Shore View Nursing & Rehabilitation Center
June 30, 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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 30, 2016
Corrected date: July 20, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not ensure that a resident clinical record was complete and accurately documented. Specifically, a resident with doctor orders for nutritional supplements (Glucerna Shake and Liquid Protein Supplement) were not transcribed. (Resident #315). The findings are: Resident #315 is a [AGE] year old with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of Medication Administration Records (MAR) dated date of 5/19/16 documented discontinuance of the LPS SF (sugar free) 30 ml PO QD and Glucerna Shake 8 oz PO TID. Review of Medication Administration Records from 5/19/16 to 6/30/16 revealed no documented evidence that the supplements were administered. The Certified Nursing Assistant Accountability Record (CNAAR) for (MONTH) (YEAR) did not document intake of Glucerna Shake supplement. On 6/28/16 at 9:39 AM, the Registered Nurse (RN) stated that the the nurse is responsible for entering in orders and the Doctor or the Nurse Practitioner (NP) signs off on the orders. The RN then stated nutritional supplements (Glucerna Shake and LPS) are documented on the MARS. On 6/28/16 at 3:46 PM, the Licensed Practical Nurse (LPN) stated that the doctor puts in orders and the nurse reviews them. The LPN further stated that she didn't think to question that the supplements were missing in the MAR because the resident has always been getting it. She further stated that she doesn't always check the doctor orders against the MARS everyday. On 6/30/16 at 10:50 AM, the Director of Nursing (DON) stated that nurses are responsible for checking the doctor's orders with the MAR, and administer medications or supplement. Nurses are trained upon hire. She further stated that since the nurses check the MAR daily, they should've caught the error. 415.22(a)(1-4)

Plan of Correction: ApprovedJuly 8, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Plan of Correction:
F514
I. Immediate Corrective Action:
? Resident #315 was identified and a special review CCP meeting was held on 6/28/16 to determine any negative outcomes from this citation. No negative outcome resulted from the omitted documentation as the resident gained weight and her [MEDICATION NAME] level improved.
? The nurses who failed to document the provision of supplements to the resident received disciplinary counseling.
? Immediate in-service was provided to the involved nurses addressing physician order [REDACTED].
Responsible Person: Director of Nursing
II. Identification of Other Residents:
The DNS developed a list of residents on supplements to ensure physician orders [REDACTED]. were properly transcribed. No negative findings were noted during the review.
III. Systemic Changes:
1. The policy on E-prescribing transcription and order entry into PCC (EMR) was
revised to ensure:
? A Licensed nurse reviews and confirms the physician orders [REDACTED].
? The second nurse on the same or next shift reviews the order in e-Mar Report and view the E-MAR to verify the correct scheduling frequency, schedule type, facility time codes, indication for use, supplemental documentation duration for administration and any additional directions.
2. The policy on Snack, Nourishment and Supplement Distribution was also revised to include:
? Documentation in the E-Mar of the amount of supplement consumed by resident
3. The In-service Coordinator will re-in serviced all licensed nurses on the revised policy on physician order [REDACTED].
? A copy of the Lesson Plan and Attendance Records will be filed for reference and validation.
Completion Date: 7/20/16
IV. Quality Assurance Monitoring:
1. The facility developed an audit tool to track the plan of correction.
2. The Dietitian will complete the tool weekly for 1 month and quarterly thereafter until 100% compliance is maintained.
3. Audits with negative findings will have immediate corrective action by the Dietitian and DNS.
4. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up as needed.
Responsible party: Chief Dietitian and Director of Nursing