Oceanside Care Center Inc
July 19, 2016 Certification Survey

Standard Health Citations

FF09 483.60(b), (d), (e):DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

REGULATION: The facility must employ or obtain the services of a licensed pharmacist who establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 19, 2016
Corrected date: September 9, 2016

Citation Details

Based on observation, record review and staff interview during the recertification survey, the facility did not ensure that all drug and biologicals were stored in a locked cabinet in accordance with State and Federal laws. This was evident on two of two units toured for medication storage. Specifically, the South Unit medication locked box in the refrigerator which stored Ativan (an antianxiety medication) was unlocked. The locked box in the refrigerator on the North Unit which stored Marinol (an antiemetic) was broken. The finding is: During a medication storage tour on the South Unit conducted on 7/19/16 at 11:15 AM, with the Registered Nurse (RN) Supervisor present, the following was observed: The medication refrigerator in the medication storage room that stored two 30 millimeter (ml) vials of Ativan in a locked metal box was observed with the unlocked padlock hanging onto the hasp of the refrigerator. The RN Supervisor was immediately interviewed on 7/19/16 at 11:15 AM. The RN stated that the medication refrigerator should have been locked. During a medication storage tour on the North Unit conducted on 7/19/16 at 11:30 AM, with the Registered Nurse (RN) Supervisor present, the following was observed: In the medication refrigerator, the metal box that stored 32 (2.5 mg) Marinol capsules was open and unlocked. The refrigerator is located at the nurse's station. The RN Supervisor stated that he was not aware that the lock on the metal box was broken. The Licensed Practical Nurse (LPN) was immediately interviewed. The LPN stated the lock just broke and she informed the Director of Maintenance for a replacement box. The Director of Nursing Service (DNS) was interviewed on 7/19/16 at 12:15 PM. The DNS stated that they had made rounds earlier and all the medication metal boxes were intact. 415.18(d)

Plan of Correction: ApprovedAugust 11, 2016

1-
I- The LPN that was on the South Unit during the medication storage tour was provided with a 1:1 in-service by the In-service Coordinator regarding the policy and procedure of controlled substance storage, handling and documentation. 7/19/16
II- Any resident receiving narcotics remain at risk. 7/19/16
III- To ensure that the highest standard of practice is maintained and to prevent a reoccurrence, the following measures were implemented.
A- The Medical Director, Pharmacy Consultant and the DNS reviewed and revised the policy and procedure on controlled substance storage, handling and documentation.
B- All licensed Nurses are to receive an in-service on the revised policy and procedure from the In-Service Coordinator. These in-services will be part of the orientation package for all licensed nurses and part of the annual mandatory in-service. A 1:1 will be given as needed. 09/09/16
IV- As part of the Quality Improvement Program, an audit tool was developed to monitor compliance with controlled substance storage, handling and documentation. The audit will be done by the ADNS/Designee weekly for the 3 months and quarterly for the next 3 quarters. Negative findings will be reported immediately to the DNS. Audit results will be reviewed during the quarterly Quality Improvement Meeting for the next 3 quarters. 09/09/16.
V- The DNS/ADNS will be responsible for the correction of the deficient practice. 09/09/16
2-
I- The LPN that was on the North Unit during the medication storage tour was provided with a 1:1 in-service by the In-service Coordinator regarding the policy and procedure of controlled substance storage, handling and documentation. 7/19/16
II- Any resident receiving narcotics remain at risk. The metal box that was identified to be open and broken was immediately replaced. 7/19/16
III- To ensure that the highest standard of practice is maintained and to prevent a reoccurrence, the following measures were implemented.
A- The Medical Director, Pharmacy Consultant and the DNS reviewed and revised the policy and procedure on controlled substance storage, handling and documentation.
B- All licensed Nurses are to receive an in-service on the revised policy and procedure from the In-Service Coordinator. These in-services will be part of the orientation package for all licensed nurses and part of the annual mandatory in-service. A 1:1 will be given as needed. 09/09/16
IV- As part of the Quality Improvement Program, an audit tool was developed to monitor compliance with controlled substance storage, handling and documentation. The audit will be done by the ADNS/Designee weekly for the 3 months and quarterly for the next 3 quarters. Negative findings will be reported immediately to the DNS. Audit results will be reviewed during the quarterly Quality Improvement Meeting for the next 3 quarters. 09/09/16.
V- The DNS/ADNS will be responsible for the correction of the deficient practice. 09/09/16

FF09 483.20(d)(3), 483.10(k)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: The resident has the right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, to participate in planning care and treatment or changes in care and treatment. A comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment; prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and periodically reviewed and revised by a team of qualified persons after each assessment.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 19, 2016
Corrected date: September 9, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview during the recertification survey, the facility did not ensure that the resident has the right, unless adjudged incompetent or otherwise found to be incapacitated to participate in care planning. This was evident for two (Resident #15 and #76) of two residents reviewed for participation in care planning in a total of thirty Stage 2 sampled residents. Specifically, during an interview with Resident #15 and #76, the residents stated that they were not invited to the annual care planning meetings. The findings are: 1) Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident Brief Interview for Mental Status (BIMS) Score as 10 which indicated moderately impaired cognition. The MDS documented that the resident was able to make herself understood and is able to understand others. The resident had no behavior problems. An interview was conducted on 7/14/16 at 11:19 AM with Resident #15. The resident stated that she did not know anything about the care plan meeting and was not invited. A Comprehensive Care Plan (CCP) for Cognition dated 10/19/16 documented that the resident was alert and oriented and had some memory deficit. A Review of the CCP attendance sheet revealed on 10/28/15 an annual care plan meeting was held and there was no documented evidence of the resident's attendance. A review of the Social Worker Notes dated 10/19/15 to 1/14/16 lacked documented evidence that the resident was invited to the care plan meeting or if she declined to attend. An interview was conducted on 7/18/16 at 11:55 AM with the Director of Social Work (SW). The SW stated that a letter of invitation to a resident's care plan meeting was mailed to each resident's designated representative and a copy of the same letter was also given to the resident. The SW could not say why the resident did not attend the care plan meeting. 2) Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated [DATE] documented the resident's BIMS Score as 12 which indicated moderately impaired cognition. The MDS documented the resident was able to make himself understood and was able to understand others. The resident had no behavior problems. An interview was conducted on 7/14/16 at 9:54 AM with Resident #76. The resident stated that he did not know anything about a CCP meeting and did not recall being invited to one. A CCP for Cognition dated 11/19/15 documented that the resident had moderate impairment for daily decision making. The CCP also documented that the resident was alert and oriented and was able to make independent decisions. A review of the CCP Attendance sheet revealed that on 11/25/15 an annual care plan meeting was held and there was no documented evidence of the resident's attendance. A review of the SW Notes dated 11/19/15 revealed no documented evidence that the resident was invited to the care plan meeting or if he declined to attend. An interview was conducted on 7/19/16 at 11:45 AM with the Registered Nurse (RN) MDS Coordinator. The RN stated that she makes the monthly MDS schedule and distributes it to the departments responsible for completing the assessment. The RN stated that she was not responsible for inviting the resident or family to the CCP meeting. An interview was conducted on 7/18/16 at 11:55 AM with the Director of Social Work (SW). The SW stated that a letter of invitation to a resident's care plan meeting was mailed to each resident's designated representative and a copy of the same letter was also given to the resident. The SW could not say why the resident did not attend the care plan meeting. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedAugust 11, 2016

1-
I- Resident #15 remains in the facility in stable condition.
A) Social Workers were provided with a 1:1 in-service by the Director of Nursing regarding the facility's Policy and Procedure on the Interdisciplinary Comprehensive Care Plan Meeting. 7/20/16
II- All alert resident who are competent and are scheduled for an initial, annual or significant change comprehensive care plan remain at risk.
A) Social Workers were in-serviced by the Director of Nursing regarding the facility's Policy and Procedure on the Interdisciplinary Comprehensive Care Plan Meeting. 7/20/16

III- To ensure that the highest standard of care is maintained and to prevent a reoccurrence, the following measures were implemented.
A) The policy and procedure on interdisciplinary comprehensive care plan meeting was reviewed and revised by the Medical Director, DNS and Director of Social Work. All Social Workers were in-serviced on the revised policy and procedure.
B) When attending the Interdisciplinary Comprehensive Care Plan meeting, the resident will sign the attendance sheet indicating their presence at the meeting.
C) Social Worker will document the residents attendance or refusal to attend the Interdisciplinary Comprehensive Care Plan Meeting in the residents' medical record.09/09/16
IV- As part of the Quality Improvement Program, an audit tool was developed to monitor compliance with residents right to participate in comprehensive care plan meetings. This audit will be done by the Social Worker/designee on all residents monthly, for the next 3 months and then quarterly for the next 3 quarters. Negative findings will be reported immediately to the DNS. Audit results will be reviewed during the quarterly Quality Improvement meetings for the next 3 quarters. 09/09/16
V- The DNS/Director of Social Work will be responsible for the correction of the deficient practice. 09/09/16
2-
I- Resident #76 remains in the facility in stable condition.
II- All alert resident who are competent and are scheduled for an initial, annual or significant change comprehensive care plan remain at risk.
A) Social Workers were in-serviced by the Director of Nursing regarding the facility's Policy and Procedure on the Interdisciplinary Comprehensive Care Plan Meeting. 7/20/16

III- To ensure that the highest standard of care is maintained and to prevent a reoccurrence, the following measures were implemented.
A) The policy and procedure on interdisciplinary comprehensive care plan meeting was reviewed and revised by the Medical Director, DNS and Director of Social Work. All Social Workers were in-serviced on the revised policy and procedure.
B) When attending the Interdisciplinary Comprehensive Care Plan meeting, the resident will sign the attendance sheet indicating their presence at the meeting.
C) Social Worker will document the residents attendance or refusal to attend the Interdisciplinary Comprehensive Care Plan Meeting in the residents' medical record.09/09/16
IV- As part of the Quality Improvement Program, an audit tool was developed to monitor compliance with residents right to participate in comprehensive care plan meetings. This audit will be done by the Social Worker/designee on all residents monthly, for the next 3 months and then quarterly for the next 3 quarters. Negative findings will be reported immediately to the DNS. Audit results will be reviewed during the quarterly Quality Improvement meetings for the next 3 quarters. 09/09/16
V- The DNS/Director of Social Work will be responsible for the correction of the deficient practice. 09/09/16