Medical Director reviewed and reassessed all the residents. No other resident was found to have a Care Plan without the appropriate documentation. All the other residents were addressed by the RD/RN/MD and documented in the progress notes.
Administrator met with Acting Medical Director to ensure appropriate and timely documentation in the chart to cover reasons why residents are taking specific medications. Other medical staff were educated by Acting Medical Director on same.

*What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Residents identified as needing medications for Anorexia, or using [MEDICATION NAME] as appetite stimulant for Anorexia will be discussed at the Daily Morning Meeting. In addition the residents will be evaluated by the MD and assessed by the RN for effectiveness and continued administration monthly and PRN. The RN will document in the 24 hour report as well as the Progress Notes. The Care Plan will be discussed at the morning meeting to ensure appropriate documentation and follow up by the team. These residents will be monitored and discussed at the monthly Nutrition Subcommittee Meeting.
A lesson plan was developed by the DON/Staff educator to in-service all clinical staff.
Lesson plan includes, but not limited to:
? Definition of unnecessary medications: [REDACTED]
? Interventions to monitor the use of medication.
? Monitoring and Documenting the effectiveness of medications.
? Updating and revising the Care Plan timely.
? Multidisciplinary approach to avoiding unnecessary drugs
? Educating the residents of risks and benefits of treatment.
*CQI monitoring to ensure deficient practice does not recur:
An audit tool has been developed by the DON to monitor and track residents who are using medications for Anorexia, including [MEDICATION NAME]. The audit will be done Q weekly by the Director of Food Service (DFS)/DON/ Designee. The results of the audit will be presented at CQI by the DFS/DON/ Designee, once a month starting 3/2017 for three months, then quarterly, x3 quarters. Any deficient practices identified will be immediately corrected.
Completion Date: 4-3-17 and on-going.

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (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; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 13, 2017
Corrected date: April 3, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not ensure for 1 of 5 residents (#185) reviewed for unnecessary medications that adequate indication for the continued use of an antidepressant ([MEDICATION NAME]) prescribed to treat anorexia was re-evaluated in light of the resident's steady and sustained weight loss. The findings are: Resident #185 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS assessment dated [DATE] revealed that the resident was not receiving an antidepressant medication during this assessment period. The Quarterly MDS assessment dated [DATE] indicated that the resident received an antidepressant medication during the last seven days of this assessment period. The current physician's orders [REDACTED]. at bedtime was initially ordered on [DATE] and on 12/9/16, it was increased to 30 mg at bedtime. The weight record in the Electronic Medical Record indicated that since admission, when the resident's weight was 159 lbs., he had experienced a steady decline in his weight. The resident's total weight loss in 7 months was 33.6 lbs. The most recent weight dated 2/8/16 was 125.4 lbs. The History and Physical form dated 12/22/16 revealed that weight loss was identified; the medication indicated was the use of [MEDICATION NAME] (indicated for treatment of [REDACTED]. The most recent History and Physical form dated 1/13/17 identified the weight loss, medication was documented [MEDICATION NAME] was discontinued, oral supplements and [MEDICATION NAME] was not documented as a treatment for [REDACTED]. The dietary notes dated 2/10/17 indicated the resident's intake for food and snack was 0-25% and the resident feeds self with tray set-up and supervision. [MEDICATION NAME] for anorexia was included with the list of medications in the dietary note. The dietary notes documented that the resident's weight loss and poor oral intake continued. There was no information on the effectiveness of the medication [MEDICATION NAME] was documented. The interdisciplinary progress notes of (MONTH) (YEAR) - (MONTH) (YEAR) were reviewed and there was no evidence in the notes that the continued use of [MEDICATION NAME] had been evaluated to determine it's effectiveness in treating the Anorexia. The primary care physician was interviewed on 2/13/17 at 10:30 AM regarding the continued use of [MEDICATION NAME] in light of the resident's ongoing weight loss. The primary care physician stated that the resident is being worked up for potential cause of the resident's steady weight loss and that he could not certainly consider discontinuing the medication. 415.12(l)(1)

Plan of Correction: ApprovedMarch 2, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** *Immediate action taken for the resident found to have been affected:
Resident #185 was reassessed by the Acting Medical Director. [MEDICATION NAME] was tapered and discontinued on 2/19/17 by Medical based on the resident?s condition and care plan goals.
The RN Unit Manager #1 reassessed the resident and immediately updated the Care Plan to document the use of [MEDICATION NAME] as an appetite stimulant for the treatment of [REDACTED].
RN Unit Manger #1 was counseled for failure to revise and update the Care Plan timely.
*Identification of other residents having the potential to be affected:
A list has been compiled of residents who are receiving medications for Anorexia including [MEDICATION NAME]. An audit tool was developed by the DON to track, monitor and evaluate residents who are receiving medications for Anorexia including [MEDICATION NAME]. This tool will be used to document the use of [MEDICATION NAME] as an appetite stimulant, continued need for the medication and effectiveness of the medications as part of the Care Plan, and in the Progress notes. The Acting Medical Director reviewed and reassessed all residents identified. No other resident chart was found to have missing documentation regarding the use of [MEDICATION NAME] ? (as an appetite stimulant). All other charts had appropriate Care Plans and Progress Notes documenting the need for continued use of the medication.
Administrator met with Associate Medical Director to discuss the importance of documenting reasons why residents are on specific medication. Acting Medical Director has discussed same with medical staff.
*What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Residents identified as needing medications for Anorexia, or using [MEDICATION NAME] as an appetite stimulant for Anorexia will be discussed at the Daily Morning Meeting. In addition, the resident will be evaluated by the MD and assessed by the RN for effectiveness and continued administration. The RN will document in the 24 hour report as well as the Progress Notes. The Care Plan will be discussed at the Morning Meeting and PRN to ensure appropriate documentation and follow up by the team. The resident will be monitored and discussed at the monthly Nutrition Subcommittee Meeting.
A lesson plan was developed by the DON/Staff educator to in-service all clinical staff.
Lesson plan includes, but not limited to:
? Definition of unnecessary medications: [REDACTED]
? Intervention to monitor the use of medication.
? Monitoring and documenting the effectiveness of medications.
? Updating and revising the Care Plan timely.
? Multidisciplinary approach.
? Educating the residents of risks and benefits of treatment.
*CQI monitoring to ensure deficient practice does not recur:
An audit tool has been developed by the DON to monitor and track residents who are taking medications for Anorexia, including [MEDICATION NAME]. Reasons for use of medication will be documented in the MAR, Care Plan and Progress Note. The audit will be done Q weekly by the Director of Food Service (DFS)/ DON/ Designee. The results of the audit will be presented at CQI by the DFS / DON/ Designee, starting 3/2017 once a month x3 months then quarterly, x3 quarters. Deficient practices identified will be immediately corrected.
Completion Date: 4-3-17 and on-going.

FF10 483.25(e)(1)-(3):NO CATHETER, PREVENT UTI, RESTORE BLADDER

REGULATION: (e) Incontinence. (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. (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. (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: February 13, 2017
Corrected date: April 3, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a re-certification survey, the facility did not ensure that care and treatment to address the decline in urinary continence, and to potentially restore the residents' previous level of urinary continence status to the extent possible, were provided to 2 of 3 residents (#207 and #75) reviewed for urinary incontinence. The findings are: 1. Resident #207 has [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set; a resident assessment tool) of 8/26/16 indicated the resident scored 7 out of 15 on the BIMS (Brief Interview for Mental Status; used to measure orientation and memory recall) which suggested the resident had severely impaired cognition for daily decision making skills and required extensive assistance of two persons with toilet use. This MDS further documented that resident was occasionally incontinent of bladder function (defined in the MDS as less than 7 episodes of incontinence). The comprehensive care plan (CCP) of 8/29/16 established a goal that the resident will not develop complications related to incontinence and will maintain current level of continence in the next 90 days. The interventions listed to achieve these goals included, but are not limited, to monitor for signs and symptoms of Urinary Tract Infection [MEDICAL CONDITION], encourage adequate fluid intake, toilet resident every 2-3 hours during waking hours and as needed, render incontinence cares promptly, provide privacy and adequate time to void, toilet resident immediately when requested, and provide urinal if needed. The resident was subsequently assessed on the Quarterly MDS of 11/21/16 which indicated the resident scored 8 out of 15 on the BIMS test which suggested the resident had moderately impaired daily decision making skills, which was an improvement from the last MDS of 8/29/16, and required extensive assistance of one person with toilet use. This MDS further indicated the resident had a decline in urinary status from being occasionally incontinent to frequently incontinent of bladder function (defined in the MDS as 7 or more episodes of urinary incontinence, but at least one episode of continent voiding). The above CCP was not revised to include measurable objectives, time frames, and interventions to minimize incontinence episodes and to potentially restore the resident's previous level of urinary continence to the extent possible. There was no documented evidence that the initial interventions listed on the 8/29/16 care plan were analyzed to determine their effectiveness. Furthermore, there was no evidence that attempts were made to identify possible contributory factors for the resident's decline in bladder function and to develop appropriate interventions to resolve or minimize the effects of the identified risk factors. The assigned day shift Certified Nursing Assistant (CNA#1) was interviewed on 2/13/17 at 10:35 AM and stated that he has been taking care of this resident for about a month now. CNA#1 stated the resident does not urinate a lot before but recently has been urinating more frequently. CNA#1 stated at times the resident is able to ask to go to the bathroom but when he checks the resident, he is already wet. CNA#1 stated he checks the resident every 2-3 hours and there had been no episodes that the resident was dry every time he checks on him. CNA#1 stated that he has been doing the same incontinent care to the resident since he had become frequently incontinent of urine. The assigned unit Registered Nurse manager (RNM#1) was interviewed on 2/13/17 at 12:30 PM regarding the current interventions to address the resident's current continency level and as to the possible risk factors that may have contributed to the resident's frequent incontinence. RNM#1 further stated she did not revise the care plan because when the resident was transferred to her unit, the resident was already frequently incontinent, and kept the same interventions. RNM#1 also stated that the resident's increased incontinence was probably due to UTI and the use of [MEDICATION NAME] (a diuretic) which was initiated on 12/7/16. RNM#1 stated the UTI had resolved during the early part of the resident's stay at the facility. The RN MDS Coordinator was interviewed on 2/13/17 at 1:00 PM as to how the care plan was being reviewed and revised upon identification of a decline in continency level (occasional to frequently). The RN MDS Coordinator stated that an assessment or investigation should have been conducted to identify various risk factors that may have contributed to the resident's incontinency. 2. Resident #75 has [DIAGNOSES REDACTED]. a. The Admission MDS of 10/11/16 indicated the resident scored 1 out of 15 on a BIMS test which suggested the resident had severely impaired cognition for daily decision making skills and required extensive assistance of one person with toilet use. This MDS further indicated the resident was occasionally incontinent of bladder function. The Certified Nurse Aide (CNA) care guide of (MONTH) 5-11, (YEAR) documented that the resident had two episodes of urinary incontinence that occurred on the evening and night shifts. The Bowel and Bladder Comprehensive Care Plan (CCP) initiated on 10/12/16 had interventions including to render incontinent care promptly, and toilet every 2-3 hours during waking hours and as needed. The CNA care guide of (MONTH) 24-30, (YEAR) documented that the resident had ten episodes of urinary incontinence on all three shifts and revealed an increase in urinary frequency. The resident was subsequently assessed on the 12/30/16 Quarterly MDS and coded the resident as frequently incontinent of bladder (defined in the MDS as 7 or more episodes of urinary incontinence, but at least one episode of continent voiding). There was no documented evidence that the Bowel and Bladder CCP of 10/12/16 was revised to include goals, time frames and interventions to address the decline in the resident's urinary status. There was no evidence that further assessments including bladder assessments, were conducted to identify possible risk factors that contributed to the resident's decline in urinary continence. Furthermore, there was no documented evidence that the CNA care guide was updated to include the changes identified on the 12/30/16 MDS. RNM#1 was interviewed on 2/13/17 at 10:56 AM and stated the resident was mostly incontinent of bladder function. RNM#1 stated she was responsible for updating the CCPs and CNA care guides, and conducting bladder re-assessment. RNM#1 stated the care plans were not updated because she was on vacation. The MDS Coordinator was interviewed on 2/13/17 at 11:09 AM and stated the resident had a decline in bladder function and the care plan should have been revised to address the decline in urinary status and activities of daily living. 415.12(d)(2)

Plan of Correction: ApprovedMarch 2, 2017

*Immediate action taken for the resident found to have been affected:
Resident #207 and #75 were both identified and assessed by the Nurse Practitioner (NP) as well as RN Nurse Manager
Comprehensive Care Plans & CNA Care Guides were reviewed to determine the probable risk factors for the declines, as well as interventions and time frames to address them.

The RN Manager was identified and counseled for failure to ensure revision and updating of the Care Plan timely.
*Identification of other residents having the potential to be affected:
Residents Care Plans/MDS were audited for bowel and bladder status.
Resident charts found with inconsistencies in MDS/CP, Bowel & Bladder status were assessed and care plans updated with appropriate interventions. Probable reasons for incontinence and urinary declines were identified. Care plans and CNA care guides were updated with interventions to reflect resident?s urinary status, and care plan goals with appropriate time frames.
*What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
An audit tool was developed by the DON for ongoing monitoring of MDS scores for Bowel & Bladder status to ensure corresponding plans of care. The tool will assist with the determination of the risk factors and reasons for declines in continence so appropriate interventions can be placed to correct them.
MDS/CP audit will be done weekly by the ADON/Designee of all residents with MDS/CP, annual, quarterly and significant changes.
Staff retraining on Bowel & Bladder status was completed for all clinical staff.
Lesson plan was developed by the DON/MDS coordinator/Staff Coordinator which includes, but not limited to:

? Determining the risk factors that may contribute to declines in continence status, as well as interventions and time frames to restore and maintain continence status
? Immediately addressing changes in incontinency status.
? Ensuring accurate documentation in MDS, Care Planning and CNA Care Guides.
? Educating residents (capable of understanding) as well as families on continence
*CQI monitoring to ensure deficient practice does not recur:
The results of the audit will be presented at CQI by DON/Designee starting 3/2017 monthly x3 months and quarterly thereafter for three quarters. Any negative findings will have immediate corrective actions.
Completion Date: 4-3-17 and on-going.

FF10 483.24, 483.25(k)(l):PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 13, 2017
Corrected date: April 3, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not ensure that care and services were provided to maintain a resident's highest practicable physical, mental and psychosocial well-being for 1 of 1 resident reviewed for [MEDICAL TREATMENT] (Resident #243). Specifically, Resident #243 was receiving [MEDICAL TREATMENT] treatments and had been placed on a fluid restriction. The fluid allowance calculated by the dietitian for nursing to provide during medication pass was not implemented to prevent potential for fluid overload. Additionally the resident was receiving 30 ml. of a protein supplement three times per day that was not included in the fluid allowance. The findings are: Resident #243 was admitted to the facility on [DATE] and was receiving [MEDICAL TREATMENT] treatment three times a week. The Admission MDS (Minimum Data Set; a resident assessment tool) of 4/22/16 indicated the resident's active [DIAGNOSES REDACTED]. This MDS further indicated that the resident required extensive assistance of one person for all activities of daily living except for eating where supervision was required. The care plan for [MEDICAL TREATMENT] included but not limited to the following interventions: [MEDICAL TREATMENT] three times a week on Mondays, Wednesdays, and Fridays; fluid restriction as ordered; monitor intake and output as ordered; and monitor weight as ordered. The dietary progress note of 8/15/16 indicated the resident was placed on a 1500 ml daily fluid restriction and was reflected on the Nutrition care plan. According to this care plan the resident exceeds the fluid restriction at times. The Licensed Practical Nurse (LPN) who administers medications to the resident was interviewed at 2:30 PM on 2/10/17 and was asked about the fluid allowance for medication administration in accordance with the resident's care plan. This LPN stated that dietary calculates the fluid restriction but she could not access the documentation pertaining to the calculation and further stated she did not know how much was allowed to be given to the resident during each medications pass. Two Registered Dietitians (RD) were interviewed on 2/10/17 at 2:40 PM and they stated the breakdown for the fluid restriction is on the menu. When it was pointed out that the nurses are not looking at the menus when they're administering medications, they stated they do not know how much fluid nursing was giving during medication passes. The RD Food Service Director (FSD) was interviewed on 2/10/17 at 2:50 PM and he stated that currently, there is no place in the Electronic Medical Record where the nurses would have access to the fluid restriction breakdown between dietary and nursing. The FSD further stated that the 30 ml of Prostat (a protein supplement) that the resident receives three times per day was not included in the fluid restriction allowance. The FSD was further interviewed on the same date at 3:10 PM and stated that nursing have been providing 160 ml per shift totaling 480 ml daily. According to the breakdown calculated by the RD, nursing was allowed 240 ml for medication administration. Fluids provided beyond the fluid restriction were 90 ml from Prostat and 240 ml from nursing, a total of 330 ml daily above the 1500 ml restriction for this resident. 415.12

Plan of Correction: ApprovedMarch 2, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** *Immediate action taken for the resident found to have been affected:
Resident #243 was identified and reevaluated by the Acting Medical Director, Nurse Manager as well as the Registered Dietician. Her fluid need was recalculated and increased to 2000 cc Q 24 hours to allow for a more liberalized fluid intake to meet her nutritional and preference needs without harm to resident?s health. Orders were written by Medical staff, to alert other clinical staff to fluid requirement allowed for this resident. The nurses will sign to indicate amount provided with each Med Pass. Any liquid medication will be accounted for in the calculation.
The LPN #1 as well as other nurses were identified and counseled by the Nursing Administrator (NA1) for failure to ensure fluid restriction was maintained.
*Identification of other residents having the potential to be affected:
A list of residents on fluid restriction was compiled by the DON. The list will be utilized to audit the records weekly by the DFS/DON/Designee. Orders were written for residents who are on fluid restriction to flag in EMAR to alert nurses to amount allowed with each med pass. This will ensure accountability, and prevent fluid overload. In addition, residents who are on fluid restrictions will have the 24 hour total fluid intake recorded nightly on the 24 hour report by Nursing. All residents on fluid restriction were reassessed. No other residents were identified as not maintaining appropriate fluid restriction needs.
*What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
An audit tool was developed by the DON to monitor and track all residents who are on fluid restriction. Any residents identified as having any discrepancies will be immediately corrected. This list has been provided to Recreation staff for ongoing monitoring and compliance. A Policy was written to ensure that residents with Physician order [REDACTED].

A lesson plan was developed by the DON and Staff Educator, the lesson plans includes but not limited to:
? Ensuring adherence to fluid restriction as prescribed by MD/NP.
? Involving and educating residents on risks and benefits of adhering to fluid restriction. and documentation to support same.
In-service conducted for clinical staff to ensure compliance with fluid restriction was done by the Staff Educator.

*CQI monitoring to ensure deficient practice does not recur:
The audit will be done Q weekly by the Director of Food & Nutrition Services
The results of the audit will be reported by the Director of Food & Nutrition Services or Designee to the CQI Committee starting 3/2017 monthly x3, then quarterly for one year.
Completion Date: 4-3-2017 and on-going

FF10 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: 483.10 (c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. (iv) The right to receive the services and/or items included in the plan of care. (v) The right to see the care plan, including the right to sign after significant changes to the plan of care. (c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-- (i) Facilitate the inclusion of the resident and/or resident representative. (ii) Include an assessment of the resident?s strengths and needs. (iii) Incorporate the resident?s personal and cultural preferences in developing goals of care. 483.21 (b) Comprehensive Care Plans (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: February 13, 2017
Corrected date: April 3, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a re-certification survey, the facility did not revise the comprehensive care plans with measurable objectives, time frames and interventions to address (1.) an assessed decline in urinary continence and to potentially restore previous urinary continence status to the extent possible for 2 of 3 residents reviewed for urinary incontinence (Residents #207 and #75); and (2.) a decline in activities of daily living (ADL) and vision (Resident #75). The findings are: 1. Resident #207 is a [AGE] year old male with [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set; a resident assessment tool) of 8/26/16 indicated the resident scored 7 out of 15 on the BIMS (Brief Interview for Mental Status; used to measure orientation and memory recall) which suggested the resident had severely impaired cognition for daily decision making skills and required extensive assistance of two persons with toilet use. This MDS further documented the resident was occasionally incontinent of bladder function (defined in the MDS as less than 7 episodes of incontinence). The comprehensive care plan (CCP) of 8/29/16 established a goal that the resident will not develop complications related to incontinence and will maintain current level of continence in the next 90 days. The interventions listed to achieve these goals included to monitor for signs and symptoms of Urinary Tract Infection [MEDICAL CONDITION], encourage adequate fluid intake, toilet resident every 2-3 hours during waking hours and as needed, render incontinence cares promptly, provide privacy and adequate time to void, toilet resident immediately when requested, and provide urinal if needed. The resident was subsequently assessed on the Quarterly MDS of 11/21/16 which indicated the resident scored 8 out of 15 on the BIMS test which suggested the resident had moderately impaired daily decision making skills that showed an improvement from the previous MDS assessment, and required extensive assistance of one person with toilet use. This MDS further indicated the resident had a decline in urinary status from being occasionally incontinent to frequently incontinent of bladder function (defined in the MDS as 7 or more episodes of urinary incontinence, but at least one episode of continent voiding). There was no documented evidence that the above CCP was not revised to include measurable objectives, time frames, and interventions to minimize incontinence episodes and to potentially restore the resident's previous level of urinary continence to the extent possible. There was no documented evidence that the initial interventions listed on the 8/29/16 care plan were analyzed to determine their effectiveness. Furthermore, there was no evidence that attempts were made to identify possible contributory factors to the resident's decline in bladder function and to initiate appropriate interventions to resolve or minimize the effects of the identified risk factors. The assigned day shift Certified Nursing Assistant (CNA#1) was interviewed on 2/13/17 at 10:35 AM and stated that he has been taking care of this resident for about a month now. CNA#1 stated the resident does not urinate a lot before, but recently has been urinating more frequently. CNA#1 stated at times the resident is able to ask to go to the bathroom but when he checks the resident, he is already wet. CNA#1 stated he checks the resident every 2-3 hours and there had been no episodes that the resident was dry every time he checks on him. CNA#1 stated that he has been doing the same incontinent care to the resident since he became frequently incontinent of urine. The assigned unit Registered Nurse manager (RNM#1) was interviewed on 2/13/17 at 12:30 PM regarding the current interventions to address the resident's current continency level and as to the possible risk factors that may have contributed to the resident's frequent incontinence. RNM#1 further stated she did not revise the care plan because when the resident was transferred to her unit, the resident was already frequently incontinent, and kept the same interventions. RNM#1 also stated that the resident's increased incontinencne was probably due to UTI and use of [MEDICATION NAME] (a diuretic) which was initiated on 12/7/16. RNM#1 stated the UTI had resolved during the early part of the resident's stay at the facility. The RN MDS Coordinator was interviewed on 2/13/17 at 1:00 PM as to how a care plan was being reviewed and revised upon identification of a decline in continency level (occasional to frequently). The RN MDS Coordinator stated that an assessment or investigation should be conducted to identify various risk factors that may have contributed to the resident's incontinency and develop a care plan to assist the resident regain as much bladder function as possible.
2. Resident #75 is a [AGE] year old male with [DIAGNOSES REDACTED]. a. The Admission MDS of 10/11/16 indicated the resident scored 1 out of 15 on a BIMS test which suggested the resident had severely impaired cognition for daily decision making skills and required extensive assistance of one person with toilet use. This MDS further indicated the resident was occasionally incontinent of bladder function. The CNA care guide of (MONTH) 5-11, (YEAR) documented two episodes of urinary incontinence that occurred on the evening and night shifts. The Bowel and Bladder Comprehensive Care Plan (CCP) initiated on 10/12/16 had interventions including to render incontinent care promptly, and toilet every 2-3 hours during waking hours and as needed. The CNA care guide of (MONTH) 24-30, (YEAR) documented that the resident had ten episodes of urinary incontinence on all three shifts and revealed an increase in urinary frequency. The resident was subsequently assessed on the 12/30/16 Quarterly MDS and coded the resident as frequently incontinent of bladder. There was no documented evidence that the Bowel and Bladder CCP of 10/12/16 was revised to include goals, time frames and interventions to address the decline in the resident's urinary status. There was no evidence that further bladder assessments were conducted, since 10/14/16, to identify possible risk factors that contributed to the resident's decline in urinary continence. Furthermore, there was no documented evidence that the CNA care guide was updated with the changes identified in the 12/30/16 MDS. b. Vision Impairment: The 10/11/16 and 12/30/16 MDS assessments coded Resident # 75 with impaired vision and able to see adequate light. No corrective lenses were identified. An 11/21/16 Report of Ophthalmology consultation documented the resident was diagnosed with [REDACTED]. There was no evidence the Vision CCP, initiated 10/12/16, was reviewed and revised to include the goals, time frames and interventions to address the [DIAGNOSES REDACTED]. c. ADL Status: The 10/11/16 MDS assessed the resident as requiring extensive assistance of one person with ADLs that included bed mobility, transfer, dressing, toileting, and personal hygiene. The ADLs CCP initiated 10/4/16 developed goals that the resident would continue with current level of performance and floor ambulation per physical therapy. The resident was subsequently assessed on the 12/30/16 MDS which indicated the resident as requiring staff assistance of two people with dressing and locomotion off the unit. This MDs showed a decline in the current ADL status from 10/4/16. There was no documented evidence that the ADLs CCP was reviewed and revised to include new goals, time frames and interventions to address the decline in ADL status on 12/30/16. The RNM#1 was interviewed on 2/13/17 at 10:56 AM and stated the resident required assistance of one person with ADLs, able to feed himself and was mostly incontinent of bowel and bladder. RNM#1 stated she was responsible for updating the CCPs, CNA care guides, and bladder re-assessment, but they were not updated because she was on vacation. The MDS Coordinator was interviewed on 2/13/17 at 11:09 AM and stated that the resident had a decline in bladder and ADL function and that the charge nurse was responsible for updating the care plans. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedMarch 2, 2017

*Immediate action taken for the resident found to have been affected:
Resident #207 and #75 were both identified and assessed by the Nurse Practitioner as well as the unit manager.
Comprehensive Care Plans & CNA Care Guides for Residents #207 and #75 were revised with measurable objectives, time frames and interventions to account for the decline in urinary continence and urinary status. Possible reasons for incontinence were identified and Care Plans and Care Guides were updated with appropriate interventions to reflect resident?s current continence status and prospective ADL goals.
The RN Manager was identified and counseled for failure to ensure revision and updating of the Care Plan.
*Identification of other residents having the potential to be affected:
All resident Care Plans/MDS were audited for bowel and bladder status.
Residents found with inconsistencies in MDS/CP, Bowel & Bladder status were assessed and corrections made.
Contributory factors for declines in Bowel and Bladder function were identified. CCPs were updated and implemented, with appropriate interventions to resolve and minimize identified factors. Where goals could not be met for a variety of reasons, appropriate documentation was made.
*What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
An audit tool was developed by the Director of Nursing (DON) for ongoing monitoring of MDS scores for Bowel & Bladder status to ensure corresponding plans of care. Audit tool will identify changes in urinary status and incontinency so that appropriate interventions can be put into place to minimize incontinence and restore bowel and bladder function.
MDS/CP audit will be done weekly by the Associate Director of Nursing (ADON)/Designee of all residents with MDS/CP, annual, quarterly and significant changes
Staff retraining on Bowel & Bladder status was completed for all clinical staff.
Lesson plan was developed by the DON/MDS coordinator/Staff Coordinator which includes, but not limited to:
? Immediately addressing changes in incontinency status.
? Identifying risk factors, and causes of urinary declines and incontinency
? Appropriate measures to restore and maintain continence status
? Ensuring accurate documentation in MDS, Care Plans and CNA Care Guides.

*CQI monitoring to ensure deficient practice does not recur:
The results of the audit will be presented at CQI starting 3/2017 by ADON/Designee monthly x3 months and quarterly thereafter for three quarters. Negative findings will have immediate corrective actions.

Completion Date: 4-3-17 and on-going.

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (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: February 13, 2017
Corrected date: April 3, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not ensure that care and services were provided in accordance with the resident's assessed needs and care plan for 1 of 1 resident reviewed for [MEDICAL TREATMENT] (Resident #243). Specifically, Resident #243 was receiving [MEDICAL TREATMENT] treatments and had been placed on a fluid restriction. The fluid allowance calculated by the dietitian for nursing to provide during medication pass was not implemented to prevent potential for fluid overload. Additionally the resident was receiving 30 ml. of a protein supplement three times per day that was not included in the fluid allowance. The findings are: Resident #243 was admitted to the facility on [DATE] and was receiving [MEDICAL TREATMENT] treatment three times a week. The Admission MDS (Minimum Data Set; a resident assessment tool) of 4/22/16 indicated the resident's active [DIAGNOSES REDACTED]. This MDS further indicated that the resident required extensive assistance of one person for all activities of daily living except for eating where supervision was required. The care plan for [MEDICAL TREATMENT] included but not limited to the following interventions: [MEDICAL TREATMENT] three times a week on Mondays, Wednesdays, and Fridays; fluid restriction as ordered; monitor intake and output as ordered; and monitor weight as ordered. The dietary progress note of 8/15/16 indicated the resident was placed on a 1500 ml daily fluid restriction and was reflected on the Nutrition care plan. According to this care plan the resident exceeds the fluid restriction at times. The Licensed Practical Nurse (LPN) who administers medications to the resident was interviewed at 2:30 PM on 2/10/17 and was asked about the fluid allowance for medication administration in accordance with the resident's care plan. This LPN stated that dietary calculates the fluid restriction but she could not access the documentation pertaining to the calculation and further stated she did not know how much was allowed to be given to the resident during each medications pass. Two Registered Dietitians (RD) were interviewed on 2/10/17 at 2:40 PM and they stated the breakdown for the fluid restriction is on the menu. When it was pointed out that the nurses are not looking at the menus when they're administering medications, they stated they do not know how much fluid nursing was giving during medication passes. The RD Food Service Director (FSD) was interviewed on 2/10/17 at 2:50 PM and he stated that currently, there is no place in the Electronic Medical Record where the nurses would have access to the fluid restriction breakdown between dietary and nursing. The FSD further stated that the 30 ml of Prostat (a protein supplement) that the resident receives three times per day was not included in the fluid restriction allowance. The FSD was further interviewed on the same date at 3:10 PM and stated that nursing have been providing 160 ml per shift totaling 480 ml daily. According to the breakdown calculated by the RD, nursing was allowed 240 ml for medication administration. Fluids provided beyond the fluid restriction were 90 ml from Prostat and 240 ml from nursing, a total of 330 ml daily above the 1500 ml restriction for this resident. 415.11(c)(3)(ii)

Plan of Correction: ApprovedMarch 2, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** *Immediate action taken for the resident found to have been affected:
Resident #243 was identified and reevaluated by the Acting Medical Director, Nurse Manager as well as the Registered Dietician. Her fluid need was recalculated and increased to 2000 cc Q 24 hours to allow for a more liberalized fluid intake to meet her nutritional and preference needs. Orders were written by Medical staff to alert other clinical staff to amount of fluid allowed for this resident to meet her fluid restriction goals. The nurses will sign to indicate amount provided with each Med Pass. Any liquid medication will be accounted for in the calculation.
The LPN #1 as well as other nurses were identified and counseled by the Nursing Administrator (NA1) for failure to ensure fluid restriction was maintained.
*Identification of other residents having the potential to be affected:
A list of residents on fluid restriction was compiled by the DON. The list will be utilized to audit the records weekly by the DFS/DON/Designee. Orders were written for residents who are on fluid restriction to flag in Electronic Medication Administration Record [REDACTED]. This will ensure accountability, and prevent fluid overload. In addition, residents who are on fluid restrictions will have the 24 hour total fluid intake recorded nightly on the 24 hour report by Nursing. All residents on fluid restriction were reassessed. No other residents were identified as not maintaining appropriate fluid restriction goals.
*What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
An audit tool was developed by the DON to monitor and track all residents who are on fluid restriction. Any residents identified as having any discrepancies will be immediately corrected. A Policy was written to ensure that residents with Physician order [REDACTED].

A lesson plan was developed by the DON and Staff Educator, the lesson plans includes but not limited to:
? Ensuring adherence to fluid restriction as prescribed by MD/NP.
? Involving and educating residents on risks and benefits of adhering to fluid restriction, and documentation to support same.
In-service conducted for all clinical staff to ensure compliance with fluid restriction was done by the Staff Educator.

*CQI monitoring to ensure deficient practice does not recur:
The audit will be done Q weekly by the Director of Food & Nutrition Services
The results of the audit will be reported by the Director of Food & Nutrition Services or Designee to the CQI Committee starting 3/2017 monthly x3, then quarterly for one year.
Completion Date: 4-3-17 and on-going

FF10 483.25(a)(1)(2):TREATMENT/DEVICES TO MAINTAIN HEARING/VISION

REGULATION: (a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident- (1) In making appointments, and (2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 13, 2017
Corrected date: April 3, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not ensure that proper treatment and the appropriate assistive devices were provided to 1 of 5 residents (#199) reviewed for vision. Specifically, an ophthalmology follow-up visit was not provided and the eye glasses that had been ordered for the resident were missing. The findings are: Resident #199 has [DIAGNOSES REDACTED]. The Annual MDS (Minimum Data Set; a resident assessment tool) dated 4/11/16 indicated the resident had impaired vision - ability to see in adequate light, and had no corrective lenses. The resident was subsequently assessed on the Quarterly MDS dated [DATE] which indicated the same. A 4/22/15 consult from Optometry indicated that the resident broke the current pair of glasses and was being seen for evaluation of new glasses. The recommendation indicated the use of glasses for Presbyopia (farsightedness) to increase vision. Additionally, an ophthalmology consult dated 5/5/16 indicated the resident was being seen for follow-up for [MEDICAL CONDITION] and the follow-up recommendation was 3-4 months. There was no documented evidence that a follow-up visit that should have occurred in (MONTH) or (MONTH) (YEAR) was done. RNM#1 was interviewed on 2/13/17 at 1:00 PM and stated she does not remember the resident wear any glasses and that as long as she has been in the unit for about a year the resident has never had any glasses. RNM#1 further stated the Nurse Practitioner (NP) reviews the consult recommendations and sets up follow-up appointments. The NP was interviewed on 2/13/17 at 1:10 PM and stated that she does not know what happened to the glasses. The NP stated the optometrist usually sends the glasses to the facility and that she did not know why the lack of glasses was never followed up. The NP stated that the follow-up ophthalmology consult was postponed because in (MONTH) (YEAR) the resident required surgery on his hand for a fracture and all other care issues were put on hold. The NP stated she did not know why the consult had not been followed up since then. The Social Worker was interviewed on 2/13/17 at 2:00 PM and stated that when glasses come from the optometrist, they first go to the clinic, then to the Social Worker to be labeled and then sent to the unit. The Social Worker stated that she never remembered the resident with glasses and that maybe the resident's son declined to pay for the new glasses. Following surveyor intervention, an ophthalmology consult was ordered and an investigation initiated regarding the missing glasses. 415.12(3)(b)

Plan of Correction: ApprovedMarch 2, 2017

*Immediate action taken for the resident found to have been affected:
An appointment was scheduled for resident #199 to see the Ophthalmologist/Optometrist.
The NP was educated (counseled) by the Acting Medical Director on the importance of consult follow-up and documenting in the Medical Record to support any reason a follow-up appointment was cancelled or recommendation not accepted.
*Identification of other residents having the potential to be affected:
An audit of residents who have had ophthalmology/Optometry visits over the past 8 months was done to ensure that no appointments or recommendations had been missed. No other residents were identified as not having had their appointments or recommendations followed.
Medical Staff were asked by Acting Medical Director to ensure appropriate documentation to address follow-up consultant visits that they chose not to honor.

*What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
A spreadsheet has been developed to monitor residents who are scheduled for Ophthalmology/Optometrist appointments. Based on set parameters, names will flagged several days before the appointment to alert the clinic coordinator to the upcoming appointment. An audit tool was developed by DON to track and monitor optometry/ophthalmology consults and follow-up.
A lesson plan was developed by the DON and Staff Educator. The Lesson Plan includes but not limited to:
Monitoring of residents for Ophthalmology/Optometry Clinics
Follow up on eye glass recommendations and appointments
Updating Care Plans to reflect consults and recommendations
In-services were conducted with clinical staff

*CQI monitoring to ensure deficient practice does not recur.
The Audit Tool will be utilized to monitor and track compliance with Optometry and Ophthalmology follow-up by the Clinic Coordinator and Unit Clerks. Reports of ongoing monitoring will be reported by the clinic coordinator to the Director of Nursing monthly. DON/Designee will report starting 3/2017 to CQI Committee quarterly for a year.
Completion Date: 4-3-17 and on-going.