Fox Run at Orchard Park
August 24, 2016 Certification Survey

Standard Health Citations

FF09 483.75(l)(1):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: August 24, 2016
Corrected date: September 18, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Standard survey completed on 8/24/16, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. One (Resident #12) of nineteen residents medical records reviewed for accuracy had issues involving an inaccurate physician order [REDACTED]. The finding is: 1. Resident #12 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, a resident assessment tool) dated 7/21/16 revealed the resident is moderately cognitively impaired, understands and is usually understood. During a medication pass observation on 8/23/16 at approximately 7:11 AM Licensed Practical Nurse (LPN #2) administered the following medications; Senna S two tablets (used to treat constipation), [MEDICATION NAME] 20 milligrams (mg) (used to treat depression), aspirin 81 mg, [MEDICATION NAME] 6.25 mg (used to treat heart failure and HTN), [MEDICATION NAME] 5 mg (used to [MEDICAL CONDITIONS]) and [MEDICATION NAME] 20 mg (promotes excretion of urine). Review of the physician's orders [REDACTED]. Review of the Medication Record dated 8/2016 revealed an order for [REDACTED]. During an interview on 8/24/16 at approximately 8:40 AM the Registered Nurse (RN) Unit Manager (UM) stated that she would need to review the original order for the Vitamin D and follow up with the surveyor. During an interview on 8/24/16 at approximately 8:41 AM LPN #2 stated that Vitamin D 50,000 units is usually a monthly dosing. The order should read that the medication is to be given monthly not daily. Additionally LPN #2 stated that the nurses do medication checks at the end of each shift. The nurses initial in the medication record that the checks have been completed and the error should have been caught. During an additional interview on 8/24/16 at approximately 10:28 AM the RN UM stated that the Vitamin D 50,000 units is to be given monthly. Additionally the RN UM stated that somehow last year on the nightshift during turnover between (MONTH) (YEAR) and (MONTH) of (YEAR) the order got changed to daily and that she is working on correcting the error now. 415.22 (a) (2)

Plan of Correction: ApprovedSeptember 14, 2016

F514
415.12(c)(1)
483.75(l)(1) RESIDENT RECORDS - COMPLETE/ACCURATE/ACCESSIBLE
1. The facility will maintain clinical records on each resident in accordance with professional standards and practice that are complete and accurately documented by ensuring that proper documentation by Nursing Staff regarding Doctor's orders are being accurately transcribed for dose, route, time, medication and resident.
2. The facility immediately corrected route of medication administration in MAR and verified with MD.
3. DON/designee will in-service all Nurses on proper documentation to include right dose, right medication, right resident, right time and right route per MD orders.
4. Pharmacy consultant to conduct monthly audits to ensure proper documentation of MD orders. All audits to be brought to QAA committee for review and the need for continuance.
5. Overall responsibility to ensure corrective action is implemented will be with the Director of Nursing. Completion date is (MONTH) 18, (YEAR).

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: August 24, 2016
Corrected date: September 18, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard Survey completed on 8/24/16, the facility did not periodically review and revise the Comprehensive Care Plan. Two (Residents #11,56) of 14 residents reviewed for Care Plans had did not have Care Plan revisions to include changes with the development of a pressure sore and treatment (Resident #11) and missing hearing aids for a resident who is hard of hearing (Resident #56). The findings are: 1. Resident #11 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 7/19/16 revealed the resident is severely impaired for decision making. Review of the Care Plan initiated 7/24/16 revealed the resident had a potential for alteration in skin integrity d/t (due to) incontinence and decreased mobility.The plan was to complete a Braden (assessment tool for potential skin breakdown) Score quarterly and prn ( when needed). Weekly skin checks on shower day by a nurse. Pressure reducing mattress and a cushion in wheel chair. Review of the Braden Scale dated 7/12/16 revealed a score of 14 indicating a risk for skin breakdown. Review of the Wound Evaluation Form dated 8/8/16 revealed the resident developed a Stage 1 pressure sore on right buttocks measuring 9 cm (centimeters) x 1 cm. A treatment of [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Care Plan Review and Update sheet revealed a lack of revision to the care plan to include the development of the pressure sore and treatment plans. Interview with Registered Nurse (RN#1) Unit Manager on 8/23/16 at 12:05 PM revealed she just got back from vacation and had not gotten to the documentation. 2. Resident #56 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/14/16 revealed the resident is understood, understands and is cognitively intact. Review of the facility Missing Property Report dated 8/9/16 revealed the resident's hearing aids were missing. Review of the Hearing Aid Accountability Form dated (MONTH) (YEAR) revealed the resident's hearing aids were missing. Review of the current Comprehensive Care Plan (CCP) revised 8/2/16 revealed a potential for alteration in communication d/t resident is hard of hearing and wears bilateral hearing aids. Review of the Care Plan Review and Update sheet revealed a lack of revision to the care plan to include the hearing aids were missing. Interview with Licensed Practical Nurse (LPN#2) on 8/23/16 at 11:15 AM revealed the hearing aids were missing on 8/10/16 and he initiated a Missing Property Report and notified the Supervisor.I did not make the change to the Care Plan. Interview with Registered Nurse (RN#1) Unit Manager on 8/23/16 at 11:28 AM revealed she just got back from vacation and was waiting to hear from the Social Worker if they had ordered new hearing aids before she made the change. During an interview on 8/24/16 at 8:18AM, the Director of Nursing (DON) stated I would expect the Care Plan to have been revised at the time the hearing aids went missing. I usually fill in for the Unit Coordinator or the shift Supervisor would be expected to make the change. Review of the Policy and Procedure labeled Care Plan Interdisciplinary revised (MONTH) 2013 revealed it is the facility policy to provide Interdisciplinary Care Plan outlining the care and treatment of [REDACTED]. The goals and timetables are measured and directed toward achieving and maintaining each resident's optimal physical, psychosocial and functional needs. 415.11(c)(2)(iii)

Plan of Correction: ApprovedSeptember 14, 2016

F280
483.20(d)(3), 483.10(k)(2) RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP
1. The facility will review and revise all comprehensive care plans immediately upon development of pressure sores and/or any changes in resident health conditions or missing property.
2. Comprehensive care plan is unable to be revised due to resident #11 death. Comprehensive care plan for resident #56 was immediately revised to include missing property/hearing aids.
3a. DON or designee will in-service all Nursing staff on revision of care plans to include any/all changes. All care plans that have been revised will be reviewed prior to weekly team care meetings.
3b. DON or designee will be notified of any new or changing pressure sores/skin issues immediately.
4. A monthly audit will be completed by DON/designee to ensure all revisions to care plans are completed. Audits will be brought to QAA Committee to be reviewed and the need for continuance.
5. Overall responsibility to ensure corrective action is implemented will be with the Director of Nursing. Completion date is (MONTH) 18, (YEAR).

FF09 483.25(c):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES

REGULATION: Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 24, 2016
Corrected date: September 18, 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 [DATE], the facility did not provide a resident having pressure sores with necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Three (Resident's #7,11, and 63) of three residents reviewed for pressure sores had issues with a lack of a complete Registered Nurse (RN) assessment of a newly identified pressure ulcer including staging and measurement (Resident #7), lack of ongoing measurements and follow up documentation regarding the status of a pressure sore (Resident #11), and the hands of a Licensed Practical Nurse (LPN) were not washed between removing a soiled wound dressing and placing a new one (Resident #63). The findings are: 1. Resident #7 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE] revealed the resident is cognitively intact, understands and is understood. Review of the Profile of Care (guide used by staff to provide care) dated [DATE] revealed the resident requires two extensive assist from staff for bed mobility, requires a mechanical lift for transfers and is non ambulatory. Review of the Care Plan Review and Update form dated [DATE] revealed the resident developed a right heel blister, the plan was to apply skin prep (protective barrier) to the right heel blister every shift (qs) until resolved. Review of the Interdisciplinary Notes dated [DATE] written by a Licensed Practical Nurse (LPN) revealed A(NAME) (area of concern) to right heel, UC (Unit Coordinator) ordered tx (treatment) for site. Further review of the Interdisciplinary Notes dated [DATE] written by a Registered Nurse (RN) revealed resident has blister to right heel, skin prep applied qs until resolved. There is no assessment documented to include the type of wound, staging or measurements. Review of the Physician's Orders dated [DATE] revealed an order to apply skin prep to the right heel blister every shift until resolved. Review of the facilities skin book (a three ring binder) revealed that there were no Wound Evaluation Flowsheets for Resident #7. During an interview on [DATE] at approximately 9:59 AM the RN Unit Manager stated that the resident did not have any pressure ulcers. During an interview on [DATE] at approximately 2:18 PM the RN Unit Manager stated that she did not know the resident had a heel blister as she had been on vacation. Additionally, during this interview the RNUnit Manager and the Director of Nursing (DON) stated that there is not an initial assessment of the pressure ulcer. The RN Unit Manager stated what should happen is that the nurse finding the area of concern should notify the supervisor. Then the supervisor should have assessed the pressure ulcer and completed a skin sheet. An observation on [DATE] at approximately 2:28 PM (in the presence of the RN Unit Manager) revealed an unstageable pressure ulcer on the resident's right heel measuring approximately 2 centimeters (cm) in length (1) x (by) 2 cm in width (w). During this observation, the resident stated that the pressure ulcer is tender at times and stings a little when the nurses apply the treatment. At this time, the RN Unit Manager stated that she would now complete the Wound Evaluation Flow Sheet. Review of the Wound Evaluation Flowsheet dated [DATE] completed by the RN Unit Manager revealed the resident has an unstageable right heel blister that was not present on admission and measured 1.8 cm (1) x 2.3 cm (w). The pressure ulcer is described as a reabsorbed blister that has dry dark tissue. During an interview on [DATE] at approximately 10:25 AM the DON stated that when the RN Unit Coordinator is off, if any new skin concerns are noted the nurses can notify the physician, get a treatment started and complete the skin sheet. I should be notified, so that I can follow up. Review of the policy and procedure entitled Wound Management Protocol dated (MONTH) 2013 revealed if the resident is identified to have a pressure ulcer, the nurse identifying the ulcer will initiate a pressure ulcer flow sheet and will notify the RN Nurse Manager. The Nurse Manager/ Supervisor will be responsible to notify the Director of Nursing. 2. Resident #11 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated [DATE] revealed the resident is severely impaired for decision making. Review of the Care Plan initiated [DATE] revealed the resident had a potential for alteration in skin integrity due /to (d/t) incontinence and decreased mobility. The plan was to complete a Braden Score (assessment tool for potential skin breakdown) quarterly and when needed (prn). Weekly skin checks on shower day by a nurse. Pressure reducing mattress and a cushion in wheel chair. Review of the Braden Scale dated [DATE] revealed a score of 14 indicating a risk for skin breakdown. Review of the Wound Evaluation Form dated [DATE] revealed the resident developed a Stage 1 pressure sore on right buttocks measuring 9 centimeters( cm) x 1 cm. A treatment of [REDACTED]. Review of the Medication Administration Record [REDACTED].Further review of the Wound Evaluation Form revealed no further documentation regarding the pressure sore. Review of the Interdisciplinary Notes dated [DATE] through [DATE] revealed a lack of documentation regarding the pressure ulcer measurements and status. Review of the skin check sheets dated ,[DATE] revealed the resident had no new issues identified. Interview with Registered Nurse (RN#1) Unit Manager on [DATE] at 12:05 PM revealed she just got back from vacation and hadn't gotten to the documentation and then the resident expired. Interview with the Director of Nursing (DON) on [DATE] at 1:00 PM revealed she would generally fill in when the Unit Manager is on vacation (or a Supervisor) and did not remember anything in regards to the resident's pressure ulcer. Review of the facility policy Entitled Wound Management Protocol dated ,[DATE] if the resident is identified to have a pressure ulcer, the nurse identifying the ulcer will initiate a pressure ulcer flow sheet and will notify the RN Nurse Manager. The Nurse Manager/ Supervisor will be responsible to notify the DON. The Interdisciplinary team led by the DON will do weekly rounds on all residents with pressure ulcers. The Pressure Ulcer/Wound Management Flow Sheet will be updated at that time. 3. Resident #63 has [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS - an assessment tool) dated [DATE] revealed that the resident is severely cognitively impaired. Review of the nursing admission assessment dated [DATE] revealed that the resident had an unstageable right heel blistered area that measure five centimeters (cm) wide by six centimeters (cm) long. Review of the comprehensive care plan dated [DATE] revealed that the resident was care planned for an unstageable right heel wound that was present on admission. Review of the wound evaluation flowsheet dated [DATE] revealed the right heel had yellow slough (a layer of dead cells in the wound that is similar to pus) and there was no odor. Review of the physician ' s order dated [DATE] revealed that the resident had orders for wound treatment consisting of applying Santyl (an ointment that cleans pressure sores so healthy tissue may grow back) with a dry, clean dressing after cleansing. Observation on [DATE] at approximately 9:52AM revealed a wound treatment for [REDACTED].#1 (LPN #1) washed her hands and put on gloves. LPN #1 then removed the old dressing that was placed the day before.The LPN showed the old dressing to the surveyor and there was a moderate amount of bloody, grayish drainage on it. The LPN #1 then removed her gloves and put on new gloves then cleansed the wound with normal saline solution. LPN #1 changed her gloves and applied the Santyl with a wooden spatula. LPN #1 changed her gloves again and then applied the dry, clean dressing on top of the wound. LPN #1 did not wash hands or use hand sanitizer in between removing the soiled dressing and replacing the clean dressing. Interview on [DATE] at approximately 10:17AM with LPN #1 revealed that she should have washed her hands between removing the soiled dressing and replacing it with the clean one. Interview on [DATE] at approximately 10:20AM with Registered Nurse #1 (RN #1) revealed that she expects her staff to wash their hands in between removing a soiled dressing and replacing with a clean one. Interview on [DATE] at approximately 10:25AM with the Director of Nursing revealed that she expects her staff to wash their hands in between taking off the soiled dressing and putting on the clean dressing. Review of the policy Dressings - Soiled dated ,[DATE] revealed that in the procedures section it states wash hands after disposing soiled dressing and removing gloves . 415.12 (c)(1) 415.12 (c)(1)

Plan of Correction: ApprovedSeptember 22, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F314
415.11(c)(2)(iii)
483.25(c) TREATMENT/SERVICES TO PREVENT/HEAL PRESSURE SORES
1. The facility will provide a resident having pressure sores with necessary treatment and services to promote healing, prevent infections and prevent new sores from developing by ensuring that an RN assessment will be completed including measurements, staging and documentation.
2a. Resident #7 - The Nursing staff immediately initiated a skin assessment sheet with completed RN assessment including measurements, staging and documentation.
2b. Resident #11 - Resident expired on [DATE]. DON/designee was unable to complete a RN assessment.
2c. Resident #63 - DON/designee immediately counseled LPN on proper hand-washing and wound care protocol.
3. An audit was completed on 100% of the residents to identify any skin issues/pressure sores. No additional skin issues/pressures were identified.
4a. Resident #7 - DON/designee will in-service all Nurses on initiating proper use of skin assessment sheet to include measurements, staging and documentation on any/all skin issues.
4b. Resident #11 - DON/designee will in-service all Nurses on proper use of skin assessment sheet to be completed by a RN every (7) seven days to include measurements, staging and documentation.
4c. Resident #63 - DON/designee will in-service all Nurses on proper hand-washing and wound care protocol.

5. DON/designee will complete two (2) audits per month for a six (6) month period to confirm that all skin/pressure sores and Nursing assessments are completed properly. DON/designee will complete two (2) audits per month for a six (6) month period on hand-washing and wound care protocol. All audits will be brought to QAA committee to be reviewed and the need for continuance.
5. Overall responsibility to ensure corrective action is implemented will be with the Director of Nursing. Completion date is (MONTH) 22, (YEAR).