| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0578 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -An advanced directive is a written instruction, such as a living will or durable power of |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0578 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) necessary throughout the patient/residents’ stay. Social Services will review the medical record and interview each patient/resident or responsible party again to discuss advanced directives and inform them of their rights to complete advanced directives. If a patient/resident has not executed an advance directive and would like to do so the Social Service Director shall obtain the necessary forms and assist the patient/resident with completing these forms. Once executed, copies are obtained and disseminated as noted above. The facility will review the residents existing choices with resident or responsible party periodically and with significant decline or improvement. 1. Record review of Resident #39’s medical record showed the following information: -Date of admission [DATE]; -[DIAGNOSES REDACTED]. -Court appointed public administrator as the resident’s legal guardian; -Admission sheet showed no code status; Record review of the (MONTH) (YEAR) and (MONTH) (YEAR) physician order [REDACTED]. Record review of the resident’s medical record did not have a green sheet (which indicated full code), red sheet (which indicated DNR), or an outside the hospital DNR sheet. Record review of the resident’s care plan, dated [DATE], did not indicate the resident’s code status. During an interview on [DATE], at 9:07 A.M., the social service director (SSD) said he/she assists with code status documentation for residents. He/she did not realize the resident did not have his/her code status in his/her medical record. The SSD said medical records should audit for a resident’s code status within 24 hours after the resident’s admission and ensure each medical record lists the resident’s code status. During an interview on [DATE], at 9:25 A.M., Medical Records (MR) staff said he/she just started back at the facility last Thursday so he/she is still trying to organize medical records. He/she said a resident’s code status should be the first item in a resident’s medical record. If a resident had a red sheet in the front of the medical record, it would show a resident to be a DNR and if there was a green sheet, it would show a resident to be a full code. If the resident or resident representative selected a DNR code status, the facility would have the resident or resident representative sign an outside the hospital DNR as well. The resident’s code status should also be on the face sheet, admission paperwork, and care plans. The MR staff agreed the resident did not have a code status listed in his/her chart and he/she said in an emergency there is not time for staff to go through a chart to see if the resident was a DNR or full code. He/she said the resident had been admitted over a month ago and should have had a code status in his/her chart. During an interview on [DATE], at 2:03 P.M., the director of nursing (DON) said every resident at the facility should have a red, green, or purple sheet in the front of his/her medical record to show the resident’s code status. Medical Records and Social Services handle this. | |
| F 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) failed to ensure the resident received a copy or summary of the baseline care plan for one resident (Resident #39). A sample of 16 residents was selected for review out of a facility census of 42. 1. Record review of Resident #45’s face sheet showed the following information: -Date of admission 6/15/18; -Diagnoses included dementia, irregular heart flutters, [MEDICAL CONDITION] with metastasis (cancer that has spread to other parts of the body) to the bone, Foley catheter (a flexible tube passed through the urethra into the bladder to pass urine), depression, anxiety, high blood pressure, weight loss with anorexia (a lack or loss of appetite for food), [MEDICAL CONDITION], pressure ulcer to coccyx; -Severe cognitive impairment; -[MEDICAL CONDITION]. Record review of the resident’s medical record showed the facility had not completed a baseline care plan. 2. Record review of Resident #97’s face sheet showed the following information: -Date of admission 7/3/18; -Diagnoses included failure to thrive, heart failure, depression, and anxiety; -admitted on Hospice; Record review of the resident’s medical record did not show any admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, to determine cognitive status. Record review of the resident’s medical record showed the facility had not completed a baseline care plan for the resident. 3. Record review of Resident #39’s face sheet showed the following information: -Date of admission 6/13/18; -Diagnoses included [MEDICAL CONDITION], lung disease, and nicotine dependence; -Cognitively intact; -Resided on the memory care unit due to history of elopement from previous facility. Record review of the resident’s medical record showed an undated partially completed baseline care plan. During an interview on 7/11/18, at 2:45 P.M., the resident said he/she had not been given a copy of his/her baseline care plan. 4. Record review of Resident #3’s face sheet showed the following information: -Date of admission 2/15/18; -Diagnoses included high blood pressure, diabetes, dementia (a brain disorder), depression, [MEDICAL CONDITIONS] and pain. Record review of the resident’s quarterly MDS, dated [DATE], showed no cognitive status listed. Staff marked the resident could be understood. Record review of the resident’s medical record showed the facility had not developed or completed a baseline care plan for the resident. 5. Record review of Resident #23’s face sheet showed the following information: -Date of admission 5/20/18; -Diagnoses included secondary malignant neoplasm (cancer) of the brain, muscle weakness, dysphagia, cognitive communication deficit and assistance with personal care. Record review of the resident’s 14 day MDS, dated [DATE], showed the following information: -admitted [DATE]; -Diagnoses included malignant neoplasm (cancer) of the brain and lung, generalized muscle weakness, other abnormalities of gait and mobility, cognitive communication deficit and |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) need for assistance with personal care; -Cognitive impairment and staff indicated the resident can be understood; -No rejection of care; -Extensive assistance from staff for bed mobility, transfers, dressing, toileting, bathing, and personal hygiene; -Resident not steady during transfers and was only able to stabilize with assistance during moving from seated to standing position, moving on and off toilet, and surface to surface transfers; -The resident used a wheelchair for mobility Record review of the resident’s medical record showed the facility had not developed or completed a baseline care plan for the resident. 6. Record review of Resident #40’s face sheet showed the following information: -Date of admission 6/19/18; -Diagnoses included acute kidney failure, chronic respiratory disease, type 2 diabetes,[MEDICAL CONDITION], high blood, [MEDICAL CONDITION] disorder, and chronic pain. Record review of the resident’s admission MDS, dated [DATE], showed the following information: -admitted [DATE]; -No cognitive impairment; -Supervision for bed mobility, transfers, eating, walking, and personal hygiene; -Limited assist with toileting and bathing; -Marked for no assistive devices; -No [DIAGNOSES REDACTED]. Record review of the resident’s medical record showed the facility had not developed or completed a baseline care plan for the resident. 7. Record review of Resident #44’s face sheet showed the following information: -Date of admission 6/25/18; -Diagnoses included [MEDICAL CONDITION] (abnormal brain development or injury that effects muscle movement), [MEDICAL CONDITION] disorder, quadriplegic (loss of movement of all four limbs), stage III pressure ulcer and difficulty swallowing. Record review of the resident’s admission MDS, dated [DATE], showed the following information: -admitted [DATE]; -No cognitive status marked; -Total dependence for bed mobility, transfers, personal hygiene, toileting and bathing; -Limited assist with eating; -Uses a wheelchair for mobility; -Diagnoses marked as [MEDICAL CONDITION], generalized muscle weakness, difficulty swallowing, and cognitive communication deficit. Record review of the resident’s medical record showed the facility had not developed or completed a baseline care plan for the resident within 48 hours. 8. During an interview on 7/17/18, at 9:37 A.M., the MDS Coordinator said he/she was responsible for completing the baseline care plans. He/she said had not been taught about baseline care plans and what should be on them. He/she did not know about a baseline care plan form that lists the areas that needed to be covered. He/she did not know the baseline care plan had to be completed within 48 hours, or that a copy had to be provided to the resident or resident’s representative. 9. During an interview on 7/17/18, at 2:03 P.M., the Director of Nursing (DON) said she did not know a baseline care plan had to be completed in 48 hours or that a copy must be |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) given to the resident or resident’s representative. | |
| F 0684 Level of harm – Actual harm Residents Affected – Few | Provide appropriate treatment and care according to orders, resident’s preferences and goals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 5) healing or non-healing); -Description of wound edges and surrounding skin as appropriate (i.e. rolled edges, redness, induration (hardened area), maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) ; -If the wound does not show some evidence of progress towards healing within two to four weeks, the wound and the resident’s overall clinical condition should be reevaluated. Reevaluation of the treatment plan and modification of the current interventions may also be indicated. Documentation of any rationale for continuing present treatments when there is little or no healing is required by the clinicians. Record review of the facility’s N.P.W.T. (E.G. Vacuum Assisted Closure (V.A C.) units and dressings) policy, dated (MONTH) 2011, showed the following information: -N.P. W. T. negative pressure is applied to a porous dressing positioned in the wound cavity or over a flap or graft. This porous dressing distributes negative pressure to the wound and helps remove interstitial fluids (fluids that surround cells) from the wound; -The vendor will provide initial facility based training and certification/competency; -Facility N.P.W.T. trained staff that has demonstrated proficiency with the N.P.W.T. will provide subsequent facility staff training; -The facility will have an individual who is N.P.W.T. trained in-house, or available to come in whenever there is a unit in use; -physician’s orders [REDACTED].W.T. will meet the following criteria prior to initiation: -Type of filler dressing (s) foam (s) to use; -Wound bed preparation, if any with non-adherent, or impregnated dressings; -N.P.W.T. pressure settings millimeters of mercury (mm/Hg) pressure/continuous vs. intermittent pressure); -Frequency of dressing changes; -Orders for pain medication; -Competency: -All N.P.W.T. users (those who are applying the device and dressings) will be evaluated for competency use for the individual N.P.W.T. units (and dressings) the location is using, using the attached form. This competency will be kept in the individual’s personnel file. -Procedures: -Follow manufacturer’s guidelines and physician’s orders [REDACTED].P.W.T. unit, dressings, or any components of the system; -Utilize existing wound care policies and procedures; -Explain the procedure to the resident; -Remove old dressing if present; -Cleanse wound of drainage, debris, and foam residue; -Evaluate and measure the wound; -Replace filler/foam dressing per manufacturer’s guidelines and physician’s orders[REDACTED].>-Apply cover dressings and tubing per manufacturer’s guidelines and attach to unit; -Set N.P.W.T. unit pressure settings per manufacturer’s guidelines and physician’s orders[REDACTED].>-Document all procedures performed and the resident’s response. Record review of the facility’s licensed nurse skin checks policy, dated (MONTH) 2011, showed the following information: -All residents will have a thorough weekly skin evaluation performed by a licensed nurse; -Weekly, the licensed nurse performs a head to toe check of the resident’s skin, paying particular attention to the following: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 6) -The surfaces of the skin that come in contact with any orthotic device, tube, brace, or positioning device; -The nurse observes for redness, rashes, bruising, and open areas; -Any significant abnormal findings are reported to the resident’s physician and resident contact person; -Documentation that the check was performed is denoted on the medication administration form (MAR), the treatment administration record form (TAR), or the weekly skin documentation form; -Abnormal findings are to be documented in the nurse’s note or to be documented on the back of the TAR if space allows; -Document the actions taken in the nurse’s note along with a summary of all persons who were notified and their responses. Record review of the World Health Organization’s (WHO) recommendations for hand hygiene and glove use showed the following information: -Summary of the recommendations on glove use: -When an indication for hand hygiene follows a contact that has required gloves, hand rubbing or hand washing should occur after removing gloves; -When an indication for hand hygiene applies while the health-care worker is wearing gloves, then gloves should be removed to perform hand-rubbing or handwashing; -In no way does glove use modify hand hygiene indications or replace hand hygiene action by rubbing with an alcohol-based product or by handwashing with soap and water; -When wearing gloves, change or remove gloves in the following situations: during patient care if moving from a contaminated body site to another body site (including a mucous membrane, non-intact skin or a medical device within the same patient or the environment); -Clean your hands as soon as the task involving an exposure risk to body fluids has ended (and after glove removal); -Situations when this applies: -When the contact with a mucous membrane and with non-intact skin ends; -After removing any form of material offering protection (napkin, dressing, gauze, sanitary towel, etc.). Record review of the facility’s wound care policy and procedure titled, performing a dressing change, dated (MONTH) 2011, showed the following information: -A dressing change will follow specific manufacturer’s guidelines and general infection control principles; -Wash hands before and after donning gloves; -Don gloves; -Remove old dressing and packing (if present) (change gloves); -Cleanse the wound of drainage, debris, or dressing/filler residue (change gloves); -Assess the wound (measuring done here) (change gloves); -Pack the dead space of large wounds (change gloves-if needed); -Apply a cover dressing; -Date and initial cover dressing, place time reference on it (remove gloves, discard waste); -The policy did not follow the WHO’s recommendations for using hand hygiene and glove use after touching a contaminated body site or non-intact skin. Record review of the facility’s hand hygiene policy, dated September, 2011, showed the following information: -Hand hygiene/hand washing is completed: -Before taking part in a medical or surgical procedure; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 7) -After contact with soiled or contaminated articles, such as articles contaminated with body fluids; -Hand washing may not be necessary until the completion of the procedure such as changing from clean gloves to sterile gloves per specific standards of practice; -The policy did not show to perform hand hygiene between glove use after handling potentially contaminated items or body fluids. 1. Record review of Resident # 21’s face sheet (general resident information) showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. (The [DIAGNOSES REDACTED]. Record review of the admission data tool, completed by facility staff, dated 3/11/18, showed no notes pertaining to a wound V.A.C. or wounds present on admission. Record review of the admission physician orders, dated 3/11/18, the date of admission, showed the following: -No orders that pertained to the resident’s wound V.A.C.; -No orders for the air boot with directions of use or frequency of monitoring skin to the feet. Record review of the (MONTH) (YEAR) treatment administration record (TAR) showed the following information: -Treatment start date of 3/11/18: Air boots to be worn at all times. Only remove to inspect the skin. 7A.M.-7 P.M. (treatment on TAR did not show how often to inspect the skin); -Treatment start date of 3/11/18: Abdominal wound V.A.C. continuous at 125 mm/HG, 7 A.M. to 7 P.M. Record review of the (MONTH) (YEAR) nurses’ progress notes showed the following information: -On 3/11/18, at 4:41 P.M., the resident refused a skin assessment. Staff did not document the presence of a wound V.A.C. -On 3/11/18, at 1:00 A.M., the resident refused a skin assessment. Staff did not document the presence of a wound V.A.C. -On 3/13/18, the resident had an abdominal wound with a wound V.A.C. Record review of the resident’s current care plan, dated 3/13/18, showed the following information: -Skin integrity: at risk; turn and reposition; -The care plan did not show information that pertained to the condition of the resident’s skin or of any wounds the resident had. -The care plan did not show any information related to a wound V.A.C. system. Record review of the (MONTH) (YEAR) daily skilled nurse’s notes which showed areas (boxes) for each shift to mark checkmarks and /or document nursing notes on, showed the following: -Dated 3/14/18: Night shift noted a rash to the abdomen under the skin assessment (no further documentation of skin or wounds); -Dated 3/15/18: Night shift noted a rash to the abdomen under the skin assessment (no further documentation of skin or wounds); -Dated 3/16/18: Night shift noted a rash to the abdomen under the skin assessment (no further documentation of skin or wounds); Record review of the resident’s admission Minimum Data Set (MDS), a federally mandated comprehensive resident assessment instrument, completed by facility staff, dated 3/16/18, showed the following information: -Cognitively intact; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 8) -Resident had a surgical wound; -At risk for pressure ulcers. Record review of the (MONTH) (YEAR) treatment administration record (TAR) showed the following information: -Treatment start date of 3/11/18: Air boots to be worn at all times. Only remove to inspect the skin. 7A.M.-7 P.M. (treatment on TAR did not show how often to inspect the skin); -Treatment start date of 3/11/18: Abdominal wound V.A.C. continuous at 125 mm/HG, 7 A.M. to 7 P.M.; -Staff initialed completion of the treatments for dates, 3/12/18 through 3/31/18, with the exception of 3/27/18; -Staff did not document completion of any weekly skin assessments; -The TAR did not include any orders to change the wound V.A.C. dressing. Record review of the resident’s care plan, dated 3/13/18, showed the following information: -Skin integrity: at risk; turn and reposition; -The care plan did not show information that pertained to the condition of the resident’s skin or of any wounds the resident had. -The care plan did not show any information related to a wound V.A.C. system; -Staff did not any document any revision of the care plan after 3/13/18, date of admission to the facility. Record review of the resident’s medical record did not show any wound treatments, progress records, or weekly skin integrity assessments completed by staff during (MONTH) (YEAR). Record review of the (MONTH) (YEAR) nurses’ progress notes showed the following information: -On 3/31/18, the wound V.A.C. was intact with green watery drainage; -Staff did not document any other refusals of skin assessments or of any wound assessments in (MONTH) (YEAR). Record review of the (MONTH) (YEAR) daily skilled nurse’s notes which showed areas (boxes) for each shift to mark checkmark and/or document nursing notes on, showed the following information: -On 3/31/18, day shift noted a surgical wound and open lesion without a location noted, along with a skin tear, and pressure ulcer, and night shift noted a surgical wound and an open lesion without location noted. Record review of the (MONTH) (YEAR) nurses’ progress and skilled nursing notes showed no documentation of any wound V.A.C. changes. Record review of the (MONTH) (YEAR) physician order [REDACTED]. -Staff handwrote an order, dated 3/2/18, (nine days prior to the resident’s admission) to change the wound V.A.C. Monday, Wednesday, and Friday. The order did not include any specific information regarding the time of day staff should change the wound V.A.C. The order did not include what type of foam or other supplies to be used, or of what type of cleanser, if any, was to be used. The physician signed the physician order [REDACTED]. -The medical record did not contain any hand written, verbal, or telephone order to indicate when the order to change the wound V.A.C. on Monday, Wednesday, and Friday was obtained from the physician. Record review of the resident’s (MONTH) (YEAR) TAR showed an order, dated 4/9/18, to perform weekly skin assessments on Mondays; -Staff initialed and circled the dates of 4/2/18 and 4/9/18 indicating skin assessment not completed. Staff did not document why the weekly skin assessment had not been completed. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 9) -The TAR contained an undated, hand written order in the treatment area to change the wound V.A.C. Monday, Wednesday, and Friday at 8:00 P.M.; -Staff initialed the wound V.A.C. dressing as changed on 4/4/18, 4/6/18, and 4/9/18. Staff circled the date, 4/11/18, indicating the dressing change as not completed. Staff did not document why the dressing change was not completed; -(Order dated 3/11/18), abdominal wound V.A.C. continuous at 125 mm/HG showed staff initialed completion of the wound V.A.C. (4/1/18 through 4/5/18, 4/7/18 through 4/9/18, and on 4/12/18), with the exception of 4/6/18, 4/10/18, 4/11/18, and 4/13/18. The treatment had a line marked through it that showed the wound clinic discontinued it on 4/13/18. Record review of the (MONTH) (YEAR) daily skilled nurse’s notes showed the following information: -On 4/1/18 and 4/2/18, the evening and night shifts had noted a surgical wound with a wound V.A.C. (no other wound description); -On 4/3/18, night shift noted a surgical wound (no other description of wound or mention of wound V.A.C.; -On 4/4/18, night shift noted a surgical wound with a wound V.A.C. Notes had been written on the back of the form that showed wound V.A.C. applied to cleansed area-operating well. (No description of the wound, the foam, and if and how many pieces of foam had been removed and/or replaced into the wound bed. No description of the wound V.A.C. drainage in the tubing had been documented; -On 4/5/18, night shift noted a surgical wound with a wound V.A.C. (no other description of the wound documented); -On 4/6/18, Night shift noted a surgical wound with wound V.A.C.; -On 4/7/18, day shift and night shift noted a surgical wound with a wound V.A.C. The 7 A.M. to 7 P.M. shift documented the wound V.A.C. had a small amount of green watery drainage; -On 4/8/18, 4/9/18, and 4/10/18, night shift documented the resident had a surgical wound with a wound V.A.C. (No other description of the wound documented); Record review of the (MONTH) (YEAR) nurses’ progress notes showed the following information: -From 4/1/18 through 4/10/18, staff did not document any difficulty changing the wound V.A.C. Staff did not document any description of the wound V.A.C. dressing change, or of the wound bed. -On 4/10/18, the nurse from the physician’s office called to schedule a surgical consult for 4/12/18. Record review of the (MONTH) (YEAR) daily skilled nurses’ notes showed the following information: -On 4/11/18, surgical wound noted by day shift (no further description of the wound or documentation of the wound V.A.C. being present); -On 4/12/18, day shift and night shift noted a wound V.A.C. An additional note on the back of the form timed 11:30 A.M. showed the wound V.A.C. was intact with serous and green colored output. The resident left by ambulance to the hospital; -On 4/13/18, night shift noted the resident had a wound V.A.C. (No other description of the wound documented); Record review of a physician’s telephone order, dated 4/13/18, showed the following information: -Wound care to left upper quadrant (of abdomen) (LUQ), clean with normal saline and gauze, apply wet to dry saline moist gauze twice a day (BID). Follow up with physician at wound |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 10) clinic on 4/23/18. Record review of the (MONTH) (YEAR) TAR showed the following order: -On 4/13/18, LUQ abdomen: Clean with normal saline and gauze. Apply wet to dry saline moist gauze twice daily (BID) A.M. and P.M. Record review of the (MONTH) (YEAR) daily skilled nurses’ notes showed the following information: -On 4/14/18, day and night shifts documented wet to dry dressing to left upper quadrant (LUQ) (of abdomen). Additional note on back of the form, timed 10:30 A.M. showed the wet to dry dressing was changed to the LUQ abdominal wound. (No description of the wound documented); -On 4/15/18, day and night shifts noted wet to dry dressing to LUQ (no other description of wound documented); -On 4/16/18, day and night shifts noted surgical wound to LUQ. An additional note timed 10:00 P.M. showed the dressing had been changed to the abdomen, and purulent light green drainage had been noted; -On 4/17/18, night shift noted a surgical wound and other open lesion. An additional note timed 1:30 P.M. showed after the resident showered, the skin assessment had been completed, and a wet to dry dressing to the LUQ continued; -On 4/18/18, night shift noted a surgical wound and an open lesion. An additional note added in the night shift portion of the notes, and untimed, showed the resident refused the treatment to the wound V.A.C. site; -On 4/19/18, night shift noted surgical wound (no further description of wound documented by any shift; -On 4/20/18, night shift noted surgical wound (no further description of wound documented); -On 4/21/18, day shift and night shift noted LUQ abdominal wound. (No further description of wound documented); -On 4/22/18, night shift noted surgical abdominal wound; An additional untimed note on the day shift portion showed wet to dry dressing treatment continued, but was not changed; -On 4/23/18, (date of surgical removal of foam dressing), Night shift noted surgical wound to abdomen. Additional note timed 8:30 A.M. showed the resident transferred to the hospital for incision and drainage of gastric tube site, and returned from the hospital at 5:05 P.M. The physician continued the wet to dry dressing with normal saline moistened gauze. The resident had a follow-up appointment 5/3/18; -On 4/24/18, night shift noted surgical wound to abdomen. (No other description of wound documented); -On 4/25/18, night shift noted surgical wound to abdomen. (No other description of wound documented); -From 4/26/18 to 4/30/18, night shift noted surgical wound to abdomen. (No other description of wound documented); -The (MONTH) (YEAR) daily skilled nursing notes showed staff did not document a wound description. Record review of the (MONTH) (YEAR) TAR showed the following order: -On 4/13/18, LUQ abdomen: Clean with normal saline and gauze. Apply wet to dry saline moist gauze twice daily (BID) A.M. and P.M. Record review of a physician’s telephone order dated 4/16/18, showed staff to perform a weekly skin assessment on Mondays. Record review of the (MONTH) (YEAR) TAR showed staff recorded the weekly skin assessment as completed on 4/16/18. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 11) Record review of the (MONTH) (YEAR) weekly skin integrity form showed the following information: -No weekly skin integrity form completed for 4/16/18 as noted on the TAR. Record review of the (MONTH) (YEAR) TAR showed the following order (order dated 4/13/18 for LUQ abdomen: Clean with normal saline and gauze. Apply wet to dry saline moist gauze twice daily (BID) A.M. and P.M.); -On 4/17/18, the A.M. shift did not document completion of the LUQ dressing change; -On 4/18/18, the A.M. shift did not document completion of the LUQ dressing change. On the P.M. shift, staff circled the dressing change and marked it as refused. -On 4/22/18, on the P.M. shift, staff circled the dressing change to indicate dressing not completed. Staff did not document why staff did not complete the treatment. Record review of the (MONTH) (YEAR) TAR showed staff recorded the weekly skin assessment as completed on 4/23/18. Record review of the (MONTH) (YEAR) weekly skin integrity form showed the following information: -On 4/23/18, staff documented wound number three indicated as gastric tube site, incision and drainage. Revision on gastric (stomach) tube site this date. Wet to dry dressings continued. No description of wound documented; -No other weekly skin integrity forms completed for (MONTH) (YEAR). Record review of the (MONTH) (YEAR) TAR showed the following order (order dated 4/13/18 for LUQ abdomen: Clean with normal saline and gauze. Apply wet to dry saline moist gauze twice daily (BID) A.M. and P.M.); -On 4/29/18 of the A.M. shift, staff did not document completion of the LUQ dressing change. On the P.M. shift, staff did not document completion of the LUQ dressing change; -On 4/30/18 of the A.M. shift, staff did not document completion of the LUQ dressing change. Record review of the resident’s hospital wound clinic discharge records, dated 4/23/18, showed the following information: -Resident had a surgical procedure of abdominal incision and drainage dated 4/23/18; -Resident required intubation for the procedure; -Resident received general anesthesia; -Antibiotics were administered; -The wound V.A.C. sponge was ellipsed (oval-shaped incisions to remove objects) out in its entirety using cautery (an agent or device used for scarring, burning, or cutting the skin or other tissues by means of heat, cold, electric current, ultrasound, or caustic chemicals) down to good healthy tissue; -Continue wet to dry dressings twice a day (normal saline with moist gauze) to LUQ abdominal wound; -Brief pre-operative Diagnosis: [REDACTED].C. sponge and left upper abdominal wound; -Post op Diagnosis: [REDACTED]. -Specimen: Retained sponge; -Indications for procedure: The resident is a quadriplegic whom the hospital had previously operated on for a gastric tube (tube that enters the stomach used for nutrition) fistula (permanent abnormal passageway between two organs in the body or between an organ and the exterior of the body, in this case caused by a previous gastric tube) tract. The hospital treated the site with a wound V.A.C. and sent the resident to a nursing facility at which point the nursing facility did not remove the wound V.A.C. sponge, and only changed the outer dressing. The abdominal wound had granulated into the sponge and it was unable to be removed. The resident was brought back to our office for |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 12) evaluation. There was no way to get the foam out without taking the resident to surgery for [REDACTED]. Record review of the wound treatment and progress record for the month of (MONTH) (YEAR) showed the following information: -On 4/25/18, left upper quadrant wound measured 4.7 centimeters (CM) Length (L) by 7.4 CM width (W) by 3.2 CM depth (D). Staff did not document any further description of the wound or of any drainage present; -Staff did not document any other wound assessments during the month of (MONTH) (YEAR), including while the resident had the wound V.A.C. Record review of the (MONTH) (YEAR) daily skilled nurses’ notes showed the following information: -From 5/1/18 to 5/3/18, night shift noted surgical wound to abdomen. (No documentation of wound description). Record review of the (MONTH) (YEAR) weekly skin integrity form showed the following information: -On 5/1/18, staff documented a treatment was in place: The areas marked on diagram had been the LUQ, along with the toes and left lower extremity (LLE). No descriptions of the skin or marked areas had been documented. Record review of the (MONTH) (YEAR) weekly wound treatment and progress record showed the following information: -On 5/1/18, measurements 6.9 CM L by 4.8 CM W by 2.0 CM D. No further description of the wound was documented. Record review of the (MONTH) (YEAR) weekly skin integrity form showed the following information: -On 5/8/18, staff documented a treatment was in place. The areas marked on the diagram had been the LUQ, along with the toes and LLE. No descriptions of the skin or marked areas had been documented. Record review of the (MONTH) (YEAR) weekly wound treatment and progress record showed the following information: -On 5/8/18, 7.1 CM L by 3.9 CM W by 2.1 CM D. No further description of the wound was documented. Record review of the (MONTH) (YEAR) physician order [REDACTED]. -Order dated 4/13/18 for LUQ abdomen, clean with normal saline and gauze. Apply wet to dry saline moist gauze twice daily (BID) A.M. and P.M. continued until order changed on 5/14/18; -On 5/14/18, change wound care orders to Calcium Alginate with Silver (a sterile, non-woven calcium alginate dressing composed of an ionic silver complex (silver sodium hydrogen zirconium [MEDICATION NAME]), which releases silver ions in the presence of wound exudate). Cover with Filacare (type of dressing cover). Measure wound with dressing changes. Change every five days. Record review of the (MONTH) TAR showed on 5/14/18, staff applied the dressing per the new treatment order, dated 5/14/18. Record review of the (MONTH) (YEAR) weekly skin integrity form showed on 5/14/18, staff documented an open area to the left abdominal wall, and the LUQ had been noted on the diagram. Staff documented a new treatment had been in place. No description of the skin or marked area on the diagram had been documented. Record review of the (MONTH) (YEAR) weekly wound treatment and progress record showed on 5/14/18, 7.0 CM L by 3.5 CM W by 1.8 CM D. No further description of the wound was documented. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 13) Record review of the (MONTH) (YEAR) TAR showed the staff changed the dressing again on 5/18/18. Record review of the (MONTH) (YEAR) weekly skin integrity form showed on 5/21/18, staff documented an open area to the left abdominal wall, and the LUQ had been marked on the diagram. No further description of the marked area had been documented. Record review of the (MONTH) (YEAR) TAR showed staff changed the dressing on 5/22/18. Record review of the (MONTH) (YEAR) weekly wound treatment and progress record showed the following information: -On 5/22/18, 5.2 CM L by 2.6 CM W by 1.4 CM D. Progress documented as granulation present, decreased size, decreased depth of undermining, and no tunneling depth. No other description of the wound was documented; No signature had been found of the staff that performed the assessment. Record review of the (MONTH) (YEAR) weekly skin integrity form showed the following information: -On 5/28/18, staff documented treatment in place. The areas marked on diagram had been the LUQ. Staff did not document any description of the skin or wounds. Record review of the (MONTH) (YEAR) TAR showed staff changed the dressing on 5/29/18 (seven days later). Record review of the (MONTH) (YEAR) weekly wound treatment and progress record showed on 5/29/18, 5.0 CM Length by 2.6 CM W by 1.5 CM. No other description of the wound had been documented. Record review of the (MONTH) (YEAR) nurses’ progress notes showed no documentation of the description of the surgical wound site to the LUQ of the abdomen. Record review of the (MONTH) (YEAR) physician’s orders [REDACTED]. Record review of the (MONTH) (YEAR) TAR showed the following information: -Order (dated 4/16/18), skin assessment check and record weekly on Monday; -Staff documented completion of the skin assessment check on 6/5/18 and 6/18/18. -Staff did not document completion of the skin assessments on any other date in (MONTH) (YEAR). Record review of the (MONTH) (YEAR) weekly skin integrity assessments showed facility staff did not complete any assessments on the forms. Record review of the resident’s (MONTH) (YEAR) nursing progress notes showed no description of the LUQ abdominal wound. Record review of the resident’s (MONTH) (YEAR) wound treatment and progress record showed the following information: -On 6/6/18, 4.5 CM L by 2.5 CM W by 0.4 CM D in center of wound and 0.3 CM at edges of wound. The wound had been draining serosanguineous (means containing or relating to both blood and the liquid part of blood (serum). It usually refers to fluids collected from or leaving the body) drainage. No other descriptions of the wound had been documented, and the form had not been signed by staff; -On 6/9/18, 4.0 CM L by 2.5 CM W by 0.3 CM D. with serosanguineous drainage. No other description of the wound had been documented, and the form had not been signed by staff; -On 6/19/18, (ten days since prior wound assessment), 4.0 CM L by 1.2 CM W by 0.2 CM D. No other descriptions of the wound had been documented, and the form had not been signed by staff; -On 6/24/18, 4.0 CM L by 3.0 CM W by 0.2 CM D. No other descriptions of the wound had been documented; -On 6/26/18, 3.6 CM L by 1.8 CM W by 0.0 CM D. No other descriptions of the wound, and no signature by staff. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Actual harm Residents Affected – Few | (continued… from page 14) Record review of the (MONTH) (YEAR) physician’s orders [REDACTED]. | |
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate pressure ulcer care and prevent new ulcers from developing. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) -The facility should have a system in place for daily observation of pressure ulcer/wounds; -It is recommended that the nursing progress notes reflect the nurse’s observation and management of wounds from a shift to shift perspective and with each dressing change. At a minimum, weekly documentation is recommended to provide a review of the wound. Weekly documentation should include the data observed and: -Wound bed characteristics (color, type of tissue i.e. granulation tissue (new vascular tissue in granular form on an ulcer or the healing surface of a wound), slough (dead tissue that can be yellow and stringy), or eschar (dark, dry scab) which give evidence to healing or non-healing); -Description of wound edges and surrounding skin as appropriate (i.e. rolled edges, redness, induration (hardened area), maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) ; -If the wound does not show some evidence of progress towards healing within two to four weeks, the wound and the resident’s overall clinical condition should be reevaluated. Reevaluation of the treatment plan and modification of the current interventions may also be indicated. Documentation of any rationale for continuing present treatments when there is little or no healing is required by the clinicians; -Documenting and staging pressure ulcer: -In 2007, the National Pressure Ulcer Advisory Panel (NPUAP) redefined the definition of pressure ulcers; -Stage I pressure ulcer: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. -Stage II pressure ulcer: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. Presents a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal (the region between the scrotum and the anus in males, and between the posterior vulva junction and the anus in females) [MEDICAL CONDITION] ([MEDICAL CONDITION] condition of the skin in the perineal area, upper part of the thigh, and buttocks that is commonly associated with incontinence. It is manifested by various degrees of skin injury, ranging from redness to areas of denuded skin. ), maceration (softening and breaking down of skin resulting from prolonged exposure to moisture), or excoriation (damage to the skin surface); -Stage III pressure ulcer: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present, but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling; -Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining (undermining occurs when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound’s edge) and tunneling (narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation). Stage IV ulcers can extend into muscle and/or supporting structures such as fascia (a thin sheath of fibrous tissue enclosing a muscle or other organ.), tendon, or joint capsule; -Necrotic wounds: Qualified staff should identify and document the presence of devitalized tissue (necrotic tissue) when evaluating wounds; -Necrotic tissue is evaluated for and identified for color, consistency, and adherence to the wound bed; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) -Necrotic tissue is described as the following: -Slough-usually yellow to tan, mushy or stringy material which indicates less severity than eschar and is in the process of separating from the viable portions of the body; -Eschar-may be black, gray, or brown in color. It usually adheres firmly to the wound edges and wound bed -Determine the percentage of wound with necrotic tissue present; -Visually divide the wound into quarters or four pie-shaped quadrants to help determine percentage of the wound involved; -Document findings on the appropriate form (s). Record review of the Wound Care Policy and Procedures: Licensed Nurse Skin Checks, dated (MONTH) 2011, showed the following information: -All residents will have a thorough weekly skin evaluation performed by a licensed nurse; -Weekly skin checks should be performed and documented by licensed staff on all residents paying particular attention to: -The surfaces of the skin that come in contact with the bed and chair; -Bony prominences (heels, tailbone, shoulder blades, elbows, back of the head, etc.) -The surfaces of the skin that come in contact with each other and any orthotic device, tube, brace, or positioning device; -All significant abnormal findings/changes should be reported to the resident’s primary care provider by the licensed nurse per facility protocol. Documentation of primary care provider notification, orders received, family notification, and resident response to any treatment should follow facility protocol as well. Record review of the World Health Organization’s (WHO) recommendations for hand hygiene and glove use showed the following information: -Summary of the recommendations on glove use: -When an indication for hand hygiene follows a contact that has required gloves, hand rubbing or hand washing should occur after removing gloves; -When an indication for hand hygiene applies while the health-care worker is wearing gloves, then gloves should be removed to perform hand-rubbing or handwashing; -In no way does glove use modify hand hygiene indications or replace hand hygiene action by rubbing with an alcohol-based product or by handwashing with soap and water; -When wearing gloves, change or remove gloves in the following situations: during patient care if moving from a contaminated body site to another body site (including a mucous membrane, non-intact skin or a medical device within the same patient or the environment); -Clean your hands as soon as the task involving an exposure risk to body fluids has ended (and after glove removal); -Situations when this applies: -When the contact with a mucous membrane and with non-intact skin ends; -After removing any form of material offering protection (napkin, dressing, gauze, sanitary towel, etc.). Record review of the facility’s Wound Care Policies and Procedures: Performing a Dressing Change; dated (MONTH) 2011, showed the following information: -A dressing change will follow specific manufacturer’s guidelines and general infection control principles; -Wash hands before and after donning gloves; -Apply gloves; -Remove old dressing and packing (if present) (change gloves); -Cleanse the wound of drainage, debris, or dressing/filler residue (change gloves); -Assess the wound (measuring done here) (change gloves); |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 17) -Pack the dead space of large wounds (change gloves-if needed); -Apply a cover dressing-date and initial cover dressing, place time reference on it (Remove gloves, discard waste); -The policy did not follow the WHO’s recommendations for using hand hygiene and glove use after touching a contaminated body site or non-intact skin. Record review of the facility’s Hand Hygiene Policy, dated September, 2011, showed the following information: -Hand hygiene/hand washing is done: -Before taking part in a medical or surgical procedure; -After contact with soiled or contaminated articles, such as articles contaminated with body fluids; -Hand washing may not be necessary until the completion of the procedure such as changing from clean gloves to sterile gloves per specific standards of practice; -The policy did not show to perform hand hygiene between glove use after handling potentially contaminated items or body fluids. 1. Record review of Resident # 46’s face sheet (general resident information) showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s comprehensive care plan, dated 10/25/17, showed the following information: -Problem: Wound infection (no site indicated); Approaches: -Keflex (antibiotic) 500 milligrams (mg) three times daily (TID) as ordered; -Monitor for changes in drainage, amount, and notify physician if treatment is ineffective; -The care plan did not address or provide interventions for the Stage IV pressure ulcer to any area of the body, and staff did not update the care plan since 10/25/17. Record review of the (MONTH) (YEAR) physician order [REDACTED]. -On 3/17/18, the physician ordered Santyl (enzymatic [MEDICATION NAME] ointment that possesses the unique ability to digest collagen in necrotic tissue) ointment 30 grams: Apply topically once daily to ischium (the curved bone forming the base of each half of the pelvis) pressure ulcer. The physician discontinued the order on 5/23/18. Record review of the (MONTH) (YEAR) treatment administration record (TAR) showed the following information: -Undated treatment for [REDACTED]. -Staff documented completion of the skin assesment on 5/3/18 as indicated by staff initials. Record review of the weekly skin assessment forms showed no weekly skin or wound assessments completed on 5/3/18. Record review of the (MONTH) (YEAR) TAR showed staff documented completion of the skin assesment on 5/10/18 as indicated by staff initials. Record review of the facility’s Weekly Wound Assessment form, dated 5/10/18, showed the following information: -Staff did not document any stage of the pressure ulcer or measurements of the ulcer; -Pressure Ulcer circled yes as present; -Color pink; -Minimal drainage (no description or color documented); -No odor or infection; -Comments: Treatment to right ischial area. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 18) -Continued area with slow healing. Granulation noted. Record review of the (MONTH) (YEAR) TAR showed staff documented completion of the skin assesment on 5/17/18 indicated by staff initials. Record review of the weekly skin assessment forms showed no weekly skin or wound assessments completed on 5/17/18. Record review of the (MONTH) (YEAR) POS showed the following information: -On 5/23/18, the physician ordered staff to clean with Vashe (wound cleanser that contains hypochlorous (weak acid obtained in solution along with [MEDICATION NAME] acid by reaction of chlorine with water and used as a disinfectant for wounds) solution), apply Santyl to the wound bed, collagen (derived from animal sources) pad, and cover with silicone adhesive bandage. Record review of the (MONTH) (YEAR) TAR showed the following information: -Staff did not document/carry over the treatment ordered by the physician written on 5/23/18 for staff to cleanse the pressure ulcer with Vashe, apply Santyl to the wound bed, collagen pad, and cover with silicone adhesive bandage. -The 3/17/18 santyl ointment treatment had a line drawn through it with a handwritten discontinued over it dated 5/23/18. Record review of the (MONTH) (YEAR) TAR showed staff documented completion of the skin assesment on 5/24/18 indicated by staff initials. Record review of the facility’s Weekly Wound Assessment form, dated 5/24/18, showed the following information: -Staff did not document any stage, measurement, color, or drainage of the ulcer; -Comments: Treatment changed to right ischial area. Granulation noted. Record review of the resident’s wound care clinic’s notes, dated 5/30/18, showed the following information: -Right ischium wound; Resident is on hospice services; admitting [DIAGNOSES REDACTED]. as the sacrum )ulcer; -Wound Measurements: 2.5 centimeters (CM) L by 1.4 CM W by 0.4 CM W; -Wound #1: Pressure ulcer injury right ischium; Not healed; Quality of tissue improved; Granulation tissue red and 100%; Moderate amount of serosanguineous (relating to both blood and the liquid part of blood (serum)) drainage; Maceration present; -Clean with hypochlorous acid 0.01 % and spray directly in wound. Don’t rinse. Don’t use with silver; Apply Santyl for enzymatic debridement; ; Apply skin prep to periwound (skin surrounding the wound) ; Dressing to be changed by staff every other day and as needed for soiling. Record review of the (MONTH) (YEAR) TAR staff documented completion of the skin assesment on 5/31/18 indicated by staff initials. Record review of the facility’s Weekly Wound Assessment form, dated 5/31/18, showed the following information: -Staff did not document any stage, measurement, color, or drainage of the ulcer; -Comments: Treatment changed to right ischium every other day. Area filling in with good granulation noted. Record review of the (MONTH) (YEAR) TAR showed the following information: -Treatment order dated, 6/4/18, for staff to complete weekly skin assessment on Thursdays; -Staff documented the weekly skin assessment as completed on 6/6/18 as indicated by staff initials. Record review of the Weekly Skin Integrity (assessment) form, 6/6/18, showed staff did not document completion of the skin assessment form. Record review of the Weekly Wound Assessment form, dated 6/7/18, showed staff did not |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 19) document any staging of the ulcer, measurements, color, or drainage amount. Staff documented skin in good condition. Treatment continued to right ischium. Record review of the resident’s wound care clinic’s notes, dated 6/13/18, showed the following information: -Status: not healed; Quality of tissue deteriorated: Wound status deteriorated; -Wound measurements: 3.0 CM L (0.5 CM longer than previous assessment) by 1.7 CM W (0.3 CM wider than previous assessment) by 0.4 CM D; -No eschar or slough present; moderate serosanguineous exudate; Maceration present; -Notes: Grey, brown, colored tissue; -No change in wound treatment orders. Record review of the (MONTH) (YEAR) TAR showed staff documented the weekly skin assessments as completed on 6/15/18 as indicated by staff initials. Record review of the (MONTH) (YEAR) Weekly Skin Integrity (assessment) form, dated 6/15/18, showed staff documented right ischium with treatment. Staff did not document any other skin assessment information. Record review of the (MONTH) (YEAR) physician’s orders [REDACTED]. Apply Santyl to the wound bed and cover with absorptive silicone dressing daily. Record review of the (MONTH) (YEAR) TAR showed the following information: -Treatment order, dated 6/21/18, for staff to cleanse pressure ulcer with hypochloric acid. Apply Santyl to wound bed, cover with absorptive silicone dressing; -Documentation on the TAR showed staff had not initialed the treatment as completed on 6/21/18, 6/22/18, 6/29/18, and 6/30/18. Staff did not document a reason for why staff did not complete the treatments. Record review of the (MONTH) (YEAR) TAR showed staff did not initial the date of 6/22/18 to indicate staff completed the treatment. Staff left the date blank. Record review of the (MONTH) (YEAR) Weekly Skin Integrity (assessment) form, dated 6/22/18, showed staff did not document completion of the skin assessment form. Record review of the (MONTH) (YEAR) TAR showed staff documented the weekly skin assessments as completed on 6/28/18 as indicated by staff initials. Record review of the (MONTH) (YEAR) Weekly Skin Integrity (assessment) form, dated 6/28/18, showed staff documented treatment to the right ischium. Staff did not document any other skin assessment information. Record review of the (MONTH) (YEAR) Weekly Wound Assessment form, dated 6/28/18, showed staff did not document any staging, measurements, color, or drainage amount. Staff documented treatment continued to right ischium. Record review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated resident assessment instrument, completed by facility staff, dated 6/30/18, showed the following information: -At risk for pressure ulcers; -The resident had one Stage II pressure ulcer; -The resident had slough; -Staff did not document the presence of a Stage IV pressure ulcer. Record review of the (MONTH) (YEAR) Weekly Wound Assessment form, undated, showed staff did not document any staging, measurements, color, or drainage amount for the pressure ulcer. Staff documented treatment continued to right ischium. Record review of Weekly Skin Integrity (assessment) form, dated 7/5/18, showed staff documented treatment in place. Staff did not document any further description of the resident’s skin. Record review of the (MONTH) (YEAR) physician’s orders [REDACTED]. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 20) -On 7/12/18, the physician ordered to change hypochlorous acid to 0.0033% per wound cleansing per wound clinic protocol; -Continuing order dated 3/17/18, the physician ordered Santyl ointment 30 grams: Apply topically once daily. Record review of the (MONTH) (YEAR) TAR showed the following: -Treatment order date 7/12/18 showed staff to clean the ulcer with hypochloric acid. Apply to skin. Skin prep (liquid that when applied to the skin forms a protective film or barrier) to periwound. Apply hypochlorous acid 0.033% to wound, apply Santyl for enzymatic for enzymatic debridement debridement. Cover with silicone dressing daily by staff and as needed. Allow hypochlorous to dry; -Treatment documented as completed by staff 7/12/18 through 7/17/18; -Treatment order with start date 3/17/18 showed staff to apply Santyl ointment 30 grams: Apply topically to the ulcer once daily; -Staff did not apply the Santyl ointment to the ulcer on 7/2/18, 7/6/18, 7/11/18, and 7/12/18. Staff did not document a reason for why staff did not complete the treatment. Record review of (MONTH) (YEAR) Weekly Skin Integrity (assessment) forms showed staff did not complete any further weekly skin Integrity forms for (MONTH) (YEAR) after 7/5/18. Record review of the (MONTH) (YEAR) Weekly Wound Assessment forms showed staff did not complete any pressure ulcer assessments for (MONTH) (YEAR). During an interview on 7/10/18, at 4:16 P.M., Resident # 46 said his ulcer occasionally got infected. He/she had osteo[DIAGNOSES REDACTED], so the ulcer would never heal, but it had been better than it was, and was a lot smaller now. He/she had the ulcer for [AGE] years. He/she was on hospice now, and the wound physician requirements had changed, so the wound physician no longer treated his/her ulcer. During an observation and interview, on 7/13/18, at 9:18 A.M., showed Registered Nurse (RN) I and Licensed Practical Nurse (LPN) J entered the resident’s room to change the pressure ulcer dressing. RN I gathered the supplies which were a silicone super absorbent dressing, sure prep, hypochloric wound cleanser placed in a plastic cup, dry gauze placed in a plastic cup, measuring tape, and Santyl ointment placed in a cup. The nurse placed the items on a sterile cover sheet. RN I removed a pair of scissors from his/her pocket and sat them on a box of gloves on the bedside table. RN I washed his/her hands. LPN J placed the supplies on a sterile drape on the resident’s bedside table. LPN J washed his/her hands and applied gloves. LPN J said he/she was not performing the wound care, but only helping position the resident. Staff assisted the resident with turning to his/her left side. RN I put gloves on, and removed a blue dressing dated 7/11/18 (two days old). The dressing had a moderate amount of tan-colored drainage on it. The wound was deep, long, and wide, with what appeared to be pink granulation tissue in the center of the wound. A dark area of skin, about 0.5 CM round was observed around 7:00 o’clock, with surrounding macerated skin. A dark are of skin around 1 CM long was observed in the wound bed extending into the perimeter of the wound around 5:00 o’clock. RN I cleansed the periphery of the wound with wound cleanser. RN I removed the gloves and applied new ones. RN I touched the resident’s wound at the 7:00 o’clock area, and the site bled, and continued to ooze a stream of blood. The ulcer had an odor at that time. RN I blotted the wound bed with the wound cleanser. RN I changed his/her gloves. RN I had not used hand hygiene between glove changes. RN I applied skip prep to the periwound area. LPN J said the wound clinic no longer saw the resident due to a hospice [DIAGNOSES REDACTED]. RN I blotted the blood that oozed into the resident’s periarea from the wound with a gauze sponge. RN I changed gloves without using hand hygiene. RN I reapplied new gloves. RN I applied Santyl ointment to the periphery of the wound edges, and covered it with a |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 21) silicone dressing. RN I dated the dressing. RN I removed his/her gloves and bagged the used supplies. RN I picked up the scissors from the resident’s bedside table, which appeared dirty with food and liquid debris. RN I placed the scissors in his/her pocket without sanitizing them. RN I told the resident he/she would return and clean his/her bedside table. During an interview on 7/13/18, at 3:16 P.M., Resident # 46 said he/she was running a temperature now, and was concerned about his/her ulcer since the wound clinic no longer attended to his/her ulcer. Record review of the resident’s nurses’ progress notes, on 7/13/18, at 4:00 P.M., showed staff did not document any description of the pressure ulcer or notification to the Director of Nursing (DON) or the physician of the ulcer drainage, odor, or darkened areas of the ulcer. During an interview on 7/17/18, at 8:20 P.M., RN G said the following: -RN G had worked at the facility as needed (PRN) for about six months. He/she had worked one to five days per month. He/she hadn’t worked for five or six weeks. He/she had worked back in March, April, and (MONTH) (YEAR). All licensed staff should complete the weekly skin assessments. It looked like the DON had taken over the skin assessments now. The weekly skin assessments are head to toe assessments. The facility used a corporate form. Staff should document bruising, open areas, and dry red areas. Those areas should be circled on the diagram. Those areas can also be described in the paragraph area on the form. If wounds were pressure areas, he/she would contact the physician, and have the wound consult company come there to see the resident. Another flow sheet is used for wound assessments that are supposed to be filled out at least weekly for pressure ulcers. Those forms should be filled out with description of the wounds such as the measurements i.e. length, width, depth, drainage, color of the wound, and changes to the wound. For wound care, he/she would gather supplies, check the orders to verify the treatment, wash his/her hands, put gloves on, get a bag for dirty supplies, and change the gloves after removing dirty gloves. He/she just swapped out gloves and didn’t use hand hygiene between glove uses. RN G didn’t use hand hygiene unless the gloves got super disgusting. RN G would not touch a dressing with his/her bare hands if it was to be applied directly to the wound bed. RN G wouldn’t touch the clean gauze with his/her bare hands as well. RN G had his/her own scissors, and would sanitize them before use. RN G would use antibacterial wipes to sanitize the scissors. She would clean a wound bed with gauze sponges from the top to the bottom of the wound. RN G would not re-swipe the wound bed. He/she would use a different wipe to clean the periphery of the wound. He/she was not comfortable with staging wounds, and just described them. As for Resident # 46, his/her wounds are cleansed. His/her wounds come and go, and appear like shearing at first. The facility obtained a wound clinic consult for Resident # 46. During an interview on 7/17/18, at 6:59 P.M., the DON said the following: -Weekly skin assessments should be performed every seven days. They use a form to describe the skin areas such as bruising or sores, and treatment should be recorded on them as well. The dates on the resident’s TARs should match the dates of the weekly skin assessments documented. Pressure ulcers and sores should be noted without details about them on the weekly skin assessments, but those wounds should be described on the wound assessment forms weekly. On the wound assessment forms, staff should chart the wound width, depth, and length, the wound bed description, any wound odor, exudate and amount such as small, medium, and large amounts, and note any necrotic tissue or slough, for example, 50 % slough present. The wound assessments should be completed weekly. The facility did not have designated wound nurse. Day shift divides up the duty, and the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 22) charge nurse would be responsible for them, both the weekly skin and the weekly wound assessments. She would expect changes in a wound to be reported to her. The TAR should match the date the weekly skin assessments had been completed if completed. The last time she knew of, staff should wash hands after using gloves anytime. When gloves were removed, they should use hand sanitizer between uses. If hand sanitizer had been used three times, staff should wash their hands. Scissors should be wiped with alcohol before and after use. Staff can place scissors in their pockets as long as they have been sanitized. For wound care, staff should wash their hands and put on gloves. Staff should remove the old dressing and discard it in a plastic bag. Staff should cleanse the wound from inside to outside. All areas under the bandage should be cleansed. Staff should visualize the wound. Staff could use a sterile cotton swab or pick up a corner of dressing with it to place the dressing in the wound bed. Staff should use clean gloves, and not touch dressings or gauze pads with their bare hands. All RNs should stage wounds at the facility. Wounds should be staged upon a resident’s admission and weekly as well with the measurements. Resident # 46 had had his/her wound forever and a day. The last wound report she had seen had shown the wound was at a stage III. She had not seen the wound since the resident had been put on hospice. The facility had not obtained measurements on Resident # 46’s wound for two weeks. Staff had not reported anything like odor, drainage, slough, or black areas in the wound to her. She would have expected staff to report those findings to her. | |
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 23) the resident refused to lay in bed and continued to crawl on the floor. Record review of a nurse’s note, dated 7/10/18, showed the resident refused to lay in bed and continued to lay on the fall mats on the floor. Observation of the resident’s room on 7/11/18, at 11:44 A.M., showed the resident had a bariatric mattress on a twin size bed frame. The mattress hung over the edge of the bed frame 10 to 12 inches. The resident had a bed in a lower position and fall mats on either side of the bed. Observation and interview on 7/13/18, at 2:58 P.M., showed the mattress remained too large for the bed frame. Staff had placed fall mats on either side of the bed. Observation of the resident showed the resident on the floor crawling around. The resident showed no signs of distress and denied falling. The resident said he/she was okay and denied any injuries. During an interview on 7/17/18, at 8:25 A.M., Certified Nursing Assistant (CNA) H said if he/she saw a mattress that did not fit a bed frame he/she would report this to the charge nurse and maintenance staff. He/she would also look to see if the bed frame had extensions for a bariatric mattress. He/she had not seen the bed frame and mattress for this resident since he/she had not worked on the resident’s hall since the resident’s admission to the facility. During an interview on 7/17/18, at 8:50 A.M., the maintenance director said he inspected the mattresses in the facility to ensure appropriate size and that the mattress was in good condition and had no low spots. He said he had not checked the mattress in the resident’s room since the resident was a new admission. He said he would have inspected the mattress prior to the resident’s admission. He said the mattress should fit the bed frame. He went and looked at the mattress and bed frame and said staff had placed a bariatric mattress on a regular sized bed frame and had not pulled out the extensions on the frame to properly support the mattress. During an interview on 7/17/18, at 2:03 P.M., the director of nursing (DON) said a resident’s mattress should fit the bed frame. She said the resident had a bariatric bed frame on a regular size bed frame and staff failed to pull out the extensions on the bed frame so the mattress had the proper support. She said staff should have used the extensions on the bed frame so the mattress had the proper support. She said no staff had reported the mattress did not fit the bed frame. During an interview on 7/17/18, at 8:55 A.M., the administrator said she would expect a mattress to fit the bed frame. If the mattress was too large for the frame, she would expect staff to adjust the extensions on the bed frame or to report to maintenance and the nurse that the mattress did not fit the frame. She said no one had reported this as far as she knew. The administrator said she would consider a mattress that hung over the bed frame a fall risk. 2. Record review of the facility’s policy, titled Nursing Policies and Procedures: Fall Management, dated as a complete revision 7/1/16 , showed the following information: -The purpose of the policy was to identify each resident who is at risk for falls and will care plan and implement interventions to manage falls; -Qualified staff evaluates all patients/residents for fall risk at a minimum upon admission, quarterly, with significant change and post fall; -If a fall occurs, qualified staff evaluates the resident for injury from the fall and determines what may have caused or contributed to the fall; -Any unwitnessed fall will have neurologic checks completed regardless of the resident’s cognitive status at the time of the incident; -The physician and family are promptly notified and an incident report is completed. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 24) Record review of the facility’s form, titled Neurologic Flow sheet, showed the following information: -The form directed staff to use this flow sheet at the following interval for events with possible head injury (witnessed and/or non-witnessed); -Any change in condition would require a phone call to the primary care physician; -The form directed staff to do an initial assessment on the resident, followed by assessments every 15 minutes for the first hour, then every 30 minutes for an hour, then hourly for two hours, the every shift for the rest of the 72 hour monitoring; -The assessments included orientation of the resident, eye opening response, handgrip strength, arm and leg strength, vital signs, and then pupil size and response to light. 3. Record review of Resident’s #3’s face sheet (information sheet) showed the following information: -admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the resident’s admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 2/21/18, showed the following information: -admitted [DATE]; -[DIAGNOSES REDACTED]. -Cognitive impairment and indicated the resident is not understood; -Required extensive assistance from staff for bed mobility, transfers, dressing, toileting, and personal hygiene; -Resident not steady during transfers and was only able to stabilize with assistance during moving from seated to standing position, moving on and off toilet, and surface to surface transfers; -The resident used a wheelchair for mobility; -The resident had a fall with injury prior to admission. Record review of the resident’s medical record did not show any care plan developed at that time. Record review of the nurses’ notes, dated 2/18/18 and 2/19/18 showed the resident was up for meals and went out for smoke breaks. Record review of a SBAR Communication Form, dated 2/26/18, indicated a fall at 2:00 P.M. The form instructed the staff to evaluate the resident and obtain vital signs (heart rate, blood pressure, temperature, respiratory rate, blood glucose level (if indicated) and Oximetry (level of oxygen in blood)) before calling the physician; -The form is a fill in the blank and check mark form; -[DIAGNOSES REDACTED]. -Vital signs listed as blood pressure 160/90, heart rate 90 and temperature 97.7; -Staff documented no change in respiratory status or abdomen; -Staff did not document blood glucose or blood oxygen level; -Staff did not document a response to a change in mental status; -Staff did not document a change in functional status other than fall; -Staff documented a request to monitor vital signs, for the resident to be in view of staff until put to bed. Staff documented the resident had been in his/her room in the wheelchair. The resident had been found on the floor on his/her right side with a raised, red/purple area on the right side of the forehead; -Staff documented a message was left in the folder for the physician to inform him of the fall. Record review of the nurses’ notes showed no documentation entry on 2/26/18. Record review of the resident’s medical record did not show a neurologic assessment flow |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 25) sheet for the fall on 2/26/18. Record review of the nurses’ note, dated 2/27/18, showed the nurse called the physician at 7:10 A.M. to report the resident complaints of pain and limited range of motion. Orders obtained for an x-ray and pain medication. Staff did not document any neurological assessment follow up assessments for day, evening, or night shifts. Record review of the nurses’ notes showed no staff documentation from 2/28/18 to 3/2/18. Record review of an untimed nurse’s note, dated 5/15/18, showed the following: -The resident wheeled his/herself to his/her room; -The resident attempted to self transfer and fell to the floor. Staff documented a staff member was in the room but did not document if a staff member actually saw the fall; -Staff documented no redness, skin tears, or pain at the time of the fall; -Staff did not document if the resident did or did not hit his/her head; -Staff did not document notification of family or physician contact; -Staff did not document any neurological checks; -Staff did not document any further follow up assessments. Record review of the nurses’ notes, dated 5/16/18, at 12:10 A.M. showed staff documented the resident rested quietly and neurological checks were within normal limits. Staff did not provide further documentation for 5/16/18. Record review of the resident’s care plan showed the following information: -Problem start date 5/16/18: The resident has behavioral symptoms and is allowed to sit him/her self on the floor if he/she so desires. Related to frustration when not getting what he/she wants/needs. Family and nursing staff aware. Record review of the resident’s medical record did not show a neurologic flow sheet sheet for the fall on 5/15/18. Record review of the nurses’ notes showed no staff documentation from 5/17/18 to 6/10/18. Record review of the resident’s nurses’ note dated, 6/14/18, at 9:30 A.M. showed the following information: -The resident had an injury from the fall; -The nurse documented the resident had been outside smoking in his/her wheelchair and attempted to transfer him/her self. The resident fell to the sidewalk striking his/her head. Staff documented a large abrasion and indention on right side of forehead above right eye. Staff documented a small skin tear to the right outer hand. -Staff cleaned the areas and applied bandages; -Staff documented neurological checks within normal limits, notification of the nurse practitioner, and family notified. Record review of the resident’s medical record did not show a neurologic flow sheet for the fall on 6/14/18. Record review of the resident’s nurses’ note, dated 6/14/18, showed the staff did not complete neurological checks or follow up assessments during the day, evening or night shifts. Record review of the resident’s care plan showed the following information: -Problem start date 6/15/18: Resident to have bed in lowest position at all times and a fall mat on the ground next to the bed; -Family requested the bed be placed against the wall. 4. Record review of Resident #36’s face sheet showed the following information: -The resident admitted to the facility on [DATE]; -[DIAGNOSES REDACTED].) Record review of the resident’s 14 day admission MDS, dated [DATE], showed the following information: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 26) -Staff did not list a [DIAGNOSES REDACTED]. -Required extensive assistance with bed mobility, transfers, toileting, and personal hygiene; -The resident used a wheelchair for mobility; -No falls prior to admission. Record review of the resident’s nurses’ notes showed the following information: -On 7/11/18, untimed, staff documented the resident’s right eye as red with yellow drainage. The nurse practitioner (NP) notified and orders for antibiotic eye drops received. Record review of the telephone physician order [REDACTED]. Observation on 7/13/18, at 1:30 P.M., showed the resident up in a wheelchair, self propelling through the main television area, both eyes noted to be red/red rimmed and left arm in an over the shoulder sling. Record review of the resident’s nurses’ notes showed the following information: -On 7/15/18, at 12:45 P.M., the nurse documented the resident had a raised red area with light bruising, measuring 3.5cm x 3.5 cm, and a small laceration, measuring .5 cm, and scabbed over. No complaints of pain or discomfort. The resident said he/she fell out of the wheelchair and got into bed. The resident said after the call light was on, the DON came into his/her room and touched the resident’s nose and said it’s not broken. The nurse documented he/she called the physician and no new orders received. Family was unable to be notified. The nurse documented vital signs and a neurological checks were within normal limits. The nurse failed to document the location of the injury. -On 7/15/18, from 1:00 P.M. to 10:45 P.M., the nurse did not document fall follow-ups. The nurse did not document a neurologic assessment of the resident; -On 7/15/18, at 11:00 P.M., the nurse documented a fall follow up and neurological checks within normal limits. Denies pain or discomfort at this time; Observation on 7/16/18, at 10:00 A.M., showed the resident up in his/her wheelchair by the nurses’ station. The resident had a large bruised area around and above the left eye. Small scabbed area noted to the bridge of the nose. Record review of the resident’s nurses’ notes showed the following information: -On 7/16/18, at 9:20 P.M., the nurse documented the resident’s neurological checks were within normal limits and the resident was alert and oriented. Bruising continued above the left eye and small laceration with scabbing to the bridge of the nose. No complaints of pain at this time. -No further documentation noted in regard to fall follow up assessments. During an interview on 7/16/18, at 3:50 P.M., Licensed Practical Nurse (LPN) J said he/she did not document on and could not locate a neurologic flow sheet for a fall on 7/14/18 or 7/15/18. The LPN said Registered Nurse (RN) G worked Saturday and Sunday and would know more about an incident. During an interview on 7/17/18, at 2:00 P.M., RN G said he/she did not document on and could not locate a neurologic flow sheet for the fall on 7/14/18 or 7/15/18. During an interview on 7/17/18, at 5:00 P.M., CNA B said the following: -When a resident has fallen, you immediately get the charge nurse to assess the resident; -After the charge nurse has assessed the resident for injuries and determined it is safe to move the resident, then you can assist the resident up with either the gait belt or the lift; -If staff witness the fall, and the resident did not hit their head, the aide obtains vital sign every 15 minutes for the first hour, then two in an hour, then once an hour later; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 27) -If no one witnesses the fall or the resident hit their head, then we add the neurologic assessments and go by the facility flow sheet; -CNA B said he/she is familiar with the resident; -The resident is oriented, but confused at times. The resident was able to verbalize his/her needs. The resident required assist with transfers, but was non-compliant; -CNA B said the resident has fallen more than one time, but is aware of the most recent fall. The resident had bruising on one side of the face; -The CNA said he/she was not here at the time of the most recent fall and the resident is not on the list for vital signs. During an interview on 7/17/18, at 7:00 P.M., the DON said the following: -When a resident falls, she expected the nurses to assess the resident head to toe, including a neurologic assessment if it was an unwitnessed fall or the resident hit their head; -The nurses then should notify the physician, family, and on-call nurse; -The DON said the nurses should fill out the event form; -The nurses should initiate follow-up documentation for 72 hours, and if the resident hit their head or the fall was unwitnessed, the nurses should initiate the neurologic flow sheet; -The follow-up documentation should include the injuries sustained in the fall, including bruising and skin tears. If the injuries remain at the end of the 72-hour documentation period, the nurses should continue documenting on those injuries until resolved; -The DON said she could not locate the neurologic flow sheet for a fall on 7/14/18 or 7/15/18; -The DON said a Resident incident/accident investigation worksheet (an internal document) had been completed. Record review of the Resident Incident/Accident Investigation worksheet provided by the facility, is an internal document, showed RN I filled out the form on 7/15/18, at 2:00 P.M. Date and time of the actual incident was not marked. The type of incident and injury the nurse indicated as unknown with bruising and a skin tear. The form showed the NP as notified at 2:30 P.M. on 7/15/18. The vital signs listed were within normal limits. The nurse documented the resident to have light blue and pink bruising to the left side of the forehead over the left eyebrow with a raised area measuring 3.5cm x 3.5 cm. A small laceration, measuring 0.5cm, and scabbed over on the bridge of the nose. Documentation showed no complaints of pain or discomfort. The resident said he/she fell out of the wheelchair and got into bed. The resident said after the call light was on the DON came into his/her room and touched the resident’s nose and said it’s not broken. The form indicated signatures of the DON on 7/16/18 and the administrator on 7/17/18. During an interview on 7/17/18, at 7:50 P.M., the DON said the following: -Resident #36 fell at approximately 10:30 P.M., on the evening of 7/14/18; -The DON said a CNA came to get her to report the resident had fallen. The DON went to the resident’s room, the resident had put himself/herself in the bed. The DON said she told the CNA to get vital signs and then turned the resident’s care over to the shift’s charge nurse; -The DON said he/she did not initiate the neurologic assessment sheet; -The DON does not recall seeing the cut on the resident’s nose; -The DON said she informed the charge nurse to complete the resident’s neurologic assessment sheet. The charge nurse did not complete the charting. -The nurses failed to document any nurses’ notes for night shift on 7/14/18 that should have included fall follow-up and neurologic assessments; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 28) -The nurses failed to document any nurses’ notes for day shift on 7/15/18 at 12:00 P.M. that should have included fall follow-up and neurologic assessments; -The nurses failed to document any nurses’ notes for day shift on 7/16/18 that should have included fall follow-up and neurologic assessments; -The DON said she had not been aware of Resident #3’s fall with injury. During an interview on 7/17/18, at 8:15 P.M., RN G said the following: -Expects the CNA/staff to report it to him/her immediately; -When a resident falls, the nurse is to perform an assessment on the resident, consisting of neurologic assessment if the resident hit their head or if the fall was unwitnessed, as well as assessment of any injuries, and range of motion; -The nurse was then to notify the physician, resident’s responsible party, and on-call nurse, initiate a nurse’s note, and 72 hour follow up charting; -If the resident hit their head, or the fall was unwitnessed, the nurse should also initiate the neurologic flow sheet that would continue for 72 hours; -The charge nurse should document the resident’s injuries sustained in the fall, including bruising, cuts, and skin tears. If those injuries remain past the 72-hour follow-up documentation period, the nurse should continue to document on the injuries until those injuries are resolved. Record review of the resident’s medical record did not show a neurologic flow sheet for the fall on 7/14/18. | |
| F 0727 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to provide the services of a | |
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 29) **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure food was stored and served in accordance with professional standards for food safety when a working thermometer was not kept in a refrigerator, temperatures were not logged and expired/undated food was kept in a refrigerator containing resident food. This could lead to contamination of food and to foodborne illness potentially affecting all residents. The facility had a census of 42. According to the Missouri Food Code, published 2013 refrigerated, potentially hazardous food prepared and held for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises or discarded when held at a temperature of forty-one degrees Fahrenheit (41 degrees F) or less for a maximum of seven days or when held at a temperature of forty-five degrees Fahrenheit (45 degrees F) or less for a maximum of four days. 1. Record review of the facility’s policy titled, Food Safety in Receiving and Storage, dated [DATE] showed the following: -Keep a thermometer in each refrigerator and freezer unit; -Check and record the refrigerator temperatures at least two times per day. Temperatures not in the appropriate range are reported to the Nutrition Director or to maintenance; -Maintain the ambient temperature of refrigerators at 34 to 38 degrees. 2. Record review of the facility’s policy titled Food Safety in Receiving and Storage dated [DATE], showed the following: -Refrigerated, ready to eat foods are properly covered, labeled, dated with a use-by date and refrigerated immediately. Mark them clearly to indicate the date by which the food shall be consumed or discarded. Discard after three days unless otherwise indicated. 3. Record review of the facility’s policy titled Safe Handling of Food Brought In by Family/Friends for Resident Consumption, dated [DATE], showed the following: -Foods are labeled to identify the resident’s name, container contents, and the date it was prepared. Food items are stored in disposable, tightly covered containers, or sealable plastic bags. Items will be stored for three days. Expired and unlabeled items will be discarded. 4. Record review of the facility Monthly Temperature Log dated May, (YEAR), for the nursing unit refrigerator showed staff did not document a temperature check 49 out of 62 times (two times per day) for the nursing unit refrigerator. Record review showed no June, (YEAR), nursing unit refrigerator temperature log. Record review showed no July, (YEAR), nursing unit refrigerator temperature log. Observation on [DATE] at 2:00 P.M., showed the interior thermometer of the nursing unit refrigerator was not readable, the mercury was broken up/fragmented and the temperature could not be determined. There was no exterior thermometer. No temperature log for (MONTH) (YEAR) was observed on the refrigerator. 5. Observation on [DATE] at 2:00 P.M., of the nursing unit refrigerator showed the following: -The freezer section contained an open, undated carton of ice cream; -The door shelf had a dried, brown sticky substance the length of the shelf; -Three small bowls of applesauce, covered with plastic wrap, were undated and stuck to the dried substance; -Three over-ripe, brown bananas, marked with a resident’s name; -An unsealed, dried out container of yogurt with a resident’s name, dated [DATE] and manufacturer’s best by date of [DATE]; -One bowl of unsealed vanilla pudding, marked 26. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 30) 6. During an interview on [DATE] at 1:50 P.M., Dietary Manager (DM) said resident food was stored in the nursing unit refrigerator. The nursing staff log the temperatures for the refrigerator. 7. During an Interview on [DATE] at 1:55 P.M., Licensed Practical Nurse (LPN) A said the nursing unit refrigerator was used to store food brought in for specific residents, food used for medication administration and the staff’s food. He/She removed the June, (YEAR) temperature log today and gave the log to the Director of Nursing. 8. During an interview on [DATE] at 3:00 P.M., Certified Nurse Assistant (CNA) B said the nursing unit refrigerator was used for resident’s food and staff’s food. The nursing staff or housekeeping staff are responsible for logging the refrigerator temperatures. Housekeeping staff used to check the refrigerator for cleanliness but he/she is not sure who monitors for cleanliness at this time. 9. During an interview on [DATE] at 03:07 P.M., Certified Medication Technician (CMT) C said he/she is new to the facility and the nursing unit refrigerator was for resident food. He/she obtains individual containers of applesauce from dietary for medication administration. He/she disposes of unused applesauce. 10. During an interview on [DATE] at 03:18 P.M., the Housekeeping Supervisor said she has been in the supervisor position for three weeks. The housekeeping staff have not logged temperatures or cleaned the nursing unit refrigerator. 11. During an interview on [DATE] at 3:30 P.M., Director of Nursing (DON) said the following: -The nursing unit refrigerator was used for resident’s food and food for the medication passes, such as applesauce; -The nursing staff are responsible for the refrigerator; -Nursing staff check for and dispose of expired foods; -She tries to clean it every Friday; -The nursing staff should log the refrigerator temperatures daily; -She does not have temperature logs and does not know who keeps the them. -She expects the staff to dispose of partially used applesauce after each (individual) resident use. 11. During an interview on [DATE] at 4:50 P.M., Administrator said the following: -The nursing staff should check for expired foods in the refrigerator and that has not been completed correctly; -She directed staff to dispose of all items in the nursing unit refrigerator; -A thermometer should be in the nursing unit refrigerator; -Nursing staff are responsible for logging the temperatures and checking for expired foods in the refrigerator and that has not been completed correctly; -She directed staff to dispose of all items in the nursing unit refrigerator. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 31) properly disinfect glucometers between resident use for three residents (Resident # 13, # 40, and # 198) and failed to ensure a glucometer disinfection policy was in place. A sample of 16 residents was selected for review out of a facility census of 42. Record review of 19 CSR 20-20.100 showed the following requirements for TB testing and monitoring of long-term care residents: -Within one month prior to or one (1) week after admission, all residents new to long-term care are required to have the initial test of a Mantoux PPD ([MEDICATION NAME] sensitivity test, tool for screening for TB and for TB diagnosis) two (2)-step [MEDICATION NAME] test; -If the initial test is negative, the second test can be given after admission and should be given one to three weeks later;. -All skin test results are to be documented in millimeters (mm) of induration; -Residents with a negative, zero to nine millimeters Mantoux PPD two-step test need not be routinely retested unless exposed to infectious [MEDICAL CONDITION] or they develop signs and symptoms which are compatible with [MEDICAL CONDITION] disease; -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of [MEDICAL CONDITION] disease. 1. Record review of Resident #14’s medical record showed the following information: -Date of admission 10/26/17; -[DIAGNOSES REDACTED]. Record review of the resident’s immunization record showed no records the resident had received the first or second TB test. 2. Record review of Resident #21’s medical record showed the following information: -Date of admission 3/11/18; -[DIAGNOSES REDACTED]. Record review of the resident’s immunization record showed no records the resident had received the first or second TB test. 3. Record review of Resident #39’s medical record showed the following information: -Date of admission 6/13/18; -[DIAGNOSES REDACTED]. Record review of the resident’s immunization record showed no records the resident had received the first or second TB test. 4. Record review of Resident #17’s medical record showed the following information: -Date of admission 8/22/16; -[DIAGNOSES REDACTED]. Record review of the resident’s immunization record showed no records the resident had received an annual signs and symptoms screening or an annual one step TB test. 5. During an interview on 7/17/18, at approximately 4:00 P.M., the medical records staff said he/she looked through the residents’ thinned medical records and did not find any records the TB test had been administered for the requested residents. He/she said if the immunization form did not list the TB test then the residents must not have received the TB test or the annual screening for TB. 6. During an interview on 7/17/18, at 7:55 P.M., the director of nursing (DON) said residents newly admitted to the facility should be given a Two-step TB test. The first TB test should be read 48-72 hours later. The second TB test should be given 7-10 days later and then read 48-72 hours later. Residents who are not new admissions should be offered an annual TB test. She did not know the TB test for the requested residents had not been done. 7. The Centers for Disease Control and Prevention (CDC) report blood glucometers approved for use for more than one person must be cleaned and disinfected. The CDC investigated |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 32) multiple outbreaks of [MEDICAL CONDITIONS] residents in long-term care (LTC) communities that were attributed to shared devices and other breaks in infection-control practices related to blood glucose monitoring devices. When blood glucose monitoring devices are shared between individuals there is a risk of transmitting [MEDICAL CONDITIONS] other blood borne pathogens. Record review of the American Society of Consultant Pharmacists Summary of Glucometer Cleaning Guidelines, dated (MONTH) 2010, showed the following information: -If the manufacturer does not provide specific cleaning recommendations, or as a conservative approach to infection control for glucometer with minimal cleaning requirements, facilities may want to consider cleaning glucometer with high-level disinfectants; -Be familiar with the amount of time the disinfectant solution is supposed to contact the equipment or how long active cleaning should be performed to ensure complete disinfection. For example, simply wiping equipment with a disinfectant-soaked swab (like an alcohol prep pad) may not be adequate. 8. Observation on 7/12/18, at 11:23 A.M., showed Licensed Practical Nurse (LPN) D applied hand gel and applied gloves. LPN D obtained a glucometer from the medication drawer. LPN D entered Resident # 198’s room with the glucometer and other supplies to perform the glucometer finger stick test. LPN D obtained the blood glucose test results and exited the room. LPN D sat the used glucometer on top of the medication cart directly, without a protective barrier. LPN D removed his/her gloves, and disposed of other used supplies. Record review of Resident # 198’s admission Minimum Data Set (MDS), a federally mandated resident assessment instrument, dated 3/8/18, completed by facility staff, showed the resident had been admitted on [DATE], and had a [DIAGNOSES REDACTED]. Observation on 7/12/18, at 11:30 A.M., showed LPN D picked up the unclean, used glucometer, along with other supplies, and entered Resident # 40’s room. LPN D obtained a paper towel and sat it on the resident’s bedside table. LPN D sat the glucometer on the paper towel, then washed his/her hands and applied gloves. LPN D obtained the blood glucose test on the resident. LPN D removed his/her gloves and washed his/her hands. LPN D exited the resident’s room. LPN D disposed of the used supplies, and sat the glucometer directly on the medication cart without a protective barrier. LPN D administered insulin to the resident. LPN D removed his/her gloves and applied hand gel. Record review of Resident # 40’s face sheet (general resident information) showed the resident admitted to the facility on [DATE], and had a [DIAGNOSES REDACTED]. Observation on 7/12/18, at 11:42 A.M., showed LPN D obtained supplies needed to administer a blood glucose test on Resident # 13. LPN D picked up the unclean, used glucometer and entered the resident’s room. LPN D obtained a paper towel and sat it on the resident’s bedside table, and sat the supplies and glucometer on the paper towel. LPN D washed his/her hands, and applied gloves. LPN D obtained the blood glucose results. LPN D left the resident’s room, and disposed of the used supplies. LPN D placed the glucometer on the medication cart. LPN D had not disinfected the glucometer. LPN D placed the unclean, used glucometer in the top drawer of the medication cart. Record review of Resident # 13’s quarterly MDS, dated [DATE], showed the resident had been admitted on [DATE], and had a [DIAGNOSES REDACTED]. 9. During an interview on 7/17/18, at 8:20 P.M., Registered Nurse (RN) G said the following: -RN G would clean glucometers with an antibacterial wipe after resident use, and leave wet for three minutes. He/she had learned this practice when working at other facilities. 10. During an interview on 7/17/18, at 6:59 P.M., the Director of Nursing said the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 33) following: -She expected staff to disinfect glucometers after resident use by wiping them off with alcohol, and letting them sit for 90 seconds before using on another resident. This practice was based on previous in-services she had received in the past. The facility didn’t have a glucometer cleaning policy. 11. During an interview on 7/17/18, at 6:50 P.M., the administrator said she did not have a glucometer cleaning policy. | |
| F 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop and implement policies and procedures for flu and pneumonia vaccinations. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 6/10/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265410 |
| (X3) DATE SURVEY COMPLETED 07/17/2018 | |||||||
| NAME OF PROVIDER OF SUPPLIER BENTONVIEW PARK HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 410 WEST BENTON STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 34) -[DIAGNOSES REDACTED]. -No consent forms to authorize the pneumococcal vaccines. Record review of the resident’s immunization record showed no records the resident had been offered either pneumococcal vaccines and no previous history the resident had ever received either pneumococcal vaccine. 4. Record review of Resident #21’s medical record showed the following information: -Date of admission 3/11/18; -[DIAGNOSES REDACTED]. -No consent forms to authorize the pneumococcal vaccines. Record review of the resident’s immunization record showed no records the resident had been offered either pneumococcal vaccines and no previous history the resident had ever received either pneumococcal vaccine. 5. Record review of Resident #39’s medical record showed the following information: -Date of admission 6/13/18; -[DIAGNOSES REDACTED]. -No consent forms to authorize the pneumococcal vaccines. Record review of the resident’s immunization record showed no records the resident had been offered either pneumococcal vaccines and no previous history the resident had ever received either pneumococcal vaccine. During an interview on 7/17/18, at 7:55 P.M., the director of nursing (DON) said the staff should send out a consent form for the resident, guardian, or resident representative to sign for authorization to administer the pneumococcal vaccine. The DON said she did not know there were two pneumococcal vaccines that should be offered. She said the facility had not been offering the pneumococcal vaccines since she had been at the facility. | |
| F 0919 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Make sure that a working call system is available in each resident’s bathroom and bathing area. Based on observation and interview, the facility failed to provide a switch in all toilet | |
