| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** | |
| F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure each resident receives an accurate assessment. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) 1. Record review of Resident #3’s quarterly MDS dated , 4/8/19, showed a [DIAGNOSES REDACTED]. Record review of the resident’s physician’s orders [REDACTED]. During an interview on 5/9/19 at 12:01 P.M., the MDS coordinator said the MDS was completed by the previous MDS coordinator and was not sure what happened. During an interview on 5/9/19 at 12:15 P.M., the Chief Nursing Officer (CNO) said the resident does not have a [DIAGNOSES REDACTED]. 2. Record review of Resident #15’s Admission MDS, dated [DATE], showed the Pre-Admission Screening and Resident Review (PASARR) marked no for screened for mental disorder or intellectual disability. Record review of the resident’s medical chart showed the PASARR completed on 8/7/17. During an interview on 5/9/19 at 2:00 P.M., The MDS coordinator said she was new to the position and did not know she was to mark that section of the MDS. She said she would get it corrected. During an interview on 5/9/19 at 4:30 P.M. the CNO said the MDS coordinator did not realize the PASARR was the same as the DA-124 review. She said the MDS coordinator would get this corrected. | |
| F 0645 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | PASARR screening for Mental disorders or Intellectual Disabilities **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** | |
| F 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) Record review of baseline care plan for Resident #17 showed: – The baseline care plan form undated and no information. 2. Record review of Resident #5’s admission orders [REDACTED] – [DIAGNOSES REDACTED]. Record review of the baseline care plan for Resident #5 showed: – No signature of resident or representative; – No documentation that a written summary given to resident and representative. During an interview on 5/9/19 at 10:00 A.M., Licensed Practical Nurse (LPN) C said: – He/she did not know the resident and representative should be given a written summary of the baseline care plan; – The baseline care plan for Resident #17 had just been missed. During an interview on 5/9/19 at 10:05 A.M., the MDS Coordinator said: – He/she did not know the resident and representative were supposed to receive a written summary of the baseline care plan; – The baseline care plan for Resident #17 had apparently just been missed. Record review of the facility’s undated Resident Plan of Care showed: – A temporary plan of care will be developed as a result of assessments from nursing, activities, social services and dietary; – Nursing personnel will utilize the temporary plan of care for the first fourteen days, or until the comprehensive care plan is completed; – A care card/temporary care plan will be kept on all residents; – A temporary care plan will be completed on all new admissions to be used until the comprehensive care plan is in the resident’s medical record. | |
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) self. 4. Record review of Resident #8’s MDS, showed: – An annual MDS completed on 6/28/18; – Quarterly MDS completed on 1/0419 and 4/08/19. Record review of the care plan, dated 2/26/19 showed: – [DIAGNOSES REDACTED]. – The resident smokes, and independent in eating, transferring, and ambulating, resist care and is verbally abusive. 5. Record review of Resident #13’s MDS, showed: – An annual MDS completed on 10/25/18; – Quarterly MDS completed on 1/25/19 and 4/29/19. Record review of the care plan, dated 2/26/19 showed: – [DIAGNOSES REDACTED]. – Can make routine daily decisions, impaired communications, at risk for falls, diet for no concentrated sweet (NCS) pureed meats. 6. Record review of Resident #14’s MDS, showed: – An annual MDS completed on 7/30/18; – Quarterly MDS completed on 1/29/19 and 5/2/19. Record review of the care plan, dated 4/4/19 showed: – [DIAGNOSES REDACTED]. – Needs assistance of one for bathing, dressing, and grooming, at risk for falls, history [MEDICAL CONDITION], pain, diet for low residue (low fiber), snacks three times a day, Ensure once daily with lunch, and potential for skin breakdown. 7. Record review of Resident #22’s MDS, showed: – An annual MDS completed on 3/26/19; – Quarterly MDS completed on 9/25/18 and 1/4/19. Record review of the care plan, dated 3/21/19 showed: – [DIAGNOSES REDACTED]. – Regular diet with no fried foods, impaired decision making skills, depression, potential for nutritional risk, uses tobacco products, and potential for psychosocial distress. During an interview on 5/9/19 at 9:40 A.M. the Social Services Director (SSD) said: – He/she sent invitation to the resident’s representative, but not to the resident; – He/she just didn’t get a chance to invite the resident. Record review of the facility’s Resident Plan of Care policy, revised on 10/2015 showed: – The Comprehensive Care Plan will be reviewed on a scheduled quarterly basis or more frequently as needed upon change of condition or per family’s request; – The Long-Term Care Plan of Care Team (DON, Dietary, Restorative Aides, Social Services, LPN and CNA) will meet weekly to review all residents scheduled and other residents with any change of condition; – The resident’s significant other (s) will be included in the plan of care process; – Nursing team members will attend care plan meetings for the residents they are assigned, and they will sign an attendance sheet to validate participation. | |
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Based on observation, interview, and record review, the facility failed to assess and complete quarterly smoking assessments for six residents (Resident #3, #9, #11, #19, #21, and #22) out of 6 sampled residents. The facility census was 24. Record review of the facility’s policy on Resident smoking, dated 2/2018 showed: – Smoking shall be prohibited in all enclosed areas of the Long-Term Care Unit except for; – One indoor designated smoking area, one on the west wing; – One outside designated smoking area on the north side of the west wing; – All smoking items must be kept at the Nursing Station, including but not limited to cigarettes, cigars, lighters, matches, and any other smoking paraphernalia; – If resident has a smoking assessment completed and is deemed capable for independent smoking, he or she may smoke in the designated outside area unsupervised at his or her discretion. 1. Record review of Resident #3’s smoking assessment completed 4/25/18, showed resident exhibits cognitive ability to smoke independently. Record review of the resident’s care plan, dated 2/27/18, showed the smoking assessment is to be completed on admission and quarterly thereafter. Record review of the resident’s medical record from 4/25/18 – 5/9/19, showed: – No smoking assessments completed for the resident; – The facility failed to complete quarterly safe smoking assessments for the resident. 2. Record review of Resident #9’s smoking assessment completed 4/25/18, showed resident exhibits cognitive ability to smoke independently. Record review of the resident’s care plan, dated 2/27/18, showed the smoking assessment is to be completed on admission and quarterly thereafter. Record review of the resident’s medical record from 4/25/18 – 5/9/19, showed: – No smoking assessments completed for the resident; – The facility failed to complete quarterly safe smoking assessments for the resident. 3. Record review of Resident #11’s smoking assessment completed 4/28/18, showed the resident does not exhibit cognitive ability to smoke independently. Record review of the resident’s care plan, dated 2/27/18, showed the smoking assessment is to be completed on admission and quarterly thereafter. Record review of the resident’s medical record from 4/25/18- 5/9/19, showed: – No smoking assessments completed for the resident; – The facility failed to complete quarterly safe smoking assessments for the resident 4. Record review of Resident #19’s smoking assessment completed 4/25/18, showed resident does not exhibit cognitive ability to smoke independently. Observation on 5/7/19 and 5/8/19 at 12:30 P.M., the resident sat outside the indoor smoking room waiting for staff to bring the cigarettes. Observation on 5/8/19 at 12:45 P.M., showed staff sitting in the hall at the doorway of smoke room, observing residents smoking. Record review of the resident’s care plan, dated 2/27/18, showed the smoking assessment is to be completed on admission and quarterly thereafter. Record review of the resident’s medical record from 4/25/19 – 5/9/19, showed: – No smoking assessments completed for the resident; – The facility failed to complete quarterly safe smoking assessments for the resident 5. Record review of Resident #21’s smoking assessment completed 4/25/18, showed resident does not exhibit cognitive ability to smoke independently. Observation on 5/7/19 and 5/8/19 at 12:30 p.m. the resident sat outside the indoor smoking room waiting for staff to bring the cigarettes. Record review of resident’s smoking assessment completed 4/25/18, showed resident does not |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) exhibit cognitive ability to smoke independently. Record review of the resident’s medical record from 4/25/19 – 5/9/19, showed: – No smoking assessments completed for the resident; – The facility failed to complete quarterly safe smoking assessments for the resident 6. Record review of Resident #22’s smoking assessment completed 4/25/18, showed resident exhibits cognitive ability to smoke independently. Record review of the resident’s care plan, dated 2/27/18, showed the smoking assessment is to be completed on admission and quarterly thereafter. Record review of the resident’s medical record from 4/25/19 – 5/9/19, showed: – No smoking assessments completed for the resident; – The facility failed to complete quarterly safe smoking assessments for the resident During an interview on 5/9/19 at 12:00 P.M. the Director of Nursing (DON) said she was not aware of the smoking assessments needing to be done on a quarterly basis. During an interview on 5/10/19 at 7:57 A.M. the Chief Nursing Officer (CNO) said they have a policy stating how often the smoking assessments should be completed and thought they did all assessments annually. The CNO was not aware the care plan said they were to be done quarterly. | |
| F 0730 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Observe each nurse aide’s job performance and give regular training. Based on record review and interview the facility failed to conduct at least twelve hours | |
| F 0732 Level of harm – Potential for minimal harm Residents Affected – Many | Post nurse staffing information every day. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0732 Level of harm – Potential for minimal harm Residents Affected – Many | Based on observation, interview, and record review, the facility failed to post the nurse staffing data in a prominent place readily accessible to residents and visitors on a daily basis at the beginning of each shift. The facility census was 24. 1. Observations showed: – On 5/07/19 the nurse staffing data sheet not posted in the facility; – On 5/08/19 the nurse staffing data sheet not posted in the facility; – On 5/09/19 the nurse staffing data sheet not posted in the facility; – On 5/10/19 the nurse staffing data sheet not posted in the facility. During an interview on 5/09/19 at 3:30 P.M. Licensed Practical Nurse (LPN) C said the posting should be on the bulletin board by the front door. LPN C said the Director of Nursing (DON) completes the forms and puts them on the bulletin board, however the form has not been there all week. During an interview on 5/10/19 at 7:45 A.M. the Chief Nursing Officer (CNO) said the staffing sheets are usually posted on the bulletin board and it has not been posted this week. The forms just did not get put up. During an interview on 5/10/19 at 10:45 A.M. the DON said she had the staffing sheets completed for the days of survey, however did not get them hung up this week. Record review of the Nurse Staffing Information facility policy, dated 7/2018 showed: – It is the responsibility of the Director of Nursing or designee to update the staffing plan; – The facility must post the nurse staffing data sheet on a daily bases at the beginning of each shift; – The information must be clear and in a readable format; – The data sheets must be located in a prominent place, readily accessible to residents and visitors. | |
| F 0744 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | 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: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0744 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 7) Observations of the resident on 5/10/19 at 9:30 A.M. and 1:45 P.M. showed: – The resident lay in bed with his/her eyes closed. During an interview on 5/10/19 at 11:45 A.M. the resident said he/she attends the activities that he/she chooses but likes to stay in his/her room. During an interview on 5/9/19 at 2:40 P.M. Licensed Practical Nurse (LPN) C said the resident stays pretty much to himself/herself most of the time. He/she needs re-direction at times, but not very often. During an interview on 5/10/19 at 11:50 A.M. the Director of Nursing (DON) said the family is very involved with the resident and takes him/her out of the facility often. She said the resident is very easily directed and expected the dementia to be addressed on the care plan. Record review of the facility’s care plan policy, dated 10/2015 showed: – It is the responsibility of nursing personnel to participate in the development and implementation of the resident’s plan of care; – A comprehensive care plan will be located in the resident’s medical record and will be accessible to the nursing staff and multi-disciplinary team at all times. | |
| F 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 8) pharmacist had not made any recommendations on the MMR’s. During an interview on 5/10/19 at 10:05 A.M., the Director of Nursing (DON) said she would expect the pharmacist to complete a medication review on an antipsychotic medication and to review the [DIAGNOSES REDACTED]. She said she would expect the physician to the antipsychotic for an appropriate diagnosis. The DON said she could not find any documentation stating there had been any recommendations on these medications to reduce or taper them. Record review of the facility’s policy on Drug Regimen Review, dated 10/2015 showed: – The drug regimen review consist of a review and analysis of prescribed medication therapy and medication use review; – The consultant pharmacist reviews the medications at least monthly; – Findings and recommendations are reported the Administrator, DON, the responsible physician; – The consultant pharmacist documents potential or actual medication therapy problems and communicates them to the responsible physician; – In performing drug regimen review, the consultant pharmacist utilized federal-mandated standards of care, in addition to other applicable standards. | |
| F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) – No attempt by the facility to document an appropriate [DIAGNOSES REDACTED]. Record review of the monthly pharmacy reviews for Resident #10, showed no recommendations for GDR’s since admission (4/25/18). During an interview on 5/9/19 at 2:30 P.M. Licensed Practical Nurse (LPN) C said he/she did not think there had been any recommendations made by pharmacy and no GDR’s had been attempted. During an interview on 5/10/19 at 10:05 A.M., the Director of Nursing (DON) said the pharmacist almost always has no recommendations marked on his reviews. She said the pharmacist should have addressed recommendations to the physician. The DON said she could not find any documentation stating there had been any recommendations on these medications. She said the medications should have been reviewed and an attempt for reduction should have been completed. Record review of the facility’s policy on Drug Regimen Review, dated 10/2015 showed: – The drug regimen review consist of a review and analysis of prescribed medication therapy and medication use review; – The consultant pharmacist reviews the medications at least monthly; – Findings and recommendations are reported the Administrator, DON, the responsible physician; The consultant pharmacist documents potential or actual medication therapy problems and communicates them to the responsible physician; – In performing drug regimen review, the consultant pharmacist utilized federal-mandated standards of care, in addition to other applicable standards. | |
| F 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | 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 observation, interview and record review the facility failed to follow the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0803 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 10) with an unmeasured amount of 2% low fat milk; – FSS A then placed the pureed chips into a pan on the steam table; – FSS A did not have a pureed recipe for the taco beef, tomatoes, lettuce or chips. During an interview on 5/09/19 at 11:10 A.M., FSS B said: – He/she thought that the ground taco beef that was taken from the pan to be pureed was about two or three cups, but was not sure. During an interview on 5/9/19 at 11:12 A.M., FSS A said: – He/she thought the ground taco beef taken from the pan was about two or three cups; – He/she also thought the pureed lettuce, tomatoes, and chips was about two or three cups; – He/she did not puree the shredded cheese, but instead just poured some nacho cheese dip from the can into a small bowl. During an interview on 5/10/19 at 8:00 A.M., the Dietary Manager said: – FSS A was new and has only worked there a few weeks; – He/she could not find a pureed recipe for the lettuce, tomatoes, chips, or shredded cheese. The facility did not provide a policy for following a pureed diet. | |
| F 0807 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0807 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 11) he/she was unsure about the residents liquids, they weren’t thickened yesterday. During an interview on 5/8/19 at 3:45 P.M., the Transportation Clerk (TC) said he/she gives the resident chips, peanut butter and crackers and sodas, he/she also sees the resident going up and down the hall, in and out of resident rooms, eating and drinking anything he/she can get his/her hands on. Observation on 5/8/19 3:45 P.M., showed a mug of water and a bottle of water (regular consistency) in residents room. During an interview on 5/8/19 at 3:55 P.M., LPN C said the resident has been in here this afternoon getting food, graham crackers, two bags of chips and peanut butter crackers and a soda. During an interview on 5/08/19 at 4:00 P.M., the Director of Nursing (DON) said there are issues with the kitchen sending the wrong diet, if a resident has an order for [REDACTED]. During an interview on 5/08/219 at 4:05 P.M., the Dietary Manager said the dietary staff | |
| F 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure therapeutic diets are prescribed by the attending physician and may be delegated |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 12) to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 13) During an interview on 5/8/19 at 3:55 P.M., LPN C said the resident has been in here this afternoon getting food, graham crackers, two bags of chips and peanut butter crackers and a soda. During an interview on 5/8/19 at 4:00 P.M., the Director of Nursing (DON) said there are issues with the kitchen sending the wrong diet, if a resident has an order for [REDACTED]. During an interview on 5/8/219 at 4:05 P.M., the Dietary Manager said the staff knows not to send a regular diet when a mechanical soft diet is ordered. He/she said they just weren’t paying attention to it. Dietary staff doesn’t thicken the drinks, the packets of thickener are placed on the tray. During an interview on 5/8/19 at 4:10 P.M., Food Service Staff (FSS) A said he/she just missed the order and would pay more attention from now on. During an interview on 5/8/19 at 4:30 P.M. Certified Nurse Aide (CNA) E said the resident has a mechanical soft diet since his/her swallow study, he/she drinks milk, Glucerna and coke that are regular liquid. During an interview on 5/8/19 at 4:35 P.M., CNA F said the resident walks into other residents rooms and will take food if he/she sees any. During activities or in the dining room he/she takes food and drinks off other resident trays causing complete chaos. He/she said the resident also digs in the trash can and eats chips popcorn or whatever he/she can find, eats and drinks really quick, can drink three milks at a time. Observation on 5/9/19 at 7:40 A.M., showed: – The resident sitting in front of the nurses station; – No water mug in his room. During an interview on 5/9/19 at 7:50 A.M., the Physician said the resident had a swallow study and it was recommended that he/she be on a mechanical soft diet with nectar thick liquids and the physician would expect that order to be followed. He/she said the residents do not need to have access to that refrigerator for a lot of other reasons, it makes it very difficult to regulate a residents blood sugar and then there are the issues of infection control. That refrigerator needs to be moved. All the staff need in-serviced on this resident’s needs. During an interview on 5/9/19 at 8:30 A.M., the DON said when she checked the residents room this morning, a mug of regular consistency water sat in his/her room. It was removed and staff would be made aware of liquids and snacks that the resident can have would need to be available. Observations made on 5/9/19, showed: – At 9:55 A.M., the resident lay in bed, eyes closed, no water mug in room; – At 11:34 A.M., the resident lay in bed, eyes closed, no water mug in room; – At 12:20 P.M., the resident lay in bed, eyes closed, no water mug in room; – At 12:25 P.M., the noon tray delivered to small dining room on 100 hall, regular diet, returned to the kitchen for mechanical soft diet. Observations made on 5/10/19, showed: – At 8:15 A.M., the resident lay in bed, no water mug in room, refrigerator and snacks remains at nurses station; – At 10:20 A.M., the resident sat on Resident #18’s bed, drinking two regular consistency drinks from the residents bedside table; – At 12:40 A.M., refrigerator and snacks remain at nurses station. During an interview on 5/10/19 at 8:47 A.M., the Chief Nursing Officer (CNO) said he/she was aware the resident got the wrong diet again at lunch yesterday but wasn’t aware he/she got the wrong one again last night at super. He/she just didn’t think the kitchen cared. The refrigerator would be moved today. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0808 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 14) During an interview on 5/10/19 at 9:20 A.M., the Dietary Manger said the cook fixes the plates, there is a sheet that says what should be on the plate for therapeutic diets. Tortilla chips should not be on a mechanical soft diet plate. The cook that was working has just been here a couple of weeks and he/she just probably doesn’t know. During an interview on 5/10/19 at 9:32 A.M., FSS G said no training is given, staff just has to watch and do what everyone else does. No policy was provided on therapeutic diets. | |
| 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 store, prepare, | |
| F 0838 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0838 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Based on interview and record review, the facility failed to review and update the comprehensive facility assessment annually in accordance with all applicable Federal requirements. Failure to review and update the comprehensive facility assessment annually could delay the services needed to care for the residents in day-to-day operations and in emergencies. This failure could affect all facility occupants. The facility census was 24 with a capacity of 66. 1. Record review showed the facility did not have a policy for a facility assessment. During an interview on 5/8/19 at 1:25 P.M. The Chief Nursing Officer (CNO) said she thought the facility had several pieces of the facility assessment but not in a binder like it needs to be. She said she had been reading on the requirements of the facility assessment, will be working on it and would have one in place soon. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 16) the hall. During an interview on 5/09/19 at 10:00 A.M., LPN H, he/she said the supplies that are needed are in the cart and it just makes sense to bring the cart inside the room instead of leaving it in the hall. During an interview on 5/09/19 at 11:00 A.M., LPN C said he/she leaves the treatment cart in the hall, that would be cross contamination if staff takes the cart in the room. During an interview on 5/10/19 at 8:00 A.M., the Chief Nursing Officer (CNO) said the treatment cart should not be taken in the resident’s rooms. She said it should be left in the hall and supplies brought from the cart to the room. 4. Record review of Resident #2’s medical record showed: – The resident admitted to the facility on [DATE]; – The resident received annual TB on 5/07/19; – No documentation of results in millimeters (mm). 5. Record review of Resident #6’s medical record showed: – The resident admitted to the facility 11/09/18; – The resident received annual TB on 2/06/19; – No documentation of results in mm. During an interview on 5/10/19 at 12:30 P.M. the Director of Nursing said the immunizations records are kept in the residents’ charts. She said the TB’s are given annually in May. She was not aware the results needed to be documented in millimeters. No facility policy provided. | |
| F 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop and implement policies and procedures for flu and pneumonia vaccinations. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 26A469 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER PEMISCOT COUNTY MEMORIAL HOSPITAL | STREET ADDRESS, CITY, STATE, ZIP PO BOX 489, HIGHWAY 61 AND REED STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 17) – The resident [AGE] years old; – [DIAGNOSES REDACTED]. – Staff did not document the resident’s pneumococcal history; – Staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal vaccines. 4. Review of Resident #6’s medical record showed: – The resident admitted on [DATE]; – The resident 87 old; – [DIAGNOSES REDACTED]. – Staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal vaccines. 5. Review of Resident #21’s medical record showed: – The resident admitted on [DATE]; – The resident [AGE] years old; – [DIAGNOSES REDACTED].>- Staff did not document the resident’s pneumococcal history; – Staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal vaccines. During an interview on 5/10/19 at 12:05 P.M. the Director of Nursing (DON) said the facility does not document giving the education to the residents or the residents representative. The pneumococcal vaccine is given to the residents prior to being admitted to this facility. During an interview on 5/10/19 at 12:10 P.M. the Social Services Director (SSD) said she puts the education sheet for immunizations in the admission packet, but does not have any documentation of giving the education to the residents’ or the representative. During an interview on 5/10/19 at 12:10 P.M. the Chief Nursing Officer (CNO) said the facility had been looking at the different pneumococcal vaccines and the recommendation in giving the injection to the residents. Record review of the facility’s policy on Pneumococcal vaccine policy, dated 7/2018 showed: – It is the policy of this facility to offer and administer annual influenza vaccination prior to the onset of the flu season, unless contraindicated, and the pneumococcal vaccination as indicated; – There is evidence that vaccinating the elderly in long-term care facilities may provide some protection against pneumonia, hospitalization and mortality; – Residents (or their next-of-kin if the resident is incapable of providing informed consent) should be provided with adequate information about the vaccine to enable them to make an informed decision about whether to be vaccinated or not; – Vaccine administration should be documented in the residents’ health care records; – New residents without prior evidence of receipt of pneumococcal vaccination should also be offered this vaccine. | |
