Bethlehem Commons Care Center
October 19, 2018 Complaint Survey

Standard Health Citations

FF11 483.45(a)(b)(1)-(3):PHARMACY SRVCS/PROCEDURES/PHARMACIST/RECORDS

REGULATION: §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who- §483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 22, 2018
Corrected date: December 21, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case #NY 028), the facility did not ensure that it provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) for one (Resident #1) of five residents reviewed. Specifically, for Resident #1, the facility did not ensure an anti-diarrheal medication prescribed as needed was available to administer as needed when the resident was experiencing diarrhea. Additionally, the facility did not ensure the anti-diarrheal medication was available to administer to the resident for continued diarrhea when the physician increased the frequency of the medication. The resident continued to have loose stools for 3 days and did not receive medication ordered for diarrhea as it was not available. This is evidenced by: Resident #1 The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderate cognitive impairment. The facility could not provide a policy and procedure for the procurement of medications from the pharmacy. The Interdisciplinary (IDT) Progress Note dated 9/6/18 at 2:00 pm, documented, staff reported the resident had several loose stools today. MD made aware. New order for [MEDICATION NAME] (antibiotic) 4 times a day, for 10 days started for possible [MEDICAL CONDITION] (infection that causes watery diarrhea). The Comprehensive Care Plan (CCP) [MEDICAL CONDITION] initiated 9/6/18, documented, increased risk for dehydration due to loose stools, as evidenced by foul smelling stool and frequent bowel movements. Resident is currently being treated with [MEDICATION NAME] for [MEDICAL CONDITION]. Stool obtained and sent to lab. The Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. There were no administrations documented for the month. The Laboratory Telefax Activity Report dated 9/7/18, documented the test was positive for the [DIAGNOSES REDACTED] toxin. The IDT Progress Note dated 9/8/18 (untimed) documented, loose stool x1; brown [MEDICATION NAME] (glutinous consistency and the quality of sticking or adhering) stool. [MEDICATION NAME] continued. The note did not document [MEDICATION NAME] was given. The IDT Progress Note dated 9/8/18 at 6:40 pm documented the resident was incontinent with loose, dark tarry stool. Complaint of intermittent cramps and nausea. LPN (licensed practical nurse) to notify MD. The note did not document [MEDICATION NAME] was given. The IDT Progress Note dated 9/9/18 at 1:25 am documented, the MD ordered the resident to have the [MEDICATION NAME] 4 times a day, for 1 week. The note did not document [MEDICATION NAME] was given. The IDT Progress Note dated 9/9/18 at 8:15 am documented, loose, [MEDICATION NAME], dark brown stool x 2. Complaint of feeling uncomfortable, but not pain. Requested Tylenol, given with positive affect. The note did not document [MEDICATION NAME] was given. The Pharmacy Proof of Delivery of physician ordered medications for date range 9/6/18 through 9/10/18 did not include [MEDICATION NAME]. During an interview on 9/18/18 at 10:55 am, MD #1 stated he was called by Nursing about the diarrhea. The resident had bad [DIAGNOSES REDACTED]. He ordered [MEDICATION NAME] to be given 4 times a day. It was a change in the original order that was to be given 4 times a day as needed. During an interview on 9/20/18 at 10:14 am, the Director of Nursing (DON) stated, the resident was having diarrhea. That's why the [MEDICATION NAME] was ordered. His expectation was the nurses would have used the prn order on 9/6/18 that they had, and let the doctor know that they initiated it. [MEDICATION NAME] is not a house stock item. The nurse would have faxed the order to the pharmacy. The actual physician order [REDACTED]. Orders faxed before 4:00 pm, will come during the evening run. The [MEDICATION NAME] should have been delivered on 9/6/18. During an interview on 9/20/18 at 11:20 am, LPN #2 stated, the order for [MEDICATION NAME] on 9/6/18 would have been faxed to the pharmacy. She said the order was initialed by her, but she didn't document the time it was faxed. When the MD writes the order, she faxes it. The fax confirmation is generated by the fax machine, not the pharmacy. She said she doesn't always check for confirmations, especially when there is just one page to fax. She said she knew the pharmacy did not send the [MEDICATION NAME] that day because she had to call the pharmacy for [MEDICATION NAME] for another resident who was having diarrhea. She did not know that Resident #1 was having diarrhea. She would have called the pharmacy. 10 NYCRR 415.18(a)

Plan of Correction: ApprovedNovember 2, 2018

Corrective Action:
Resident #1 was hospitalized and later passed away. LPN that made transcription and medication error was immediately re-educated. RN Nursing Supervisor was immediately re-educated on medication and transcription error process and documentation.
Other Residents affected by deficient practice:
Upon review of medication and transcription errors no other discrepancies were noted.
Systemic Changes to ensure deficient practice does not recur:
Policy and Procedure developed to specifically address PRN medication availability and delivery. All nursing staff will be in-serviced on newly developed policy and procedure.
MD and pharmacy notification if PRN medication is not delivered.
Monitoring:
Weekly audits will be performed by RN Nurse Manager and/or designee of documentation as pertains to newly developed Policy and Procedure for 3 months. Results of the audits will be reviewed by DNS. The DNS will then report findings to QAPI committee until it is determined resolved for the purposes of the Committee.
Responsible person: Director of Nursing
Date of Completion : 12/21/2018

FF11 483.25:QUALITY OF CARE

REGULATION: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 22, 2018
Corrected date: December 21, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case #NY 174), the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for one resident (Resident #2) of five residents reviewed. Specifically, for Resident #2, whose [DIAGNOSES REDACTED]. Also, the facility did not ensure that the medical record did not include differing information regarding the resident's level of pain. The resident was transferred to the hospital on [DATE], for complaints of right leg pain, swelling, redness and for the presence of necrotic (dead) tissue on the right great toe. This is evidenced by: Resident #2: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. The facility's Policy and Procedure (P&P) for Care Planning dated 3/2012, documented that the resident-centered, goal oriented care plan process is interdisciplinary, realistic, individualized, and utilized on a daily basis to promote quality of life for all residents. When a resident experiences a change of status, care plans will be revised to reflect current status. Goals must be set for each problem identified. Goals must be measurable, attainable and have a time frame. Approaches/interventions are to be developed that assist the resident to achieve the stated goals. Care plans will be updated as new problems arise. All disciplines are responsible for updating the care plans. The licensed nurse noting orders that are relevant to the care plan is responsible for placing them on the care plan. The facility's Clinical Services Physician/Family Notification P&P dated as revised 5/18, documented that a bruise was an example of a change of condition. When a change of condition occurs, a complete physical/mental assessment should be done, and the findings documented in the medical record. The presence or absence of abnormalities should be noted in the resident's medical record. The resident's reaction to symptoms (i.e. pain, anxiety or discomfort) should be documented. The RN (registered nurse) Supervisor/Unit Manager must assess the resident and document findings. If the LPN (licensed practical nurse) has documented, the supervisor may state she agrees with the above documentation. When a change in condition is identified, the resident's name is entered on the 24 hour report sheet for that shift, with specific changes of condition noted. The Weekly Skin Check form dated as revised 9/2016, documented the following instructions: The nurse documents all new and old findings on the body/foot images; If the skin is altered, broken, or injured, mark each area with a number on the body and write the number in the box (bruise, redness, blister, wound, other); The nurse will document any new findings in-between skin checks on the Weekly Skin Check form. The Pain Management P&P dated 4/25/17, documented that the overall goals of care of the resident with pain are to monitor treatment efficacy and side effects. Document all findings in Nursing Notes and/or on the Pain Score sheet on the MAR (medication administration record). Nurses will re-screen resident pain score during their shift to document the effectiveness of medications given (both scheduled and PRN) and record on the MAR. The interdisciplinary care plan will reflect the location and type of pain, pharmacological and non-pharmacological interventions, with evaluation and revision as indicated. The World Health Organization (WHO) Cancer Pain Ladder: mild pain (1-3), moderate pain (4-7), severe pain (8-10). The Accident and Incident Report (A&I) dated 11/8/17 at 6:00 am, written by the RN Supervisor (RNS) #1 documented the resident had a bruise located on the right great toe with complaints of pain. The origin of the bruise was unknown. It documented that it looked as if the resident may have hit the right foot up against the window sill or heater. The MD (medical doctor) was notified at 6:40 am. There were no new orders. The Comprehensive Pain Screen dated 11/8/17, documented the bruise on the resident's right great toe was noted to be 3cm x 2.5 cm, and was tender to touch/palpation. The resident pulled away upon physical assessment. The Wong-Baker FACES Rating Scale (pain rating scale) dated 11/8/17, documented a 7-8 (hurts whole lot), and the resident moaned. The pain screen on the MAR dated 11/8/17, documented a pain score of 0 (no pain) for all 3 shifts. The Comprehensive Care Plan (CCP) Alteration in Blood Glucose Levels initiated 2/15/17, documented to monitor for pain and skin integrity. The last care plan update was dated 6/7/17. The 24-Hour Report (nursing communication tool) dated 11/7/17 (11p - 7a) documented that a bruise was found on the resident's right big toe and that the Supervisor was made aware. The CCP Risk for Skin Impairment related to diabetes initiated 2/16/17, documented an update by RNS #1 on 11/8/17: 3 cm x 2.5 cm bruise on the right great toe. The CCP did not include interventions, or measurable goals and timeframes for the care/treatment of [REDACTED]. The CCP Alteration in Comfort due to Pain initiated 3/7/17, documented an update by RNS #1 on 11/8/17; bruise on right great toe 3cm x 2.5 cm noted. Tender on palpation and pulls away. Facial grimacing noted, moaned. Unknown origin of bruise. The CCP did not include interventions, or measurable goals and time frames for the care/treatment of [REDACTED]. The Interdisciplinary (IDT) Progress Note dated 11/8/17 at 6:00 am, written by RNS #1, documented that RNS #1 was called to assess the resident's right great toe. The resident's right outer toe noted a purple bruise, tender on palpation. Resident will pull away when touched. The bruise measures 3cm x 2.5 cm. The resident was asked what happened. Resident just moaned, and was unable to give an answer. Resident noted with history of dementia, diabetes and [MEDICAL CONDITION]. The IDT Progress Note dated 11/8/17 at 7:40 am, written by RNS #1, documented that MD #1 was aware. No new orders. Review of Physician order [REDACTED]. The 24-Hour Report dated 11/8/17 (7a - 3p) documented, no change in toe. The 24 Hour Report dated 11/9/17, 11/11/17, and 11/13/17, did not include documentation regarding the condition of the resident's right great toe. The facility did not provide a 24 Hour report for 11/10/17 and 11/12/17. The medical record did not include documentation regarding the condition of the resident's right great toe from 11/9/17 through 11/13/17. The resident's Weekly Skin Check report dated (MONTH) (YEAR) did not include documentation regarding the condition of the resident's toe. The physician progress notes [REDACTED].#1 documented that diabetes with [MEDICAL CONDITION] was reviewed. No history from patient because of dementia. The note did not include documentation regarding the right great toe. The Physician order [REDACTED].#1, documented a consult with podiatry and for the application of a hot pack every shift to the right great toe for 10 minutes until seen by podiatry. The IDT Progress Note dated 11/14/17 (untimed) documented that the resident's right toe was swollen, red, and painful. The MD was notified. New orders for a Podiatry consult, and to apply hot pack on for 10 minutes until seen by Podiatry. The CCP did not include documentation regarding the change in condition of the resident's toe or for the physician ordered interventions for care/treatment. The IDT Progress Note dated 11/14/17 (untimed) documented the Supervisor was made aware that the resident's right big toe was reddened. The resident complained of pain (8/10). Tylenol 650 mg was given at 10:00 pm. Also, hot pack applied. The pain screen on the MAR dated 11/14/17, documented a pain score of 0 for all 3 shifts. The 24 Hour Report dated 11/14/17 (3p - 11p) documented that the right great toe was red, swollen, and painful. Podiatry consult ordered. Apply hot pack 10 min, every day until seen by the podiatrist. The 24 Hour Report dated 11/14/17 (11p - 7a) documented to apply a hot pack as ordered. Right great toe remains red and swollen. The 24 Hour Report dated 11/15/17 through 11/18/17 (all 3 shifts) documented instructions to monitor the right great toe. The IDT Progress Note dated 11/15/17 at 7:00 am, documented that the right great toe remains red, swollen, and tender to touch near the toenail. The pain screen on the MAR dated 11/15/17 documented, pain score of 0 for all 3 shifts. The Podiatry Consult dated 11/15/17, documented that there was purplish discoloration of the right great toe, mild [MEDICAL CONDITION], and palpable discomfort. There is no open wound, drainage, or sign of active infection. The patient has vascular insufficiency. Assessment: Possible trauma to right great toe. Recommendation: Monitor right great toe. No shoe for now. Review of the CCP did not include the above recommendations. The Physician order [REDACTED].#1, documented a stat x-ray of the right great toe. The IDT Progress Note dated 11/15/17 at 10:30 am, documented the resident was seen by podiatry today regarding the right great toe. MD updated. New order received for stat x-ray to rule out fracture. The Physician order [REDACTED].#1, documented to tape the right great toe together with 2nd toe for 10 days. The IDT Progress Note dated 11/15/17 at 5:50 pm, documented the MD was updated re: x-ray results. Negative for fracture/dislocation, minimal [MEDICAL CONDITION] (inflammation of joint), no osteo[DIAGNOSES REDACTED] (infection in the bone). Great toe remains discolored, tender to touch. New order received to tape great toe to 2nd toe for 10 days. Continue to monitor. Review of the CCP did not include documentation of the above interventions for the care and treatment of [REDACTED]. The IDT Progress Note dated 11/16/17 at 3:00 pm, documented the resident complained of pain in the right great toe. Tylenol 650 mg given. The pain screen on the MAR dated 11/16/17 documented a pain score of 8 for the day shift. The resident's Weekly Skin Check report for (MONTH) (YEAR), did not include documentation about the condition of toe. The Physician order [REDACTED].#1 documented, start [MEDICATION NAME] (dilates arteries that supply blood to the legs) 60 mg daily. The IDT Progress Note dated 11/16/17 at 5:00 pm, documented an update by the MD that the toe continues with discoloration, [MEDICAL CONDITION], tenderness. MD also updated to podiatrist note. New order received to start [MEDICATION NAME] 60 mg daily. The CCP did not include an update to include the above orders. The Physician order [REDACTED]. (MONTH) give first dose when arrives from pharmacy. The IDT Progress Note dated 11/17/17 at 3:00 pm documented a telephone order clarification to start [MEDICATION NAME] 50 mg daily. The IDT Progress Note dated 11/17/17 at 10:30 pm, documented the right great toe continues to be purplish in color. (MONTH) give first dose of [MEDICATION NAME] when arrives from pharmacy. The 24 Hour Report dated 11/17/17 (3p - 11p) documented, right great toe continues with purplish color. (MONTH) give first dose of [MEDICATION NAME] when arrives from pharmacy. The 24 Hour Report dated 11/18/17 through 11/20/17 (all 3 shifts) documented to monitor great right toe. The reports did not include documentation of the condition of the toe/response to [MEDICATION NAME]. The medical record did not include documentation about the condition of the resident's right great toe from 11/18/17 through 11/20/17. The Weekly Skin Check report for (MONTH) (YEAR), did not include documentation regarding the condition of the resident's toe. The physician progress notes [REDACTED].#1, documented that since last week the resident has had cyanosis (bluish coloring of the skin due to lack of oxygen in the blood) to the right great toe with no injury, and negative x-ray. Assessment and plan: [MEDICAL CONDITION] with [MEDICAL CONDITION] to right great toe. Not a surgical candidate. Treat with [MEDICATION NAME]. Review of physician's orders [REDACTED]. The medical record did not include documentation that the practitioner informed the resident's representative of treatment risks and benefits, options, or alternatives. The 24 Hour Report dated 11/21/17 (3p - 11p) documented that the MD was in, 30 day renewals signed and no new orders. The report did not include documentation about the condition of the toe. The CCP, was not updated to include the [DIAGNOSES REDACTED]. The 24 Hour Report dated 11/22/17 (7a - 3p) and the medical record did not include documentation of the condition of the toe. The 24 Hour Report dated 11/22/17 (3p - 11p) documented the right great toe continues with discoloration. The condition of the toe was not documented in the medical record. The 24 Hour Report dated 11/22/17 (11p - 7a) documented that the right great toe remains with slight [MEDICAL CONDITION]. The condition of the toe was not documented in the medical record. The 24 Hour Report dated 11/23/17 (all 3 shifts) did not include documentation of the condition of the toe. The IDT Progress Note dated 11/23/17 at 11:00 pm, documented that the right great toe continues with discoloration and slight swelling. The IDT Progress Note dated 11/24/17 at 7:00 am, documented the right great toe remains with slight [MEDICAL CONDITION]. The Physician order [REDACTED].#1, documented to send the resident to ER (emergency room ) for evaluation. The IDT Progress Note dated 11/24/17 at 8:30 pm, written by the RN, documented the RN was called to the unit to assess the resident's right leg and right great toe. Resident complaint of pain in right leg. Noted to have necrotic pockets, not raised (multiple) on calf of right leg. Shiny, red, and swollen up to knee. Seven cm of blackened necrotic tissue on right great toe with blister (fluid-filled) noted on toe. LPN reported the toe looks worse than before. MD informed. New order to send to ER for evaluation. 911 called. Leg began weeping. Transported to hospital for evaluation. The 24 Hour Report dated 11/24/17 (3p - 11p), documented an RN assessment. Resident noted to have necrotic pockets (not raised) multiple on calf of right leg. Shiny, red, swollen up to knee. Seven cm of blackened necrotic tissue on right great toe with blister (fluid filled) noted on toe. LPN reports leg looks worse. MD informed. New order to send to ER. The Nursing Home to Hospital Transfer Form dated 11/24/17 documented the resident had blotchy areas on calf of right leg. Right leg swelling, redness, and pain. The Emergency Medical Services (EMS) patient care report (PCR) dated 11/24/17, documented, facility staff states the resident has had a persistent infection of his right great toe that is being addressed. Staff noticed new marks on the lateral side of his right leg this morning that is painful on palpation. Right great toe appears necrotic. Four suspicious discolorations roughly 6 cm x 2cm noted on the lateral side of the right calf, midway up the leg. One of the marks was blistering, 3 were dark in color, and not uniform in shape. Patient was turned over to the RN in the ER. RN was informed that the facility staff did not seem to have a consistent story on the progression of the patient's great toe infection and new marks on the patient's right leg. The Hospital ED (emergency department) Provider Note dated 11/24/17 documented for the diagnostic impression that the patient presents with poor perfusion on the right lower extremity with discoloration to the first digit and blackened area to the distal medial end. This is concerning for arterial occlusion and this appears to have been ongoing for weeks. The Supervisory Note documented that the exam showed necrotic great toe and volar (pertaining to the sole) aspect fifth toe with evidence of arterial insufficiency. Cool from right ankle to foot with intact sensation and motor. The IDT Progress Note dated 11/25/17 at 12:00 pm, documented that the hospital reported the resident's admitting [DIAGNOSES REDACTED]. The IDT Progress Note dated 11/27/17 at 5:00 pm, written by the Director of Nursing (DON), documented a late entry for 11/15/17. Resident noted to have change in color to right great toe. Toe is purplish in color, almost dusky looking. Mild [MEDICAL CONDITION] to right foot noted, positive tenderness to touch, faint pedal pulse. Seen by podiatry today. MD made aware of color of right great toe and positive tenderness. X-ray of right great toe negative for fracture. MD asked to have right great toe and 2nd toe taped. Resident to start on [MEDICATION NAME]. MD did not want doppler study or antibiotics given. During a phone interview on 10/11/18 at 2:43 pm, MD #1 stated she did not recall the initial problem with the resident's toe. Regarding the order to tape the right great toe, sMD #1 stated she might have given that order for an injury. The negative x-ray result of the right great toe done on 11/15/17 and the order to tape the toe was discussed. She said there was no reason for the toe to be taped, unless it was painful. Regarding the MD progress note dated 11/21/17 ([MEDICAL CONDITION] with [MEDICAL CONDITION] to right great toe), she said she saw that it was vascular. She didn't think he was a surgical candidate. She did not order any vascular studies. She stated there would have been no benefit for the test since he wasn't a surgical candidate. The resident was being treated with [MEDICATION NAME]. MD #1 did not recall talking to the family about treatment options. Regarding pain in the right leg and the right great toe necrosis on 11/24/17, she said the blockage probably progressed. She said she would expect that Nursing would be looking at the foot and should be telling her if something was going on. She said she saw a small [MEDICAL CONDITION]. She did not know if the resident got worse progressively. She said she if he did, then they would see the changes. Nursing would not see the changes if it happened suddenly. During a phone interview on 10/12/18 at 9:22 am, MD #2 stated that when you see a black area on the toe, it indicates an [MEDICAL CONDITION]. It is seen in people with vascular disease. He said the family should have been informed and there should be documentation by Nursing regarding the details of the treatment. Regarding the taping of the toes, he said if there is concern about trauma the toes could be taped to prevent mobility. If it's a vascular issue, the taping is not necessary. It will not change things. If the resident is not a surgical candidate, then they try medically to do something. The resident was prescribed [MEDICATION NAME]. He said a little more documentation from Nursing would have been helpful, but would not have changed the outcome. Regarding the initial discovery of the bruise, he said they can think about trauma at first, but if it's not trauma, it's vascular. That's when they decided to try the [MEDICATION NAME]. He said that even if it was vascular on 11/8/17 and [MEDICATION NAME] was started then, it would not have made a difference in the outcome. He said if there were necrotic areas on the calf, game over. During a phone interview on 10/16/18 at 10:57 am, RN Supervisor #1 stated that anytime a bruise is found, they call the MD. The MD will tell the nurse what he/she wants them to do. If there are no orders, Nursing will monitor the resident. The nurses should have been documenting whether the bruise was getting better or worse. The changes to the toe and treatments should have been documented on the CCP. She believes the doctor wanted the toe taped to keep it stable. When the podiatrist noted vascular insufficiency, there should have been an order for [REDACTED]. When the [MEDICATION NAME] was started, the nurses should have been documenting the resident's response in the Nurse's notes. She said that sometimes the nurses think that since they documented on the medication administration record, they don't need to document anywhere else. The Nurses utilize a 24-hour report that should include wound changes with treatments, and new orders. The report gets reviewed daily in morning meeting, and the supervisors use it for shift report. Regarding the standard of nursing care, she said the nurses should have been checking the color, temperature, and for increased pain in the foot/leg on a daily basis. The CCP gets updated whenever something new comes up or if no issues, quarterly. During a phone interview on 10/16/18 at 3:03 pm, the interim DON stated she believed a care plan was initiated when the bruise was discovered. She could not explain why there was no documentation of the condition of the toe from 11/9/17 - 11/13/17. The changes to the toe on 11/14/17 were documented in a nurse's note. Regarding updating the CCP to reflect the change in condition and the treatment order by the physician, she said Nursing did everything they were supposed to do. The treatments were on a treatment sheet. She said the resident had a long history of vascular insufficiency, [MEDICAL CONDITION], and diabetes. The podiatrist said [MEDICAL CONDITION]. The resident had an e.coli infection (intestinal infection) and was very sick. She said they did their due diligence by calling the MD every time. She said she asked the doctor about doing a doppler (a form of ultrasound that can detect and measure blood flow) when she reported the toe was dusky. The doctor didn't want it done. She said the changes to the toe should have been documented on the Weekly Skin Assessment sheet. 10NYCRR 415.12

Plan of Correction: ApprovedNovember 16, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action:
Resident #2 was hospitalized and suffered [MEDICAL CONDITION] surgery for [REDACTED].
Other residents identified:
All residents with bruises identified will be assessed by RN and documentation will be reviewed and updated if necessary. MD will be updated on any change in condition of area. MD will assess all bruises on next visit. Any change in condition of area, treatment or care RN or designee will notify resident and/or responsible party.
Systematic changes to ensure deficient practice does not recur:
Policy and Procedure newly developed to specifically target documentation and monitoring for 72 hours; progress notes and 24 hour report until area identified is resolved.
All nursing staff will be in-serviced on the Policy and Procedure developed for documentation and monitoring.
Monitoring:
Weekly Audits will be performed by RN Nurse Manager and/or designee of documentation (Progress notes and 24 hour report) as pertains to newly developed Policy and Procedure for 3 months. Results of the audits will be reviewed by DNS. The DNS will then report findings to QAPI Committee until it is determined resolved for the purposes of the Committee.
Responsible person: Director of Nursing
Compliance date: