| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0565 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to organize and participate in resident/family groups in the facility. Based on interview and record review, the facility failed to provide the Resident Council |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0565 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 1) form. He/she talked to kitchen staff about wanting more meat in meals, such as pork steak, ham, fried chicken and meatloaf. Staff served salads consisting of only lettuce and cheese. Residents want lettuce salads to include meat and other vegetables. The DM and SS told him/her it was left to the RD to change. He/she told the administrator about the food service problem and nothing was done about it. He/she got up hungry from the table three times last month due to dissatisfaction with the menu. The only response from staff was there was nothing they could do about it, it was up to the RD. Staff told him/her they expected him/her to tell the RD about the residents dissatisfaction with the menu. In an interview on 1/10/19 at 3:30 P.M., the Administrator said: – The DM was to respond to the RC and individual residents’ food complaints, but did not. The DM should have communicated resident food complaints to the RD in order for the menu to be adjusted. – She agreed with the residents that there was too much soup served in the evenings. The DM should have worked on preferences with the residents and responded to resident complaints. – The resident council meeting minutes showed no resolution to resident complaints. In an interview on 1/11/19 at 9:20 A.M., the SS said: – She had the DM come to the 10/2018 RC meeting to address resident complaints of too much soup and wanting more meat and other food items served. She expected the DM to get back with the council on their concerns. She was unaware that the DM had not done so. – She agreed with the residents that there was too much soup served and the menu needed more variety. – The facility did not have a RC policy. – RC meetings should, but did not include follow-up on RC complaints, resolutions and result satisfaction. In an interview on 1/14/19, Resident #21 said he/she told the DM a long time ago that there was too much soup and not enough meats served. The issue had never been resolved. Review of resident council meeting minutes dated 1/14/19, showed: – The RC would like to meet with the dietician as a group to talk about menus. – Residents want to be informed in advance of substitutions to the planned menu. – No response to resident complaints from prior meetings. | |
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Respond appropriately to all alleged violations. Based on observation, interview and record review, the facility failed to follow their |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) approaches. – Any person witnessing or suspecting abuse shall immediately remove the resident from a harmful environment. Upon receiving a report of physical abuse, the charge nurse shall report to his/her supervisor. – Staff was to notify the immediate supervisor, department head and administrator by phone, if not present. Along with completing an Incident Report. – Staff was to notify the primary care physician, or on-call physician if after hours, of the incident. – Failure to report occurred when a suspected abuse has taken place, a person is aware of the situation and this person has allowed a period greater than two hours to elapse without reporting suspected abuse to the Administrator. – Any resident-to-resident altercation shall be reported to state agencies where there is evidence of psychological distress to either resident involved. – The Administrator or his/her designee must complete an Incident Report and obtain written, signed and dated statements from the person reporting the incident. A completed copy of the Incident Report and written statement from witnesses must be provided to the Administrator within 24-hours of the incident occurrence. An immediate investigation will be made and will include interviewing all staff who worked in the area where the incident occurred and who worked during the 24-hours prior to the incident, and a copy of the finding of such investigation will be provided to the Administrator within three working days of the occurrence of such incident. – Any person who has knowledge or reason to believe that a resident has been a victim of mistreatment or abuse SHALL report, or cause a report to be made of the mistreatment or offense. – Report information to include a representative of the social services department monitor the resident’s feelings concerning the incident. – The administrator was to keep the residents’ representative informed of the progress of the investigation on a daily basis. 2. Review of Resident #13’s nurses’ notes dated 1/6/19, showed Licensed Practical Nurse (LPN) B documented that the resident was in bed asleep when another resident entered room, took nebulizer tubing and wrapped it around the resident’s neck. This resident woke up, grabbed the tubing away from his/her neck, while cursing at the other resident. Nebulizer tubing and machine placed in night stand drawer. In an interview on 1/11/19 at 8:15 A.M., the Interim Director of Nursing (IDON) said she was unaware of the 1/6/19 nebulizer incident/altercation involving Resident #13. She did not know who the resident was that wrapped tubing around Resident #13’s neck. At the time of the incident, staff should have notified her and the administrator and started an incident investigation. Observation on 1/11/19 at 11:30 A.M., showed Resident #13’s nebulizer machine and plastic tubing at his/her bedside. During interviews on 1/11/19 at 10:44 A.M. and 11:35 A.M., the Administrator said: – Staff did not inform her of the 1/6/19 incident involving Resident #13. – She did not understand why staff did not report the incident. – At the time of the incident, staff should have informed her, started an investigation and implemented interventions to prevent reoccurrence. – She did not know who wrapped tubing around Resident #13’s neck. She was trying to get in touch with LPN B in order to find out incident details. During interview and record review on 1/11/19, at 2:20 P.M., – The Administrator said she spoke with LPN B and found out on 1/6/19, Resident #33 put |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 3) nebulizer tubing around Resident #13’s neck. – Review of LPN B’s 1/11/19 written statement, showed a certified nurse aide (CNA) called him/her to the special Care Unit (SCU) reporting he/she heard Resident #13 cursing. The CNA entered Resident #13’s room and found tubing loosely around the resident’s neck. Resident #13’s hands were on the tubing pulling it. Another resident was in Resident #13’s room walking away from the resident’s bedside. The CNA stated he/she heard a noise and the resident’s nebulizer machine was on the floor. The CNA did not witness the incident. During an interview on 1/11/19 at 3:00 P.M., LPN B said: – CNA F called him/her to the SCU on 1/6/19 at 8:00 P.M. and reported that Resident #33 put nebulizer tubing around Resident #13’s neck. The CNA said he/she heard Resident #13 cursing and then the resident’s nebulizer machine fall to the floor. The CNA then went into Resident #13’s room to find Resident #33 wandering around the room and nebulizer tubing wrapped around Resident #13’s neck. – He/she assessed Resident #13 and completed quick charting without knowing all the incident details. He/she was to complete an incident report, but did not. If he/she followed the Incident Report process and obtained written statements then the facts of the incident would be known. He/she should have called the Administrator at the time of the incident. 3. During an interview on 1/11/19 at 2:40 P.M., the IDON said: – LPN B never reported the incident to her. – At the time of the incident, LPN B did not follow the facility policy. LPN B should have followed the policy by assessing the residents involved, notifying the Administrator and IDON, starting an incident investigation and completing an incident report. In an interview on 1/14/19 at 11:17 A.M., the Administrator said she found the nurse’s notes regarding the incident and staff interviews conflicted. Due to LPN B not following the facility incident policy, there was no way to know what happened in order to implement appropriate interventions for resident care. | |
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure services provided by the nursing facility meet professional standards of quality. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 4) of [MEDICAL CONDITION]), nosebleeds, pink or amber colored urine, or bleeding of the gums to the charge nurse. Use hair removal product for legs and face as needed or safety razor. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 5) Review of the resident’s Medication Administration Record [REDACTED] – Staff initialed to show they gave the [MEDICATION NAME] from [DATE] through [DATE]. Review of the resident’s POS, dated [DATE] through [DATE], showed: – PT/INR, HgbA1c and BMP semi-annually (every six months) – [MEDICATION NAME] 3 mg once a day, every other day; – [MEDICATION NAME] 4 mg once a day, every other day. – The POS did not show the PT/INR monthly order. Review of the resident’s Medication Administration Record [REDACTED] – Staff initialed to show they gave the [MEDICATION NAME] from [DATE] through [DATE]. During an interview on [DATE], at 11:15 A.M., Physician A said: – He/she did not order the resident’s PT/INR every six months. – He/she ordered a monthly PT/INR and the PT/INR should be done every month. During an interview on [DATE], at 2:29 PM, [DATE], at 10:50 A.M., and [DATE] at 10:40 A.M., Registered Nurse (RN) A said: – Resident #6 had a monthly PT/INR order for years. – He/she did not know the order showed PT/INR every 6 months, and did not know how that happened. – When he/she received lab orders, he/she entered those orders into the laboratory computer system, but those orders did not show on the Matrix system POS. – Resident #6’s PT/INR orders expired in the laboratory computer system, in (MONTH) (YEAR). – On Friday [DATE], Physician A gave orders for Resident #6’s monthly PT/INR and he/she entered those orders into the lab computer system. During an interview on [DATE] 11:16 A.M., the Administrator said: – LPN A reviewed the orders after he/she and staff entered all the orders into Matrix. – LPN A checked the medications listed on Pharmacy A’s POS against the Matrix POS, to make sure the medication orders matched, but did not check the lab orders to see that they were entered and correct. During an interview on [DATE], at 3:12 P.M., LPN A said: – He/she was not told to check the residents’ Matrix system POS to ensure staff entered the lab orders correctly. 2. Review of the facility’s undated policy for Fast Acting Insulin (Novalog – Humalog), showed: – Fast acting insulin is to be given no more than 15 minutes prior to a meal or immediately after a meal due to its fast acting effect on blood sugars; – All fast acting insulin will be given immediately after the meal; Certified Medication Technician (CMT) or charge nurse will take resident from dining room table after they have eaten to their room and administer the insulin; – If for any reason the insulin has to be given before a meal, immediately after administering insulin, a glass of milk or juice along with crackers will be given to the resident and staff will sit with resident to ensure consumption. 3. Review of Resident #3’s current ,[DATE] physician’s orders [REDACTED]. Observation on [DATE] at 7:29 A.M., showed CMT A administered 6 units of Humalog to the resident and pushed the resident to the breakfast table in the independent main dining room and left him/her without offering the resident any type of snack or food. Glasses of milk and tomato juice sat in front of the resident, which he/she did not consume. The resident sat at the breakfast table without food to eat until staff served his/her breakfast of biscuits and gravy at 8:40 A.M. During an interview on [DATE] at 11:40 A.M., CMT A said the resident should have had |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) something to eat within 15 minutes after he/she received Humalog. Breakfast was served very late that morning. He/she did not offer the resident a snack. During an interview on [DATE] at 12:53 P.M., the Interim Director of Nurses said: – When staff administered fast acting insulin, they should provide a snack or meal within ,[DATE] minutes. | |
| F 0661 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on interview and closed record review, the facility staff failed to complete a | |
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide care and assistance to perform activities of daily living for any resident who is unable. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 7) CONDITION] and shave against the direction of hair growth; – Encourage resident to participate in care as much as possible. 1. Review of Resident #25’s Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/19/18, showed: – Both long and short term memory problems: – Dependent on staff assistance for toilet use and personal hygiene; – Always incontinent of urine and occasionally incontinent of bowel. Review of the resident’s undated care plan, showed: – The resident needed assistance in keeping clean and dry, since he/she was incontinent of bladder; – Provide incontinence care as needed, use house barrier after incontinence. Observation on 1/11/19 at 10:14 A.M., showed Certified Nurse Assistant (CNA) B placed a gait belt around the resident to transfer him/her from the wheelchair to the resident’s recliner. CNA B said the resident did not like to lay in bed, so he/she would perform perineal care if needed at the resident’s recliner. After CNA B assisted the resident to stand, he/she pulled out the resident’s brief and said it was wet. The resident had much difficulty walking, so CNA B sat the resident back in his/her wheelchair after he/she pulled the resident’s pants and brief down. CNA B manipulated and cleaned the resident’s front perineal folds, but did not clean between the resident’s legs or the resident’s buttocks. CNA B applied a clean brief, assisted the resident to stand, pulled up the resident’s clean brief and pants. During an interview on 1/11/19 at 2:07 P.M., CNA B said: – The resident did not act his/her normal self today; – When doing perineal care on incontinent residents, he/she should clean all skin where the urine touched; – He/she should have washed the resident’s backside as he/she was incontinent in his/her brief. 2. Review of Resident #22’s MDS, dated [DATE], showed: – Both long and short term memory problems; – Dependent on staff for personal hygiene and bathing. Review of the resident’s undated care plan, showed: – The resident needed supervision and cueing with activities of daily living, because of dementia; – Assist to keep the resident’s face clean daily; – Monitor his/her ability to see if further assistance is needed; – Monitor his/her skin with routine cares; – Provide his/her showers if Hospice was unable to. Observation on 1/10/19 at 8:51 A.M., showed the resident sat in a broda type chair that rocked at the breakfast table. The resident had at least eight inch long white whiskers that grew from the resident’s jaw line and from the resident’s neck. 3. Review of Resident #12’s MDS, dated [DATE], showed: – Some difficulty with decision making skills; – Independent with personal hygiene and needed assistance with bathing. Review of the resident’s undated care plan, showed: – The resident can bathe him/herself with staff set up; – Monitor his/her activity of daily living ability and provide further assist if needed; – Remind him/her to comb his/her hair, brush his/her teeth, wash his/her face in the morning and at bedtime. Observation and interview on 1/8/19 at 11:07 A.M., showed the resident sat in an easy |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 8) chair in his/her room. The resident had one quarter inch gray whiskers on both sides of his/her upper lip. The resident said: – Staff helped him/her with showers; – He/she asked staff to remove his/her facial hair; – The resident does not like when his/her facial hair gets long, it bothers me. – When the resident lived at home, he/she kept the whiskers plucked. During an interview on 1/14/19 at 10:45 A.M. CNA B said: – Some days the facility did not have a shower aide and on those days, he/she gave showers for the residents; – During showers he/she shaved both the men and the women residents; – He/she thought all the female residents wanted their chin whiskers shaved. 4. Review of Resident #16’s MDS, dated [DATE], showed: – Short and long term memory problems; – Dependent on staff for personal hygiene and bathing. Review of the resident’s undated care plan, showed: – The resident liked to be clean; – Keep the resident’s hands and face clean throughout the day; – Make sure the resident’s fingernails were cut and clean underneath them. Observation on 1/8/19 at 12:21 P.M. showed the resident sat in the assist dining room, eating his/her lunch and picked up food that had spilled off the plate unto the table. His/her right middle, ring and little fingernails had a dark brown substance underneath his/her fingernails. Observation on 1/9/19 at 8:47 A.M., showed the resident sat in his/her room in a wheelchair. A dark brown substance partially filled the underneath side of the right middle, ring and little fingernails. During an interview on 1/14/19 at 10:45 A.M., CNA B said: – He/she cleaned the resident’s fingernails when he/she gave showers; – He/she clipped and cleaned residents’ fingernails whenever they needed done, if they were not diabetics. During an interview on 1/14/19 at 12:53 P.M., the Interim Director of Nurses said: – When staff removed a brief soiled with feces or urine, they should provide complete perineal care; – Staff should always provide good, complete perineal care, front and back; – If the resident was incontinent in bed, staff should clean between the resident’s legs, down the backs of the legs and up the resident’s back. – Staff should shave resident’s facial hair whenever needed, but at least on their shower days. – Staff should keep nails clean as needed and on shower days, some of the residents use their fingers to eat, staff should make sure fingernails were clean. | |
| F 0686 Level of harm – 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: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 – Actual harm Residents Affected – Few | (continued… from page 9) failed to notify the physician, in a timely manner, of a change in the resident’s pressure ulcer. The facility census was 38. Record review of the facility’s Care and Prevention of Pressure Ulcers (PU) Policy and Procedure, dated (MONTH) 2006, showed: – Purpose- to prevent and treat further breakdown of pressure ulcers; – Equipment included a pressure reducing chair pad; – Guidelines included to use pressure-reducing devices to relieve pressure. Review of the facility’s Wound Care and Treatment Policy and Procedure, dated (MONTH) 2006, showed: – The care plan should reflect the current status of the PU, appropriate goals, and approaches; – Positioning and pressure reduction included wheelchair position: pressure-reduction cushion. Review of the facility’s undated, Change in a Resident’s Condition or Status Policy and Procedure, showed: – Policy statement: The facility shall promptly notify the resident’s attending physician of changes in the resident’s condition and/or status; – Policy interpretation and implementation – The nurse supervisor will notify the resident’s attending physician when there is a need to alter the resident’s treatment significantly and when it is deemed necessary or appropriate in the best interest of the resident. Review of Resident #38’s quarterly Minimum Data Sets (MDS), a federally mandated assessment completed by facility staff, dated 12/11/18, showed: – Staff scored the resident as 00 (severely cognitively impaired), out of a possible 15, for the brief interview for mental status; – Dependent on two or more staff for bed mobility and transfers; – Wheelchair for mobility; – One Stage III PU (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough (yellow, tan, gray, green, brown or tan dead tissue) may be present but does not obscure the depth of tissue loss. (MONTH) include undermining (destruction of tissue extending under the skin edges so the PU is larger at the base) or tunneling (passageway of tissue destruction under the skin that has an opening at the skin level at the edge of the PU). – [DIAGNOSES REDACTED]. Review of the resident’s undated current care plan, showed: – Coccyx (the tailbone) PU; – Pressure reducing mattress and needed staff to help him/her position side to side every two hours. The resident would argue about turning side to side, as he/she just wanted to lay on his/her left side. – Dependent for transfers with mechanical lift (a device to transfer non weight bearing residents) and did not want to get out of bed. – admitted to hospice services for end stage [MEDICAL CONDITION] on 1/2/19. – The approaches did not include a pressure-relieving cushion for the Broda chair (a tilt-in-space wheelchair). During an interview on 01/09/19 at 2:36 P.M., Family member (FM) A said: – The resident developed a PU about two months ago; – FM A felt the facility did not put preventative measures in place to prevent the PU. During an interview on 1/10/19, at 9:50 A.M., Registered Nurse (RN) A said the facility did not have a wound nurse. Licensed Practical Nurse (LPN) A measured the PUs weekly and |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 – Actual harm Residents Affected – Few | (continued… from page 10) documented assessments in the wound book. During an interview on 1/11/19, at 11:04 A.M., LPN A, said: – The resident had a previous PU, which healed on 10/1/18; – He/She first documented the resident’s new PU on 11/16/18, and it measured 2.1 centimeters (cm) by 0.5 cm; – LPN A said the PU got worse very rapidly and the next week, on 11/21/18, it measured 3.5 cm by 1.0 cm with a depth of 0.3 cm. He/She sent a fax to the physician for orders, but did not receive a response from the physician by the time the resident went to the hospital; – The PU measured 3.0 cm x 1.0 cm when the resident returned from the hospital on [DATE], with orders for Santyl (an ointment to remove dead tissue) topical ointment to the coccyx PU covered with border dressing and [MEDICATION NAME] (an antibiotic to treat an infection) daily; – On 12/5/18, LPN A sent a fax to the physician because the PU contained a bloody sack. The physician said the order for [MEDICATION NAME] daily was an error and increased the [MEDICATION NAME] to three times a day. Review of Physician B’s telephone orders showed: – 11/29/18, Santyl topical ointment to coccyx PU with [MEDICATION NAME] (a highly absorbent foam dressing to absorb drainage), change daily. Low air loss mattress. Reposition side to side every two hours and use pressure relieving cushion when up in chair; – 11/30/18, [MEDICATION NAME] 300 milligrams (mg) twice a day for 10 days for PU. Review of LPN A’s fax to Physician B, dated 12/5/18, showed: – Started Santyl to PU on 11/29/18, upon return from hospital; – On [MEDICATION NAME] 300 mg daily for ten days; – PU not improving, bleeding daily, thick blood/pus like sack protruding from PU and does not move with cleansing; – LPN A asked if staff could try something else; – The bottom of the fax had a physician’s orders [REDACTED].M. Review of Physician B’s telephone orders showed: – 12/6/18, clarification give [MEDICATION NAME] 300 mg three times a day until 12/10/18. Resident to see Physician B in wound clinic at 11:00 A.M., on 12/11/18; – 12/11/18, discontinue current PU treatment, new PU treatment to pack coccyx PU with [MEDICATION NAME] gauze (a gauze dressing used for infected wounds that may have a build-up of dead tissue) daily for three days, cover with [MEDICATION NAME], then switch to plain gauze in PU daily, and return to wound clinic in one month. During an interview on 1/11/19, at 11:04 A.M., LPN A, said: – On 12/10/18, the PU measured 3.3 cm by 0.8 cm; – On 12/11/18, the resident went to the wound clinic and after [MEDICATION NAME] the PU, it measured 2.0 cm by 0.5 cm and for a while the PU looked great although the tunneling never got better and he/she still had a lot of drainage. RN A entered the wound clinic orders and there was a mix-up in wound clinic orders. The wound clinic wanted Santyl on the wound bed, but that did not get written in the order; – On 12/19/18, the PU measured 2.0 cm x 0.4 cm. Physician B made rounds and LPN A told Physician B the PU looked pretty nasty. Physician B [MEDICATION NAME](an antibiotic to treat the infection) and [MEDICATION NAME] (an antibiotic to treat the infection) for seven days and asked if staff used the Santyl. LPN B told Physician B about the mix-up with the wound clinic orders. Physician B ordered the Santyl and staff started using the Santyl on 12/19/18. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 – Actual harm Residents Affected – Few | (continued… from page 11) Review of Physician B’s progress notes, dated 12/19/18, showed: – The resident had malodorous drainage from the PU area. – Physician B’s assessment/plan showed the resident had an infected PU and orders for [MEDICATION NAME] 100 mg twice a day [MEDICATION NAME] mg twice a day. Review of Physician B’s telephone orders showed: – 12/19/18, [MEDICATION NAME] (an antibiotic to treat infection) 100 mg twice a day for seven days [MEDICATION NAME](antibiotic to treat infection) 500 mg twice a day for seven days for PU. Discontinue current PU treatment. New orders to cleanse wound and pack with plain packing gauze, apply Santyl to PU bed, cut [MEDICATION NAME] to wound size, place in PU bed, and cover with dressing, daily and as needed. Review of the resident’s vital sign flow sheet, dated (MONTH) (YEAR), showed: – Staff documented the resident was on antibiotics for the PU from 12/20/18 through 12/27/18. – No documentation of antibiotics from 12/27/18 through 12/30/19. Review of the physician’s telephone orders, showed: – 12/30/18, send the resident to the emergency room for blood sugar of 524. – 12/31/18, readmit the resident under Physician B’s services, resume medications as ordered, resume care and treatment. During an interview on 1/11/19, at 11:04 A.M., and 1/14/19 at 1:20 P.M., LPN A, said – On 12/26/18, the PU measured 2.0 cm by 0.5 cm with a 5.0 cm tunnel. – On 1/2/19, the PU measured 2.0 cm by 0.8 cm with a 7 cm tunnel. – He/she did not see the PU between last Tuesday 1/2/19, and today, 1/11/19. – Last Tuesday, 1/2/19, the PU had nasty drainage, but did not have the necrotic (dead tissue) area around the PU. – He/she and RN A covered the day shift every week and did the resident’s PU dressing. – LPN A said about 75% of the time when he/she did the PU dressing changes the resident had thick brownish drainage. He/she said that drainage either saturated the dressing or flowed from the PU during the dressing change. He/she said the resident had the drainage since returning from the hospital in late (MONTH) (YEAR). – He/she had not contacted the physician about the odorous drainage. Review of the resident’s vital sign flow sheet, showed: – No documentation of antibiotics from 12/31/18 through 1/11/2019. During an interview and observation on 1/10/19, at 9:50 A.M., RN A did and said: – RN A and a certified nurse aide (CNA) positioned the resident on the left side. – When RN A removed the PU dressing and packing, a foul odor and a large amount of thick tan drainage flowed from the open coccyx PU onto the incontinent pad. – RN A gently pressed on the PU and more thick tan drainage flowed from the PU followed by pink-tinged drainage. – RN A applied Santyl to the approximately 16 inch long piece of gauze, packed the gauze into the open PU, applied a piece of [MEDICATION NAME] over the upper edge of the PU, covered the PU with a thick dressing, and secured it with tape. – RN A said the resident was on antibiotics before going to the hospital, but was not on any antibiotics when he/she returned from the hospital. – RN A said he/she mentioned to the other nurses that the physician needed to be notified of the drainage. – RN A said if staff sent a fax to Physician B it would be under the fax tab in the chart. – He/she did not contact the physician about the PU drainage since the resident returned from the hospital. – He/she said the resident went on hospice a few days ago. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 – Actual harm Residents Affected – Few | (continued… from page 12) Record review of the faxes in the resident’s chart showed: – No fax to a physician regarding the resident’s PU drainage since returning from the hospital. Observations showed: – On 1/10/19, at 10:50 A.M., the resident sat in the Broda chair. The Broda chair had a thin, approximately one-half inch, pad covering the straps that made up the back and seat of the chair. The chair did not have the physician’s orders [REDACTED]. – On 1/10/19, at 12:15 P.M., the resident sat upright in the Broda chair at a dining room table, with no pressure relieving cushion in the chair. – On 1/10/19, at 1:30 P.M., the resident slept in the on his/her back in the slightly reclined Broda chair. The Broda chair had the thin pad covering the seat and back straps, but did not have the physician ordered pressure relieving cushion in the chair. – On 1/10/19, at 3:34 P.M., the resident remained in the slightly reclined Broda chair in his/her room, without the physician’s orders [REDACTED]. During an interview on 1/15/19, at 8:45 A.M., Certified Occupational Therapy Assistant (COTA) A said: – Therapy put the resident in a tilt in space wheelchair with the facility’s best cushion. – Therapy staff were in the process of trying to get a ROHO cushion (an adjustable pressure relief cushion with soft flexible air cells), but the resident went on hospice, so he/she would not qualify for a specialty cushion. During an interview on 1/10/19, at 3:34 P.M., RN A said he/she called Physician B about the PU drainage and received orders for Bactrim (an antibiotic to treat the infection) and to obtain a culture (a test to identify the type of bacteria) of the PU. Observation and interview 1/11/19 at 9:50 A.M., provided the following information: – LPN A and RN A positioned the resident on his/her left side. – A very foul smelling brownish bloody drainage saturated the resident’s compound PU dressing. – A purplish, black three-pointed star-shaped area surrounded the open PU. – LPN A said the PU measured 3.5 cm by 1.3 cm with a 5.3 cm tunnel at five o’clock. LPN A said the PU and the purplish black area measured 5 cm by 5.3 cm. – LPN A obtained a culture of the pressure ulcer. – RN A said he/she always gently pressed on the resident’s pressure ulcer and usually there was drainage from the PU. During interviews on 1/14/19, at 10:30 A.M., and 2:30 P.M., the Interim Director of Nursing (IDON) said: – When she started working at the facility in (MONTH) (YEAR), the resident walked to the dining room. – She was not aware the resident recently went on hospice. – The facility did not have a wound nurse, so the DON would be responsible to get a pressure-relieving cushion for the resident’s Broda chair. – She did not know the resident did not have a pressure relieving cushion in his/her Broda chair. During an interview on 1/11/19 at 2:30 P.M., the Administrator said: – She expected staff to follow physician’s orders [REDACTED]. – Staff should notify the physician of a change in a resident’s condition. | |
| 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 |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 13) 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: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 14) mechanical lift, then lifted the resident from the bed. – The legs of the mechanical lift remained closed while CNA C raised the resident from the bed, left the legs closed and pulled the mechanical lift from under the bed and turned the lift towards the shower chair; – CNA C lowered the resident onto the shower chair. Observation on 1/9/19 at 9:40 A.M., showed CNA B and CNA C used the mechanical lift to transfer the resident from his/her shower chair back to bed. – CNA B opened the lift around the shower chair, locked the castors and attached the loops of the sling to the mechanical lift; – CNA B raised the mechanical lift and the resident from the shower chair, unlocked the castors and backed the lift away from the shower chair, closed the legs of the lift and pushed the lift over to the resident’s bed; – CNA B locked the castors and lowered the resident on to bed. During an interview on 1/9/19 at 10:45 A.M., CNA C said he/she should close the legs of the lift when moving the resident and open the legs to position around the wheelchair. He/she did not know if the castors should be locked at any time. During an interview on 1/9/19 at 11:10 A.M., CNA B said he/she locked the castors, so the lift would not tip. The legs of the lift should be closed when moving the resident. 2. Review of the facility’s, undated, policy for Gait Belt Use showed: – Assist the resident at the waist rather than pulling his/her arms or shoulders; – Make sure the gait belt is never next to bare skin. Review of Resident #20’s MDS dated [DATE], showed: – Some difficulty making decisions; – Required extensive assist with transfers. Observation on 1/10/19 at 1:28 P.M., showed CNA D transferred the resident from his/her wheelchair to his/her low bed in the following way: – Loosely placed a gait belt around the resident’s waist; – Placed a forearm on each side of the resident under the resident’s arms and grabbed the gait belt; – As the CNA lifted, turned and lowered the resident from the wheelchair to the low bed, the gait belt and resident’s shirt raised at least eight inches around the resident’s abdomen, back and sides, The CNA’s forearms raised under the resident’s armpits and raised the resident’s shoulders; – The resident did not assist with the pivot transfer. During an interview on 1/10/19 at 2:01 P.M., CNA D said: – He/she put the gait belt on the resident around the waist and loose enough he/she could place both hands under the gait belt; – When the gait belt rose, he/she should stop, reposition and tighten the gait belt; – The resident did not help with the transfer, because he/she was paralyzed on the left side. During an interview on 1/14/19 at 12:53 P.M., the Interim Director of Nurses (IDON) said: – She expected staff to place the gait belt snugly around the resident’s waist, tight enough it would not slide up on the resident; – If the gait belt slid up, staff should stop, reposition the gait belt and tighten it more; – Staff should never place their arms under the resident’s arms and should not place the gait belt on bare skin. 3. Review of the facility’s, undated, policy for Gait Belt Use showed: – Assist the resident at the waist rather than pulling his/her arms or shoulders; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 15) – Make sure the gait belt is never next to bare skin. Review of Resident #6’s MDS, dated [DATE], showed: – Able to make daily decisions: – Dependent on staff for transfers. Observation and interview on 1/11/19 at 9:58 A.M., showed CNA B and CNA D assisted the resident to transfer from his/her bed to a wheelchair. CNA B said staff used a pivot disc with the resident, because the resident’s left foot did not work. Both staff assisted the resident to sit up on the side of the bed, the resident wore a hospital gown that was open in the back. CNA B placed the gait belt on the resident and tightened it around the resident’s waist. The gait belt laid against the resident’s bare back. Both staff placed their forearms under the resident’s arms and grabbed the gait belt at the resident’s back. When staff transferred the resident, both their forearms raised under the resident’s armpits as the gait belt rose. CNA D said he/she should not have had the gait belt on the resident’s bare skin. During an interview on 1/14/19 at 12:53 P.M., the Interim Director of Nurses (IDON) said: – She expected staff to place the gait belt snugly around the resident’s waist, tight enough it would not slide up on the resident; – If the gait belt slid up, staff should stop, reposition the gait belt and tighten it more; – Staff should never place their arms under the resident’s arms and should not place the gait belt on bare skin. 4. Review of the facility’s Preventive Maintenance Checklist and Inspections showed staff was to conduct weekly random room checks, per wing, for proper hot water temperatures. The water temperatures should be between 105 and 120 degrees Fahrenheit (F) per regulations. Observation on 1/8/19 at 4:30 P.M., showed resident room [ROOM NUMBER]’s hot water temperature at 121.7 degrees F. Observation, interview and record review on 1/8/19 at 5:30 P.M., showed: – The Administrator checked water temperatures that showed, resident room [ROOM NUMBER]’s water temperature were 123.4 F and the front entry women’s restroom water temperature was 122.5 F. She also found resident room [ROOM NUMBER]’s water temperature at 123.4 F. – The Administrator checked the hot water heater and it showed the temperature set at 120.2 F. – Review of the Facility Water Temperature Log, showed staff last checked facility water temperatures on 12/7/18. – The Administrator said water temperature checks should be conducted weekly. The former Maintenance Supervisor (MS) was responsible to conduct water temperature checks. She temporarily took on the MS responsibilities. She forgot to conduct weekly checks of water temperatures. The temperature in resident rooms 214, 219 and the front women’s restroom was too high and could potentially burn someone. | |
| F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) care and catheter bag and tubing placement, to prevent urinary tract infections for one resident (Resident #20). The facility census was 38. Review of the facility’s procedure from the 2001 Nurse Assistant in a Long Term Care Facility for Steps for Giving Peri Care with Catheter, showed: – Check the catheter and drainage bag for leaks, kinks, level of bag, color and character of urine; ensure that it is securely attached to the bed; – Separate all perineal folds and provide peri care; – Clean around the insertion site of the catheter; – With a clean cloth wash the catheter tubing from the insertion site outward at least four inches. Do not pull the catheter tubing. 1. Review of Resident #20’s medical record showed a laboratory report dated 8/27/18, that showed many bacteria consistent with a urinary tract infection [MEDICAL CONDITION]. Review of the resident’s Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/9/18, showed: – Some difficulty with decision making skills; – Required extensive assist with toilet use and personal hygiene; – Suprapubic catheter (type of urinary catheter that empties the bladder through an incision in the abdomen instead of a tube inserted in the urethra); – Occasionally incontinent of urine and frequently incontinent of bowel. Review of the resident’s undated care plan, showed: – The resident needed two staff to assist with toilet use; – The resident could be incontinent of the bladder even though he/she had a catheter; – The resident needed catheter care done every shift; – The resident takes medication for bladder spasms, but can still urinate through the urethra; – Assess for signs and symptoms of a UTI. Observation and interview on 1/8/19 at 9:54 A.M., showed the resident sat in a wheelchair in his/her room and watched television. The catheter tubing, with yellow brownish colored urine, lay on the floor under the wheelchair. The resident said he/she had frequent UTIs and bladder spasms. His/her physician recently injected [MEDICATION NAME] to help with the urine leaking from the urethra, but he/she did not know if it worked, because he/she still had a lot of bladder spasms. Night shift staff often forgot to empty his/her urinary drainage bag. Observation on 1/8/19 at 12:20 P.M., showed the resident in the main assist dining room in his/her wheelchair. Both the dignity bag that contained the urinary drainage bag and the drainage tubing lay on the floor. Observation on 1/10/19 at 8:51 A.M., showed the resident in the main assist dining room in his/her wheelchair. Both the dignity bag that contained the urinary drainage bag and the drainage tubing lay on the floor. Observation on 1/10/19 at 1:28 P.M., showed Certified Nurse Aides (CNA) A and D transferred the resident from his/her wheelchair to bed and to provide catheter care. While the resident sat in his/her wheelchair, CNA D hung the urinary drainage bag on his/her waist pocket which was as high as the resident’s chest, then transferred the resident into a low bed. CNA A told CNA D he/she needed to keep the drainage bag below the resident’s bladder. CNA D used an alcohol wipe and cleaned the resident’s abdominal insertion site around the tubing. With the same alcohol wipe, CNA D wiped down the catheter tubing. The resident did not wear a leg strap to help secure the catheter tubing in place. During an interview on 1/10/19 at 2:00 P.M., CNA D said: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 17) – The resident should have had a STAT lock or leg strap to secure the tubing, so it did not get pulled; – He/she should clean around the site in the resident’s belly, then wipe down the catheter tubing; – He/she should use an alcohol wipe to clean around the insertion site and down the catheter tubing. He/she should not have used the same alcohol wipe for both areas. Observation on 1/14/19 at 10:25 A.M., showed the resident sat in his/her wheelchair in the hallway outside his/her room. The catheter tubing and the dignity bag that contained the urinary drainage bag dragged on the floor. The resident propelled down the hallway towards the assist dining room. Nursing staff were in the hallway as the resident wheeled by them. During an interview on 1/14/19 at 12:53 P.M., the interim Director of Nursing said: | |
| F 0710 Level of harm – Immediate jeopardy Residents Affected – Few | Obtain a doctor’s order to admit a resident and ensure the resident is under a doctor’s care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0710 Level of harm – Immediate jeopardy Residents Affected – Few | (continued… from page 18) nurses’ P/P book. – She said she would put a copy of the policy in the nurses’ P/P book. Review of Resident #19’s care plan, dated 7/19/18, showed: – The resident was at risk for bleeding or bruising because of an anticoagulant medication to treat his/her risk of blood clots. – The goal was to be free from complications from unusual bleeding. – Interventions – [MEDICATION NAME] to prevent blood clots, PT/INR labs as ordered, help the resident avoid sudden bumps or jarring to prevent bruising, report new areas of bruising to the charge nurse, immediately report to the charge nurse any bleeding from the nose or gums, rust or amber colored urine, dark black, tarry stools, pale and clammy skin, or any weakness. If the resident reported any rectal bleeding, notify the charge nurse immediately. Review of Physician A’s order report, dated 8/28/18 through 9/28/18, showed: – The resident’s [DIAGNOSES REDACTED]. During an interview on 1/11/19, at 11:15 A.M., Physician A said: – Initially, the resident was on an anticoagulant that did not require lab monitoring. – When the resident’s insurance would not pay for that mediation, he/she switched the resident to [MEDICATION NAME] (an anticoagulant that required routine laboratory monitoring). – Physician A said he/she did not pick- up on the fact that the resident did not have an order for [REDACTED].>- Physician A said he/she just missed it, but expected that probably the pharmacy consultant should have caught the fact that the resident did not have a monthly PT/INR lab order. – Physician A said the resident should have a monthly PT/INR lab order. During an interview on 1/15/19, at 10:40 A.M., Registered Nurse (RN) A said: – The facility switched from Pharmacy A to Pharmacy B in (MONTH) (YEAR). During an interview on 1/14/19, at 9:20 A.M., Pharmacy B’s consulting pharmacist said: – He/she did the facility’s medication consults every month, made medication recommendations, and was a second or third set of eyes, but their pharmacy’s computer system did not interact with the facility’s electronic medical records (EMR). – Since, the pharmacy’s computer system did not have access to the facility’s EMR physician’s orders [REDACTED]. – Usually, the current month’s POS were not on the chart when he/she did the review. – Whenever he/she saw a [MEDICATION NAME] order, he/she checked for an INR. He/she checked the most recent INR to see that it was in a reasonable range and if not, he/she checked to see that staff notified the physician. – Sometimes, lab results were not in the chart. If labs were not in the charts, then he/she did not see them and did not know about them. – He/she was not saying a resident might not fall through the cracks, but typically, he/she checked for the INR. – If a resident was on [MEDICATION NAME], he/she checked to ensure the resident was not on aspirin or any blood thinner. If the resident was on [MEDICATION NAME] and aspirin or [MEDICATION NAME] he/she made a recommendation to the physician about the aspirin or [MEDICATION NAME]. Record review of faxes staff sent to Physician A, dated 10/10/18, and 10/11/18, showed: – 10/10/18, the insurance would not pay for the resident’s current anticoagulant. – 10/11/18, the resident wanted to stay on an anticoagulant and was aware he/she would be back on [MEDICATION NAME] and have blood drawn for PT/INR. Review of Physician A’s telephone orders (TO) showed: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0710 Level of harm – Immediate jeopardy Residents Affected – Few | (continued… from page 19) – An order, dated 10/11/18, for [MEDICATION NAME] 2 milligram (mg) tablet, daily at 5:00 P.M. and a PT/INR one week from the start date of [MEDICATION NAME]. – An order, dated 10/24/18, to recheck the PT/INR on Friday 10/26/18. Review of the resident’s Medication Administration Record [REDACTED] – Staff initialed the MAR indicated [REDACTED]. Record review of the resident’s laboratory test results, dated 10/19/18, showed: – PT of 26.3 seconds and an INR of 2.6; – A handwritten notation that the resident was on [MEDICATION NAME] 2 mg daily; – A physician’s orders [REDACTED]. Record review of the resident’s laboratory test results, dated 10/26/18, showed: – PT of 24.8 seconds and an INR of 2.5; – A handwritten notation showed faxed 10/26/18. Review of the nurses’ notes showed: – 10/24/18 – new order to recheck PT/INR on Friday, 10/26/18. – From 10/26/18 until 1/9/19, no staff documentation of contacting the physician about the resident’s 10/26/18, PT/INR results and no reference of any new PT/INR order. During an interview on 1/14/19, at 11:30 A.M., Laboratory A’s Client Service Representative said: – His/her records showed 10/26/18, was the resident’s most recent PT/INR. – Laboratory B took over the long-term care accounts. During an interview on 1/14/19, at 11:13 AM, Laboratory B’s Customer Service Representative said: – They took over the facility’s lab testing account in (MONTH) (YEAR). – They did not do any lab tests for the resident in (MONTH) (YEAR). – The first lab they did for the resident was on 1/10/19. During an interview on 1/11/19, at 3:23 P.M. RN A said: – Staff just did not follow up with Physician A about the 10/26/18, PT/INR results. – Even when Physician A was out of town, he/she called every day to check on the residents. Physician A gave staff a cell number to make sure staff could contact him/her. – Usually when staff contacted Physician A with the PT/INR results, he/she gave the order for the next PT/INR. – Physician A always responded to a fax or telephone call. Review of the resident’s November, (YEAR) and (MONTH) (YEAR), POS showed: – [MEDICATION NAME] 2 mg daily at 5:00 P.M. – No PT/INR lab orders to monitor the effect of the [MEDICATION NAME]. Record review of the resident’s MAR, dated (MONTH) (YEAR) and (MONTH) (YEAR), showed: – In (MONTH) (YEAR), staff initialed the MAR indicated [REDACTED]. Staff documented the [MEDICATION NAME] was not available on seven of the 30 days. – In (MONTH) (YEAR), staff initialed the MAR indicated [REDACTED]. Review of Pharmacy B’s drug regimen reviews, dated 10/18/18, 11/20/18, and 12/18/18 showed: – No recommendations related to [MEDICATION NAME] or for laboratory tests to monitor the effect of the [MEDICATION NAME]. Review of the resident’s quarterly Minimum Data Sets (MDS), a federally mandated assessment completed by facility staff, dated 1/6/19, showed: – Staff scored the resident as 14, out of a possible 15 (cognitively intact), for the brief interview for mental status (BIMS). Review of the resident’s POS for (MONTH) 2019, showed: – [MEDICATION NAME] 2 mg daily at 5:00 P.M. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0710 Level of harm – Immediate jeopardy Residents Affected – Few | (continued… from page 20) – No order for PT/INR to monitor the effect of the [MEDICATION NAME]. Record review of the resident’s MAR, dated (MONTH) 2019, showed: – Staff initialed the MAR indicated [REDACTED]. Observation and interview on 1/8/19, at 9:17 A.M., showed: – The resident had a large purple bruise on the back of his/her right hand. – The resident was not sure how he/she got the bruise, but said he/she bruised really, easily. – He/she had a bruised toe and was not sure how that happened. During an interview and record review on 1/9/19, at 11:20 A.M., the Interim Director of Nursing (IDON): – Handed the surveyor the PT/INR, dated 10/26/18, and said this is the resident’s most recent PT/INR. – Said she just had staff contact the physician and received orders for a PT/INR and a routine monthly PT/INR. Review of a fax to Physician A, dated 1/9/19, showed: – The resident had bruising of arms and a bloody nose. The resident was concerned that his/her INR was high. The resident has not had a PT/INR done since 10/26/18, and is on [MEDICATION NAME] 2 mg daily. – A notation on the bottom of the fax showed order received. During an interview on 1/14/19, at 9:30 A.M., and 1/15/19 at 3:12 P.M., Licensed Practical Nurse (LPN) A said: – No one told him/her to check residents’ orders to see if they had lab orders when on an anticoagulant. – He/she did not know anything about a policy stating a resident with an order for [REDACTED]. During an interview on 1/14/19, at 10:30 A.M., the IDON said: – She worked at the facility for about 3 months last year and then came back in (MONTH) (YEAR), as the MDS coordinator. – About the middle of (MONTH) (YEAR), she became the IDON along with being the MDS coordinator. – She did not know anything about the automatic stop date policy. – The IDON said she had never seen that policy and was never told that a nurse should check to see that there were routine labs ordered when a resident was on [MEDICATION NAME]. – Usually, physicians gave orders to check the PT/INR for residents on [MEDICATION NAME] and then gave the next lab order when staff sent them the results. During an interview on 1/14/19, at 10:50 A.M., RN A said: – He/she did not know anything about an automatic stop date policy that required routine labs for any resident on [MEDICATION NAME]. – He/she was not told that nurses should check that residents on [MEDICATION NAME] had a routine PT/INR order. During an interview on 1/14/19, at 1:20 P.M., LPN A said: – After staff send a fax to a physician, they put the fax on a clipboard until the physician responded. – Physician A usually called the staff with orders when he/she received the fax. – Even when Physician A was out of town he/she called the facility every day. Review of RN A’s nurse’s notes, dated 1/9/18 and 1/10/19, showed: – 1/9/19, at 11:00 A.M., fax sent to Physician A regarding a lapse in the resident PT/INR lab work, resident bruising easily, and resident had bloody nose. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0710 Level of harm – Immediate jeopardy Residents Affected – Few | (continued… from page 21) -1/9/19 at 12:21 P.M., call received from Physician A with orders to draw PT/INR tomorrow and monthly. – 1/9/19 at 12:30 P.M., informed resident of orders. During an interview on 1/11/19, at 3:35 P.M., RN A said about 5:00 P.M., last evening the lab staff called with the resident’s critical lab value. He/she called Physician A, who gave orders to hold the [MEDICATION NAME] from last night until Tuesday and then repeat the PT/INR on Tuesday. Record review of the resident’s laboratory test, dated 1/10/19, showed: – PT flagged as high at 67.3 seconds with an INR flagged as a critical high at 6.2. Review of RN A’s nurse’s notes, dated 1/9/18 and 1/10/19, showed: – 1/10/19 at 4:00 P.M., received call from lab with critical values of PT 67.3 and INR of 6.2 – 1/10/19, at 4:10 P.M., called Physician A and received orders to hold [MEDICATION NAME] until Tuesday and recheck PT/INR on Tuesday. During an interview on 1/11/19, at 2:14 P.M., the resident said: – A couple of days ago, he/she had a bloody nose. His/her nose just started bleeding, but then stopped. – The resident said when he/she coughed this morning there was blood in the tissue. He/she had the nurse check and the nurse said it was blood. During an interview on 1/11/19, at 3:23 P.M. RN A said: -The resident coughed up some dark blood this morning, but not much, just like two or three strands of blood. – RN A said the blood was not bright red, it was dark blood. – RN A told the resident that since his/her PT/INR was so high that his/her gums would probably bleed if he/she brushed his/her teeth. – He/she did not assess the resident, because it was just a small amount of blood. During an interview on 1/11/19 at 2:30 P.M., the Administrator said: – Physician A usually called staff in response to a fax. – She expected staff to follow up with a physician, by the next day, if the physician did not respond to a fax. – She expected the nurses to review the POS monthly to ensure any resident on an anticoagulant that required monitoring had routine lab orders. Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, record review, and interview completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. During the onsite visit, the facility staff immediately began in-servicing all nurses, prior to the start of their shift, that all residents with orders for [MEDICATION NAME]/[MEDICATION NAME] must have orders for a routine PT/INR monitoring on their POS and in the lab draw computer system. On 1/14/19, the DON added the PT/INR orders to the resident’s POS. The Administrator, DON, or designee will train all newly hired nurses, during their initial orientation that all anticoagulants requiring lab monitoring are to have an order for [REDACTED]. All new admissions and re-admissions orders will be reviewed within 24 hours of admission to ensure the POS reflected the order for lab monitoring. The DON created an anticoagulation therapy tracking log. The DON, Administrator, or designee will monitor all residents on anticoagulants requiring lab monitoring weekly with the anticoagulation therapy log for 90 days to ensure that the appropriate labs orders are on the POS and are being followed. After those 90 days, the DON, Administrator, or designee will monitor anticoagulants monthly to ensure that appropriate labs are put on the POS and are being followed. All |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0710 Level of harm – Immediate jeopardy Residents Affected – Few | (continued… from page 22) above corrective actions will be discussed and addressed at the next all staff in-service along with annual state survey findings, and in the next quarterly QAA meeting, scheduled for 1/23/19. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity level was lowered to a D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address a Class I violation | |
| F 0732 Level of harm – Potential for minimal harm Residents Affected – Many | Post nurse staffing information every day. Based on observation, interview, and record review, the facility failed to post the nurse | |
| F 0744 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0744 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 23) and so all activities provide meaning for the residents. – Wandering is a part of this disease and that is okay in the SCU. Review of the facility Resident Activities policy dated 3/2012 showed: – The Activities Services of each facility will plan, organize and carry out a program of activities to meet individual resident needs. The program is designed to give resident entertainment, communication, exercise, relaxation and an opportunity to express their creative talent. Through the activities, residents can fulfill basic psychological and social needs. – All staff are responsible for assisting residents to activities of their choice. – An activity program is planned for each resident as part of their total resident care by the Activity director (AD). Residents shall be encouraged to participate in activities of choice. An individualized program will be implemented for residents unable to participate in or attend activities. 1. Review of Resident #13’s quarterly review Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/16/18, showed: – Minimal difficulty hearing. – Speaks clearly. – Responds adequately to simple direct communication only. – Moderately impaired vision. – Severely impaired skills for daily decision making. – [DIAGNOSES REDACTED]. Review of the residents undated care plan showed: – He/she was a retired farmer and tractors were his/her [MEDICATION NAME]. – He/she had impaired vision due to [MEDICATION NAME] degeneration in his/her left eye. He/she needed large print to read. – He/she had impaired thinking and recall and was at risk for impaired communication because of his/her Alzheimer’s dementia and being hard of hearing. – Staff to ask the resident about preferences throughout the day. Staff to remember he/she was forgetful and needed frequent cues and reminders. – He/she was at risk for social isolation because of his/her poor vision, agitation and being recently widowed. Staff to check with the resident daily about activities. He/she needed staff supervision to get to and from activities. He/she liked to stay in bed between meals and needed staff to provide a lot of encouragement for him/her to participate in activities. It was okay for the resident to sit in the common sitting area to watch television and visit with staff and peers. He/she liked to do simple trivia, to tell stories and reminisce. He/she was interested and collected tractors. He/she used to like to play bingo, checkers, dominoes, poker, solitaire and horseshoes. He/she liked to listen to country music. He/she liked to watch old television shows and movies, especially westerns. Observations of the resident on 1/8/19, showed: – At 10:15 A.M., the resident lay in bed. – At 12:02 P.M., resident sleeping in bed with food tray positioned on a bedside table next to him/her. Staff woke resident up and verbally encouraged him/her to eat. The resident sat up at bedside began eating and the staff left the residents room. During an interview on 1/8/19 at 1:30 P.M., Certified Nurse Aide (CNA) D and CNA I said during the day shift, the resident normally slept a majority of the time. Observation on 1/8/19 at 5:32 P.M., showed the resident lay in bed. Observation of the resident on 1/9/19 at 8:20 A.M., showed the resident lay in bed with food tray partially eaten on a bedside table next to him/her. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0744 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 24) During an interview on 1/9/19 at 9:46 A.M., the resident’s family members (FM) B and FM C said staff do not interact with the resident. They leave him/her in bed all the time and do not try to engage him in anything. It is hard for him/her to participate if staff do not engage or encourage him/her to get involved. There is no quality of life for the resident due to lack of staff attention. The resident spends his/her days in bed and eats at bedside. Staff never turn the television on for the resident or visit with him/her. The resident needed activities for stimulation. The family provided a CD music player with country music CD’s in the resident’s room. The family has never observed staff set up the CD player for the resident to hear the music. The resident’s life consisted of him/her eating, staring at the wall and no one interacting with him/her. Observations of the resident on 1/9/19, showed: – At 10:48 A.M., the resident was lay in bed. – At 5:25 P.M. the resident lay in bed. Observation on 1/10/19 at 5:50 A.M., showed the resident lay in bed with water and crackers at bedside. The resident sat up, said he/she would eat breakfast and then laid back down. In an interview on 1/10/19 at 5:52 A.M., CNA K said during the night shift, the resident normally got up every two hours for only two to five minutes to get snacks, drinks and use the toilet then lays back down in bed. Observation on 1/10/19 at 5:58 A.M., showed the resident lay in bed. In an interview on 1/10/19 at 1:53 P.M.: – Certified Med Tech (CMT) C said during the day shift the resident remained in bed the majority of the time. The resident got up a couple times a day for about four minutes to wonder up the corridor, to get a sandwich and look for his/her spouse. Staff assisted the resident up and down the corridor. The resident’s favorite activity was to eat and sleep. – CNA L said the resident roams, but due to the resident’s poor vision and being hard of hearing he/she is not able to see or hear what is showing on the television. Staff are not able to visit with the resident one on one in his/her room due to the care needs of the other residents on the SCU. During an interview on 1/10/19 at 2:30 P.M., CNA F said four months ago, he/she began working on the SCU during the facility evening shift. The resident normally only got up and walked 10 to 15 minutes during the eight-hour shift. Staff assisted the resident to toilet, to get a snack and to set up his/her food tray at bedside for supper. The resident did not like group activities. The resident did not see well enough to do puzzles. The resident enjoyed visiting, but staff were not always able to offer the resident activities due to other resident behaviors. He/she thought the resident needed more activities that would encourage him/her to get up out of bed and give the resident a better quality of life. In an interview on 1/10/19 at 2:58 P.M., CNA H said the resident refuses to come to the SCU common area for supper stating he/she does not know anybody and he/she misses his/her spouse. In an interview on 1/10/19 at 3:12 P.M., the Interim Director of Nursing (IDON) said in the past three months during her daily visiting on the SCU, she has only seen the resident out of bed twice. Even when she administers the resident his/her medications the resident sits at bedside and lays back down. In an interview on 1/11/19 at 5:00 A.M., CNA M said he/she normally worked the SCU night shift. The resident’s activities during the night shift, consisted of sleeping, eating snacks, drinking soda and coming out to the corridor to get assistance to the toilet. The total time the resident is up is sporadic, but is approximately two to three hours. No |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0744 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 25) activities are provided to the resident during the night shift. The resident just stayed in his room, drank soda and ate snacks. The resident rarely walked the corridor but did sometimes just to have something to do. The resident stayed to him/herself. In an interview on 1/11/19 at 9:20 A.M., Social Services (SS) said Resident #13 was just existing on the unit. The resident had no quality of life. The resident preferred to stay in his/her room. Staff were not able to provide one on one activity for the resident as they had to meet other resident care needs. 2. Review of the facility SCU activity calendar showed on 1/9/19 at 10:00 A.M., Sit Dancing was scheduled. Observation on 1/9/19 at 10:00 A.M. showed staff did not offer SCU residents Sit Dancing. 3. In an interview on 1/10/19 at 1:53 P.M., CMT C and CNA L said there were not many activities on the SCU. They offer residents coloring, but the residents do not like it. They did not have activities specifically for men. They painted female residents nails. Two weeks ago, they complained to the AD and the SS that they did not have enough materials or creative activities to provide the SCU residents. The SCU was only staffed with a CNA and CMT who stayed on the unit. The CMT tried to assist the CNA with activities, but the SCU was hectic due to some residents who are aggressive, while others are wandering with other residents being a potential fall risk. With all the residents having different needs at the same time, they were not able to keep the residents occupied. They did not have the correct activities and activity materials to keep the residents engaged and occupied. The AD told them funding for activities was limited. In an interview on 1/11/19 at 5:00 A.M., CNA M said he/she normally worked the SCU night shift. No activities were provided on the SCU during the night shift. He/she attempted to come up with stuff to occupy residents who are up in the common area during the shift. He/she was unaware of activity care plans for the SCU residents and had not used them. In an interview on 1/11/19 at 9:20 A.M., the SS said for the last couple of months she was aware that SCU activities are not stimulating enough for the residents. Staff are concerned about the activity needs of the residents. SCU activity schedule was separate from the rest of the facility. The SCU is assigned two staff. In order for the two staff to manage resident care needs, they are not able to provide the residents with stimulating activities. More needed to be done to keep the residents on the unit occupied with appropriate activities. The facility needed more activity resources. The staff needed training on providing activities for the needs of residents with dementia diagnoses. The AD was kept busy with other facility services and not able to provide the SCU activities. In an interview on 1/11/19 at 12:00 P.M., the AD said she had many responsibilities in providing facility services. She was not able to spend much time on the SCU for activities. The two staff assigned on the unit were to provide the activities, but were kept too busy with the care needs of the residents preventing them from providing activities. The SCU should have staff assigned to specifically provide for the activity needs of the residents. In an interview on 1/11/19 at 12:10 P.M. and 1/14/19 at 2:25 P.M., the administrator said: – If staff say they are not able to provide activities for the SCU residents, then the facility system should be changed to ensure staff provided quality activities for the residents. – If the facility improved on providing SCU residents with activities that kept residents interested it could correlate in less resident behavior problems that are due to resident boredom. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0744 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | ||
| F 0755 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** | |
| F 0800 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, record review and interview, the facility failed to consider the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 0800 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 27) -He/she did not wear his/her dentures and has requested staff to meat chop his/her meat, but they did not. Observation on 1/09/19 at 08:34 AM showed: -The resident ate breakfast, pancakes, oatmeal and sausage; -The sausage was not chopped. During an interview on 1/11/19 at 09:06 AM the Director of Nursing said the resident had never mentioned wanting his/her food chopped. During an interview on 1/10/19 at 2:08 P.M. Cook A said the speech therapist would send a communication log regarding resident’s mechanical diets. He/she was not aware of any for the resident. During an interview on 1/11/19 at 09:51 AM the Dietary Manager said: -The resident had not asked her to have his/her meat chopped; – She completed food assessments on all new admissions to determine residents’ preferences; -She was unable to find an assessment completed for the resident. | |
| F 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on interview and record review, the facility failed to obtain the Registered | |
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to provide for food |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 – Many | (continued… from page 28) Resident #7 ate two eggs cooked over-easy daily. The DM then covered the eggs with foil and sat them on top of the oven. The DM said sometimes she cooked over-easy eggs for Resident #21. She was unaware if the eggs were pasteurized or not. In an interview on 1/10/19 at 8:00 A.M., the Administrator said she would check egg invoices to see what type of eggs staff used in the kitchen. During interview and record review on 1/10/19 at 11:09 A.M. and 3:30 P.M. and 1/11/19 at 10:44 A.M., the administrator showed the facility food order invoice had large Grade A eggs. The Administrator said the eggs were not pasteurized. Over the last six months, the DM was in charge of the kitchen. Since this morning’s breakfast, she found that the DM did not know she was not to serve residents non-pasteurized eggs. The DM told the administrator, she served residents soft eggs, fried eggs and egg sandwiches daily. The Administrator instructed the DM she was only allowed to serve residents pasteurized eggs. The facility did not have a policy on the use of non-pasteurized eggs. She expected kitchen staff to serve only eggs that are pasteurized to residents for resident safety. Non-pasteurized eggs had the potential to cause Salmonella poisoning. 3. Observation and interview 1/08/19 at 9:11 A.M., of the kitchen walk in refrigerator showed: – A container marked chicken casserole dated 12/26. – A substance wrapped in undated foil marked ham slices positioned above dishes of strawberry shortcake and apple sauce, that dripped with liquid when lifted. – An undated container of what the DM said appeared to be spinach. – Uncovered cheese slices. – A plastic bag of undated hot dogs. – Three unlabeled squeeze bottles appearing to contain salad dressing. – Two undated squeeze bottles of barbeque sauce. – Two undated loosely covered pies, with one of the pies partially eaten. – Undated coleslaw. – The DM said staff were to store meat/meat products on trays to prevent cross contamination of other foods. Staff were to store foods that were not in the original packaging in a labeled, dated, sealed plastic bag. Staff was to discard all food that was unsealed from original packaging after three days. Staff should have labeled the opened coleslaw to show the third day after they opened it. When staff put the sauces and dressings in the squeeze bottles they should have labeled the bottles showing contents and discard date. Observation on 1/08/19 at 11:03 A.M., showed an undated squeeze bottle of barbeque sauce in the special care unit refrigerator. 4. Observations on 1/10/19 at 8:37 A.M., showed the DM: – Placed uncovered bread directly on the counter top to prepare toast. – Used gloved hands to pick up bacon, toast, biscuits, ladles, push food carts in the kitchen and out into the dining room without washing her hands between touching food products, ladles and carts. In an interview on 1/10/19 at 9:17 A.M., the DM said for kitchen sanitation; – All kitchen staff were to wash their hands between food contact, between tasks, when they touched something and when they leave the kitchen. – During today’s breakfast preparation, she should have used utensils instead of her hands to pick up food. She should have used a cutting board instead of the counter surface to make toast. She should have washed her hands before leaving the kitchen. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265729 |
| (X3) DATE SURVEY COMPLETED 01/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER DAVIESS COUNTY NURSING AND REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1337 WEST GRAND | |||||||||
| 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 – Many | ||
| 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** | |
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