Meadow Park Rehabilitation and Health Care Center LLC
October 7, 2016 Complaint Survey

Standard Health Citations

FF09 483.13(c)(1)(ii)-(iii), (c)(2) - (4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 7, 2016
Corrected date: November 21, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review conducted during an abbreviated survey, the facility did not ensure that an allegation of Injury of Unknown Origin was thoroughly investigated. Specifically, the facility did not investigate a housekeeping staff who watched Certified Nursing Assistant #1 (CNA #1) as she transferred a resident with the mechanical lift by herself. In addition, the facility did not investigate a pain medication that was not administered in a timely manner for 1 of 3 residents sampled for Injury of Unknown Origin (Resident #1). Complaint # 5 The findings include: Resident #1 was an 81year old Male who was admitted on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified the resident with long/short-term memory impairments. Section B of the MDS under Speech Clarity identified the resident with a score of 2 points. This denotes no speech - absence of spoken words. The facility's in-house summary of investigation revealed that on 8/22/2015 at approximately 12:00 AM CNA #2 reported to RN #1 that Resident #1's left upper arm appeared swollen. Upon assessment, RN #1 observed that Resident #1 grimaced in pain when his left arm was moved. The Registered Nurse Supervisor #1 (RNS #1) was informed and assessed the resident with slight swelling and limited range of motion. The physician was notified and an x-ray was ordered and done in the morning. Resident #1 was transferred to the emergency room at 2:30 PM. In addition, the facility investigation showed that CNA #1 provided the facility with a written statement, noting that the housekeeping staff watched her as she performed a one person Hoyer-Lift transfer for Resident #1. The nurse's progress note dated 8/22/2015 at 7:31 AM, documented that Resident #1 was noted with grimacing pain during movement to his left shoulder, and muscle tone more pronounced on the arm. No redness or swelling noted. The doctor made aware with telephone order for an x-ray of the left shoulder to rule out fracture, and Tylenol 650mg every 6 hours via Percutaneous Endoscopic Gastrostomy (PEG) as needed for pain. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The Diagnostics Patient Report dated 8/22/2015 documented that an x-ray was done of Resident #1's left shoulder with impressions: Acute complete mildly displaced proximal humeral shaft fracture. The nurse's note dated 8/22/2015 at 3:30 PM documented that the x-ray result revealed [MEDICAL CONDITION] shoulder. The doctor was made aware and Resident #1 was transferred to the hospital for evaluation. Resident #1 was identified with signs of pain on 8/22/2015 at 1:00 AM. Tylenol 650mg was ordered on [DATE] at 7:32 AM. Resident #1 did not receive the pain medication until 12:39 PM on 8/22/2015. The Resident Nursing Instruction dated 10/08/2014, under title transfer documented that Resident #1 requires two plus person physical assist with Hoyer-Lift. Although, CNA #1 provided the facility with a statement noting that she performed a one person Hoyer-Lift transfer on Resident #1; with the surveillance of a non-nursing staff, the facility did not investigate these issues. On 12/23/2015 at 3:44 PM, the Director of Nursing (DON) was interviewed. She stated that she did not investigate CNA #1's statement, noting that she allowed the housekeeping staff to watch her perform a one-person transfer task with the Hoyer-Lift. In addition, the DON stated that she did not investigate the pain medication and that she was sure the pain medication was administered. The facility's Policy and Procedure on Accident/Incident dated (MONTH) 2011 documented that the purpose for the policy is to facilitate and enable the facility to complete a thorough investigation. 483.13(c)(3)

Plan of Correction: ApprovedOctober 28, 2016

Disclaimer: The facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department?s directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long term care. This should not be construed as either a waiver of the Facilities right to appeal and to challenge the accuracy or severity of the alleged deficiencies or an admission of any wrong doing or an admission of past or ongoing violations of Federal and State Regulations.
Immediate Corrective Action:
1. Investigation regarding Resident # 1 was re-opened, and a statement from involved staff member was obtained on 10/21/2016.
2. Resident is currently residing in our facility in a stable condition. Resident recent X-ray revealed left humeral fracture healed.
3. The Director of Nursing compiled a list of all accidents and incidents related to Injury of Unknown Origin for the past 2 months. All Accidents and Incidents reports were reviewed to ensure that an allegation of Injury of Unknown Origin was thoroughly investigated through the following criteria:
a. All written statements of witnesses and staff who handled the resident for the past 72 hours were obtained
b. Plan of Care was consistently followed. There were no additional quality issues identified.
4. The Director of Nursing compiled a list of all Accidents and Incidents for the past 2 months. All Accident/Incidents were reviewed to ensure that an RN pain assessment was done after the Accident/Incident, and appropriate interventions were implemented.
5. There were no additional quality issues identified.

Identification of Other Residents:
The facility respectfully states that no other residents were affected by the deficient practice.
Systemic Changes:
The following systemic changes were implemented to ensure continuing compliance with regulations:
1. The Policy and Procedure for Accident and Incident Investigation/Abuse Mistreatment Investigation Policy was reviewed by the DNS, and was found to be compliant.
2. All staff were re-inserviced on the Policy and Procedure for Accident and Incident Investigation/Abuse Mistreatment Investigation Policy by the In-service Coordinator. The Lesson Plan concentrated on the following areas: Facility Policy and Procedure for Accident and Incident Investigation/Abuse Mistreatment Investigation, Gathering of Statements of witnesses and assigned staff.
3. The Policy and Procedure for Pain Assessment and Management was reviewed by the DNS and was found compliant.
4. All licensed RN were in-serviced on the Policy and Procedure for Pain Assessment and Management by the In-service Coordinator. The Lesson Plan concentrated on the following areas: Facility Policy on Pain Assessment and Management, RN Assessment after an Accident or Incident, Referral to MD for medical intervention if there is pain or injury. A copy of the Lesson Plan and attendance sheets will be filed for reference and validation.
QA Monitoring:
The facility?s compliance will be monitored utilizing the following quality assurance system:
1.The Director of Nursing has developed an audit tool to monitor compliance with Pain Assessment after an Accident/Incident. Audits will be done on all Residents initially, then 5 Residents per week over the next quarter. Audits with negative findings will have corrective action taken if indicated by the DNS and CCP team. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up as needed.
2.The Director of Nursing/designee has developed an Audit Tool to monitor compliance for thorough investigation of Accident/Incidents related to Injury of Unknown Origin. Audits will be done on all Incident reports pertaining to Injury of Unknown Origin initially, then 3 residents every month until (MONTH) (YEAR). Audits with negative findings will have corrective actions taken if indicated by the DNS and CCP team. Audit Findings will be presented to the QA Committee at the quarterly QA meeting for evaluation and follow up as needed.
Responsible Party:
The Director of Nursing will be responsible for attaining and maintaining compliance with this F tag.


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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 7, 2016
Corrected date: November 21, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review conducted during an abbreviated survey, the facility did not ensure that a resident received the necessary care and services to attain the highest practicable level of physical, mental, and psychosocial well-being. Specifically, the facility did not ensure prompt pain management for 1of 3 residents sampled for Injury of Unknown Origin (Resident #1). Complaint # 5 The findings include: Resident #1 is an 81year old Male who was admitted on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 10/03/2015 identified the resident with long/short-term memory impairments. Section B of the MDS under Speech Clarity identified the resident with a score of 2 points. This denotes no speech - absence of spoken words. The facility's in-house summary of investigation revealed that on 8/22/2015 at approximately 12:00 AM CNA #2 reported to RN #1 that Resident #1's left arm appeared swollen. The charge nurse observed Resident #1 with grimacing in pain, when his left arm was moved and she reported it to RNS #1. RNS #1 assessed Resident #1 at 1:00AM, and observed slight swelling with limited range of motion to the left arm. The doctor was notified and an x-ray was ordered. The x-ray result showed left upper extremity fracture. The nurse's progress note dated 8/22/2015 at 7:31AM, documented that Resident #1 was noted with grimacing pain during movement of left shoulder. Muscle tone more pronounced on the arm, no redness noted, no swelling. The medical doctor made aware and telephone order obtained for x-ray to the left shoulder to rule out fracture and Tylenol 650mg every (Q) 6 hours via Percutaneous Endoscopic Gastrostomy (PEG) as needed for pain. The physician's orders [REDACTED]. Although, the physician's orders [REDACTED].#1 has a feeding tube and receives medications via peg tube route as the physician's orders [REDACTED]. The facility's investigation, including statements from the staff, did not mention anything regarding Resident #1 receiving Tylenol 650mg for pain. The Medication Administration Record [REDACTED]. The Diagnostic Patient Report dated 8/22/2015 documented that an x-ray was done on Resident #1's left shoulder with impressions: Acute complete mildly displaced proximal humeral shaft fracture. The nurse's progress note dated 8/22/2015 did not provide any documented evidence that Resident #1 received Tylenol or any other medications for pain relief. The Nursing Home to Hospital Transfer Form dated 8/22/2015, documented under title most recent pain medication -Tylenol 650mg given on 8/22/2015. Under title Time Taken documented 12:39 PM. There are two boxes next to time given, AM and PM. The PM box has the letter x marked in the box. This transfer form is the only document that showed Resident #1 received pain medication approximately 12 hours after being identified with pain. The nurse's progress note dated 8/22/2015 at 10:14PM, documented that Resident #1 returned from the hopital. X-ray done - shows communitede spiral [MEDICAL CONDITION] left humerus, with lateral displacement, humeral splint in place. Resident #1 returned with wife and two EMS via stretcher. will continue to monitor. No new orders from hospital noted. A late entry nurse's progress note dated 8/24/2015 at 9:21PM for 8/22/15, documented am I was called to the resident's room by CNA at 12:30AM because she notice resident grimacing every time she move his arm, resident L arrm was assessed, no [MEDICAL CONDITION], no discolaration noted, resident's upper L arm was hard lik a stone and resident was grimacing every time his L arm was touche. I notified night supervisior and she contacted MD in AM and order x-ray. A late entry correction note dated 8/24/2015 at 9:33PM for 8/22/15, documented am I was called to the resident's room by CNA at 12:30AM because she notice resident arm being hard, resident L arm was assessed, no [MEDICAL CONDITION], no discoloration noted, resident's upper L aram was hard like a stone. I notified night supervisor and she contacted MD in AM and ordered x-ray. The MAR indicated [REDACTED]. Resident # 1 received this pain medication on 8/25/2015 and twice a day from 8/26/15 through 8/31/2015 . An interview was conducted on 6/24/2016 at 5:03PM with CNA #2 who was assigned to Resident #1 on 8/21/2015 on the 11:00PM to 7:00AM shift. She stated that when she arrived on the unit, she made rounds, at which time she observed that an area of Resident #1's arm was hard. She further stated that Resident #1 looked at her when she touched the hard area on his arm. She added that Resident #1 is deaf and dumb, so he did not speak. In addition, she stated that she reported her observation immediately to the RN #1. An interview was conducted on 6/23/2016 at 3:04 PM with RN #1 who worked on 8/21/2015 on the 4:00 PM to 12:00AM shift. She stated approximately 12:30 AM on 8/22/2015, CNA #2 notified her that Resident #1's arm was hard. She further stated that she assessed the resident and confirmed the hardness to his arm and she notified RNS #1. An interview was conducted on 6/29/2016 at 12:33PM with the RNS #1, who worked on 8/22/2015 on the 12:00AM to 8:00AM shift. She stated that RN #1 notified her that an area of Resident #1's arm was hard to touch. She further stated that she assessed the resident and had the feeling that he was in pain. In addition, she stated that she was not quite certain that Resident #1 was given Tylenol for pain as it was relatively early and the Jewish Sabbath was in progress. She stated that she texted the doctor, but was not certain that he responded. She also stated that she does not remember at what time the staff notified her. RNS #1 provided the facility with a statement dated 8/22/2015. The statement reads, during the 4-12 shift at around 1:00AM, I was informed by the charge nurse (RN #1) that staff reported to her that Resident #1's left arm is slight swollen with limited Range of Motion, noted with pain. X-ray was ordered to rule out fracture. An interview was conducted with the Director of Nursing (DNS) on 12/23/2015 at 3:44PM. She stated, even though it is not written anywhere, Resident #1 must have gotten the pain medication. The facility's revised Policy and Procedure on Pain Management dated 3/2009, on page 2 documented under title Cognitive Response to Pain - note behavior suggested pain in residents who are cognitively impaired or who have a communication problems relating to education, language, ethnicity, or culture. Use appropriate (e.g. simpler or translated) pain assessment tools. Under title Response to Treatment - document any treatments used (e.g. Tylenol, heat, cold) and how well it works. The Nursing Home to Hospital Transfer Form dated 8/22/2015 documented that Resident #1 is deaf and mute. A pain assessment tool was not utilized to identify Resident #1's pain level. 483.25

Plan of Correction: ApprovedOctober 28, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action:
1. Investigation regarding Resident # 1 was re-opened, and a statement from involved staff member was obtained on 10/21/2016.
2. Resident is currently residing in our facility in stable condition. Resident recent X-ray revealed thatleft humeral fracture healed.
3. The Director of Nursing compiled a list of all residents who are cognitively impaired or who have communication problems for the past month and utilized it as a sample to review that a Pain Assessment tool was done by an RN to identify pain level. There were no additional quality issues identified.
4. The Director of Nursing compiled a list of all residents who have an order of Pain Medications for the past 2 months. MARs for respective residents were reviewed as well as pain assessments. Above documentation was reviewed for timeliness of pain medication administered, as well as completed pain assessments. There were no additional quality issues identified

Identification of Other Residents:
The facility respectfully states that no other residents were affected by the deficient practice.

Systemic Changes:
The following systemic changes were implemented to ensure continuing compliance with regulations:
1. The Policy and Procedure for Pain Management was reviewed by the DNS, and was found to be compliant.
2. All licensed nurses were re-inserviced on the Policy and Procedure for Pain Management by the In-service Coordinator/Designee. The Lesson Plan emphasized on utilization of Pain Assessment tool, re-evaluation of pain after pain medication was administered, and documentation of pain medication administration. A copy of the Lesson Plan and attendance sheets will be filed for reference and future validation.

QA Monitoring:
The facility?s compliance will be monitored utilizing the following quality assurance system:
1. The Director of Nursing has developed an Audit Tool to monitor compliance with Pain Assessment on all residents who have communication problems or are cognitively impaired. Audits will be conducted by the Director of Nursing/Designee on all residents initially, then 5 Residents per week over the next quarter. Audits with negative findings will have corrective action taken immediately by the DNS and CCP team. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up as needed.
2. The Director of Nursing has developed an Audit Tool to monitor compliance for Pain Medication administration based on the Physician order [REDACTED]. Audits will be done by the Director of Nursing/Designee on all residents initially, then 10 residents every month until (MONTH) (YEAR). Audits with negative findings will have corrective actions taken if indicated by the DNS and CCP team. Audit Findings will be presented to the QA Committee at the quarterly QA meetings for evaluation and follow up as needed.

Responsible Party:
The Director of Nursing will be responsible for attaining and maintaining compliance with this F tag.