Momentum at South Bay for Rehabilitation and Nursing
September 26, 2018 Certification Survey

Standard Health Citations

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 15, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the recertification survey, the facility did not develop a Comprehensive Care Plan (CCP) for a resident with limited Range of Motion of the lower extremities. This was evident for one of three residents reviewed for Accidents/Falls. Specifically, Resident # 56 was observed with contractures of both lower extremities. There was no CCP developed with specific goals and interventions addressing the contractures. The finding is: The facility policy titled Comprehensive Care Plans (CCP) and Resident/Patient meeting effective 11/17 .2 Section 1-The purpose of the assessment is to accurately communicate the resident's capability to perform daily life functions and to identify significant impairments in functional capacity and the plan suggested by the CCP team for improvement/maintenance for each of the resident's primary care issues. Resident # 56 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) Score of 6, indicating severe cognitive impairment. The MDS documented that the resident required the assistance of two staff members for bed mobility, was totally dependent on two staff members for transfers, and was non- ambulatory. The resident had impairment in Range of Motion (ROM) on both sides of the lower extremities. The Rehab Screening form dated 2/9/18 documented that the resident had limited ROM of both sides of lower extremities with limitations in knee extension and contractures of both ankles. The Certified Assistant Assignment and Accountability Record for (MONTH) (YEAR) did not include ROM instructions as part of the CNA assignment. An Annual Rehab Screening dated 8/9/18 documented that the resident had limitations in ROM with limited extension of both knees and contractures of the lower extremities. The Activities of Daily Living CCP, dated 8/3/18 and updated on 8/17/18 and 9/8/18 did not include the limitations in ROM of the lower extremities. In addition, there was no mention of the contractures nor any plan to prevent further contractures. The resident was observed on 9/19/18 at 9:45 AM. The resident was in a low bed with both legs visibly contracted. A second observation was made on 9/19/18 at 12:30 PM. The resident was observed in the dining room, positioned in a high back recliner with side support. Both legs were visibly contracted and the resident was leaning on left side. The Unit Manager/Registered Nurse (RN) was interviewed on 09/26/18 at 10:13 AM and stated the resident can move her upper body at times. The RN further stated that the CCP addressing the resident's mobility should have included the contractures. The Director of Nursing Services (DNS) was interviewed on 9/26/18 at 11:14 AM. The DNS stated that the facility does not have a specific CCP for contractures. The DNS stated that the resident's contractures should have been addressed by the team. The Director of Rehabilitation was interviewed on 9/26/18 at 12:28 PM and stated that the resident's plan of care is reviewed by the entire team for each care area. 415.11(c)(1)

Plan of Correction: ApprovedOctober 15, 2018

F656
1. Resident #56 was seen by PT/OT for contracture evaluation. The residents CCP was updated to include a comprehensive person centered care plan for the resident, including goals , interventions and preventative measures.
Date completed: 9/26/18
2. All residents with contractures have the potential to be affected by this practice.
The DNS reviewed all residents with contractures to ensure the accuracy of the CCP implementation and documentation. Revisions will be made as identified to comply with documenting the care, treatment and monitoring of the residents with contractures.
A comprehensive person centered care plan for contractures has been created and instituted.
Date completed:9/26/18
3. All facility licensed staff will be educated by the in-service educator with regard to appropriate completion of CCP?s as they relate to contractures.
4. A weekly facility audit of 100% of the CCP?s for all residents with diagnosed contractures will be completed by the DNS to ensure appropriate implementation and completion of CCP?s until 100% compliance is achieved for 4 weeks. The audit will continue quarterly thereafter and presented at the QAPI meeting for a minimum of 2 quarters or until 100% compliance achieved for 2 quarters.
5. The Director of Nursing is Responsible for this correction
Date of correction: 11/15/18

FF11 483.45(c)(3)(e)(1)-(5):FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 15, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the Recertification Survey, the facility did not ensure that for 1 (Resident # 113) of 5 residents reviewed for Unnecessary Medications 1) non-pharmacological interventions were documented prior to the administration of a PRN (as needed) [MEDICAL CONDITION] drug ([MEDICATION NAME]). In addition, 2) the resident's antipsychotic medication ([MEDICATION NAME]) was doubled on the second day after the resident was admitted to the facility without documented clinical indications for the increase. The finding is: Resident #113 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The 30-day Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was rarely/never understood and could rarely/never understand. The resident also had severely impaired cognitive skills for daily decision making with long and short term memory problems. The resident received Antipsychotic and Antianxiety medications. 1) The Physician order [REDACTED]. The Physician order [REDACTED]. The Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. The Nurse's Notes dated 8/9/18 at 2:00 PM, 8/10/18 at 2:00 PM, 8/11/18 at 2:00 PM, 8/12/18 at 2:00 PM, and 8/13/18 at 1:00 PM documented that the prn [MEDICATION NAME] was administered due to the resident having frequent verbal outbursts. There were no non pharmacological interventions documented prior to the administration of the [MEDICATION NAME]. The Licensed Practical Nurse (LPN #3) Medication Nurse who administered the prn [MEDICATION NAME] on 4 occasions on the 7:00 AM-3:00 PM shift on 8/9/18, 8/11/18, 8/12/18, and 8/13/18 was interviewed on 9/24/18 at 11:30 AM. LPN #3 stated that when the resident would have verbal outbursts she would try to give the resident something to eat because she liked to eat. LPN #3 stated that she would ask the resident what was wrong, but the resident could not describe what was the matter. LPN #3 also stated that she should have written in the Nursing Notes what non pharmacological interventions she had done prior to administering [MEDICATION NAME]. The LPN (LPN #4) Medication Nurse who administered the prn [MEDICATION NAME] on the 7:00 AM-3:00 PM shift on 8/10/18 was interviewed on 9/24/18 at 11:45 AM. LPN #4 stated that when the resident would have verbal outbursts she would offer her something to eat or play music on her CD player for her. LPN #4 stated she had been inserviced on documenting non-pharmacological interventions before administering a [MEDICAL CONDITION] ([MEDICATION NAME]). LPN #4 stated that she guessed it was a mishap that she had not. The Director of Nursing Services (DNS) was interviewed on 9/24/18 at 1:30 PM. The DNS stated that she would expect the Nurses to document what non-pharmacological interventions were done prior to giving the resident the prn [MEDICATION NAME]. 2) The Physician order [REDACTED]. This order was discontinued (d/c'd) 8/8/18. The [MEDICAL CONDITION] Medication Comprehensive Care Plan (CCP) dated 8/7/18 documented under Interventions: Behavior modification techniques and non-pharmacological interventions attempted prior to implementing standing/prn [MEDICAL CONDITION] medications. The Physician order [REDACTED]. This order was d/c'd on 8/9/18. The Physician order [REDACTED]. The Initial Psychiatric Evaluation dated 8/9/18 documented that the resident screamed almost continuously and other residents complained about it. The evaluation also documented that the resident's family member informed the Physician Assistant (PA) that the resident had been taking 5 mg of [MEDICATION NAME] three times daily at home. The Psychiatrist was interviewed on 9/24/18 at 1:55 PM and stated that he doubled the resident's dose of [MEDICATION NAME] on her second day in the facility based on what she had been taking at home and that other resident's were complaining about her screaming. On 9/26/18 at 3:30 PM the facility's Physician Assistant (PA) was interviewed and stated that the resident's family member was concerned about the resident's yelling and wanted her back on the 5 mg dosage that she was on at home. 415.12(l)(2)(i)

Plan of Correction: ApprovedOctober 25, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F758
1. Resident #113 has been evaluated by psychiatry and is calm, cooperative with controlled behavior
The residents medical record has been updated to reflect documented clinical indications for the increase of the residents [MEDICAL CONDITION] medication as well as non- pharmacological approaches designed to meet the individual needs of the resident. The IDT along with the residents designated representative have met and determined that the current medication regime is appropriate in order to promote and maintain the residents highest practical mental, physical and psychosocial well-being as well as implementation of non-pharmacological approaches designed to meet the needs of the individual resident.
Date completed:9/27/18
2. All residents receiving [MEDICAL CONDITION] medication have the potential to be affected by this practice.
The DNS will review all residents receiving [MEDICAL CONDITION] medication to ensure that non-pharmacological approaches designed to meet the needs of the individual resident were documented in the clinical record prior to the administration of a PRN [MEDICAL CONDITION] medication as well as any [MEDICAL CONDITION] medication changes that were initiated were reviewed by the IDT for appropriate clinical indications.
Date completed:9/27/18
3. All licensed staff, physician, physician extenders and the IDT will be re-educated on the use of non-pharmacological interventions that are specific to the needs of the individual residents prior to the administration of PRN [MEDICAL CONDITION] medications as well as an increase in dose or frequency of [MEDICAL CONDITION] medication and the importance of documenting such in the clinical record.
Date completed: 11/15/18
The facility policy for [MEDICAL CONDITION] drug use was reviewed , no changes necessary.
4. The DNS will audit 100% of residents receiving PRN [MEDICAL CONDITION] medications to ensure non-pharmacological interventions are being documented in the clinical record, specific to the individual needs of the resident prior to the administration of PRN [MEDICAL CONDITION] medication, the DNS will audit 100% of the residents that have had a [MEDICAL CONDITION] medication dose increase to ensure the change was reviewed by the IDT for appropriate clinical indications until 100% compliance achieved for 4 weeks. The Audit will continue quarterly thereafter and presented at the QAPI meeting for a minimum of 2 quarters or until 100% compliance achieved for 2 quarters.
5. The Director of Nursing is responsible for this correction
Date Completed: 11/15/18

FF11 483.20(f)(5); 483.70(i)(1)-(5):RESIDENT RECORDS - IDENTIFIABLE INFORMATION

REGULATION: §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 15, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey the facility did not ensure that, in accordance with accepted professional standards and practices, medical records were accurately documented, for one (Resident #195) of one resident reviewed for non-respiratory or non-urinary infections. Specifically, Resident #195 has a peripherally inserted central catheter (PICC), which requires a Registered Nurse (RN) to change the dressing. Review of the (MONTH) (YEAR) treatment administration record (TAR) revealed the dressing change was being incorrectly signed by a Licensed Practical Nurse (LPN) rather than the RN when the dressing was changed. The finding is: Resident #195 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/17/2018 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident was severely cognitively impaired. The MDS documented that the resident was receiving intravenous (IV) medications. The initial nursing assessment, dated 9/10/2018, documented that the resident had a PICC in his right arm. A comprehensive care plan (CCP) titled IV Therapy/IV Meds, dated 9/10/2018, documented that the resident was receiving IV medications for [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Additional physician's orders [REDACTED]. Review of the (MONTH) (YEAR) TAR revealed a LPN signed on 9/15/2018 and 9/22/2018 for the weekly PICC line dressing change. The LPN whose initials appeared on the TAR for both weekly PICC line dressing changes was interviewed on 9/25/2018 at 2:40 PM. She stated she did not change the PICC dressing. She stated she thinks the RNs who did the dressing changes signed for it using the LPN's computer login. A RN who worked on 9/22/2018 was interviewed on 9/26/2018 at 9:50 AM. She stated she changed the PICC dressing on 9/22/2018. She stated she may have thought that she was logged in, or the screen must have been left open and she signed inadvertently thinking that it was her login screen. The RN who did the PICC dressing changes on 9/15/2018 was unavailable. The Director of Nursing Services (DNS) was interviewed on 9/26/2018 at 11:46 AM. She stated the LPN has to make sure she signs out of her computer after she is done, and everyone has to sign in to the computer under their own name. 415.22(a)(1-4)

Plan of Correction: ApprovedOctober 15, 2018

F842
1. Resident #195, the medical record was updated to reflect the proper documentation of PICC line dressing change.
DateCompleted:9/26/18
The RN and LPN in question were educated with regard to accurate documentation in the medical record in relation to PICC line standards of care.
Date completed: 9/26/18

2. All residents with PICC lines have the potential to be affected by this practice.
The DNS/designee will review all residents with PICC lines to ensure accurate documentation in the medical record in relation to professional standards.
Date completed: 9/26/18
The facility policy for PICC line care was reviewed , no changes necessary.
3. All facility Registered Nurses will be educated by the in-service educator with regard to accurate documentation in the medical record as it relates to PICC line standards of care.

4. A weekly facility audit of all residents with PICC lines will be completed by the DNS/designee to ensure accurate documentation in the medical record until 100% compliance achieved for 4 weeks. The Audit will continue quarterly thereafter and presented at the QAPI meeting for a minimum of 2 quarters or until 100% compliance achieved for 2 quarters.
5. The Director of Nursing is Responsible for this correction
Date of correction: 11/15/18

FF11 483.25(b)(1)(i)(ii):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER

REGULATION: §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 15, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review during the Recertification Survey the facility did not ensure that residents with pressure ulcers received care consistent with professional standards of practice for 3 (Residents # 101, # 130, and # 344) of 3 residents reviewed for pressure ulcers. Specifically, 1) Resident #101 developed a Stage IV Pressure Ulcer (P/U) between the thumb and second finger of the left hand. There was no thorough assessment performed of the original open wound when initially identified. 2) Resident #130 was identified with a dry scabbed area to the left posterior ankle on 5/16/18 and there was no documented evidence that the wound was being monitored daily or a protective dressing applied until 5/20/18 when the area worsened and 3) Resident #344 was admitted to the facility with a Stage 2 pressure ulcer; however, the wound was not properly assessed until three days after admission. The findings are: The facility Policy and Procedure effective dated 5/2012 documents: #1.The RN will refer any resident who is at risk for skin breakdown to the wound care nurse or physician for determination of treatment regime. #6 the Skin Risk Assessment tool is the instrument used to assess and predict pressure ulcer risk. #8 Measurements are to be done by the Wound Care Nurse and Wound Care Physician or their designee. Treatment Guidelines include #1 All pressure ulcers noted on admission or newly developed must be reported to the Nurse Manager/Supervising RN. 1) Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment documented the resident had a BIMS score of 8, indicating that the resident had moderately impaired cognition. The MDS documented the resident was totally dependent on staff for personal hygiene and bathing. The assessment documented that the resident was at risk for Pressure Ulcers and that there were no current unhealed Pressure Ulcers. A facility Pressure Ulcer Investigation dated 7/20/18 documented that a Stage II P/U was discovered on the resident's left thumb. The Braden Score was documented as 17, indicating that the resident was at moderate risk for P/U. The investigation lacked any further description of the wound. The physician's orders [REDACTED]. A Nurse's Note (N/N) dated 7/20/18 at 2:56 PM documented the resident was ordered [MEDICATION NAME] for the skin opening between the first and second digit of the left hand. The N/N did not document any further assessment of the wound. The Comprehensive Care Plan (CCP) titled, Actual Pressure Ulcer, dated 7/23/18, documented the resident had a Stage II Pressure Ulcer, location of the left thumb The CCP was not updated when the P/U was identified to have deteriorated to a Stage IV on 7/23/18. The Wound Report Sheet, completed by the Wound Care Nurse/Registered Nurse (RN), was completed by the Wound Care/RN on 7/23/18. The RN documented the left thumb was a Stage IV Pressure Ulcer measuring 1.0 X 0.5 X 0.3 centimeters (cm). The wound was described as moist with red wound bed and white tendon exposure. The N/N titled Wound Care dated 7/23/18 at 2:00 PM by the Wound Care/RN documented that the resident was assessed for the left hand wound with measurements of 1.0 X 0.5 X 0.3, with a small amount of drainage and red granular tissue with tendon visible. A Physician's Assessment/Progress Note dated 7/23/18 by the Physician's Assistant (PA) identified the resident with a new wound to the left thumb measuring 1 X 0.5 cm with visible tendons. The note documented a Stage IV to the left thumb and ordered Collagen to the wound. The physician's orders [REDACTED]. The Wound Care Physician (MD) assessed the resident's left thumb wound on 7/25/18 and documented a Stage IV Pressure Ulcer with 100 % tendon exposure. The Wound Care/RN was interviewed on 9/21/18 at 11:30 AM. The RN stated that the actual, complete assessment of the wound was done by the Wound Care/RN on 7/23/18. The Wound/RN stated that the wound could definitely have declined from a Stage II identification on 7/20/18 to the Stage IV identification on 7/23/18. The Wound Care/RN stated that the wound was first described as an open blister which would be a Stage II. The RN stated that she had not actually assessed the wound on 7/20/18 when it was documented as a Stage II, and when the tendon was visible on her assessment on 7/23/18 it was a Stage IV. The resident's attending Physician/MD was interviewed on 9/24/18 at 8:56 AM. The MD stated that the resident had significant potential for Pressure Ulcers. The MD Stated that the Physician's Assistant (PA) was called on 7/20/18 and initiated a telephone order based on the description given by the RN. The Director of Nursing Services (DNS) was interviewed on 9/24/18 at 9:35 AM. The DNS stated that the Wound Care/RN did the measurements and actually observed the wound on Monday 7/23/18. The resident's regular Certified Nurse Assistant (CNA) was interviewed on 9/24/18 at 11:42 AM. The CNA stated that the resident had splints since her admission and that they were being worn at all times during the month of (MONTH) (YEAR). The CNA stated that a different type of splint is being used and it is removed for hygiene and at night. The CNA stated that the resident had a piece of skin hanging off the thumb area and reported it to the nurse on Friday, 7/20/18. The covering RN who documented the only N/N on 7/20/18 was interviewed on 9/24/18 at 12:37 PM. The RN stated that the CNA reported the skin opening and that she, the RN, obtained the order but did not assess the wound. The Unit RN/Manager was interviewed on 9/25/18 at 11:08 AM. The RN stated that the P/U had not been staged by the Unit RN. The RN stated that she had done measurements, however, she does not stage P/Us and did not do any further assessment. The RN stated that she forwards information to the Wound Care/RN for assessment and staging and stated that the measurements were not documented in the medical record. The PA was interviewed on 9/25/18 at 11:24 AM. The PA stated that the RN/Manager called the PA on Friday, 7/20/18, and the RN was given a telephone order for the open area. The PA stated that when the resident was examined on Monday, 7/23/18, it was a Stage IV and the tendon was visible at the time. The PA then changed the order. The left hand wound between the thumb and left second finger has healed on observation on 9/25/18 at 9:50 AM. The DNS was interviewed on 9/26/18 at 2:08 PM. The DNS stated that an RN can measure the wound but only the Wound Care/RN or Physician will stage them.
2) Resident #130 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short term and long memory problems and was severely impaired for daily decision making. The resident required extensive to total assist of one to two staff members for all activities of daily living. The resident was at risk for pressure ulcers and had a Stage 4 pressure ulcer measuring 1.5 centimeter (cm) by 1.0 cm x 0.2 cm. A dressing change observation of the resident's left posterior ankle PU was conducted on 9/26/18 at 7:35 AM with LPN #5 and RN #1. The wound bed was noted with tendon exposure, was clean, and free of odor. There was no signs and symptoms of infection. A Comprehensive Care Plan (CCP) dated 2/16/18 documented the resident had potential for alteration in skin integrity. The goals were for the resident's skin to remain intact. Interventions included to turn and position the resident every 2-4 hours and as needed (PRN). A Braden Scale dated 5/11/18 documented a Score of 12 which indicated the resident was at high risk for pressure ulcer development. A Nurse's note dated 5/16/18 at 2:15 PM titled Wound Care documented the left posterior ankle was noted with a dry tan-brownish scab. The edges were intact, the upper aspect was reddened, and the dorsal aspect was swollen but no redness was noted. The left lower extremity was contracted and a dry protective dressing (DPD) was applied. A Pressure Ulcer Investigation dated 5/16/18 documented an Unstageable Pressure Ulcer (PU) to the resident's left posterior ankle. New interventions included to apply Moisture barrier cream every shift, treatment daily as per order; pressure relieving mattress, cushioned calf and foot board, turning and positioning every two hours and to off load the heels. The preventative measures in place prior to the PU discovery were pressure relieving device, highback wheel chair with calf board and foot rest. The conclusion section of the investigation was not completed regarding why the PU was unavoidable. A Wound Report Sheet dated 5/16/18 documented an unstageable PU to the left posterior ankle measuring 2.1 centimeter (cm) x 1.8 cm x 0 cm. The wound bed was 100% black and the wound margins were reddened. The current treatment was a DPD. A CCP dated 5/16/18 documented a PU to the left posterior ankle. The goal was for left ankle to demonstrate healing x 60 days. Interventions included treatment as ordered, and turn and position program every 2-4 hours and PRN. A physician's orders [REDACTED]. A Wound Report Sheet dated 5/24/18 documented a Stage III PU to the resident's Left posterior Ankle measuring 2.0 cm x 1.5 cm x 0.2 cm. The wound bed was 100% red. A Wound Report Sheet dated 5/30/18 documented a Stage IV PU to the resident's left posterior ankle measuring 2.5 cm x 1.2 cm x 0.2 cm. The wound bed was 10% red and with tendon exposure. Review of the physician's orders [REDACTED]. A Review of the Treatment Administration Record (TAR) dated (MONTH) (YEAR) revealed from 5/16/18 to 5/19/18 there was no documented evidence that a DPD was ordered or being administered to the resident's Left Achilles. A review of the resident's medical record lacked documented evidence that the Physician was notified of the resident's alteration in skin integrity on 5/16/18. A Certified Nursing Assistant Assignment and Accountability Record (CNAAAR) dated (MONTH) (YEAR) was reviewed and lacked documented evidence of preventative pressure ulcer measures for the resident's feet. The record also lacked documented evidence that turning and positioning and checking the resident's skin was included in the resident's plan of care prior to 5/16/18. On 5/18/18 padding was added to the resident's foot cradle. The CNAAAR dated (MONTH) (YEAR) to (MONTH) (YEAR) documented bilateral heel boots while in bed, and to off load the resident's heel while in bed and in a chair. The CNAAAR also documented to monitor the resident's skin integrity, to report changes to the nurse, and to turn and position the resident every two hours. The CNAAAR dated 8/2018 to 9/2018 documented to turn and position the resident every two hours, pillows between bilateral lower extremities. During an interview conducted on 9/24/18 at 3:38 PM with the Wound Care Registered Nurse (RN #1), she stated the staff nurse brought to her attention that the resident had a dry scab on her left ankle. The RN stated that she assessed the wound and at the time of the assessment the wound was unstageable and a dry protective dressing (DPD) was applied. The RN stated after the assessment she discussed the findings and the treatment plan with the unit staff nurses and that she or the unit nurses could have notified the Physician to obtain an order. The order is then entered into the electronic medical record. The RN stated that she did not notify the Physician of the Unstageable Pressure Ulcer (PU) and that she believed the Unit Manager had notified the Physician. The RN further stated that the treatment plan was a DPD daily and that there should have been a physician's orders [REDACTED]. During a subsequent interview conducted on 9/26/18 at 2:53 PM with RN #1, she stated that heel float booties, turning and positioning (T/P), pillows to aid in positioning and a pressure relief (Gravity-7) air mattress were in place prior to the identification of the wound on 5/16/18. The RN further stated that after the wound was identified extra padding was initiated on the resident's calf board. During an interview conducted on 9/24/18 at 3:51 PM with RN #2 Unit Manager, she stated that it was brought to her attention by the treatment Licensed Practical Nurse (LPN) on 5/16/18 that there was a scabbed area to the resident's left ankle. The RN stated after she assessed the resident's left ankle she notified the wound care nurse but did not document her assessment. The RN stated after discussing the treatment plan with the Wound Care nurse an order should have been obtained and then entered into the electronic medical record by the LPN treatment nurse. The RN stated that she did not notify the Physician of the Unstageable PU; however, she was responsible for notifying the Physician after the wound was identified. During an interview conducted on 9/25/18 at 11:22 AM with the day shift medication Licensed Practical Nurse (LPN #2), she stated that on 5/16/18 the CNA brought to her attention during morning care that the resident had a scabbed area to the left ankle. The LPN stated that she went with the CNA to the resident's room and observed a scabbed area to the resident's left ankle, then she went and notified the charge RN. The LPN stated that she was not the treatment nurse on 5/16/18, but happened to be down the hall when the CNA brought the change in the resident's skin integrity to her attention. The LPN further stated that she did not notify the Physician regarding the change in the resident's skin integrity and did not know who did. During an interview conducted on 9/25/18 at 11:33 AM with CNA #2, she stated that she was the resident's caregiver for the last nine months. The CNA stated that every day at the start of her shift she checks the resident's skin and if something was wrong she reports it to the nurse. The CNA stated that the first time she saw a change in the resident's skin was on 5/16/18 when she saw a little sore and she reported it to the nurse. The CNA stated the resident gets out of bed every day on her shift and the resident wears a non-skid sock; however, on the night shift she wears heel booties. During an interview conducted on 9/25/18 at 1:10 PM with the Physician, he stated the resident was identified with a scab on 5/16/18. The area opened on 5/20/18 and treatment was started. The Physician stated that he was notified in passing about the scabbed area to the resident's left ankle but things are not always written down. He stated that he did give an order for [REDACTED]. The Physician stated that his expectation is that orders given are entered into the computer and are administered to the resident. The Physician stated the resident's PU was not addressed in his note until his monthly note in June. During an interview conducted on 9/26/18 at 7:59 AM with the treatment LPN #5, she stated that she was not on duty 5/16/18 when the wound was identified; however, once a physician's orders [REDACTED]. The LPN stated that she was the treatment nurse on duty on 5/17/18 and 5/18/18 but was not involved in applying a DPD to the resident's left foot. The LPN stated not until an order is in place does she administer treatment for [REDACTED]. The LPN stated that an order is required for a DPD and that it is transcribed in the TAR to be carried out by the nurses. During an interview conducted on 9/26/18 at 8:12 AM with the treatment LPN #6, she stated that she was on duty when the PU was identified to the resident's left ankle; however, the resident was seen by the wound care RN. The LPN stated that on 5/16/18 a DPD was applied to the resident's left ankle and that she believed the resident was receiving a DPD daily until the wound opened. The LPN stated that she was on duty on 5/19/18 and that she was sure she applied a DPD to the resident's left foot. A review of the TAR dated 5/2018 with the LPN present, lacked documented evidence that a DPD was being applied to the resident's left ankle. The LPN then stated that she could not give a definitive answer that she applied a DPD to the resident's ankle. During an interview conducted on 9/26/18 at 2:03 PM with the DNS, she stated that she could not say why the wound to the resident's left ankle was not identified prior to an unstageable pressure ulcer. The DNS stated that the resident's skin was checked daily by the CNAs and a verbal report is given to the charge nurse if there are any changes in skin integrity. The DNS stated that on 5/16/18 a DPD was applied to the resident's left ankle and that an order for [REDACTED].
3) Resident #344 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/21/2018 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident was severely cognitively impaired. The MDS documented that the resident had one Stage 2 pressure ulcer present on admission. A CCP titled Actual Ulcer/Wound, with an initiated date of 9/14/2018, documented the resident was admitted with a Stage 2 sacral pressure ulcer. The body illustration in the initial nursing assessment, dated 9/14/2018, documented that the resident had a small open area to the left buttock area and blanchable redness to the right buttock. There was no information in the ulcer assessment section (type, site, stage, length, width, or depth). The admission nursing note, dated 9/14/2018 at 9 PM, written by the 3 PM-11 PM admission nurse, documented that the resident had a small open area to buttocks. The note did not indicate what type of wound it was, which side, and did not include any other assessment information regarding the wound. A physician's orders [REDACTED]. The wound care RN's progress note, dated 9/17/2018, documented Stage 2 small open area at sacral area, size 0.8 x 0.4 x 0.1, red, periwound skin intact, pink in color. The wound treatment was observed on 9/21/2018 at 8:44 AM. The treatment was performed by the LPN treatment nurse who was assisted by the RN wound care nurse. There was a reddened area that extended from the sacrum to the upper left buttock and there were two separate areas of open skin, approximately 1 cm x 1 cm, each within the reddened area. There were no signs and symptoms of infection. The wound care RN was interviewed on 9/21/2018 at 10:11 AM. She stated that the first time she assessed the wound was on 9/17/2018 (Monday) and there was only one open area of skin. She stated it was a Stage 2 pressure ulcer. When asked about the two open areas of skin that were observed during wound care, she stated she was not at the right vantage point during wound care to confirm the two open areas, but in her opinion the area was improving. The admission RN was interviewed on 9/24/2018 at 9:06 AM. She stated she should have elaborated more on the wound assessment and that she did not think it was a pressure ulcer. The wound care RN was re-interviewed on 9/24/2018 at 9:35 AM. She stated she created the Actual Ulcer/Wound CCP on 9/17/2018. She stated the care plan initiation date of 9/14/2018 indicated the onset of the wound. She further stated she did not see the resident on 9/14/2018. The Director of Nursing Services (DNS) was interviewed on 9/24/2018 at 1:30 PM. She stated that the admission nurse could have done a more thorough assessment, and that it was not routine policy for the admission nurse to size the wound. In addition, she stated the Actual Ulcer/Wound care plan initiation date should have been 9/17/2018. 415.12(c)(1)

Plan of Correction: ApprovedOctober 25, 2018

F686
1. Resident #101, left hand thumb and second finger was re-assessed by the DNS and wound care nurse to ensure proper location staging , treatment , description, drainage and size of the pressure ulcer. The residents ulcer has healed.
Date Completed: 9/27/18
Resident #130, the DNS and wound care nurse re-assessed the residents left posterior ankle and reviewed the residents medical record to ensure proper documentation in the medical record including proper location, staging ,treatment, description , drainage and size of the wound as it relates to professional standards of practice. The residents certified nursing assistant accountability record was reviewed to ensure appropriate preventative measures are in place and documented.
Date completed : 9/27/18
Resident #344, the wound was re-assessed by the Director of Nursing and the wound care nurse to ensure accurate documentation of the wound including proper location, staging , treatment, description, drainage and size as it relates to professional standards of practice.
Date Completed: 9/27/18

2. All residents with pressure ulcers, including new admissions with pressure ulcers or the potential for pressure ulcers have the potential to be affected by this practice.
All Residents with pressure ulcers, including new admissions with pressure ulcers or the potential for pressure ulcers were reviewed by the Director of Nursing to ensure that the clinical record contains an thorough assessment of the pressure ulcer, including proper location , staging, treatment , description, drainage and size as it relates to professional standards of practice. Revisions will be made as identified to comply with professional standards of practice.
Date Completed:9/27/18
3. The facility policy on Pressure Ulcer-Prevention and Care has been reviewed and amended.
Date Completed: 9/28/18
All Licensed staff will be in-serviced on proper assessment, care and documentation of pressure ulcers including proper location, staging, treatment, description, drainage and size as it relates to professional standards of practice.
Date Completed : 11/15/18
4. The Director of Nursing will audit 100% of the residents with pressure ulcers, new admissions with the potential for and with pressure ulcers weekly ensure accurate assessment and documentation of the wound including proper location , staging, treatment, description, drainage and size as it relates to professional standards of practice is being performed weekly for 4 weeks or until 100% compliance is achieved. The Audit will continue quarterly thereafter and presented at the QAPI meeting for a minimum of 2 quarters or until 100% compliance achieved for 2 quarters.

The Director of Nursing is responsible for this correction
Date if completion. 11/15/18

Standard Life Safety Code Citations

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: September 26, 2018
Corrected date: November 23, 2018

Citation Details

2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. Based on observation and staff interview, the facility did not ensure that fire-rated doors were provided with a fire-rated label. This was noted on two of two floors. The findings are: On 9/24/18 between 9:45am- 3:00pm during the recertification survey, smoke barrier doors on the 1st and 2nd floor were not provided with a fire-rated label. In an interview on 9/24/18 at approximately 10:38am, the Director of Environmental Services stated that the facility will address the issue. 2012 NFPA 101: 19.3.7.8, 8.5.4.4, 7.2.1.15.2 2010 NFPA 105: 4.1.1

Plan of Correction: ApprovedOctober 31, 2018

A. No residents were affected by the deficient practice.
B. All residents have the potential to be affected by the deficient practice.
C. 1. The Director of Maintenance contacted a door vendor to inspect and re-label the affected doors to comply with NFPA standards.
2. The Director of Maintenance will conduct audits monthly to ensure all door labels are rated to meet NFPA standards.
D. 1. Director of Maintenance/designee will report finding of audit to administrator.
2. Administrator will report findings of this audit at the quarterly QA meetings
E. Director of Maintenance is responsible for the correction of this deficiency.