Elderwood at Grand Island
August 5, 2016 Certification/complaint Survey

Standard Health Citations

FF09 483.25(a)(3):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 5, 2016
Corrected date: September 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 8/5/16, the facility did not ensure that residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain good grooming and personal hygiene. One (Resident #149) of two residents observed for personal care had issues with the Certified Nurse Aide (CNA) did not wash hands and change gloves after providing fecal incontinence care and applying barrier cream to resident's buttocks. The finding is: 1. Resident #149 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/28/16 revealed the resident is cognitively intact, is understood, understands, and has an indwelling catheter (tube inserted into the bladder to drain urine). Review of an undated Comprehensive Care Plan revealed Focus: Indwelling Urinary Catheter use r/t (related to) [MEDICAL CONDITION](inability of the bladder to empty); At risk for UTIs r/t indwelling catheter and [MEDICAL CONDITION]. Goal: Will be free from complications r/t catheter use through next review; Resident will remain free from UTIs through next review. Interventions: Provide catheter care daily and as needed; Monitor s/s (signs/symptoms) of UTIs. Review of the CNA My Profile of Care dated 8/2/16 revealed the resident requires extensive assistance of 2 people for toileting hygiene. Observation of morning care on 8/4/16 at 7:47 AM revealed CNAs #1 and #2 provided care to the resident. While wearing gloves, CNA #2 cleansed the resident's indwelling catheter tubing from proximal (closest to body) to distal (furthest from body) using a washcloth. Approximately 20 cm (centimeter) down the catheter tubing CNA #2 removed a dark greenish/black substance from the tubing with the washcloth. Using the same washcloth, CNA #2 then wiped the resident's genitalia from the front of the body downward between the resident's legs.The washcloth contained dark greenish/black stool. With the assistance of CNA #1, the resident was rolled onto her right side, CNA #2 wiped a small amount of dark greenish/black stool from the rectum. While wearing the same contaminated gloves, CNA #2 then cleansed the rear perineal (the area between the anus and genitalia) area and buttocks and applied barrier cream to the resident's buttocks. CNA #2 was then observed to remove the contaminated gloves and wash her hands. Interview on 8/4/16 at 8:04 AM, CNA #2 stated, You would want to wash hands and change gloves before applying the barrier cream because you can transfer residue and transfer bacteria/infection. Normally I would change my gloves, I don't know why I didn't. Interview with Registered Nurse (RN) #3, on 8/4/16 at approximately 8:07 AM revealed the expectation is to wash hands and change gloves after providing incontinence care and before applying barrier cream. Review of an undated facility policy and procedure entitled Perineal/Incontinence Care included perineal care will be provided with AM and HS (hour of sleep) care, and when residents are incontinent or cannot provide such care for themselves. Perineal care will be given to cleanse the genital area, to prevent infections and to eliminate odors. 415.12(a)(3)

Plan of Correction: ApprovedAugust 29, 2016

1. Resident # 149 did not suffer any untoward effect as a result of the identified deficient practice. C.N.A. #1 and #2 were reeducated on the facilities policy regarding perineal care, hand washing and changing of gloves on 8/5/16 & 8/6/16.
2. All residents who are dependent for perineal care have the potential to be affected by this practice.
3. C. N. A. 's will be re-educated on the facilities policies regarding perineal / incontinence care with a special emphasis on hand washing, changing of gloves after providing fecal incontinence care and applying barrier cream to a residents buttocks.
4. Unit Managers/Designee will compete 10 care observation/incontinent care audits per month for a period of 3 months. All Results will be reported to the Quality Assurance Committee in which time progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility administrator will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/23/2016.

FF09 483.15(a):DIGNITY AND RESPECT OF INDIVIDUALITY

REGULATION: The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 5, 2016
Corrected date: September 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard Survey completed on 8/5/16, the facility did not promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. One (Resident #125) of two residents observed had issues with a staff member entering and remaining in the resident's room during care without informing the resident and asking permission to do so. The finding is: 1. Resident #125 has [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set (MDS- a resident assessment tool) dated 7/14/16 revealed the resident usually understands, is usually understood and has severely impaired vision. Review of the resident's Comprehensive Care Plan dated 7/6/16, revealed the resident has impaired visual function related to legally blind in both eyes. Staff interventions are to include to introduce self upon entering the room and announce when you will be leaving the room and explain to the resident the care to be provided prior to providing that care. Review of the Certified Nurse Aide (CNA) My Profile of Care dated 7/26/16 revealed the resident requires extensive assistance by the staff to bathe, dress, transfer and has [MEDICAL CONDITION]. Observation of the resident's morning care on 8/4/16 at 6:49 AM revealed that CNAs#1 and #2 knocked and entered the resident's room after identifying self and the resident saying OK. The CNA's explained the morning care routine and asked the resident's preferences for clothing to wear. Midway during the resident's care, a soft knock was at the door and a Registered Nurse (RN) #3 Inservice Director entered the room without the resident's awareness or expressed approval and stood at the corner of the room observing the CNA's perform bathing, dressing and transfer via a mechanical lift out of bed to the wheelchair. Interview with CNA #1 on 8/4/16 at approximately 7:20 AM revealed that staff are to knock on the door and when the resident or another person says come in staff may enter the room. The resident is to be informed of who you are and why you are in the room. CNA #1 stated that this would be especially important when caring for Resident #125 as the resident has a severe visual impairment. Interview with CNA #2 on 8/4/16 at approximately 7:22 AM revealed that staff are to knock on the door and when the resident or another person says come in then the staff may enter the room. The resident is to be informed of who you are and why you are in the room. CNA #2 stated that this would be especially important when caring for Resident #125 as the resident has a severe visual impairment. Interview with RN #3 on 8/4/16 at 7:29 AM revealed RN #3 was aware the resident had a visual impairment. RN #3 stated she entered the room without informing the resident who she was and without requesting permission from the resident to observe the resident's morning care and it should have. An interview with the Director of Social Work on 8/4/16 at 10:02 AM revealed that it is very important to knock on the door and await permission to enter all resident's rooms. All staff should announce their name when entering a resident's room and explain care to be rendered.This is especially important due to Resident #125's visual impairment. Interview with Resident #125 on 8/4/16 at approximately 10:55 AM revealed the resident has an extensive visual impairment and due to this, depends on the staff to say who they are and what they are going to do in the room. Review of the facility Bill of Rights for Residents revealed that each resident has the right to dignity in care, independent decision making and respect and privacy in personal care. 415.5(a)

Plan of Correction: ApprovedAugust 29, 2016

This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
1. Resident # 125 was interviewed on 8/4/16 and did not suffer any untoward effect as a result of the identified deficient practice. RN #3 was re-educated on 8/4/16.
2. All residents have the potential to be affected by the identified deficient practice.
3. Nursing staff will be re-educated on promoting care for residents in a manner and in an environment that enhances each resident? dignity and respect in full recognition of his or her individuality. Specific focus will be placed on knocking on doors, seeking permission to enter, introducing self upon entering the room, explaining care to be provided prior to providing the care and to announce when they are leaving the room.
4. Ten random monthly audits will be conducted by the facility social worker to ensure staff are knocking on the door, seeking approval to enter, introducing self upon entering the room, explain the care to be provided prior to providing that care and announce when they are leaving the room for a period of 3 months. Results will be reported to the Quality Assurance Committee in which time progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility administrator will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/23/2016

FF09 483.25(l):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Scope: Isolated
Severity: Actual harm has occurred
Citation date: August 5, 2016
Corrected date: September 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Complaint investigation (Complaints #NY 212, NY 071) conducted during a Standard survey completed on 8/5/16, the facility did not ensure that each resident's drug regimen was adequately monitored to ensure that correct dosing of the drug was maintained to prevent adverse consequences. Three(Residents #45, 113, 151) of ten residents reviewed for unnecessary drugs had an issue where the resident received [MEDICATION NAME] (anticoagulant medication) with no monitoring of the resident's PT([MEDICATION NAME] time-clotting time)INR (international normalizing ratio-standardized normalized blood clotting values) from 6/30/16 until 7/14/16. On 7/14/16 the resident had a critically high INR value of 18 (reference range is 0.9 - 1.2) which indicates a lack of blood clotting. The resident developed left upper extremity (LUE) bruising and a hematoma (collection of blood under the skin) as well as conjunctival (mucous membrane surrounding the eye) hemorrhage that required hospitalization . There was actual harm that is not immediate jeopardy. In addition, there was a lack of adequate monitoring while on a Beta Blocker (medication used to treat hypertension, [MEDICAL CONDITION], abnormal heart rhythms, and chest pain) (Resident #113), and the lack of adequate monitoring while on a Beta Blocker and diuretic (promotes excretion of urine) medication (Resident #151). The findings are: 1. Resident #45 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] for subacute rehabilitation. Review of the hospital Discharge Summary dated 6/29/16 revealed a discharge medication list which included the medication Eliquis (anticoagulant medication) 2.5 milligrams (mg) twice a day. Under the [DIAGNOSES REDACTED]. The discharge medication list did not include [MEDICATION NAME]. Review of the hospital Transfer/Post OP (operative) Medication Orders printed on 6/29/16 revealed an order for [REDACTED]. Review of the hospital Medication Administration Record (MAR) revealed [MEDICATION NAME] 5 mg was last administered on 6/28/16 at 8:47 PM. Review of hospital Laboratory (lab) Reports revealed an INR performed on 6/28/16 was 1.38 and an INR performed on 6/29/16 was 2.4 (INR goal range 2-3). Review of the facility Medication Reconciliation / Physician Orders worksheet dated 6/29/16 revealed admission orders [REDACTED]. The worksheet included admission lab orders for CBC (complete blood count), CMP (complete metabolic profile), and Hgb A1C (blood test to determine average blood glucose levels). In addition, orders for routine labs of a CBC and BMP (basic metabolic profile) to be done weekly. The worksheet was completed by RN #1 and co-signed by RN #2 as the second Nurse Reconciliation Review. The area indicating labs for PT/INR was blank. Review of a Progress Note written by the day Supervisor RN #1 dated 6/29/16 at 9:39 PM revealed the resident was admitted to the unit on 6/29/16 in the evening with [DIAGNOSES REDACTED]. The orders were confirmed with the PA (Physician Assistant). RN #1 clarified the order for Eliquis 2.5 mg BID (twice daily) which was on the med list from the hospital, however in the discharge narrative, [MEDICATION NAME] was chosen over Eliquis due to the resident's fluctuating creatinine (blood test to determine kidney function). RN #1 documented that [MEDICATION NAME] will be started. Review of an Order Summary Report (Physician's Orders) dated 6/29/16 revealed an order for [REDACTED]. Review of a Progress Note - Order Note dated 6/29/16 signed by RN #2 revealed a lengthy note describing possible drug interactions between [MEDICATION NAME] and multiple other medications that were ordered for the resident. There is no documented evidence that the medical provider was notified of these potential interactions. Review of a fax from the hospital pharmacy labeled Anticoagulant Management Service to the facility dated 6/30/16 documented that the patient has been discharged from the hospital on [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The discharge dosage directions were to hold [MEDICATION NAME] ([MEDICATION NAME]) tonight (6/29/16) due to a 1 pt (point) jump in INR over past 24 hours after only 2 doses. The fax indicated that [MEDICATION NAME] 5 mg was administered in the hospital on [DATE] and 6/28/16. The discharge comments on the fax state to obtain a PT/INR the morning of 6/30/16 for further [MEDICATION NAME] dosing. (It should be noted that the document was faxed to the facility on [DATE] at 12:03 PM, the day after the resident was admitted to the facility). Review of the History and Physical (H&P) exam dated 6/30/16 completed by the Physician revealed Eliquis was discontinued due to renal function fluctuations and the resident was placed on [MEDICATION NAME]. The Physician note documents the discrepancy noted between the Hospital Discharge medication list, the Discharge Summary and the facility medication list. The H&P revealed that the resident is on [MEDICATION NAME] and off Eliquis and the plan is to monitor INRs while on [MEDICATION NAME]. Review of a Nurse Practitioner note (NP) #2 dated 7/5/16 revealed the resident has chronic [MEDICAL CONDITION] and the rate was stable on [MEDICATION NAME] and [MEDICATION NAME] (medication used to treat high blood pressure, heart failure and chest pain). The plan is to follow the INR and monitor rate. Review of a Progress Note written by RN #3 dated 7/14/16 at 8:22 AM revealed the resident complained of an inability to move her left shoulder and arm this morning. Some bruising was noted near the axilla (arm pit) and upper deltoid (shoulder muscle) area. The resident is unsure how the bruising occurred. Review of a NP #2 note dated 7/14/16 revealed that staff reported the resident had LUE pain and ecchymosis (purplish patch caused by blood under the skin), the resident denied injury to the area. The resident was also noted with conjunctival hemorrhage and was unaware of how she acquired it. Multiple areas of ecchymosis were observed over the left clavicle (shoulder blade) into the axillary area. The area was tender to palpation. Pain in the left arm appears to be musculoskeletal in nature. The plan is to get an x-ray to rule out underlying pathology, to check the INR to rule out a hypercoaguable (condition in which there is an abnormally increased tendency toward blood clotting) state, and to order pain medication. The resident likely developed a hematoma in the area due to repetitive exercises. Under assessment for [MEDICAL CONDITION] revealed that the rate is stable on [MEDICATION NAME] and [MEDICATION NAME] and the plan is to follow the INR closely as the resident has been hypercoaguable in the past. Review of an Order Summary Report dated 7/14/16 revealed an order for [REDACTED]. Review of a Licensed Practical Nurse (LPN) Progress Note dated 7/14/16 at 1:38 PM revealed NP #2 was in to see the resident with new orders for [MEDICATION NAME] (opioid pain medication) 10/325 mg every 4 hours as needed for pain and a CBC on 7/18/16. The Progress Note revealed an INR was not ordered at this time. Review of a Progress Note dated 7/14/16 at 10:26 PM revealed the left shoulder x-ray showed [MEDICAL CONDITION] changes and no fracture or dislocation. The left humerus x-ray showed no acute fracture or destructive lesion. Review of the Medication Administration Summary for (MONTH) and (MONTH) (YEAR) revealed the resident received [MEDICATION NAME] 4 mg at 9:00 PM every day from 6/30/16 through and including 7/14/16. Review of an Order Summary Report dated 7/14/16 revealed an order from the NP for a stat (immediate) PT/INR. Review of the lab slip dated 7/14/16 revealed the PT/INR was drawn at 11:35 PM. Review of the lab report dated 7/14/16 revealed the PT value reported on 7/15/16 at 12:30 AM was 230.2 (reference range is 9.3 - 13.5) and the INR value was 18 (reference range is 0.9 - 1.2). Review of an RN Progress Note dated 7/15/16 at 12:30 AM revealed the resident had a critically high PT/INR, the NP was called and gave orders for a Vitamin K (helps to clot the blood) 10 mg injection one time now. The resident denied chest pain, shortness of breath and there were no new areas of bruising noted on the resident. Labs are to be repeated in the morning. Review of a Progress Note written by RN #1 dated 7/15/16 at 2:43 PM revealed the INR result was 12.3. The NP was notified of the result by a secure text. Review of a Progress Note dated 7/15/16 at 5:32 PM revealed the NP returned the call related to the INR result of 12.3 and discontinued [MEDICATION NAME] and ordered Vitamin K 10 mg SQ (subcutaneously-beneath the skin) stat; repeat INR in the morning and call the NP with the results. Review of a LPN Progress Note dated 7/15/16 at 10:10 PM revealed that a sling is in place at all times to the left shoulder/arm; and bruising remains to the left upper arm. Review of an unsigned Progress Note dated 7/16/16 at 11:51 AM revealed the NP reviewed the labs from today and yesterday, the INR remained the same at 12.3. Vitamin K was given twice on 7/15/16. New order was received to send the resident to the ER (emergency room ) for evaluation due to uncorrected critical level. The resident left via ambulance on 7/16/16 at 12:30 PM. Review of an RN Progress Note dated 7/16/16 at 11:59 PM revealed the resident returned from the ER at approximately 9:30 PM. The resident was given oral Vitamin K in the ER and had a repeat INR of 13.2. There were no new recommendations or orders. The Physician service was notified of the resident's return and left message to question when the next INR level to be drawn. The Care Plan and Door Profile were changed to reflect bleeding/bruising precautions and a nurse order to monitor every shift for bleeding/bruising for 7 days. Review of a RN Progress Note dated 7/17/16 at 2:33 PM revealed that no signs of bleeding or new bruises were noted. Orders were received to repeat PT/INR on 7/18/16. Review of the lab slip dated 7/18/16 revealed the INR value remained high at 3.9. Review of an Order Summary Report dated 7/20/16 revealed an order for [REDACTED]. Review of the lab slip dated 7/20/16 revealed the INR value was 2.9. Review of an email from NP #2 to the facility dated 7/20/16 revealed NP #2 saw the resident on 7/5/16 and noted the resident was on [MEDICATION NAME] from a review of the Discharge Summary and the 6/30/16 Physician Note. NP #2 documented in the email that on 7/5/16 she requested lab results but was told by staff that the results were not available for her visit. NP #2 was told the facility had not received the results from the lab as of the time of her visit as Monday was a holiday and all routine labs were done on Tuesday. NP #2 stated in the email that she did not specifically ask for an INR at the time, she just asked for lab values. NP #2 further stated that on 7/14/16 she saw the resident for an acute onset of LUE pain/decreased ROM (range of motion). She noted ecchymosis at her shoulder and a conjunctival hemorrhage, the resident denied injury and was unaware of the hemorrhage. NP #2 documented that she spoke with the nurse and requested the INR results. After investigating further, the nurse discovered that the INR had not been done in two weeks. The email states that a stat INR was requested at that time. Review of the facility investigation related to the incident dated 7/14/16 revealed that the resident was admitted to the facility on [DATE]. The Discharge Summary indicated Eliquis 2.5 mg orally twice a day. The narrative indicated that [MEDICATION NAME] was chosen over Eliquis due to fluctuating renal function. The resident had been receiving [MEDICATION NAME] in the hospital and her INR was therapeutic at 1.38 on 6/28/16 per the hospital Discharge Summary dated 6/29/16. [MEDICATION NAME] 4 mg was started on 6/30/16 after clarification with the PA per the Nurse's Note dated 6/29/16. Drug to drug interaction notifications were present per Nurse's Note review, however the facility was unable to locate documentation that the covering NP/MD (medical doctor) was notified by RN Supervisor (RN #2) who entered the orders and received notification of the drug to drug interactions. The Medication Reconciliation/Physician Order worksheet reflects that the area indicating labs for PT/INR was blank. The worksheet was completed by RN #1 as the primary nurse and was signed by RN #2 as the second nurse as the Nurse Reconciliation Review. The facility investigation conclusions included the following: -The resident received multiple doses of [MEDICATION NAME] in the absence of PT/INR monitoring and exhibited bruising, conjunctival hemorrhage and the need for treatment with two doses of vitamin K in the facility and an ER visit with one dose of Vitamin K administered. -Licensed nurses failed to verify PT/INR results prior to administration of [MEDICATION NAME] (per the Therapeutic Anticoagulation Monitoring System Policy) resulting in an elevated PT/INR. -RN #2 failed to appropriately obtain an order for [REDACTED]. Observation and interview of the resident on 7/25/16 at approximately 1:30 PM revealed the resident had a bluish large bruise to the left upper arm axillary area. The resident stated that the area hurts at times and she takes pain pills for the pain. During an interview with RN #1 on 7/25/16 at approximately 11:45 AM, RN #1 stated that on 6/29/16 she worked a double shift and the resident was admitted to the facility between approximately 7:00 PM - 8:00 PM. RN #1 stated that Nursing Supervisors do the new admissions. RN #1 stated that she did the medication reconciliation using the Discharge Summary, and MARs from the hospital. RN #1 stated she documented her admission orders [REDACTED]. She reviewed the admission medications by telephone with the PA who ordered [MEDICATION NAME] 4 mg for the resident. RN #1 stated that there was some confusion with this case because the hospital Discharge Summary medication list stated that the resident was to continue on Eliquis. RN #1 stated that it was only through reviewing the written narrative in the Discharge Summary the resident was to be on [MEDICATION NAME] instead of Eliquis because of the resident's kidney function. RN #1 stated that she does not recall discussing the need for INRs with the PA and stated that there was no order for an INR on the worksheet that she used. RN #1 stated that normally PT/INRs are done with the admission labs usually within 24 - 48 hours of admission. RN #1 stated that she left the facility at 10:00 PM on 6/29/16 and handed off the admission paperwork to the night shift RN Supervisor who entered the admission orders [REDACTED]. RN #1 stated that the [MEDICATION NAME] Worksheet was never written up for the resident. [MEDICATION NAME] Worksheets are normally kept in the lab book maintained on each unit that contain the lab reports for all residents. RN #1 stated that the medication nurses are supposed to check the [MEDICATION NAME] Worksheet prior to administering any dose of [MEDICATION NAME] to check the most recent INR value. In addition, RN #1 stated that she did not see the fax from the hospital pharmacy dated 6/30/16 that gave instructions to hold the [MEDICATION NAME] on 6/29/16 and obtain a PT/INR the morning of 6/30/16 for further [MEDICATION NAME] dosing. RN #1 stated that the fax was sent by the hospital pharmacy on 6/30/16 at approximately 12:00 PM. In addition, RN #1 stated that NP #2 assessed the resident earlier in the day on 7/14/16 due to the resident's complaints of pain, immobility and bruising to the LUE ordered an x-ray and INR to be drawn. There was no order to hold [MEDICATION NAME] on 7/14/16. (Surveyor review of the orders revealed NP #2 did not order an INR on 7/14/16 but ordered a CBC to be done on 7/18/16). RN #1 stated that she was the Nursing Supervisor and acting as medication nurse on 7/14/16 during the evening shift and administered [MEDICATION NAME] 4 mg at bedtime. Later in the evening RN #1 was looking for the resident's INR results and could not find one. She informed NP #2 that ordered a stat INR. The results on 7/15/16 at approximately 12:30 AM was 18.0 critically high. During an interview on 7/25/16 at approximately 3:15 PM, LPN #1 stated that per the initials on the MAR she administered [MEDICATION NAME] 4 mg to the resident at approximately 9:00 PM on 6/30/16, 7/2/16, 7/7/16, 7/8/16, 7/11/16, and 7/12/16. LPN #1 stated that she did not check for the INR level prior to administering the medication. LPN #1 stated that it was a mistake not to check the INR level and she has been re-educated on the importance of checking the INR value prior to administering [MEDICATION NAME] to any resident. The Physician stated during a telephone interview on 7/26/16 at approximately 2:30 PM that on 6/30/16 she completed the resident's initial H&P exam and also noted the discrepancy between the Eliquis and [MEDICATION NAME] while reviewing records on the computer system. The Physician stated that she did not find any INR results in the computer system and asked a nurse about the INRs. The nurse told her that they were monitoring the INRs and the nurses were still in the process of entering orders on the resident. The Physician stated that the nurses seemed to be aware of the need to monitor INRs and that it is her expectation that INRs are monitored on all residents on [MEDICATION NAME]. During a telephone interview on 8/3/16 at approximately 11:30 AM, NP #2 stated she made a visit to the resident on 7/5/16 and asked the nurse about the labs. She was told that labs were not done on 7/4/16 due to the holiday, labs were done on 7/5/16 and the results were not available during her visit. NP #2 stated that she noted that the Physician had seen the resident on 6/30/16 and had documented that INRs were being monitored. NP #2 stated she did not note whether there were orders for the INRs. NP #2 further stated that on 7/14/16 she evaluated the resident and noted bruising and pain to the resident's LUE and a conjunctival hemorrhage and ordered an x-ray of the LUE. She asked about the INR and nurse could not find one so NP #2 stated that she ordered a stat INR. NP #2 stated that she did not attempt to review previous labs because she did not have access to the facility's computer lab program as she was covering for another NP who was on vacation. NP #2 stated that the stat INR result was not reported until after she had left the facility and the on-call practitioners were taking calls. Review of the facility policy and procedure (P&P) entitled Therapeutic Anticoagulation Monitoring System for Nursing Services dated 9/2008 revealed that residents receiving anticoagulation therapy for the management of thrombus (blood clot), thrombus prevention or for management of [MEDICAL CONDITION] will receive periodic monitoring of PT/INR levels as ordered by the Attending Physician. Procedure #1 regarding PT/INR testing-Results are recorded on the MAR and/or [MEDICATION NAME] Record. The medication nurse must verify PT/INR test results prior to anticoagulant medication administration, as indicated. All PT/INR parameters are followed accordingly. Any contact with the Attending Physician regarding test results is recorded in the Nursing Progress Notes. Review of the facility P&P entitled Admission, Annual and Routine Lab Tests for Medical Services dated 11/2007 revealed under Procedure #3 -Routine Tests Based on Medical Conditions: Laboratory tests will be obtained routinely for residents with identified Medical Conditions and/or medication orders, according to the schedule below and/or as ordered by the Physician. a.)[MEDICATION NAME]/ [MEDICATION NAME]/Anticoagulant Therapy- PT/INR time is obtained weekly. If the resident is stable, PT/INR may be obtained every (2) weeks. 2. Resident #113 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/15/16 revealed the resident is cognitively intact, understood, and understands. Review of the Order Summary Report dated 4/9/16 revealed an order for [REDACTED]. Give 12.5 mg by mouth one time a day [MEDICAL CONDITION](Use ½ of 25 mg tablet); Hold if SBP (systolic-the upper blood pressure (BP) number that measures the pressure exerted by circulating blood on the blood vessels) is less than 100 or pulse less than 60. Review of the (MONTH) (YEAR) MARs revealed [MEDICATION NAME] ([MEDICATION NAME]) signed as administered 4/9/16 through 4/23/16. Review of the Electronic Medical Record (EMR) revealed the resident's pulse was not monitored prior to the administration of t [MEDICATION NAME] on the following dates: 4/12/16, 4/13/16, 4/15/16, 4/16/16, 4/17/16, 4/18/16, 4/19/16, 4/21/16, 4/22/16 and 4/23/16. During an interview on 8/4/16 at approximately 8:59 AM RN #3 stated, There is usually a box on the MAR to document the BP and pulse, I don't know what happened here, there should be some documentation of the BP. If he (Physician) has parameters to hold a med (medication) that should be documented on the MAR. 3. Resident #151 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understood, and understands. Review of the Order Summary Report dated 7/21/16 revealed orders for [MEDICATION NAME] (Beta-Blocker) ER (extended release) Tablet 24 Hour 25 mg. Give 3 tablets by mouth one time a day for HTN. 3 tablets = 75mg. Hold if SBP is less than 100. [MEDICATION NAME] (diuretic) Tablet 25 mg. Give 1 tablet by mouth one time a day for HTN. Hold if SBP is less than 100. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) MARs revealed [MEDICATION NAME] ER Tablet and [MEDICATION NAME] signed as administered 7/21/16 through 8/4/16. Review of the EMR revealed BPs taken from 7/18/16 through 7/21/16 range 93/52 (low) to 126/76 (normal) with the last documented BP 94/62 (low) on 7/21/16 at 11:30 PM. During an interview on 8/4/16 at approximately 8:59 AM RN #3 stated, There is usually a box on the MAR to document the BP and pulse, I don't know what happened here, there should be some documentation of the BP. If he (Physician) has parameters to hold a med that should be documented on the MAR. Review of the undated facility policy entitled Vital Signs (Monitoring) included the following: -A resident's pulse or BP is recorded on the MAR prior to the administration of specified medications. -A resident's vital signs are monitored for specific medical conditions, as designated by Physician order or as deemed necessary by the Unit Manager/designee. 415.12(l)(1)

Plan of Correction: ApprovedAugust 29, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident # 45 had labs drawn (PT/INR) on 7/14/16. Subsequent medical orders were received and implemented appropriately. A notation to prompt nurses to check/verify and monitor INR prior to administration was added to the resident Medication Administration Record [REDACTED]. Resident # 151 - On 8/5/16, physician orders [REDACTED]. Prompts to obtain vital signs prior to administration was added to the Medication Administration Record [REDACTED].
2. a)All residents receiving [MEDICATION NAME] have the potential to be affected by the identified deficient practice. All residents receiving [MEDICATION NAME] have been identified and full house audits where completed on 7/14/16 and 8/16/16 to ensure PT/INR monitoring was being completed per the facility policy.
b)All residents receiving Antihypertensive, Beta Blockers and Diuretics with parameters have the potential to be affected by the identified deficient practice. All full house audit will be completed identifying those residents ensuring that accurate vital sign monitoring prompts are on the Medication Administration Record [REDACTED].
3. a)Licensed nursing staff will be re-educated on the facilities policy of Anticoagulation Therapy and PT/INR monitoring and documentation requirements. The Medical Director will provide re-education to the facilities medical providers outlining the expectations from a comprehensive and accurate review of the resident?s total plan of care, including medications and treatments at each visit; with a special emphasis on resident?s receiving [MEDICATION NAME] to ensure that orders are in place for lab monitoring (PT/INR).
b)Licensed nurses will be re-educated on the facilities policies for Vital Sign Monitoring and required documentation/prompts to be added when entering orders on the Medication Administration Record [REDACTED]
4. a)Weekly audits will be completed for every resident receiving [MEDICATION NAME] by the Unit Managers for a period of 6 months to ensure PT/INR monitoring and documentation standards are being applied.
b)The pharmacy consultant will review residents requiring receiving Antihypertensive, Beta Blockers and Diuretics with parameters to ensure vital sign prompts are located on the Medication Administration Record [REDACTED]. Audits will occur monthly for a period of 3 months. All Results will be reported to the Quality Assurance Committee in which time progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
c)Monthly audits for a period of 3 months will be completed, by the Unit Managers, on residents requiring vital signs as part of medication monitoring.
5. The facility administrator will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/23/2016.

FF09 483.60(c):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. The pharmacist must report any irregularities to the attending physician, and the director of nursing, and these reports must be acted upon.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 5, 2016
Corrected date: September 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint investigation (NY 071) conducted during the Standard survey completed on 8/5/16, the facility did not ensure that the pharmacy consultant identify and report drug regimen irregularities to the Attending Physician and the Director of Nursing. One (Resident # 45) of two resident reviewed for drug regimen review had an issue that involved an incomplete monthly pharmacy review completed on 7/13/16. Specifically, the pharmacist completed the monthly drug regimen review on 7/13/16 and documented that there were no irregularities although the resident had been receiving Coumadin (anticoagulant medication) from 6/30/16 through 7/14/16 with no PT(prothrombin time-clotting time)INR (international normalizing ratio-standardized normalized blood clotting values) levels drawn until 7/14/16 to assess the blood coagulation status. The finding is: 1. Resident #45 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] for subacute rehabilitation. Review of the Order Summary Report (physician's orders [REDACTED]. Review of a fax dated 6/30/16 from the hospital pharmacy to the facility revealed that the INR goal range is 2-3. Review of the Medication Administration Summary for (MONTH) and (MONTH) (YEAR) revealed the resident received Coumadin 4 mg at 9:00 PM every day from 6/30/16 through and including 7/14/16. Review of the Pharmacy Consultant Monthly Review Tracking dated 7/13/16, signed by the Pharmacist revealed that there were no irregularities. Review of the laboratory (lab) report dated 7/14/16 revealed the PT/INR value reported on 7/15/16 at 12:30 AM was 230.2 (reference range is 9.3 - 13.5) and the INR value was 18 (reference range is 0.9 - 1.2). During a telephone interview on 7/27/16 at approximately 2:15 PM the Pharmacy Consultant stated that his first time at the facility was on 7/13/16 where he did a cursory review of the residents to obtain basic information such as comparing psychoactive medications and determining which residents are current. He stated that he did not check lab reports on any residents during the 7/13/16 visit. The Pharmacy Consultant stated that he signed the resident's Pharmacy Consultant Monthly Review Tracking sheet on 7/13/16 indicating that there were no irregularities. He stated that he performed a comprehensive review of the residents at the facility on 7/26/16 and noted that the resident is on multiple medications that can interact with Coumadin which he will be addressing. In summary, the resident was on Coumadin from 6/30/16 through 7/14/16 with no PT/INR monitoring until 7/14/16. The Pharmacy Consultant completed the monthly drug regimen review on 7/13/16 and documented that there were no irregularities. The Pharmacist did not identify the fact that the resident's PT/INR levels were not being monitored during this time frame. 415.18(c)(2)

Plan of Correction: ApprovedAugust 29, 2016

1. Resident # 45 had labs drawn (PT/INR) on 7/14/16. Subsequent medical orders were received and implemented appropriately. A subsequent, pharmacy consultant review was completed on 7/26/16.
2. All residents receiving Coumadin have the potential to be affected by the identified deficient practice. The consultant pharmacist will review all of those residents identified to ensure there is a complete monthly drug review.
3. The pharmacy consultant will conduct a comprehensive MRR for each resident currently admitted to include documentation of appropriate medication orders, monitoring including necessary laboratory testing and subsequent reporting of any irregularities.
4. An audit will be completed monthly on all resident receiving Coumadin by the pharmacy consultant monthly for a period of 6 months to ensure no irregularities exist and that INR levels are being completed. All Results will be reported to the Quality Assurance Committee in which time progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility administrator will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/23/2016.

FF09 483.25(e)(2):INCREASE/PREVENT DECREASE IN RANGE OF MOTION

REGULATION: Based on the comprehensive assessment of a resident, the facility must ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 5, 2016
Corrected date: October 27, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 8/5/16, the facility did not ensure that a resident with a limited range of motion (ROM)receives appropriate treatment and services to increase ROM and/ or to prevent further decrease in ROM. One (Resident #58) of two residents observed with contractures lacked placement of a left palm Posey (palm grip for contracture treatment) for a hand contracture. The finding is: 1. Resident #58 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/27/16 revealed the resident is severely impaired for decision making. Interview with the Registered Nurse (RN) #5 Unit Manager on 8/2/16 at 11:50 AM revealed the resident has contractures and wears a left palm Posey. Observation of the resident on 8/2/16 at 1:35 PM revealed the resident's left hand was contracted and there was no palm Posey present during the observation. Review of Occupational Therapy (OT) Plan of Care dated 3/1/16 revealed resident demonstrates severe tightness, full contracture and pain in left hand and is unable to use it functionally to assist with ADLs (activities of daily life) such as feeding. The resident demonstrates pain in left hand and is unable to open the left hand without severe pain and argument. Long term goal is for optimal positioning of left hand in palm Posey and in wheelchair in order to achieve better feeding and skin integrity. Review of the current Certified Nurse Aide (CNA) My Profile of Care revealed AAROM (active assistive range of motion) to all upper extremities (especially hands) geri gloves and left hand palm Posey to be worn AATs (at all times) except for meals and hygiene. Observation of the resident on 8/4/16 at 9:00 AM, 9:50 AM, 10:25 AM, 11:15 AM, and 1:50 PM revealed the resident did not have the left palm Posey in place. Observation of the resident on 8/5/16 at 9:30 AM revealed the resident did not have the left palm Posey in place. Interview with RN #5 on 8/5/16 at 9:35 AM revealed the resident should have the left palm Posey on. Interview on 8/5/16 at 9:36 AM, the assigned CNA stated, It wasn't in her drawer so I didn't put it on. Interview on 8/5/16 at 9:40 AM, the OT stated, I don't know how long the Posey was missing but the resident should be wearing it daily. Observation of the OT applying a new palm Posey on the resident on 8/5/16 at 9:55 revealed it was somewhat painful to the resident. The OT stated, It was difficult to assess if the contracture was worse as the resident hasn't been on program since March. It's still about a 90 degree angle contracture. 415.12(e)(2)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during Post Survey Revisit #1 completed on 10/5/16, the facility did not ensure that a resident with limited range of motion (ROM) receives appropriate treatment and services to increase ROM and or to prevent further decrease in ROM. One (Resident #58) of three residents observed with contractures (loss of joint mobility) did not have a left hand palm Posey pillow (small soft pillow used for contracture treatment) in place as planned and recommended by therapy. The finding is: 1. Resident #58 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/27/16 revealed the resident is severely cognitively impaired, usually understands, is usually understood, and has functional limitations of the upper extremity on one side. Review of an Occupational Therapy Plan of Care note dated 9/29/16 revealed the resident has positioning deficits of the left hand, including maintaining the left hand with the middle two digits in a flexion posture (a fisted position). The plan includes splinting and reducing pain in the hand with maximal ROM. Review of the current Comprehensive Care Plan (CCP) with a revision date of 6/5/16 revealed a focus problem that the resident has limitations in ROM with a goal for the resident to maintain/ improve ROM status by the next review. CCP interventions include a plan for the resident is to wear a left hand palm Posey pillow at all times except during hygiene and meals. Review of the My Profile of Care, used by staff to provide care, dated 8/25/16 revealed instructions for a splint device - left hand palm Posey pillow to be worn at all times except for meals and hygiene. Observation on 10/4/16 at approximately 12:25 PM revealed that a Licensed Practical Nurse (LPN #1) removed the palm pillow from the resident's left hand and placed the palm pillow on the right hand grip of the resident's wheel chair. The fingers of the resident's left hand were observed to have an approximate 90 degree contracture and all of the fingers were closed to the palm of the hand (a fisted position). Observation on 10/4/16 at approximately 1:00 PM revealed that a Certified Nurse Aide (CNA #1) transported the resident in a wheelchair from the dining area to her room and placed the resident in bed. The palm pillow was observed on the right hand grip of the resident's wheel chair. Additional observations on 10/4/16 at approximately 1:22 PM, 2:15 PM, and 3:00 PM revealed the resident was in bed; her hands were visible; and the palm Posey pillow remained on the right hand grip of the resident's wheel chair. During an interview on 10/4/16 at approximately 3:00 PM, LPN #2 reviewed the My Profile of Care dated 8/25/16 (posted in the resident's room) and stated that she is not the resident's nurse today, but according to the My Profile of Care the palm pillow should be on the resident's left hand. During an interview on 10/4/16 at 3:05 AM, the Director of Therapy stated that the resident does have a contracture of her hand, and the palm pillow is to be worn at all times except for meals and hygiene. Per the Director of Therapy, no one has reported to therapy that the resident has been refusing the palm pillow or that the pillow was missing. The Director of Therapy stated that the resident will open her hand slightly if you involve her in putting the pillow in place, versus just trying to put the pillow in place. Review of a Task Report dated 10/4/16 at 1:58 PM revealed that CNA #1 checked yes that the resident's left hand Posey palm pillow, to be worn at all times except hygiene and meals, was completed according to the resident's plan of care. During an interview on 10/4/16 at approximately 3:15 PM, the Regional Registered Nurse (RN) stated that the expectation is that the CNAs follow the plan of care and the palm pillow should be in place when the resident is not at meals or during hygiene. In addition, when the CNA checks off the task, the CNA is indicating that the task was completed according to the resident's plan of care (palm Posey pillow on at all times except for meals and hygiene). During an interview on 10/5/16 at approximately 8:57 AM, CNA #1 stated that she was responsible for the care of Resident #58 on 10/4/16. CNA #1 stated that she was aware that the resident is to wear the left hand palm pillow at all times except for hygiene and meals. CNA #1 stated that she could not locate the palm pillow on 10/4/16, and that she was not aware that the palm pillow was on the hand grip of the resident's wheel chair. CNA #1 further stated that she thought that the pillow was maybe in the wash. CNA #1 stated that she did not report to anyone that the resident's palm pillow was missing and that she was not able to put the palm pillow in place. 415.12(e)(2)

Plan of Correction: ApprovedOctober 20, 2016

1. Residents # 58 was not identified with any untoward effects from the identified deficient practice. The resident was reassessed for range of motion and a new palm poesy was issued on 8/23/16
2. All residents requiring a device to treat contractures have the potential to be affected by the identified deficient practice. An audit was conducted on 8/18/16 identifying those residents with contractures who require a device. All devices were validated to be present and implemented per the plan of care.
3. C.N.A. staff will be reeducated on the facilities policy on following the plan of care with a special emphasis on the importance of device application
4. The rehabilitation department will audit all residents who require a device to treat contractures monthly for a period of 3 months to ensure the device is present and being applied per the plan of care. All Results will be reported to the Quality Assurance Committee in which time progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility administrator will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/23/2016.

FF09 483.75(j)(2)(i):LAB SVCS ONLY WHEN ORDERED BY PHYSICIAN

REGULATION: The facility must provide or obtain laboratory services only when ordered by the attending physician.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 5, 2016
Corrected date: October 27, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during Post Survey Revisit #1 completed on 10/5/16, the facility did not ensure that laboratory (lab) services were provided only when ordered by the Physician. One (Resident #45) of four residents reviewed for laboratory services had blood work obtained without a physician's order. The finding is: 1. Resident #45 was re-admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Order Summary Report revealed physician's orders as follows: - 9/17/16 - CBC (complete blood count) and BMP (basic metabolic panel - blood chemistries) every week. - 9/19/16 - CBC every Monday and Thursday - 9/23/16 - BMP on 9/26/16 There were no physician's orders for a PT/INR ([MEDICATION NAME] time-clotting time/ international normalizing ratio- standardized normal clotting time). Review of the current comprehensive care plan dated 9/18/16 revealed upon the resident's re-admission from the hospital MD (medical doctor) discontinued [MEDICATION NAME] (medication used to thin the blood) and will be on aspirin (asa). Review of the Nurse Practitioner Note dated 10/3/16 revealed the following plan; chronic [MEDICAL CONDITION], heart rate controlled keep on asa. Review of Laboratory Reports dated 9/26/16 revealed that a BMP, CBC, and a PT/ INR were drawn. Review of Resident Information/ Status/ Blood Work Order (change notification) forms dated 9/17/16, 9/19/16, and 9/27/16 revealed that the lab was notified in writing that orders for routine PT/ INR's to be drawn on Mondays and Thursdays were to be discontinued for Resident #45. Review of the Phlebotomy Collection Log dated 9/26/16 revealed that a lab technician signed that a CBC was drawn for Resident #45. During an interview on 10/4/16 at 11:14 AM, the Registered Nurse (RN) Unit Manager stated that the resident was not on [MEDICATION NAME] and that a PT/ INR was not ordered to be drawn. In addition, on 9/17/16, 9/19/16, and on 9/27/16 a notification change form was submitted to the lab to discontinue routine PT/ INR draws. When interviewed on 10/4/16 at 2:40 PM, the RN Regional Nurse (Quality Assurance Nurse) stated that the lab has up to five days to follow up on new or discontinued routine blood work. During further interview on 10/5/16 at 9:54 AM, the RN Regional Nurse stated that she followed up with the Lab Manager. Per the Regional RN, the Lab Manager stated that the lab did receive the three change forms to discontinue the routine PT/ INR's for Resident #45 and the lab would need to check with their IT (information technology) department as to why the routine PT/ INR showed back up again. In addition, the Lab Manager stated that the lab technician should be following up with the nurses if there is a discrepancy with the paper work and verifying what blood work should be drawn. 415.20

Plan of Correction: ApprovedOctober 20, 2016

This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
1. Resident #45 was not noted with any untoward effects from the identified deficient practice. The lab was contacted on 10/4/2016, to D/C the PT/INR order.
2. All residents requiring a lab draws have the potential to be affected by the identified deficient practice. An audit was conducted on 10/21/16 and immediately after facility notification of the deficient practice and all lab orders were validated to be present per provider orders.
3. Nurse staff will be educated on the facility's procedures: RN Supervisor will verify on lab draw days that Facility Phlebotomy Collection Log matches the Lab Draw report provided by Lab Technician prior to the technician performing any draws for each visit. In servicing will be completed by 10/27/2016.
4. The Director of Nursing will audit 10 random lab orders compared to the Phlebotomy Collection Log weekly for 12 weeks. All results will be reported to the Quality Assurance Committee in which time progress will be reviewed.
5. The facility Administrator will be responsible to ensure the completion of the corrective action. The plan will be completed by 10/27/2016

FF09 483.40(b):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDERS

REGULATION: The physician must review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; write, sign, and date progress notes at each visit; and sign and date all orders with the exception of influenza and pneumococcal polysaccharide 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: August 5, 2016
Corrected date: September 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint investigation (Complaint #NY 071) conducted during the Standard survey completed on 8/5/16, the facility did not ensure Physician review of the resident's total plan of care, including medications and treatments at each visit. One (Resident #45) of two resident reviewed for physician visits the Physician did not review the resident's total plan of care during the visit of 6/30/16. The Physician did not ensure that the resident, who was on [MEDICATION NAME] (anticoagulant medication), had orders in place to monitor the resident's PT([MEDICATION NAME] time-clotting time)INR (International normalizing ratio-standardized normalized blood clotting values). The finding is: 1. Resident #45 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] for subacute rehabilitation. Review of the hospital Discharge Summary dated 6/29/16 revealed a discharge medication list which included the medication Eliquis (anticoagulant medication) 2.5 milligrams (mg) twice a day. Under the [DIAGNOSES REDACTED]. Review of the hospital Transfer/Post OP (operative) Medication Orders printed on 6/29/16 revealed an order for [REDACTED]. Review of the hospital Medication Administration Record [REDACTED]. Review of hospital Laboratory (lab) Reports revealed an INR performed on 6/28/16 was 1.38 and an INR performed on 6/29/16 was 2.4 (INR goal range 2-3). Review of the facility Medication Reconciliation/ Physician Orders Worksheet dated 6/29/16 revealed admission orders [REDACTED]. The worksheet included admission lab orders for CBC (complete blood count), CMP (complete metabolic profile), and Hgb A1C (blood test to determine average blood glucose levels). In addition, orders for routine labs of a CBC and BMP (basic metabolic profile) to be done weekly. The worksheet was completed by RN #1 and co-signed by RN #2 as the second Nurse Reconciliation Review. The area indicating labs for PT/INR was blank. Review of a Progress Note written by the day Supervisor Registered Nurse (RN) #1 dated 6/29/16 at 9:39 PM revealed the resident was admitted to the unit on 6/29/16 in the evening with [DIAGNOSES REDACTED]. The orders were confirmed with the PA (Physician Assistant). RN #1 clarified the order for Eliquis 2.5 mg BID (twice daily) which was on the med list from the hospital, however in the discharge narrative, [MEDICATION NAME] was chosen over Eliquis due to the resident's fluctuating creatinine (blood test to determine kidney function). RN #1 documented that [MEDICATION NAME] will be started. Review of the Order Summary Report (Physician's Orders) dated 6/29/16 revealed an order for [REDACTED]. Review of a fax from the hospital pharmacy labeled Anticoagulant Management Service to the facility dated 6/30/16 documented that the patient has been discharged from the hospital on [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The discharge dosage directions were to hold [MEDICATION NAME] ([MEDICATION NAME]) tonight (6/29/16) due to a 1 pt (point) jump in INR over past 24 hours after only 2 doses. The fax indicated that [MEDICATION NAME] 5 mg was administered in the hospital on [DATE] and 6/28/16. The discharge comments on the fax state to obtain a PT/INR the morning of 6/30/16 for further [MEDICATION NAME] dosing. (It should be noted that the document was faxed to the facility on [DATE] at 12:03 PM, the day after the resident was admitted to the facility). Review of the History and Physical (H&P) exam dated 6/30/16 completed by the Physician revealed Eliquis was discontinued due to renal function fluctuations and the resident was placed on [MEDICATION NAME]. The Physician note documents the discrepancy noted between the Hospital Discharge medication list, the Discharge Summary and the facility medication list. The H&P revealed that the resident is on [MEDICATION NAME] and off Eliquis and the plan is to monitor INRs while on [MEDICATION NAME]. Review of a NP #2 note dated 7/14/16 revealed that staff reported the resident had left upper extremity pain and ecchymosis (purplish patch caused by blood under the skin), the resident denied injury to the area. The resident was also noted with conjunctival (whites of eyes) hemorrhage and was unaware of how she acquired it. Multiple areas of ecchymosis were observed over the left clavicle (shoulder blade) into the axillary area. The area was tender to palpation. Pain in the left arm appears to be musculoskeletal in nature. The plan is to get an x-ray to rule out underlying pathology, to check the INR to rule out a hypercoaguable (condition in which there is an abnormally increased tendency toward blood clotting) state, and to order pain medication. The resident likely developed a hematoma in the area due to repetitive exercises. Under assessment for [MEDICAL CONDITION] revealed that the rate is stable on [MEDICATION NAME] and [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] (chest pain), hypertension (high blood pressure) and to treat or prevent [MEDICAL CONDITION]) and the plan is to follow the INR closely as the resident has been hypercoaguable in the past. Review of the Medication Administration Summary for (MONTH) and (MONTH) (YEAR) revealed the resident received [MEDICATION NAME] 4 mg at 9:00 PM every day from 6/30/16 through and including 7/14/16. Review of the Order Summary Report dated 7/14/16 revealed an order for [REDACTED]. Review of the lab report dated 7/14/16 revealed the PT value reported on 7/15/16 at 12:30 AM was 230.2 (reference range is 9.3 - 13.5) and the INR value was 18 (reference range is 0.9 - 1.2). Review of an RN Progress Note dated 7/15/16 at 12:30 AM revealed the resident had a critically high PT/INR, the NP called and gave orders for a Vitamin K (helps to clot the blood) 10 mg injection one time now. The resident denied chest pain, shortness of breath and there were no new areas of bruising noted on the resident. Labs are to be repeated in the morning. Review of the facility policy and procedure entitled Admission, Annual and Routine Lab Tests for Medical Services dated 11/2007 revealed; -Routine Tests Based on Medical Conditions: Laboratory tests will be obtained routinely for residents with identified Medical Conditions and/or medication orders, according to the schedule below and/or as ordered by the Physician. [MEDICATION NAME]/ [MEDICATION NAME]/Anticoagulant Therapy- PT/INR time is obtained weekly. If the resident is stable, PT/INR may be obtained every (2) weeks. The Physician stated during a telephone interview on 7/26/16 at approximately 2:30 PM that on 6/30/16 she completed the resident's initial H&P exam and also noted the discrepancy between the Eliquis and [MEDICATION NAME] while reviewing records on the computer system. The Physician stated that she did not find any INR results in the computer system and asked a nurse about the INRs. The nurse told her that they were monitoring the INRs and the nurses were still in the process of entering orders on the resident. The Physician stated that the nurses seemed to be aware of the need to monitor INRs and that it is her expectation that INRs are monitored on all residents on [MEDICATION NAME]. In summary, the Physician did not ensure that medical orders were in place to monitor INR results for the resident on [MEDICATION NAME]. 415.15 (b)(2)(iii)

Plan of Correction: ApprovedAugust 29, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The filing of this plan of correction does not constitute that the deficiencies alleged did not in fact exist, rather this P(NAME) is filed as evidence of the facility?s continuing commitment to high quality resident care in full compliance with state and federal regulations.
1. Resident ID # 45 had labs drawn (PT/INR) on 7/14/16. Subsequent medical orders were received and implemented appropriately. A physician review of the residents plan of care, including medications was completed on 7/18/16.
2. All residents receiving [MEDICATION NAME] have the potential to be affected by the identified deficient practice. All residents receiving [MEDICATION NAME] have been identified and full house audits where completed on 7/14/16 and 8/16/16 to ensure PT/INR monitoring was being completed per the facility policy. In addition, all physician visits will be reviewed to ensure the resident plan of care, including medications are accurately reflected.
3. The Medical Director will provide education to facility medical providers regarding expectations for comprehensive and accurate review of the resident?s total plan of care, including medications and treatments at each visit; with a special emphasis on resident?s receiving [MEDICATION NAME] and their responsibility to ensure that orders are in place for lab monitoring (PT / INR)
4. Physician visit notes will be reviewed monthly on every resident receiving [MEDICATION NAME] by the Medical Director for a period of 6 months to the ensure the visit is comprehensive and accurate reviewing the total plan of care. All Results will be reported to the Quality Assurance Committee in which time progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility administrator will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/23/2016.

FF09 483.25:PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: 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, in accordance with the comprehensive assessment and plan of care.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 5, 2016
Corrected date: September 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint investigation (Complaints #NY 004 and NY 212) conducted during the Standard survey completed on 8/5/16, the facility did not ensure that each resident receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Three (Resident #55, 84, 148) of nine residents were reviewed for unnecessary medications had issues. Specifically, [MEDICATION NAME] [MEDICATION]) was discontinued in error, resulting in missed doses and breakthrough [MEDICAL CONDITION] (Resident #55); lack of an accurate reconciliation and transcription of admission orders [REDACTED]. In addition, orders for daily vital signs and monthly/every three month laboratory (lab) work was not completed (Resident #84). The findings are: 1. Resident #55 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/1/16 revealed the resident has severe cognitive impairment, rarely/never understands, and is absent of spoken words. Review of the facility Medication Reconciliation/Physician order [REDACTED]. -[MEDICATION NAME] 100 mg/ml (millgrams per milliliter) 1500 mg = 15 ml solution via PEG (percutaneous endoscopic gastrostomy tube - feeding tube inserted into the stomach) TID (three times a day) Q (every) 8 hours. - CBC (complete blood count), BMP (basic metabolic profile), [MEDICATION NAME] [MEDICATION]), [MEDICATION NAME] [MEDICATION]) level, [MEDICATION NAME] [MEDICATION]) level Q week. Review of Provider Note dated 5/6/16 included the Assessment Other [MEDICAL CONDITION] with the Comment Keep on current medications and doses. Review of Prescriber Phone Orders, confirmed by the Licensed Practical Nurse (LPN), dated 5/12/16 included the following orders: -4:06 PM Discontinue [MEDICATION NAME] Solution 100 mg/ml (Levetiracetam) Give 15 ml via PE[DEVICE] Q 8 hours for [MEDICAL CONDITION]. -4:07 PM Discontinue CBC with diff (differential), CMP (complete metabolic profile), [MEDICATION NAME] level, [MEDICATION NAME] level Q Friday. -4:08 PM CBC with diff, CMP, [MEDICATION NAME] ([MEDICATION NAME]) level, [MEDICATION NAME] level, [MEDICATION NAME] level, Levetiracetam level Q Friday for [MEDICAL CONDITION] disorder. Review of a Discontinue Order, created by the LPN on 5/12/16 at 4:06 PM revealed an order for [REDACTED]. Interview with Quality Manager Officer Registered Nurse (RN) #6 on 8/5/16 at 7:49 AM revealed upon the facility investigation of the medication error it was determined that the LPN entered the discontinue order for the [MEDICATION NAME] into the EMR in error. The NP then electronically confirmed the discontinue order for the [MEDICATION NAME] in a batch of multiple orders without specifically reviewing each order contained within the batch. Review of the NP's written statement dated 5/17/16 revealed, Resident #55 should not have been taken off his [MEDICATION NAME] medication. It was discussed with his nurses earlier that he should be on [MEDICATION NAME] and [MEDICATION NAME] [MEDICATION]) and that blood work should be done to verify the therapeutic levels. It was inadvertently discontinued when a group of orders were signed. Review of Medication Error Report dated 5/16/16, signed by LPN #1 included Unanticipated data entry errors made by 2 individuals with EMR system resulted in error that required treatment or intervention and caused temporary harm. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of Prescriber Phone Order dated 5/14/16 at 1:35 AM revealed an order to send to hospital for unconvulsive [MEDICAL CONDITION] activity. Review of an undated facility policy and procedure (P&P) entitled Medication Reconciliation Process included the following: -Medication reconciliation will be completed to provide a safe and effective process for obtaining, documenting and communicating medications across a resident's continuum of care. -Electronic Records - Appropriate medication, dose and frequency of routine orders will be verified at the time of confirmation and signature. 2. Resident #148 was admitted to facility on 4/27/16 with [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary dated 4/27/16 revealed the following Medications At Discharge: -[MEDICATION NAME] (medication used to prevent blood clot formation) 40 milligrams (mg) SubQ (subcutaneous - beneath the skin) daily for 10 days. Then aspirin 325 mg daily for 3 weeks. -[MEDICATION NAME] (antianxiety medication) 0.25 mg BID (twice daily) PRN (as needed). -[MEDICATION NAME] (medication used to treat high cholesterol) 10 mg daily -[MEDICATION NAME] (steroid) 0.5% (percent) cream BID PRN itching. -[MEDICATION NAME] (steroid) 0.5% cream BID PRN itching. -[MEDICATION NAME] sulfate 0.125mg 1-2 tablets Q 4 hours PRN diarrhea. -[MEDICATION NAME] (Advil) 200 mg Q 8 hours PRN. -Advil PM for sleep at night. -[MEDICATION NAME] ([MEDICATION NAME]) 25 mg three times daily PRN nausea. -[MEDICATION NAME] (medication used to treat HTN) 50 mg daily. -Refresh tears. -[MEDICATION NAME]. -Vitamin B12 one tablet daily. -Vitamin D 1000 units daily. -[MEDICATION NAME] ([MEDICAL CONDITION] and immunosuppressant medication) 2.5.mg 6 tablets Q Saturday. Review of an unsigned, undated Medication Reconciliation /Physician order [REDACTED]. -[MEDICATION NAME] 0.25 mg BID PRN. -[MEDICATION NAME] 10 mg daily. -Refresh tears. -[MEDICATION NAME]. Review of the Order Summary Report revealed orders for [MEDICATION NAME] 0.25 mg by mouth at bedtime was ordered on [DATE]. Further review revealed neither the [MEDICATION NAME], Refresh tears, nor [MEDICATION NAME] were ordered for the resident. In addition, Aspirin 325 mg was ordered upon admission and the resident began receiving the Aspirin on 4/28/16 prior to the Physician's instructions. Interview with Quality Manager Officer Registered Nurse (RN) #6 on 8/5/16 at 7:49 AM revealed the transcription errors resulted in the omission of five doses of [MEDICATION NAME]. In addition, the resident received five doses of Aspirin in error. Also, the number omitted doses is unknown for the [MEDICATION NAME], Refresh Tears and [MEDICATION NAME]. Review of an undated facility P&P entitled Medication Reconciliation Process included the following: -Medication reconciliation will be completed to provide a safe and effective process for obtaining, documenting and communicating medications across a resident's continuum of care. The process will be completed by appropriately trained, licensed nurses for all resident admissions/readmissions, transfers and discharges to obtain/provide a complete and accurate list of a resident's medications. 3. Resident #84 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident is severely cognitively impaired, is sometimes understood and understands. Review of the Order Summary Report dated 8/4/16 revealed the following orders; -4/28/16 [MEDICATION NAME] 3.125 mg give 1 tablet by mouth Q 12 hours for HTN. Vital signs (VS) checked QD (every day). -7/5/16 Discontinue VS QD. -7/20/16 [MEDICATION NAME] tablet 3.125 mg give 1 tablet by mouth BID for HTN. VS checked QD. Review of (MONTH) (YEAR) MAR indicated [REDACTED]. No VS were taken from 7/20/16 through 8/4/16. Review of the Order Summary Report dated 11/3/15 revealed lab orders for BMP, H/H (hemoglobin/ hematocrit) to start monthly on 11/27/15. In addition, orders dated 12/7/15 revealed CBC with diff, CMP, HbA1C (glycosylated hemoglobin) Q three months starting on 12/28/15. Review of monthly lab draws revealed BMP, H/H were drawn on 11/9/2015, 12/18/15, 12/21/15, 12/28/15, and 1/22/16. There were no blood draws for the next 6 months which included: February, March, April, May, June, and (MONTH) (YEAR). Review of Q three month lab draws for CBC with diff, CMP, HbA1C revealed no lab draw on 12/28/15 and the first draw was on 2/26/16. There were no blood draws for (MONTH) (YEAR). Review of the current Comprehensive Care Plan under Cardiac/ Vascular Status revealed interventions to monitor VS/ pulse oximetry (amount of oxygen in the blood) PRN/ ordered and lab work/ diagnostic tests per MD (medical doctor)/ NP order. During an interview on 8/4/16 at 10:48 AM, Unit Manager RN #5 stated, There is no reason for getting vitals (VS) every day. I was on sub-acute and they do vitals every day on that unit. But the verbiage for the order does state she (Resident #84) should have them. Vitals to me are blood pressure, temperature, pulse and respirations. Also, the labs were not done as ordered. During an interview on 8/4/16 at 11:05 AM Quality Manager Officer RN #6 stated, Everyday vitals were discontinued because the patient went to long term care and did not require them. It really depends on if the Physician wanted the vitals continued for that particular medication. I would've expected someone to have questioned the continuation of the vitals signs. Also, the labs should've been done per the MD order and they were not. 415.12

Plan of Correction: ApprovedAugust 29, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident # 55 medication was resumed on 5/25/16 and was subsequently discharged home on[DATE]. NP was re-educated on 5/23/16. Resident # 148 was discharged from the facility on 5/2/16. Resident # 84 ? On 8/4/16, orders were clarified with the medical director by the Unit Manager. Labs were obtained on 8/5/16. Parameters associated with the [MEDICATION NAME] order was determined not to be required.
2. a)All residents that the potential of having an order discontinued and confirmed by a medical professional in error. All discontinued orders from 7/1/16 through 8/23/16 were reviewed to ensure a discontinuation error did not occur.
b)All admissions/readmissions have the potential to be affected by the identified deficient practice. On 5/4/16, a full house medication reconciliation was completed to identify any inaccurate reconciliation or transcription of admission orders [REDACTED]
c)All residents requiring lab work have the potential to be affected by the identified deficient practice. A full house audit will be completed verifying current orders with obtained lab results.
All residents requiring vital signs as part of medication monitoring have the potential to be affected by the identified deficient practice. A full house audit will be completed verifying current orders with obtained vital signs.
3. a)Medical staff will be re-educated on the steps of confirming orders via the Electronic Medical Record System by the facilities Medical Director. Licensed Nurses will be re-educated on the importance of ensuring that the correct order is discontinued and the rationale for discontinuation is documented.
b)Nursing staff will be educated on the facilities policy on Processing and Reconciliation of admission orders [REDACTED]
c)Licensed nurses will be re-educated on the facilities policy of ordering and receiving results of laboratory (lab) work. A tracking system will be implemented to ensure laboratory (lab) work is ordered and results obtained.
Licensed nurses will be re-educated on the facilities policy of obtaining vital signs per the physician order.
4. a)Ten random discontinued orders will be selected monthly for a period of 3 months to ensure orders have not been discontinued in error. This audit will be completed by the Unit Mangers.
b)Every admission/readmission?s medical record will be audited for a period of 3 months to ensure accurate reconciliation and transcription of admission orders [REDACTED].
c)10 Monthly audits for a period of 3 months will be completed, by the Unit Managers, on residents requiring vital signs as part of medication monitoring.
d)10 Monthly audits for a period of 3 months will be completed, by the Unit Managers, on resident lab orders to ensure lab work is ordered and obtained accurately.
All Results will be reported to the Quality Assurance Committee in which time progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility administrator will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/23/2016.

E3BP 402.5(c):REQUIREMENTS BEFORE SUBMITTING A REQUEST FOR

REGULATION: Section 402.5 Requirements Before Submitting a Request for a Criminal History Record Check. ...... (c) The provider shall obtain the signed, informed consent of the subject individual in the form and format specified by the Department which indicates that the subject individual has: (1) been informed of the right and procedures necessary to obtain, review and seek correction of his or her criminal history information; (2) been informed of the reason for the request for his or her criminal history information; (3) consented to the request for a criminal history record check; and (4) supplied on the form a current mailing or home address.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: August 5, 2016
Corrected date: September 23, 2016

Citation Details

Based on interview and record review conducted during the Standard survey completed on 8/5/16, employee consent forms (CHRC 102 Form) were not completely filled out. Four (Activity Leader, Memory Care Specialist and two Certified Nurse Aides (CNA) of five employees reviewed for compliance with the Criminal History Record Check (CHRC) program had issues with CHRC 102 Forms not completely filled out. The finding is: 1. Review of the personnel files for Employee #1 (Activity Leader), Employee #2 (Memory Care Specialist), Employee #3 (CNA) and, Employee #4 (CNA) on 8/4/16 revealed the CHRC 102 Form, Acknowledgement and Consent Form for Fingerprinting and Disclosure of Criminal History Record Information, was not completely filled out. Further record review at this same time revealed Section Three (Agency Authorized Person Information) was blank for all four employees, including the signature of the Authorized Person. Interview with the Human Resources Coordinator/Authorized Person on 8/4/16 at approximately 9:40 AM revealed she has been the Authorized Person for approximately one year and during that time, she has not completed Section Three of any CHRC Form 102 because she was not instructed to do so. 402.6(b)

Plan of Correction: ApprovedSeptember 20, 2016

1. CHRC 102 Form, Section 3 was not signed by Agency Authorized Person for Employee #1, #2, #3 & #4. These forms were reviewed and noted as, incomplete by the authorized person for future reference.
2. All staff requiring the CHRC 102 Form completion have the potential to be affected by the identified deficient practice. Human Resources representative reviewed all CHRC 102 Forms of active staff on 8/26/16.
3. Human Resources representative who is the Agency Authorized Person was educated on 8/26/16 to complete Section 3 of the CHRC 102 Form for all new hires.
4. An audit will be conducted monthly to review all new hires to ensure proper completion of the CHRC 102 Form. This audit will be conducted for 6 months and results will be reported to the Quality Assurance Committee. Determination for ongoing monitoring will be determined after 6 months of auditing.
5. The facility administrator will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/23/2016.

FF09 483.20(k)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: The services provided or arranged by the facility must 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: August 5, 2016
Corrected date: September 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard Survey completed on 8/5/16, the facility did not ensure that services are provided by qualified persons in accordance with the resident's written plan of care. One (Resident #125) of five residents reviewed for care plans had an issue involving staff not applying a urinary leg bag (urine collection bag that attaches to the resident's leg and is worn beneath slacks/ clothes) when out of bed per the plan of care. The finding is: 1. Resident #125 has [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set (MDS- a resident assessment tool) dated 7/14/16 revealed the resident usually understands, is usually understood, and requires extensive assistance in managing their catheter (a tube inserted into the bladder to drain urine) and has severely impaired vision. Review of the Comprehensive Care Plan dated 7/26/16 revealed the resident uses a urinary catheter due to [MEDICAL CONDITION] (inability of the bladder to empty). Interventions include that the resident wears a leg bag when OOB (out of bed). Review of the Certified Nurse Aide (CNA) My Profile of Care dated 7/26/16 revealed the resident requires extensive assistance by the staff to bathe, dress, transfer, and has a catheter and [MEDICAL CONDITION]. Observation of the resident's morning care on 8/4/16 at 6:49 AM revealed CNAs #1 and #2 assisted the resident to bathe and dress. The catheter drainage bag (a larger bag used to collect urine) was not changed to a leg bag. The resident was transferred OOB to the wheelchair with the assistance of a sit to stand lift (a mechanical lift machine that transfers residents using a sling and the device). The resident's catheter drainage bag was placed below the seat of the wheelchair in a catheter privacy bag. Observation of the resident on 8/4/16 at approximately 11:00 AM revealed the resident seated in the lounge area with the catheter drainage tubing hanging below the seat of the wheelchair. Interview with Licensed Practical Nurse (LPN) #2 on 8/5/16 at approximately 11:00 AM revealed the resident is care planned for a leg bag to be worn when OOB and that CNA #1 did not inform LPN #2 that a leg bag was not available for the resident. LPN #2 obtained a leg bag and brought the resident to her room to connect the device. Interview on 8/4/16 at 11:05 AM revealed CNA #1 is aware the resident's care plan includes a leg bag when OOB. CNA #1 stated that before getting Resident #125 up there was no leg bag in the resident's room and should have asked the nurse for a leg bag and attached it, but did not. Observation of the resident on 8/5/16 at approximately 9:15 AM revealed the resident seated in the wheelchair with the catheter drainage tubing hanging below the seat of the wheelchair. Interview on 8/5/16 at approximately 10:20 AM revealed CNA #3 had not applied the leg bag on the resident when gotten OOB on many occasions and had not informed the nurse. Interview on 8/5/16 at approximately 10:50 AM revealed LPN #2 is the full time medication/treatment nurse on Resident #125's hall. LPN #2 stated that neither CNAs or other staff have informed her that the resident had no leg bag on when OOB. LPN #2 stated when the staff is not able to perform care per the care plan, whether due to supply, resident refusal or other reasons, the nurse should be notified and if needed documented in the resident's record and on report. 415.11(c)(3)(ii)

Plan of Correction: ApprovedAugust 29, 2016

1. Resident # 125 care plan was reviewed and remains appropriate
2. All residents with indwelling catheters have the potential to be affected by the identified deficient practice. Residents identified will have their care plans reviewed for appropriate interventions, including the application of urinary leg collection bags.
3. C.N.A. staff will be re-educated on following the plan of care with a special emphasis on the importance of reporting any discrepancy, refusal of intervention, non-use, inability to locate needed equipment / device or resident concerns/difficulty.
4. Monthly audits for a period of 3 months, on all residents will indwelling catheters, will be completed to ensure the plan of care is being followed. This will be conducted by the Unit Managers. All Results will be reported to the Quality Assurance Committee in which time progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility administrator will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/23/2016.

FF09 483.20(k)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: The services provided or arranged by the facility must meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 5, 2016
Corrected date: September 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Complaint investigation (Complaints #NY 071 and NY 004) during the Standard survey completed on 8/5/16, the facility did not provide services that met professional standards of quality. Two (Residents #45, 55) of 23 residents reviewed for professional standards had issues with [MEDICATION NAME] (anticoagulant medication) and laboratory instructions sent from the hospital pharmacy not reviewed by facility nursing staff resulting in the administration of [MEDICATION NAME] without checking INR (international normalizing ratio - standardized normalized blood coagulating values) from 6/30/16 through and including 7/14/16 (Resident #45); and the Nurse Practitioner (NP) confirmed an order that was entered into the Electronic Medical Record (EMR) in error to discontinue [MEDICATION NAME] [MEDICATION]) and the resident was subsequently hospitalized with a breakthrough [MEDICAL CONDITION] (Resident #55). The findings are: 1. Resident #45 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] for subacute rehabilitation. Review of the hospital Discharge Summary dated 6/29/16 revealed a discharge medication (med) list which included Eliquis (anticoagulant medication) 2.5 milligrams (mg) twice a day. Under the [DIAGNOSES REDACTED]. The discharge medication list did not include [MEDICATION NAME]. Review of the hospital Transfer/Post OP (operative) Medication Orders printed on 6/29/16 revealed an order for [REDACTED]. Review of the hospital Medication Administration Record (MAR) revealed [MEDICATION NAME] 5 mg was last administered on 6/28/16 at 8:47 PM. Review of hospital Laboratory (lab) Reports revealed an INR performed on 6/28/16 was 1.38 and an INR performed on 6/29/16 was 2.4 (INR goal range 2-3). Review of the facility Medication Reconciliation / Physician Orders Worksheet dated 6/29/16 revealed admission orders [REDACTED]. The worksheet included admission lab orders for CBC (complete blood count), CMP (complete metabolic profile), and Hgb A1C (blood test to determine average blood glucose levels). In addition, orders for routine labs of a CBC and BMP (basic metabolic profile) to be done weekly. The worksheet was completed by RN #1 and co-signed by RN #2 as the second Nurse Reconciliation Review. The area indicating labs for PT/INR was blank. Review of a Progress Note written by the day Supervisor RN #1 dated 6/29/16 at 9:39 PM revealed the resident was admitted to the unit on 6/29/16 in the evening with [DIAGNOSES REDACTED]. The orders were confirmed with the PA (Physician Assistant). RN #1 clarified the order for Eliquis 2.5 mg BID (twice daily) which was on the med list from the hospital, however in the discharge narrative, [MEDICATION NAME] was chosen over Eliquis due to the resident's fluctuating creatinine (blood test to determine kidney function). RN #1 documented that [MEDICATION NAME] will be started. Review of an Order Summary Report (Physician's Orders) dated 6/29/16 revealed an order for [REDACTED]. Review of a Progress Note - Order Note dated 6/29/16 signed by RN #2 revealed a lengthy note describing possible drug interactions between [MEDICATION NAME] and multiple other meds that were ordered for the resident. There is no documented evidence that the medical provider was notified of these potential interactions. Review of a fax from the hospital pharmacy labeled Anticoagulant Management Service to the facility dated 6/30/16 documented that the patient has been discharged from the hospital on [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The discharge dosage directions were to hold [MEDICATION NAME] ([MEDICATION NAME]) tonight (6/29/16) due to a 1 pt (point) jump in INR over past 24 hours after only 2 doses. The fax indicated that [MEDICATION NAME] 5 mg was administered in the hospital on [DATE] and 6/28/16. The discharge comments on the fax state to obtain a PT/INR the morning of 6/30/16 for further [MEDICATION NAME] dosing. (It should be noted that the document was faxed to the facility on [DATE] at 12:03 PM, the day after the resident was admitted to the facility). Review of a Progress Note written by RN #3 dated 7/14/16 at 8:22 AM revealed the resident complained of an inability to move her left shoulder and arm this morning. Some bruising was noted near the axilla (arm pit) and upper deltoid (shoulder muscle). The resident is unsure how the bruising occurred. Review of a NP #2 note dated 7/14/16 revealed that staff reported the resident had LUE (left upper extremity) pain and ecchymosis (purplish patch caused by blood under the skin), the resident denied injury to the area. The resident was also noted with conjunctival (white of the eye) hemorrhage and was unaware of how she acquired it. Multiple areas of ecchymosis were observed over the left clavicle (shoulder blade) into the axillary area. The area was tender to palpation. Pain in the left arm appears to be musculoskeletal in nature. The plan is to get an x-ray to rule out underlying pathology, to check the INR to rule out a hypercoaguable (condition in which there is an abnormally increased tendency toward blood clotting) state, and to order pain medication. The resident likely developed a hematoma in the area due to repetitive exercises. Under assessment for [MEDICAL CONDITION] revealed that the rate is stable on [MEDICATION NAME] and [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] (chest pain), hypertension (high blood pressure) and to treat or prevent [MEDICAL CONDITION]) and the plan is to follow the INR closely as the resident has been hypercoaguable in the past. Review of the Order Summary Report dated 7/14/16 revealed an order for [REDACTED]. Review of a Licensed Practical Nurse (LPN) Progress Note dated 7/14/16 at 1:38 PM revealed NP #2 was in to see the resident with new orders for [MEDICATION NAME] (opioid pain medication) 10/325 mg every 4 hours as needed for pain and a CBC on 7/18/16. The Progress Note revealed an INR was not ordered at this time. Review of a Progress Note dated 7/14/16 at 10:26 PM revealed the left shoulder x-ray showed [MEDICAL CONDITION] changes and no fracture or dislocation. The left humerus x-ray showed no acute fracture or destructive lesion. Review of the Medication Administration Summary for (MONTH) and (MONTH) (YEAR) revealed the resident received [MEDICATION NAME] 4 mg at 9:00 PM every day from 6/30/16 through and including 7/14/16. Review of the Order Summary Report dated 7/14/16 revealed an order for [REDACTED]. Review of the lab slip dated 7/14/16 revealed the PT/INR was drawn at 11:35 PM. Review of the lab report dated 7/14/16 revealed the PT value reported on 7/15/16 at 12:30 AM was 230.2 (reference range is 9.3 - 13.5) and the INR value was 18 (reference range is 0.9 - 1.2). Review of an RN Progress Note dated 7/15/16 at 12:30 AM revealed the resident had a critically high PT/INR, the NP called and gave orders for a Vitamin K (helps to clot the blood) 10 mg injection one time now. The resident denied chest pain, shortness of breath and there were no new areas of bruising noted on the resident. Labs are to be repeated in the morning. Review of a Progress Note written by RN #1 dated 7/15/16 at 2:43 PM revealed the INR result was 12.3. The NP was notified of the result by a secure text. Review of a Progress Note dated 7/15/16 at 5:32 PM revealed the NP returned the call related to the INR result of 12.3 and discontinued [MEDICATION NAME] and ordered Vitamin K 10 mg SQ (subcutaneously-beneath the skin) stat; repeat INR in the morning and call the NP with the results. Review of a LPN Progress Note dated 7/15/16 at 10:10 PM revealed that a sling is in place at all times to the left shoulder/arm; and bruising remains to the left upper arm. Review of an unsigned Progress Note dated 7/16/16 at 11:51 AM revealed the NP reviewed the labs from today and yesterday, the INR remained the same at 12.3. Vitamin K was given twice on 7/15/16. New order was received to send the resident to the ER (emergency room ) for evaluation due to uncorrected critical level. The resident left via ambulance on 7/16/16 at 12:30 PM. Review of an RN Progress Note dated 7/16/16 at 11:59 PM revealed the resident returned from the ER at approximately 9:30 PM. The resident was given oral Vitamin K in the ER and had a repeat INR of 13.2. There were no new recommendations or orders. The Physician service was notified of the resident's return and left message to question when the next INR level to be drawn. The Care Plan and Door Profile were changed to reflect bleeding/bruising precautions and a nurse order to monitor every shift for bleeding/bruising for 7 days. Review of the facility policy and procedure (P&P) entitled Therapeutic Anticoagulation Monitoring System for Nursing Services dated 9/2008 revealed that residents receiving anticoagulation therapy for the management of thrombus (blood clot), thrombus prevention or for management of [MEDICAL CONDITION] will receive periodic monitoring of PT/INR levels as ordered by the Attending Physician. Results are recorded on the MAR and/or [MEDICATION NAME] Record. The medication nurse must verify PT/INR test results prior to anticoagulant medication administration, as indicated. All PT/INR parameters are followed accordingly. Any contact with the Attending Physician regarding test results is recorded in the Nursing Progress Notes. Review of the facility investigation related to the incident dated 7/14/16 revealed that the resident was admitted to the facility on [DATE]. The Discharge Summary indicated Eliquis 2.5 mg orally twice a day. The narrative indicated that [MEDICATION NAME] was chosen over Eliquis due to fluctuating renal function. The resident had been receiving [MEDICATION NAME] in the hospital and her INR was therapeutic at 1.38 on 6/28/16 per the hospital Discharge Summary dated 6/29/16. [MEDICATION NAME] 4 mg was started on 6/30/16 after clarification with the PA per the Nurse's Note dated 6/29/16. Drug to drug interaction notifications were present per Nurse's Note review, however the facility was unable to locate documentation that the covering NP/MD (medical doctor) was notified by RN Supervisor (RN #2) who entered the orders and received notification of the drug to drug interactions. The Medication Reconciliation/Physician Order Worksheet reflects that the area indicating labs for PT/INR was blank. The worksheet was completed by RN #1 as the primary nurse and was signed by RN #2 as the second nurse as the Nurse Reconciliation Review. The facility investigation conclusions included the following: -The resident received multiple doses of [MEDICATION NAME] in the absence of PT/INR monitoring and exhibited bruising, conjunctival hemorrhage and the need for treatment with two doses of Vitamin K in the facility and an ER visit with one dose of Vitamin K administered. -Licensed nurses failed to verify PT/INR results prior to administration of [MEDICATION NAME] (per the Therapeutic Anticoagulation Monitoring System Policy) resulting in an elevated PT/INR. -RN #2 failed to appropriately obtain an order for [REDACTED]. Observation and interview of the resident on 7/25/16 at approximately 1:30 PM revealed the resident had a bluish large bruise to the left upper arm axillary area. The resident stated that the area hurts at times and she takes pain pills for the pain. During an interview with RN #1 on 7/25/16 at approximately 11:45 AM, RN #1 stated that on 6/29/16 she worked a double shift and the resident was admitted to the facility between approximately 7:00 PM - 8:00 PM. RN #1 stated that Nursing Supervisors process the new admissions. RN #1 stated that she completed the medication reconciliation using the Discharge Summary and MARs from the hospital. RN #1 stated she documented her admission orders [REDACTED]. She reviewed the admission meds by telephone with the PA who ordered [MEDICATION NAME] 4 mg for the resident. RN #1 stated that there was some confusion with this case because the hospital Discharge Summary med list stated that the resident was to continue on Eliquis. RN #1 stated that it was only through reviewing the written narrative in the Discharge Summary the resident was to be on [MEDICATION NAME] instead of Eliquis because of the resident's kidney function. RN #1 stated that she does not recall discussing the need for INRs with the PA and stated that there was no order for an INR on the worksheet that she used. RN #1 stated that normally PT/INRs are done with the admission labs usually within 24 - 48 hours of admission. RN #1 stated that she left the facility at 10:00 PM on 6/29/16 and handed off the admission paperwork to the night shift RN Supervisor who entered the admission orders [REDACTED]. RN #1 stated that the [MEDICATION NAME] Worksheet was never written up for the resident. [MEDICATION NAME] Worksheets are normally kept in the lab book maintained on each unit that contain the lab reports for all residents. RN #1 stated that the medication nurses are supposed to check the [MEDICATION NAME] Worksheet prior to administering any dose of [MEDICATION NAME] to check the most recent INR value. In addition, RN #1 stated that she did not see the fax from the hospital pharmacy dated 6/30/16 that gave instructions to hold the [MEDICATION NAME] on 6/29/16 and obtain a PT/INR the morning of 6/30/16 for further [MEDICATION NAME] dosing. RN #1 stated that the fax was sent by the hospital pharmacy on 6/30/16 at approximately 12:00 PM. In addition, RN #1 stated that NP #2 assessed the resident earlier in the day on 7/14/16 due to the resident's complaints of pain, immobility and bruising to the LUE ordered an x-ray and INR to be drawn. There was no order to hold [MEDICATION NAME] on 7/14/16. (Surveyor review of the orders revealed NP #2 did not order an INR on 7/14/16 but ordered a CBC to be done on 7/18/16). RN #1 stated that she was the Nursing Supervisor and acting as medication nurse on 7/14/16 during the evening shift and administered [MEDICATION NAME] 4 mg at bedtime. Later in the evening RN #1 was looking for the resident's INR results and could not find one. She informed NP #2 that ordered a stat INR. The results on 7/15/16 at approximately 12:30 AM was 18 critically high. During interview on 7/25/16 at approximately 3:15 PM, LPN #1 stated that per the initials on the MAR she administered [MEDICATION NAME] 4 mg to the resident at approximately 9:00 PM on 6/30/16, 7/2/16, 7/7/16, 7/8/16, 7/11/16, and 7/12/16 without checking the resident's INR level prior to administering the med. LPN #1 stated that it was a mistake not to check the INR level and she has been re-educated on the importance of checking the INR value prior to administering [MEDICATION NAME] to any resident. In summary, the facility nursing staff did not inform the Physician/NP of the need to monitor the resident's PT/INR and obtain orders for the lab studies. In addition, facility nursing staff administered [MEDICATION NAME] 4 mg every evening for approximately 2 weeks without checking the INR results prior to administering the medication. 2. Resident #55 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/1/16 revealed the resident has severe cognitive impairment, rarely/never understands, and is absent of spoken words. Review of the facility Medication Reconciliation/Physician Orders Worksheet dated 5/5/16 included the following orders: -[MEDICATION NAME] 100 mg/ml (milliliter) 1500 mg = 15 ml solution via PEG (percutaneous endoscopic gastrostomy tube - feeding tube inserted into the stomach) TID (three times a day) Q (every) 8 hours. - CBC, BMP, [MEDICATION NAME] [MEDICATION]), [MEDICATION NAME] [MEDICATION]) level, [MEDICATION NAME] [MEDICATION]) level Q week. Review of Provider Note dated 5/6/16 included the Assessment Other [MEDICAL CONDITION] with the Comment Keep on current medications and doses. Review of Prescriber Phone Orders, confirmed by the LPN, dated 5/12/16 included the following orders: -4:06 PM Discontinue [MEDICATION NAME] (Levetiracetam) Solution 100 mg/ml Give 15 ml via PE[DEVICE] Q 8 hours for [MEDICAL CONDITION]. -4:07 PM Discontinue CBC with diff (differential), CMP, [MEDICATION NAME] level, [MEDICATION NAME] level Q Friday. -4:08 PM CBC with diff, CMP, [MEDICATION NAME] ([MEDICATION NAME]) level, [MEDICATION NAME] level, [MEDICATION NAME] level, Levetiracetam level Q Friday for [MEDICAL CONDITION] disorder. Review of a Discontinue Order, created by the LPN on 5/12/16 at 4:06 PM revealed an order for [REDACTED]. Give 15 ml via PE[DEVICE] Q8 hours for [MEDICAL CONDITION]. Further review of the Discontinue Order revealed the NP signed the order, via Web Application, on 5/12/16 at 5:59 PM. Review of the NP's written statement dated 5/17/16 revealed, Resident #55 should not have been taken off his [MEDICATION NAME] medication. It was discussed with his nurses earlier that he should be on [MEDICATION NAME] and [MEDICATION NAME] [MEDICATION]) and that blood work should be done to verify the therapeutic levels. It was inadvertently discontinued when a group of orders were signed. Interview with Quality Manager Officer RN #6 on 8/5/16 at 7:49 AM revealed upon the facility investigation of the med error it was determined that the LPN entered the discontinue order for the [MEDICATION NAME] into the EMR in error. The NP then electronically confirmed the discontinue order for the [MEDICATION NAME] in a batch of multiple orders without specifically reviewing each order contained within the batch. Review of an undated facility P&P entitled Medication Reconciliation Process included the following: -Medication reconciliation will be completed to provide a safe and effective process for obtaining, documenting and communicating medications across a resident's continuum of care. -Electronic Records - Appropriate medication, dose and frequency of routine orders will be verified at the time of confirmation and signature. Review of undated facility P&P entitled Prescribing of Medical Orders included the following: -The Attending/Alternate, consulting specialist or Medical Director will be responsible for issuing, renewing or changing medical orders for the resident, as required. -Requirements for Review/Renewal of Physician Orders - all orders for care must be written and signed by a Licensed Physician/Nurse Practitioner/Physician Assistant. 415.11(c)(3)(i)

Plan of Correction: ApprovedAugust 29, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident # 45 had labs drawn (PT/INR) on 7/14/16. Subsequent medical orders were received and implemented appropriately. A notation to prompt nurses to check/verify and monitor INR prior to administration was added to the resident Medication Administration Record [REDACTED].
2. a)All residents receiving [MEDICATION NAME] have the potential to be affected by the identified deficient practice. All residents receiving [MEDICATION NAME] have been identified and full house audits where completed on 7/14/16 and 8/16/16 to ensure PT/INR monitoring was being completed per the facility policy.
b)All residents that the potential of have an order discontinued and confirmed by a medical professional in error. All discontinued orders from 7/1/16 through 8/23/16 were reviewed to ensure a discontinuation error did not occur.
3. a)Licensed nursing staff will be re-educated on the facilities policy of Anticoagulation Therapy and PT/INR monitoring and documentation requirements. The Medical Director will provide re-education to the facilities medical providers outlining the expectations from a comprehensive and accurate review of the resident?s total plan of care, including medications and treatments at each visit; with a special emphasis on resident?s receiving [MEDICATION NAME] to ensure that orders are in place for lab monitoring (PT/INR).
b)Medical staff will be re-educated on the steps of confirming orders via the Electronic Medical Record System by the facilities Medical Director. Licensed Nurses will be re-educated on the importance of ensuring that the correct order is discontinued and the rationale for discontinuation is documented.
4. a)Weekly audits will be completed for every resident receiving [MEDICATION NAME] by the Unit Managers for a period of 6 months to ensure PT/INR monitoring and documentation standards are being applied.
b)Ten random discontinued orders will be selected monthly for a period of 3 months to ensure orders have not been discontinued in error. This audit will be completed by the Unit Mangers.
All Results will be reported to the Quality Assurance Committee in which time progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility administrator will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/23/2016.