rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2017-05-19,166,D,0,1,YBQY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to ensure: 1) prompt efforts to resolve 2 residents (#s 3 and 4) concerns over lost clothing that was laundered at the facility, 2) prompt efforts to resolve a resident's (#9) concerns related to activities and lost items, and 3) residents (based on a census of 25) knew how to file a grievance with the grievance officer. Failure to ensure complaints and grievances were resolved and residents had access to accurate information on how to file a grievance, placed residents at risk for not having their concerns addressed in a timely manner. Findings: Missing clothing Resident #3 Record review from 5/16-19/17 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. During a group interview on 5/17/17 from 9:00 am - 9:50 am, Resident #3 stated he/she had a white dress shirt that went missing. The Resident stated the facility knew the shirt was missing and had looked for it. The item had not been found or replaced. Resident #4 Record review from 5/16-19/17 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. During a group interview on 5/17/17 from 9:00 am - 9:50 am, Resident #4 stated he/she lost a pair of black pants. The Resident stated the pants went missing around 6 months ago and said at this point they will never show up. The Resident further stated the facility did not offer to replace the pants and told the Resident to make sure the clothing is labeled. During an interview on 5/19/17 at 10:00 am the Activities Staff (AS) #2 stated the facility tried their best to find missing clothing, but we are not responsible (for missing clothing). Additionally, on 5/19/17 at 9:30 am, the facility provided a form titled Lost Item Report. The Charge Nurse (CN) stated activities staff kept track of the missing items using the lost item report form. The CN further stated the facility was only responsible to replace lost medical equipment. During an interview on 5/19/17 at 10:00 am, when asked where the residents lost item report forms were, AS #2 stated he/she did not use this form. Review on 5/19/17 at 9:30 am of the facilities policy, Clothing Labeling and Washing last reviewed 7/14/16, revealed .All clothing and/or personal bedding of a residents is labeled upon admission to the Transitional Care Unit .The resident and/or family member is informed that any new clothing and/or personal bedding brought into the facility must be labeled before being placed in resident's room .If a resident's family member elects to wash the resident's clothing and/or personal bedding the Transitional Care Unit is not respon Follow up on complaint/grievance Resident #9 Record review on 5/17-19/17 revealed Resident #9 was admitted to the facility with a history of depression. Further review revealed Resident #9 was previously transferred from the facility on 3/30/17 and then readmitted on [DATE]. Review of the social worker notes (SW) dated 4/17/17, revealed .Concerns- When pt (patient) was discharged it was reported that pt had a lot of knives in (his/her) room, (he/she) does a lot of art work so currently (he/she) is able to use (his/her) knives in the activity room but (he/she) would like to have them in (his/her) room. (He/She) is still working with LTC management to clear these guidelines up. Review of the care conference notes dated 5/2/17 revealed ACTIVITIES .states that (he/she) wants to do (his/her) hobbies in (his/her) room instead of activities room .enjoys creating things out of anything (he/she) can find and boarders on hoarding. Staff discussed .what could be kept, how long things could be kept, and how the room must be clean. (He/she) is very satisfied when (he/she) creates (his/her) projects. Review on 5/18/17 of Resident #10's comprehensive care plan last revised 5/3/17 revealed Problem: Additional Psych/Social Problem .Goal .Resident will be able to maintain sense of well-being by working on crafts in room . During an interview on 5/17/17 at 10:05 am, Resident #9 stated when he/she was transferred to another facility for a few weeks some of his/her belongings were missing. The missing items were a box of craft supplies and a power cord for a digital camera. Additionally, Resident #9 stated the facility no longer allowed him/her to do his/her arts and crafts projects in his/her room. Resident #9 stated he/she sometimes awakes at night and wants to work on his/her crafts. Resident #9 stated he/she was told he could not have scissors or knives in his room and therefore needs to do his activities in the activity room. The Resident was unaware there was a grievance officer he/she could contact. During an interview on 5/17/17 at 3:45 pm Activity Staff (AS) #1 stated Resident #9 had a history of [REDACTED]. Multiple items had to be boxed up when the Resident had been previously transferred and discharged to the hospital. During an interview on 5/19/17 at 8:50 am the Grievance Officer (GO) stated she had not received any grievances related to Resident #9. During an interview on 5/19/17 at 9:00 am, the Charge Nurse (CN) stated the facility was still working on the issue with Resident #9 being able to do his/her arts and crafts in his/her room. The CN stated there was concern over the health and safety of the Resident's use of carving knives. The CN confirmed the issue was not resolved and stated the issue was brought up at the last care conference meeting. Grievance Officer Information During a group interview on 5/17/17 at 9:00 am - 9:40 am, when asked about filing a complaint or grievance Resident #3 stated he/she was not sure how to file a complaint. Resident #4 stated he/she tells anyone who is handy if he/she has a concern. During an interview on 5/18/17 at 3:00 pm, Resident #9 stated he/she did not know who to contact within the facility to resolve his/her concerns. The Resident stated he/she was not aware of the GO. During an interview on 5/19/17 at 10:00 am Activities Staff (AS) #2 stated if a Resident issue cannot be resolved, it goes to the Director of Nursing (DON). The AS further stated he/she had never notified the GO. During an interview on 5/18/17 at 8:00 am, the GO stated the process for filing a grievance was to call the grievance telephone number, Hotline to the Heart. The GO further stated the grievance telephone line was managed by a staff member (Staff #1). The GO stated Staff #1 either entered the information in the grievance log or informed the GO of the concern. Observation on 5/18/17 at 8:40 am revealed the facility's policy Resident Grievance page 5 was posted in the dining room and at the nurse's station. Review of the POS [REDACTED]. The posting first listed the DON, then facility Administrator, and next the GO. Review on 5/18-19/17 of the facility's policy Resident Grievance last revised 3/9/10 revealed Resident Complaint .Calling and leaving a voice mail on the local Grievance telephone lines or any of the toll-free numbers titled, Hotline to the Heart .Writing a letter or sending an email, expressing dissatisfaction to the LTC (long term care) .DON, Risk Management, or Administration . Additionally, the Resident Grievances policy revealed .Grievances are expressions of dissatisfaction or complaints that cannot be resolved to the resident's satisfaction .All Grievances and investigative review responses are documented . Review on 5/18-19/17 of the facility's Resident Rights and Responsibilities last revised 3/31/17 revealed the last page listed contact information .IF YOU HAVE A COMPLAINT you may file a complaint .concerning resident abuse, neglect, and/or misappropriation of resident property in the facility with . The telephone listed for the GO was different then for the Hotline to the Heart number listed in the Resident Grievance policy. Additional review of the facility's Resident Rights and Responsibilities revealed, Grievance Procedure You have the right to: Voice or write your concerns and complaints to the charge nurse about treatment of [REDACTED]. The Grievance Procedure did not identify that the Residents could contact the grievance officer.",2020-09-01
2,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2017-05-19,241,D,0,1,YBQY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide cares and services in a manner that maintained and promoted dignity for 3 residents (#'s 5, 14 and 15). Specifically, the facility failed to: 1) ensure personal care was provided in a manner to promote dignity and comfort for 1 resident (#5) out of 5 residents observed during personal cares, and 2) removed gait belts (devices used by caregivers to transfer residents with mobility issues from one position to another, from one location to another or while ambulating residents who have problems with balance) for 2 residents (#'s 14 and 15) out of 5 observed during a group meeting who required gait belt use for transfers. These failed practices had the potential to negatively affect the residents' self-esteem and quality of life. Findings: Personal Cares: Resident #5 Record review from 5/16-18/17 revealed Resident #5 was admitted to the facility with failure to thrive, [MEDICAL CONDITION], recurrent skin integrity issues, diabetes, stroke and flaccidity to left side of body. Review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE], revealed the Resident was coded as needing extensive assistance with 2 persons for bed mobility, dressing and personal hygiene. Observation on 5/16/17 at 11:18 am, revealed certified nursing assistants (CNA) #s 1 and 2 provided morning cares to Resident #5. During cares, CNA #2 rolled the Resident to the left side exposing his/her buttocks and genitals. During the observation CNA #2 left the bedside multiple times to obtain various items such as clothing, mechanical lift and sling. The CNAs did not cover the Resident while CNA #2 left to get supplies. As a result, the Resident was exposed while waiting for staff to obtain supplies. Observation on 5/16/17 at 12:27 pm revealed CNA#s 1 and 3 were dressing Resident #5. During the observation both CNAs raised Resident #5's legs off the bed approximately 12 to 14 inches to place the Resident's pants on each leg. The Resident began to rapidly swing his/her upper right arm and meaningfully grimaced and attempted to yell in discomfort. Neither CNA noticed the Resident's reaction to the Activities of Daily Living (ADL) until prompted by the Surveyor. During an interview on 5/17/17 at 2:49 pm the Administrator stated staff should cover residents during cares to decrease unnecessarily exposure. In addition, the Administrator stated staff should always be mindful of residents' response to cares and find adaptations to cares if causing pain. Gait Belts: Resident #14 Record review from 5/17-19/17 of Resident #14's care plan, dated 5/17/17, revealed .Resident needs FWW (front wheeled walker) with gait belt and stand by assist for ambulation. Observation during a group interview on 5/17/17 from 9:00 am to 9:40 am revealed Resident #14 arrived ambulating with a walker and had a gait belt on. The Resident sat in a chair during the meeting and had the gait belt on during the entire meeting. Resident #15 Record review from 5/17-19/17 revealed Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, an admission assessment dated [DATE], revealed the Resident was coded as needing extensive assistance with locomotion and limited assistance with transfers. Review of Resident #15's most recent care plan, dated 4/20/17, revealed .Assist/supervise with transfers and ambulation Continuous observation on 5/17/17 from 9:05 am - 9:50 am revealed Resident #15 wearing a gait belt around his/her waist throughout the entire Resident group meeting. During an interview on 5/17/17 at 2:15 pm, CNA #s 3 and 4 stated gait belts should come off when not being used. During an interview on 5/19/17 at 10:10 am, the MDS Coordinator stated she understood the gait belts should come off when not transferring the Resident. Review on 5/16-19/17 of New Horizon Transitional Care Unit .Resident Rights and Responsibilities, revised 3/31/17, revealed .You have the right to .Be treated with consideration, respect and dignity .",2020-09-01
3,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2017-05-19,242,D,0,1,YBQY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure 2 residents (#s 7 and 9) out of 10 sampled residents were provided the opportunity to make choices significant to them and consistent with his or her interests and plan of care. Specifically, the facility failed to provide opportunities for: 1) Resident #7 to sit in the recliner in the activities room, and 2) Resident #9 to do activities such as arts and crafts, in his/her room. This failed practice had the potential to affect the residents' quality of life in general. Findings: Resident #7 Record review from 5/16-18/17 revealed the [AGE] year-old Resident was admitted to the facility with [DIAGNOSES REDACTED]. The Resident had a Personal Representative (PR) to assist in making health care decisions for him/her. Review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE], revealed the Resident was coded as total dependence for transfers. Additionally, the Resident was coded as having short and long-term memory problems and was moderately impaired (decisions poor; cues/supervision required) for cognitive skills for daily decision making. Review of the comprehensive care plan revealed the Problem: Alteration in cognition .Goal: Resident will be able to function to their highest level, as is compatible with their current cognition .Intervention: Offer resident choice (where to sit .) . Random observations from 5/15-18/17 revealed Resident #7 was sitting in the wheelchair for the lunch time meal and remained up until after dinner. During the observations facility staff did not offer the Resident an opportunity to relax in the recliner or other alternative seating. During an interview on 5/18/17 at 11:40 am, Resident #7's PR stated he/she would like to see the Resident in the recliner in the activity room more often. The PR stated the Resident was up in the wheelchair for a long time and sometimes fell asleep in the wheelchair. Resident #7's PR stated Resident #7 enjoyed sitting in the recliner. The PR stated he/she had asked facility staff to transfer the Resident to the recliner in the afternoon. During an interview on 5/19/17 at 10:00 am, Activities Staff (AS) #2 stated the facility staff transferred Resident #7 to a recliner if the PR requested it. AS #2 further stated Resident #7 had last used the recliner a couple weeks ago. As a result, the Resident was not constantly offered an alternative more comfortable option for seating between meals. Resident #9 Record review on 5/17-19/17 revealed Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. Further review revealed Resident #9 was previously transferred from the facility on 3/30/17 and then readmitted on [DATE]. Review of the admission MDS assessment dated [DATE], revealed the Resident was assessed for activity preferences. The Resident answered very important to the question how important is it to you to do your favorite activities? Review of the care conference notes dated 5/2/17 revealed ACTIVITIES ~ .states that (he/she) wants to do (his/her) hobbies in (his/her) room instead of activities room .enjoys creating things out of anything (he/she) can find and boarders on hoarding. Staff discussed .what could be kept, how long things could be kept, and how the room must be clean. (He/she) is very satisfied when (he/she) creates (his/her) projects. Review on 5/18/17 of Resident #10's comprehensive care plan last revised 5/3/17 revealed Problem: Additional Psych/Social Problem .Goal .Resident will be able to maintain sense of well-being by working on crafts in room . Review of the social worker notes (SW) dated 4/17/17, revealed .Concerns- When pt (patient) was discharged it was reported that pt had a lot of knives in (his/her) room, (he/she) does a lot of art work so currently (he/she) is able to use (his/her) knives in the activity room but (he/she) would like to have them in (his/her) room. (He/She) is still working with LTC management to clear these guidelines up. Further record review revealed the facility had not conducted an assessment on the Resident's ability to use scissors and/or carving knifes in a safe manner, nor had the facility explored options for safer methods. During an interview on 5/17/17 at 10:05 am, Resident #9 stated he/she was transferred to another facility for a few weeks and when he/she returned the facility no longer allowed him/her to do his/her crafts in his/her room. Resident #9 stated he/she sometimes woke at night and wants to work on his/her crafts in his/her room. The Resident stated the facility stated he/she could not have scissors or knives in his/her room and needed to do the activities in the activity room. During an interview on 5/19/17 at 9:00 am, the Charge Nurse (CN) stated the facility was still working on the issue with Resident #9 being able to do his/her arts and crafts in his/her room. The CN stated there was concern over the safety of the Resident's use of carving knives. Further record review revealed the facility had not conducted an assessment on the Resident's ability to use scissors and/or carving knifes in a safe manner, nor had the facility explored options for safer methods. Review on 5/18/17 of the facility's Resident Rights and Responsibilities revealed You have the right to .Have your needs and preferences accommodated .",2020-09-01
4,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2017-05-19,278,E,0,1,YBQY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure MDS (Minimal Data Set), a Federally required nursing assessment, were accurately completed to reflect the status of 3 residents (#s 4, 5 and 6) out of 6 residents who's MDS's were reviewed. This failed practice resulted in inaccurate information about 3 residents and placed them at risk for inaccurate care planning and care. Findings: Resident #4 Record review from 5/16-19/17 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Further review of Resident #4's Medication Administration Record [REDACTED]. Review of the discontinued and completed medication lists from 10/16/16 to 5/18/17 revealed no antipsychotic medications were listed. Review of the most recent MDS comprehensive assessment, an annual assessment dated [DATE], revealed the assessment coded the Resident as receiving antipsychotic medications during the last 7 days. During an interview on 5/17/17 at 2:30 pm the MDS Coordinator stated Resident #4 had not taken any antipsychotics should not have been coded as taking them on the 2/15/17 MDS assessment. Resident #5: Record review from 5/16-18/17 revealed Resident #5 was admitted to the facility with failure to thrive, [MEDICAL CONDITION], depression, recurrent skin integrity issues, diabetes, stroke and flaccidity to left side of body. Initial/Admission Assessment: Review of the MDS assessment, an admission assessment, dated 2/14/17, revealed the Resident was coded as dressing did not occur under the activities of daily living (ADLs). In addition, the Resident was coded as having an unstageable pressure ulcer that was not present on admission and taking antipsychotic medication during assessment period. During an interview on 5/17/17 at 1:34 pm the MDS Coordinator stated the ADL dressing did occur and it was a miscoding. The MDS Coordinator further stated the Resident did have a pressure ulcer on admission and the MDS was miscoded. The MDS Coordinator reviewed the medication the Resident took during the admission assessment period and confirmed the Resident did not an antipsychotic medication. Quarterly Assessment: Review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE], revealed Resident #5 was coded as not toileting. Further review revealed the Resident was coded as have taken antipsychotic medications during the quarterly assessment review period and had a [MEDICAL CONDITION]. During an interview on 5/17/17 at 1:34 pm, the MDS Coordinator stated the ADL toileting was miscoded as not occurring. In addition, the MDS Coordinator confirmed the Resident was not taking antipsychotic medications during the quarterly assessment review period. The MDS Coordinator further stated the Resident did not have a [MEDICAL CONDITION]. Resident #6 Record review from 5/16-19/17 revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated 3/20/17 revealed the discharge [DIAGNOSES REDACTED]. Review of the nurse's progress note dated 3/22/17 revealed .dressing to stage 1 pressure injuries . No Stage 2 pressure injuries were identified. Review of the care plan for the problem Alteration in skin integrity revealed Document comprehensive description of pressure ulcer .Stage 1 x3, lt (left) hip, lt heel, and sacrum . Review of the admission MDS assessment dated [DATE], revealed the Resident was coded as having 3 - Stage 1 pressure injuries. During an interview on 5/18/17 at 10:00 am, Licensed Nurse (LN) #3 stated pressure injuries are never downgraded. The LN stated the pressure injury on the sacrum should have been identified as a Stage 2. Review on 523/17 of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.14, dated (MONTH) (YEAR), Chapter 3 Section M Page 1, revealed Review the medical record for the history of the ulcer .Review for location and stage at the time of admission/entry or reentry . Review on 5/23/17 of the National Pressure Ulcer Advisory Panel (NPUAP) website at http://www.npuap.org/wp-content/uploads/2012/01/NPUAP-Position-Statement-on-Staging-Jan-2017.pdf, revealed, .The numerical staging system does NOT imply linear progression of pressure injuries from Stage 1 through Stage 4, nor does it imply healing from Stage 4 through Stage 1 .The NPUAP has long maintained this position and issued a position statement recommending against down staging as early as the year 2000. One of the unintended consequences of identifying numerical stages of pressure injuries is that it invites the misinterpretation that stage implies a progression (forward or backward). NPUAP's system implies no progression . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.14, dated 10/2016, revealed It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the (Interdisciplinary Team) completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment .The RAI process, which includes the Federally-mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA process provide the foundation upon which the care plan is formulated .",2020-09-01
5,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2017-05-19,280,D,0,1,YBQY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to update and revise the care plan to reflect the current level of care and services for 1 resident (#3) out of 7 residents whose care plans were reviewed. Specifically, the facility failed to revise a care plan to reflect the need for a gait belt when the resident was out of bed. Failure to assess and revise care plan problems, goals, and interventions placed the resident at risk for not receiving appropriate and/or necessary care and services. Findings: Record review from 5/16-19/17 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED].) and frequent falls. Review of the comprehensive care plan, dated 4/26/17, revealed .Use assistive device when assisting with transfers and ambulation .1 person stand by assist with gait belt and FWW (front wheeled walker) Random observations throughout the survey from 5/15-19/17 revealed the resident had a gait belt on his waist while he/she sat in his/her wheelchair. During an interview on 5/16/17 at 8:50 am certified nursing assistant (CNA) #5 stated, We keep (his/her) gait belt on when (he/she) is out of bed, just in case (he/she) is impulsive and rises on (his/her) own. Observation during Resident group meeting on 5/16/17 from 9:00 am to 9:50 am revealed Res #3 left the meeting briefly. On his/her return at 9:25 am, he/she wore a gait belt. Res #3 stated have to leave gait belt on all the time so they can grab you I guess. The facility did not provide a policy for care plans as requested.",2020-09-01
6,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2017-05-19,314,D,0,1,YBQY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, observation and policy review, the facility failed to: 1) prevent a pressure injury, and 2) follow treatment interventions for a pressure injury. Specifically, the facility failed to implement preventative measures in a timely manner and failed to provide the necessary treatment for [REDACTED].#5) out of 6 sampled residents who were identified by the facility for at risk for pressure injuries. This failed practice caused the resident to obtain an avoidable pressure injury and delayed treatment which resulted in pain with an increased risk for infection, delayed healing, and poor medical outcome. Findings: Resident #5 Record review from 5/16-18/17 revealed Resident #5 was admitted to the facility with failure to thrive, recurrent skin integrity issues, diabetes, stroke and flaccidity to left side of body. Further review revealed, the Resident had a pressure injury on the left heel on admission. Review of the admission MDS (Minimum Data Set) assessment dated [DATE] revealed the Resident was coded as: 1) Being at risk for pressure ulcers; and 2) Had an unhealed unstageable (slough/eschar) pressure ulcer on the left heel. Further review of the admission MDS revealed the Resident coded as the following under Activities of Daily Living (ADLs): 1) Extensive assist with two staff during bed mobility and transfer. 2) Supervision with locomotion on the unit; and 3) Total assistance with bathing and hygiene. Review of the medical record revealed Resident #5 had a new pressure injury to the right heel, identified on 4/27/17. The pressure injury was staged as - Unstageable .Yellow; Brown; Eschar . Review of the most recent MDS quarterly assessment, dated 5/9/17, revealed the Resident was at risk for pressure ulcers and had two unhealed pressure ulcers: an unstageable deep tissue ulcer to the left heel and a new unstageable (slough/eschar) ulcer to the right heel. Further review revealed the Resident's required assistance with Activities of Daily Living (ADLs): 1) Total assistance with two staff during bed mobility; 2) Extensive assistance with two staff during transfers; 3) Extensive assistance with one staff during locomotion on unit; 4) Extensive assist with one staff during hygiene; and 5) Total assistance with bathing. Record review of the Resident's comprehensive care plan, with various revision dates, revealed the Resident had an alteration in skin integrity with a start date of 5/3/17. Interventions included: follow treatment plan as ordered by provider, bilateral pressure relieving boots. The boots to relieve pressure were implemented after the discovery of the second pressure injury on the right heel. Avoidable pressure ulcer - right heel. Record review of a physical therapy note, dated 4/3/17, revealed Reiterated recommendations of repositioning (Resident) correctly in (wheelchair) throughout the day, angled foot rest or elevating leg rest. Review of a physical therapy note, dated 4/27/17, revealed the Resident had developed an unstageable pressure ulcer to the right heel. The note described the wound as black, eschar, fragile tan and slough. During an interview on 5/17/17 at 9:46 am Charge Nurse (CN) stated Resident #5 had an extensive history of recurrent pressure ulcers and poor sensation in the lower extremities. The CN continued to state the Resident had flaccidity to the left side and was only able to use the right side for mobility in and out of bed. The CN added, the Resident had self-propelled in a wheelchair with the right foot while wearing house shoes prior to the discovery of the pressure ulcer to the right heal. The Resident was described as using the right heel to dig on the floor to gain momentum to propel self in the wheelchair. During an interview on 5/17/17 at 10:45 am, Physical Therapist (PT) #1 stated Resident #5 currently had a pressure ulcer to the right heel. The PT further stated the wound was most likely caused by the Resident using right heal to perform bed mobility adjustments and propelling self in wheelchair. The PT stated house shoes were not an appropriate form of footwear for this resident to propel self, the house shoes could have contributed to development of the ulcer. PT #2 then joined the interview. PT #s 1 and 2 stated there were other options the facility could have tried prior to the pressure ulcer development to decrease the Resident's chance of developing an ulcer within the facility. During an interview on 5/17/17 at 12:57 am the Medical Director stated the cause of the pressure ulcer could have been associated to Resident #5 wearing house shoes while using the right heal to propel him/her self in the wheelchair. The Medical Director stated the Resident could have benefited from the use of a motorized wheelchair in efforts to relieve pressure to the right heel. The Medical Director added the facility could have placed pressure releasing boots on sooner to prevent a pressure ulcer in conjunction with the Resident's history of poor circulation and previous pressure ulcers. During an interview on 5/17/14 at 2:22 pm the MDS Coordinator stated it would have been best practice to have placed pressure relieving boots on Resident #5 since admission due to the Resident's history of recurrent pressure ulcers. Pressure Injury care Review of the Resident #5's comprehensive care plan, with various revision dates, revealed the Resident had a plan of care for alteration in skin integrity with a start date of 5/3/17. Interventions included: follow treatment plan as ordered by provider, bilateral pressure relieving boots. Record review of physical therapy note, dated 5/12/17, revealed dressing to right heel santly to wound bed on right side, not on left, covered by foam dressing cut to approximate size .[MEDICATION NAME] heavily applied to entire leg, foot and toes, [MEDICATION NAME] gauze wrap and secure with coban . During an observation on 5/16/17 at 11:18 am Resident #5 had hard-framed foam and Velcro pressure relief boots on both feet. During an observation on 5/16/17 at 12:27 pm, certified nursing assistant (CNA) #1 removed the hard-framed foam and Velcro pressure relief boot from the right foot to dress the Resident. At that time, the bandage fell off the Resident's right heal, exposing the wound to the exterior environment. When the CNA reapplied the boots, he/she gathered the excess pant material and wadded the material around the top of each boot. Random observations on 5/16/17 from 12:27 pm to 2:47 pm (2 hours) revealed the Resident's wound was still uncovered. During an interview on 5/16/17 at 2:27 pm Licensed Nurse (LN) #1 was asked by the Surveyor if the uncovered bandaged was reported by CNA #1. The LN stated he/she was unaware of the wound being uncovered until the Surveyor informed him/her. The LN further stated the wound was not to be uncovered. During the same interview the LN went to assess the Resident and noted the pants fabric rolled up on the top of each boot and stated the area was too constricted by the wadded up excess material. The LN added this was concerning because of the Resident's poor circulation. Review of the facility's policy entitled Skin Assessment and Pressure Ulcer Management, dated 5/14/15, revealed The following risk factors increase resident's risk for skin breakdown: The presence of cardiac, vascular, renal, metabolic or respiratory impairment(,) Advanced age (,) Obesity(,) Infection(,) Dementia(,) [MEDICAL CONDITION] .(,) Presence of previously healed pressure ulcer(,) .receiving .steroid therapy. NOTE: A resident with one or more of these factors should be considered at the next higher risk .Preventive measures will be utilized to decrease the risk of pressure ulcer development and improve health of existing ulcers. Existing pressure ulcers will receive appropriate therapeutic and preventive interventions.",2020-09-01
7,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2017-05-19,332,D,0,1,YBQY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure 2 residents (#s 12 and 13), out of 5 residents observed during medication administration, received medications per physician's orders [REDACTED].#12) was given a medication without measuring blood pressure prior to administration per physician's orders [REDACTED].#13) was given a medication that was administered contrary to manufacturer recommendation and physician order, specifically crushed vs. whole. This failed practice placed the facility's medication error rate above 5% and placed the resident at risk for not receiving therapeutic benefits from the medications. Findings: Resident #12 Record review on 5/16-18/17 revealed Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. Review on 5/16/17 revealed Resident #12's medication regime included the Resident had an order for [REDACTED]. Observation during a medication pass on 5/16/17 at 12:00 noon, revealed LN #2 entered Resident #12's blood pressure results in the Medication Administration Record [REDACTED]. During an interview on 5/16/17 at 12:00 noon, licensed nurse (LN) #2 stated he/she only takes Resident #12's blood pressure in the morning and the afternoon. The LN further stated Resident #12's blood pressure was always high. During an interview on 5/18/17 at 8:30 am, LN #3 reviewed the order and stated Resident #12's blood pressure should be taken prior to giving [MEDICATION NAME]. During an interview on 5/17/17 at 3:30 pm, Pharmacist (PH) #2 stated the blood pressure should be taken within 1 hour of giving the blood pressure medication [MEDICATION NAME]. He/she further stated the blood pressure reading from the prior dose should not be used for the current dose. Resident #13 Record review on 5/16-19/17 revealed Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 5/18/17 revealed Resident #13's medication regime included Aspirin EC ([MEDICATION NAME] coated) 81mg (milligrams) po (by mouth) QD (every day) Admin (Administration) Instructions: Do not crush. Observation of a medication pass on 5/16/17 at 10:30 am revealed, LN #1 crushed Resident #13's medications which included the [MEDICATION NAME] coated aspirin. During an interview on 5/17/17 at 3:15 pm, PH #2 stated that [MEDICATION NAME] coated aspirin shouldn't be crushed. Review of the WebMD website http://www.webmd.com/drugs/2/drug- -3/aspirin-ec/details, accessed on 5/25/17, revealed: Swallow [MEDICATION NAME]-coated tablets whole. Do not crush or chew [MEDICATION NAME]-coated tablets.",2020-09-01
8,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2017-05-19,492,D,0,1,YBQY11,"Based on observation, document review and interview the facility failed to ensure blood glucose testing competencies for 16 active certified nursing assistants (CNAs) out of 18 reviewed were conducted in compliance with Alaska Nursing Statutes and Regulations. This failed practice placed 4 residents (#s 2, 5, 9 and 12) out of 14 active residents who required blood glucose monitoring, at risk for improper technique of obtaining blood glucose. This failed practice had the potential for complications such as infection or inaccurate reading. Findings: Random observations from 5/15-17/17 revealed various CNAs completing blood glucose testing on residents. Review on 5/17/17 at 3:47 pm of the CNA Glucometer Competency packet, last updated 4/2017, revealed the following: - CNA #s 1, 10, 12, 13 and 14 had no initial competency or 90-day evaluation; - CNA #s 2, 3, 4, 5, 6, 7, 9, 15 and 16 did not have a 90-day evaluation completed; and - CNA #s 8 and 11 90-day evaluations were completed late. During an interview on 5/17/17 at 3:47 pm the Charge Nurse (CN) stated it was his responsibility to complete the CNA glucometer competencies. The CN confirmed some competencies had been either late or not completed. Review of the Alaska Nursing Statues and Regulations, dated 9/2016, revealed 12 AAC 44.960 .Specialized nursing duties may be delegated to another person under the standards set out in 12 AAC 44.950. (b) Specialized nursing task that may be delegated include .(3) obtaining blood glucose levels .(8) A nurse who delegates a nursing duty to another person under this section shall develop a nursing delegation person. The delegating nurse shall evaluate a continuing delegation as appropriate, but must perform an evaluation of the performance of the delegated duty by the other person. The delegating nurse shall evaluate the continuing delegation as appropriate, but must perform an evaluation on-site at least every 90 days after the delegation was made. The delegating nurse shall keep a record of the evaluations conducted.",2020-09-01
9,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2017-05-19,514,E,0,1,YBQY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation the facility failed to maintain accurate and complete medical records. Specifically, the facility failed to: 1) document the indication of use for medications in the residents' medical record for 4 residents (#s 1; 3; 4 and 10) out of 10 sampled residents whose medical records were reviewed, and 2) accurately document the current medical treatment (saline lock flush and pain medication) for 1 resident (#5) out of 7 sampled residents. These failed practices placed the residents at risk for not receiving services needed to address medical conditions. Findings: Indications for Use of Medications: Resident #1 Record review from 5/16-19/17 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the current medication administration record (MAR) and medication order detail revealed no documentation of [DIAGNOSES REDACTED]. Resident #3 Record review from 5/16-19/17 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED].) and frequent falls. Review of the current MAR and medication order detail, revealed no documentation of [DIAGNOSES REDACTED]. Resident #4 Record review on 5/16-19/17 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Further review revealed Resident #4's medication regime included: 1) Atorvastatin ([MEDICATION NAME]) - used to treat high cholesterol 2) [MEDICATION NAME] ([MEDICATION NAME]) - an antidepressant 3) [MEDICATION NAME] ([MEDICATION NAME]) - an antidepressant 4) [MEDICATION NAME] ([MEDICATION NAME]) - a diuretic Review of the current MAR and medication order detail, revealed no documentation of [DIAGNOSES REDACTED]. Resident #10 Record review on 5/18-19/17 revealed Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. Further review of Resident #10's medication regime revealed Resident #10 was taking the antipsychotic medication [MEDICATION NAME] 10 mg nightly. Review of the current MAR and medication order detail, revealed no documentation of [DIAGNOSES REDACTED]. During an interview on 5/18/17 at 1:00 pm, Pharmacist #1 stated the indication for use for all medications should be on the MAR and order details. The Pharmacist confirmed the facility was missing the indications for use on some of the Resident's medications. Review of the website Institute for Safe Medication Practices, accessed on 5/30/17 at http://www.ismp.org/tools/guidelines/SCEMI/SCEMIGuidelines.aspx, revealed, Provide a field to enter the purpose/indication for all medications communicated electronically .Communicating the drug's indication reduces the risk of improper drug selection and offers clues to proper dosing when a medication has an indication-specific dosing algorithm. Documented Accuracy of Medical Treatment: Resident #5 Saline Flush Record review from 5/16-18/17 revealed Resident #5 was admitted to the facility with failure to thrive and gastrointestinal hemorrhaging. Random observations from 5/15-18/17 revealed, Resident #5 had a saline-locked intravenous (IV) access located in forearm. Record review from 5/16-18/17 of the most current physician's orders [REDACTED]. Record review from 5/16-18/17 of the current MAR revealed no documentation or order for the administration of saline through the IV access. During an interview on 5/18/17 at 10:08 am, Pharmacist #1 and #2 both stated there should have been an order for [REDACTED]. In addition, Pharmacist #1 and #2 stated the MAR should reflect the order to ensure documentation of the saline administration was in a resident's chart. Review of the facility provided IV access guidelines, undated, revealed a peripheral IV should be flushed every eight hours with 10 milliliters normal saline. Pain Medication Order Record review of Resident #5's MAR, dated 5/2017, revealed the following order: [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME] - narcotic pain medication) 5-325 mg per tablet, 1-2 tablets every four hours as needed for moderate to severe pain. Further review revealed the nurses had been administering the [MEDICATION NAME] prior to wound dressing changes. During an interview on 5/17/17 at 12:57 pm, the Medical Director stated an order should be written to specify the use of [MEDICATION NAME] prior to wound dressing changes to reflect a more accurate portrayal of the Resident's medical record and care and ensure the Resident is receiving the appropriate pre-treatment pain medication. During an interview on 5/18/17 at 8:15 am the Charge Nurse (CN) confirmed the nurses had been providing the [MEDICATION NAME] prior to wound dressing changes each day.",2020-09-01
10,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-06-10,600,D,1,0,TIZ611,"> Based on record review and interviews the facility failed to ensure 1 resident (#3) out of 4 sampled residents was protected from verbally and physically assaultive behavior by staff. This failed practice placed the resident at risk for psychosocial and physical harm from abusive staff behaviors. The facility had implemented corrections prior to the investigation. Findings: Record review on 6/7/19 revealed Resident #3 had a disorder that resulted in dementia, mood disorders, and uncoordinated muscle movements. The Resident was one of several residents on the unit on enhanced observation (individual staff that monitored the resident one to one, due to a high fall risk). Review of the report provided to the State Agency on 6/3/19 revealed on 5/30/19 at approximately 7:30 pm, Licensed Practical Nurse (LPN) #1, who had been assigned to provide enhanced observation of the Resident, was to be heard 'screaming' at the Resident and telling (him/her) couldn't come out of (his/her) room. (LPN #1) was further noted to be yanking at the Resident's shirt attempting to pull (him/her) back in the bed, by force. Further review revealed Certified Nursing Assistant (CNA) #s 1 and 2 interceded, redirected the Resident, and reported the event to the Registered Nurse (RN) that was in charge on 5/30/19. The RN assessed the Resident, administered his/her evening medications and assisted the Resident back to (his/her) room. The Resident did choose to have (LPN #1) remain sitting with (him/her) rather than a new and unknown CNA floated from outside the unit. LPN #1 continued to provide enhanced observation of the Resident the remainder of the night. During an interview on 6/6/19 at 8:30 pm, LPN #2 stated he/she had been left out of the loop. The LPN stated the evening of 5/30/19, the CNAs had mentioned there had been a confrontation, as Resident #3 is normally very vocal, LPN #2 stated he/she planned to address it when after he/she finished passing medications. The LPN stated when he/she checked the Resident was sleeping and LPN #1 was seated at the Resident's bedside. During the interview, when asked if there had been earlier indicators of abuse by LPN #1, LPN #2 stated LPN #1 would make statements such as Resident #3 can't always get (his/her) own way. During an interview on 6/7/19 at 4:00 pm, Registered Nurse (RN) #1 stated he/she was the charge nurse that night. When asked about the event that had transpired between Resident #3 and LPN #1 the RN stated he/she did not hear the confrontation. After the CNAs notified him/her, the RN examined the Resident and observed pink marks around his/her neck. When she/he asked about the incident, Resident #3 stated, I don't like (LPN #1) and was tearful, but not hysterical. The RN stated because a change in staffing or scheduling could easily upset the Resident, he/she asked Resident #3 if he/she wanted LPN #1 to remain in the room or provide different staff from the hospital. The Resident chose to have LPN #1 remain the rest of the night. The RN stated it was quiet the remainder of the night. The RN stated he/she was unaware there was a specific protocol for protecting the residents that needed to be followed. During an interview on 6/7/19 at 4:15 pm, CNA #1 stated he/she and CNA #2 were working the evening of 5/30/19 and had witnessed the incident. CNA #1 stated LPN #1 had ahold of the Resident by the collar of the shirt and had yanked the shirt so hard it caused red marks around the Resident's neck. The CNA stated LPN #1 was verbally arguing with the Resident and made the statement Resident #3 cannot always get (his/her) own way. CNA #2 interceded and redirected the Resident, who was agreeable with putting on slippers and a gait belt for his/her evening walk to the nurses' desk for his/her medication. CNA #1 stated he/she immediately notified the charge nurse of the event and reported it to the Director of Nursing (DON) the next morning. In addition, the CNA stated he/she was surprised the red marks on the Resident's neck had faded by the morning. Corrections: During an interview with the DON on 6/7/19 at 4:30 pm stated he/she had learned of the altercation between Resident #3 and LPN #1 the next morning. The DON stated the LPN #1 was from a travel agency and they ended the nurse's contract early, the facility also reported the abusive behavior to the State Agency and the contracting travel agency. The DON stated he/she had notified the Resident's spouse, who had not been aware of the event. In addition, the DON stated he/she had conducted education for all staff on 6/5/19 regarding the reporting, investigation, and protection requirements. Several staff were interviewed regarding the training and confirmed they had attended. The content of the in-service titled State Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act and the sign in sheet was reviewed. The Surveyor confirmed LPN #1 was no longer employed at the facility.",2020-09-01
11,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2018-08-03,578,E,0,1,RHGS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to 1) have a written Advanced Directives (AD) policy and 2) ensure evidence AD information was provided for 5 residents (#s 2; 3; 7; 12 and 14) out of 14 sampled residents. This failed practice had the potential to deny the residents the right to choose and make end of life medical care decisions. Findings: Resident #2 Record review on 7/30/18 - 8/3/18 revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set - a Federally required assessment) assessment, a quarterly assessment dated [DATE], revealed Resident #2 has a BIMS (Brief Interview for Mental Status) score of 15 (a score of 13-15 means the person is cognitively intact). Review of Resident #2's medical record revealed an incomplete AD. Resident #2 only had 2 pages of a 9 page packet entitled Five Wishes: Page 2 of the packet, Wish 1, and page 8, Signing the Five Wishes Form. Further review revealed no documentation that Resident #2 had completed an AD or was offered assistance to formulate an AD. Resident #3 Record review on 7/30/18 - 8/3/18 revealed Resident #3 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, a quarterly assessment dated [DATE], revealed Resident #3 had a BIMS score of 0 (a score of 0-7 means the person is severely impaired). Review of Resident #3's medical record revealed no AD. A Power of Attorney was present. Further review revealed no documentation that Resident #3's guardian was asked if Resident # 3 had an AD or offered assistance to make one if desired. Resident #7 Record review on 7/30/18 - 8/3/18 revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, a significant change dated 5/28/18 revealed Resident #7 had a BIMS score of 15. Review of Resident #7s electronic medical record revealed no AD. When asked for the residents AD, the facility produced a physician order [REDACTED]. Resident #12 Record review on 7/30/18 - 8/3/18 revealed Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, a quarterly assessment dated [DATE], revealed Resident #12 had a BIMS score of 15. Review of Resident #12's medical record revealed no AD on file or indication that Resident #12 was offered the right to formulate an AD. Resident #14 Record review on 7/30/18 - 8/3/18 revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent MDS, a quarterly assessment dated [DATE], revealed Resident #14 has a score of 9 (a score of 8-12 means the person is moderately impaired). Review of Resident #14's medical record revealed no AD. A Power of Attorney was on file. Further review revealed no documentation that Resident #14 or the guardian were asked if Resident #14 had an AD or offered information about an AD. During an interview on 8/1/18 at 2:10 pm, the Long Term Care Administrator stated there was no AD policy or system in place to ask residents on admission if they had an AD or to offer assistance or declination to formulate an AD. During an interview on 8/3/18 at 11:27 am, Social Worker #1 could not provide documentation where he/she asked the Residents if they had an AD or if they would like help making one. He/she stated they only document who the guardian is and who makes medical decisions for the residents on their assessments.",2020-09-01
12,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2018-08-03,657,E,0,1,RHGS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to update and revise the care plan to reflect the current level of care and services for 3 residents (#s 3, 14, 16) out of 14 sampled residents. Failure to assess and revise care plan problems, goals, and interventions placed the residents at risk for not receiving appropriate and/or necessary care and services. Findings: Resident #3 Record review on [DATE] - [DATE] revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #3's most recent care plan, undated, revealed 18 Multidisciplinary Problems (Active). The expected end date, or target date, for all of these identified problems expired on [DATE]. Review of the most recent MDS (Minimum Data Set - a federally required nursing assessment) assessment revealed a quarterly assessment was completed on [DATE] preceeding the expired dates on the careplan. Review of the Quarterly Team Conference, dated [DATE], revealed the team reviewed the current care plan for all identified problems and approaches. Resident #14 Record review on [DATE] - [DATE] revealed Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, an annual assessment dated [DATE], revealed Resident #14 required extensive assistance in bed mobility, locomotion on and off unit, toileting, and dressing. He/she was coded total dependence for transfers and personal hygiene. Review of Resident #14's care plan revealed a Problem: Impaired strength and/or mobility . dated [DATE] and a Description: Related to left side [MEDICAL CONDITION] and [MEDICAL CONDITION] post [MEDICAL CONDITION]. Interventions for this problem were documented as restorative aid, range of motion exercises, with the goal needs to maintain current flexibility and prevent contractures. Further review of Resident #14's medical record revealed Occupational Therapy (OT) added instructions for a palm protector with finger separators on [DATE] with the following interventions: - Please place palm shield on (Resident #14) when in bed (in place of previous palm protector). - If finger separators out of place, please fix them - Keeping left arm up on pillow for support will help keep it in place and provide comfort to left arm - If (Resident #14) is having any discomfort with palm shield, please remove and give a break. Attempt to replace in 30 (minutes) - 1 hour. Additional review of Resident #14's care plan Problem: Impaired strength and/or mobility . revealed no documentation of the palm protector recommended by OT. Resident #16 Record review on [DATE] - [DATE] revealed Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. Record review revealed a physician order [REDACTED]. Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, a quarterly assessment dated [DATE], revealed the Resident was coded for taking an anticoagulant medication during the last 7 days of the MDS assessment. Review of Resident #16's most recent care plan, undated, revealed the problem Potential for complication r/t bleeding (see description) Description: I am on [MEDICATION NAME] .review of INR and [MEDICATION NAME] dose adjustment. Review of MDS Nurse Note dated [DATE], revealed Care conference complete . There was no documentation regarding the change in Resident #16's medication change from [MEDICATION NAME] ([MEDICATION NAME], a blood thinning medication that requires diagnostic monitoring) to Eliquis. During an interview on [DATE] at 7:46 am, Licensed Nurses (LN) #s 2 & 5 stated they do not use the care plan binders at the nurse's station and they do not regularly incorporate the care plans into their daily care for residents. During an interview on [DATE] at 9:00 am, the interim MDS Nurse (MDSN) could not state why a revision to a care plan would not be done. She stated revisions are manually completed by the full-time MDSN, who was on vacation at the time of this survey. Review of the facility's policy Care Planning, dated [DATE], revealed: The Care Plan is to be considered a dynamic document. It is to be kept up-to-date on a continual basis, and based on the assessed needs of the individual resident. Further review of the policy revealed: The MDS RN-Coordinator is in charge of and responsible for completing, reevaluating and revision of the Resident Care Plan. And Each discipline is encouraged but not required to make changes on the care plan as necessary. These changes can be written on the paper copy of the care plan, in the care plan notebook, or this can be taken to the MDS RN-Coordinator .",2020-09-01
13,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2018-08-03,684,D,0,1,RHGS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation the facility failed to provide nail care for a fungal infection that may have contributed to major nail deformity and discomfort for 1 resident (#14) out of 14 sampled residents. This failed practice placed the resident at risk for actual decline in physical, mental, and/or psychosocial well-being. Findings: Record review on 7/30/18 - 8/3/18 revealed Resident #14 was admitted to the facility with a [DIAGNOSES REDACTED]. During an interview on 7/31/18 at 11:57 am, Resident #14 and his/her spouse stated there was a need for nail care due to a fungal infection. The spouse stated they have not been able to see a nail doctor and he/she has requested assistance to get Resident #14 to a nail doctor from staff, but it hasn't happened. Resident #14 further states his/her nails hurt all the time, and they embarrass him/her, they make me feel like a witch, and he/she hides his/her hand under blankets. An observation on 7/31/18 at 11:57 am, revealed two nails (middle and ring finger) on Resident #14's left hand that were deformed, growing out and almost perpendicular to the nail bed. The nails themselves were extremely thick and overgrown, pushing into the nail bed of the finger. During an interview on 8/1/18 at 1:44 pm, the Infection Preventionist and Director of Nursing stated the charge nurse has been trying to get Resident #14 a podiatry (foot doctor) appointment with a traveling podiatrist. The facility could not provide documentation that a nail appointment is pending for Resident #14. During an interview on 8/3/18 at 11:19 am, the Social Worker indicated that they are not involved in making medical appointments. Review of Quarterly Team Conference notes, dated 10/27/17, 1/23/18, and 4/12/18, revealed no documentation of the need for nail care or any steps taken to get a podiatry consult made. Review of Resident #14's Care Plan revealed Problem: Health Promotion, start date 6/1/18: - Appointment with Dr. Lam, Podiatry, Yearly diabetic foot (evaluation)/nail care. 6-30-18. - 6-28-18 Rescheduled by doctor however facility did not receive notification. Doctor evaluating whether he wants to continue to see resident. Office will call back. Review of Resident #14 most recent MDS (Minimum Data Set-a federally required nursing assessment), an annual assessment dated [DATE], revealed no indication nail care is an identified problem and no plan of attaining a podiatry consult. Review of the Annual Team Conference note, dated 7/17/18, revealed no mention for the need of nail care or any steps taken to get a podiatry consult made. Review of MDS Nurse notes, dated 10/24/17, 1/23/18, 4/12/18 and 7/17/18, revealed no documentation for the need of nail care or any steps taken to get a podiatry consult made.",2020-09-01
14,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2018-08-03,689,E,0,1,RHGS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the adequate supervision for 1 resident (#7) out of 14 sampled residents. Specifically, the facility failed to conduct a safety assessment on one resident (#7) utilizing a wheelchair to leave the facility. This finding places the resident at a potential risk for an accident. Findings: Resident #7 Record review on 7/30/18 - 8/3/18 revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Observation on 7/31/18 at 7:00 am, revealed the Resident outside the facility in a wheelchair. The Resident was observed stationary in a wheelchair on the sidewalk at the top of a steep incline needing to be navigated in order to gain access to the facility. Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, a significant change assessment dated [DATE], revealed Resident #7 had a BIMS (Brief Interview for Mental Status) score of 15 (a score of 13-15 means the person is cognitively intact). Further review revealed the significant change MDS assessment dated [DATE] was a result of the resident experiencing a fracture from a fall. During an interview on 8/2/18 at 15:35 pm, the Director of Nursing (DON) and Administrator (ADM) both stated no, when asked if the Resident had a safety assessment based on observations of the Resident behaviors. Additionally the DON and ADM stated no when asked if the facility had a policy for safety assessments for residents leaving the facility in wheelchairs.",2020-09-01
15,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2018-08-03,755,F,0,1,RHGS11,"Based on observation and interview the facility failed to have consistent safeguards in place for appropriate disposition of controlled substance medications within the medication storage room. Specifically, the Cactus Smart Sink (a secured, closed cartridge for controlled substance medication disposal) was overfull with disposed medication to the point the medications were accessible. This failed practice had the potential to affect all residents (based on a census of 18), disrupt facility reconciliation of disposed controlled substance medication and/or cause potential loss, diversion, or accidental exposure. Findings: During an observation of the medication storage room on 8/2/18 at 9:45 am, it was noted the Cactus Smart Sink was overfull. Multiple pills and powder were visible and accessible by hand. It was further observed that the red light was blinking on the Smart Sink system. During an interview on 8/2/18 at 10:10 am, Pharmacist #1 stated when the red light blinks on the Cactus Smart Sink it needs to be emptied. During an interview on 8/2/18 at 10:20 am, Pharmacy Tech #1 visualized the Cactus Smart Sink in the medication storage room and stated the cartridge was overfull. He/she further stated the pills and powder should not be visible within the sink. During an interview on 8/2/18 at 10:30 am, Licensed Nurse (LN) #4 stated when the red light blinks, it means the cartridge within the Cactus Smart Sink need to be changed because it is full. LN #4 had not called the pharmacy for them to replace the cartridge prior to this observation. Review of facility's policy Cactus Smart Sink Use Policy, dated 3/9/18, revealed: Cactus Smart Sink: Cactus Smart Sink is a secure pharmaceutical waste container that accepts the disposal of solids and liquids converting them into an unusable and unrecoverable state. Further review revealed: When a cartridge is full, the unit will notify the pharmacy to replace it.",2020-09-01
16,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2018-08-03,758,D,0,1,RHGS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review the facility failed to ensure 1) PRN (as needed) [MEDICAL CONDITION] (any drug capable of affecting the mind, emotions, and behavior) medication was limited to a 14 day duration in compliance with federal regulation and 2) was re-evaluated by a physician with appropriate documentation for continued use in 2 residents (#5 & #14), out of 6 sampled residents. This failed practice placed the residents at risk for receiving unnecessary medication and for experiencing potentially severe and debilitating side effects of [MEDICAL CONDITION] medication. Findings: Resident #5 Record review on 8/1/18 of Resident #5 most recent MDS (Minimum Data Set-a federally required nursing assessment), a significant change assessment dated [DATE], revealed [DIAGNOSES REDACTED]. Review of Resident #5's Medication Administration Record [REDACTED]. Further review revealed this medication started on 11/29/17 with an end date of 11/29/18 (a 1 year order). [MEDICATION NAME] is a medication used to relieve anxiety. Review of Resident #5's medication administration history revealed the following PRN use for anxiety: - (MONTH) (YEAR): 5 doses received - (MONTH) (YEAR): 8 doses received - (MONTH) (YEAR): 5 doses received - (MONTH) (YEAR): 5 doses received - (MONTH) (YEAR): 6 doses received - (MONTH) (YEAR): 3 doses received - (MONTH) (YEAR): 2 doses received Additional review of the MAR indicated [REDACTED]. Review of the physician's notes, dated 12/1/17, 2/5/18, 4/2/18, and 6/4/18, revealed no documentation of the number of times [MEDICATION NAME] PRN was used, or the efficacy of the [MEDICATION NAME] PRN use. Further review revealed no documentation of a possible dosage reduction or projected duration of [MEDICATION NAME] PRN use. Review of the Pharmacist's 30 day Drug Regimen Reviews, dates (MONTH) (YEAR) through (MONTH) (YEAR), revealed no recommendation on the [MEDICATION NAME] PRN use, nor any recommendation to attempt a dosage reduction or elimination. Review of Quarterly Team Conference notes, dated 10/19/17 and 1/11/18, revealed no documentation of [MEDICAL CONDITION] PRN drug use for anxiety: BEHAVIORAL SYMPTOMS: None. Further review revealed no discussion on possible reduction or elimination of the medication. Review of the Annual Team Conference note, dated 4/17/18, revealed no documentation of [MEDICAL CONDITION] PRN drug use for anxiety: BEHAVIORAL SYMPTOMS: None. Further review revealed no discussion on possible reduction or elimination of the medication. Resident #14 Review of Resident #14 most recent MDS, an annual assessment dated [DATE], revealed [DIAGNOSES REDACTED]. Review of Resident #14's MAR indicated [REDACTED]. Further review revealed this medication started on 1/30/18, with an end date of 7/29/18 (a 6 month order). Review of Resident #14's medication administration history revealed the following PRN use for anxiety: - (MONTH) (YEAR): 2 doses received - (MONTH) (YEAR): 11 doses received - (MONTH) (YEAR): 14 doses received - (MONTH) (YEAR): 13 doses received - (MONTH) (YEAR): 15 doses received - (MONTH) (YEAR): 11 doses received - (MONTH) (YEAR): 14 doses received Review of the Physician's Progress notes, dated 2/12/18, 4/9/18, 5/31/18, and 7/27/18, revealed no assessment of anxiety, the number of times [MEDICATION NAME] PRN was used, or the efficacy of [MEDICATION NAME] PRN use. Further review revealed no documentation of a possible dosage reduction or projected duration of [MEDICATION NAME] PRN use. Review of the Pharmacist's 30 day Drug Regimen Reviews, dates (MONTH) through (MONTH) (YEAR), revealed no recommendation on [MEDICATION NAME] PRN use, nor any recommendation to attempt a dosage reduction or elimination. Review of Quarterly Team Conference notes, dated 10/24/17, 1/23/18, and 4/12/18, revealed no documentation of [MEDICAL CONDITION] PRN drug use for anxiety: BEHAVIORAL SYMPTOMS: None. Further review revealed no discussion on possible reduction or elimination of the medication. Review of the Annual Team Conference note, dated 7/17/18, revealed no documentation of [MEDICAL CONDITION] PRN drug use for anxiety: BEHAVIORAL SYMPTOMS: None. Further review revealed no discussion on possible reduction or elimination of the medication. During an interview on 8/2/18 at 11:20 am, Pharmacist (RPH) #1 stated only antipsychotic (medication used to treat delusions, hallucinations, paranoia, or disordered thoughts) medication needed a 14 day limit on orders. When regulation was reviewed with RPH #1, he/she stated he/she missed this and was not monitoring for this limitation. During an interview on 8/2/18 at 11:20 am, Medical Director (MD) #1 stated the only protocol in place for [MEDICAL CONDITION] PRNs was they were to be re-evaluated every 6 months. He/she was unaware of the 14 day limit on [MEDICAL CONDITION] PRN use. Review of facility's policy Pharmacy Medication Reviews for (Long Term Care) Patients, dated 6/1/18, revealed no monitoring for [MEDICAL CONDITION] PRN orders to be limited to 14 days, unless specific documentation from the attending physician is present within the resident's medical record. Review of the facility's policy Psychotherapeutic Medications, dated 8/1/14, revealed: Procedure: Attending Medical Staff: c. if the provider determines that it is clinically contraindicated for the psychotherapeutic medication therapy dose to be tapered or discontinued, they must document the reason in the resident's medical record. Further review revealed: e. 1. PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days. 2. if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.",2020-09-01
17,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2018-08-03,812,F,0,1,RHGS11,"Based on observation, interview, and record review of the central kitchen area, the facility failed to prepare food under proper sanitation and food handling practices. Specifically, the food service staff failed to perform hand hygiene according to accepted professional practices during the provision of food care and services. This failed practice placed all residents (based on a census of 18) at risk for the development of disease and infection in a vulnerable population. Findings: Observation on 7/30/18 at 16:40 pm, revealed Kitchen Staff (KS) #s 2 & 3 preparing meal trays for the long term care residents. Continual observations revealed KS #3 not performing hand hygiene between glove changes during tray assembly. The assembly of the meal trays included handling the food with gloved hands. Observations further revealed KS #2 with gloves on, going to the freezer, opening the door and pulling out a loaf of frozen bread. KS #2 continued to open the bag, reach in, break the loaf apart and grab a piece of bread from the middle of the loaf. KS #2 then put the piece of bread in toaster and continued back to the tray line to assemble meals without glove changes or hand hygiene. During an interview on 8/3/18 at 7:20 am, KS #4 stated yes when asked if hand hygiene should be performed between glove changes. During an interview on 8/3/18 at 10:05 am, the Dietary Manger stated yes when asked if hand hygiene should be performed between glove changes. Review of the facility policy Washing Hands-Ketchikan Medical Center Food Service Department - SOP, undated, revealed 7. Wash Hands: Before putting on or taking off gloves. Review of the State of Alaska, Department of Environmental Conservation, Alaska Safe Food Worker Handbook accessed 8/6/18 at https://dec.alaska.gov/eh/fss/training.html, revealed Part 1: Food Worker Knowledge and Health, Handwashing, When to Wash your Hands .When changing gloves.",2020-09-01
18,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2018-08-03,842,D,0,1,RHGS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure resident information was accurately documented for 3 residents (#s 2, 3, 14) of 14 sampled residents. This failed practice placed the residents at risk for not receiving services needed to address medical conditions. Findings: Resident #2 Record review on 7/30/18 - 8/3/18 revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #2's most recent care plan, undated, revealed 13 Multidisciplinary Problems (Active). Additional review of the individual problems revealed the following omission and/or discrepancies: 1) Review of the Problem: Difficulty swallowing . revealed no start date to the problem or the 4 interventions. 2) Review of the Problem: Alterations in comfort . revealed a start date of 4/26/17. This problem describes a cervical fracture that occurred on 4/8/18 (start date is almost one year before incident occurred). All 8 interventions to this problem also have a start date of 4/26/17. Resident #3 Record review on 7/30/18 - 8/3/18 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #3's care plan, undated, revealed 18 Multidisciplinary Problems (Active). Additional review of the individual problems revealed the following discrepancy: 1) Review of the Problem: Elevated A1C . (A blood test that reflects your average blood glucose levels over the past 3 months) revealed a start date of 5/10/16 and an expected end of 5/14/18. Two interventions to this problem are 1) Monitor resident's blood sugars as ordered and 2) Monitor A1c level as ordered. During an interview on 8/3/18 at 11:20 am, Licensed Nurse (LN) #4 stated there are no current orders for blood sugar or A1C monitoring. The last blood sugar on Resident #3 was 2/22/16. The last A1C drawn was 7/17/15. Resident #14 Record review on 7/30/18 - 8/3/18 revealed Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #14's most recent care plan, undated, revealed 19 Multidisciplinary Problems (Active). Additional review of the individual problems revealed the following discrepancy: 1) Review of the Problem: Impaired strength and/or mobility . revealed a start date of 10/17/17 and a Description: Related to left side [MEDICAL CONDITION] and [MEDICAL CONDITION] post [MEDICAL CONDITION]. Interventions for this problem were documented as restorative aid, range of motion exercises, with the goal needs to maintain current flexibility and prevent contractures. Further review of Resident #14's medical record revealed Occupational Therapy (OT) added instructions for a palm protector with finger separators on 5/29/18 with the following interventions: - Please place palm shield on (Resident #14) when in bed (in place of previous palm protector). - If finger separators out of place, please fix them - Keeping left arm up on pillow for support will help keep it in place and provide comfort to left arm - If (Resident #14) is having any discomfort with palm shield, please remove and give a break. Attempt to replace in 30 (minutes) - 1 hour. Additional review of Resident #14's care plan Problem: Impaired strength and/or mobility . revealed no documentation of the palm protector as recommended by OT. During an interview on 8/2/18 at 7:46 am, Licensed Nurses (LN) #2 & #5 stated they do not use the care plan binders at the nurse's station and they do not regularly incorporate the care plans into their daily care for residents. They had no knowledge of how care plans were updated. During an interview on 8/2/18 at 9:00 am, the interim MDS Nurse (MDSN) could not state why a revision to a care plan would not be done. She stated revisions are manually completed by the full-time MDSN, who was on vacation at the time of this survey. Review of the facility's policy Care Planning, dated 7/20/16, revealed: The Care Plan is to be considered a dynamic document. It is to be kept up-to-date on a continual basis, and based on the assessed needs of the individual resident. Further review of the policy revealed: The MDS RN-Coordinator is in charge of and responsible for completing, reevaluating and revision of the Resident Care Plan. And Each discipline is encouraged but not required to make changes on the care plan as necessary. These changes can be written on the paper copy of the care plan, in the care plan notebook, or this can be taken to the MDS RN-Coordinator .",2020-09-01
19,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2018-08-03,880,D,0,1,RHGS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure staff performed hand hygiene according to accepted professional practices during the provision of care and services for 1 resident (#4) out of 14 sampled residents. This failed practice increased the risk for the development and transmission of disease and infection in a vulnerable population. Findings: Record review on 7/30/18 - 8/3/18 revealed Resident #4 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of Resident #4 most recent MDS (Minimum Data Set-a federally required nursing assessment), a quarterly assessment dated [DATE], revealed he/she was assessed as totally dependent on staff assistance to eat. During an observation on 7/30/18 at 5:20 pm, Certified Nursing Assistant (CNA) #2 prepared to assist Resident #4 with dinner. The CNA entered the room, washed his/her hands, and donned a pair of gloves. Further observation revealed CNA #2 then went to the bedside picked up a safety mat off the floor, folded it, and placed it against the wall. With the same gloves on, CNA #2 then positioned the Resident's head of bed up and positioned Resident #4 for eating dinner. Further observation revealed CNA #2 positioned Resident #4's food tray on the bedside table and began handling the food and food items without changing the gloves he/she had used to handle the floor mat. CNA #2 mixed all of Resident #4 pureed food together as well as prepared the rest of the tray before he/she changed gloves to assist Resident #4 to eat dinner. During an interview on 7/30/18 at 5:32 pm, CNA #2 stated he/she should have changed gloves and completed hand hygiene prior to making contact with the Resident #4's bed and before preparing his/her food. Review of the facility's competency training Your 5 Moments for Hand Hygiene, no date, revealed: clean your hands after touching a patient and her/his immediate surroundings . Review of the facility's competency training verification Hand Hygiene Verification, dated 3/30/17, revealed when to wash hands: .to perform work in any health care settings are required to clean their hands .also when touching any object or furniture in a patient's immediate surroundings .",2020-09-01
20,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2018-08-03,908,F,0,1,RHGS11,"Based on observation and interview the facility failed to ensure patient care equipment was maintained in safe operating condition. Specifically, the plate warmer in the kitchen, SECO model 66 lacked a preventive maintenance or inventory sticker placing all residents (based on a census of 18) at risk for receiving foods at inconsistent and/or potentially dangerous temperature ranges. Findings: Observations on 7/30 - 8/3/2018 revealed kitchen staff retrieving plates from a SECO model 66 plate warmer. Further observation revealed the equipment lacked a preventive or any type of maintenance or inventory sticker. During an interview on 8/1/18 at 12:25 pm with the Dietary Manager (DM) when asked how maintenance on the plate warmer was completed, the DM reported when the machine breaks we submit a work order and it gets fixed. When asked to see the policy for maintenance/use and owner's manual for the plate warmer the DM was unable to produce these documents. During an interview on 8/1/18 at 2:30 pm with Environmental Services (ES) employee #s 1 and 2, when asked to produce a policy or any documentation for maintenance/use or the owner's manual for the plate warmer they were unable to produce these documents.",2020-09-01
21,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,550,D,1,1,0OWF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, document review, interview, and state statute review, the facility failed to ensure that the rights of a resident with a guardian were exercised to the extent provided by state law. Specifically, the facility failed ensure 1 resident (#1) out of 4 residents reviewed, code status accurately reflected his/her wishes to be comfortable at the end of his/her life and conflicting views were resolved prior to the resident's death. This failed practice placed the resident at risk for pain and suffering from futile traumatic medical treatment. Findings: Record review 8/22-23/19 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #1's most recent MDS (Minimum Data Set- A federally mandated nursing assessment) dated 5/20/19 revealed Resident #1 had a BIMS (Brief Interview for Mental Status) of 15, which indicated no impairment to Resident #1's attentiveness, orientation to person, place, time and situation, and ability to recall events. Record review of POLST (Physicians Orders for Life Sustaining Treatment) dated 3/7/18 revealed that Resident #1 was made a DNR (do not resuscitate). The document was signed by a public guardian. Resident #1 did not sign the document. Review of ethicist note dated 6/5/19 revealed, (Physician #1) spoke to me about the patient's disposition and Code Status. (Resident #1) . admitted to our LTCU (long term care unit) .with multiple medical and behavioral challenges which necessitated the state of Alaska appointing a public guardian through the office of Public Advocacy. (Resident #1's) guardian has the right and responsibility to ensure (his/her) financial, legal, and medical concerns are addressed, and while the courts have declared (him/her) no longer capable of making these decisions, a guardians role is to ensure the patient's wishes are taken into consideration. There has been considerable confusion regarding Code Status based on a POLST document completed in Washington and Alaska that identified DNR/DNI (do not resuscitate/do not intervene). (Physician #1) spoke with (Resident #1) at length about advance care planning and the patient clearly articulated (his/her) desires to remain Full Code. (Physician #1) will speak with the patient guardian to confirm this conversation and obtain assent on the patients request for Full Code. Review of a physician note dated 6/5/19 revealed, Lengthy discussion with (Resident #1) regarding diagnosis, medical management, and plan of care .I stressed that we are doing everything medically to make (him/her) comfortable and prolong (his/her) life. (He/she) admits to refusing care and stopping transfusion early saying that (he/she) gets 'confused' and doesn't want to be a 'pill head'. (He/she) also said that (he/she) did not want a 'bandaid'. (His/her) mortality and code status are brought up on a regular basis by providers and staff in the LTC and (he/she) becomes very anxious. I asked (him/her) when (he/she) is dying does (he/she) want to be comfortable or suffer. (He/she) stated to me that (he/she) wants to be full code until I get to the end, then I will be ready to take what makes me comfortable .(Resident) has state appointed guardian .(Resident #1) does not have decision making capacity. It is not appropriate to ask (him/her) to make medical decisions when (he/she) does not have legal authority to make these decision. Confronting (Resident #1) with (his/her) medical condition and re clarifying code status is not beneficial and I feel it is actually harmful to this patient . Recommendations Code Status-full code until pt is dying, the 2 physicians feel that ACLS (advanced life support) would be non beneficial futile care. When pt is actively dying-change code status to comfort and provide her with comfort measures only, pt understands this is the plan. Document review of the court Order Appointing Full Guardian With Powers of Conservator is dated as 6/6/19 with an unreadable note next to the judge's signature indicating a date of 7/6/19. Review of a Patient Care Coordination note dated 6/8/19 revealed, Pt (patient) has been disenrolled living permanently in SNF (skilled nursing facility) on 6/4/18. Record review of IP (Inpatient) Palliative Care note dated 8/9/19 revealed that Resident #1 was on palliative care. Random review of nursing notes from 6/1/19 through 8/1/19 revealed Resident #1 frequently declined medications, food and water. He/she would take pain medications and other ordered items on occasion. Review of a nursing note dated 8/9/19 revealed, Resident stood up from beside commode unaided without calling for assistance, fell to floor, sustained tibia/fibula (lower leg) fractures. See by hospitalist, awaiting ortho consult. Witnessed by PT (physical therapy) volunteer. Resident said knees gave way and fell . Resident does not use call light. Immobilizer on . Review of nursing notes dated 8/12/19 revealed: 0533- At this time CNA (certified nurse assistant) summoned this nurse to resident's bedside to assess her because residents condition had changed. This nurse immediately went to bedside to assess Residents. Upon entering the room the resident was found to have a pulse and to have agonal breathing (abnormal breathing pattern but short, sporadic gasps of air, common before death). 0535- This nurse immediately called code blue and proceeded to get the crash cart to the resident's room .Supervisor was the first to arrive to the unit to assist with the code. As I attempted to get the pads off the crash cart to place on resident, the Rapid Response Team arrived on unit and at bedside. (Physician #1) was with this group. (Physician #1) proceeded to tell staff not to code the resident. He/she said very loudly a minimum of three times 'nothing is to be done'. This nurse nor the house supervisor was aware that the residents code status had changed. It (code status) was still listed on the computer as full code. (Physician #1) proceeded to inform the staff of the conversations that the care team had with the patient prior to the incident. 0540- (Physician #1) called the time of demise at this time .Supervisor stated for me not to call the family and that he/she would ask Physician #1 to do so. House Supervisor will handle paperwork and proper notifications. Review of physician #1's note dated 8/12/19 revealed, Code blue was called for (patient) who was found without a pulse. When I arrived (he/she) had no pulse and was not breathing. Due to prior conversations with (Resident #1's) MPOA (medical power of attorney), PCP (primary care provider), and ethics committee it was previously determined that (patient) has irreversible, progressive terminal illness/multiorgan failure and given (his/her) decision to refuse care including medications and blood draw and blood [MEDICAL CONDITION] despite severe [MEDICAL CONDITION], that attempting ACLS (Advanced Cardiovascular Life Support) at the time of the (patient's) death would be futile care. Two physicians have concluded that attempting to code (patient) would be futile. (Physician #2) and myself. This plan was discussed with (patient) and (his/her) MPOA, please see note from 6/5/19. (Public Guardian) (Resident's) medical decision maker agreed with plan of care. (Patient's) code status was changed to DNR (do not resuscitate) and a code was not performed. During an interview on 8/23/19 at 3:58 pm the Medical Director (MD) stated that when a Resident lacks capacity for medical decision making, the decisions were deferred to the court appointed decision makers with documentation by two physicians. The MD was unaware if the process was different between the hospital and long term care. The MD was unaware if there was a policy to address these types of issues. During an interview on 8/23/19 at 4:00 pm, request made for policy related to Resident choice on end of life care. No policy was provided prior to exit. During an interview on 9/3/19 at 10:00 am, the Ethicist (ETH) stated that the facility did not have a process or ethics review committees. Staff had met with the Resident and other legal parties to discuss medical issues. The ETH stated there was no hospital directive in regards to Resident #1's case. The ETH was aware that a Public Guardian was unable to make a decision regarding code status but could not reject the medical doctor's recommendation. The ETH further stated that there could have been a different outcome if a different doctor had responded to the code blue. The ETH stated that he/she was aware that Resident #1 wished to remain full code and not to be DNR (do not resuscitate). Review of Alaska Statute 13.26.150(e) states that a guardian may not do the following things: A guardian may not consent on behalf of the ward to the withholding of lifesaving medical procedures. However, a guardian is not required to oppose the withholding of lifesaving medical procedures under certain circumstances where the procedures would only serve to prolong the dying process, unless the ward has clearly stated that life saving medical procedures not be withheld. Review of the facility policy Medically Non-Benefical Treatment (MNBT), reviewed 12/19/18, revealed Patient/Family Conference. If agreement is not reached between the primary treating physician, and the patient or the legally authorized decision-maker, a patient/family family conference facilitated by the Network Director of Mission and Ethics or designee, should be organized .If disagreement persists the Network Director of Mission and Ethics, or designee documents in the patient medical record the underlying conflict(s) and facilitate the conflict guidelines below. 3. Second Physician Review .a second medical opinion from a physician not currently treating the patient who has personally examined the patient and signed a note documenting the findings in the chart .If the second physician confirmed the intervention in question is MNBT then the case is refereed to the ethics committee. .",2020-09-01
22,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,585,F,0,1,0OWF11,"Based on observation, interview, and policy review, the facility failed to: 1) follow the grievance policy on patient care issues, 2) clearly inform residents and/or their families of the process for filing an anonymous grievance, and 3) provide correct information to contact external agencies. This failed practice had the potential to affect all residents of the facility, based on a census of 21, to deny their right to have their grievances investigated with the potential to compromise the quality of care provided by the facility. Findings: An observation on 8/19/19 at 2:54 pm, revealed no grievance box or forms were visible in the common areas. During an interview on 8/21/19 at 11:06 am with the Resident Council, Resident #'s 3, 4, 10, 12, 15, and 174 did not know who the Grievance Officer (GO) was, or where to find the contact information. Resident #16 knew the information was posted in the common area. Residents further stated they did not know how to file a grievance and stated they would talk to the nurses if they had a problem. During an interview on 8/21/19 at 11:32 am, Resident #16 stated that with high nursing turnover, he/she was not always sure who the best staff to ask was when issues came up. During an interview on 8/21/19 at 2:03 pm, Resident #6 stated that he/she had not submitted any grievances and further stated he/she felt it would fall on deaf ears. Resident #6 stated he/she thought the grievance process was sending a letter to the ombudsman and/or state agency. During an interview on 8/21/19 at 3:31 pm, the GO stated he/she did not come to the unit to see the Residents. There was no box or forms available on the unit. He/she was asked by the Activities Coordinator (who arranged the Resident Council meetings) to attend and meet the Residents. The GO stated he/she had attended one meeting since January. The GO stated that grievances could be submitted by phone, through contact with the Director of Nurses, or through variance (incident) reports. When asked how a Resident would file an anonymous grievance, the GO stated Residents could have called the organization integrity line. The GO was unsure if the number was posted. Record review on 8/21/19 at 3:40 pm, revealed two grievances documented in the past 12 months. During an interview on 8/23/19 at 11:06 am, the Administrator (AD) and Quality Improvement Coordinator (QIC) stated that they had no concerns about the grievance process. The AD and QIC could not state why the Residents' unresolved complaints had not been forwarded to the facility as grievances, per the facility policy. The AD and QIC stated they had not identified any trends in care for quality improvement based on the two documented grievances received. An observation on 8/23/19 at 12:06 pm, revealed the patient rights posters on the wall in the main hallway. The poster contained the name, email and number of the GO. No additional information was posted on how to file a grievance. Observation on 8/23/19 at 3:31 pm, revealed an 8.5 x 11 sheet of paper with 12 font Arial, bold print taped approximately 5 feet height on the wall behind the dining table seats that stated the Residents had the right to file grievances orally, in writing, and anonymously with a list of numbers and emails. The email for Health Facilities Licensing and Certification was incorrect and the Ombudsman contact number was not to the complaint line, but the direct number for the Ombudsman. There was no specific information on which contact option allowed for an anonymous grievance. Review of the facility policy entitled, Resident Grievance, with an effective date of 3/9/10 revealed Residents and/or families have the right to file grievances orally (meaning spoken) or in writing; and to file grievances anonymously . The policy explained the contact options to include, .telling any caregiver, contacting the grievance officer, calling and leaving voicemail on the local Grievance telephone line or any toll free numbers titled, 'Hotline to the Heart', writing a letter or email to the GO, the LTC Director of Nursing (DON), or Administrator .also directly to the State Health Care Facility Licensing agency or the LTC Ombudsman's Office . The policy stated, When a resident expresses dissatisfaction, or concern or makes a complaint during the episode of care, the caregiver present at the time of complaint: 3:1 Acknowledges the Complaint without expressing judgement and asks the resident what action(s) he/she feels are needed to resolve their concern; 3:2 Resolves the issues independently, at the point of care, as quickly as possible; 3:3 Follows up with the resident after the corrective action to determine if the issue has been resolved to the resident's satisfaction. 3:4 The Caregiver is to file an Electronic Incident Report (EIR) .4. If a resident care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or required further action for resolution, then the complaint is a grievance for the purposes of these requirements. 5. If the issue is not resolved to the resident's satisfaction during the episode of care, the Complaint will be escalated to the Grievance Officer (GO) for resolution, at which time it will be handled as a Grievance. 6. The Director of Nursing, and/or Patient Care Administration will be contacted, who will then contact the Grievance Officer. 7. The caregiver may also contact the GO directly.",2020-09-01
23,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,600,D,0,1,0OWF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure that a resident was from free from racially directed verbal abuse by another resident for 1 resident (#6) out of 14 sampled residents. This failed practice had the potential to cause the resident to experience humiliation, shame and/or degradation. Findings: Record review on 8/19-23/19 revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. During an interview on 8/21/19 at 8:14 am, Resident #6 stated that another Resident of the facility had used racially biased language directed at him/her. Resident #6 further stated that staff blew off Resident #6's concerns by making excuses for the other Resident. Resident #6 identified a single Resident as the perpetrator of the verbal abuse and stated that staff had not done anything to address the abuse or prevent it from re-occurring. Resident #6 stated that he/she was directed to avoid the perpetrator or go to his/her room if the perpetrator was present in the common areas. Resident #6 stated he/she felt insulted and abused by the racial verbal abuse and was angry that staff did not make efforts to address the abuse. During an interview on 8/21/19 at 10:00 am, Licensed Nurse (LN) #4 stated that he/she had heard of altercations between Resident #6 and the alleged perpetrator. LN #4 stated that re-direction was given to the perpetrator but that he/she often continued the behaviors despite re-direction. LN #4 did not think the language was aggressive but that the Resident perpetrator, was asking for a change in the situation by voicing his/her displeasure about living with people of a race he/she felt was undesireable. LN #4 did not know if there was an investigation or action taken to protect Resident #6 from further abuse. During an interview on 8/22/19 at 2:00 pm, the Director of Nursing (DON) stated there was not any additional policy or procedure that addressed Resident to Resident verbal, physical, emotional or sexual abuse. During an interview on 8/22/19 at 2:28 pm, LN #2 and Certified Nurse Assistant (CNA) #2 stated they were unsure of a procedure for protecting Residents against abuse from other Residents. LN #2 had not witnessed the racially based verbal abuse of Resident #6 but had heard there was an issue during shift report. LN #2 and CNA #2 both stated that the alleged perpetrator had a history of [REDACTED]. LN #2 and CNA #2 did not think it had been reported as a grievance or been through an investigation process. They felt Resident #6 was fine because he/she was cognitively intact and understood the perpetrator was not. During an interview on 8/22/19 at 4:02 pm, LN #4 stated there were no additional policies or procedures that addressed Resident to Resident verbal, physical, emotional or sexual abuse. Review of a policy and procedure entitled, State Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act, with an effective date of 2/5/13 did not contain any information on process for Resident to Resident abuse.",2020-09-01
24,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,610,D,0,1,0OWF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure that a resident was from free from racially directed verbal abuse by another resident for 1 resident (#6) out of 14 sampled residents. This failed practice had the potential to cause the resident to experience humiliation, shame and/or degradation. Findings: Record review on 8/19-23/19 revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. During an interview on 8/21/19 at 8:14 am, Resident #6 stated that another Resident of the facility had used racially biased language directed at him/her. Resident #6 further stated that staff blew off Resident #6's concerns by making excuses for the other Resident. Resident #6 identified a single Resident as the perpetrator of the verbal abuse and stated that staff had not done anything to address the abuse or prevent it from re-occurring. Resident #6 stated that he/she was directed to avoid the perpetrator or go to his/her room if the perpetrator was present in common areas. Resident #6 stated he/she felt insulted and abused by the racial verbal abuse and was angry that staff did not make efforts to address the abuse. During an interview on 8/21/19 at 10:00 am, Licensed Nurse (LN) #4 stated that he/she had heard of altercations between Resident #6 and the alleged perpetrator. LN #4 stated that re-direction was given to the perpetrator but that he/she often continued the behaviors despite re-direction. LN #4 did not think the language was aggressive but that the Resident perpetrator was asking for a change in the situation by voicing displeasure about living with people of a race he/she felt living with was undesirable. LN #4 did not know if there was an investigation or action taken to protect Resident #6 from further targeted abuse. During an interview on 8/22/19 at 2:00 pm, the Director of Nursing (DON) stated there was not any additional policy or procedure that addressed Resident to Resident verbal, physical, emotional or sexual abuse. During an interview on 8/22/19 at 2:28 pm, LN #2 and Certified Nurse Assistant (CNA) #2 stated they were unsure of a procedure for protecting Residents against abuse from other Residents. LN #2 had not witnessed the racially based verbal abuse of Resident #6 but had heard there was an issue during shift report. LN #2 and CNA #2 both stated that the alleged perpetrator had a history of [REDACTED]. LN #2 and CNA #2 did not think it had been reported as a grievance or been through an investigation process. They felt Resident #6 was fine because he/she was cognitively intact and understood the perpetrator was not entirely. During an interview on 8/22/19 at 4:02 pm, LN #4 stated there were no additional policies or procedures that address Resident to Resident verbal, physical, emotional or sexual abuse. Review of a policy and procedure entitled, State Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act, with an effective date of 2/5/13 did not contain any information on process for Resident to Resident abuse but addressed staff and or family mistreatment, neglect, abuse, exploitation, and/or misappropriation of property.",2020-09-01
25,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,637,D,0,1,0OWF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement care plan interventions within 14 days after an identified significant change in a resident's physical condition that impacted the ability to maintain independence and complete activities of daily living for 1 resident (#6) out of 14 sampled residents. This failed practice had the potential to cause further decline in the resident's ability to complete independent hygiene and self-care activities. Findings: Record review on 8/19-23/19 revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #6 had difficulty walking and used a wheelchair for mobility. During an interview on 8/21/19 at 8:32 am, Resident #6 stated that he/she was concerned because he/she had gained approximately 80 pounds since admission. Resident #6 stated that the facility had not addressed his/her weight gain. Resident #6 stated the weight gain had caused difficulty to independently attend to activities of daily living. Record review of the weight chart revealed that Resident #6 weighed 166.2 kilos on 2/27/19 and 191.1 on 8/20/19. The weight calculator revealed a 14.98% weight gain in slightly less than 6 months. During an interview on 8/21/19 at 1:53 pm, Resident #6 stated that he/she had discussed the weight gain with both the doctor and the dietitian. Resident #6 further stated he/she had not been provided with any information or options to address the weight gain. During an interview on 8/21/19 at 3:16 pm, the Registered Dietitian (RD) stated that Resident #6 was difficult because he/she would not follow diet recommendations, bought food from outside, and failed to follow recommendations of the staff and RD. The RD further stated that the weight gain could be due to fluid retention, that Resident #6 had been on fluid restriction, but that there were not current restrictions. Record review of Resident #6's admission MDS (Minimum Data Set- a federally mandated assessment tool), dated 3/6/19 revealed the Resident was independent with transfers and personal hygiene. The most recent quarterly assessment dated [DATE], revealed the resident now required extensive assistance in transfers and personal hygiene. During an interview on 8/22/19 at 1:47 pm with the MDS Coordinator (MDSC), he/she stated that he/she felt Resident #6 had experienced a significant change in functional ability but did not complete a significant change update. The MDSC further stated that the change had been discussed in the care conference meeting but the team thought the weight gain was due to Resident #6's personal choices so it was not addressed. When asked if a significant change assessment should have been done for Resident #6, the MDSC replied, probably, yes.",2020-09-01
26,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,657,D,0,1,0OWF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to update and revise the care plan to reflect the current care and services for 2 residents (#s 6 and 17) out of 14 sampled residents. This failed practice placed the residents at risk for not receiving appropriate and/or necessary care and services. Findings: Resident #6 Record review on 8/19-23/19 revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #6 had difficulty walking and used a wheelchair for mobility. During an interview on 8/21/19 at 8:32 am, Resident #6 stated that he/she was concerned because he/she had gained approximately 80 pounds since admission. Resident #6 further stated the facility had not addressed his/her weight gain and the weight gain had caused difficulty to independently attend to his/her activities of daily living. Record review of the weight chart revealed Resident #6 weighed 166.2 kilograms on 2/27/19 and 191.1 kilograms on 8/20/19. The weight calculator revealed a 14.98% weight gain in less than 6 months. During an interview on 8/21/19 at 1:53 pm, Resident #6 stated he/she had discussed the weight gain with both the doctor and the dietitian. The Resident further stated he/she had not been provided with any information or options to address the weight gain. During an interview on 8/21/19 at 3:16 pm, the Registered Dietitian (RD) stated Resident #6 was difficult because he/she would not follow diet recommendations, bought in food from outside the facility, and failed to follow recommendations of the staff and RD. The RD further stated the weight gain could be due to fluid retention and Resident #6 had been on fluid restrictions, but that there were no current restrictions. Record review of Resident #6's most recent MDS (Minimum Data Set- a federally mandated assessment tool), a quarterly assessment dated [DATE], revealed the increased need for assistance in the following areas of functional status independence; 1) transfer from bed, wheelchair, standing, 2) dressing, and 3) personal hygiene. Record review of the Resident #6's most recent care plan revealed no changes to the care plan since initiation on 2/27/18. Interventions implemented in the care plan related to weight loss, and include monitoring weight trends (with) [MEDICAL CONDITION], I&0s (intake and output) . During an interview on 8/22/19 at 1:47 pm, the MDS Coordinator (MDSC), stated she felt Resident #6 had experienced a significant change in functional ability and she did not complete a significant change update. The MDSC further stated that the change had been discussed in the care conference meeting but the team thought the weight gain was due to personal choices so it was not addressed. When asked if a significant change assessment should have been done for Resident #6, the MDSC replied, probably, yes. Resident #17 Record review from 8/19-23/19 revealed Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #17's weight log for the timeframe of 2/24/19-8/18/19 revealed the resident had a history of [REDACTED]. The documented weights revealed the most recent weight on 4/28/19 was 41.2 kg and a weight done on 2/24/19 revealed 47.7kg. During an interview on 8/21/19 at 3:14 pm, the Registered Dietician (RD) stated Resident #17 had been refusing to be weighed, however his/her observation revealed weight lost. The RD stated he/she had made adjustments to the Resident's diet to help decrease the weight loss, such as initiation of finger foods. The RD further stated that Resident #17's intake had improved since the initiation of the finger foods. Review of Progress Note LTC (long term care) Initial/Re-assessment Visit, dated 7/18/19 revealed Diet orders are in place offering a mechanical soft diet with finger foods for ease of intake and independence with self-feeding. Resident #17's current diet was Diet General; Mechanical soft; Finger Foods. Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, an annual assessment dated [DATE], revealed Nutrition approach .Mechanically altered diet. Review of the Resident's most current care plan entitled Multidisciplinary Problems (Active), not dated, revealed Current Diet: Diet General; High protein with start date 8/27/18. There was no documentation of finger foods in the care plan. During an interview of 8/22/19 at 1:33 pm, the MDSC stated the Resident's care plan should have been updated to state the nutrition recommendations with the finger foods added to the care plan.",2020-09-01
27,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,684,D,0,1,0OWF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide treatment in accordance with professional standards for 1 (#10) resident out of 14 sampled residents. Specifically, the resident was receiving oxygen without a physician's order. This failed practice placed the resident at risk for receiving less than optimal care and incorrect treatments. Findings: Record review from 8/19-23/19 revealed Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set, a federally required nursing assessment), assessment dated [DATE] revealed the Resident did not use oxygen therapy. Review of Resident #10's H&P (history and physical), dated 6/17/19, revealed Continue respiratory medications .oxygen as needed. An observation on 8/19/19 at 4:00 pm revealed the Resident lying in bed with his/her eyes closed and wearing oxygen via nasal cannula (oxygen delivery system tubing). During an interview on 8/20/19 at 9:45 am, Resident #10 stated he/she wore oxygen mostly while he/she slept. The oxygen in the Resident's room was turned on at 3 l/min (liter per minute of oxygen flow). The nasal cannula was positioned next to the Resident in the Resident's bed. During an interview on 8/22/19 at 8:40 am, Licensed Nurse (LN) # 4 stated Resident #10 used oxygen as needed. LN #4 further stated that the Resident would use the oxygen when the Resident had chest pain. During an interview on 8/22/19 at 12:40 pm, LN # 2 stated Resident #10 used oxygen as needed. He/she would check the Resident's oxygen saturation (a noninvasive test to see how much oxygen is in the blood stream) and would provide the Resident oxygen as needed. A review of Resident #10's most recent physician's orders with LN # 2 revealed no physician order for [REDACTED].# 2 further stated that he/she would call the physician for the oxygen order. During an interview on 8/22/19 at 1:44 pm, LN # 4 stated he/she did not know if a physician order was required for oxygen use of 2 l/min or less, that oxygen use may have been at the LN discretion. A copy of the facility's policy for oxygen was requested of LN #4 at this time and was not provided by the close of the survey. A review of Resident #10's care plan Multidisciplinary Problems (Active), not dated, revealed no interventions for oxygen therapy. During an interview on 8/22/19 at 1:50 pm, the MDS Coordinator stated that oxygen therapy should be documented on the Resident's care plan. The MDS Coordinator further stated that a physician's order for oxygen would have triggered him/her to add oxygen to the care plan. According to Nurses Service Organization, accessed 9/9/19 at https://www.nso.com/Learning/Artifacts/Articles/Administer-meds-without-a-doctor-s-order-Proceed> Registered nurses generally should administer medications only with a physician's order .Giving a patient medication .without a physician's or nurse practitioner's knowledge has many risks. Most important, the medication could be contraindicated, even if it seems innocuous.",2020-09-01
28,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,686,D,1,1,0OWF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure one resident #2 (out of 4 residents) reviewed for pressure injuries, did not develop an avoidable stage 2 pressure injury(partial thickness skin loss with exposed dermis (second layer of skin)presenting as a shallow open ulcer) . This failed practice caused the resident unnecessary pain, an increased risk for infection, and the potential for poor medical outcome. Findings: Pressure injury According to the National Pressure Ulcer Advisory Panel, accessed 9/7/19 at www.nouap.org A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Record review from 8/20-23/19 revealed Resident # 2 was admitted to facility with [DIAGNOSES REDACTED]. a clot of blood), and [MEDICAL CONDITION]. Review of the most recent Minimum Data Set (MDS-a federally mandated assessment) a quarterly assessment dated [DATE] revealed the Resident had no pressure injuries. Further review of the MDS revealed Resident #2 was non-ambulatory, totally dependent on staff for bed movement, locomotion in the wheelchair, bathing, and needing extensive assistance (requiring two personal physical assistance) for dressing, toileting, transfers, and personal hygiene. Review of Resident #2's care plan Problem: Additional Communication Problem .Start: 9/07/18 Description: (Resident) is non-verbal, unable to speak .Problem: Requires extensive assistance/dependent with mobility and ADL's (activities of daily living) .Goal: Resident will receive max (maximum) assistance with mobility and ADL's .Start 3/23/17 Expected End: 8/31/19 . Intervention: Provide total assist with dressing .Start: 3/23/17 Description: 2 person assist . Further review of the care plan revealed no documentation of Resident # 2 pressure injury of the right great toe or how to care for the Resident with this. Record review of Wound Assessment: Pressure injury Date: 06/24/19 Location: Right great toe . site Distal right great toe .Length 0.8 cm Width 0.9 cm Depth 0cm . Treatment/dressing: Open to air Dressing type: Open to air. Wound noted during skin assessment. Appears to have been caused by shoes that resident was wearing prior to bath. Shoes have been removed from the room. Staff is educated to keep pressure off the toe and not to put shoes on resident at this time. Record review of Nursing Note (NN) dated 6/24/19 at 3:15 pm, revealed On bath day skin assessment, writer noticed a red, non-blanchable area on distal portion of right great toe. Charge nurse to bedside to assess. Appears to be pressure related injury. Record review of a NN dated 6/25/19 at 11:30 am, revealed Provider made aware of new pressure injury with no new orders noted at this time. Resident's daughter made aware of injury as well as plan to use socks instead of shoes to prevent further pressure. During an interview 8/21/19 at 10:24 am, with Licensed Nurse (LN) #4 stated they (the facility) was not able to determine how long Resident # 2 had been wearing the shoes of another resident. The other resident whom was Resident # 2 former roommate (whom passed away 3/27/19). The skin injury on the right great toe tip was noticed on the Residents bath day 6/24/19 by the Certified Nurse Assistants (CNAs) who reported to LN #4. LN #4 assessed the wound, documented with pictures, and received orders from the provider for the wound team to treat the skin injury. During an interview on 8/22/19 at 2:06 pm, with the MDS Coordinator (MDSC), when asked if Resident #2's care plan contained information on the pressure injury and how to care for the Resident, the MDSC stated the care plan did not have the information in it and he/she would expect it to be in the care plan.",2020-09-01
29,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,687,D,0,1,0OWF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to ensure proper treatment and care was provided to maintain good foot health in accordance with professional standards was provided to 1 resident (#6) out of 14 sampled residents. This failed practice had the potential to cause the resident discomfort and prevent necessary foot care to prevent development of foot problems secondary to the disease process. Findings: Record review on 8/19-23/19 revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #6 had difficulty walking and used a wheelchair for mobility. During an interview on 8/21/19 at 8:45 am, Resident #6 stated that he/she needed to have his/her toenails trimmed. Resident #6 stated that he/she had asked nursing staff for several months and was told a podiatrist appointment had to be scheduled. Resident #6 was concerned about his/her feet as he/she was unable to complete the task independently. Record review on 8/21/19 at 10:00 am, of Resident #6's undated, most recent care plan provided by facility staff, revealed for the problem area of Alteration in skin integrity, an intervention that Resident #6 would receive, .weekly full body skin and nail assessment by primary RN, with a start date of 2/27/19. There were no documentation of toenail assessment and findings. During an observation on 8/21/19 at 1:06 pm, Resident #6's toenails were long, some were jagged from being broken, and his/her socks caught on the jagged pieces. During an interview on 8/21/19 at 1:08 pm, when asked how often residents get nail care, Certified Nurse Assistant (CNA) #2 stated as needed. When asked if Resident #6's toenails looked like they needed trimmed, CNA #2 stated yes. During an interview on 8/21/19 at 1:10 pm, LN #4 stated that if the Resident was not diabetic, toenails could be clipped by facility staff. LN #4 further stated that nursing staff would review, and if needed, would make an appointment with the podiatrist. Podiatry appointments happen monthly. During an interview on 8/21/19 at 2:19 pm, Resident #6 stated he/she had asked for toenail care more than once, but when he/she got no response, he/she stopped asking. During an interview on 8/21/19 at 2:21 pm, the Activities Coordinator (AC) stated that toenail care was discussed quarterly at care conference meetings. The AC further stated nursing staff check on the Residents during bathing and/or cares, to assess toenail needs between quarterly conferences. When asked specifically about Resident #6, the AC stated that he/she had not had any podiatry appointments and was not on the schedule for a podiatry appointment. During an observation on 8/21/19 at 2:46 pm, of Resident #6's feet, LN #4 stated that Resident #6's toenails were long and the big toe was somewhat thickened and would need a referral to the podiatrist to get the toenails clipped. Record review on 8/21/19 at 2:52 pm, revealed no prior notes for toenail care from the podiatrist.",2020-09-01
30,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,689,D,0,1,0OWF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure; 1) a malfunctioning bed was recognized and removed from service in a timely manner for 1 (#17) out of 14 sampled residents, and 2) staff were trained on the proper use of the bed. Specifically, the resident was lying in a malfunctioning bed for an unknown length of time. This failed practice created a potential risk for harm and/or injury from 1) potential improper inflation leading to increased risk of pressure ulcers and 2) risk of entrapment from potentially improper inflation of the mattress and impingement of bed rails. Findings: Record review from 8/19-23/19 revealed Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. An observation on 8/19/19 at 4:00 pm, revealed the Resident lying on an air mattress in his/her [NAME]-rom (a brand of facility) bed, with both upper 1/2 bed rails in the up position. The monitor at the foot of the bed was blinking with a service required message, and a yellow light was illuminated below the monitor. An observation on 08/20/19 at 1:49 pm, revealed Resident #17 lying in bed, with both upper 1/2 bed rails in the up position. The monitor read please call [NAME]-rom [PHONE NUMBER] service code 7,and a yellow light was illuminated below the monitor. An observation on 08/21/19 at 2:47 pm, revealed the Resident's bed was functioning properly. There was no error message and a green light was illuminated. A dressing change to the Resident's head was attempted by Licensed Nurse (LN) #1. LN #1 lowered the head of the Resident's bed prior to the procedure. Once the head of the bed was lowered, the service required message reappeared on the monitor, and the yellow light was illuminated. When the head of the bed was raised back up, the air mattress began working properly. During an interview on 8/21/19 at 2:49 pm, LN #1 stated he/she was not aware of any problems with the Resident's air mattress. An observation on 8/22/19 at 8:01 am, revealed Resident #17 lying in bed, with both upper 1/2 bed rails in the up position. The monitor of resident's bed revealed a service required message, and a yellow light was illuminated. During an interview on 8/22/19 at 10:00 am, LN #4 stated he/she was not aware of any problems with Resident #17's bed, or any service codes. LN #4 further stated that the [NAME]-rom bed would have had an audible alarm if it was not functioning properly. During an interview on 8/22/19 at 11:00 am, the Biomed Staff (BMS) stated he/she was not aware of any bed malfunctions, and no service issues were reported to him/her. During an interview on 8/22/19 at 11:52 am, the BMS stated Resident #17's bed was taken out of service and the Resident was moved onto a new bed. The malfunctioning bed was placed in an empty room. The BMS stated he/she contacted [NAME]-rom and was told error message 7 indicated a malfunction of the mother board. The BMS turned the damaged bed on, and audible alarms started beeping with error codes 3 and 4 illuminating on the monitor. The BMS stated that was indicative of a problem right away. The BMS stated if there was a problem with the bed, an audible alarm would sound and a yellow light would illuminate. When asked how staff would know this information, the BMS stated staff could have referred to the manual attached to the foot of each bed. An observation on 8/22/19 at 11:55 am, revealed no manual attached to the foot of the Resident's malfunctioning bed. The BMS stated there should have been a manual provided with each bed. The BMS further stated that he/she does not train staff regarding the [NAME]-rom beds. During an interview on 8/23/19 at 11:06 am, the Administrator (AD) stated that the BMS attended the Quality Improvement/Performance Improvement (QAPI) committee meetings but the focus was on the equipment safety and not staff training. The AD further stated that staff were trained on equipment during new hire training and during annual mandatory training fairs. When asked what the process was for addressing malfunctioning equipment, the AD stated that the staff would check the sticker on the piece of equipment, alert the charge nurse, and place a phone call for a work order. The AD stated that the facility had been trying to order two new air beds due to an issues with malfunctioning beds. Document review of the most recent Facility Assessment, dated (MONTH) & (MONTH) 2019, revealed no plan for staff training on new or standard medical equipment such as air mattresses or other resident specific equipment. During an interview on 8/23/19 at 12:48 pm, LN #2 and LN #3 stated that they had not received training on the new beds, and the facility had not yet offered that training to staff. LN #2 further stated that if he/she was familiar with new equipment, he/she would have educated Certified Nursing Assistants (CNAs) individually. LN #2 and LN #3 were both unaware of a process for facility wide training for all staff when new equipment was introduced. During an interview on 8/23/19 at 1:32 pm, CNA #1 stated that sometimes the facility provided training on new equipment but other times the staff would have ask the boss. When asked how they would know if the equipment was malfunctioning, CNA #1 stated, common sense. A review of Multidisciplinary Problems (Active)' not dated, revealed Problem: Alteration in skin integrity . with start date 5/10/16, with Goal: Resident will be free of any skin breakdown or pressure ulcers . An intervention listed included Verify and document use of pressure reduction mattress for wound prevention. A review of a physician progress notes [REDACTED]. A review of Multidisciplinary Problems (Active)' not dated, revealed Problem: Risk for injury r/t (related to) assist device (s) on bed ., with start date 5/10/16, with Goal: Resident will be free from injury associated with assist device (s) on bed.",2020-09-01
31,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,690,D,0,1,0OWF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure 1 resident's (#8) catheter, of 4 sampled residents with an indwelling catheter, was secured to prevent free movement of tubing and discomfort. This failed practice placed the resident at risk for discomfort, pain, trauma and further catheter complications. Findings: Urinary Catheter or UTI Resident #8 Review of the most recent quarterly Minimal Data Set (MDS-federally required nursing assessment), dated 6/18/19, revealed Resident #8 was coded as having an indwelling catheter. During an observation on 8/20/19 at 2:00 pm revealed Certified Nurse Assistant (CNA) #3 was providing activities of daily living cares to Resident #8. While the CNA was dressing the Resident, the catheter tubing was noted to be passed through a securing device adhered to Resident #8's left inner thigh. The clamp on the securing device ([MEDICATION NAME] Foley Stabilization Device) was over the tan-colored catheter tubing approximately 4 inches above the bifurcation section (area that contained the balloon control port and the connection to the clear drainage tubing). As a result, the tan-colored tube was observed to freely slide up and down through the securing device. During an interview on 8/20/19 at 2:00 pm, CNA #3 was asked if the catheter tube was properly secured to the Resident's left inner thigh. CNA #3 stated the securing device should have held the tubing in place. During a subsequent observation on 8/20/19 at 2:10 pm, CNA #3 proceeded to secure the tubing in the securing device but was unable to do so successfully. During the CNA's attempt to secure the catheter tubing, Resident #8 yelled out in discomfort and stated it was uncomfortable when the CNA was pulling on the catheter tubing. During an observation on 8/21/19 at 1:09 pm, Licensed Nurse (LN) #4 assessed the securing device for Resident #8's catheter. LN #4 stated the catheter tubing was not properly held in place by the securing device. Next, LN #4 attempted to secure the tubing but was unable to successfully place the tubing in the device to prevent movement. During the observation, Resident #8 was grimacing and stated it was uncomfortable while LN #4 was attempting to secure the tubing. During an interview on 8/21/19 at 1:11 pm, LN #4 stated the tubing was not properly secured to prevent movement of the catheter tubing. LN #4 further stated the catheter tubing and the securing device were not compatible because the securing device clamp was too small for the catheter tubing. During an interview on 8/21/19 at 1:16 pm, LN #1 stated he/she was able to secure the catheter tubing to the inner thigh securing device by placing only the balloon control port inside the securing device's clamp. Review of the undated [MEDICATION NAME] Foley Stabilization Device Information Guide, revealed the bifurcation area of the catheter should be placed in the clamp. Specifically, both the balloon control port and the area immediately above the junction of the tan-colored tubing and the clear draining tubing should be secured under the clamp. The information guide did not indicate to only secure the balloon control port. Further review revealed the securing device was designed to reduce the risk of pulling on the catheter which could have caused pain and trauma. In addition, the information guide stated the securing device was to provide a comfortable, secure and hygienic placement of the catheter away from areas of the body that could have led to bacteria contaminating the surface of the catheter. Review on 8/21/19 at 1:20 pm of the facility's CAUTI (Catheter Associated Urinary Tract Infection) Prevention Bundle Book, dated 8/20/19 revealed the day and night shift nurses documented Resident #8's securement device was properly used and the tubing was free from kinks and dependent loops. Further review revealed the day nurse on 8/21/19 also documented the securement device was properly used and the tubing was free from kinks and dependent loops.",2020-09-01
32,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,812,F,1,1,0OWF11,"> Based on observation, interview and record review the facility failed to ensure: 1) Food was stored, prepared and distributed in a safe and/or sanitary manner in accordance with professional standards and 2) the environment was maintained and monitored in a clean and sanitary condition. This failed practice placed all residents (based on a census of 21) at risk for foodborne illness. Findings: Food Storage/Cleanliness: During random observations on 8/19/19 of the central kitchen's dry storage area revealed: - 27 eight ounce cans of Nepro Supplement with best by dates of 8/1/19; - 1 case of Tostito's chips stored on the floor; - Shredded Sauerkraut (6 lbs 3 oz) with large dent located on the seal; - Sliced nacho jalapeno peppers with a 2 inch dent located just below the can's seal; and - 50 oz can of cream of mushroom with 1 inch dent located on the can's seal. During an interview on 8/19/19 at 2:00 pm the Dietary Manager stated the items identified in the dry storage should have been removed. Review of the U.S. Department of Health and Human Services (USDHHS) - Food and Drug Administration (FDA) Food Code, dated (YEAR), revealed Food shall be safe, unadulterated .dented cans may .present a serious potential hazard. During random observations on 8/19/19 of the central kitchen's walk-in cooler revealed a cracked and leaking plastic container of thawed pot roast. A leak of red tinged fluid that was dripping on the shelving unit and on the top of the plastic bin just below the pot roast. Review of the USDHHS - FDA Food Code, dated (YEAR), revealed food shall be protected from cross contamination by separating raw animal foods during storage. During an interview on 8/19/19 at 2:10 pm the Dietary Manager stated he/she was unaware of the leaking container and it should have been removed from service. During an observation on 8/19/19 of the central kitchen's walk-in freezer revealed a four pound package of salami slices that were open-to-air. The salami slices had frozen white crystals and appeared to be pale and green in color. Review of the USDHHS - FDA Food Code, dated (YEAR), revealed food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulterations or potential contaminants. During an observation on 8/19/19 of the central kitchen's cooking area revealed: - 27 eight ounce cans of Glucerna 1.2 cal with an expiration date of 8/1/19; - Dietary Aide Cooler in central kitchen contained approximately 1 inch of white frozen crystals on the interior back wall; and - Chef Fridge had large amounts of food debris located on the lower shelf behind stored boxes of food. Further observation revealed a 16 oz piping bag of whipped cream with the tip of the bag wrapped in a paper towel that was stuck to the tip by dried whipped cream. During an interview on 8/19/19 at 2:30 pm, the Dietary Manager stated he/she was not sure the last time the chef fridge and kitchen aide cooler were cleaned and/or defrosted. Random observations from 8/19-22/19 revealed food debris and dust build up in multiple kitchen drawers, under equipment and serving areas. During a second interview on 8/21/19 at 3:10 pm, the Dietary Manager stated he/she was unable to provide any documentation related to cleaning logs as the facility had not maintained the cleaning binder since (MONTH) of (YEAR). Review of the USDHHS - FDA Food Code, dated (YEAR), revealed the person in charge should have the ability to describe the relationship between the prevention of foodborne illness and the management and control of the facility in a clean condition. Further review revealed food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulterations or potential contaminants. Cleaning/Food Quality Duties: Review of the central kitchen's staff position descriptions, revision date 3/16/15, revealed the position #11 (Morning Cook) was to ensure daily that all items in chef cooler and freezer were labeled and dated; waste any outdated items and check cleaning binder. Further review revealed position #11 was to walk through the kitchen, dry storage, walk in coolers and freezers to check for any food safety or sanitation problems during each shift. Review of the central kitchen's employee schedule, dated 8/17-24/19 revealed position #11 was scheduled each day. Review of the central kitchen's staff position descriptions, revision date 3/16/15, revealed the position #13 (Morning Dietary Aide) was to ensure all items are labeled and dated and waste old items in the Diet Aide refrigerator and freezer daily. Review of the central kitchen's employee schedule, dated 8/17-24/19 revealed position #13 was scheduled each day. Review of the central kitchen's staff position descriptions, revision date 3/16/15, revealed the position #18 (Cook/Stocker/Support) was to pull out meats to thaw and place them in a bin to contain the juices; check cleaning binder to ensure dry storage, chef's freezer, walk-in freezer, and underside of grill and oven were cleaned. Review of the central kitchen's employee schedule, dated 8/17-24/19 revealed position #18 was scheduled each day. Review of the central kitchen's staff position descriptions, revision date 3/16/15, revealed the position #21 (Evening Cook) was to have cleaned the chef's freezer and fridge inside and out on Mondays; clean the plate warmer and grill area by pulling out the equipment; and clean out chef's refrigerator's on Saturday. Review of the central kitchen's employee schedule, dated 8/17-24/19 revealed position #21 was scheduled daily. Review of the central kitchen's staff position descriptions, revision date 3/16/15, revealed the position #23 (Evening Dietary Aide) was to ensure all items are labeled and dated and waste old items on Sundays in the cooler and refrigerator. Review of the central kitchen's employee schedule, dated 8/17-24/19 revealed position #23 was scheduled to be completed on 8/17/19. Review of the central kitchen's staff position descriptions, revision date 3/16/15, revealed position #'s 13; 16 (Food Preparation); and 23 were to ensure all items were within date and discard any dented cans. Review of the central kitchen's employee schedule, dated 8/16-24/19 revealed position #s 13; and 23 were scheduled daily. Further review revealed position #16 was scheduled Monday through Friday. Review of the facility's food service policy Cleaning, review date of 8/20/19, revealed the staff were to have clean all kitchen equipment on a regular schedule and utilize the cleaning checklist to insure periodic cleaning of all non-food contact surfaces. Food Handling: During an observation on 8/20/19 at 11:45 am Dietary Staff (DS) #2 was plating food for residents of the long term care unit. During the observation DS #2 used right gloved hand and a scoop to obtain a serving of ground chicken. Next, DS #2 used the left gloved hand to push ready-to-eat ground chicken into the scoop and continued to use the left hand to cover the scoop as it was transported to the plate. This was repeated for two resident's lunch meals. During the lunch observation, DS #2 was observed using the unchanged left gloved hand to obtain various items around the kitchen such as blenders, open containers and plates in between plating meals and touching the meat directly. No hand hygiene or glove change was conducted during the observation. During an observation on 8/21/19 at 11:45 am DS #1 directly handled carrots with gloved hand after touching handles of serving utensils. DS #1 would next wipe gloved hand on washcloth which was resting on the left side of the counter, then continued to plate food. After using a knife to cut food items, DS #1 wiped off the knife with the same washcloth used to wipe gloved hands, touched bread with same gloved hand, then wiped off counter with same washcloth. When soiled, DS #1 then rinsed the washcloth in the sink located next to the serving line, which had an open bag of thawing chicken under continuously running water. During an observation on 8/21/19 at 11:55 am DS #1 grabbed ready to eat chicken with gloved hand and plated the meat. Next, DS #1 grabbed other utensils and continued plating the meat. DS #1 proceeded to wipe the knife with a wet washcloth located on the left side of the counter and continued to directly plate meat with unchanged gloved hand. This process was repeated multiple times during the lunch observation. No hand hygiene or glove change was conducted during the observation. Review of the USDHHS - FDA Food Code, dated (YEAR), revealed when utilizing single-use gloves they shall be used for only one task such as working with ready-to-eat foods and used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. During an interview on 8/21/19 at 12:00 pm, DS #1 stated the washcloths he/she was using was to wipe gloved hands, and knife. When asked if the washcloth was rinsed in the sink with thawing chicken, DS #1 stated yes. Review of the facility's Food Service policy Food Handling, last review date of 8/20/19, revealed .compliance reduces the risk of food contamination .Food handling is at all times in compliance with federal, state, and local sanitation and safety laws and regulations. During an interview on 8/22/19 at 9:11 am, the Infection Preventions stated that potentially contaminated gloves should be discarded when completing different task. Sanitation During an observation on 8/20/19 at 11:40 am DS #1 prepared a sanitation compartment of the three-sink method (alternative method to manually wash kitchen utensils and cutlery). DS #1 turned the hot and cold valves to an open position. Next, DS #1 turn a knob on box labeled ECOLAB APEX Solid Quat Broad Range Sanitizer which mixed the sanitizer and the water supplied by the faucet. During an interview on 8/20/19 at 11:40 am DS #1 was asked to explain the sanitation process. DS #1 stated that he/she would test the sanitation/water mix. During a secondary observation on 8/20/19 at 11:42 am DS #1 obtained a cylinder container of test strips to test the solution. As DS #1 was obtaining a strip, the Dietary Manager stopped DS #1 and instructed him/her that the strips were not the correct type to test the sanitation. The Dietary Manger proceeded to obtain a roll of orange test strip paper to test the solution. Next, DS #1 proceeded to take a three inch piece of the orange test paper from a product entitled Hydrion QT-10 and swirled the test paper though out the soapy foam floating on top of the sanitation solution for approximately 1-2 seconds. During an interview on 8/20/19 at 11:45 am, DS #1 was asked if there were parameters for testing the solution at certain temperatures. DS #1 was not aware of any temperature parameters. When asked to obtain the temperature of the water, DS #1 and the Dietary Manager obtained a facility kitchen thermometer and tested the solution at 85 degrees Fahrenheit. Review of the Hydrion QT-10 Testing Strips instructions, undated, revealed Dip paper in quat solution, NOT FOAM SURFACE, for 10 seconds .Testing solution should be between 65-75(degrees Fahrenheit) .FOLLOW MANUFACTURER'S DILUTION INSTRUCTIONS CAREFULLY. During an interview on 8/21/19 at 1:14 pm, the Dietary Manager stated DS #1 incorrectly tested the sanitation solution. When asked for any training records or in-services related to the sanitation solutions, the Dietary Manager stated the staff had not received training on sanitation solutions. Review of the facility's policy Sanitation Monitoring, effective date 7/6/17 and a review date of 8/20/19, revealed an evaluation of sanitation guidelines compliance shall be conducted by the Dietary Manager and deficiencies and violations will be addressed and corrected and an in-service with dietary staff will be conducted. Review of the facility's policy Personnel Management - Food Service Policy, last reviewed 9/16/18, revealed that qualified employees who have met pre-established criteria and competency and performance expectations shall staff the Food Service departments.",2020-09-01
33,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,837,F,0,1,0OWF11,"Based on document review and interview, the facility failed to ensure an engaged and involved governing body was responsible for establishing and implementing policies regarding management and operation and management of the facility. This filed practice had the potential to effect all residents, based on a census of 21, to receive less than optimal care. Findings: Document review on 8/23/19 at 10:14 am, of the Community Health Board minutes, identified by the Administrator (AD) as the Governing Body (GB), revealed no information on reporting, policies, management or operation of the long term care (LTC) facility for the past 12 months. The content of the minutes was strictly related to hospital governance. During an interview on 8/23/19 at 10:16 am, the AD stated there was no LTC representative who reported information to the GB. The AD further revealed there had been no reports submitted to the GB. The AD had tried to get on the agenda and had been cancelled. The AD stated there is no GB oversight for the LTC.",2020-09-01
34,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,838,F,0,1,0OWF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review,observation, interview, and facility document review the facility failed to develop a process to train staff on the use of standard and specialized equipment to meet residents complex medical needs. Specifically, the facility assessment did not include a training plan for staff on new, replacement, or resident specific equipment. This failed practice had to potential to effect all residents, based on a census of 21, to receive less than optimal care: Findings: Resident #17 Record review from 8/19-23/19 revealed Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. An observation on 8/19/19 at 4:00 pm, revealed the Resident lying on an air mattress in his/her [NAME]-rom (a brand of facility) bed, with both upper 1/2 bed rails in the up position. The monitor at the foot of the bed was blinking with a service required message, and a yellow light was illuminated below the monitor. An observation on 8/20/19 at 1:49 pm, revealed Resident #17 lying in bed, with both upper 1/2 bed rails in the up position. The monitor read please call [NAME]-rom [PHONE NUMBER] service code 7,and a yellow light was illuminated below the monitor. An observation on 08/21/19 at 2:47 pm, revealed the Resident's bed was functioning properly. There was no error message and a green light was illuminated. A dressing change to the Resident's head was attempted by Licensed Nurse (LN) #1. LN #1 lowered the head of the Resident's bed prior to the procedure. Once the head of the bed was lowered, the service required message reappeared on the monitor, and the yellow light was illuminated. When the head of the bed was raised back up, the air mattress began working properly. During an interview on 8/21/19 at 2:49 pm, LN #1 stated he/she was not aware of any problems with the Resident's air mattress. An observation on 8/22/19 at 8:01 am, revealed Resident #17 lying in bed, with both upper 1/2 bed rails in the up position. The monitor of resident's bed revealed a service required message, and a yellow light was illuminated. During an interview on 8/22/19 at 10:00 am, LN #4 stated he/she was not aware of any problems with Resident #17's bed, or any service codes. LN #4 further stated that the [NAME]-rom bed would have had an audible alarm if it was not functioning properly. During an interview on 8/22/19 at 11:00 am, the Biomed Staff (BMS) stated he/she was not aware of any bed malfunctions, and no service issues were reported to him/her. During an interview on 08/22/19 at 11:52 am, the BMS stated Resident #17's bed was taken out of service and the Resident was moved onto a new bed. The malfunctioning bed was placed in an empty room. The BMS stated he/she contacted [NAME]-rom and was told error message 7 indicated a malfunction of the mother board. The BMS turned the damaged bed on, and audible alarms started beeping with error codes 3 and 4 illuminating on the monitor. The BMS stated that was indicative of a problem right away. The BMS stated if there was a problem with the bed, an audible alarm would sound and a yellow light would illuminate. When asked how staff would know this information, the BMS stated staff could have referred to the manual attached to the foot of each bed. An observation on 8/22/19 at 11:55 am, revealed no manual attached to the foot of the Resident's malfunctioning bed. The BMS stated there should have been a manual provided with each bed. The BMS further stated that he/she does not train staff regarding the [NAME]-rom beds. During an interview on 8/23/19 at 11:06 am, the Administrator (AD) stated that the BMS attended the Quality Improvement/Performance Improvement (QAPI) committee meetings but the focus was on the equipment safety and not staff training. The AD further stated that staff were trained on equipment during new hire training and during annual mandatory training fairs. When asked what the process was for addressing malfunctioning equipment, the AD stated that the staff would check the sticker on the piece of equipment, alert the charge nurse, and place a phone call for a work order. The AD stated that the facility had been trying to order two new air beds due to an issues with malfunctioning beds. During an interview on 8/23/19 at 12:48 pm, LN #2 and LN #3 stated that they had not received training on the new beds, and the facility had not yet offered that training to staff. LN #2 further stated that if he/she was familiar with new equipment, he/she would have educated Certified Nursing Assistants (CNAs) individually. LN #2 and LN #3 were both unaware of a process for facility wide training for all staff when new equipment was introduced. During an interview on 8/23/19 at 1:32 pm, CNA #1 stated that sometimes the facility provided training on new equipment but other times the staff would have ask the boss. When asked how they would know if the equipment was malfunctioning, CNA #1 stated, common sense. Document review of the most recent Facility Assessment, dated (MONTH) & (MONTH) 2019, revealed no plan for staff training on new or standard medical equipment such as air mattresses or other resident specific equipment.",2020-09-01
35,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,880,F,0,1,0OWF11,"Based on observations and interviews the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment in the central kitchen. This failed practice placed all residents (based on a census of 24) at risk for food borne illnesses. Findings: Random observations and interviews from 8/19-22/19 revealed multiple deficiencies noted in food handling (single-use gloves during food plating), food storage, cleanliness of environment and competencies in the sanitation process. During an interview on 8/22/19 at from 8:00 am to 9:30 am, the Infection Preventionist (IP) was asked what oversight the Infection Control Program had in the dietary department, The IP stated he/she completed an annual walkthrough but was overdue for an evaluation of the central kitchen. When asked if he/she provides any infection control in-services to the dietary staff, the IP stated he/she would only conduct in-services if a deficiency or gap in education was identified. The IP further stated the last infection control in-service conducted for dietary staff was over year ago. The IP stated he/she was not aware of the systematic failures in the kitchen and an evaluation needed to be conducted. During an interview on 8/22/19 at 9:14 am the Administrator stated that the facility's infection control program should have been conducting more frequent oversight due to the deficiencies and systematic failures noted by the State Survey Agency.",2020-09-01
36,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-08-23,909,E,0,1,0OWF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure 2 sampled residents' (#s 2 and 7) and 1 non-sampled resident's (#21) bed mattresses out of 24 residents reviewed were inspected and maintained in a safe manner to reduce the risk of improper use and entrapment. Specifically, the facility failed to ensure the mattresses were appropriately fitted in the bed frame. This failed practice place the residents at risk for entrapment and less than optimal comfort level while in bed. Findings: Resident #2 Record review from 8/19-22/19 revealed Resident #2 had a history of [REDACTED]. Review of the most recent annual Minimum Data Set (MDS - a federally required assessment), dated 8/22/19, revealed Resident #2 was coded as having severely impaired cognitive skills for daily decision making. During random observations from 8/19-22/19 revealed Resident #2's mattress was pushed against the footboard of the bed and curved upwards approximately 4 to 6 inches. Further observation revealed a 2 - 4 gap between the headboard and the mattress. Resident #7 Record review from 8/19-22/19 revealed Resident #7 had a history of [REDACTED]. Review of the admission MDS, dated [DATE], revealed Resident #7 was coded as having severely impaired cognitive skills for daily decision making, as well as having short and long term memory problems. During random observations from 8/19-22/19 revealed Resident #2's mattress was pushed against the footboard of the bed and curved upwards approximately 4 to 6 inches. Further observation revealed a 2 - 4 gap between the headboard and the mattress. Resident #21 Record review from 8/19-22/19 revealed Resident #7 had a history of [REDACTED]. Review of the most recent MDS dated [DATE], revealed Resident #21 was coded as having severely impaired cognitive skills for daily decision making; short and long term memory problems; and disorganized thinking. During random observations from 8/19-22/19 revealed Resident #21's mattress was pushed against the footboard of the bed and curved upwards approximately 4 to 6 inches. Further observation revealed a 2 - 4 gap between the headboard and the mattress. During an interview on 8/23/19 at 4:19 pm Licensed Nurse (LN) #4 stated the beds were new to the long term care unit and he/she was unaware the bed mattresses for Resident #'s 2; 7; and 21 were pushed down and vertically upwards at the footboard. During an interview on 8/23/19 at 4:21 pm the Director of Nursing (DON) stated the beds recently came from the medical-surgical unit in the critical access hospital. The DON further stated the beds had adjustable footboards that allowed the length of the bed to be adjusted. When asked if the mattresses were to be pushed down and forced upwards several inches, the DON stated the beds were designed to that to prevent drop foot ([MEDICAL CONDITION] in which the dropping of the forefoot happens due to weakness, irritation or damage). The DON further stated that the biomedical technician could provide documentation regarding the beds. During an interview on 8/29/19 at 2:30 pm Biomedical Technician (BT) #1 stated the beds were [NAME]-Rom Versicare beds Model P3200/P3201 that were recently transferred to the long term care from the hospital. When asked about the mattresses curving upward at the foot of the bed, BT #1 stated he/she visualized the mattresses and stated the bed and mattress assembly were not designed to function in that manner. The BT further stated due to the adjustable feature the frame could have been set on the shortest setting which caused the mattress to be compressed and move upward. Review of the Versacare Bed User Manual for Models P3200/P3201 USR 119, revision 8 - undated, revealed The retractable foot section provides multiple patient benefits. However, a retracted foot section may increase the risk of patient entanglement between the siderails and footboard for certain patients. If a potential for entanglement exists, such as with patients who are agitated or disoriented, or who lack the physical strength to extract themselves should they become entangled, the foot section should be left fully extended when the patient is not under direct supervision. Further revealed no feature that allowed the mattress to compressed and pushed up vertically at the footboard. Review of the U.S. Food and Drug Administration publication Practice Hospital Bed Safety, dated 2/11/13, accessed at https://www.fda.gov/consumers/consumer-updates/practice-hospital-bed-safety, accessed on 9/6/19, revealed Ensure that each component-the bed frame, mattress, rails, and any added accessories-properly fits together. Make sure the mattress is the correct size for the bed frame so unsafe gaps are not present.",2020-09-01
37,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-10-11,609,E,1,0,566T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure allegations of potential neglect were reported to the appropriate officials in accordance with State law, including to the State Survey Agency, within required time frames and facility policy. Specifically, the facility failed to notify the State Survey Agency and the State Medical Board in the required timelines set forth by federal and/or state regulation/statute/law. This failed practice caused 10 residents (#s 1; 2; 3; 4; 5; 6; 7; 8; 9; and 10) out of 27 residents to have received physician care and services not in accordance with State law and had the potential to cause further allegations of neglect. Findings: Review of the facility provided physicians' schedule, dated [DATE] to [DATE], revealed Physician #1 was scheduled and employed by the facility. Record review of the CareConnect Provider Activity Report, dated [DATE] to [DATE] revealed Physician #1 provided care and/or services to 10 residents (#s 1; 2; 3; 4; 5; 6; 7; 8; 9; and 10). Review of Alaska's Division of Corporations, Business and Professional Licensing under the Department of Commerce, Community, and Economic Development website, accessed at https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing.aspx on [DATE], revealed Physician #1 had a lapsed licensure status from [DATE] to [DATE]. During an interview on [DATE] at 1:20 pm, the Long Term Care (LTC) Administrator stated the LTC facility was made aware of Physician #1 [MEDICATION NAME] without a license from [DATE] to [DATE] on [DATE]. The Administrator further stated the facility did not report the event to the State Agency until [DATE]. Review of the facility policy State Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act, dated [DATE], revealed In accordance with Alaska state law, 42CFR483.13(b)(c), all suspected cases of abuse and/or neglect will be reported as outlined below: Health Facilities Licensing and Certification (HFL&C): The initial reporting of the incident must be faxed or phoned immediately .The results of the investigation must be followed up through a written report within five days of the initial reporting of the incident. Review of the RULES AND REGULATIONS of PEACEHEALTH KETCHKIAN MEDICAL CENTER and PEACEHEALTH NEW HORIZONS TRANSITIONAL CARE CENTER, last approved on [DATE], revealed a .report, in writing and confidentially, to the Chief of Staff, or the Professional Practice Evaluations Committee physician chair any conduct, acts, or omissions by other Medical Staff member which are believed to be detrimental .to the proper functioning of the Facility, or which violate professional ethics. Review of the PEACEHEALTH KETCHKIAN MEDICAL CENTER MEDICAL STAFF BYLAWS AND PEACEHEALTH NEW HORIZONS TRANSITIONAL CARE CENTER, dated [DATE], revealed Reports of actions taken pursuant to these Bylaws shall be made by the CAO (Chief Administrative Officer) to such governmental agencies as may be required by law. During an interview on [DATE] at 1:00 the facility's Medical Director stated he/she was Physician #1's direct supervisor. When asked about at what point was he/she made aware of Physician #1 working without a valid licensure, the Medical Director stated the information was sent to him around [DATE]. The Medical Director further stated the State Medical Board was contacted on [DATE] (10 days after notice of lapse in licensure and 2.5 months after licensure was expired). Record review of the facility document Actions to Notify (Physician #1) Professional Licensure Expiration, undated, revealed on [DATE] the CVO verified Physician #1's license was reinstated with an expiration of [DATE]. The Physician's status was changed to current. CVO documented the state licensing entity would not retroactively reinstate the licensure due to a status of inactive from [DATE] to [DATE]. Review of the Alaska Statute (AS) 08.64.336(b), accessed at http://www.akleg.gov/basis/statutes.asp#08.64.336 on [DATE], revealed Duty of physicians and hospitals to report .A hospital that revokes, suspends, conditions, restricts, or refuses to grant hospital privileges to, or imposes a consultation requirement on, a person licensed to practice medicine or osteopathy in the state shall report to the board the name and address of the person and the reasons for the action within seven working days after the action is taken. A hospital shall also report to the board the name and address of a person licensed to practice medicine or osteopathy in the state if the person resigns hospital staff privileges while under investigation by the hospital or a committee of the hospital and the investigation could result in the revocation, suspension, conditioning, or restricting of, or the refusal to grant, hospital privileges, or in the imposition of a consultation requirement. A report is required under this subsection regardless of whether the person voluntarily agrees to the action taken by the hospital .In this subsection consultation requirement means a restriction placed on a person's existing hospital privileges requiring consultation with a designated physician or group of physicians in order to continue to exercise the hospital privileges. Review of the Alaska Administrative Code 12 AAC 40.967, accessed at http://www.akleg.gov/basis/aac.asp#12.40.967 on [DATE], revealed For purposes of AS 08.64.240(b) and AS 08.64.326, unprofessional conduct means an act or omission by an applicant or licensee that does not conform to the generally accepted standards of practice for the profession for which the applicant seeks licensure or a permit under AS 08.64 or which the licensee is authorized to practice under AS 08.64. Unprofessional conduct includes the following .[MEDICATION NAME] a profession licensed under AS 08.64 without a required license or permit or with a lapsed, expired, retired, or inactive license or permit .",2020-09-01
38,KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE,25010,3100 TONGASS AVENUE,KETCHIKAN,AK,99901,2019-10-11,839,F,1,0,566T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure a physician retained a current licensure under Alaska Statute (AS) 08.64.170 and 12 Alaska Administrative Code (AAC) 40. This failed practice placed 10 residents (#s 1; 2; 3; 4; 5; 6; 7; 8; 9; and 10) out of 27 residents at risk for receiving care and services from an unlicensed physician. Findings: Review of the facility provided physicians' schedule, dated [DATE] to [DATE], revealed Physician #1 was scheduled and employed by the facility. Record review of the CareConnect Provider Activity Report, dated [DATE] to [DATE] revealed Physician #1 provided care and/or services to 10 residents (#s 1; 2; 3; 4; 5; 6; 7; 8; 9; and 10). Review of Alaska's Division of Corporations, Business and Professional Licensing under the Department of Commerce, Community, and Economic Development website, accessed at https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing.aspx on [DATE], revealed Physician #1 had a lapsed licensure status from [DATE] to [DATE]. Record review of the facility document Actions to Notify (Physician #1) Professional Licensure Expiration, undated, revealed the following timeline: [DATE] - Credential Verification Office (CVO) sent notification to the Provider Administrative Coordinator (PAC) of Physician #1 licensure expiration on [DATE]. [DATE]; [DATE]; [DATE]; [DATE]; [DATE] - The PAC sent email communication to Physician #1 with no response. The document indicated the facility did not have documentation to confirm these communication attempts. [DATE] - The PAC sent a copy of Physician #1's licensure to the CVO stating his/her license had been renewed and had a new expiration of [DATE]. However, the PAC sent a copy of the current licensure that had an expiration of [DATE]. The license for Physician #1 was not renewed at this time as indicated by the PAC. [DATE] - The CVO notified the PAC that he/she sent the expiring licensure for Physician #1 and confirmed it had not been renewed through the state licensing entity. [DATE] - Medical Staff Office (MSO) attempted to notify Physician #1 via phone but the number was not working. An email was then sent to Physician #1 and Clinical Manager (CM) #1. No response from either party could be provided by the facility. [DATE] - CVO notified MSO that Physician #1's licensure was still not renewed and a letter was allegedly sent to Physician #1. The facility was not able to provide evidence of this action. [DATE] - CVO contacted the state licensing entity for status update. The CVO contacted the PAC requesting licensure update. In addition, the CVO contact the MSO to request a Systems Credit Verification Office Change Form be completed and show a status of suspended as of [DATE]. [DATE] - CVO stated they contacted the PAC and the MSO again. [DATE] - CVO received a Systems Credit Verification Office Change Form from the MSO that changed Physician #1's status to suspended. The Cactus software (a software used to track credentialing information) was reportedly updated with the change in status. [DATE] - [DATE] - The CVO stated they monitored the state licensing entity for licensure updates on a weekly basis. [DATE] - CVO verified Physician #1's license was reinstated with an expiration of [DATE]. The Physician's status was changed to current. CVO documented the state licensing entity would not retroactively reinstate the licensure due to a status of inactive from [DATE] to [DATE]. Record review of the facility provided document Systems Credit Verification Office Change Form, dated [DATE], revealed the Medical Staff Coordinator sent the request form to Credential Verification Office Staff #1 indicating Physician #1's status was changed from Active/Current to Suspended. Further review revealed the form indicated that CVO Staff #1 the form was processed and changes made in Cactus. Review of the facility provided email, dated [DATE], revealed Physician #1 was sent an email by the Provider Administrative Coordinator (PAC) that indicated he/she had recently became aware of Physician #1's medical licensure was expired (62 days post expiration). The PAC further indicated the physician's name did not come up for renewal in the systematic report and There are other checks and balances in place but they failed. During an interview on [DATE] at 1:11 pm, the Director of Credential Verification Office (DCVO) stated it was the duty of the CVO to notify the MSO of upcoming expiration of licensure for physicians. During the same interview The Medical Staff Coordinator (MSC) stated a notification was sent to Physician #1 on [DATE], but no confirmation or validation of this notification was able to provided to the Surveyor. The DCVO further stated the CVO office received the change form of Physician #1's suspension, but the Cactus software did not tell the facility's medical record software that Physician #1 was not eligible to provide services. As a result, the Physician was able to continue to use and chart in the electronic medical records system. During the same interview, the DCVO was asked what the expectation of the MSO was in the credentialing process and notification of appropriate individuals. The DCVO stated due to the unlicensed physician event, it was noted that the MSO did not have a listed job duty that explained the process to support the Medical Staff Bylaw requirements. During an interview on [DATE] at 1:00 the facility's Medical Director stated he/she was Physician #1's direct supervisor. When asked about at what point was he/she made aware of Physician #1 working without a valid licensure, the Medical Director stated the information was sent to him around [DATE]. During an interview on [DATE] at 1:00 am, the facility Chief Executive Officer (CEO) stated the process for ensuring the medical staff maintained current licensure was in the process of being relayed to the facility's Credential Committee (CC), Medical Executive Committee (MEC) and Community Health Board (CHB) for review in November. Review of the PEACEHEALTH KETCHKIAN MEDICAL CENTER MEDICAL STAFF BYLAWS AND PEACEHEALTH NEW HORIZONS TRANSITIONAL CARE CENTER, dated [DATE], revealed the duties of the CC were to include review and make recommendations regarding appropriate threshold eligibility criteria for clinical privileges within the hospital. Further review revealed the duties of the MEC included recommending directly to the Board mechanisms used to review credentials and performance revealed improvement activities. In addition, the document revealed the BOARD refers to the CHB, which is responsible for the credentialing, privileging, and peer review activities at the facility. Further review of the Medical Staff Bylaws revealed medical staff members' qualifications include all physicians .much satisfy the following requirements in order to eligible to practice .have a current, unrestricted license . Review of the Alaska Statute 08.64.170(a), accessed at http://w3.legis.state.ak.us/index.php on [DATE], revealed A person may not practice medicine, podiatry, or osteopathy in the state unless the person is licensed under this chapter .",2020-09-01
39,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2019-04-24,558,E,0,1,FNNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure that resident needs were accommodated for 1 resident (# 1), out of 8 sampled residents. Specifically, the facility failed to ensure the call light was accessible while a resident was in his/her room. This failed practice inhibited the residents' ability to call for assistance and placed the resident at risk for a delay in receiving care. Findings: Record review from 4/15-19/19 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of Resident #1's care plan revealed Resident #1 was at risk for falls with interventions to include frequent reminders to slow down .use footwear .ask for help at night when unsteady .and ensure (his/her) call bell is within reach. During an interview on 4/16/19 at 10:07 am, Resident #1 stated that he/she was unsure where the call light was in his/her new bedroom. Resident #1 further stated that he/she would not know how to contact staff if he/she needed help in the bedroom. Observation on 4/16/19 at 10:14 am of Resident #1's bedroom revealed the call light and cord were wound up and hanging on the wall over the oxygen supply valve near the room curtain divider approximately two feet above the bedside table. Further review revealed Patient #1 was not able to reach the call light from his/her wheelchair. Observation on 4/17/19 at 8:52 am and 4/18/19 at 8:20 am revealed the call light and cord remained coiled on the wall over the oxygen supply valve. During an interview on 4/19/18 at 8:25 am, the Director of Nursing (DON) stated that every resident should have access to their call lights and the call lights should never be out of reach. The DON further stated that staff do frequent rounding and that she would be surprised if a resident did not know where the call light was in the room. During an interview on 4/19/18 at 8:31 am, the DON stated there was no policy on call lights. During an interview on 4/19/19 at 10:09 am, the Long Term Care (LTC) Care Services Coordinator stated that all residents should have access to their call light. The LTC Care Services Coordinator further stated that it is the responsibility of all floor staff to ensure the residents have access to their call lights.",2020-09-01
40,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2019-04-24,568,F,0,1,FNNN11,"Based on record review and interview the facility failed to provide quarterly statements of personal funds accounts to 6 residents (#1, 5, 6, 7, 8, and 10), out of 8 sampled residents. This failed practice placed all residents (based on a census of 12) at risk for not receiving a complete and accurate accounting of their personal funds entrusted to the facility. Findings: Review of the facility personal fund accounting record, on 4/18/19 at 12:50 pm, revealed Residents #1, 5, 6, 7, 8, and 10 had personal fund accounts through the facility. During an interview on 4/18/19 at 1:10 pm, the Personal Funds Manager stated the facility did not have a process for providing residents or their representatives a quarterly statement, and as a result, the facility did not provide residents or their representatives quarterly statements of their personal fund accounts. During an interview on 4/19/19 at 11:00 am, the Director of Nursing (DON) stated the facility does not have a policy on personal funds.",2020-09-01
41,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2019-04-24,570,F,0,1,FNNN11,"Based on record review and interview the facility failed to acquire a surety bond that would financially cover all potential funds within personal funds accounts for 6 residents (#1, 5, 6, 7, 8, and 10), out of 8 sampled residents. This failed practice placed all residents (based on a census of 12) at risk for not being compensated for the potential loss of personal funds entrusted to the facility. Findings: Review of the facility personal fund accounting record, on 4/18/19 at 12:50 pm, revealed Residents #1, 5, 6, 7, 8, and 10 had personal fund accounts. During an interview on 4/18/19 at 1:10 pm, the Personal Funds Manager stated the maximum amount of cash a resident can have within their personal funds account was $50.00. He/she stated if a resident or their family brought in more than $50.00 to add to their personal funds account, he/she would inform them a checking account would need to be opened at the bank for the extra money over the $50.00 limit. Review of the facility's surety bond Patient Trust Funds Bond, dated 1/14/19, revealed the bond amount was $1,000.00. During an interview on 4/18/19 at 1:25 pm, the Finance Manager stated the surety bond was only for $1,000.00 because residents at the facility could only have $50.00 in their personal funds accounts. He/she stated the total amount for the surety bond was calculated and based off of the $50.00 limit per resident. During an interview on 4/19/19 at 11:00 am, the Director of Nursing (DON) stated the facility does not have a policy on personal funds.",2020-09-01
42,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2019-04-24,585,D,0,1,FNNN11,"Based on record review, interview and policy review, the facility failed to provide a written response to 1 resident's (#7) grievance that included: a statement that the grievance was confirmed/not confirmed; actions to be taken by the facility; date grievance was resolved; and date the written decision was given to the resident. This failed practice denied 1 resident (out of a census of 12) their right to participate in improving their experience and to receiving responses in a timely manner. Findings: Record review on 4/17/19 at 8:43 am, of the grievance log revealed there was no follow up process or outcome recorded for a grievance filed by Resident #7 on 12/27/18. The facility was unable to provide evidence that the grievance was resolved in a timely manner or that a written decision was provided in response to the grievance. During an interview on 4/17/19 at 8:45 am, the Grievance Officer (GO) revealed that he/she had not documented the investigation to address the grievance, nor did he/she document the date the grievance was resolved. The GO further stated the issue was resolved several months later, however, could not recall an actual date of completion, and did not provide a written response to the resident. Review on 4/16/19 of the facility's policy entitled, Grievance Policy, last reviewed on 3/2019, revealed, The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative .the Compliance (Grievance) Officer will receive and track grievances through to their conclusion .the resident .will be informed by written decision and this will include: a) The date the grievance was received. b) A summary statement of the grievance received. c) The steps taken to investigate the grievance. d) A summary of the pertinent findings or conclusions regarding the grievance. e) A statement as to whether the grievance was confirmed or not confirmed. f) Any corrective action taken or to be taken by the facility as a result of the grievance. g) The date the written decision was issued.",2020-09-01
43,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2019-04-24,623,D,0,1,FNNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to incorporate all required contents in a written notice of discharge prior to mailing this notice to 1 resident's (#3) representative, out of 8 sampled residents. This failed practice placed the resident at risk for being inappropriately discharged from the facility. Findings: Record review on 4/15-19/19 revealed Patient #3 was admitted to the facility with [DIAGNOSES REDACTED]. This includes an increased risk of violence, aggressive behavior) and physical deconditioning (a physical and psychological decline in function). Record review revealed a Notice of Intent to Discharge, dated 4/10/19, that was mailed to Resident #3's representative, who was his/her power of attorney (POA), on 4/11/19. Review of the notice revealed the reasons for this action were: 1) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility and 2) The safety of individuals (other residents) in this facility if endangered. Further review revealed the location to be discharged and date of discharge were documented as yet to be determined. During an interview on 4/19/19 at 3:10 pm, the Director of Nursing (DON) stated Resident #3's Notice of Intent to Discharge was sent to the POA without a facility/location identified, or date of discharge. He/she stated he/she was unaware these stipulations needed to be ascertained prior to notification.",2020-09-01
44,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2019-04-24,637,D,0,1,FNNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to identify a significant change in condition for 1 resident (#10), out of 8 sampled residents. Specifically, the facility failed to complete a significant change in status assessment for the care areas of mood and ADLs (activities of daily living), within 14 days from the time the significant change should have been identified. This failed practice placed the resident at risk for not receiving interventions and care to maintain the highest practicable level of well-being. Findings: Resident #10 Record review on 4/15-19/19 revealed Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. Mood: Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment), a quarterly assessment dated [DATE], revealed Resident #10 was coded as having no trouble falling or staying asleep. Review of Resident #10's Physician Notes, dated 2/20/19 at 2:56 pm, revealed Asked to be assessed because of increasing confusion, decreasing mobility, and ongoing [MEDICAL CONDITION] .This is a mild to moderate decrease from (him/her) regular level of functioning. Review of Resident #10's Nurses Notes, dated 2/22/19 at 5:24 am, revealed Resident was restless last night. Up and down multiple times. Further review revealed Resident #10 had restlessness or yelling out on the nights of 2/10-13/19, and [MEDICAL CONDITION] on 2/26/19. Review of Nurses Notes, dated 3/6/19 at 2:49 pm, revealed Resident #10's .behavior last evening was a significant change from normal .(He/She) asked to go to the bathroom [ROOM NUMBER] times in an hour .(He/She) kept calling out that (he/she) was falling out of bed. Review of Physician Notes, dated 3/15/19 at 4:34 pm, revealed Resident #10 .had increasing difficulties with middle of the night [MEDICAL CONDITION] .This has occurred 12 nights this month with increasing frequency. During an observation on 4/15/19 at 2:20 pm, the Physician had asked Registered Nurse (RN) #1 about Resident #10's ability to sleep at night. RN #1 replied to the Physician, It's hit or miss. During an interview on 4/17/19 at 8:08 am, RN #1 stated Resident #10 had a rough night with [MEDICAL CONDITION] last night. Nutrition: Review of the Quarterly MDS assessment, dated 1/11/19, revealed Resident #10 was coded for receiving supervision and encouragement to eat, with set up help only. Review of ADL Assistance and Support, for eating during daytime, revealed Resident #10 required extensive assistance, total dependence or activity did not occur: none for (MONTH) 2019; 4 times for (MONTH) 2019; 4 times for (MONTH) 2019; and 10 times between (MONTH) 1-17/2019. Review of Nurses Notes, dated 2/24/19 at 5:06 pm, revealed Resident #10's .appetite is poor, but seems to do better eating if someone feeds her and encourages her. Review of Nurses Notes, dated 2/27/19 at 6:27 pm, revealed Resident had to be fed .due to confusion. Review of Nurses Notes, dated 2/28/19 at 2:52 pm, revealed Resident has needed increased attention during meals (total feed, direction for eating). Random Observations on 4/15-19/19 revealed Resident #10 had been fed his/her meals. ADLs: Review of ADL Assistance and Support, dated (MONTH) 2019, revealed Resident #10 required extensive assistance, total dependence or activity did not occur: 18 times for transfers; 8 times for locomotion on unit; 16 times for toilet use; and 13 times for personal hygiene. Review of ADL Assistance and Support, dated (MONTH) 2019, revealed Resident #10 required extensive assistance, total dependence or activity did not occur: 33 times for transfers; 24 times for locomotion on unit; 29 times for toilet use; and 24 times for personal hygiene. Review of ADL Assistance and Support, dated (MONTH) 2019, revealed Resident #10 required extensive assistance, total dependence or activity did not occur: 33 times for transfers; 22 times for locomotion on unit; 35 times for toilet use; and 30 times for personal hygiene. During an interview on 4/16/19 at 3:56 pm, CNA #1 stated he/she had noted a decline in Resident #10's activity of daily living since (MONTH) 2019. During an interview on 4/17/19 at 11:34 am, Resident #10's family member stated the Resident had needed more staff assistance with activities of daily living over the last 3 months. Random Observations on 4/15-19/19 revealed Resident #10 had required extensive assistance for toileting and transfers. The Resident required total dependence for locomotion on unit. During an interview on 4/18/19 at 2:00 pm, the MDS Coordinator stated he/she would have conversations with staff members and review notes to learn if a resident had a significant change. Once he/she suspected a significant change, he/she will discuss this with the interdisciplinary team. The MDS RN stated he/she was aware of a significant change with Resident #10's mood last month and wanted to give it a little more time before updating the MDS. He/she had updated the MDS on 4/3/19 due to anxiety, calling out and [MEDICAL CONDITION]. In addition, when the MDS Coordinator was handed the ADL Assistance and Support document, dated (MONTH) 2019, and asked if these numbers would trigger and significant change. The MDS Coordinator stated, Yes, that would prompt me to do a significant change (assessment). The MDS Coordinator further stated the facility had a systemic issue with charting and there needed to be a better system of communication among staff. He/she stated that a significant change assessment done in the MDS more timely would help the residents preserve their functioning. Review of the facility's policy Resident MDS Assessment and Care Planning, last updated on 6/2018, revealed All residents will have Comprehensive Assessment completed .with any Significant changes .All Residents will have an individual Plan of Care .revised as needed with subsequent assessments.",2020-09-01
45,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2019-04-24,641,D,0,1,FNNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review, the facility failed to ensure pressure ulcers were accurately coded on a significant change MDS (Minimum Data Set - A Federally mandated nursing assessment) for 1 Resident (#10), out of a sample of 8 residents. This failed practice had the potential to inaccurately reflect the resident's status and care planning and placed the resident at risk of physical and psychosocial decline. Findings: Record review from 4/15-19/19 revealed Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS, a Significant Change assessment, dated 4/3/2019, revealed that Resident #10 was coded as having one Stage II pressure ulcer (pressure injury to the skin that involves partial-thickness skin loss with exposed under skin layers. Wound is pink or red, moist, and may be intact or a ruptured serum-filled blister). During an interview on 4/19/19 at 11:04 am, the MDS Coordinator stated that she was aware of the pressure ulcer to Resident #10's left foot, but unaware of a second pressure ulcer to the Resident's right toe. The MDS Coordinator reviewed the most recent MDS dated [DATE] and stated I must have missed it. Review of the facility policy and procedure entitled, Resident MDS Assessment and Care Planning revealed: All residents will have Comprehensive Assessment completed on admission, Annually, and with any Significant changes . the purpose of the policy is to provide interdisciplinary observation and assessment to ensure the most accurate assessment of functional capacity .Risk Factors and Assessment to be completed by a nurse .Braden, Pressure Ulcer Risk, Urine Incontinence Risk, Fall Screen, Constipation Screen, Risk of Dehydration, Risk of Elopement, Risk for skin tears, additional assessments as needed .",2020-09-01
46,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2019-04-24,656,D,0,1,FNNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement a resident-centered care plan, based on dental care needs identified during an MDS (Minimum Data Set, a federally required nursing assessment) assessment for 1 resident (#4), out of 8 sampled residents. This failed practice delayed dental care/repair of loose dentures which placed the resident at risk for impaired nutritional intake, as well as, optimal health and well-being. Findings: Record review on 4/15-19/19 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. (MONTH) manifest as weight loss, decreased appetite, poor nutrition, and inactivity). Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, an admission assessment dated [DATE], revealed Resident #4 was coded as having broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose). Review of Care Area Assessment (CAA) Summary of the admission MDS assessment revealed dental care was a care area triggered within the MDS and should have been addressed in Resident #4's care plan. Review of Resident #4's care plan, start date 3/15/19, revealed dental/dentures were not an identified problem. There were no goals or interventions associated to dental/denture care. During an interview on 4/16/19 at 1:32 pm, Resident #4's Daughter stated Resident #4's dentures are too big and they fall out of his/her mouth at times and this had affected his/her ability to chew. The Daughter stated the facility had not mentioned to her what they were going to do about Resident #4's dentures. During an interview on 4/16/19 at 3:42 pm, the Senior Office Specialist stated all appointments, to include dental appointments, for the Long Term Care Residents were logged in the appointment book kept at the front desk. He/she stated there had been no dental appointments made for Resident #4. During an interview on 4/17/19 at 9:15 am, the MDS Coordinator stated all care areas triggered in the MDS should have been added to Resident's care plan so a plan of care could be initiated. When Resident #4's care plan was reviewed, the MDS Coordinator stated Resident #4's denture issue was not on the care plan. During an interview on 4/18/19 at 8:10 am, the MDS Coordinator stated a dentist appointment was made for Resident #4 during the course of this survey for 4/22/19. Review of the facility policy Dental Services, revision date 5/2017, revealed: The facility will have an advisory dentist who proves consultation, recommends policies concerning oral hygiene, and is available in case of emergency. It shall be the responsibility of the facility, when necessary, to arrange for resident to be transported to the dentist's office. During an interview on 4/19/19 at 11:00, the Director of Nursing (DON) stated there was no facility policy for oral hygiene. Review of the facility policy Resident MDS Assessment and Care Planning, revision date 6/2018, revealed: CAA triggers are used as basis for care planning. Additional areas care planned as determined by (interdisciplinary team), additional assessment, diagnoses, facility policy or other concerns specific to resident.",2020-09-01
47,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2019-04-24,657,F,0,1,FNNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation the facility failed to ensure resident care plans were reviewed and revised based on MDS (Minimum Data Set - A federally required nursing assessment) assessments for 6 residents (#1, 3, 8, 9, 10, 11), out of 8 sampled residents. This failed practice placed the residents at risk for not receiving care/services to maintain the highest practicable mental, physical, and psychosocial well-being. Findings: Care Plan Reviews and Revision Process: During an interview on 4/16/19 at 10:00 am, Registered Nurse (RN) #1 stated the most recent care plans for residents were kept in a binder in the dining room/common area of the unit for staff to review when providing care to the residents During an interview on 4/16/19 at 2:00 pm, RN #1 stated that care plans were reviewed and revised by the MDS Coordinator. During an interview on 4/17/19 at 8:50 am, the MDS Coordinator stated care plans were reviewed during quarterly MDS reviews or when a significant change occured. The start date on the care plan identified problems and interventions indicated the date of the MDS finalization or when the problem was identified. The review date indicated when the next quarterly MDS was due and when the problem, goals, and interventions needed to be evaluated. The MDS Coordinator further stated changes would be made based on that quarterly review, or if any changes had come to light based on the resident's care. He/she stated the review dates for all categories identified in the care plan should move forward, to the next scheduled assessment date of the MDS quarterly review or MDS assessment, to show they remain active and up to date. Observation on 4/17/19 at 3:30 pm revealed Resident care plans were placed in a binder located in the common area of the unit. Sticky notes were placed on the care plans from all staff to share information that should be updated in the care plan. During an interview on 4/17/19 at 3:53pm, RN #1 stated the MDS Nurse used the sticky notes as guidance to update the care plans. During an interview on 4/18/19 at 12:35 pm, RN #2 stated staff were trained to go to the binder to review the care plans for the residents. Resident #1 Record review from 4/15-19/19 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Depression/Psychoactive Drug Use/Behaviors Review of Resident #1's latest annual MDS, dated [DATE] revealed that Resident #1 was coded as having a Total Severity Score (A summary of the frequency scores that indicates the extent of potential depression symptoms) of 3 which indicated minimal depression. Further review revealed the Resident did not exhibit behavior symptoms not specifically toward others. Review of Resident #1's most recent MDS, a quarterly assessment dated [DATE] revealed that Resident #1 was coded as having a Total Severity Score of 7 which indicated mild depression. Further review revealed the Resident did exhibit behavior symptoms not specifically toward others. Record review on 4/17/19 of Resident #1's most current Medication Administration Record [REDACTED]. Record review of a physician's note dated 4/15/19 revealed the physician recommended a further dose reduction because Resident #1 reported no depressive symptoms. Review of Resident #1's care plan, start date of 6/20/18 (with an anticipated review due of 12/12/18), revealed categories of care that included at risk for loneliness/lack of social participation and the use of antidepressant medication. Interventions included a quarterly review of the behavior plan. The care plan had no indications of review or revision since the last MDS. Review of Resident #1's behavior plan revealed the last review date was 12/21/18. Falls Review of Resident #1's latest annual MDS, dated [DATE] revealed that Resident #1 was coded as using a wheelchair as a mobility device. Review of Resident #1's most recent MDS, a quarterly assessment dated [DATE] revealed that Resident #1 was coded as using a wheelchair and walker as a mobility device. In addition, the MDS coded the Resident as not having any falls since admission. During an interview on 4/16/19 at 9:56 am, Resident #1 revealed that he/she had fallen recently. Review of Resident #1's care plan, start date of 6/20/18 (with an anticipated review due of 12/12/18), revealed Resident #1 was at risk for falls. The care plan had no indications of review or revision since the last MDS. Dental During an interview on 4/16/19 at 9:49 am Resident #1 stated he/she needed to go to the dentist to have his/her dentures evaluated. He/she further stated he/she had not been using dentures but wants to go to appointment to see how they fit. Review of Resident #1's care plan, start date of 6/20/18 (with an anticipated review due of 12/12/18), revealed a category of dental. The care plan had no indications of review or revision since the last MDS. During an interview on 4/17/19 at 9:15 am, the MDS Nurse stated that he/she had not updated Resident #1's care plan for any of the identified care areas. Resident #3 Record review on 4/15-19/19 revealed Patient #3 was admitted to the facility with [DIAGNOSES REDACTED]. This includes an increased risk of violence, aggressive behavior) and physical deconditioning (a physical and psychological decline in function). A review of the most recent MDS assessment, a quarterly assessment, revealed it was completed on 3/22/19. Review of Resident #3's care plan revealed: - 1 identified problem area with a start date of 10/24/18 and an anticipated review date of 1/24/19; - 17 identified problem areas with a start date of 10/24/18 and an anticipated review date of 3/24/19; - 2 identified problem areas with a start date of 11/9/18 and an anticipated review date of 1/5/19; - 2 identified problem areas with a start date of 11/9/18 and an anticipated review date of 3/24/19; - 2 identified problem areas with a start date of 12/15/18 and an anticipated review date of 3/24/19; - 1 identified problem area with a start date of 12/24/18 and an anticipated review date of 3/24/19; and - 1 identified problem area with a start date of 12/26/18 and an anticipated review date of 3/26/19. During an interview on 4/17/19 at 9:20 am, the MDS Coordinator stated the review dates in Resident #3's care plan were not up to date. He/she further stated the goals and interventions had not been updated to reflect the 3/22/19 MDS quarterly assessment or the current interventions being provided to Resident #3. Resident #8 Record Review on 4/15-19/19 of Resident #8's medical record revealed the Resident had [DIAGNOSES REDACTED]. Care Plan Revision/Review: Review of the most recent MDS comprehensive assessment, an annual assessment dated [DATE], revealed the Resident was triggered for the areas of skin, cognitive loss/dementia, [MEDICAL CONDITION] drug use, pain, falls, visual function and activities of daily living function. Review of Resident #8's care plan revealed the triggered care areas from the most recent MDS comprehensive assessment, dated 3/19/19, were documented to have an anticipated review of 12/29/19. Further review revealed each care area had a goal dated for evaluation in (MONTH) (YEAR). Behaviors: Review of the most recent MDS comprehensive assessment, an annual assessment dated [DATE] revealed the Resident was coded as having verbal behaviors symptoms toward others and other behaviors symptoms not directed toward others. Review of Resident #8's care plan revealed a category of Cognition, with an anticipated review date of 12/29/18. In addition, the care plan goal for cognition stated .will have reduced episodes of agitation and distress through (December) (YEAR). An intervention indicated to monitor the behaviors and use behavior care plan. Further review of the intervention stated to contact the social worker with concerns related to behaviors so he/she may address it in the Resident's behavioral care plan. Review of Resident #8's behavior care plan, attached to the active comprehensive care plan, revealed the behavioral care plan had been last reviewed and/or updated on 12/21/18. During an interview on 4/17/19 at 8:55 am, the MDS Coordinator stated the facility had been without a social worker since (MONTH) 2019. Communication: Review of the most recent MDS assessment, an annual assessment dated [DATE] revealed the Resident was coded as being rarely/never understood with unclear speech. Review of Resident #8's care plan revealed a no category, goals or interventions related to communication. Bowel & Bladder: Review of the most recent MDS comprehensive assessment, an annual assessment dated [DATE], revealed the Resident was coded as always being incontinent of bowel and bladder. Review of Resident #8's care plan revealed no category specific to incontinence. However, review of the category Skin, with a review date of 12/29/18 revealed an intervention that stated the Resident was Usually incontinent of bowel and bladder. Skin: Review of the most recent MDS comprehensive assessment, an annual assessment dated [DATE], revealed the Resident was coded as always being incontinent of bowel and bladder and risk for developing pressure ulcers. Observation on 4/16/19 at 10:28 am revealed linear red irritated areas to both of Resident's inner thighs. During an interview on 4/16/19 at 11:09 am Resident's Family Member stated the Resident's inner thigh skin issue had been ongoing for approximately six months. During an interview on 4/16/19 at 12:51 am, the Director of Nursing (DON) stated the issue had been going on for several months with various interventions attempted. Review of Resident #8's care plan revealed a category of skin, with an anticipated review date of 12/29/18. Further review of care plan revealed no interventions documented for the on-going issue of skin irritation on the inner thighs of Resident #8. Resident #9 Record review from 4/15-19/19 revealed Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #9's care plan, start date of 7/11/18 (with an anticipated review due of 1/2/19), revealed the Resident was at risk for impaired physical mobility, self-care deficit, alteration to skin integrity, ineffective coping skills, weight issues due to diabetes, pain, and communication deficits. Review of Resident #9's annual MDS dated [DATE] revealed Resident #9 should be care planned for ADL functional/rehabilitation potential, behavioral symptoms, nutritional status, [MEDICAL CONDITION] drug use, and pain. Behaviors (Anxiety) Record review on 4/17/19 of Resident #9's MDS, a quarterly assessment dated [DATE], revealed that Resident #9 was coded as not exhibiting behavior symptoms not specifically directed toward others. Record review on 4/17/19 of Resident #9's most recent MDS, a quarterly assessment dated [DATE], revealed that Resident #9 was coded as exhibiting behavior symptoms not specifically directed toward others During an interview on 4/19/19 at 8:42 am, the DON stated that Resident #9 has a number of challenging behaviors and multiple non-pharmacological interventions have been tried to meet the Resident's needs. Review of Resident #9's behavior plan revealed the last revision/review date was 12/18/19. Review of Resident #9's care plan, start date of 7/11/18 (with an anticipated review due of 1/2/19), revealed a category of anxiety. The care plan had no indications of review or revision since the last MDS. Pain Record review on 4/17/19 of Resident #9's MDS, a quarterly assessment dated [DATE], revealed that Resident #9 was coded as experiencing pain frequently. Record review on 4/17/19 of Resident #9's most recent MDS, a quarterly assessment dated [DATE], revealed that Resident #9 was coded as experiencing pain almost constantly. During an interview on 4/15/19 at 3:12 pm, Resident #9 stated that he/she had chronic pain and takes Tylenol #3 (Tylenol with a narcotic combination) or Tylenol for pain. Record review on 4/18/19 at 10:47 am of the physician's orders [REDACTED].#9 is on [MEDICATION NAME] for neuralgia (nerve pain) and Tylenol #3 for pain. Review of Resident #9's care plan, start date of 7/11/18 (with an anticipated review due of 1/2/19), revealed a category of pain. The care plan had no indications of review or revision since the last MDS. During an interview on 4/17/19, the MDS Coordinator stated he/she had not updated Resident #9's care plan for any of the identified care areas. Resident #10 Record review on 4/15-19/19 revealed Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. Record review revealed Quarterly MDS assessments were completed on 10/18/18 and 1/11/19; and a significant change MDS assessment was completed on 4/3/19. Review of Resident #10's current care plan revealed a start date of 8/8/18 with an anticipated review date of 11/8/18. During an interview on 4/17/19 at 3:53pm, RN #1 stated Resident #10's care plan, dated 8/8/18, was the most recent care plan that staff used to guide Resident #10's care. Falls/Activities of Daily Living/Bed alarm: Review of the most recent quarterly MDS, dated [DATE], revealed Resident used bed alarm daily, required limited assistance with ambulation, transfer, and locomotion on the unit. Review of the most recent MDS, a significant change assessment, dated 4/3/19, revealed Resident used bed alarm daily, required extensive assistance with ambulation, transfer, and locomotion on the unit. Random observations from 4/15-19/19 revealed a bed alarm (an alarm to alert staff of Resident movement) was located on Resident #10's bed. Staff responded to the Resident when the alarm sounded. During an interview on 4/16/19 at 9:00 am, CNA #1 stated he/she was not sure if the bed alarm was effective to prevent falls and the Resident gets up on (his/her) own and is wobbly. During an interview on 4/19/19 at 12:38 pm, the MDS Coordinator stated the bed alarm interventions had not been updated on the paper copy that was used by direct care staff. Review of Resident #10's current care plan, with a start date of 8/8/18 (and an anticipated review date of 11/8/18, revealed categories of activities of daily living, mobility and falls. The care plan had no indication of revision or review since the previous two MDS assessments. Diet: Review of the most recent quarterly MDS, dated [DATE], revealed Resident was coded as having weight gain that was not a result of a physician-prescribed weight-gain regimen. Review of the most recent MDS, a significant change assessment, dated 4/3/19, revealed Resident was coded as not having any weight gain. Review of LTC/SB Physician Orders, dated 4/9/19 at 1:00 pm, revealed Diet Change: Mechanical Soft, thin liquids with dysphagia (difficulty swallowing). Review of Resident #10's current care plan, dated 8/8/2018, revealed no documentation regarding a dysphagia problem or an intervention for a mechanical soft diet. Review of Resident #10's current care plan, with a start date of 8/8/18 (and an anticipated review date of 11/8/18, revealed a category of nutrition. Further review revealed no documentation regarding a dysphagia problem or an intervention for a mechanical soft diet. The care plan had no indication of revision or review since the previous two MDS assessments. Wound: Review of the most recent quarterly MDS, dated [DATE], revealed Resident was coded having no unhealed pressure ulcers. Review of the most recent MDS, a significant change assessment, dated 4/3/19, revealed Resident was coded as having one unhealed stage II pressure ulcer (pressure injury to the skin that involves partial-thickness skin loss with exposed under skin layers. Wound is pink or red, moist, and may be intact or a ruptured serum-filled blister) that was to be addressed in the care plan. Review of LTC/SB Physician Orders, dated 1/28/19 at 9:45 am, revealed Daily dressing change with localized to left foot wound . Review of LTC/SB Physician Orders, dated 3/19/19 at 11:00 am, revealed Wound care consult- Decubitus (pressure) ulcer Rt (Right) foot. Observation of Resident #10's wound care on 4/15/19, at 2:20 pm, revealed decubitus ulcers (a wound caused by pressure) to the right great toe and the left foot. Review of Resident #10's current care plan, with a start date of 8/8/18 (and an anticipated review date of 11/8/18), revealed no documentation regarding wounds or ulcerations to feet. Further review revealed no interventions for dressing changes or pain management related to the foot wounds. The care plan had no indication of revision or review since the previous two MDS assessments. Behavior/Mood: Review of most recent MDS assessment, a significant change assessment dated [DATE], revealed Resident #10's care area assessment was coded as having behavior symptoms that was to be addressed in the care plan. Review of Physician Notes, dated 3/15/19 at 4:34 pm, revealed Resident #10 had increasing difficulties with middle of the night [MEDICAL CONDITION]. (He/She) is been agitated, crying, frightened, and unconsolable. This has occurred 12 nights this month with increasing frequency. Review of LTC/SB Physician Orders, dated 3/23/19 at 8:55 pm, revealed order Strict Sleep hygiene as follows .should be exposed to sunlight as much as possible .naps should be strongly discourage during the day .(naps) should be limited to 45 minutes or less . During an interview on 4/17/19 at 8:08 am, RN #1 stated Resident #10 had a rough night with [MEDICAL CONDITION] last night. Review of Resident #10's most recent care plan, with a start date of 8/8/18 (and an anticipated review date of 11/8/18), revealed no documentation of a night time [MEDICAL CONDITION] problem or any interventions pertaining to sleep hygiene. The care plan had no indication of revision or review since the previous two MDS assessments. During an interview on 4/19/19 at 12:38, the MDS Coordinator stated the care plan dated 8/8/18 was the most recent care plan used by the staff to guide Resident #10's care. He/she further stated that care plans should be updated with significant change and quarterly MDS assessments. The MDS Coordinator also stated better care is received when the care plan was up to date. Resident #11 Record Review on 4/15-19/19 of Resident #11's medical record revealed the Resident had [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, an admission assessment dated [DATE], revealed the Resident had constipation. Review of Resident #11's physician's orders [REDACTED]. Review of the Resident's Bowel Movement Details Rosters, dated 4/1-13/19 revealed a time span of 4/2/19 at 7:17 pm to 4/6/19 at 3:15 pm with no bowel movement. Review of the medication administration recorded, dated 4/1-6/19, revealed MOM was administered on 4/3/19 at 10:11 am with no result until 4/6/19 at 3:15 pm (3 days and 5 hours post administration of MOM). Review of the Resident's Bowel Movement Details Rosters, dated 4/1-13/19 revealed a time span of 4/9/19 at 9:26 am to 4/13/19 at 3:52 am with no bowel movement. Review of the medication administration recorded, dated 4/9-13/19, revealed no medication intervention was provided. During an interview on 4/17/19 at 11:24 am Resident #11's Family Member stated the resident had a history of [REDACTED]. During an interview on 4/18/19 the Pharmacy Nurse stated the two episodes of multi-day constipation were not addressed in accordance with Resident #11's physician's orders [REDACTED]. Review of Resident #11's current comprehensive care plan, with a start date of 3/14/19, revealed no category, goal or interventions pertaining to constipation.",2020-09-01
48,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2019-04-24,761,D,0,1,FNNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to label drugs and biologicals in accordance with currently accepted professional practices. Specifically, the facility failed to: 1) ensure the expiration date on a bottle of [MEDICATION NAME] tablets (a heart medication to treat and prevent chest pain caused due to heart complications) was readable for 1 resident (#1), out of 12 medication drawers inspected and 2) ensure glucometer control solutions (solutions used to perform quality checks on glucometers (a device that measures blood sugar concentrations in the blood) to ensure accurate readings) were properly labeled with open dates. This failed practice placed residents at risk for not receiving effective and accurate nursing interventions for potentially life-threatening conditions. Findings: Resident #1 Record review on 4/15-19/19 revealed Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. Further review revealed Resident #1 had a pacemaker (a small device implanted near the heart that provides a small electric stimulation to help the heart beat more regularly). Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, a quarterly assessment dated [DATE], revealed Resident #1 was coded as having unspecified [MEDICAL CONDITION] (an irregular, often rapid heart rate that commonly causes poor blood flow) and [MEDICAL CONDITIONS] of native coronary artery (a buildup of plaque inside the artery walls in the heart which causes narrowing of the arteries and slows the blood flow. This affects the blood supply to the heart). Review of Resident #1's medical record revealed a medication order for [MEDICATION NAME] 0.4mg tablet (sublingual - under the tongue) every 5 minutes as needed for chest pain. Call (doctor) if no relief after 3rd dose. Monitor for [MEDICAL CONDITION] (low blood pressure) [MEDICATION NAME]. Observation on 4/17/19 at 11:24 am, of Resident #1's medication drawer in the nurse's medication cart, revealed a bottle of [MEDICATION NAME] sublingual 0.4mg/tab. 25 tab bottle with 5 tabs left within the bottle. Further review revealed the expiration date was unreadable. During an interview on 4/17/19 at 11:24 am, Registered Nurse (RN) #1 stated he/she could not read the expiration date on the [MEDICATION NAME] sublingual tablet bottle. During an interview on 4/17/19 at 12:02 pm, the Pharmacy Nurse stated he/she could not read the expiration date on the [MEDICATION NAME] sublingual tablet bottle. He/she could not state how long this particular bottle of [MEDICATION NAME] has been in Resident #1's medication drawer. Glucometer Control Solutions Observation on 4/17/19 at 11:24 am, of the nurse's medication cart revealed an Accu-check glucometer kit. Further review revealed 2 control solutions bottle, one labeled Control 1 for the low range readings and one labeled Control 2 for the high range readings. There were no open dates written on either bottle. Additional review of the bottles revealed instructions Discard 3 months after opening. During an interview on 4/17/19 at 11:38 am, RN #1 stated the Accu-check control bottles Control 1 and Control 2 did not have open dates on the bottles. He/she further stated the control bottles expire 3 months after they were opened. He/she could not state when they were opened. During an interview on 4/19/19 at 11:00 am, the Director of Nursing (DON) stated there was no facility policy on glucometer quality control.",2020-09-01
49,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2019-04-24,790,D,0,1,FNNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility to obtain dental services for 1 resident (#4), out of 8 sampled residents. Specifically, the facility failed to provide service to fix loose dentures. This failed practice affected the resident's ability use his/her dentures effectively and maintain a general diet. Findings: Record review on 4/15-19/19 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. (MONTH) manifest as weight loss, decreased appetite, poor nutrition, and inactivity). Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, an admission assessment dated [DATE], revealed Resident #4 was coded as having broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose). Further review revealed the assessment indicated no altered or therapeutic diets were needed. Review of Care Area Assessment (CAA) Summary of the admission MDS assessment revealed dental care was a care area triggered within the MDS and would have been addressed in Resident #4's care plan. Review of Resident #4's care plan, start date 3/15/19, revealed dental/dentures were not an identified problem. There were no goals or interventions associated to dental/denture care. Review of the Physician Orders for Resident #4 revealed a diet order, dated 3/2/19, food consistency general. Review of (Wrangell Medical Center) Nutritional Assessment, dated 4/12/19 revealed Nutrition Related Assessment Comments: Dentures are apparently loose per MDS . The plan on the assessment indicated add (mechanical) soft to order for ease of chew. During an interview on 4/16/19 at 12:52 pm, the Dietician stated Resident #4 was placed on mechanical soft diet (ground meat) because his/her dentures were loose and it would ease Resident #4's ability to chew meat. During an interview on 4/16/19 at 1:32 pm, Resident #4's Daughter stated Resident #4's dentures were too big and they fell out of his/her mouth at times and this had affected his/her ability to chew. The Daughter stated the facility had not mentioned to her what they were going to do about Resident #4's dentures. During an interview on 4/16/19 at 3:42 pm, the Senior Office Specialist stated all appointments, to include dental appointments, for the Long Term Care Residents were logged in the appointment book kept at the front desk. He/she stated there had been no dental appointments made for Resident #4. During an interview on 4/17/19 at 9:15 am, the MDS Coordinator stated all care areas triggered in the MDS should have been added to Resident's care plan so a plan of care could be initiated. When Resident #4's care plan was reviewed, the MDS Coordinator stated Resident #4's denture issue was not on the care plan. During an interview on 4/18/19 at 8:10 am, the MDS Coordinator stated a dentist appointment was made for Resident #4 during the course of this survey for 4/22/19. Review of the facility policy Dental Services, revision date 5/2017, revealed: The facility will have an advisory dentist who proves consultation, recommends policies concerning oral hygiene, and is available in case of emergency. It shall be the responsibility of the facility, when necessary, to arrange for resident to be transported to the dentist's office. During an interview on 4/19/19 at 11:00, the Director of Nursing (DON) stated there was no facility policy for oral hygiene. Review of the facility policy Resident MDS Assessment and Care Planning, revision date 6/2018, revealed: CAA triggers are used as basis for care planning. Additional areas care planned as determined by (interdisciplinary team), additional assessment, diagnoses, facility policy or other concerns specific to resident.",2020-09-01
50,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2019-04-24,804,D,0,1,FNNN11,"Based on interview, observation, and policy review, the facility failed to ensure that food was prepared by methods to conserve nutritive value. Specifically, there was no consistent method for preparing pureed diets and the addition of thickening powder for 1 non-sampled resident (#6) out of census of 12. This failed practice had the potential to decrease the nutritive value of pureed foods and placed residents on a pureed diet at risk for weight loss. Findings: During an interview on 4/15/19 at 8:45 am, Cook #1 stated he/she used water to puree breakfast items such as pancakes and French toast. Cook #1 further stated that he/she would add syrup to the water to improve flavor. Cook #1 further stated that she used broth for meats and apple juice for sweet items. During an observation on 4/16/19 at 12:45 pm, Cook #1 measured 4 ounces of salmon then poured an unmeasured amount of broth into the blender canister to puree the salmon. The Cook then proceeded to add thickener a little bit at a time with the measured scoop until it was the consistency desired. The process was repeated for the rice pilaf and carrots. During an interview on 4/16/19 at 1:00 pm, Cook #1 stated that the puree was to be honey thick consistency and that he/she eyeballs the puree until it appeared to be at the texture he/she desired. During an interview on 4/17/19 at 12:30 pm, when asked about the pureed lunch meal preparation, Cook #1 stated there was thickener in the sherbet, mashed potatoes, roast beef, and carrots. When asked if there were guidelines available for pureeing diets in the kitchen, he/she stated there were none that he/she knew of. During an interview on 4/17/19 at 12:45, Cook #2 stated that he/she prepared the pureed lunch items and that there was only thickener in the sherbet. He/she stated they melt the sherbet then add the thickener so that it doesn't melt as fast. Cook #2 further stated there were no guidelines in the kitchen for preparing pureed items and that the cooks determine the consistency based on food type and how it appeared. During an interview on 4/19/19 at 11:07 am, the Support Services Manager stated that cooks have been trained and there are guidelines for preparing pureed diets posted on the bulletin board in the kitchen. The Support Services Manager stated that thickeners should be used according to the recommended guidelines on the package. The Support Services Manager stated cooks would use some type of thinning liquid for all food types and had been trained on how to use the thickener. When asked if he/she would expect the cooks to melt the sherbet then add thickener, the Support Services Manager replied, No. That preparation would be unusual because sherbet is already a puree. Observation of the kitchen on 4/19/19 at 2:00 pm revealed multiple bulletin boards in the kitchen. No signage or procedure for pureeing foods was prominently displayed. Review of the facility policies entitled, Dietary Standards; Dietary Procedures; Food Prep/Temp/Leftovers; and Meals did not contain procedural guidelines on preparing pureed diets.",2020-09-01
51,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2019-04-24,880,F,0,1,FNNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the infection control and prevention program included: 1) a timely facility infection control risk assessment, for use in conjunction with the annual review of the facility-wide assessment, to complete an accurate Facility Assessment; 2) the tracking/trending of employee illness; and 3) required elements of the Water Management Program to prevent the growth and spread of Legionella. These failed practices increased the risk of an insufficient Infection Control Program and increased the potential risk for development and transmission of disease and/or infection in all residents (based on a census of 12). Findings: Facility Infection Control Risk Hazards Assessment Review of the Facility Assessment Tool, updated 3/7/19, revealed: We model our infection control and prevention practices to the current CDC (Centers for Disease Control) guidelines and conduct quality monitoring to evaluate practice effectiveness in our facility. Review of the CDC guidelines Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 3/15/17, revealed: Performance Monitoring and Feedback: Monitor adherence to infection prevention practices and infection control requirements. During an interview on 4/17/19 at 2:50 pm, the Infection Prevention & Control Registered Nurse (IPCRN) stated a facility infection control risk assessment had not been completed in over a year. He/she stated this was late in getting done. During a second interview on 4/19/19 at 12:40 pm, the IPCRN confirmed the last facility infection control risk assessment was completed in (YEAR)-2017. Review of the most current (Wrangell Medical Center) Infection Control Risk Assessment Tool: Environmental Risks revealed it was dated (YEAR)-17. Review of the facility's policy Infection Prevention and Control Program: SEARHC (Southeast Alaska Regional Health Consortium) Wrangell Medical Center Long Term Care, approved 2/26/19, revealed: SEARHC Wrangell Medical Center Long Term Care maintains an organized, effective facility-wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors, healthcare workers. Employee Illness Tracking During an interview on 4/17/19 at 2:50 pm, the IPCRN stated he/she did not track/trend employee illness/infection. He/she stated this information had never been provided to him/her. Review of the facility's policy Infection Prevention and Control Program: SEARHC Wrangell Medical Center Long Term Care, approved 2/26/19, revealed: In collaboration with the DON (Director of Nursing) and the facility Medical Director the infection preventionist has the authority to institute emergency medical and or administrative action when there is danger or threat to residents and/or personnel regarding infection prevention/control matters. This includes .Collaborate with the Medical Director and Administration to restrict, from job duties, any healthcare personnel, with communicable disease or infected [MEDICAL CONDITION] of job duties have potential to transmit disease. Water Management Program (Legionella Program) During an interview on 4/17/19 at 2:50 pm, the IPCRN stated there was no information he/she could provide on the Water Management Program to prevent the growth and spread of Legionella other than the policy. He/she stated the facility's water had been tested recently, however could not state where the water was sourced from within the facility or if there was more than once source tested . During an interview on 4/19/19 at 12:43 pm, the IPCRN stated that he/she did not know if the facility's Water Management Program included the creation of a diagram of the building water system or if areas where legionella could grow and spread were identified based on this diagram. He/she could not provide any control measures that would have resulted from this procedure of the program. He/she stated maintenance would have been involved with the mapping and diagraming of the facility's water system. During an interview on 4/19/19 at 1:03 pm, the Facility Manager stated maintenance did not participate in any mapping or diagraming of the facility water system. Review of the facility's Water Management Policy, revised 3/2018, revealed the following procedures: 1. Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens .would grow and spread in the facility water system. 2. Implement a water management program that considers the ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) industry standard and the CDC toolkit, and includes control measures . Review of the Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings CDC Toolkit (which used the ASHRAE 188: [DIAGNOSES REDACTED]: Risk Management for Building Water Systems, dated 6/26/2015, as reference), dated 6/5/17, revealed: Elements of a Water Management Program: 1. Establish a water management program team; 2. Describe the building water systems using text and flow diagrams; 3. Identify areas where Legionella could grow and spread; 4. Decide where control measures should be applied and how to monitor them; 5. Establish ways to intervene when control limits are not met; 6. Make sure the program is running as designed and effective; 7. Document and communicate all activities.",2020-09-01
52,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2019-04-24,947,F,0,1,FNNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure the required nurse aide training, specifically a minimum of 12 hours per year of training, was provided for the assurance of continued competence of nurse aides (#'s 1; 2, and 3) hired by the facility through a travel agency. This failed practice had the potential to affect all residents (based on a census of 12), to receive less than optimal care. Findings: Record review on 4/18/19 at 10:00 am of employee files revealed no documentation of 12 hour annual nurse aide training (to include job specific and dementia training) for 3 certified nurse aides (#'s 1; 2, and 3) out of 3 contracted travel nurse aides. During an interview on 4/18/19 at 10:25 am, the Senior Human Resource (HR) Generalist stated the facility did not have documentation that nurse aide training was completed on an annual basis. He/she stated that the contract agency may keep records of continuing education. He/she stated that the facility did not have a process for ensuring that travel nurse aides had completed a minimum of 12 hours of training, to include dementia training, annually. During an interview on 4/19/19 at 12:37 pm, the Long Term Care (LTC) Care Services Coordinator stated he/she did not have a process to track [MEDICATION NAME] training requirements to ensure competency. During an interview on 4/19/19 at 12:41 pm, the Senior HR Generalist stated that he/she called the contract agency who confirmed they did not maintain documentation that education requirements had been completed. The Senior HR Generalist further stated that there was no record that job specific training had been completed for traveling nurse aides who work in the LTC. Travel nurse aides were invited to attend facility offered trainings if staffing and/or time allowed. No additional documentation that travel nurse aides had received the required minimum of 12 hours of training including dementia training were provided by end of survey. A review of the Facility Assessment tool dated 2/22/19 & 3/8/19 did not contain any information about required nurse aide training to ensure travel nurse aide competency. A review of the Administrative Policies index provided by the DON on 4/19/19 did not contain a policy for staff training or education requirements to ensure competency in the long term care unit.",2020-09-01
53,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,552,D,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide medication education to 1 resident (#11) out of 4 residents observed receiving medication. This failed practice inhibited the resident's right to be informed of his/her medication regimen and treatment. Findings: Review of the most recent MDS (Minimum date Set) assessment, a quarterly assessment dated [DATE], revealed Resident #11 was coded as having minimal difficulty hearing; clear speech; ability to make self understood; and usually understands others. During an observation on 4/26/18 at 8:55 am, Licensed Nurse (LN) #2 administered Resident #11's morning medication. Resident #11 asked LN #2 three different times, What are these pills? LN #2 replied each time by saying, It's your morning meds. LN #2 did not offer to explain the medications to the Resident during medication administration. During an interview on 4/26/18 at 3:00 pm, LN #2 was asked what the process was when a resident asked about medications he/she was taking. In response, the LN stated, I'll just sit down and talk to them about it. When asked about the morning medication pass on 4/26/18 with Resident #11, LN #2 stated he/she should have taken the opportunity to explain the medications to him/her. Review of Wrangell Medical Center's Resident's Bill of Rights, undated, reveals, Resident has the right to participate in the development and implementation of his or her person-centered plan of care, including to identify individuals or roles to be included in the planning process; to request meetings and the right to request revisions to the plan of care; to identify the expected goals and outcomes of care; and to identify the type, amount, frequency, and duration of care, among other factors.",2020-09-01
54,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,554,D,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to conduct appropriate interdisciplinary team (IDT) assessments on 1 resident (#7) out of 8 sampled residents to determine if resident was capable of appropriately administering his/her own medication. This failed practice places all residents at risk for improper self-administration; more specifically, the possibility of over medicating or omitting medications ordered by a physician. Findings: Record review on 4/23-27/18, revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, a quarterly assessment dated [DATE], revealed Resident #7 was coded as having a Brief Interview for Mental Status score of 15 (a score of 13-15 determines mental status is intact). Observation on 4/24/18 at 12:06 pm, revealed Resident #7 had an unsecured bottle of multivitamins with an easy-open lid on his/her bedside table. During an interview on 4/24/18 at 12:06 pm, Resident #7 stated he/she took the vitamins daily without notifying any staff and further stated he/she has not taken a vitamin for that day. During an interview on 4/27/18 10:00 am, Licensed Nurse (LN) #2 stated if a resident wanted to self-administer medication, the LN on duty would call the doctor, for an order. Next the nurse would complete a self-administration form and place in chart. During an interview on 4/24/18 at 11:19 am, LN #1 stated, If a Resident requests to self-administer medication, the RN completes the Self-Administration Assessment and puts it in the chart. When asked if the IDT is involved in any way to complete the assessment, LN #1 said, No, only the nurse does them. Review of Resident #7's Medication Administration Record [REDACTED]. Review of Resident #7's medical record did not reveal any self-administration assessment documentation for the ordered multivitamin. Further review of the medical record revealed self-administration assessment was not documented on any Interdisciplinary Team (IDT) notes since admission. Review of Wrangell Medical Center's Resident's Bill of Rights reads, To take your own (self-administer) prescribed medications provided the interdisciplinary team has determined this is a safe practice for you. Review of Wrangell Medical Center's policy for Resident Self Administering Medication reads: Purpose: Residents will be able to self-administer medications with a physician order [REDACTED]. There will be a physician order [REDACTED]. 2. Resident will agree and complete a medication administration competency. The resident must demonstrate to the registered nurse safe handling and administration of the medication. The resident will be able to state the medication, purpose, and prescription information to the staff. 3. The registered nurse will check in with the resident daily for proper medication usage and storage. 4. Physician will be notified of any concerns or failure of resident to follow manufacturer's recommendations.",2020-09-01
55,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,576,C,0,1,O8F911,"Based on interview and record review the facility failed to ensure resident mail was delivered to the facility on Saturdays. This failed practice affected all residents in the facility (based on a census of 10) and denied residents access to mail on Saturdays and delayed receipt of mail until the following Monday. Findings: During an interview with the Resident Group Council on 4/25/18 at 2:06 pm, Resident #s 1; 6; 7; 10 & 11 unanimously concurred there is no mail delivery on Saturday, only Monday through Friday. During an interview on 4/27/18 at 2:10 pm, the facility Purchasing Agent (PA) confirmed she is responsible for getting the resident's mail from the Post Office. The PA further disclosed mail is retrieved from the Post Office Monday through Friday only because no one is trained to get the mail. The Resident mail is mixed in with the facility business mail. Review of Resident Bill of Rights provided by the facility stated Residents had a right to access their mail. Review of the facility policies table of contents did not reveal a policy for resident mail.",2020-09-01
56,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,578,D,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure 1) 2 residents #'s (3 & 6) out of 8 sampled residents had been offered an opportunity to develop advanced directives, and 2) the facility had a policy to implement Advanced Directives. This failed practice denied the residents (and/or their representatives) the right to choose and make end of life medical decisions and placed the residents at risk for receiving unwanted or unnecessary care. Findings: Resident #3 Record review from 4/23-27/18, revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Further review of the medical record revealed no advance directive declaration or information had been given to the resident or their representative. Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, a quarterly assessment dated [DATE], revealed the Resident was coded as having a Brief Interview for Mental Status score of 11 (a score of 8-12 determines mental status is moderately impaired). During an interview on 4/25/18 at 11:02 am, the LTC Social Worker (SW) revealed she had not given advanced directive information to Resident #3. She further disclosed the Office of Public Advocacy (OPA) guardian would have been responsible for advanced directive information. Review of a letter dated 4/25/18, from the OPA guardian stated the Office of Public Advocacy is essentially unable to make end of life decisions for a client. Resident #6 Record review from 4/23-27/18, revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Further review of the medical record revealed no advance directive declaration or that information had been given to the resident or their representative. Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, a quarterly assessment dated [DATE], revealed the Resident was coded as having a Brief Interview for Mental Status score of 14 (a score of 13-15 determines mental status is intact). During an interview on 4/25/18 at 2:40 pm, the SW stated she did not give any advanced directive information to Resident #6. During an interview on 4/26/18 10:50 am, the Chief Nursing Officer stated she could not find a policy on Advanced Directives.",2020-09-01
57,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,585,C,0,1,O8F911,"Based on record review and interview the facility failed to ensure the grievance policy included all necessary components. Specifically, the grievance policy did not address: 1) all the processes for written grievance decision; and 2) immediately reporting all alleged violations involving neglect and/or abuse, to the administrator, reporting which is required by state law. This failed practice placed all residents (based on a census of 10) at risk of not receiving feedback for grievances filed with the facility and placed them at risk for potential abuse and/or neglect from unreported allegations. Findings: Grievance Policy Review of the facility policy provided on 4/24/18, titled Grievance Policy Date of Revision 3/2017, revealed the following elements were not addressed in the policy: 1) Written grievances decisions include all required information; and 2) Immediately reporting certain allegations as required. During an interview on 4/27/18 at 3:17 pm, the Grievance Officer confirmed the policy did not contain the complete information.",2020-09-01
58,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,600,D,0,1,O8F911,"Based on record review and interviews the facility failed to ensure 1 resident (#10), out of 8 sampled residents, was free from verbal abuse during cares. This failed practice placed the resident at risk for further mistreatment, undo stress/suffering and a less than optimal psychosocial environment. Findings: Record review on 4/23-27/18, of Resident #10's care plan, dated 2/12/18, revealed he/she was wheelchair bound and requires mechanical lift (machine used to move a resident), using 2 staff members for transfers. During an interview on 4/25/18 at 1:28 pm, Resident #10 stated that approximately a week ago CNA #3 was helping him/her, slipped, and caused the bar of the mechanical lift to hit the area above the Resident's right eye. The Resident had requested CNA #4 to help him/her instead. The Resident further stated that CNA #3 got frustrated, took off his/her gloves, threw them in the trash can and in a raised voice said, I am never going to help you again. The Resident further stated soon after this, a LN (licensed nurse) asked CNA #3 to help get Resident #10 into bed. Resident #10 stated he/she saw CNA #3 whisper in the LN's ear and left the area. After this, the LN obtained another CNA to help the Resident that day. Resident #10 stated this event made him/her feel like CNA #3 did not want to work with him/her. During an interview on 4/27/18 10:30 am, the Chief Nursing Officer (CNO) stated she was informed that Resident #10's head was bumped by the mechanical lift and the Resident requested a different CN[NAME] She further stated it was her understanding that CNA #3 removed his/her gloves and stated he/she wasn't going to help anymore. When asked about the manner in which CNA #3 spoke to the Resident, the CNO stated she was unaware that CNA #3 spoke to Resident #10 in a raised voice. When the Surveyor asked if the CNO felt the incident of how the staff spoke the Resident was a reportable incident, CNO replied, I understand it's reportable if there was a bump or bruise. After surveyor showed the CNO the mandatory reporting criteria of any allegation, perception, suspicion, or observation of any type of abuse from the Wrangell Medical Center Event Mandatory Reporting Form, dated 5/2/16, the CNO stated, Yes, it needs to be reported. CNO concluded by stating the facility had not filed a report with the State Survey Agency concerning this incident. During an interview on 4/27/18 at 1:15 pm, CNA #3 stated he/she was assisting Resident #10 in a transfer when a his/her scrub pocket got caught on a piece of the mechanical lift. As a result, this caused the arm of the lift to swing and make contact with the right side of the Resident's face. The CNA further stated the Resident wanted a different CNA to assist. In response, CNA #3 stated he/she removed gloves and left the room. CNA #3 denied saying anything to Resident. During an interview on 4/27/18 at 2:00 pm, CNA #4 stated he/she was going to take over assisting Resident #10 with transfer when he/she approached the door and noted that CNA #3 had accidently bumped the Resident's forehead with the mechanical lift. CNA #4 stated the Resident requested that he/she should assist instead of CNA #3. CNA #4 further stated that CNA #3 became angry and threw his/her gloves into the trash and stated to the Resident I won't help you again. CNA #4 stated he/she filled out a Stop and Watch form (document filled out when any identified changes occur) and immediately reported the incident to the CNO and while handing in the Stop and Watch form. During an interview on 4/26/18 at 3:10 pm, the CNO confirmed when a Stop and Watch form is completed it does go to her for review. When surveyor asked to see past Stop and Watch forms, the CNO stated, no one knows where the past forms are and did not produce past forms. Review of Wrangell Medical Center's Policy and Procedure of Abuse Prevention and Protection from Abuse and Neglect in the Vulnerable Adult, dated 3/2017, stated under Prevention: Management and staff will remain alert for signs of stress, fatigue, or inappropriate behavior among their peers. Inappropriate language, rough handling, or failure to attend to a resident's care needs will not be tolerated. Review of Wrangell Medical Center's Policy and Procedure of Incident/Adverse Reporting Policy, dated 4/2017, revealed Any incident involving a patient/resident that involves alleged mistreatment, abuse, or neglect, misappropriation of property, injury of unknown origin or unwitnessed falls will be reported within 24 hours to the State of Alaska Department of Health and Social Services, Certification & Licensing.",2020-09-01
59,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,609,D,0,1,O8F911,"Based on record review and interviews the facility failed ensure alleged verbal abuse occurring with 1 resident (#10), out of 8 sampled residents, was reported to the State Survey Agency. This failed practice placed resident at risk for further mistreatment, undo stress/suffering and less than optimal psychosocial environment. Findings: Record review on 4/23-27/18, of Resident #10's care plan, dated 2/12/18, revealed he/she was wheelchair bound and requires mechanical lift (machine used to move a resident), using 2 staff members for transfers. During an interview on 4/25/18 at 1:28 pm, Resident #10 stated that CNA #3 was helping him/her, slipped, and caused the bar of the mechanical lift to hit the area above the Resident's right eye. The Resident had requested CNA #4 to help him/her instead. The Resident further stated that CNA #3 got frustrated, took off his/her gloves, threw them in the trash can and in a raised voice said, I am never going to help you again. Furthermore, the Resident stated a separate event occurred when a Licensed Nurse (LN) asked CNA #3 to help get Resident #10 into bed. Resident #10 stated he/she saw CNA #3 whisper in the LN's ear and left the area. This was immediately followed by the LN obtaining another CNA to help the Resident that day. Resident #10 stated this event made him/her feel like CNA #3 did not want to work with him/her. During an interview on 4/27/18 10:30 am, the Chief Nursing Officer (CNO) stated the process for staff reporting was that the nurse makes a report, writes up the incident, and then provides the report to the CNO. The CNO further explained she has 5 days to do an investigation and report to state. The CNO stated she was informed that Resident #10's head was bumped by the mechanical lift and the Resident requested a different CN[NAME] She continued to state it was her understanding that CNA #3 removed his/her gloves and stated he/she wasn't going to help anymore. When asked about the manner in which CNA #3 spoke to the Resident, the CNO stated she was unaware that CNA #3 spoke to Resident #10 in a raised voice. The CNO concluded by stating the facility had not filed a report with the State Survey Agency and the occurrence happened more than 5 days prior to the interview. During an interview on 4/27/18 at 2:00 pm, CNA #4 stated he/she was going to help Resident #10 with a transfer when he/she approached the door and noted that CNA #3 had accidently bumped the Resident's forehead with the mechanical lift. Next CNA #4 stated the Resident requested that he/she should assist instead of CNA #3. CNA #4 further stated that CNA #3 became very angry and proceeded to throw his/her gloves into the trash and stated to the Resident I won't help you again. The CNA concluded he/she immediately reported the incident to the CNO. Review of Wrangell Medical Center's Policy and Procedure of Incident/Adverse Reporting Policy, dated 4/2017, revealed Any incident involving a patient/resident that involves alleged mistreatment, abuse, or neglect, misappropriation of property, injury of unknown origin or unwitnessed falls will be reported within 24 hours to the State of Alaska Department of Health and Social Services, Certification & Licensing.",2020-09-01
60,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,640,F,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the MDS (Minimum Data Set, a federally mandated assessment) for 5 residents (#s 1; 3; 6; 9; and 10) out of a census of 10 and 1 closed record (resident #5), were transmitted within 14 days after completion. This failed practice placed all residents at risk for less than optimal care or lack of adequate care to meet their individual needs. Findings: Record review on 4/26/18, revealed Resident #1's MDS assessment dated [DATE] was not transmitted. Record review on 4/26/18, revealed Resident #3's MDS assessment dated [DATE] was not transmitted. Record review on 4/26/18, revealed Resident #5's MDS assessment dated [DATE] was not transmitted. Record review on 4/26/18, revealed Resident #6's MDS assessment dated [DATE] was not transmitted. Record review on 4/26/18, revealed Resident #9's MDS assessment dated [DATE] was not transmitted. Record review on 4/26/18, revealed Resident # 10's MDS assessment dated [DATE] was not transmitted. An interview on 4/26/18 at 2:37 pm, Licensed Nurse (LN) # 3 stated no staff in the facility have transmittal ability/access for sending MDS information as required. The LN confirmed the MDS information has not been submitted for any resident. During an interview on 4/26/18 at 2:50 pm, with the Chief Nursing Officer confirmed no facility staff have the ability to transmit the MDS data as required.",2020-09-01
61,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,642,D,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a MDS (Minimum Data Set) assessment was completed accurately in accordance with standards set forth by Center for Medicare and Medicaid Services (CMS). Specifically, the facility failed to review five subsections of the MDS for the full 7-day look back period for 1 resident (#10) out of 8 sampled residents. This failed practice placed the resident at risk for improper care planning and denied the resident an accurate assessment of his or her current health care status. Findings: Record review on 4/23-27/18, revealed Resident #10 was admitted to facility with [DIAGNOSES REDACTED]. He/She has a history of bilateral [MEDICAL CONDITION] that left her wheelchair bound. Review of the Long-Term care Facility Resident Assessment Instrument 3.0 User manual, dated 10/2017, revealed Assessment Reference Date (ARD) refers to the last day of the observation (or 'look back') period that the assessment covers for the resident .Most of the MDS (Minimum Data Set) 3.0 items have a 7-day look back period. Review of the Long-Term care Facility Resident Assessment Instrument 3.0 User manual, dated 10/2017, revealed the following sections required a 7-day look back review: C1310; E0100; E0200; E0500; E0600; E0800; E0900; J1100; J1500; J1800; K0100; K0510; P0100; and P0200. Review of the admission MDS (Minimum Data Set) assessment, dated 10/11/17, revealed the Social Worker signed Sections C and [NAME] as completed on 10/10/2017 under Section Z (a day before the last day of review). Additional review revealed LN#3 signed Sections J, K and P as completed on 10/10/17 under Section Z (a day before the last day of review). During random interviews on 4/25-27/18, LN #3 stated he/she was unable to explain why Sections C, E, J, K and P were signed before the ARD date of 10/11/17. The LN further stated that some sections can be done early. Review of the Long-Term care Facility Resident Assessment Instrument 3.0 User manual, dated 10/2017, revealed the rationale for Section Z was To obtain the signature of all persons who completed any part of the MDS. Legally, it is an attestation of accuracy with the primary responsibility for its accuracy with the person selecting the MDS item response. Each person completing a section or portion of a section of the MDS is required to sign the Attestation Statement .The importance of accurately completing and submitting the MDS cannot be over- emphasized.",2020-09-01
62,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,658,D,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to follow professional standards for nursing during medication administration for 3 residents (#s 7, 10 and 11) during 4 of 4 observations. This failure to administer medications correctly can result in residents receiving more medication than ordered and/or not taking their medications as prescribed. Findings: Resident #7 Record review on 4/23-27/18, revealed Resident #7 was admitted to the facility with a [DIAGNOSES REDACTED]. During an observation on 4/24/18 at 8:58 am, Licensed Nurse (LN) #1 performed medication administration at Resident #7's bedside. The LN gave Resident #7 his/her [MEDICATION NAME] bottle to self-administer the medication. Resident #7 was observed to self-administer 2 sprays in each nostril. LN #1 did not correct this dosing error or provide education. Observation on 4/24/18 at 12:06 pm, revealed Resident #7 had a bottle of multi vitamins on his/her bedside table. During an interview on 4/24/18 at 12:06 pm, Resident #7 stated he/she took the vitamins daily without notifying any staff. Review of Resident #7's physician orders [REDACTED]. Review of Resident #7's medical record revealed no form of self-administration assessment documentation approved by the Interdisciplinary Team (IDT). Resident #10 Record review on 4/23-27/18, revealed Resident #10 was admitted to facility with [DIAGNOSES REDACTED]. During an observation on 4/24/18 at 8:10 am, LN #1 performed medication administration with Resident #10. The LN placed a cup of pills next to Resident #10 and walked away without observing Resident #10 taking the mediation. During an observation on 4/25/18 at 7:18 am, LN #1 performed medication administration at Resident #10's bedside. He/she gave Resident #10 his/her [MEDICATION NAME] bottle to self-administer his/her medication: [MEDICATION NAME] 50mcg 1 spray both nares. Resident was observed to self-administer 2 sprays in each nostril. LN #1 did not correct this dosing error. During an interview on 4/27/18 at 1:42pm, LN #1 stated he/she should not have left the medications at Resident #10's table without ensuring all medications were taken. In addition, the LN stated he/she was not able to guarantee Resident #10 took all of his/her medication during the medication administration on 4/24/18. Furthermore, LN #1 stated the administration of 2 sprays of the medication [MEDICATION NAME] did not meet the provider's order and should have been corrected at the time of administration. Review of Resident #10's physician orders [REDACTED]. - [MEDICATION NAME] SUCC (treats high blood pressure) ER 50mg by mouth daily - Multivitamin Daily Vite (nutritional supplement) by mouth daily - [MEDICATION NAME] (treats high blood pressure and heart failure) 10mg by mouth daily - Aspirin EC (blood thinner, reduces risk of [MEDICAL CONDITION]) 81mg by mouth daily - Tylenol (fever/pain reliever) 500mg by mouth twice a day - [MEDICATION NAME] (treats/prevents heartburn) 150mg by mouth daily - [MEDICATION NAME] DN (prevents chest pain) 20mg by mouth twice a day - [MEDICATION NAME] (treats high blood pressure) 25mg by mouth 2 tabs daily - Folic Acid (treats [MEDICAL CONDITION]) 1mg by mouth daily - [MEDICATION NAME] (nasal spray for allergy relief) 50mcg, 1 spray both nares. Review of Lippincott's document entitled 8 Rights of Medication Administration, dated 2011, revealed to ensure a healthcare professional is to ensure they are administering the correct dose in conjunction with the provider's order. Resident #11 Review of the most recent MDS (Minimum date Set) assessment, a quarterly assessment dated [DATE], revealed Resident #11 was coded as having minimal difficulty hearing; clear speech; ability to make self understood; and usually understands others. Observation on 4/26/18 at 8:55 am, revealed LN #2 administering Resident #11 his/her morning medication. Resident #11 asked LN #2 three different times, What are these pills? LN #2 replied each time by saying, It's your morning meds. LN #2 did not offer to explain the medications to Resident #7 during medication administration. During an interview on 4/26/18 at 3:00 pm, LN #2 was asked what the process was when a resident asked about medications he/she was taking. In response, the LN stated, I'll just sit down and talk to them about it. When asked about the morning medication pass on 4/26/18 with Resident #11, LN #2 stated he/she should have taken the opportunity to explain the medications to him/her. Review of Lippincott's document entitled Medication Safety: Go Beyond the Basics, dated (YEAR), revealed the healthcare professional should educate patients about their medications. During an interview on 4/26/18, the Chief Nursing Officers stated the facility used Lippincott as their professional reference. Review of Wrangell Medical Center's Resident's Bill of Rights, undated, revealed, Resident has the right to participate in the development and implementation of his or her person-centered plan of care, including to identify individuals or roles to be included in the planning process; to request meetings and the right to request revisions to the plan of care; to identify the expected goals and outcomes of care; and to identify the type, amount, frequency, and duration of care, among other factors.",2020-09-01
63,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,684,D,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure 1 resident (#1) out of 1 resident with a cardiac pacemaker had necessary care and follow up of the device. This failed practice placed the resident at risk for undiagnosed heart rhythm irregularities, missed device changes or alerts and decreased heart health. Findings: Record review from 4/24-27/18, revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the record revealed an EKG (a graphic record of the heart muscle rhythm) dated (MONTH) 19, (YEAR) with results .paced rhythm (a heart rhythm controlled by an internal pacemaker) . Further review revealed a Medtronic Device Identification card (a card with information for implanted medical device) that showed resident information with implant dates, serial and model numbers of the pacemaker and leads (wires attached to the heart muscle from the pacemaker device) in addition contact numbers for Medtronic were listed. Record review of Resident #1's Multi-Disciplinary Care Plan dated 2/7/18, revealed no documentation of the Residents pacemaker or monitoring of the device or implantation site. During an interview on 4/27/18 at 9:18 am, LN #4 stated he/she did not know of any special monitoring or equipment needed for care of a Resident with a pacemaker and was not aware of what provider or facility would be monitoring the pacemaker. During an interview at 4/27/18 at 11:50 am, Licensed Nurse (LN) #1 stated, he/she was not aware of any Resident who had any devices that would require any special care or monitoring. During an interview on 4/27/18 at 2:58 pm, the Chief Nursing Officer (CNO) stated she was not aware of any resident in the facility who had a pacemaker. The CNO further stated staff were unaware of a resident with a pacemaker or any care needed for monitoring the device or implant (surgical) site.",2020-09-01
64,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,686,D,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure 1 resident (#10), out of 8 sampled residents, received the necessary care and services to prevent the development of a pressure ulcer. Failure to identify potential risk for development of, or provide appropriate interventions on a timely basis upon admission, to prevent pressure ulcers, placed resident at an increased risk for developing an avoidable pressure ulcer. Findings: Record review on 4/23-27/18, revealed Resident #10 was admitted to facility on 10/2/17 with [DIAGNOSES REDACTED]. Review of admission MDS (Minimum Data Set), dated 10/11/2017, revealed Resident #10 was coded as requiring extensive assistance during bed mobility and locomotion on/off unit. The Resident was coded as being totally dependent during transfers and toileting. Review of Resident #10's Admission Nursing Assessment, dated 10/2/17, revealed no skin assessment completed upon admission. Further review of nursing notes for the month of (MONTH) (YEAR) revealed the first documented skin assessment was completed 10/11/17 which stated .(had) a bath today, and skin was intact. Review of Resident #10 nursing note dated 10/18/1,7 revealed During shift change report I was informed that (Resident #10) has a healed decubitus ulcer to coccyx (tailbone area); during .weekly skin assessment I noted that the ulcer is still there, but healing. Review of Resident #10's Wound Assessment Report dated 10/19/17, revealed a Stage 2 (Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist) pressure ulcer was present on the coccyx. The assessment further revealed the wound was described as: Length 0.20cm, Width 0.20cm, Depth 0.10cm. Picture taken on 10/19/17, by the wound care nurse, revealed an open red area to the coccyx. Review of Resident #10s admission orders [REDACTED]. Review of Resident #10's medical record nursing note dated 10/19/17, revealed has a new bed to assist with coccyx soreness. Review of Resident #10's Wound Assessment Report dated 10/25/17, revealed pressure ulcer remained at a Stage 2 with unchanged dimensions. Review of the wound picture taken on 10/25/17, by the wound care nurse (WCN), revealed the pressure ulcer area had become an open area, exposing the moist pink/red tissue bed. Review of Resident #10's medical record revealed a physician's orders [REDACTED]. Cleanse with (normal saline), Foam dressing BIW (twice weekly) & PRN (as needed), Report if not better 4 weeks. Review of Resident #10's treatment report revealed weekly skin assessments were marked as intact from 10/14/17 to 12/30/17, despite having a wound assessment done on 10/19/17 and 10/25/18. In addition, the treatment report indicated dressing changes to pressure ulcer from 10/31/17 to 11/24/17. During an interview on 4/26/18 at 2:15 pm, with Licensed Nurse (LN) #2 confirmed no skin assessment was completed upon Resident #10's admission. During an interview on 4/26/18 at 2:30 pm, WCN confirmed documentation showed no assessment completed upon admission. The WCN stated Resident #10's pressure ulcer was acquired/re-opened post-admission to the facility.",2020-09-01
65,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,689,D,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure CNA (Certified Nursing Assistant) staff were implementing consistent, safe interventions when conducting Hoyer lift transitions. This deficient practice increased the hazard and risk of falls for one resident (#10), out of 5 residents requiring the use of a mechanical lift, while being transferred from bed to wheelchair. Findings: Record review on 4/23-27/18 of Resident #10's care plan, dated 2/12/18, revealed he/she was wheelchair bound and required mechanical lift (machine used to move a resident), using 2 staff members for transfers. Review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE], revealed Resident #10 was coded as requiring extensive assistance (resident involved in activity, staff provide weight-bearing support) during bed mobility; transfer; toileting; dressing; and personal hygiene. His/her functional limitation to range of motion in lower extremities was coded as impairment to both sides. Resident #11's mobility device was a wheelchair. During an observation on 4/25/18 at 7:46 am, Certified Nursing Assistant (CNA) #1 used Hoyer lift to assist Resident #10 from his/her bed to his/her wheelchair. As Resident #10 was suspended in the Hoyer, CNA #1 placed the wheelchair under Resident #10, tilted the wheelchair back onto its rear wheels and held the wheelchair in that position as Resident #10 was lowered into the wheelchair. During an interview on 4/25/18, CNA #1 stated he/she always tilts the wheelchair back when the resident is lowered from the Hoyer lift. During an interview on 4/25/18 at 2:12 pm, Resident #10 expressed that he/she does not like the wheelchair being tilted back as it makes him/her feel unsafe and unstable. During an interview on 4/27/18 at 9:31 am, CNA #2 stated the wheelchair should be sideways and never tilted, because there is a risk of injury due to tilting. During an interview on 4/27/18 at 2:59 pm, the Chief Nursing Officer (CNO) stated it was not a safe practice to position wheelchair onto its back wheels during Resident lift transfer into wheelchair. Review of Wrangell Medical Center's Policy and Procedures for Mechanical Lift Transfers revealed there is no clear guidance on wheelchair placement/position. Item 11 under Procedures for Bed to Chair reads, Position resident over the wheelchair or chair, first person will guide the resident's legs while the second person is holding resident (in) place using the sling for positioning.",2020-09-01
66,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,726,D,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure staff had appropriate competencies and skills necessary to care for 1 resident (#1) of 1 resident with a cardiac pacemaker. This failed practice placed the resident with a pacemaker at risk for receiving less than optimal care from nursing staff. Findings: Record review from 4/24-27/18, revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review on 4/24-27/18, of Resident #1's Multi-Disciplinary Care Plan, dated 2/7/18, revealed no documentation of Resident #1's pacemaker or any special care the Resident or the device may require. During an interview at 4/27/18 at 11:50 am, LN #1 stated he/she was not aware of any Resident who had any devices that would require any special care or monitoring. During an interview on 4/27/18 at 9:18 am, Licensed Nurse (LN) #4 stated he/she did not know of any special monitoring or equipment needed for care of Resident #1's pacemaker and was not aware of what provider or facility would be monitoring the pacemaker. During an interview on 4/27/18 at 2:58 pm, the Chief Nursing Officer (CNO) stated she did not know there was a Resident in the facility who had a pacemaker. The CNO further stated staff did not have any special training on how the pacemaker is monitored, equipment to use, or care of the implant (surgical) site.",2020-09-01
67,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,756,E,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure: 1) the pharmacist had access to the complete medical record (#9); 2) the pharmacist noted and reported unnecessary medications for two residents (#s 2 and 10); and 3) policies and procedures were developed and maintained for the monthly drug regimen reviews that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. These failed practices placed 1 resident (#9) at risk for ineffective medication management; 2 residents (#s 2 and 10) at risk for receiving unnecessary medication (based on a sample of 8) and placed all residents (based on a census of 10) at risk for delay in review of their current drug regimen reviews. Findings: Resident #9 Record review on 4/24-27/18, revealed Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED].) Review of the Drug Regimen Review (DRR), dated 12/17/17, revealed Resident #9 had a dosage change in (MONTH) (YEAR) to [MEDICATION NAME] 1mg by mouth HS (evening time). Further review of Resident #9's medical record revealed multiple month behavior logs and AIMS assessments (Abnormal Involuntary Movement Scale-a screening tool used to identify movements in people taking antipsychotic medications) in the medical record from (MONTH) (YEAR) to (MONTH) (YEAR). Review of monthly DRR in Resident #9's medical record from (MONTH) (YEAR) to (MONTH) (YEAR), revealed no comments by the Pharmacist to verify review of AIMS assessments and behavior logs. During an interview on 4/27/18 at 11:00 am, the Pharmacist stated AIMS assessments and behavior logs were not looked at for DRR. The Pharmacist further stated they do not have access to those documents for review. These documents should be part of the Pharmacist review for Residents taking medications that stabilize mood, control behaviors, and monitor for severe side effects from antipsychotic medication. Resident #2 Record review on 4/23-27/18 revealed Resident #2 was admitted to the facility with a [DIAGNOSES REDACTED]. Review on 4/26/18 at 7:15 pm of the physician orders [REDACTED]. Review of Resident #2's MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed [MEDICATION NAME] had not been administered during these months. Review on 4/26/18 at 6:45 pm, of the monthly pharmacist DRR dated (MONTH) (YEAR) through (MONTH) (YEAR), revealed, under the resident medication listing no [MEDICATION NAME] used for the months of July, August, September, November, January, (MONTH) and use was not addressed for the months (MONTH) and March. Further review revealed the Pharmacist had not documented recommendations to the physician on any of the DRRs that [MEDICATION NAME] had not been administered for an extended period and possible consideration for discontinuance. During an interview on 4/27/18 at 11:24 am, Pharmacist stated when asked about the nonuse of [MEDICATION NAME] I would just hope they (Physicians) would not order it if it wasn't being used. Review on 4/27/18 at 3:45 pm, of the facility policy LTC Medication/Treatment Discontinuation, revision date 11/2016, revealed When prescription medications or treatments that are PRN are found that have not been used in the previous 90-days, they will be discontinued . Resident #10 Record review on 4/23-27/18, revealed Resident #10 was admitted to facility with [DIAGNOSES REDACTED]. Medication: [MEDICATION NAME] ([MEDICAL CONDITION] medication) Review of Resident #10's medical record revealed physician's orders [REDACTED]. - 10/2/17 - Give [MEDICATION NAME] 1gram (three times a day) (for) 7 days followed by 500mg (twice a day) until discontinued. - 12/19/17 - Increase [MEDICATION NAME] to 1,000mg (by mouth) (twice a day) unitl [MEDICAL CONDITION] clear. - 2/1/18 - (Discontinue) [MEDICATION NAME]. Review of Resident #10's lab work did not reveal any diagnostic confirmation of [MEDICAL CONDITION] Simplex Virus (HSV-virus that can cause shingles). Physician ordered a [MEDICAL CONDITION] culture on 1/5/18 which had negative results for HSV. Review of Resident #10's DRR revealed no review was completed for (MONTH) (YEAR). In addition, the DRR for (MONTH) (YEAR) and (MONTH) (YEAR) listed [MEDICATION NAME] on Resident #10's drug regimen. Resident #10 was not on Valacylovir during the review period of (MONTH) and (MONTH) of (YEAR). During an interview on 4/27/18 at 11:05 am, the Pharmacist stated the facility did not follow up on the [MEDICATION NAME] medication order. The Pharmacist further stated the pharmacy department did not complete a DRR for (MONTH) (YEAR). In addition, the Pharmacist also stated the DRR for (MONTH) (YEAR) and (MONTH) (YEAR) did not accurately reflect the correct regimen at the time of review. Medication: [MEDICATION NAME] (Antibiotic) Review of Resident #10's medical records revealed admission orders [REDACTED]. [MEDICATION NAME] was started on 10/2/17 after lab work indicated a urinary tract infection [MEDICAL CONDITION]. [MEDICATION NAME] was restarted on 10/31/17, rationale UTI (urinary tract infection) for 7 days. Review of Resident #10's physician notes and nursing notes from 10/24/17 to 10/31/18 did not reveal symptoms of UTI. Review of Resident #10's physician note, dated 10/31/17, revealed Functional incontinence with chronic Foley as well as recurrent colonization versus UTI again showing colonization or UTI and will treat with [MEDICATION NAME] 500mg twice a day x 7 days. Review of Resident #10's lab work from 10/2/18 to 4/26/18, revealed 1 UA dated 10/2/17. During an interview on 4/27/18 at 11:00 am, the Lab Director confirmed that only 1 UA, dated 10/2/17, and 1 culture and sensitivity, dated 10/3/17, was performed. During an interview on 4/27/18 at 11:05 am, Pharmacist stated there was no review by pharmacist completed on the event occurring on 10/31/17 to support second antibiotic use. Policy Review During random interviews on 4/26-27/18, when asked for a DRR policy, the CNO stated there was no specific policy related to DRR but provided a policy entitled Pharmacist Duties and Responsibilities. Review of the facility's policy entitled Pharmacist Duties and Responsibilities, dated 8/2016, revealed no established policy for the time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Review of the facilities policy table of contents from 4/27-30/18, revealed no other specific policies related to the expectations and explanatory information regarding the DRRs. During an interview on 4/27/18 at 11:15 am, the Pharmacist stated it was the expectation of the pharmacist to conduct DRR every 30 days and make recommendations the physician.",2020-09-01
68,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,757,D,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure 1 resident's (#10), out of 8 sampled residents, drug regimen was free from unnecessary drugs. The failed practice exposed the resident to 2 drugs without adequate indications for their use or continued use. As a result, this placed the resident at risk for adverse reactions and tolerance to drug therapy. Findings: Record review on 4/23-27/18, revealed Resident #10 was admitted to facility with [DIAGNOSES REDACTED]. Medication: [MEDICATION NAME] Review of Resident #10's medical record revealed physician's orders [REDACTED]. Record review of physician notes, dated 10/7/17 to 1/5/18, revealed multiple notes indicating treatment with [MEDICATION NAME] ineffective: -10/7/17 - .continues (to) complain of (body) pain even though we started (Resident #10) on [MEDICATION NAME] to treat what seemed like active [MEDICATION NAME]. -10/31/17 - .continuing to complain of (pain) which is related to .shingles and is now being treated with [MEDICATION NAME]. -12/5/17 - .continues to have chronic pain related to the open shingles [MEDICAL CONDITION] . -12/19/17 - chronic shingles .with suboptimal response to [MEDICATION NAME] .complains of chronic pain .as well as pain over (Resident #10's) [MEDICAL CONDITION] for which we have not made much progress .increase (Resident's) dose of [MEDICATION NAME] to 1000mg (twice a day) . -1/5/18 - Patient still complaining of 10 out of 10 pain .today I cultured the open wound on (the Resident) .if this does not grow any [MEDICAL CONDITION] I will discontinue oral [MEDICAL CONDITION] medication . Review of Resident #10's lab work, since admission, revealed the Physician ordered a [MEDICAL CONDITION] culture on 1/5/18 which had negative results for [MEDICAL CONDITION] Simplex Virus (HSV). Further review of the resident's medical record revealed [REDACTED]. Review of Resident #10's monthly Drug Regimen Reveiws revealed no review in (MONTH) (YEAR). During an interview on 4/27/18 at 11:05 am, the Pharmacist agreed the consultant pharmacist failed to confirm the necessity of the [MEDICAL CONDITION] mediation and communicate with the physician the lack of [MEDICAL CONDITION] testing. In addition, the Pharmacist stated the continued use of [MEDICATION NAME] with no results should have been noted on the monthly DRR. Medication: [MEDICATION NAME] Review of Resident #10's medical records revealed admission orders [REDACTED]. [MEDICATION NAME] was started on 10/2/17 for 7 days after lab work indicated a urinary tract infection [MEDICAL CONDITION]. [MEDICATION NAME] was restarted for 7 days on 10/31/17, rationale UTI. Review of Resident #10's physician notes and nursing notes from 10/24/17 to 10/31/18 did not reveal symptoms of UTI. Additional review revealed no further diagnostic testing. Review of Resident #10's physician note, dated 10/31/17, revealed Functional incontinence with chronic Foley as well as recurrent colonization versus UTI again showing colonization or UTI and will treat with [MEDICATION NAME] 500mg twice a day x 7 days. During an interview on 4/27/18 at 11:00 am, Lab Director confirmed only 1 UA, dated 10/2/17, and 1 culture and sensitivity, dated 10/3/17, was performed. During an interview on 4/27/18 at 11:05 am, the Pharmacist stated that if a Resident is colonized and there are no symptoms, the Resident should not have been treated with antibiotics on 10/31/17. The Pharmacist further stated validation of a proper indication for use of an antibiotic should always be conducted to prevent unnecessary use resulting in potential resistance.",2020-09-01
69,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,759,D,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure medication error rate was less than 5%. Specifically, 2 residents (#s 7 and 10), out of 4 residents observed receiving medications, were free of medication errors. This failed practice placed the residents at risk for over medication. Findings: Resident #7 Record review on 4/23-27/18, revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #7's physician orders [REDACTED]. During an observation on 4/24/18 at 8:58 am, Licensed Nurse (LN) #1 performed medication administration at Resident #7's bedside. The LN gave Resident #7 his/her [MEDICATION NAME] bottle to self-administer the medication. Resident #7 was observed to self-administer 2 sprays in each nostril. LN #1 did not correct this dosing error or provide education. Resident #10 Record review on 4/23-27/18, revealed Resident #10 was admitted to facility with [DIAGNOSES REDACTED]. Review of Resident #10's physician orders [REDACTED]. During an observation on 4/25/18 at 7:18 am, LN #1 performed medication administration at Resident #10's bedside. The LN gave Resident #10 his/her [MEDICATION NAME] bottle to self-administer the medication. Resident was observed to self-administer 2 sprays in each nostril. LN #1 did not correct this dosing error or provide education. During an interview on 4/27/18 at 2:00pm, LN #1 confirmed he/she did see both Residents dispense 2 sprays of [MEDICATION NAME] in each nostril and that he/she did not correct the dosing error or provide education on correct dosing.",2020-09-01
70,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,800,D,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to provide 2 residents (#s 1 and 10) out of 8 sampled residents the appropriate diet as ordered by the physician. This failed practice placed the residents at risk for inadequate nutritional intake and risk for medical complications. Findings: Resident #1 Record review on 4/23-27/18, revealed Resident #1 was admitted with [DIAGNOSES REDACTED]. Review of Resident #1's physician orders [REDACTED]. During an observation on 4/24/18 at 12:00 pm, the Cook #1 prepared and served Resident #1 a mechanical soft diet. This preparation was completed without the use of a diet card. A dietary sticker was placed on the plate container lid once completed and placed on cart for delivery. During an observation on 4/24/18 at 12:35 pm, Resident #1 stated she didn't like the way the food was chopped up and pushed the meal away, refusing to eat it. During an interview on 4/27/18 at 2:00 pm, the Cook #1 could not remember what type of diet he/she prepared and served Resident #1 on 4/24/18. Resident #10 Records review on 4/23-27/18, revealed Resident #10 was admitted with [DIAGNOSES REDACTED]. Review of Resident #10's physician orders [REDACTED]. Review of definitions from Simplified Diet Manual 11th Edition, published 2012, reveals NAS diets are used for residents with [MEDICAL CONDITION] who are at risk for high blood pressure and [MEDICAL CONDITION]. Consistent carb diets are used for residents with diabetes. Review of Wrangell Medical Center's dietary menu for 4/24/18, reveals NAS diet means no pickle and consistent carb diet means fruit instead of cookie. During an observation on 4/24/18 at 12:00 pm, the Cook #1 prepared and served Resident #10 a regular diet that included a pickle and a cookie. This preparation was completed without the use of a diet card. A dietary sticker was placed on the plate container lid once completed and placed on cart for delivery. During an interview on 4/27/18 at 2:00 pm, the Cook #1 was not aware Resident #10 was on a NAS diet, but was aware he/she was a consistent carbohydrate diet. Cook #1 stated Resident #10 should have been served a meal consistent with his/her diet order and nutritional guidelines.",2020-09-01
71,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,812,F,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review of central kitchen area, the facility failed to prepare and/or store food under proper sanitation and food handling practices. This failed practice placed all residents (based on a census of 10) at risk for foodborne illness and communicable disease. Findings: Food Preparation During a 33 minute observation on [DATE] at 4:57 pm, Cook #2 was observed during dinner preparation. The Cook's hair was exposed (coming out of) hair net; did not wear a mask during food prep and plating despite coughing repeatedly over food; handled food with ungloved hand(s); licked food off of his/her ungloved hand while preparing pureed spinach and resumed food prep without washing hands; and wiped nose with ungloved hand and continued to complete food prep without washing her hands. During a 22 minute observation on [DATE] at 12:10 pm, Cook #1 prepared and plated meals without gloves on, scooping mashed potatoes from a pot using a metal scooper. Next, Cook #1 tossed the scooper into the pot of mashed potatoes and later retrieved the scooper with an ungloved hand, handle of scooper was covered in mashed potatoes, and continued to plate meals with scooper. Food Storage An observation of the central kitchen on [DATE] at 4:57 pm, revealed expired food/damaged containers in freezers: plastic bag labeled turkey carcass ,[DATE] that was covered in ice crystals; plastic container labeled bean soup ,[DATE] lid and lip of container itself was broken exposing food to the environment; 1.5 quart carton of sherbet ice cream, opened with no date, side of carton damaged exposing ice cream to the environment; plastic bag labeled chicken enchilada filling [DATE] food covered in ice crystals; plastic bag labeled ham ,[DATE] covered in ice crystals; 2 - 18oz bags of white tortilla shells expiration date 10 APR (YEAR). Observation of the central kitchen refrigerator on [DATE] at 4:57 pm, contained: 1 - 17.8oz opened bag of white tortilla shells stored in metal bin on bottom shelf next to thawing meat. Head of iceberg lettuce with rotten leaves (broken; dark green; paper-thin; with slimy residue) observed in vegetable bin. During an interview on [DATE] at 12:10 pm, Cook #1 clarified dates on food in freezers; 1) meat: the date is when it arrived at facility; 2) anything opened and put back into the freezer, the date is when it was opened; 3) plastic bags of left overs is the date it was put in the freezer. Cook #1 confirmed storage times for frozen foods, 6 months for frozen meat, 3 months for anything else. If it is post-cooked left overs, its 3 months. Review of facility's document entitled Freezer Food Storage Guideline, no date, revealed specified food items and their corresponding time frame for freezer storage: Bread/Rolls: ,[DATE] months; Ham: 2 months; cooked chicken parts: 4 months; and soups/stews: ,[DATE] months. Review of Wrangell Medical Centers Policy & Procedure Dietary Department: Infection Control, Dietary, Revision date ,[DATE], revealed, Hair nets must be worn during food preparation.",2020-09-01
72,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,838,D,0,1,O8F911,"Based on record review and interview the facility failed to ensure the facility assessment identified the clinical needs of residents with pacemakers in the facility, as well as, competency opportunities for staff caring for the pacemakers. This failed practice placed 1 resident (#1) out of 1 Resident with a pacemaker at risk for not having necessary cardiac monitoring equipment and care. Findings: Review of the facility assessment on 4/24-27/18, revealed the facility assessment had not identified Resident #1 who had a cardiac pacemaker who needed special monitoring equipment and care. During an interview on 4/27/18 at 2:58 pm, the Chief Nursing Officer (CNO) stated she did not know there was a Resident in the facility who had a pacemaker. The CNO further disclosed the resident was not identified in the facility assessment. In addition, the assessment did not identify any special training or care the Resident would require.",2020-09-01
73,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,842,D,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to maintain accurate and complete medical records. Specifically, the facility failed to provide documentation for 1 resident (#5) out of 1 record reviewed for distribution of belongings after death. This failed practice placed the resident's estate at risk for misappropriation of the resident's belongings. Findings: Record review on ,[DATE]-,[DATE], revealed Resident #5 was admitted to the facility on [DATE] and expired on [DATE]. Further review revealed there was no documentation of the Resident's belongings disposition after death and no signature documenting disposition on the facility list of Resident #5's belongings. During an interview on [DATE] at 2:50 pm, the Chief Nursing Officer confirmed the Resident's belongings had not been signed for and there was no documentation of disbursement of the Resident's belongings after death.",2020-09-01
74,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,865,F,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the QAPI (Quality Assurance Performance Improvement), used to identify and implement change for improvement, and had identified areas that had been or should have been identified. Specifically , the QAPI committed failed to ensure: 1) the need for an updated facility assessment to include 1 resident #1 who needed specialized care; 2) identify late transmissions of MDS (material data set-a federal mandated assessment); 3) identify the lack of antibiotic stewardship program. (based on a census of 10). Without identifying or adequately addressing areas of quality deficiencies systematic correction could not be achieved and/or maintained. Failure to identify systemic processes for improvement had the potential to place all residents at risk for poor outcomes. Findings: Review of the QAPI Plan revised 4/2018, revealed .Improve the safety of the healthcare system and work processes; Identify indicators of quality related to structure, process and outcomes of patient care; .design or redesign care processes . Facility assessment Review of the facility assessment on 4/24-27/18, revealed the facility assessment had not identified Resident #1 who had a cardiac pacemaker who needed special monitoring equipment and care. Record review revealed Resident #1 had been admitted to the facility on [DATE] with an implanted cardiac pacemaker. During an interview on 4/27/18 at 2:58 pm, the Chief Nursing Officer (CNO) stated she did not know there was a Resident in the facility who had a pacemaker. The CNO stated the pacemaker should have been in the facility assessment to ensure special training or care required of staff. MDS Transmittals Record review from 4/24-27/18, revealed Resident #'s 1; 3; 5; 6; 9; and 10 had MDS assessments completed but not transmitted. Refer to Citation 640. During an interview on 4/27/18 at 9:29 am, the Quality Director (QD) revealed, she did not know the MDS assessments had not been submitted or that they should have be monitored for timely submission. Antibiotic Stewardship Record review on 4/25/18 at 10:00 am, revealed a draft antibiotic stewardship policy that was not implemented at the time of review. During an interview on 4/27/18 at 12:18 pm, the Infection Control Nurse stated the antibiotic stewardship policy was in draft and had not been implemented yet. Refer to Citation 881.",2020-09-01
75,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,880,F,0,1,O8F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation the facility failed to ensure the infection prevention and control committee had reviewed the infection control plan and policies/procedures on an annual basis, developed and implemented a program specific to the facility assessment, and include required infection prevention and control plan elements. In addition a medical device was not maintained in a clean manner for 1 Resident (#10) out of 1 resident reviewed for indwelling urinary catheter. Specifically the facility failed to; 1. Conduct an annual review of its Infection Prevention Control Plan and Infection control policies 2. Identify the criteria used for infection surveillance to identify possible communicable diseases or infections before they can spread to other persons in the facility, identify what infections, when and to whom the infections should be reported to and document antibiotic process, outcome surveillance and action plans 3. Establish and implement a water management program that included policies and procedures, specific for the facility to mitigate the risk of growth and spread of Legionella and other opportunistic water borne pathogens in the facility's water system 4. Prevent an indwelling urinary catheter bag from resting on the floor These failed practices increased the risk for development and transmission of disease and infection and increased the risk of multidrug resistance in a vulnerable population of all residents based on a current census of 10. Findings: 1) Annual Review of Infection Prevention Control Program and Policies Review of the facility's policy Infection Prevention and Control Program with a revision date of 6/2016, revealed the policy had not been reviewed for 22 months. Additionally randomly reviewed infection control policies revealed last reviewed dates of: - Glucometer Cleaning, revision date 3/2016 - Hospital Acquired Infections, revision date 6/15/2016 - Hand Washing, revision date 6/2016 - Universal Precautions, revision date 6/2016 - Exposure Control Plan: [MEDICAL CONDITION], did not have any dates and appeared to be a draft form During an interview on 4/26/18 at 1:02 pm, the Infection Control Preventionist (ICP) stated the Infection Control Committee was behind on reviewing infection control policies and procedures. 2) Infection Prevention and Control Plan Policy Elements Review of the facility's Infection Prevention and Control Program revealed the plan was missing the required elements of: a) Criteria to define a system of surveillance for the identification of communicable diseases/infections to prevent the spread to other persons/residents in the facility based on the facility assessment b) Identify what infections, when and to whom the infections should be reported to c) Documented antibiotic process, outcome surveillance and action plans. Record review of the Infection Control Quality Reports dated 3/29/18 and 4/19/18 did not reveal surveillance data analysis, action plans or antibiotic stewardship criteria. During an interview on 4/26/18 at 1:02 pm, the ICP stated there were no current infection control action plans or projects and the antibiotic stewardship program had not been implemented yet and was in draft form. 3) Water Management Program Review of the facility's policies from 4/23-27/18 revealed there was no program to manage the facility's water to prevent the risk of Legionella or other opportunistic water borne pathogens in the facility's water system. During an interview on 4/26/18 at 1:02 pm, the ICP further disclosed there was no water management plan for Legionella. 4) Resident #10 Indwelling Urinary Catheter Bag (a bag to collect urine from a tube inserted through the urinary tract into the bladder) During three random observations on 4/24/18 at 10:42 am, 4/25/18 at 9:14 am and 4/27/18 at 1:31 pm, revealed Resident #10 sitting in wheelchair with indwelling urinary catheter bag attached to underside of wheelchair. The catheter bag dragged on the ground as the Resident propelled his/her wheelchair throughout the facility. During an interview on 4/26/18 at 2:30 pm, Licensed Nurse (LN) #2 stated catheter bags should not be touching the floor. During an interview on 4/27/18 at 2:30 pm, the Chief Nursing Officer (CNO) stated the facility does not have a written policy and procedure in regards to indwelling urinary catheter care. The CNO stated the facility follows Lippincott Procedures and provided copies of Indwelling Urinary Catheter .Care and Management from online source, Lippincott Procedures, dated (MONTH) 17, (YEAR). Review of Lippincott Procedures Indwelling Urinary Catheter .Care and Management, dated (MONTH) 17, (YEAR), Guidelines read, Don't place the drainage bag on the floor to reduce the risk of contamination and subsequent catheter-associated urinary tract infections.",2020-09-01
76,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2018-04-30,881,F,0,1,O8F911,"Based on record review and interview the facility failed to implement a facility specific antibiotic stewardship program to monitor the use of antibiotics. Failure to monitor the appropriate use of antibiotics had the potential to increase antibiotic resistance among all residents (census of 10). Findings: Record review on 4/25/18 at 10:00 am, revealed a draft antibiotic stewardship policy that was not implemented at the time of review. During an interview on 4/27/18 at 12:18 pm, the Infection Control Preventionist stated the antibiotic stewardship policy was in draft and had not been implemented yet and she was not checking on Loeb (a standard used for initiation of antibiotics) criteria at this time.",2020-09-01
77,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2017-06-09,328,D,0,1,8G9Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure humidified oxygen was maintained for 1 resident (#2) of 1 sampled resident who received oxygen. This failed practice failed to ensure the use of humidified oxygen to relive dryness of nasal passages and maintain resident comfort. Findings: Resident #2 Record review on 6/6-9/17, revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 6/7/17, of Resident#2's most current care plan revealed, Oxygen at 2L via nasal cannula , round hourly when resident is in bed. Specifically check her for oxygen being on at 2L via NC (nasal cannula) . Observation on 6/7/17, at 10:10 am revealed the humidifier bottle attached to the wall oxygen was near empty. The oxygen delivery was set at 2L, via nasal cannula. Observation on 6/7/17, at 3:10 pm revealed the humidifier bottle attached to the wall oxygen was near empty. The oxygen delivery was set at 2L, via nasal cannula. Observation on 6/8/17, at 7:38 am revealed the humidifier bottle attached to the wall oxygen was empty. The oxygen delivery was set at 2L, via nasal cannula. Observation on 6/8/17, at 1:30 pm revealed the humidifier bottle attached to the wall oxygen was full of water and bubbling. The oxygen delivery was set at 2L, via nasal cannula. During an interview on 6/9/17, at 8:45 am, RN #1 stated the oxygen humidification bottles were all staffs responsibility to fill daily. In addition, the purpose of oxygen humidification is to prevent nasal dryness and provide resident comfort.",2020-09-01
78,WRANGELL MEDICAL CENTER LTC,25015,P.O. BOX 1081,WRANGELL,AK,99929,2017-06-09,514,C,0,1,8G9Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to maintain accurate and complete medical records. Specifically, the facility failed to: 1) document the indication of use for medications in the residents' medical record for 6 residents (#s 1; 2; 3; 4; 5 and 7) out of 8 sampled residents whose medical records were reviewed, and 2) provide documentation for one Resident's (#6) distribution of belongings after death. These failed practices placed the residents at risk for 1) receiving inappropriate medications and 2) misappropriation of the resident's belongings. Findings: Indications for Use of Medications: Resident #1 Record review from ,[DATE]-,[DATE] revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most current medication administration record (MAR) and medication order detail, revealed no documentation of [DIAGNOSES REDACTED]. Resident #2 Record review on ,[DATE]-,[DATE] revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most current MAR and medication order detail, revealed no documentation of [DIAGNOSES REDACTED]. Resident #3 Record review from ,[DATE]-,[DATE] revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most current MAR and medication order detail revealed no documentation of [DIAGNOSES REDACTED]. Resident #4 Record review from ,[DATE]-,[DATE] revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most current MAR and medication order detail revealed no documentation of [DIAGNOSES REDACTED]. Resident #5 Record review on ,[DATE]-,[DATE] revealed Resident #5 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of the most current MAR and medication order detail, revealed no documentation of [DIAGNOSES REDACTED]. Resident #7 Record review on ,[DATE]-,[DATE] revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most current MAR and medication order detail, revealed no documentation of [DIAGNOSES REDACTED]. During an interview on [DATE] at 2:45 pm, the Director of Nursing (DON) stated the indication for use for all medications should be on the MAR and physician order [REDACTED]. Review of the website Institute for Safe Medication Practices, accessed on [DATE] at http://www.ismp.org/tools/guidelines/SCEMI/SCEMIGuidelines.aspx, revealed, Provide a field to enter the purpose/indication for all medications communicated electronically .Communicating the drug's indication reduces the risk of improper drug selection and offers clues to proper dosing when a medication has an indication-specific dosing algorithm. Documentation of resident belongings after death: Record review on [DATE] revealed Resident #6 was admitted to the facility on [DATE] and expired on [DATE]. Further review revealed there was no documentation that the Resident's personal belongings were given to the resident's daughter and the daughter did not sign any documentation regarding the belongings. During an interview on [DATE] at 2:50 pm the DON confirmed there was no documentation of who received Resident #6's belongings after his/her death. Pain Medication Resident #2 Record review on ,[DATE]-,[DATE] revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most current MAR and medication order detail, revealed order detail as to when 1 or 2 tablets of [MEDICATION NAME], (a pain medication) should be given. During an interview on l[DATE] at 3:15 pm the Pharmacist and the Director of Nurses confirmed the finding and stated the order detail should define the pain scale or severity when two tablets should be given vs one tablet.",2020-09-01
79,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2019-01-08,638,D,1,0,MBVY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to complete a quarterly MDS (Minimum Data Set, a federally required nursing assessment) assessment for 1 resident (#1) of 3 sampled residents whose MDS assessments were reviewed. This failed practice created a potential for incomplete and/or inaccurate care planning. Findings: Record review on 1/7-8/19 revealed Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessments revealed the following: an admission assessment dated [DATE], a quarterly assessment dated [DATE], a discharge assessment with return anticipated dated 12/24/18 and an Entry tracking record dated 12/28/18. A quarterly assessment, due by 9/13/18, was missing. During an interview on 1/8/19 at 11:56 am, MDS Coordinator (MDSC) #2 stated he/she had not done the quarterly assessment. During an interview on 1/9/19 at 2:13 pm, MDSC #1 stated there are 3 MDS coordinators. Each coordinator is responsible for their assigned residents. A hand written calendar is used to document when MDS assessments are due for each resident.",2020-09-01
80,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2018-03-15,585,F,1,0,M2PE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation and interview, the facility failed to ensure a method for grievances to be filed anonymously and/or verbally. This failed practice had the potential to affect all residents in the facility (based on a census of 48) and denied residents and interested parties the ability to exercise their rights by filing grievances anonymously or to have their concerns recieved verbally. Findings: Observation on 3/14/18 at 9:00-9:15 am of the facility dining rooms, revealed a large monitor screen that flashed information about the facility rules and activities. The information included the residents right to file a grievance and the grievances officer information was listed. In addition, the screen included information about the residents and/or their families right to file a grievance verbally and anonymously. There was no information on the screen, or on the bulletin board, located across the room, that instructed people on how to file a grievance anonymously. There were no forms, used for filing complaints in the area, nor was there an obvious secure place to put the forms once they had been filled out. Anonymous/ Verbal Grievances Resident #2 Record review on 3/14-15/18 revealed Resident #2 was admitted to the facility with a [DIAGNOSES REDACTED]. The Resident was receiving MS ([MEDICATION NAME] sulfate) via a PCA (patient controlled [MEDICATION NAME]) for pain management. During an interview on 3/14/18 at 10:50 am, Resident #2's Family Member stated he/she had expressed several concerns to facility staff about the care Resident #2 had been receiving. When asked if he/she had ever filed a grievance or complaint with the facility, the Family Member stated he/she approached the Shift Supervisor about it a couple weeks ago, and was handed a bunch of forms to fill out. The Family Member did not want to have to fill out forms and stated he/she had a stack of these forms. During the interview the Family Member stated he/she came in yesterday afternoon to find Resident #2 had pulled out his/her indwelling urinary catheter and the Resident's bedding was saturated with urine. The Family Member stated the Director of Nursing (DON) promised him/her that would never happen to Resident #2 again. During an interview with Licensed Nurse (LN) #1 on 3/14/18 at 10:00 am, when asked how a resident and/ or family member could file an anonymous grievance, the LN stated he/she would get them the form and the complainant could just leave their name off the form. When the surveyor pointed out the LN would know who the complainant was, LN #1 responded I wouldn't say anything. During an interview on 3/14/18 at 2:00 pm, when asked how Residents and their families were to file a grievance, Shift Supervisor (SS) #1 stated she would have them fill out a concern form. When asked if residents and their families could file a grievance verbally, the SS stated it was best to have it written down, for tracking reasons. When asked how a resident or family member could file a grievance anonymously, the SS stated the phone number and email information was posted on the wall in the dinning room. The SS was unable to provide information on how to file a written grievance anonymously. Further interview and record review revealed the Family Member continued to have concerns regarding Resident #2's care and pain management at the facility. During a second interview on 3/15/18 at 9:45 am, Resident #2's Family Member stated when his/her daughter had come in to visit the Resident on 3/14/18 at about 3:00 pm, the Resident had soiled him/herself and the room had an odor so putrid the window had to be cracked open. The Family Member went on to state the PCA had run out of MS, Resident #2's family had pressed the call light; the bell had sounded for 17 minutes before someone responded. Review of the Social Service Notes, dated 2/9/18, revealed Writer placed call to .Life Partner (Family Member) .stated currently in (Resident #2's) room and there was a smell of urine (his/her) room. Writer did speak with the DON and she and the writer went to the room and (Family Member) had opened the window to clear the smell. Writer noticed a smell this time .shirt was wet determined it was from the mattress and thus the mattress was changed out and the floor was cleaned. Review of the medical record revealed a late entry nursing note for 3/9/18 charted 3/14/18 at 11:18 am, Looked in (Resident #2's) room noticed the PCA pump was flashing stating the MS was empty. Asked who turned off the alarm, daughter stated she had. Asked he if she had pressed call light, she stated yes. Went and spoke with CNA's they stated no one had answered call light and that none of them knew the PCA alarm was going off. Went back changed MS. Asked family who came in and answered call light. They stated they had turned off the call light themselves .informed them not to touch the PCA pump . During an interview on 3/15/18 at 1:20 pm, when asked about the incident with Resident #2 yesterday, LN #1 stated the event with the PCA pump had happened last week. The LN stated yesterday he/she knew it was about to run out and was waiting to change the MS syringe, so the unused MS wouldn't be wasted. The LN stated the Resident was incontinent of stool yesterday afternoon. Resident #3 During an interview on 3/14/18 at 12:25 pm, Resident #3's Family Member was asked about the facilities grievance process, specifically if implementations were in place to ensure anonymous filing, the Family Member stated No. The Family Member stated he/she was afraid to file a grievance because he/she didn't want the staff to retaliate or be upset with Resident #3. The Family Member stated he/she had been instructed to fill out a form and return it to the nursing manager, the Family Member stated he/she didn't want to fill the form out. During an interview on 3/15/18 at 1:30 pm with the Administrator and DON, when asked how a resident or family member could submit a grievance anonymously and maintain confidentiality, the Administrator stated the concern/grievance could be filled out without names or the grievance could be emailed or left on the phone # as voice message. When asked where anonymous complainants would place the completed form, the Administrator and DON stated the complainant could just place it under the door of the shift supervisor or the social worker. Random observations during the survey on 3/14-15/18 revealed the shift supervisor and social worker doors were often open during the day. Record review on 3/14-15/18 of the facilities As a Resident, you have the Right, revision date 12/17 stated residents have the right to file grievances anonymously. There were no instructions how to file anonymously. Record review on 3/14-15/18 of the form provided to residents/families to file grievances titled, Concern/Feedback Communication form #559.006f, revision date 7/17, revealed no mechanism to file anonymously. Record review on 3/14-15/18 of facility policy titled Resident Concerns and Grievances revision date 12/14/17 revealed in section C subsection 2, Concerns and grievances may be submitted anonymously. The policy revealed no mechanism for filing anonymously.",2020-09-01
81,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2018-03-15,677,D,1,0,M2PE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, and interview the facility failed to ensure activities of daily living (ADL care such as hygiene and skin care) were offered and/or provided to 1 resident (#2) out of 4 residents observed receiving care. This failed practice placed the resident at risk for poor outcomes from lack of hygiene and a risk for infection and/or poor skin conditions and a decreased feeling of self-worth. Findings: Record review on 3/14-15/18 revealed Resident #2 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of Resident #2's Care Plan, dated 2/19/18, revealed Can't move around well on my own. lose control of by bladder and/or bowels. Sometimes get confused or can't remember things. don't receive the proper nutrition. have an existing skin injury. The approach included I need my aides to-help me with hygiene and general skin care . Grooming During an observation on 3/14/18 of incontinence care being provided to Resident #2 at 6:20 am and 10:30 am, and repositioning of the Resident at 8:00 am and 9:10 am, the Resident was not offered the opportunity to wash his/her face and hands nor was oral care offered or provided. In addition, the Resident had significant facial hair growth. During an interview on 3/14/18 at 10:40 am, Resident #2's family member stated the Resident had not had his/her teeth brushed. The Family member showed the surveyor two travel sized tubes of toothpaste, kept in the bathroom, one of which was slightly used, and stated Resident #2 had the same tubes of tooth paste since admission nearly 3 weeks ago. Closer examination of the tooth brush revealed it was dry. During an observation on 3/14/18 at 10:50 am, when Certified Nursing Assistant (CNA) #2 entered Resident #2's room, the Family Member stated to the CNA he/she had told evening shift staff the Resident needed to be shaved, the CNA replied I didn't get that message. The CNA then offered to shave the Resident. Observation on 3/15/18 at 8:40 am, observation of the tooth brush and toothpaste, revealed the 2 tubes of toothpaste had not been moved from their position the previous day, and the Resident's tooth brush was dry. During an observation on 3/15/18 at 8:42 am, CNA #3 changed Resident #2's soiled brief. The CNA did not offer the Resident the opportunity to wash his/her face and hands and did not offer oral care to the Resident. During an interview on 3/15/18 at 8:52 am, when asked about Resident #2's oral care, CNA #3 stated Resident #2's oral care was usually done after breakfast. Review of Resident #2's Baseline Care Plan /RDCP (Resident Daily Care Plan), dated 3/13/18, revealed Grooming I do hygiene/grooming tasks: with the help of one person. Review of the CNA documentation dated 3/14/18 at 4:15 pm revealed Additional Care: Oral care performed. Shaving performed. On 3/14/18 at 4:53 pm, AM Hygiene Care was documented Underarms/Peri area cleaned. lotion applied. Skin Care Observation on 3/14/18 at 6:30 am, LN #2 assisted CNA #5 with changing Resident #2's brief. the Resident's brief was saturated with urine. the Resident had a large pink foam dressing covered his/her coccyx (tailbone area). The perineal area, directly below the dressing, was red and appeared macerated (broken down from exposure to mosisture). After washing the Resident's perinea and buttocks and changing the Resident's brief, CNA # 5 and 6 attempted to assist the Resident with putting on some pajama bottoms. Neither of the staff applied a protective barrier cream to the reddened area located on the Resident #2's perineum. During an observation on 3/14/18 at 10:30 am, CNA #s 2 and 7 changed the Resident's incontinence brief after the Resident had voided. The Resident's perineum was red and maserated looking, after cleaning the Resident's buttocks, the CNAs assisted the Resident with donning a dry brief, neither staff applied any protective barrier cream to the reddened area on the Resident's perineum. Observation on 3/15/18 at 8:42 am, Resident #2's incontinent brief and bottom sheet was saturated with urine. CNA #3 washed the Resident's perinea and buttocks, and changed the Resident's brief and bedding. The Resident's perineum, below the dressing was red and raw. During an interview on 3/15/18 at 8:52 am, when asked if any protective ointment was used on the Resident, CNA #3 showed the surveyor a tube of silicone based barrier cream and stated he/she didn't think the Resident needed it right now. During an interview on 3/15/18 at 1:00 pm, when asked about treatment for [REDACTED].#2's perineum, the Wound Nurse stated the Resident should have had a protective barrier cream applied. The Wound Nurse stated there was no order for the barrier cream as it was considered a standard of care. Review of the Resident's Baseline Care Plan/ RDCP revealed Skin Care .check my skin during care Apply lotion/ cream to my barrier cream. Review of the CNA documentation dated 3/14/18 at 7:08 am revealed barrier cream applied. Review of the Providence Anchorage Long Term Care Standard of Care, rev. 2/2017, revealed [NAME]M. care every morning: Hands and face washed . Oral Care completed . Shaved: diabetics shaved with electric razor . Offer a drink of water. Ongoing Care .Use designated continence management products. During an interview on 3/15/18, at 1:32 pm, the Director of Nursing stated the continence management products referred to the disposable incontinence briefs.",2020-09-01
82,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2018-03-15,686,D,1,0,M2PE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > . Based on record review, observation, and interviews the facility failed to ensure measures to prevent a pressure injury for 1 resident ( #1) out of 2 residents reviewed with pressure injuries, were implemented. This failed practice placed the resident at risk for worsening pressure injuries. findings: Record review on 3/14-15/18 revealed Resident #1 was admitted to the facility for comfort care (care for someone with a terminal illness) and had [DIAGNOSES REDACTED]. The Resident was admitted with a pressure injury to the right hip, a deep tissue injury to the right metatarsal head (on the foot), and a reddened area to the left heel. Review of the Wound/Skin Care Orders/ TAR (Treatment Administration Record), (MONTH) (YEAR), revealed Wound Number:3 Dx. Wound [MEDICATION NAME] (prevention) Location: L (left) Heel. the treatment was a Foam Dressing Allevyan heel. Review of the Resident's Care Plan, dated 12/14/17, revealed I have a skin injury .sometimes get confused or can't remember things, can't move around well on my own . The Approach included I need my aides to-help me reposition at least every 1-2 hours while I'm in bed .elevate my heels in bed. Observation on 3/14/18 at 12:24 pm, Resident #3 was observed lying supine on an air mattress. The Resident's heels were resting directly on the mattress. Observation on 3/14/18 at 12:50-1:00 pm, Certified Nursing Assistant (CNA) #1 and Licensed Nurse #1 repositioned Resident #1 in the bed. Both Resident's feet were lying directly on the bed and the heels were not elevated on a pillow to be off the bed. The Resident began to cry out that his/her left leg hurt. During an interview on 3/14/18 at 1:03 pm, when asked about Resident #1's heels, CNA #2 stated the Resident had sores on both his/her heels. When asked if there were any skin precautions for the heels, the CNA replied Resident #1 had a pink dressing to his/her left heel to protect it and the staff place a pillow between the Resident's legs to prevent them from rubbing together. During an observation on 3/15/18 at 9:00 am, Resident #1 was observed lying on his/her right side in the bed, the Resident's left heel was covered with the pink foam dressing. Both of the Resident's heels were both resting directly on the bed. During an interview on 3/15/18 at 1:00 pm, when asked about Resident #1's pressure injuries, and how facility staff were to keep pressure off the Resident's right heel, the Wound Nurse stated it was on the care plan. Review of Resident #1's Baseline Care Plan/RDCP (Resident Daily Care Plan), undated, revealed Special Precautions: float heels on heel elevation cushion while in bed.",2020-09-01
83,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2017-06-22,166,C,0,1,NLCD11,"Based on observations, admission packet review, and interview, the facility failed to ensure residents (based on a census of 39) had been provided with the name of the grievance officer. This failed practice denied residents and their families and/or interested parties, needed information on who to file a grievance with. Findings: Random observations during the survey on 6/19-22/17 revealed the name of the Grievance Officer was not posted on the wall in the common areas. Review on 6/19/17 of the admission packet provided to Resident's upon admission revealed the name of the Grievance Officer was not listed with the contact information. During a group interview on 6/21/17 at 11:00 am, all 5 Residents (#2; #16; #17; #18; and #19) stated they did not know who the Grievance Officer was. Review on 6/21/17 at 3:00 pm of Resident #17's admission packet, with the Resident, revealed the information did not contain the Grievance Officer's name.",2020-09-01
84,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2017-06-22,205,D,0,1,NLCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure bed hold information was provided to 1 resident (#11) out of 2 residents reviewed for emergency transfers. The failure to provide information regarding the bed hold policy, denied the resident and/or family members current information about their right to return to the facility. Findings: Record review on 6/22/17 revealed Resident #11 had an unplanned transfer to the hospital on [DATE]. There was no information in the medical record indicating the Resident and/or Resident's family member(s) were provided information about their right to return to the facility after the transfer. During an interview on 6/22/17 at 4:05 pm, the Director of Nursing was unable to produce documentation the Resident and/or Resident's family was notified of the facility's bed hold policy.",2020-09-01
85,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2017-06-22,221,D,0,1,NLCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and protocol review the facility failed to ensure 1 resident (#3) out of 7 sampled residents was free from physical restraints. Specifically, the facility failed to ensure a transfer belt was not used as a restraint. This failed practice had the potential to cause a decrease in self-worth and self-esteem related to respect and dignity of the individual. Findings: Resident #3 Record review from 6/19-22/17 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Further review of the Resident Daily Care Plan (RDCP) dated 6/7/17 and updated on 6/14/17 revealed no mention of a transfer belt on the care plan. Observation on 6/19/17 at 8:30 am, revealed Resident #3 sitting in the dining area at the table with a bright colored orange belt wrapped around the back of his/her wheelchair and buckled at his/her waist. The back of the belt had writing on it from a black marker that said Do Not Remove. Observation on 6/19/17 at 11:55 am revealed Certified Nursing Assistant (CNA) #1 assisted Resident #3 from the bed to the wheelchair using a white cloth transfer belt. Once in the wheelchair, CNA #1 wrapped a bright orange belt around the Resident and the back of the chair. When asked why the belt was wrapped around the wheelchair, CNA #1 stated To keep (him/her) upright in the chair. Observation on 6/19/17 at 12:05 pm, revealed Resident #3 at the dining table in the common room. The bright orange belt was wrapped around the Resident's wheelchair and buckled at the waist. During an interview on 6/19/17 at 1:00 pm, Resident #3's family member was in the Resident's room. When asked about the belt around the wheelchair, the family member stated It is for positioning, to keep (him/her) from falling over. During an interview on 6/19/17 at 1:02 pm, Resident #3 stated he/she could not release the buckle on the orange transfer belt. Observation on 6/19/17 at 1:25 pm revealed Occupational Therapist #1 pushed Resident #3's wheelchair down the hall near the nurse's station. The bright orange transfer belt was around the wheelchair and buckled at Resident #3's waist. During an interview on 6/20/17 at 10:50 am, Physical Therapy Aide (PTA) #1 stated At no point should it (transfer belt) be attached to the wheelchair and the patient (resident). The PTA further stated if the belt was wrapped around the wheelchair it would be a restraint. The PTA also said if it was for positioning it would be on the Resident Daily Care Plan. During an interview on 6/20/17 at 11:18 am, Licensed Nurse (LN) #7 stated he/she first noticed the transfer belt yesterday (6/19/17). LN #7 said I thought it was supposed to be there. During an interview on 6/20/17 at 12:30 pm, LN #5 said a gait (transfer) belt should never be attached to a wheelchair that is a restraint. Review on 6/22/17 of the facility's protocol Transfer Belts last revised 4/20/16, revealed .Belt may NOT be left on patient for use as a restraint .",2020-09-01
86,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2017-06-22,242,E,0,1,NLCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure 1 resident (#1) was allowed to go to bed as he/she wished and failed to ensure 9 residents (#s 1; 2; 6; 12; 13; 14; 15; 16; and 17), out of 39 residents residing in the facility, were able to dine in a timely manner after the meal trays had arrived. This failed practice denied the residents the right to exercise their right to make choices about their schedule and accommodate their needs and placed residents at risk for poor feelings of self-worth and psychological harm. Findings: Resident Choice Record review on 6/20-22/17 revealed Resident #1 was admitted to the facility for rehabilitation. The Resident's [DIAGNOSES REDACTED]. The Resident needed extensive assistance for transfers with 2 staff and used a wheelchair for mobility. During an observation on 6/20/17 at 11:45 am, Resident #1 was brought back to the unit dining room after completing occupational and physical therapy for the past 2 1/2 hours. During the observation Resident #1 told Certified Nursing Assistant (CNA) #4 he/she was tired and wanted to lay down in bed for a little bit. The CNA replied to the Resident, If you lay down you'll have to get right back up. You only have 45 minutes until lunch. Why don't you wait until after lunch? CNA #4 spent several minutes explaining to the Resident why he/she could not take a nap just yet. The CNA then offered Resident #1 a glass of water. The Resident continued to sit at the dining room table until lunch was served at 1:00 pm, over an hour after he/she had requested to lie down. Review on 6/22/17 of the facility's Reisdents handbook provided to the residents at amittance revealed, .As a Resident, you have the Right: .To receive services that meet your individual needs and preferences . Delay in Meal Service South Side During an observation in the south dining room on 6/19/17 at 12:15 pm Resident #s 1; 6; 12; and 13 were observed sitting in the dining room waiting for the noon meal. During the observation Resident #6 repeatedly stated how hungry he/she was. CNA #5 served the Resident a cup of coffee. After both meal carts arrived on the units at 1:05 pm, the staff took both carts down the hallways to pass the room trays. The Residents in the dining room continued to sit and wait until the carts were returned and were served lunch at 1:15 pm, 10 minutes after they had arrived. Observation in the south dining room on 6/20/17 at 12:50 pm revealed 1 cart containing lunch trays was sitting in the hallway when the 2nd lunch cart arrived. Resident #s 1, 6, and 13 were seated at the dining room table waiting for lunch. Staff pushed the cart past the Resident's seated in the dining room, and down the hallways to pass the room trays. There was no staff located in the dining room to assist the 3 residents. Observation on 6/20/17 at 1:00 pm revealed the carts were returned to the dining room area; CNA #2 returned to the dining room, served the meal and assisted Residents with their meals. Review of the CNA assignment sheet, dated 6/20/17 revealed CNA #2 had Assignment 4 and 1230 (pm) Assist in Dining room, clean dining room. During an interview on 6/21/17 at 12:28 pm, the Coordinator of Food Services stated the room trays needed to be served in the rooms first because some residents in the dining room needed to be observed and watched during their meal. During an interview on 6/21/17 at 1:11 pm, CNA #5 stated the rooms were first and the dining room second because there needed to be staff in the dining room. Observation in the south dining room on 6/21/17 at 1:05 pm revealed 1 cart containing the lunch trays was sitting in the hallway when the 2nd cart was brought down. Resident #s 1, 14, and 15 were seated in the dining room. At 1:10 pm Resident #14 stated been here about 3 weeks waiting for trays. Resident #14 was then served his/her lunch. Both carts were taken down the hallway while Resident #s 1 and 15 waited at the table in the dining room. After 10 minutes, at 1:15 pm, CNA #3 retrieved a small cart and went down the hallway to pull the trays from the cart. After returning to the dining room with 2 lunch trays, the CNA served Resident #s 1 and 15 their lunch trays at 1:20 pm, 15 minutes after the trays had arrived. North Side Observation in the north side dining room on 6/19/17 at 12:30 pm revealed Resident #s 2, 16, and 17 sitting in the dining room waiting for lunch. After both carts arrived, staff took them down the hall and served the room trays. The staff then returned to the dining room and served the Residents waiting in the dining room, 10 minutes after the trays had arrived. Observation in the north side dining room on 6/20/17 at 12:30 pm, revealed Resident #s 2, 16, and 17 were seated in the dining room waiting for the noon meal. After the carts arrived, staff took both carts down the hall and served the room trays. The Residents in the dining room had to wait 10 minutes until their lunched were served. During a group interview with residents on 6/21/17 at 11:00 am, several Residents stated it felt discourteous for the staff to pass them by with the food trays and to deliver the room trays first, when they were sitting in the dining room waiting for their meal. During an interview on 6/22/17 at 12:45 pm, when asked about the residents having to wait for the meals, the Dietitian replied it was an ongoing project. The Dietitian stated he/she was told a CNA needed to be in the dining room before service. Review on 6/22/17 of the facility's Reisdents handbook provided to the residents at amittance revealed, .Dining Services .Meals are scheduled .at the following times: Breakfast 8:15 a.m. Dining room or in-room Lunch 12:30 p.m. Dining room or in-room Dinner 5:00 p.m. Dining room or in-room",2020-09-01
87,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2017-06-22,281,D,0,1,NLCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure resident care and services were provided in accordance with professional standards for 1 Resident (#4) out of 7 residents whose medical care was reviewed. Specifically, the facility failed to alert the physician if the Resident experienced 2 blood sugar readings above 200mg/dl in a 24 hour period. Failure to provide services according to professional standards of practice placed the Resident at a greater risk of poor outcomes. Findings: Record review from 6/19-22/17 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Record review from 6/19-22/17 of Resident #4's electronic medical record (EMR) revealed a physician's orders [REDACTED]. Further review from 6/19-22/17 of Resident #4's EMR dated 6/18/17 revealed entries for the evening blood sugar of 203 mg/dl and bedtime blood sugar of 207 mg/dl. Additional review of the EMR Nursing Notes dated 6/18/17, revealed no additional notations in the nursing notes indicating communication of the two reportable blood sugar levels to the physician. During an interview on 6/20/17 at 7:00 am when asked what do you do when medication administration parameter were not met, LN #1 responded, to notify the MD, document findings in the communication log and notify the nursing supervisor. During an interview on 6/20/17 at 9:25 am Licensed Nurse (LN) #2 states: notify the MD, document findings in the communication log and notify the nursing supervisor when parameters are not met. Record review of the facilities communication log dated 6/18-19/17 revealed no documented communication to the physician of Resident #4's blood sugar results. During an interview on 6/20/17 at 10:00 am, Nursing Supervisor #1 confirmed the MD should have been notified. Review of the Alaska State Nursing Statutes and Regulations, dated (MONTH) 2014, revealed .practice of registered nursing' means the .execution of a medical regimen as prescribed by a person authorized by the state to practice medicine . Review of the American Nurses Association Code of Ethics for Nurses, dated (YEAR), revealed Nurses bear the primary responsibility for the nursing care of that their patients and clients receive and are accountable for their own practice. Nursing practice includes .care as ordered by an authorized healthcare provider .",2020-09-01
88,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2017-06-22,309,E,0,1,NLCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and protocol review the facility failed to ensure 1 resident (#1) received necessary services for: 1) urinary incontinence, 2) pain, and 3) oral care; and 1 resident (#2) received prompt treatment and physician notification after experiencing increased pain after a fall, out of 7 sampled residents reviewed. These failed practices denied residents necessary interventions and services to promote health and well-being and placed them at risk for increased pain and suffering. Findings: Resident #1 Record review on 6/20-22/17 revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident was at the facility to receive rehabilitation for an anticipated discharge home. The Resident's medication regime included [MEDICATION NAME] 0.4 mg at bedtime (medication used to improve urination); [MEDICATION NAME] 50mg 2 times a day (medication used for [MEDICAL CONDITION] that is used for neuropathic pain); and Tylenol 325mg 2 tablets every 6 hours as needed for pain. 1) Urinary Incontinence Care Review of most recent Minimum Data Set (MDS-a federally required assessment) admission assessment, dated 5/3/17, revealed the Resident required extensive assistance with transfers and was frequently incontinent of bowel and bladder. Review of the Care Area Assessment (CAA), dated 5/9/17, revealed under type of incontinence Resident #1 was Frequently incontinent of bladder and bowel. Continuous observation on 6/20/17 from 7:20 am until 2:00 pm (6 hours and 40 minutes) revealed the Resident was awake, ate breakfast, went to occupational therapy (OT) and physical therapy (PT), and returned to the unit and ate lunch. The Resident was not offered toileting or checked for incontinence during the observation. During an observation on 6/20/17 at 2:00 pm, Certified Nursing Assistant (CNA) #4 and Licensed Nurse (LN) #4 transferred the Resident into bed. The CNA removed the Resident's incontinence brief which had become saturated with dark foul smelling urine. Both of the Resident's inner buttocks were red and excoriated. Review of Resident #1's Resident Daily Care Plan (RDCP), updated 6/15/17, revealed Toileting: Incontinent of bladder. Continent of bowel. Offer toileting in am, before and after meals, prior to rehab, at HS (bedtime) and PRN (as needed). Review of All Care Plans a comprehensive care plan, dated 5/9/17, revealed a Problem of Altered urinary elimination .as evidenced by Urinary incontinence The Goal included I will be free of skin irritation/ breakdown and odor due to incontinence. The Approach for care referred back to the RDCP. During an interview on 6/20/17 at 2:15 pm, when asked about Resident #1's incontinence care and toileting, CNA #4 replied I try to do it before and after therapy. When asked about today, the CNA replied I was hoping (Resident #1) would be changed in therapy, they do change them sometimes if needed. CNA #4 stated the Resident was already up in a wheelchair when he/she had started work that morning. 2) Pain During an observation on 6/20/17 from 9:50 am until 10:40 am Resident #1 was observed working with OT #2 in the rehab department (located in the same building). During the observation the Resident performed several upper body and extremity movements. As the Resident utilized his/her right hand, the Resident stated Ouch! with a pained expression and ouch that hurts! When crossing both arms the Resident again stated Ouch! When the Resident used the right hand and arm to work at putting rags in a laundry basket the Resident stated Oh, it still hurts! The Resident was frowning and had a pained facial expression. The Resident then picked up and held his/her right hand with the left hand and held it while rubbing it and frowning. During the observation, the OT did not ask the Resident about the pain. Review of the OT Progress Note, dated 6/20/17 at 12:31 pm, revealed no information about the Resident's complaint of pain to the right hand during the session. Review of the electronic Medication Administration Record [REDACTED]. During an interview on 6/20/17 at 1:50 pm, when asked about the [MEDICATION NAME] medication, LN #4 stated Resident #1's morning medications had not been given because the Resident had been at therapy all morning. On 6/20/17 at 1:50 pm LN #4 asked the Resident if he/she was in pain the Resident replied Not now. Review of the MDS assessment, dated 5/3/17, revealed the Resident was on a pain management program and utilized PRN pain medications. The Resident rated the pain as an 8 (very severe), on a scale of 0-10 with 0 being no pain and 10 being the worst pain. Review of the CAA for Pain, dated 5/9/17, revealed pt. states her back teeth are painful, also has c/o (complaints of) pain to RUE (right upper extremity). Review of the All Care Plans, dated 5/9/17, revealed Problem Comfort alteration in pain. The Goal included I will be able to attend PT as scheduled without limitations due to pain. The Approaches included Give meds as ordered, monitor for effectiveness/adverse effects. Review of a MDS Pain Assess/Interview, dated 6/20/17 at 5:48 pm, revealed the Resident rated his/her pain at a 6 (severe) and stated it was in the right hip and back. During an interview on 6/21/17 at 4:00 pm, when asked about the missed medications, Pharmacist #1 stated she/he would have expected the medications to be given before or after therapy. The Pharmacist stated if the am meds were given after 10:30 am they were considered late. 3) Oral Care Record review of Resident #1's MDS assessment, revealed the Resident needed extensive assistance with personal hygiene. Review of the RDCP, revised 6/15/17, revealed Oral Care: 1 person limited assist. Oral care after each meals. (SP) Resident has full upper dentures. During a continuous observation on 6/20/17 from 7:20 am to 2:10 pm, the Resident ate breakfast and lunch in the dining room. The Resident was not provided any oral care after either meal. During an interview on 6/20/17 at 2:15 pm, CNA #4 was asked about the Resident's oral care. The CNA stated the Resident had dentures in the top and a partial in the bottom. The CNA #4 stated he/she does the Resident's denture care in the morning. Resident #2 Record review from 6/19-22/17 revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Further review revealed Resident #2 had a fall on 5/19/17 at 9:00 pm. Review of the nurses notes dated 5/20-23/17 revealed: 5/20/17 at 1:53 am - .patient requested Tylenol for left hand pain that (she/he) rated at 4:10. Not related to fall . 5/20/17 at 1:07 pm - .L (left) wrist noted to be slightly larger than .R (right) wrist with limited ROM (range of motion) compared to R wrist as well .Pt was given PRN (as needed) Tylenol for 6/10 pain level in L wrist this morning with good relief noted but pt. (patient) states there was still some pain there. CNA (certified nursing assistant) states that patient has been able to transfer with her today with only mild pain noted to (his/her) L wrist. Note left for MD and supervisor notified. Pt has had increased ROM in her L wrist throughout the day. Ice was applied as well to help reduce swelling . 5/21/17 at 1:01 am - .left hand and wrist has faint indication of being swollen . 5/21/17 at 6:49 pm - .wrist of (his/her) left hand is slightly swollen. No discoloration noticed to the hand. Patient complained of pain, was given a PRN pain medication .Will continue to monitor and assess functionality of the left hand . 5/22/17 at 2:55 am - .Mild swelling noted on L wrist, no bruises noted . 5/22/17 at 10:35 am - .Patient continues with mild swelling to .left hand and wrist area . 5/22/17 at 2:32 pm - .Left .wrist slightly swollen . 5/22/17 at 5:16 pm - . (Tylenol .REASON: pain . 5/10 L[NAME]ATION: left hand(s) . 5/22/17 8:52 pm - . (Tylenol) .given for pain .7/10 L[NAME]ATION: left arm(s) wrist(s) . 5/23/17 at 2:25 pm - . (Tylenol) .pain .5/10 L[NAME]AION: both arm(s) shoulders (s) . Review of the Physical Therapy (PT) note: 5/21/17 at 8:00 am revealed .left wrist appears to have some swelling on ulnar (outer) side. Review of the physician's orders [REDACTED].>5/21/17 at 2:39 am - .Icing as needed .GIVEN FOR: Left wrist slight swelling. 5/22/17 at 2:39 pm - .Imaging Requisition Report .Xr (x-ray) Wrist Left 2 (view) .Diagnosis: [REDACTED].status [REDACTED]. 5/23/17 at 11:39 pm - .splint brace L[NAME]ATION: Left wrist .GIVEN FOR: potential .fracture of left wrist . As a result of waiting to contact the physician, the physician did not order an x-ray until 5/22/17, 3 days after the fall. Additionally, the physician did not order a splint until 5/23/17, 4 days after the fall. During an interview on 6/20/17 at 1:30 pm, the Director of Nursing stated the facility should have called the physician the evening of 5/20/17 instead of using the physician communication log as the log delayed the communication to the physician. Review on 6/22/17 of the facility's protocol Contacting Family Practice Resident MD last dated 2/2013, revealed .Never compromise resident safety by causing a delay in care .",2020-09-01
89,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2017-06-22,314,D,0,1,NLCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to prevent a pressure injury for 1 resident (#5) out of 7 sampled residents. The failure to prevent a Stage II pressure injury caused the resident unnecessary pain and resulted in an increased risk for infection, delayed healing, and poor medical outcome. Findings: Resident #5 Record review from 6/19-22/17 revealed Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set-a federally required nursing assessment), an admission assessment dated [DATE], revealed the Resident was coded as having short and long-term memory loss; severely impaired cognitive skills for daily decision making; incontinence of urine; requiring extensive assistance with bed movement and transfers; and at risk for developing pressure injuries. Further review revealed the Resident was coded as not having any pressure injuries. Record review on 6/20-22/17 of Resident #5's Comprehensive Care Plan (CCP) dated 5/8/17, revealed Problem .at risk for skin breakdown related to: decreased mobility, incontinence and diabetes . Further review revealed Braden score (an assessment tool that helps predict pressure injury risk) of 13. A Braden score of 13 represents a moderate risk for skin injury. Review of the Residents Daily Care Plan (RDCP) dated 4/25/17 with updates on 5/18/17, 5/23/17, 6/1/17, 6/8/17, and 6/14/17 revealed, Positioning .float heels when in bed . Review on 6/20/17 at 10:30 am of Resident #5's Admission and Readmission body check dated 5/23/17 revealed no indication of right heel skin injury. Review on 6/20-22/17 of the Certified Nurse Assistant (CNA) charting from 4/25/17 to 6/22/17 under the section, .SKIN OBSERVATION revealed no documentation of the right heel skin injury. Further review revealed no documentation that the Resident's heels were floated. Nursing Notes Review on 6/20-21/17 of Resident #5's nursing notes revealed the following: * 6/15/17 at 3:36 pm - Time Discovered 15:29 (3:29 pm) .possible pressure injury Wound Location: Right heel .PAIN identified? Yes Contributing Factors: Pressure-immobility .PTCC wound team notified . * 6/15/17 at 3:41 pm - .right heel appears to have a pressure injury. It has a blackish/purplish hue. When I applied pressure (he/she) jerked and said ouch. (His/her heel feels soft to touch in the raised area of (his/her) heel. WCT (wound care team) notified. Both legs elevated . * 6/15/17 at 6:40 pm - .received new wound care orders. Patient has an allevyn (thin protective foam) dressing to the right heel. Prevalon (soft Velcro boots used to keep pressure off the heels) to be worn at all times while in bed . Record review on 6/20-21/17 of the provider's note, dated 6/15/17 at 4:10 pm, revealed Resident #5 had a recent weight loss, new stage II pressure injury on right heel which was discovered by nursing staff on 6/15/17. In addition, the new pressure injury was described as a 2.5 cm x 1.5 cm fluid filled blister . Review of the physician orders [REDACTED].Nutrition consult DX: New pressure injury, weight loss .Prevalon boots to B/L (bilateral leg) heels while in bed DX: Stage 2 pressure injury . During an interview on 6/20/17 at 2:50 pm, the DON (Director of Nursing) confirmed Resident #5's acquired a Stage II pressure injury while at the facility. Review on 6/21/17 at 2:00 pm of the facility's protocol Standards of Patient Care for Nursing with a revision date of (MONTH) 2013 revealed, Skin Care Monitor skin when providing care, paying special attention to pressure areas such as heels .report any changes in skin . Review on 6/28/17 of the Braden Scale Interventions Algorithm at https://www.clwk.ca/buddydrive/file/braden-scale-interventions-algorithm revealed Braden scores of 13 to18 list of interventions included .elevate heels off the bed at all times, even with therapeutic support surfaces .inspect skin when repositioning, toileting & assisting with ADLs (activities of daily living) .use elbow and heel protectors . According to the National Pressure Ulcer Advisory Panel, accessed 6/27/17 at www.nouap.org A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue .Definition and Stages .Stage II Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister .",2020-09-01
90,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2017-06-22,315,D,0,1,NLCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and policy review the facility failed to ensure 1 resident (#1), out of 7 sampled residents, urinary incontinence was assessed for participation in an individualized toileting program to improve urinary function. This failed practice placed the resident at risk for diminished feelings of self-worth, reduced quality of life, and for a potentially unsuccessful discharge. Findings: Record review on 6/20-22/17 revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident was at the facility to receive rehabilitation for an anticipated discharge home. Continuous Observation: Observation on 6/20/17 from 7:20 am until 2:00 pm (6 hours and 40 minutes), revealed the Resident was awake, ate breakfast, went to occupational and physical therapy, returned to the unit and ate lunch. The Resident was not offered toileting or checked for incontinence during the observation. At 2:00 pm, Certified Nursing Assistant (CNA) #4 and Licensed Nurse (LN) #4 transferred the Resident to bed. After the Resident was assisted to bed the CNA checked his/her adult incontinence brief. The brief was heavily saturated with dark foul smelling urine. During an interview on 6/20/17 at 2:10 pm, when asked if he/she was able to feel the urge to void Resident #1 stated I'm not sure. Review of the Nursing Physical Examination for Resident #1, dated 4/26/17, revealed under the GU ([MEDICAL CONDITION]) section Incontinent was circled; the section where the assessing nurse was to mark the type of incontinence was not filled out. Review of the Resident's Daily Care Plan (RDCP), updated 4/26/17, revealed Toileting: Incontinent of bladder. Continent of bowel. Offer toileting in am, before and after meals, prior to rehab, and HS (bedtime) and prn (as needed) . Review of the most recent Minimum Data Set (MDS-a federally required assessment) admission assessment, dated 5/3/17, revealed the Resident required extensive assistance with transfers and was frequently incontinent of bowel and bladder. Review of the Care Area Assessment, dated 5/9/17, revealed under type of incontinence was Frequently incontinent of bladder and bowel. During an interview on 6/21/17 at 10:00 am, when asked about the facility's prompted voiding program, Nursing Supervisor (NS) #1 stated the bladder continence program was initiated by the nurse. The CNAs then documented the Resident's intake and times of voiding, after which the nurse would determine if the resident had improved or the program needed to be discontinued. The NS was asked to provide a copy of Resident #1's assessment. During a second interview on 6/21/17 at 10:25 am, the NS stated he/she was unable to find the toileting program assessment for the Resident and stated the program fell apart after the 3 days. During an interview on 6/22/17 at 4:10 pm, MDS Nurse #1 stated the CNAs were to collect 3 consecutive days of voiding data (called the CACTUS program). The Resident's primary care nurse was to assess the data and determine if the Resident was a candidate for the toileting program. During the interview, the MDS Nurse stated Resident #1's assessment for bowel and bladder continence may not have been done. Review of the documentation provided by the MDS Nurse on 6/22/17, revealed urinary voiding data from 4/26-28/17 revealed there was no assessment of the data by a nurse. In addition, the intake and voiding information from the electronic medical record CACTUS record, documented by the CNA's was missing information and did not always indicate if the Resident was offered toileting and/or a bed pan throughout the 3 day assessment period. Review of the facility policy, Bladder Continence (Prompted Voiding) Program, dated 4/11/16, revealed Patient is candidate for bladder training Admission or Clinical Supervisor/ MDS nurse initiates assessment of prompted voiding for 3 days utilizing cactus worksheet .1. Monitor that CNA is doing prompted voiding program while patient (resident) awake. 2. pass on information to Clinical Supervisor/MDS Nurse .after 3 days of consistent CACTUS assessment, pass on the information and forms to MDS Nurse/Clinical supervisor .Patient is excluded from bladder training . 1. writes check and change on the RDCP (resident daily care plan) 2. If the patient has refused bladder training documents that the risk and benefits of this action has been reviewed with the patient. Care planning decision: After the initial screening for 3 days of successfully utilizing the CACTUS form, PCN (primary care nurse) to refer the form to MDS Nurse/Clinical Supervisor to assess and care plan on one of the two: [NAME] Care plan to toilet on schedule that has been indicated by the prompted voiding .B. check and change program.",2020-09-01
91,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2017-06-22,329,D,0,1,NLCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to adequately monitor the drug regime for 1 resident (#3) out of 3 sampled residents reviewed for antipsychotic use. Specifically, the facility failed to perform an Abnormal Involuntary Movement Scale (AIMS) upon admission. Failure to adequately assess and review for possible side effects placed the resident at risk for undesirable side effects of an antipsychotic medication. Findings: Record review from 6/19-22/17 revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admitting physician's orders [REDACTED].>Review of the medication order on 6/21/17 at 11:22 am, revealed [MEDICATION NAME] was started on 5/22/17, at another facility. Review of the pharmacist's admission review note dated 6/10/17, revealed .an AIMS assessment is to be completed on all patient's taking an antipsychotic upon admission and then every 6 months thereafter .Please complete an AIMS assessment. Review of the Nursing Notes dated 6/19/17 at 3:31 am, revealed an AIMS assessment was completed on 6/18/17, 11 days after admission. During an interview on 6/20/17 at 10:07 am, Nursing Supervisor (NS) #1 stated the AIMS assessment should be done within 1 week of admittance. The NS stated it is a little late. During a follow up interview on 6/21/17 at 11:25 am, NS #1 confirmed the Resident did not have an AIMS test done prior to admittance at the facility. During an interview on 6/21/17 at 3:15 pm, when asked when Residents AIMS testing should be done, the Pharmacist stated the AIMS test should be done within 3 days of admission. Review of the facility's policy [MEDICAL CONDITION] Medications dated 12/1/16, revealed .Licensed Nursing Staff .Complete the [MEDICAL CONDITION] Assessment and AIMS scale upon admission of a resident/patient with orders for [MEDICAL CONDITION] therapy . Review on 6/28/17 of the website http://www.rxlist.com/[MEDICATION NAME]-drug.htm#warnings_precautions revealed, Tardive Dyskinesia (involuntary movements) - A syndrome of potentially irreversible, involuntary dyskinetic movements may develop in patients treated with antipsychotic drugs. There is no known treatment for [REDACTED].If signs and symptoms of tardive dyskinesia appear in a patient treated with [MEDICATION NAME](R), consider drug discontinuation .",2020-09-01
92,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2017-06-22,332,D,0,1,NLCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and policy review the facility failed to ensure their medication (med) error rate was below 5%. Specifically, the facility failed to ensure 1 resident (#1), out of 7 residents observed during med pass observations, had received physician ordered medications at the correct scheduled times. In addition, the facility failed to ensure the medication error had been reported. The failure to follow the safe medication administration practices placed the resident at risk for not receiving necessary medications and placed all residents at risk for medication errors from a systemic failure to identify a root cause analysis of medication errors. Findings: Record review on 6/20-22/17 revealed Resident #1 was admitted to the facility 4/26/17 with [DIAGNOSES REDACTED]. The Resident was at the facility to receive rehabilitation for an anticipated discharge home. Observation during a med pass on 6/20/17 at 1:50 pm revealed Licensed Nurse (LN) #4 prepared to administer medications to Resident #1. The LN removed 1 [MEDICATION NAME] 75 mg (a blood thinner) and 1 [MEDICATION NAME] 40 mg (an antidepressant) from the medication cart and administered them to the Resident. Review of the electronic Medication Administration Record [REDACTED]. Continuous observation on 6/21/17 from 7:20 am until 1:50 pm revealed the Resident was awake, ate breakfast, went to occupational therapy (OT) and physical therapy (PT) in the rehab department located in the building down the hallway, and returned to the unit and ate lunch. The Resident was not offered any scheduled morning medications during that time frame. During an interview on 6/20/17 at 1:50 pm, LN #4 stated Resident #1 had not received any of his/her am medications because the Resident had been in rehab all morning. Further review of the EMAR on 6/20/17 at 3:00 pm revealed the [MEDICATION NAME] and [MEDICATION NAME] had not been signed off. In addition, the medications Polyethylene [MEDICATION NAME] powder (used for constipation); sennosodes-[MEDICATION NAME] Sodium (used for constipation); [MEDICATION NAME] (long acting insulin); calcium [MEDICATION NAME] ([MEDICAL CONDITION]); and [MEDICATION NAME] (anticonvulsant used for neuropathic pain) had not been signed. Review of the Pyxis (medication dispensing system) report with LN #6, on 6/20/17 at 4:25 pm, revealed the Resident's am medications had been pulled from the Pyxis medication cart on 6/20/17 at 8:46 am. During an interview on 6/21/17 at 4:00 pm, when asked about the am medications not being given because the Resident was in the rehab department, the facility's Pharmacist #1 stated he/she would have expected the Resident to receive the medications either prior to attending therapy or after he/she had returned. The Pharmacist stated not administering the medications at the right time was considered a medication error and am medications were to be given by 10:30 am. The Pharmacist stated all medication error reports came to him/her and he/she had not received a medication error report on this incident. During an interview on 6/22/17 at 1:15 pm, LN #8, the nurse educator for the LNs, stated am meds needed to be given by 10:30 am. Review of the nurses' notes for 6/20/17 revealed at 8:21 pm [MEDICATION NAME]; calcium [MEDICATION NAME]; [MEDICATION NAME]; and senna (sennosodes-[MEDICATION NAME]) had not been documented as given. The reason listed was out of the building. Review of the facility policy Medication Administration Times, revised 12/16 revealed Facility administration times for oral and topical medications . Assigned Time Acceptable Time Range .d. AM 0800 0730-1030 . Review of the facility policy Medication Error Documentation, revised 1/15, revealed A medication error has occurred when .c. The dose is administered more than 1 hour early or late .e. A dose is omitted . Review of the facility policy Medication Administration, revised 12/16, revealed Medication errors are reported to the resident's prescriber and the pharmacy manager. An Unusual Occurrence Report is completed.",2020-09-01
93,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2017-06-22,466,C,0,1,NLCD11,"Based on observation and interview, the facility failed to ensure a written protocol was in place for: 1) loss of water, potable and non-potable, 2) a method for distributing water, and 3) a method for estimating the volume of water required. The failure to ensure a written protocol was in place had the potential to affect all residents (based on a census of 39) in an event of loss water. Findings: Observation during a facility tour on 6/22/17 at 9:45 am, revealed 129 5-gallon containers in a storage unit. Further observation revealed 127 gallons of drinking water was also stored for emergency use. During an interview on 6/22/17 at 10:00 am the Director of Support Services (DSS) stated the facility did not have a written procedure in place for emergency water loss. The DSS further stated the water in the 5 gallon containers were to be changed every 2-3 years. During an interview on 6/22/17 at 11:00 am, Maintenance Staff (MS) #1 confirmed the facility did not have a written procedure related to emergency water loss. MS #1 further stated the 5 gallon water containers were to be refilled every 2 years. During an interview on 6/22/17 at 1:30 pm, the Infection Preventionist (IP) stated she understood that water never expired and therefore the 5 gallon water jugs were adequate. Additionally, the IP stated the facility used FEMA (Federal Emergency Management Agency) guidelines for the amount of water needed for an emergency. The IP stated the formula was 1 gallon/day per person times 3 days. Review on 6/22/17 at 1:50 pm of the FEMA pamphlet entitled Food and Water in an Emergency provided by the facility revealed Emergency Water Supplies .Store at least one gallon per person, per day. Consider storing at least a two-week supply of water for each member of your family. If you are unable to store this quantity, store as much as you can.",2020-09-01
94,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2018-07-13,565,E,0,1,FK4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to actively encourage and notify the residents (census of 47) participation in Resident Council meetings. This failed practice denied the residents' right to participate in resident group meetings and advocate for themselves. Findings: During an interview on 7/11/18 at 10:00 am, at an arranged meeting with residents, the residents present at the meeting (Resident #'s 15, 17, 30, 31 and 195) stated that they were not aware that the facility had a Resident Council and had not been invited to any Resident Council meetings. Record review on 7/9-13/18 revealed: Resident #15 was admitted to the facility on [DATE] Resident #17 was admitted to the facility on [DATE] Resident #30 was admitted to the facility on [DATE] Resident #31 was admitted to the facility on [DATE] Resident #195 was admitted to the facility on [DATE] During an interview on 7/13/18 at 1:40 pm, with the Director of Nursing and Quality Director, when it was brought to their attention that the residents were not aware of a Resident Council, they stated it could be fixed easily. Review of the facility's policy titled Resident Council, dated 7/1/17, revealed . (PTCC) recognize the residents' right to organize and participate in resident or family groups in the facility. Further review of the policy revealed .4. Each resident is a voting member of their facility's council and is encouraged to attend and participate in Council meetings.",2020-09-01
95,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2018-07-13,656,E,0,1,FK4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop/implement care plans to: 1) Address certain medical, mental and/or psychosocial needs and 2) Implement written care plan approaches for 4 out of 17 sampled residents (#s 24, 39, 194 and 195). This failed practice had the potential to effect all residents (based on a census of 47) of the facility by providing necessary services to maintain the residents highest practicable level of well being. Findings: Resident #24 Pacemaker Record review from 7/9-13/18 revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #24's care plan, last updated 6/6/18, revealed no documentation of the presence of a cardiac pacemaker. In addition, there was no documentation any type of pacemaker device monitoring. Review of Resident #24's Resident Daily Care Plan (RDCP), dated 6/28/18, revealed no mention of a cardiac pacemaker. Random observations of the Residents room from 7/9-13/18 revealed no telephonic equipment for cardiac pacemaker monitoring for the Resident. Resident #39 Anti-coagulant Therapy Record Review from 7/9-13/18 revealed Resident #39 was admitted with [DIAGNOSES REDACTED]. Review of the Resident's Admission History & Physical dated5/25/18 revealed he/she was on [MEDICATION NAME] (a blood thinner that interferes with Vitamin K- clotting factors in the blood. [MEDICATION NAME] is a drug that may cause major or fatal bleeding, requires frequent blood monitoring, careful dosing adjustment, and diet monitoring. Other medications and over the counter supplements can affect this medication that may result in further thinning of the blood. It is important to avoid activities that could cause injury or bleeding as this has the potential to be fatal.) Record review of Resident #39's care plan, last updated 6/13/18, revealed no need/approach, preference, or goals to for issues related to anticoagulant therapy. Record review of the Resident Daily Care Plan (RDCP), dated 6/1/18 listed anticoagulant therapy as a special precaution but listed no interventions or goals. Observation and interview on 7/12/18 at 3:00 pm, Resident #39 was observed looking uncomfortable in the bed, asked if he/she was feeling okay, Resident #39 stated I'm not feeling so well today, I took a tumble in PT (physical therapy). Pacemaker/BI-V ICD (BI-V ICD- a special type of pacemaker with a defibrillator used to resynchronize the heart muscle in heart failure patients) Interview with Resident #39 on 7/9/18 at 9:17 am, Resident stated he/she had a pacemaker (bi-ventricular implantable cardiac defibrillator; BI-V ICD- a special type of pacemaker with a defibrillator used to resynchronize the heart muscle in heart failure patients) for many years and recently had and left ventricular assistive device (LVAD- a mechanical heart pump that is implanted into the person's chest where it helps the heart in circulation when the heart muscle function is failing) placed which caused him to throw a clot and have a stroke. Review of the medical record from 7/9-13/18 revealed Resident #39 was admitted to the facility for rehabilitation from physical weakness secondary to the stroke. Record review of the Nursing Facility Needs Assessment (a facility form used for residents who are being admitted to the facility) dated 5/17/118 revealed under Cardiac, documentation that Resident #39 had a pacemaker/BI-V ICD. Record review of Resident #39's care plan, last updated 6/13/18, revealed no documentation of a plan to monitor Resident's pacemaker. Review of Resident #39's Resident Daily Care Plan (RDCP), dated 6/1/18, revealed no mention of a cardiac pacemaker/BI-V ICD. Random observations in Resident # 39's from 7/9/18 through 7/13/18 revealed no telephonic equipment for cardiac pacemaker/defibrillator monitoring for the Resident. Resident #194 Activities Record review from 7/9-13/18 revealed Resident #194 was admitted to the facility with a [DIAGNOSES REDACTED]. Resident #194 had severe mobility issues. Observation on initial rounds on 7/9/18 at 8:32 am, revealed Resident #194 lying in bed awake. When surveyor came into the room for introduction, the Resident was observed to be in tears. The Resident was unable to verbalize cause due to the inability to speak. Record review of the care plan, last updated on 7/9/18 revealed Resident #194 would like individual activities because Resident has difficulty communicating and feels lonely, isolated and depressed. Listed approaches included inviting and assisting Resident to participate in activities and to engage Resident in 1:1 (one to one) activities, provide music, outdoor time, and pet visits. During an telephone interview on 7/10/18 at 1:07 pm the Resident's Power of Attorney (POA) stated that Resident has had difficulty with transition to the facility from home and was likely depressed. Random observations from 7/9-13/18 revealed Resident #194 in bed with the TV on. No 1:1 activity interactions by facility staff were observed. Observation of facility activities on 7/11/18 at 4:00 pm, revealed a music activity in the common area. Two dogs were observed present on the unit, one belonging to a staff person, and the other visiting the facility. Other residents present in the activity room were observed interacting with the dogs. Interview on 7/12/18 with a visitor that spent most of the past two days with Resident #194 revealed that no activities staff had been by to offer Resident activity choices. The Resident did not have a visit with the animals that were present on the unit the previous day. Record review of Activity Notes from 7/3-10/18 reveal two entries, with no description other than active participation for 1:1 visitation for the week. Resident #195 Hydration During an interview with Resident #195 on 7/10/18 at 8:50 am, Resident stated he/she was admitted facility post hip, rib, and humerus bone fractures for routine healing. Resident #195 stated he/she was on fluid restriction. An observation of Resident #195's room on 7/10/18 at 8:50 am, revealed a sign posted on wall indicating Resident #195 was on fluid restriction. Record review of Resident #195's care plan, last updated on 7/9/18 revealed no hydration/fluid concerns listed as a need, approaches or goal. Activities Record review of care plan last updated 7/9/18 revealed that Resident #195 did not like to attend many activities because of lack of motivation. Approach indicated nurses and activity staff to invite and assist Resident to participate in activities, activity staff to invite Resident to activities he/she might enjoy, spend time outdoors, pet visits, music, and games, and all staff to encourage participation and/or offer conversation. During an interview on 7/12/18 at 9:15 am, Resident #195 stated he/she had not participated in any activities since admission on 6/27/18. Resident #195 was unaware of ever meeting activities staff and indicated staff had never come to encourage/invite participation in any activity or provided a 1:1 activity.",2020-09-01
96,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2018-07-13,679,E,0,1,FK4811,"Based on observation, interview and record review the facility failed to ensure support of resident participation in activity programs that included a variety of facility-sponsored group and individual activities based on individual assessment, care plan, and preference for 2 residents (#s 194 and 195), of 17 sampled residents reviewed. This failure practice placed residents at risk for boredom, loneliness, and decreased quality of life. Findings: Observation on 7/9/18 at 10:00 am, revealed one resident participating in the scheduled activity, Wheel Chair Exercise, alone. Observation on 7/9/18 at 11:39 am, revealed two residents in the common area. One Resident (#4) was observed to tell the other resident that it was time for Bible Study, the scheduled activity. Announcement of the activity overhead or staff efforts to ensure resident participation were not observed. Observation on 7/10/18 at 9:25 am, revealed the Activities Assistant (AA) coming in to the common area and starting the scheduled wheel chair exercise video. The AA did not leave the area to encourage or invite residents to the activity. A Resident arrived in the common area shortly after and the AA set up cards to play 1:1 (one to one). Observation on 7/10/18 at 10:00 am, revealed only one un-sampled Resident participating in the scheduled bible study group with the Pastor. No announcement of the activity or staff effort to invite residents to participate was observed. After 15 minutes, the Resident was taken out of the group to go to physical therapy. During an interview on 7/10/18 at 10:25 am, Certified Nursing Assistant (CNA) #1 stated it was the person performing the activity who is responsible for going around and asking the residents if they want to participate. During an interview on 7/10/18 at 11:00 am, the Pastor for bible study stated there was consistently poor participation in his groups because of all the therapy that is taking place at that time. He stated he was mainly responsible for inviting Residents to his group and rarely sees staff invite residents or encourage participation. Resident #194 Record review of Resident #194 care plan on 7/9-11/18 revealed that Activity staff were to invite, assist, and provide 1:1 activities for the Resident. Record review of Resident #194's care plan, last updated on 7/9/18 revealed the Resident would like individual activities because Resident has difficulty communicating and feels lonely, isolated and depressed. Listed approaches included inviting and assisting Resident to participate in activities and to engage Resident in 1:1 activities, provide music, outdoor time, and pet visits. Random observations from 7/9-13/18 revealed Resident #194 in bed with the TV on. No 1:1 activity interactions by facility staff were observed. Observation of facility activities on 7/11/18 at 4:00 pm, revealed a music activity in the common area. Two dogs were observed present on the unit, one belonging to a staff person, and the other visiting the facility. Residents present in the activity room were observed interacting with the dogs. Interview on 7/12/18 with a visitor that spent most of the past two days with Resident #194 stated no activities staff had been by to offer Resident activity choices. The Resident had not visited with the animals that were present on the unit the previous day. Record review of Resident # 194's Activity Notes from 7/3-10/18 revealed two entries, with no description other than active participation for 1:1 visitation for the week. During an interview on 7/11/18 at 9:30 am, the AA stated that physical therapy activities took priority over activities. The AA stated that they knew which activities each resident enjoys but they were still supposed to invite them to activities. The AA stated the CNA staff role was primarily to help accommodate and transport residents to activities, but the invitations were the activities staff responsibility. The AA stated that the activities were posted on the units in the common area and that they were given a calendar of activities and residents know what time each activity is occurring. Resident #195 Interview on 7/12/18 at 9:15 am, Resident #195 stated that he/she had not participated in any activities since admission on 6/27/18. Resident #195 stated they had no recall of meeting an activities staff and nobody had never come to encourage/invite participation in any activity or provided a 1:1 activity. Record review of Resident #195's care plan on 7/9-11/18 revealed that Activity staff were to invite, assist, and provide 1:1 activities for the Resident.",2020-09-01
97,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2018-07-13,684,E,0,1,FK4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure 3 residents (#'s 16, 24 and 39), out of 3 residents reviewed with cardiac devices (devices implanted under the skin with wires attached to the heart to ensure a regular heartbeat) had the required monitoring of the device. This failed practice placed the residents at risk for undiagnosed heart rhythm irregularities, missed device changes or alerts, and decreased heart health. Findings: Resident #16 Record review from 7/9-13/18 revealed Resident #16 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of Resident #16's care plan, last updated 5/9/17, revealed no documentation of the presence of a pacemaker or any type of cardiac device monitoring. Review of Resident #16's Resident Daily Care Plan (RDCP), dated 5/15/18, revealed no documentation of a cardiac pacemaker. Record review of Providence Alaska Medical Center's Admission History and Physical, dated 4/11/18, revealed Review of old records indicate that patient is had a pacemaker placed for heart block following a [MEDICAL CONDITION] infarction. This was in 2008. Record review of PTCC (Providence Transitional Care Center) ADMISSION TRANSFER REPORT, dated 4/26/18, revealed PMH (past medical history): .PACEMAKER. Review of PHYSICIAN ORDER REVIEW, dated 5/3/18, 5/27/18 and 6/28/18 revealed INFO: Patient has PACEMAKER . Observations of the resident's room from 7/9-13/18 revealed no telephonic equipment, used for cardiac pacemaker monitoring, present for the Resident. An interview on 7/12/18 at 3:10 pm, with Alaska Heart & Vascular Institute Electrophysiology Clinic Manager (AH&VI EP Manager), revealed Resident #16 had his/her last pacemaker transmittal on 1/24/18. The Resident was scheduled for transmittals 5/1/18, 5/15/18, 6/5/18, and 6/19/18. The Manager stated as these transmittals were all missed, no other transmittals had been scheduled for this Resident. Resident #24 Record review from 7/9-13/18 revealed Resident #24 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #24's care plan, last updated 6/6/18, revealed no documentation of the presence of a cardiac pacemaker or pacemaker device monitoring. Review of Resident #24's Resident Daily Care Plan, dated 6/28/18, revealed no documentation of a cardiac pacemaker. Random observations of the resident's room from 7/9-13/18 revealed no telephonic equipment, used for cardiac pacemaker monitoring, present for the Resident. During an interview on 7/12/18 at 10:10 am, with Resident #24's son, the son stated he had no interaction with the staff regarding Resident #24's pacemaker. During an interview on 7/12/18 at 3:10 pm, with AH&VI EP Manager stated Resident #24's last pacemaker check was on 11/14/17. The next scheduled pacemaker check was for 2/16/18, this check was canceled by Resident #24's son. The Manager stated device checks are recommended every three months and no other device checks were scheduled for Resident #24. Resident #39 Record review from 7/9-13/18 revealed Resident #39 was admitted to the facility with [DIAGNOSES REDACTED]. Interview on 7/9/18 at 9:17 am, Resident #39 stated that they had a BI-V ICD for several years. Record review of the Nursing Facility Needs assessment dated [DATE] revealed under Cardiac, documentation Resident #39 had a pacemaker/ICD. Record review of Resident #39's care plan, last updated 6/13/18, revealed no documentation of a plan to monitor Resident's pacemaker/ICD. Review of Resident #39's Resident Daily Care Plan, dated 6/1/18, revealed no documentation of a cardiac pacemaker/ICD. Random observations of the Resident's room from 7/9-13/18 revealed no telephonic equipment, used for cardiac pacemaker/ICD monitoring, present for the Resident. During an interview on 7/11/18 at 2:35 pm, Licensed Nurses #1 and #2 stated they did not know of telemetry boxes or need of monitoring equipment for pacemakers. During an interview with the Alaska Heart & Vascular Institute Electrophysiology Clinic Manager (AH&VI EP Manager), when asked how often cardiac devices are monitored, he/she stated that telephonic transmittals should be done every 3 months. During an interview on 7/12/18 at 4:03 pm, the Director of Nursing (DON) stated the Nurse Educator assesses where the resident is being seen for his/her pacemaker care. The DON also stated if residents have a device at home to check the pacemaker they bring the device so it can be done at the facility. The family or resident tells staff they have a pacemaker check coming up and the residents are sent out for the check. In addition, the DON stated she is not sure what happens after the pacemaker is put on the [DIAGNOSES REDACTED]. Review of the facility policy index from 7/10-13/18 revealed no policy on pacemakers or ICD's. During an interview on 7/11/18 at 4:02 pm the DON stated the facility did not have a policy. The facility provided the survey team a list of their policies during the survey. The Surveyors requested a policy on pacemakers and defibrilators which the Surveyors hand wrote on the list. When the policies requested and the list given were given to the Surveyors a hand written protocol was by the cardiac device request. A protocol was then requested. The protocol was not provided by the survey exit.",2020-09-01
98,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2018-07-13,689,D,1,1,FK4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure the safety of 1 Resident (#2) who resided in the facility. Specifically, the facility failed to ensure the Roam Alert Resident Safety (RARS- a door alarm system intended to alert staff of elopement/wandering from the building or a designated area of the building) was checked regularly for proper functioning that resulted in resident #2 leaving the facility unsupervised. This failed practice placed the resident at risk being without medical supervision and unsafe environment conditions. Findings: Based on a closed record review of an elopement the facility is cited for past non-compliance for elopement of resident #2. Upon the Resident's return to the facility, the facility found no system in place for checking the monitoring device and had developed a protocol for monitoring and recording this information on the Residents Treatment Administration Record. Record review of a closed record from 7/10-13/18 revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's care plan dated 4/2/18, revealed NEED/PREFERENCE .I LIKE: to wander about and sometimes go outside .I SHOW THIS BY: going outside at times, without telling staff .APPROACH .I need my nurses to---chart on my behavior in regards to the wander guard that I wear .GOAL .MY GOAL IS TO: stay safe while I'm moving about . Record review revealed no documentation of the Resident using the RARS and no documentation of staff checking the system. Further review of the medical record revealed no documentation of resident eloping in the medical record. Review of the facility report incident dated 5/24/18, revealed the facility reported the elopement to the state agency (Health Facilities Licensing & Certification). During an interview with Nursing Supervisor (NS) #1 on 7/13/18 at 12:05 pm, when asked for documentation in the medial record of Resident #2's elopement the NS stated he/she could not find any documentation. Further review on site revealed a protocol Wander Guard Sensors-Care and Management of the Resident dated 5/28/18 was developed, 4 days after Resident #2 had eloped. During an interview on 7/13/18 at 1:39 pm, with the Director of Nursing (DON) and Quality Director (QD), when asked about Resident #2's elopement the DON stated Resident #2 monitor had not alarmed and was gone from the facility about 3 to 4 hours. When the Resident was brought back to the facility, entering the building, the monitoring system did not alarm. The monitor Resident #2 was wearing was replaced 5/29/18. The DON further stated the Licensed Nurse did not document in the medical record of the Resident as it was reported to the State Agency and did not need further documentation. Review of the facility policy titled AMA (Against Medical Advice) and Elopement revision date 12/14 revealed .Elopement .e. A thorough documentation of the elopement is made in the medical record by appropriate clinical disciplines .",2020-09-01
99,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2018-07-13,726,E,0,1,FK4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure staff had appropriate competencies and skills necessary to care for include the clinical needs of 2 residents #s (16 and 24) with pacemakers and 1 resident (#39) bi-ventricular implantable cardiac defibrillator (BI-V ICD- a special type of pacemaker with a defibrillator used to resynchronize the heart muscle in heart failure patients) in the facility, out of 3 sampled residents with implanted devices. This failed practice placed the residents at risk for undiagnosed heart rhythm irregularities, missed necessary cardiac monitoring, equipment, care and decreased heart health. Findings: Resident #16 Record review from 7/9-13/18 revealed Resident #16 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of Resident #16's care plan, last updated 5/9/17, revealed no documentation of the presence of a pacemaker or any type of cardiac device monitoring. Review of Resident #16's Resident Daily Care Plan (RDCP), dated 5/15/18, revealed no documentation of a cardiac pacemaker. Random observations from 7/9-13/18 revealed no telephonic equipment for cardiac pacemaker monitoring for the Resident. Resident #24 Record review from 7/9-13/18 revealed Resident #24 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #24's care plan, last updated 6/6/18, revealed no documentation regarding any type of pacemaker monitoring. During an interview on 7/12/18 at 10:10 am, with Resident #24's son and daughter, Resident's #24's son stated that he had no interaction with the staff regarding Resident #24's pacemaker. Random observations of the resident's room from 7/9-13/18 revealed no telephonic equipment, used for cardiac pacemaker monitoring, present for the Resident. Resident #39 Record review from 7/9-13/18 revealed Resident #39 was admitted to the facility with a [DIAGNOSES REDACTED]. During an interview on 7/9/18 at 9:17 am, Resident #39 stated that they had a BI-V ICD for several years. Record review of Resident #39's care plan, last updated 6/13/18, revealed no documentation of a plan to monitor Resident's pacemaker/ICD. Review of Resident #39's Resident Daily Care Plan (RDCP), dated 6/1/18, revealed no documentation of a cardiac pacemaker/ICD. Random observations of the resident's room from 7/9-13/18 revealed no telephonic equipment, for cardiac pacemaker/ICD monitoring, present for the Resident. During an interview on 7/11/18 at 2:35 pm, Licensed Nurse (LN) #1 and LN #2 stated they did not know of telemetry boxes or need of monitoring equipment for pacemakers. During an interview with the Alaska Heart & Vascular Institute Electrophysiology Clinic Manager (AH&VI EP Manager), when asked how often cardiac devices are monitored, he/she stated that telephonic transmittals should be done every 3 months. During an interview on 7/12/18 at 4:03 pm, the Director of Nursing (DON) stated the Nurse Educator was to ask where the resident is being seen for his/her pacemaker care. The DON also stated if residents have a device at home to check the pacemaker they bring them in so it can be done at the facility. The family or resident tells staff they have a pacemaker check coming up and the residents are sent out for the check. In addition, the DON stated she is not sure what happens after the pacemaker is put on the [DIAGNOSES REDACTED]. When asked for a policy on pacemakers, surveyors were told the facility did not have one. A pacemaker protocol was then requested. The protocol was not provided by survey exit.",2020-09-01
100,PROVIDENCE TRANSITIONAL CARE CENTER,25018,910 COMPASSION CIRCLE,ANCHORAGE,AK,99504,2018-07-13,756,D,0,1,FK4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure accurate drug regimen review for 1 resident (#7) out of 17 sampled residents, reflected a medication contraindication as referred by the Beers list ( Criteria for Potentially Inappropriate Medication use in Older Adults) was acted on in a timely manner. This failed practice placed the resident at increased risk for confusion, [MEDICAL CONDITION], falls and fractures. Findings: Record review on 7/9-13/18 revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. (A benzodiazepine that is primarily used to treat anxiety). Review of Pharmacy Recommendations for Resident #7 revealed a monthly review, dated 6/27/18 at 12:35pm, revealed: .PRN [MEDICATION NAME] ([MEDICATION NAME]) was ordered last night for use PRN agitation or [MEDICAL CONDITION]. Not the best choice, but better than a PRN antipsychotic. Will increase fall risk at night and will need close monitoring. Nursing staff to attempt 1:1 (one to one) care when staffing allows. Further review of Resident #7's chart revealed no drug regimen review sheet to alert the physician of these recommendations for increased observation. Record review of Resident #7's active care plan last reviewed 4/4/18 revealed: I need to have someone help me .am unaware of safety risks .have the potential to fall down and hurt myself. I am at risk for injuring myself . During an interview on 7/11/18 at 12:50 pm, the Pharmacist stated the 6/27/18 monthly review did not address the [MEDICATION NAME] order was contraindicated for the elderly population on the Beers list for treatment of [REDACTED]. The Pharmacist further stated the Pharmacist reviewing the record should have reported the concern and documented it on the review. Review of the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication use in Older Adults, dated 2012, reads, Avoid Benzodiazepines (any type) for treatment of [REDACTED]. Older adults have increased sensitivity to benzodiazepines .In general, all benzodiazepines increase risk of cognitive impairment, [MEDICAL CONDITION], falls, fractures .in older adults.",2020-09-01