rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2019-01-30,565,E,0,1,IS8311,"Based on record review and interview, the facility did not ensure that guests and/or other individuals attended the resident group meetings only at the respective group's invitation; and did not always act promptly upon the grievances and recommendations raised by the residents regarding issues of resident care and life in the facility. Findings include: 1. During an interview on 1/28/19, Resident 9, a member of the resident council, stated that meetings were held at least monthly by the residents. Resident 9 added that while a facility staff member was present during the meetings to provide assistance such as documenting minutes of discussion, the ombudsman however, was also always present. In the same interview, Resident 9 stated that she did not know that attendance by the ombudsman was by invitation of the resident council only. The resident added that in some cases , the meeting was postponed when the ombudsman was not available. Review of council meeting notes provided by an activity staff member (AD1) on 1/29/19 revealed that the ombudsman was in attendance during meetings including those held in May, (YEAR); June, (YEAR); July, (YEAR); September, (YEAR); and (MONTH) (YEAR). In a separate interview on 1/29/19, AD1 verified that the ombudsman was a regular participant during the resident group meetings. 2. Review of the resident council meeting minutes revealed that efforts made by the facility to address complaints or grievances by the residents were not always sustained. Review of the (MONTH) (YEAR) meeting minutes, for example, noted a complaint by residents waiting to be attended to and not being attended at all. While the complaint was acknowledged by nursing staff as an ongoing problem and corrective actions were undertaken, including reminding staff about addressing resident needs attentively and immediately, the same (or similar issues) were raised again during the September, (YEAR) meeting with the residents reporting being told by staff to wait for your nurse, or I'll come back but does not return. In (MONTH) (YEAR), meeting minutes also noted that white boards were not being updated so that residents could identify the nurse or CNA (certified nurse aide) assigned to them. While nursing staff were reminded about the importance of updating the white boards, the same issue was raised once again in September. During the same interview on 1/28/19, Resident 9 stated that while the situation would get better after having been discussed during the meeting, the same issues however would come up again after especially on the night shift.",2020-09-01
2,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2019-01-30,583,C,0,1,IS8311,"Based on observation and interview the facility failed to provide privacy and confidentiality for 18 out of 18 residents in the nursing unit. This failure exposed the resident's diagnosis, treatments, medications and personal concerns when the census flow sheet was left out on the cart in the hallway. Findings include: During a unit tour on 1/29/2019 at 9:00 a.m., noticed on top of the medication cart the census entire unit flow sheet record. The census flow sheet contained the resident names, diagnosis, medications, treatments and personal concerns. The census flow sheet was not secured and all the resident's information was displayed and anyone walking in the hallway would have access to the residents' confidential medical record information. During an interview on 1/29/2019 at 9:05 a.m., with Staff #5 she acknowledged that the census flow sheet was left out on top of the medication cart which exposed all the residents' personal and confidential information. Staff # 5 quickly apologized and stated that she knows better and should have placed the form into her binder or inside the medication cart. During an interview concurrent with a policy review on 1/29/2019 at 9:50 a.m., with administrative Staff #2 she acknowledged that the census flow sheet definitely disclosed confidential information about the 18 residents on the unit and it should not be left exposed to everyone. She also specified that she had multiple in-services with the nursing staff in regards to safe guarding the patient's confidential information. During the review of the facility policy titled Medical Record Processing for Skilled Nursing Unit disclosed that the medical record will be systematically organized, stored in a safe, secured manner to ensure patient confidentiality. The facility will maintain all patient information in a secure location to ensure protection from loss, destruction or unauthorized use.",2020-09-01
3,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2019-01-30,585,D,0,1,IS8311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to implement grievances as per policy and regulation for 1 out of 8 sampled residents (R # 301). Resident's grievances are not being investigated, tracked, no corrective action plans are implemented, no documentation of resolutions and no evidence of the grievance log available for review. This failure prevents proper resolutions to resident and family concerns. Findings include: During a record review on 1/29/2019 reveals that resident #301 was admitted to facility on 3/24/18 with the [DIAGNOSES REDACTED]. Minimum Data Set (MDS) 14 day assessment completed on 4/7/18 disclosed a Brief Interview for Mental Status (BIMS) score of 14. Resident #301 was also admitted to facility for intravenous (IV) antibiotic treatment for [REDACTED]. Additional record review revealed that resident #301 had several nursing notes with documentations of the IV infiltration occurrence during the [MEDICATION NAME] administration and resident IV site was red, swollen, warm to touch and tender. During an interview on 1/29/2019 at 10:00 a.m., with Administrative Staff #9 she indicated that resident #301 spouse was very out spoken with all her concerns and she frequently voiced her concerns. She further explained that the residents and spouse concerns were addressed to their satisfaction but was never documented. When asked if she was aware of the police coming into the facility to question Staff #12 she indicated No during that time she was out on leave and that the person that was providing coverage at the facility did not forward the information to the administration staff. She further explained that her expectation from all staff is to report all concerns to administration. Administrative Staff #9 was not able to provide any evidence that the patient and spouse concerns were ever investigated or resolved. During an interview on 1/29/2019 at 12:00 p.m., with the Staff #12 she indicated that the residents spouse complained that she was not changing her gloves and washing her hands when caring for resident # 301. She also indicated that she apologized to the resident and the spouse after they complained to management. In addition she confirmed that the police came into the facility to question her because the resident spouse also reported that she was trying to run her off the road in retaliation. During an interview on 1/29/2019 at 12:10 p.m., with Administrative Staff #2 she indicated that the residents spouse had multiple complaints and they were resolved immediately. Staff #2 further explained that the complaints had to do with dissatisfaction with care, staff and personal issues. When asked to provide evidence of the grievance/complaint process and log she verbalized that she does not maintain a grievance/complaint log on reported complaints and concerns'. When asked about the IV infiltration that was documented in the resident clinical record she indicated that no incident reports were filed. Administrative Staff #2 was not able to provide any evidence that the patient and spouse concerns were ever investigated or resolved. During an interview on 1/30/2019 at 2:00 p.m., with Administrative Staff #13, the patient safety person/guest relation coordinator she indicated that she visits residents quarterly and pass out patient satisfaction surveys. In addition she started the grievances/complaint process since (MONTH) (YEAR) and have not had any reported concerns about resident #301. The complaint for resident #301 was never reported to her staff 13 indicated, as a result she had no evidence of the reported concerns. Reviewed the facility policy on 1/30/2019 titled Patient Grievances /Complaints disclosed: 1). The purpose of this policy is to assure that all patient complaints and grievances are addressed and resolved in a timely manner, as well as improve the service provided to patients. 2). A patient has the right to submit a grievance and complaint either written or oral and may be brought to the attention of the staff present. 3). A patient may file or report a grievance, once received it will be investigated and a written response will be provided to the grievant within 7 days from the filling date. If resolution of the complaint will take longer than 7 days a letter must be sent informing the grievant that additional time is needed and the letter must give an estimated time frame for completion.",2020-09-01
4,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2019-01-30,655,E,0,1,IS8311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement baseline nursing care plans for 1 of 8 sampled residents (Resident 18). Failure to assess, develop, and implement baseline nursing care plans for Resident 18's history of smoking could subject the resident and other residents at risk for potential injury associated with smoking. Additionally, failure to assess, develop and implement a base line nursing care plan associated with the use of [MEDICATION NAME] could potentially lead to the failure to identify signs and symptoms of adverse effects associated with use of the anticoagulant. Findings include: 1. Resident 18 is a [AGE] year-old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. His social history shows he had a history of [REDACTED]. The records also reflect he had no desire to quit tobacco use. During the resident interview on 1/28/2019, the resident stated that while at the skilled nursing unit he had been smoking unsupervised in the designated smoking area, and that he maintained his own cigarettes and lighter. On 1/30/2019 during a concurrent record review and interview with a licensed nurse (LN2) she validated that the facility did not complete an assessment to determine if Resident 18 was safe with the use of his cigarettes. LN2 also validated the facility did not develop and implement a nursing care plan associated with Resident 18's cigarette use. On that same day the facility policy titled Skilled Nursing Unit (SNU) Smoking Policy was reviewed. The procedure within the policy had several items listed 1 through 24 and the relevant items state: #7 .Residents with authorization from their physician or licensed independent practitioner may be allowed to smoke in designated areas. #12 .Staff is responsible for ensuring that smoking by residents is done in a safe manner. #13 .Residents will be allowed to smoke and use smoking material only as specified in their care plan. 2. During further investigation with LN2, it was validated that Resident 18's physician had ordered [MEDICATION NAME] 5000 units twice a day and the medication was to be administered subcutaneously. The medication [MEDICATION NAME] can prolong the bleeding time. Potential negative outcomes associated with [MEDICATION NAME] use is bleeding within or from tissues of the body such as the gums, rectum, urine and etc. LN2 also validated that the facility failed to develop and implement a short term nursing care plan to help the nursing staff monitor and identify any potential adverse outcomes associated with the use of [MEDICATION NAME].",2020-09-01
5,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2019-01-30,656,D,0,1,IS8311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person centered nursing care plan with measurable objectives to meet the resident smoking needs for 1 of 8 sampled residents (R#4). Failure to develop and implement the nursing care plans for R #4, a current smoker could place the resident and other residents at risk for potential injury associated with smoking. Findings include: During an interview on 1/28/2019 at 12:45 p.m., resident #4 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident is alert and oriented x 3, his Minimum Data Set (MDS) Annual Assessment disclosed a Brief Interview for Mental Status (BIMS) score of 15. Resident #4 indicated that he was waiting for proper home placement because he needs ADL care. In addition Resident #4 validated that he is a current smoker since admitted at the facility. He verbalized that he maintained all of his smoking supplies at bedside which includes the cigarette and the lighter and only smoke at the designated smoking areas assigned by the facility. During an interview on 1/29/2019 at 1:30 p.m., with the administrative staff #2 she indicated that the R #4 according to the smoking policy should have had a smoking care plan identifying his safety needs and expectations. During an interview on 1/29/2019 at 1:40 p.m., with the Administrative Staff #11, she validated that a smoking care plan was not developed or implemented for resident #4 as per policy. During an a record review of the smoking policy on 1/29/2019 titled SNU Smoking Policy disclosed that resident would be allowed to smoke and use smoking materials only as specified in their care plan.",2020-09-01
6,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2019-01-30,690,D,0,1,IS8311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure that a resident who had an indwelling catheter was assessed for removal of the catheter as soon as possible and received treatment and services to prevent urinary tract infections. Findings include: 1. Resident 9 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the quarterly minimum data set ((MDS) dated [DATE] revealed that the resident had a BIMS (brief interview of mental status) score of 15 indicating that she had no cognitive impairments and that she was dependent on staff for most activities of daily living. The medical record also noted that the resident also had a [MEDICAL CONDITION] as well as an indwelling catheter. During the survey on 1/28/19, Resident 9 was observed with a urinary drainage bag at the bedside draining yellow urine. Review of the care area assessment dated [DATE] revealed that urinary incontinence was triggered because of the resident's use of an indwelling catheter due to restricted mobility and presence of healing stage 4 sacral pressure sore. The assessment noted that a care plan will be developed to ensure that the resident will maintain continuous drainage of her bladder while minimizing the risk of negative outcomes. Review of the medical record revealed that Resident 9 has had several urinary tract infections which were treated with antibiotics: On 6/27/18, a urine culture and sensitivity (C&S) test result revealed infection with Citrobacter koseri (100,000 org/ml). On 7/13/18, another urine C&S test result revealed the presence of Eschirichia coli (100,000 org/ml). On 7/27/18, a urine C&S result indicated continuing infection with Eschirichia coli (100,000 org/ml) and yeast (100,000 org/ml). On 10/04/18, a C&S obtained revealed the presence of infection with Eschirichia coli (100,000 org/ml) and proteus mirabilis (100,000) org/ml). On 11/19/18, another urine C&S revealed infection with [DIAGNOSES REDACTED] pneumoniae (100,000 org/ml). In spite of this, there was no indication that an assessment of the resident's continuing use of the indwelling catheter was conducted. While a physician's note dated 11/14/18 revealed that the resident had recurrent [MEDICAL CONDITION] and required an indwelling catheter, there was no documentation that the retention was evaluated or that a urology consult requested was conducted. The same note described that the sacral pressure sore was healing. In addition, there was no indication that the catheter care procedure in the care plan was reviewed for effectiveness in light of the resident's [MEDICAL CONDITION] and frequent infection with Eschirichia coli, a bacteria that normally lives in the intestines. During an interview on 1/29/19, a licensed staff (LS9) stated that Resident 9 did not always have an indwelling catheter, and that the catheter was inserted to help heal the stage 4 pressure sore she was admitted with. During wound care observation on 1/29/19, the resident's sacral pressure injury was noted to be about 2.5 cms long, intact, without drainage, and was granulating well. The wound was cleaned with saline solution and covered with a small piece of Duoderm, a moisture barrier dressing. The licensed nurse (LS8) nurse stated that the wound had significantly improved from when the resident was first admitted . 2. Resident 17 was initially admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the medical record indicated that the resident was transferred to an acute care hospital for pneumonia and readmitted back on 11/19/18. Review of the MDS 60-day assessment dated [DATE] revealed that the Resident 17 had moderately impaired cognitive skills and required extensive assistance with most activities of daily living. During the survey, Resident 17 was observed with a urinary drainage bag at the bedside. Review of the medical record revealed that the resident had an indwelling catheter related to: Stage 4 pressure ulcer on (there resident's) sacrum. Further record review revealed the lack of indication that an evaluation of the continuing use of the catheter was conducted. During wound care observation on 1/30/19, the resident's sacral pressure sore was noted to be about 3.5 cms long, was pinkish in color, with minimal drainage and without any redness or swelling. A licensed staff (LS7) stated that the pressure sore was much improved from when the resident was initially admitted on [DATE]. LS7 added that the resident had recently completed a course of antibiotics because of a urinary tract infection with multi-drug resistant organisms including Acinotobacter baumanni. Further review of the medical record revealed that a urine C&S test result dated 12/19/18 also revealed the presence of Acinobacter baumanni and Pseudomonas aeruginosa bacteria.",2020-09-01
7,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2019-01-30,693,D,0,1,IS8311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that one of eight sample residents (Resident 5) who was fed by enteral means received appropriate care and services to prevent potential complications associated with the tube feeding. Failure to administer tube feedings as ordered and in accordance with standards of practice has the potential to contribute to facility acquired conditions. Finding includes: Resident 5 is a [AGE] year old female that was admitted into the skilled nursing unit on 1/13/2019. Her admission [DIAGNOSES REDACTED]. The records also identified that she was totally dependent on staff for all care. Her other [DIAGNOSES REDACTED]. The resident also had a gastric tube which was being used for nutritional feeding and was placed sometime in the past. On 1/29/2019, a licensed nurse (LN5) was observed preparing seven medications that were to be administered to Resident 5 at 9:00 a.m. At that same time the resident was to receive her ordered intermittent bolus tube feeding of [MEDICATION NAME] (1 carton) which equaled to approximately 250 milliliters (ml) of liquid. Prior to administering the medications or tube feeding LN5 checked placement of the tube and checked for gastric residual. Resident 5 had a gastric residual of approximately 50 - 60 ml. LN5 consulted with the physician and held the medications and feeding till 10:00 a.m. At 10:00 a.m., LN5 again checked placement of the gastric tube and assessed for gastric residual. Resident 5 had After administering the medications and the tube feeding LN5 acknowledged she did not flush the gastric tube with water between each medication. She also validated that she gave 1 and 1/2 cartons of the [MEDICATION NAME] tube feeding. LN5 validated that the only times Resident 5 was to receive one and a half carton of tube feeding was at 1:00 a.m. and at 1:00 p.m. Later that same day, LN2 provided the Enternal (SIC) Tube Medication Administration policy. Within the procedure it stated, The enternal (SIC) tubing is flushed with at least five (5) ml of water between each medication to avoid physical interaction of the medications. She also validated LN5 should have flushed the tube feeding line between each medication. After reviewing the Medication Administration Record, [REDACTED].",2020-09-01
8,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2019-01-30,732,C,0,1,IS8311,"Based on observation and interview, the facility did not post the actual hours worked by nursing staff directly responsible for resident care per shift. Finding includes: The facility's staffing information was noted on a white, dry erase board in the hallway across from the nursing station. While the posting included the current date, census, as well as the number of registered nurses, licensed vocational nurses, and certified nurse aides directly responsible for resident care per shift, it did not, however, include their actual number of hours worked, as required.",2020-09-01
9,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2019-01-30,757,D,0,1,IS8311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure that the resident's was free of unnecessary drugs including drugs used without adequate monitoring. Findings include: 1. Resident 9 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The medical record revealed that the resident had a [MEDICAL CONDITION] and an indwelling catheter and was described as being a paraplegic. The most recent minimum data set assessment ((MDS) dated [DATE] described the resident has having a BIMS (brief interview of mental status) score of 15 indicating that she had no cognitive impairments. The MDS also noted that she had no [MEDICAL CONDITION], no mood disorders except for poor appetite (or overeating), and was totally dependent on staff for all activities of daily living. A physician's note dated 11/14/18 revealed that the resident had [MEDICAL CONDITION] disorder that was Likely contributing to issues medically; and that she was being followed by a psychiatrist. Review of the medical record revealed that Resident 9 was receiving [MEDICATION NAME] 20 mgs for depression daily. The depression, according to behavior monitoring sheets, was manifested by withdrawal. On 12/20/18, a physician's orders [REDACTED]. Review of monitoring sheets including those completed in (MONTH) (2018), and (MONTH) (2019) revealed that monitoring for withdrawal was not always being conducted on all three shifts, and at times, for several days to a week (12/12/18 - 12/19/18). For days when entries were available, monitoring noted 0 indicating no withdrawal behaviors were observed. In addition, monitoring for side effects was not always being conducted. During the survey, Resident 9 was observed being wheeled to the day room by staff in her bed where she could watch television or interact with other residents who were in the room. In an interview on 1/29/19, the resident stated that she was usually brought to the day room around mid-day because it was good to be out of her room for a while. During an interview on 1/29/18, a pharmacy staff (PH1) stated that Resident 9 was no longer being monitored for withdrawal but for loss of appetite resulting in poor oral intake; which was also why, according to PH1, the [MEDICATION NAME] dose was increased (on 12/20/18). PH1 added that this was discussed in an interdisciplinary team meeting in (MONTH) 2019, that the antidepressant could help stimulate the resident's appetite and improve her food intake. 2. Resident 17 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] described the resident as having moderately impaired cognitive skills and that he required extensive assistance for most activities of daily living. The medical record also noted that the resident was speech and hearing-impaired. Review of the medical record revealed that Resident 17 had a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of behavior monitoring sheets including (MONTH) (YEAR), and (MONTH) 2019 revealed that monitoring (for combativeness) was not always being conducted for days and weeks including on 12/01/18 - 12/14/18 (on the day shift), and from 12/25/18 - 12/31/18 (day shift). In addition, monitoring for side effects was not also always being conducted. During an interview on 1/29/19 regarding the lack of monitoring of problem behaviors and side effects, PH1 stated that it was something that the licensed staff had to be better at.",2020-09-01
10,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2019-01-30,761,E,0,1,IS8311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that all single use medical solutions without preservatives were used only once. Failure to use single use irrigation solutions per the manufacture recommendations could result in health care acquired infections. In addition the facility failed to store all drugs in a locked medication cart. This failure has the potential to have an unauthorized person with access to the residents medications. Findings include: 1. On 1/29/2019 a licensed nurse (LN6) was observed doing a dressing change for Resident 5 on the right buttock and sacral area pressure ulcers. Resident 5 is a [AGE] year old female who was admitted to the skilled nursing unit on 1/13/2019. Her admission [DIAGNOSES REDACTED]. The records also identified that she was totally dependent on the facility for all care. Her other [DIAGNOSES REDACTED]. Resident 5 also had a gastric tube and left heel wound. The left heel wound, the gastric tube site, the sacral pressure ulcer and the right buttock pressure ulcer were all to be cleaned initially with normal saline solution. During the sacral and right buttock pressure ulcers wound care observation, LN6 cleaned the wounds with normal saline solution then applied a wet dressing of 0.125% Dakin's solution. The wounds were then covered with a clean dry gauze and secured with paper tape. The Dakin's solution was labeled with an open date and a discard date. The 500-milliliter (ml) normal saline solution was marked with an open date of 1/28/2019. The normal saline solution was used and returned to its storage area. On 1/30/2019 another observation of Resident 5's normal saline solution occurred. The bottle of solution that had been opened on 1/28/2019 and was still being used for her all her wound or gastric tube site care. The manufactures label indicated the solution was a single use item, there was no reference stating the solution had any form of preservative or bacterial static or antibiotic nor did any label indicate that the solution could be used over multiple days. The consulting pharmacist was asked to read the label and to determine if the solution was stable and if it could be used more than one day. The consulting pharmacist validated that the solution was a single use solution and that the solution was not stable to be used over multiple days. 2. During an observation tour on the nursing unit on 1/29/2019 at 9:00 a.m., noticed an opened medication cart with the keys on top of the cart without the supervision of an authorized staff. During an interview on 1/29/2019 at 9:09 a.m., with Staff #5 she indicated that she went to answer the call light and forgot to lock the cart and take her cart keys. She also explained that usually she locks the cart and she has been in-serviced about the safety of drug storage. She validated that there were no current wondering residents on the unit. She also validated with me while the list of the twenty six medications were being recorded that there were no control drugs in the medication cart. During an interview on 1/29/2019 at 9:20 a.m., with the Staff #3 she indicated that the staff are aware of the safety of drug storage and she routinely in-service the staff. During an interview concurrent with the policy review on 1/29/2019 at 9:40 a.m., with Administrative Staff # 2 she confirmed that the staff have been in-serviced. She further explained that she will began another round of in-services on drug storage immediately. The policy titled Locking of medication Cart and Medication room Purpose is to ensure the proper method for safely locking the medication cart and medication room. 1). Medication carts shall be locked at all times when not in use. 2). Licensed staff shall carry the medication keys all times",2020-09-01
11,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2019-01-30,812,C,0,1,IS8311,"Based on observation, interview, and record review, the facility's kitchen failed to always monitor the refrigerated food temperatures. Failure to monitor refrigerated food temperatures can lead to a potential for food loss and or food-borne illness. Finding includes: On 1/28/2019, the initial tour of the kitchen was completed. On 1/30/2019, the meal service observation was completed and further investigation occurred regarding periodic failures to record the refrigerator and freezer food temperatures. The facility policy titled Storing Food and Supplies stated, Freezer and refrigerator walk-ins and reach-ins are provided with a built in outside thermometer and an inside thermometer. Temperatures are checked and recorded twice daily by cooks on duty . During an interview with the food service manager (FS1) she indicated her expectation was for temperatures to be recorded twice a day. During a concurrent record review of the walk-in chiller and walk-in freezer temperatures, FS1 manager acknowledged that on 12/21/2018 and 12/20/2018 there were failures to document the refrigerator temperature readings twice a day. Additionally, on 12/24/2018, FS1 also validated there was a failure to document the freezer temperatures twice a day.",2020-09-01
12,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2019-01-30,814,C,0,1,IS8311,"Based on observation, interview, and record review, the facility failed to ensure that the facility garbage and food waste container on the exterior of the building was covered. Failure to cover the facility garbage container had the potential to attract insects and vermin to the facility. Finding includes: On 1/28/2019 the initial tour of the kitchen was completed in the presence of the food service manager (FS1). On 1/30/2019, the meal service observation and investigation was completed near 11:45 a.m. with the all the dietary staff. During the observation FS1 was requested to show the location where the kitchen trash was located. The manager stated the exterior dumpster was the receptacle for all of the facility trash. The manager acknowledged the lid of the dumpster was off and she proceeded to replace the lid on the dumpster.",2020-09-01
13,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2019-01-30,880,F,0,1,IS8311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record, review the facility failed to operationalize its infection control program to control to prevent the spread of infections. Failure to always monitor, track, trend, and plot infections within the facility had the potential to contribute to healthcare acquired infections. Additionally, failure to follow the facility policy related to handwashing can also contribute to healthcare acquired infections. Findings include: 1. On 1/29/19, an observation of a pressure ulcer dressing change occurred on Resident 5. The staff completing the procedure were a licensed nurse (LN6) and a certified nursing assistant (CNA4). During the dressing change, the resident defecated 4 times. CNA4 was observed cleaning the bowel movement 3 of the 4 times. After she cleaned the bowel movement she removed her gloves and used a hand sanitizer but did not wash her hands. The facility policy titled hand hygiene was reviewed on that same day. The policy stated in the procedure at item H to, Perform Hand Hygiene after contact with body fluids or excretions mucous membranes non-intact skin and wound dressings. Later that day during an interview with a nursing administrative staff (LN2), she stated that CNA4 should have washed her hands rather than just using the hand sanitizer. On 1/29/2019, during an interview with the infection control prevention (IP1), it was acknowledged that an on-site visit of the contracted laundry service had not been completed within the last year or recertification period. IP1 was also unable to validate if the contracted service was washing facility laundry at the appropriate temperatures and with the appropriate cleaning agents to help prevent the transmission of infectious. 2. During a record review on 1/28/2019 at 1:00 p.m., resident #301 was admitted to facility on 3/24/18 with the [DIAGNOSES REDACTED]. Minimum Data Set (MDS) 14 day assessment completed on 4/7/18 disclosed a Brief Interview for Mental Status (BIMS) score of 14. The facility infection control program failed to monitor, track, trend and document resident #301 for the risk and benefits of receiving an antibiotic therapy as per standard of care and policy. Physician order [REDACTED]. During an interview concurrent with a record review on 1/29/2019 at 2:30 p.m., with the Administrative Staff #2 which is the acting person for infection control program at the facility and Staff #3 both acknowledged that they failed to monitor, track, trend and document on resident #301 antibiotic use upon admission. Staff #2 indicated that upon admission usually it is documented but in this case it was missed. Staff #3 also indicated that usually she monitors the residents that are receiving antibiotics but in this case it was missed on her end also. The facility data collection clinical record disclosed no evidence of the resident receiving any [MEDICATION NAME] mg twice a day from 3/24/18 - 3/31/18 and on 4/15/18 to 4/18/18 resident started on [MEDICATION NAME] 750 mg daily.",2020-09-01
14,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2017-08-24,157,D,0,1,10C511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to notify 1 resident's (R) R5, out of a survey sample of 8 residents, physician of an abnormal blood sugar before administering 2 packets of sugar. Findings include: Per clinical record review, R5 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A physician's order dated 8/17/17 noted, for the clinical staff, to do accuchecks twice a day and to administer regular insulin according to the results of the sliding scale (SS) via subcutaneous (SQ) as follows: if the resident's blood sugar was greater than 400 units to administer 20 units of Regular Insulin; if the resident's blood sugar was between 301 and 400 to administer 16 units of Regular Insulin; if the resident's blood sugar was between 201 and 300 to administer 8 units of Regular Insulin; finally, if the resident's blood sugar was greater than 150 to administer 4 units of Regular Insulin. There was no physician ordered parameters for blood sugar levels less than 149. The Medication Administration Record [REDACTED]. The Nurse's Notes dated 8/19/17 documented the following .Head of bed elevated for aspiration. Blood sugar 74 mg/dl (Milligrams per Deciliter) GT (gastrostomy tube) feeding with 2 packets of sugar added. At around 1800 (6:00 p.m.) blood sugar rechecked 102 mg/dl . There was no nursing documentation to show the physician was notified of the resident's low blood sugar nor were there any notes, from the physician, that would have directed the clinical staff to administer the resident 2 packets of sugar. An interview was conducted with Staff Member 11 on 8/22/17 at 9:05 a.m. The staff member stated she would expect that a physician's order would be in place before giving 2 packets of sugar. Staff Member 11 stated that there were also no parameters, in the electronic medical records, for notifying the physician when the blood sugar was low. An interview was conducted with Staff Member 3 on 8/22/17 at 9:15 a.m. Staff Member 3 said there should be a physician's order when the blood sugar drops low and the nurse should have called the physician when there was an abnormal blood sugar. The facility policy entitled Critical Tests and Critical Results with a revision date of 2/16, noted, .To ensure that Critical test results and critical results are identified and reliably reported to the responsible caregiver in time to meet the needs of patient care .A test that suggests a serious medical condition that may require prompt treatment. A critical result can come from a non-critical test .Within five minutes thereafter, the tech, will phone the service unit and ask to speak to the ordering physician .",2020-09-01
15,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2017-08-24,205,B,0,1,10C511,"Based on record review and interview the facility failed to ensure 1 of 8 sample residents (closed record 8) received proper notification of the facility bed hold policy on admission or during any time during the resident's stay at the facility. Failure to issue notification of information regarding the bed hold policy has the potential to infringe on the resident's rights. Findings include: On 08/23/2017 the facility policy titled Skilled Nursing Unit (SNU) Notice of Bed-Hold and Readmission Policy was reviewed. The policy indicates Upon admission and before a resident is transferred to a hospital or goes to on therapeutic leave, GMHA's (Guam Memorial Hospital Authority) Skilled Nursing Unit will provide written information to the resident and a family member or legal representative that specifies the facility Bed-Hold Policy. The policy also specifies Obtain resident, family member or legal representative sign (sic) form indicating receipt of bed-hold information. On that same date during a concurrent close record review and interview with Staff 18, she validated Resident 8's close record did not contain a signed bed-hold form and acknowledged it would be difficult to ascertain if the facility policy was followed.",2020-09-01
16,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2017-08-24,226,E,0,1,10C511,"Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent all forms of abuse, neglect, and exploitation of residents. Failure to operationalize policies and procedures that prohibit and prevent all forms of abuse, neglect and exploitation prior to initial access to residents allows of the potential opportunities for abuse. Findings include: On 08/23/2017 the facility policy titled Patient/SNU Resident Abuse, Neglect and Injuries of Known or Unknown Source (with an effective dated (MONTH) 06, (YEAR)) was reviewed and it indicates GMHA (Guam Memorial Hospital Authority)/SNU staff shall be educated regarding recognition of abuse, neglect, mistreatment and misappropriation of property, identification of victims of abuse, and the mandatory reporting duties. Staff education will take place during employee orientation, as well as in unit-specific in-service train programs and other hospital-wide training sessions. On that same date during a concurrent interview and record review of the staff training records with Staff 18 it was validated that 4 of 59 total Skilled Nursing Unit (SNU) staff failed to complete abuse training during orientation or prior to access to potentially vulnerable residents.",2020-09-01
17,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2017-08-24,241,E,0,1,10C511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and facility policy review, the facility failed to ensure that 2 stage 2 sample Residents (R)1 and R4 and 5 random residents were served meals in a dignified manner by the kitchen staff. The residents were served part of their meal in Styrofoam cups. The facility failed to ensure that R5 was provided privacy during personal care. The survey sample is 8. Findings include: 1. Per clinical record review R1 was admitted to the facility on [DATE]. Per clinical record review R4 was admitted to the facility on [DATE]. An initial kitchen tour was conducted on 8/21/17 at 9:20 am. During this tour, it was discovered that the dishwasher was broken and kitchen staff were washing dishes manually. Per interview with staff, the dishwasher was in disrepair since 6/29/17. Maintenance staff were in the process of getting dishwasher repaired during this time, and eventually purchased a new dishwasher. As of the date of this observation, the dishwasher still had not been delivered or installed. A tray line observation was conducted on 8/22/17 at 7:15 a.m. It was during this observation that a random dietary staff member placed hot oatmeal into a Styrofoam cup. An interview was conducted at 7:21 a.m. with dietary staff member 6. Staff Member 6 stated that the dietary staff communicated with her that they could only manually wash dishes, silverware, cups and not bowls. She went onto say the residents have been spoken to about the use of the Styrofoam cups and Staff Member 6 stated that residents were fine using the Styrofoam cups. A resident group interview, which included R1 and R4, was conducted on 8/22/17 at 2:00 p.m. The group of sample and random residents were asked if they were served part of their meals in Styrofoam cups. Each resident responded yes and 1 random resident gave a thumb up gesture. When asked what type of food was served in the Styrofoam cups, multiple residents stated that they were served fruit, soup, and salad in Styrofoam cups. The group stated that they were not informed by staff there would be a temporary use of the Styrofoam cups to serve meals related to the dishwasher was not in operating condition. An interview was conducted with Staff Member 3 and staff member 18 on 8/22/17 at 3:00 p.m. revealed both stated the use of Styrofoam cups instead of traditional dishware bowls was considered to be a dignity issue. The Facility policy entitled .Dignity . dated last revised as 2/16 was reviewed. There was no reference to the use of Styrofoam cups instead of dishware in the policy. 2. On 08/22/2017 the Medication Pass Observation occurred with several facility nurses. On that date Staff 20 poured all the medications for Resident 5 who was to receive her medications through her gastric tube. Prior to administering the medications Staff 20 requested the resident to pull up her gown to expose the gastric tube so placement of the gastric tube could be checked. Resident pulled up her gown above her left breast. Staff 20 then proceeded to check placement by aspirating on the tube to ascertain the presence of gastric contents. The second method Staff 20 used to check for placement was by auscultation. Staff 20 listened for placement by inserting air in the gastric tube and listening with a stethoscope for a distinct the sound created when inserting the air near the insertion site of the gastric tube. During the entire time while checking for gastric tube placement Staff 20 did not close the curtain nor did she close the door. Again, Resident 5 had pulled up her gown above her left breast. The door was open and Staff 21 had full view of what was occurring. After checking gastric tube placement and washing her hands and observing Staff 21 from across the hall Staff 20 closed the door and proceeded to administer the medications. Immediately after the Medication Pass Observation during an interview with Staff 20 she acknowledged she could have conserved the resident's dignity by closing the door or closing the curtain within the resident's room. Later that day the facility policy titled Privacy and Confidentiality (Revision date of 02/2016) When providing care for a resident, bed curtains will be drawn to provide privacy.",2020-09-01
18,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2017-08-24,253,B,0,1,10C511,"Based on observation and interview the facility failed to ensure all resident restroom water faucets were continuously operational to promote a sanitary orderly and comfortable interior. Failure to ensure all resident room water faucets are operational may potentially contribute to the spread of health care acquired infections. Finding include: On 08/21/2017 the Initial Tour of the facility, resident rooms and restrooms occurred with Staff 11. During the tour observations were made and Staff 11 tested several bed call lights, rest room call lights, toilet functionality and sink water temperature/functionality. When checking the restroom sink faucet for room 129, Staff 11 validated after several attempts, the restroom sink was non-operational. Staff 11 immediately requested that Staff 8 be informed of the nonfunctional water faucet. Later that same date Staff 8 acknowledged the nonfunctional water faucet for room 129 had been repaired; he could not validate how long the sink had been nonfunctional.",2020-09-01
19,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2017-08-24,279,E,0,1,10C511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive plan of care that was individualized for each resident to meet the resident's medical, nursing, mental and psychosocial needs identified nor did the facility update the care plan when there was a change in the resident's condition for 3 Residents (R)2, R3, R7) of 8 sampled residents. Findings include: 1. Review of the medical record for Resident (R) 3, revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the R3's care plan dated 11/10/17, with Staff Member 18 on 8/22/17 at 2:00 p.m., revealed that the facility uses the Nursing [DIAGNOSES REDACTED]. a. R3 had a care plan for constipation. Comments stated Patient is having [MEDICAL CONDITION]. The Problem statement read; Constipation: related to abdominal muscle weakness; habitual denial; habitual ignoring of urge to defecate; inadequate toileting; irregular defection habits; insufficient physical activity; recent environmental changes; depression, emotional stress, mental confusion, nonsteroidal anti-[MEDICAL CONDITION] drugs (NASAIDs), opioids, phenothiazine's, and sedatives, neurological impairment, electrolyte imbalance, hemorrhoids, Hirschsprungs's disease (a dis condition that affects the large intestine (colon) and causes problems with passing stool). pregnancy, prostate enlargement . The care plan failed to be individualized. The long-term outcome was that the Patient will maintain passage of soft formed stool every 1 to 3 days without straining; state relief from discomfort of constipation and identify measures that prevent or treat constipation. Intervention 1: included to assess usual pattern of defecation, history of bowel habits or laxative use; diet, obstetrical/gynecological history, alterations in perianal sensation. Intervention 6: included to encourage patients to resume walking and activities of daily living as soon as possible if their mobility has been restricted. Intervention 7: included to ask patients when they normally have a bowel movement and assist them to the bathroom at that same time every day to establish regular elimination. Intervention 9: included to help patients onto a bedside commode or toilet so they can either squat or lean forward while sitting. Although it had been noted in the comments section that R3 had a [MEDICAL CONDITION], there was nothing in the problem statement or in the interventions that spoke to the care of the resident's [MEDICAL CONDITION] or [MEDICAL CONDITION] care. b. R3 was admitted to the facility with an indwelling Foley catheter (a Foley catheter is a urinary catheter that collect urine from the bladder). The Foley catheter was replaced with a supra pubic catheter (suprapubic catheter is a surgically created connection between the urinary bladder and the skin which is used to drain urine from the bladder) on 7/13/17. The resident's care plan was not updated to show the change in the type of catheter that the resident had or any changes to the care the resident would have with the supra pubic catheter. 2. R7, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident went to an offsite [MEDICAL TREATMENT] facility 3 days a week for treatment. Review of R7's care plan revealed a problem statement of on-going outpatient HD ([MEDICAL TREATMENT]). The expected outcome/goal was that the resident will retain her established outpatient HD treatment as follows: Tuesday, Thursday, and Saturday, with transport via hospital transport while admitted . Intervention noted that the social worker will maintain follow-up with resident/family and providers to ensure continuity of treatment and assist coordinate necessary changes during admission. The care plan did not include any interventions for monitoring the resident's vascular access (vascular access, is a way to reach the blood for [MEDICAL TREATMENT]. The access allows blood to travel through soft tubes to the [MEDICAL TREATMENT] machine where it is cleaned as it passes through a special filter, called a dialyzer) for bleeding, signs of infection, not using the access arm for blood pressures, keeping the area clean, or checking the thrill in the access every day (the thrill is the rhythmic vibration a person can feel over the vascular access). During the review of these care plans 8/22/17 at 2:00 p.m. with Staff Member 18, the staff member confirmed that the care plans for both R3 and R7 were not individualized to meet the residents' needs.",2020-09-01
20,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2017-08-24,309,D,0,1,10C511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility policy Bowel Management dated as revised 12/15 review, the facility failed to ensure that a bowel protocol was implemented for 1 Resident (R) 4 out of a survey sample of 8. Findings include: Per clinical record review, R4 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Per clinical record review, the Nurse's Notes dated 4/21/17 noted that the resident had a bowel movement (BM) on 4/18/17. A care plan, dated 4/25/17, identified the resident would be assisted to the bathroom or use a bedpan when the resident feels the urge to have a BM. There was no indication that the resident was on a bowel protocol. The admission Minimum Data Set (MDS) assessment for R4 dated 4/28/17, Section C for cognition, identified the resident's Brief Interview Mental Status (BIMS) score was 13 which indicated that the resident was cognitively intact. Section H, for Bowel and Bladder, identified that the resident was always incontinent of bowel. Review of the clinical record for R4 included physician orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. [MEDICATION NAME] 10 mg suppository, to be administered rectally daily, as needed if no BM for 3 days. The Medication Administration Record [REDACTED]. From 5/7/17 through 10/17 and from 5/12/17 through 5/14/17 that the resident did not have a BM during this time period. There was no evidence on the MAR indicated [REDACTED]. There were no Nurse's Notes to indicate that the resident refused bowel care on these dates. On the MAR indicated [REDACTED]. There was no documented evidence, on the MAR, or in the Nurse's Notes that the resident was administered laxatives on these dates, per physician order. There were no Nurse's Notes notes to indicate that the resident refused bowel care on these dates. The MAR indicated [REDACTED]. There was no documented evidence, on the MAR indicated [REDACTED]. There were no Nurse's Notes to indicate that the resident refused bowel care on these dates. The MAR indicated [REDACTED]. There was no documented evidence, on the MAR, or in the Nurse's Notes that the resident was administered laxatives on these dates, per physician order. There were no Nurse's Notes to indicate that the resident refused bowel care on these dates. An interview was conducted on 8/22/17 at 1:35 p.m. with Staff Member 9. Per Staff Member 9, the resident has a history of refusing to take laxatives for bowel care. Staff Member 9 said that R4's refusals should be in the Nurse's Notes. The facility policy entitled, Bowel Management dated as revised 12/15 noted, .To serve as a guideline to assist nursing staff to ensure the residents in the facility do not have complications with their bowel functions .Treatment will be initiated per the following protocol .(Non-[MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) .After 48 hours without a BM, the medication nurse will give Polyethylene [MEDICATION NAME] 3350, 17 g (grams) po ( administered by mouth) in 8oz (ounces) water Daily (max 7 days) .After seventy-two (72) hours, if there is no BM, the medication nurse will administer [MEDICATION NAME] 10 mg suppository every 24 hours prn (as needed) .Residents with End Stage [MEDICAL CONDITIONS] will have the following bowel protocol .After 48 hours without a BM, the medication nurse will administer [MEDICATION NAME] 30 ml by mouth .After seventy-two (72) hours, if there is no BM, the medication nurse will administer [MEDICATION NAME] 10mg every 24 hours prn .If 4 days without a BM call attending physician .",2020-09-01
21,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2017-08-24,315,D,0,1,10C511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, Catheterization with a revised date of 2/16, the facility failed to ensure there was a physician's order, upon admission, for the use of an indwelling urinary catheter, and the care and management of an indwelling urinary catheter for 1 resident (R4). The survey sample was 8. Findings include: Per clinical record review R4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was admitted to the facility with a urinary indwelling catheter put in place during her hospital stay. Per electronic clinical record review for R4, there was no physician order for [REDACTED]. The initial admission Minimum Data Set (MDS) assessment dated [DATE] for R4, Section H for Bowel and Bladder, identified that the resident had a indwelling urinary catheter. Under the Care Area Assessment (CAA), Section V, identified that the resident triggered for urinary incontinence and indwelling catheter and directed the staff to care plan. The Skilled Nursing Unit (SNU) Interdisciplinary Plan of Care dated 5/1/17 identified R4 was to receive Foley catheter care per shift. The Medication Administration Records (MAR) were reviewed for the months of 5/17, 6/17, 7/17, and 8/17. It was documented R4 received Foley catheter changes on 5/2/17, 6/3/17, 7/2/17, and on 8/3/17. An interview was conducted with Staff Member 9 on 8/22/17 at 1:35 p.m. and she stated R4 was admitted to the facility from a local hospital with a catheter already inserted. Staff Member 9 said that the nurse should have obtained a physician's order for catheter care, French size, and identify how often the catheter should be changed. Staff Member 9 confirmed that there was no physician's order in place, in the electronic clinical record for the resident. A review was conducted of a facility policy entitled Catheterization with a revised date of 2/16. This policy failed to identify that a physician's order was required for the use of a Foley catheter, upon admission to the facility, which includes French size, and catheter care and changes made to the catheter.",2020-09-01
22,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2017-08-24,318,D,0,1,10C511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure 1 of 8 sample residents (Resident 2), a resident with limited range of motion, receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion (ROM). Failure to provide services to increase and/or prevent a further decrease in ROM may potentially contribute to worsening of contractures. Findings include: Resident 2 is a [AGE] year old female admitted into the facility on [DATE]. The record reflects some of her [DIAGNOSES REDACTED]. Resident 2 was interviewed on 08/21/2017 and she acknowledged that she had been admitted into the facility with contractures. During further investigation on 8/22/2017, Resident 2 denied consistently receiving ROM exercises 2-3 times a week to her lower extremities. The resident assessments dated 05/10/2017 and 07/23/2017 show both Brief Interviews of Mental Status resulted in a score of 15 indicating the resident is cognitively intact. Both assessment also show the resident has a functional limitation in range of motion to both lower extremities. On 08/23/2017 during a concurrent record review and interview with Staff 18 it was validated: Resident 2 was admitted with lower extremity contractures; that the resident's assessments confirmed the contractures; that no nursing care plan existed to maintain or prevent the worsening of the lower extremity contractures; and, that the Recreational Therapy (RT) notes did not reflect that the patient was receiving ROM exercises 2-3 times each week to improve the contractures and mobility as outlined in the RT care plan. On 08/23/2017 during a concurrent interview and record review of the Recreational Therapy notes with Staff 4 it was validated that the RT care notes did not reflect that the patient was receiving ROM exercises 2-3 times each week to improve contractures or prevent the worsening of the contractures as outlined in the RT care plan",2020-09-01
23,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2017-08-24,431,E,0,1,10C511,"Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were secure. Failure ensure all drugs and biologicals are secure has the potential for a mishap should a resident, visitor or anybody else happen to ingest any unsecured medications. Findings include: On 08/22/2017 the Medication Pass Observation occurred with several facility nurses. During the medication pass observation for Resident 5 Staff 20 poured the mediations at the entrance of the resident's room then, before administering the medication Staff 20 pushed the medication cart to the nurse's station. The staff member left the poured medications for Resident 5 on top of the cart and departed to check on some information. During the period of time for this observation Staff 20 did not request for another staff member to monitor the unsecured medications left on top of the mediation cart. After returning to the nurse's station, Staff 20 proceeded to push the medication cart back to Resident 5's room and administered the medications. Immediately after the Medication Pass Observation during an interview with Staff 20 she acknowledged she no control of what could have happened to the unsecured poured medications that were left on top of the cart. Later that day during a concurrent interview and record review with Staff 3 and Staff 18 regarding the facility policy titled Locking of Medication Cart and Medication Room (Revision date of 02/2016) it was acknowledged that is the facility's expectation for staff to keep medications secured at all times.",2020-09-01
24,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2017-08-24,441,F,0,1,10C511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of the facility policy MANAGEMENT OF PATIENTS WITH EPIDEMIOLOGICALLY SIGNIFICANT ORGANISMS (E.[NAME]MULTI-DRUG RESISTANT ORGANISMS, METHICILIN RESISTANT STAPH AUREUS, and [MEDICATION NAME] RESISTANT [MEDICATION NAME] (VRE), last revised in (YEAR), the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of diseases and infection. This had the potential to affect all resident in the facility and observation revealed the facility failed to follow policy and procedure to prevent the spread of infection for 2 of 8 sampled Residents (R)1 and R4. Findings include: 1. Interview with Staff Member 3 who is the assigned infection control nurse for the skilled nursing unit on 8/23/17 at 8:55 a.m., revealed that she did not have an infection control log to show which residents have infections, where the infection is located, symptoms, any tests that were done, or antibiotics given. The facility also was unable to provide any documentation to show tracking and/or trending of infections. Review of the facility policy titled, MANAGEMENT OF PATIENTS WITH EPIDEMIOLOGICALLY SIGNIFICANT ORGANISMS (E.[NAME]MULTI-DRUG RESISTANT ORGANISMS, METHICILIN RESISTANT STAPH AUREUS, and [MEDICATION NAME] RESISTANT [MEDICATION NAME] (VRE), last reviewed in (YEAR), revealed that the purpose of the policy was to provide guidance on preventing the spread of epidemiologically significant organism infection transmission from patients to other patients, personnel and visitors. Section 4 speaks to personal protective equipment with the following guidelines; a. Gloves: wear gloves upon entry for all interactions i. Minimize touch contamination with use of gloves. ii. Remove gloves and wash hands in between procedures or after contact with material that could contain high concentrations of the MDRO (multi drug resistant organisms). iii. Remove gloves and wash hands prior to leaving the patient's room. b. Isolation Gown: i. Gowns much be donned upon entry for all interactions. ii. Remove gown before leaving the patient's room and immediately wash hands with an antiseptic soap or a waterless antiseptic agent. 2. The facility uses an educational handout for the patient/family/visitors. There are two copies, one is kept by the facility and the other is given to the patient. The form notes, In the hospital, we work to prevent the spread of germs that can cause infections. This is both to help patients from getting sicker while they are in the hospital and to prevent any patient's illnesses from spreading to the staff and other patients. If you are placed in isolation, it is because you may have a germ that can spread easily in the hospital setting. In some cases, you may be contagious even if you do not feel sick. An isolation sign will be placed on your door asking all who enter to wear gloves and gowns when they enter your room. Instructions: Everyone entering must wear gloves and an isolation gown prior to room entry. Visitors are RESTRICTED. Watcher/support person is required to wear an isolation gown and gloves upon room entry and for the duration of stay in the patient's room. A watcher/support person should not be present if they are sick. Everyone (Staff/Watcher/Support Person) must hand wash or use alcohol hand rub before entering and before leaving the room. The patient and family sign this form noting that they have been given education regarding instructions for isolation. Observation of a visitor for Resident 1 on 8/22/17 at 1:55 p.m., revealed that the visitor stopped at the nursing station and then went to the resident's room. Staff member 13 was not aware of who the visitor was, and went to ask, noting that it was a family member. The visitor put on gloves and entered the room. When questioned by the surveyor as to the visitor not wearing a gown, Staff Member 13 said that visitors only have to wear gloves if just talking to resident. Staff Member 13, went to the resident's room to talk to the visitor and came back to the nursing station and said that the visitor said she would only talk with the resident. Observation also noted that the visitor did not wash her hands or use an alcohol hand rub prior to entering the room. 2. A physician's order dated 4/21/17 was in place for R4 to be placed on contact isolation precautions related to [DIAGNOSES REDACTED], from her buttocks to her groin. A care plan, dated 4/22/17, identified that R4 was on contact isolation and the clinical staff would monitor staff, resident and family members for compliance, with proper hand washing, proper donning (putting on) of gown and gloves. An observation was conducted outside of the room of R4 on 8/22/17 at 7:30 a.m. Staff Member 19 was observed in the resident's room, without a gown and gloves, and had placed the resident's meal tray on her bedside table. It was also during this observation, that the resident was served her meal on a regular tray and dishes. These items were not disposable. This staff member was observed to wash her hands prior to exiting the resident's room. The staff member was interviewed immediately after this observation and Staff Member 4 said that there were no gowns present in the drawers. The drawers sat on the outside of the resident's room. An observation was made of the contents of the drawers and there were blue gowns present. During this observation period, there was a sign located on the outside of R4's room which stated the following, .Everyone entering must wear gloves and an isolation gown prior to room entry . A second observation was made on 8/22/17 at 7:50 a.m. with Staff Member 4. Staff Member 4, entered the room of the resident without donning a gown or gloves. When the staff member was asked why she did not don a gown and gloves, she stated that she did not touch the resident. An interview was conducted with Staff Member 18 on 8/22/17 at 9:31 a.m. Staff Member 18 stated that any time a resident is on contact isolation, they should be served on disposable trays and dishes. Another interview was conducted with Staff Member 18 on 8/22/17 at 9:40 a.m. Staff Member 18 stated that staff should follow the guidelines as identified on the contact isolation sign located on the outside of a resident's room. Staff Member 18 said anytime a staff member enters an isolation room, they should don a gown and gloves. An interview was conducted with Staff Member 6 on 8/22/17 at 10:01 a.m. Staff member 6 said that the kitchen has not served any resident who is on contact isolation with disposable trays. The dishwasher was out of service at the time of the survey. Dishes were being washed by hand.",2020-09-01
25,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,241,E,0,1,H7FJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that residents were treated with dignity and respect residents' individuality for 3 of 10 sampled residents (Residents 3, 4, and 5). Findings include: 1. On [DATE] at 2:30 p.m., during an interview, Resident 4 complained about the facility's slow response to call light when he calls for assistance. The resident indicated that at one instance he needed to be changed and he had to wait for a long time. Review of a nurses' progress notes dated [DATE] at 20:41 revealed that at 1730, a licensed nurse went to the resident's room to give his medicine and the resident was so mad and cursed the nurse. Resident 4 refused to take his medication because he was wet, pointing his diaper. The licensed nurse documented, I told him I will call (name of assigned CNA) to help you. Review of Resident 4's latest quarterly assessment dated [DATE] revealed the resident has a Brief Interview of Mental Status (BIMS) of 9 indicating moderate impairment of cognitive skills. Also the resident's functional status for toilet use was extensive assistance with one-person physical assist. Although the resident was identified as always continent of urine, he was assessed as frequently incontinent of bowel. This was confirmed by a licensed nurse (LN1) during the initial tour of the facility on [DATE] at 10:40 a.m. LN1 indicated that the resident uses the urinal located at the resident ' s bedside. Review of the resident council meeting minutes dated [DATE] revealed an old business related to resident concern indicating that a resident called for help and it took them more than 20 minutes. The resident ended up having to call anyone else out there. The facility's corrective action revealed that the Unit supervisor has discussed the issues with her staff at the monthly staff meeting and reminded them of the importance of responding to resident call lights and bedside manners. Review of the resident council meeting minutes dated [DATE] revealed a nursing issue that stated, they (nurses) moved my (call) bell too far away from my reach after I rang it. The corrective action revealed, Nurse Aides will ensure all call bell/switches are well within reach for each resident. There was no indication of how the facility will monitor the implementation of the corrective actions formulated to ensure that staff response to resident calls will be addressed accordingly. On [DATE] during lunch meal observation Resident 4 stated that food spills from the disposable Styrofoam plate because it was slippery. The latest quarterly assessment dated [DATE] revealed the resident was independent with setup help only with eating indicating the resident needed no help or staff oversight at any time. On [DATE] at 12:15 p.m. the resident was observed up in the dining area eating lunch. The resident's plate was a styrofoam disposable container with a cover used for takeout food items. The resident stated that type of container held the food better but he preferred to eat using a regular plate. On [DATE] at 12:10 p.m. Resident 4 stated that he was told by a nurse that he should not be calling for assistance because a resident has expired that time. The resident kept asking the identity of the resident who expired. Further investigation confirmed that another resident in the unit expired that time. LN1 indicated that services continue to be delivered to all the residents in the facility regardless of a death event. 2. On [DATE] at 8:30 a.m. during breakfast meal observation, Resident 5 was observed in his room eating pureed meal with foamy liquid at the side of his mouth. A nurse at the hallway was notified and assisted the resident in suctioning his mouth by himself. Review of the resident's electronic record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the latest assessment dated [DATE] revealed the resident has a BIMS of 15 indicating that he was cognitively intact and he was totally dependent with one person physical assist with eating. Interview with LN1 revealed the resident receives a pureed diet for oral pleasure in addition to tube feedings four times a day. Interview with a licensed nurse revealed the resident is capable of eating independently once the tray is set up next to him. The resident was observed using his back scratcher to lift the lid of the disposable styrofoam plate to access the pureed food served. 3. Resident 3 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The most current quarterly MDS (minimum data set) assessment dated [DATE] described the resident as having no short or long term memory problems, had intact cognitive skills for daily decision making, and had no mood, [MEDICAL CONDITION], or behavioral problems. During the initial tour on [DATE], a licensed facility staff (LN6) described the resident as alert and oriented but non-verbal as a result of the stroke, and able to communicate or make his needs known by gestures. During the same initial tour, Resident 3 was observed in a wheelchair wearing a hospital gown that was open at the top exposing his upper back. This same observation was made throughout the survey. While the resident went up and down the hallway in his wheelchair, or spent time in the day room watching TV with other residents, none of the staff intervened to protect the resident and ensured that he was fully covered. 4. During the survey, residents were also observed wearing hospital gowns at all times while they were in bed or in the day room. None of the residents were observed wearing their own personal clothing even while they were around visitors or other residents and during meals or group activities. There was no indication that residents were being offered to wear their own clothes in a home-like environment instead of an institutional setting. (Reference Residents 3 and 9) During an interview on [DATE], Resident 3 shrugged his shoulders as a response to why he was not wearing his own clothing. When the question was repeated, the resident shook his head side-to-side indicating that he did not know. 5. During meal observations including those made on [DATE] and [DATE], residents were observed eating their meals using disposable Styrofoam plates and food containers, and plastic eating utensils. During the lunch meal observation on [DATE], Resident 3 was observed eating pureed fruit straight out of the disposable Styrofoam cup, raising the cup over his mouth and waiting until the last of the fruit was gone. When asked why he wasn't using the spoon, the resident was unable to respond verbally. During the meal, the resident was also observed having some difficulty eating from the Styrofoam container because it was too light and the plate would slide especially when the resident would scoop food against the sides. The resident could not use his other hand to keep the container in place because of the [MEDICAL CONDITION]. During the kitchen/trayline observation (on [DATE]), a dietary staff worker (DS01) stated that the facility's dishwasher was broken and that disposable Styrofoam containers and plates, and eating utensils were being used instead. DS01 stated that the dishwasher had been broken for months. In a separate interview on [DATE], a maintenance staff member (MS1) stated that the dishwasher's booster pump was broken and that the required water temperature to adequately sanitize the plates could not be reached. In the same interview, MS1 stated that the dishwasher had been broken since (MONTH) (YEAR).",2020-09-01
26,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,248,E,0,1,H7FJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental and psychosocial well-being of each resident for four (4) of 10 sampled residents. (Residents 3, 4, 5 and 9). Findings include: 1. Resident 4 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the initial assessment dated [DATE] revealed that Resident 4's activity preferences included having books, newspapers and magazines to read; keeping up with the news; listening to music he liked; doing things with groups of people; going outside to get fresh air when the weather was good; being around animals as pets, and participating in religious activities. Resident care plan dated 1/12/16 revealed a problem of activity deficit - little or no involvement in activities. Comments documented include for the patient to have at least one enjoyable activity to participate in throughout stay, and also to participate in socialization with staff or friends/family members when demonstrating appropriate behavior at least once a week. The care plan outcome noted: Will participate in activities ___ times per ___. Interventions documented: Review level of activity prior to change in health status by talking with Family/Representative/Resident; Explain importance of social or relaxation or leisure activities; Advise daily of activities available and invite to participate; Offer a variety of both in and out of room activities; also allow resident to make choices; Ask family or representatives to encourage activities and to accompany resident in activity. From 9/26/16 to 9/29/16 during the days of the survey, Resident 4 was observed staying in the room most of the time and occasionally going to the dining/activity room to have lunch. On 9/26/16 at 10:45 a.m. to 12:00 p.m., the resident was observed to remain in his bed taking naps at intervals. Review of the activity calendar for September, (YEAR) revealed current events occurred at 10:00 a.m., and at 1:00 p.m. visits/social hour was scheduled. Interview with Resident 4 on 9/26/16 at 2:15 p.m. revealed that he did not participate in those activities. In another interview on 9/28/16 at 12:10 p.m., the resident stated that he didn't have any family members to visit him and that he wanted to talk to his ex-wife to ask her opinion about the surgery. On 9/29/16 at 10:45 a.m. during an interview with activity staff (AS)2, she stated that Resident 4 refused to join the activities and stayed in his room most of the time depending on his mood. AS2 added that activity staff provided room visits and try to engage him in conversations. Review of recreational therapy notes however, revealed the lack of documented evidence that a variety of activities were offered to the resident to meet his activities preference. 2. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the latest assessment dated [DATE] revealed the resident had a BIMS of 15 indicating that he was cognitively intact, was totally dependent, and required one person physical assist with bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. The last annual assessment dated [DATE] revealed the following activity preferences as very important to the resident: having books, newspapers and magazines to read; keeping up with the news; listening to music he liked; doing things with groups of people; going outside to get fresh air when the weather was good, and participating in religious activities. Review of the resident's care plan dated 6/09/15 revealed a problem of activity deficit - little or no involvement in activities. The comments documented: Patient (Pt.) always active texting on his phone. Incorporate card games, exercise and sunshine into 1:1 visits. On 9/26/16 at 10:50 a.m., during the initial tour, the resident was observed in bed inside a dark resident room with all window curtains drawn. The resident was awake and communicated by text messages using his personal cell phone. The resident was observed with right upper extremity contracture and able to move his left hand. On the days of the survey from 9/26/16 to 9/29/16, Resident 5 was observed in bed inside his room with the radio on at times and/or texting on his phone. On 9/29/16 at 10:30 a.m., AS2 stated that they take Resident 5 outside of his room by bed to enjoy good weather at least once a month. AS2 added that he did not join group activities in the dining/activities room but that 1:1 room visits were done on regular visits. 3. Resident 9 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The most current MDS dated [DATE] described the resident as having short or long-term memory problems and that she was dependent on staff for most activities of daily living (ADLs). While the same MDS noted that the resident had severely impaired cognitive skills for daily decision making, recreational therapy notes dated 9/17/16, however, described Resident 9 as awake and alert, able to follow simple commands, and can understand word but having (a) hard time to constructing words. Review of the medical record revealed that while there was lack of indication that Resident 9 was bedbound, Resident 9 during the survey was always observed in bed sleeping or looking out to the hallway when repositioned on her right side. During an interview on 9/28/16, a licensed staff (LN7) stated that the resident did not want to get out of bed but received 1:1 visits in her room (at the bedside) with recreational therapy staff. Further record review revealed that while the resident refused to get out of bed, and engaged in isolative behavior, there was no indication that attempts to determine the reasons for the refusal (to get out of bed) were made. In the same interview on 9/28/16, LN7 added that when the resident was brought to the nursing station in her wheelchair where she stayed for several minutes, the resident had tears in her eyes. She was then, according to LN7 returned to her bed. While recreational therapy notes described room visits and activities provided such as read newspaper for current event, socialization for self awareness on day, time, and the weather for today, assisting in grooming, setting up meal tray, and providing range of motion exercises, there was no documentation whether the activities were meaningful to the resident and met the resident's psychosocial needs as well as needs for recreation and diversion. Review of the admission MDS dated [DATE] for example, revealed the lack documentation that an assessment of the resident's customary routine and preferred activities was conducted, or that the resident's family members were involved in eliciting information to determine past or present preferences. In addition there was no evidence that an activity care plan was developed to identifying goals and objectives to be achieved. Without the assessment and care plan, any interaction or activity provided could not be determined whether it was meaningful or effective. 4. Resident 3 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The most current quarterly MDS (minimum data set) assessment dated [DATE] described the resident as having no short or long term memory problems, had intact cognitive skills for daily decision making, and had no mood, [MEDICAL CONDITION], or behavioral problems. During the initial tour on 9/26/16, a licensed facility staff (LN6) described the resident as alert and oriented but non-verbal as a result of the stroke, but was able to communicate or make his needs known mostly by gestures. Review of the annual MDS assessment dated [DATE] revealed that while an interview was not conducted, an assessment by staff noted the resident's daily and activity preferences included listening to music and doing things with groups of people. In addition, a care plan developed (initially dated 6/09/15) for activity deficit noted that the resident had little or no involvement in activities. During the survey, the resident was often observed alone and engaged in solitary activities, On 9/27/16 for example, after Resident 3 was observed in the day room in front of the television set for about 20 minutes, he was found wheeling himself up and down the hallways several times from the day room to the dining room stopping only to briefly look outside into the courtyard. When asked how he was doing and whether he was doing exercises, the resident was unable to verbally respond but shook his head to indicate no. During meal observations, the resident was also observed eating in the dining room by himself separate from other residents. Review of recreational notes revealed that while observations were being documented regarding the resident eating meals in the dining room, going out for sunshine, and watching television (on 9/26/16); performed conditioning exercises, observed in the courtyard, observed singing and praying, and watching TV (on 9/17/16); and observed wheeling himself around unit in outdoor sunshine, spending most of his time in the day room watching television, and going in and out of the recreation room (on 9/03/16); the documentation did not always include any group or organized activity attended, the length of time, whether the resident was an active participant or a bystander, and whether it met the resident's needs for psychosocial stimulation, recreation, or diversion. Further record review revealed that while the same care plan (dated 6/09/15; revised 8/10/16) identified an outcome that the resident will participate in activity or activities 2 times per week, it did not, however, address whether the activities provided were designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of the resident.",2020-09-01
27,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,250,D,0,1,H7FJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not provide medically-related social services to enable the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Finding includes: Resident 9 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The most current MDS dated [DATE] described the resident as having short or long-term memory problems, with severely impaired cognitive skills for daily decision making, and was dependent on staff for most activities of daily living (ADLs). The MDS also noted that the resident did not have any mood or behavior problems. Review of the medical record also revealed the the lack of any indication that Resident 9 was bedbound. During the survey, Resident 9 was always observed in bed sleeping or looking out to the hallway when repositioned on her right side. In an interview on 9/28/16, a licensed staff (LN7) stated that the resident did not want to get out of bed but received 1:1 visits in her room (at the bedside) with recreational therapy staff. In separate interviews on 9/28/16, two recreational therapy staff members (AS1, AS2) stated that as far as they can remember, Resident 9 had been out of bed only twice since admission. Both AS1 and AS2 added that Resident 9 did not want to get out of bed but received 1:1 visits instead. AS1 and AS2 stated that they did not know why the resident preferred to stay in bed in her room. Further review of the medical record revealed that in spite of the isolation and refusal to get out of bed, there was no evidence of social services participation in determining the cause of the behavior or in identifying potential functional and/or psychosocial factors, and correlating these with her [DIAGNOSES REDACTED]. On 4/12/16, another RT note revealed that Resident 9's spouse who was admitted with a [DIAGNOSES REDACTED]. In the same interview on 9/28/16, LN7 stated that Resident 9's spouse subsequently passed away thereafter. Notwithstanding, there was no social services documentation of this significant loss in the medical record, as well as Resident 9's life-changing event and functional deficits as a result of the stroke. There was no indication that referrals to other healthcare professionals for guidance, counseling and/or other interventions were explored or considered in spite of the [DIAGNOSES REDACTED].",2020-09-01
28,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,279,D,0,1,H7FJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not develop a comprehensive plan of care for each resident to meet the resident's medical, nursing, mental and psychosocial needs identified in the initial assessment for one of 10 sampled residents (Resident 6). Finding includes: Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the printed skilled nursing unit's (SNU) Admission Assessment form dated 9/22/16 lacked information related to over all condition of the resident upon admission. On 9/28/16 a handwritten Assessment form dated 9/21/16 timed at 10:35 p.m. was presented. The assessment revealed the resident was lethargic and verbally non-responsive, and that the information was obtained from the resident's husband. The resident had a [MEDICATION NAME] lock as an intravenous access on the right hand and an indwelling catheter on admission. She was also identified as totally dependent for all activities of daily living. The resident's code status was Do Not Resuscitate (DNR). A pain assessment revealed the presence of generalized mild pain on movement. There was also the presence of a Stage 2 pressure ulcer on the left buttocks upon admission. The assessment form identified the following problems: acute pain, alteration in tissue perfusion, alteration in nutrition, risk for aspiration, risk for constipation, impaired gas exchange, and impaired skin integrity. The nursing [DIAGNOSES REDACTED]. As a newly admitted resident that had been in the facility for less than 14 days, the facility identified a problem list for the resident's special needs, however, an individualized plan of care was not initiated to address each of the problem area identified. On 9/26/16 at 11 a.m., during the initial tour the SNU's nursing supervisor revealed that Resident 6 has been designated as comfort care due to metastatic [MEDICAL CONDITION]. On 9/27/16 during a concurrent review of the resident's plan of care, she confirmed the absence of an individualized plan of care to address the identified needs of the resident such as pain management, intravenous therapy, pressure ulcer and comfort care.",2020-09-01
29,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,286,E,0,1,H7FJ11,"Based on observation, interview, and record review, the facility did not maintain all minimum data set (MDS) assessments completed within the previous 15 months in the resident's active record. Finding includes: Review of medical records revealed that completed MDS assessments were not always available in the resident's active medical records. While a request for the assessments were made following the initial tour on 9/26/16, the documents were then made available only in the afternoon on 9/27/16 at about 3:00 p.m. when a request was made to print them for residents in the sample whose assessments were missing. During an interview on 9/27/16, a licensed staff (LN1) stated that the MDS assessments were not part of the electronic medical records and was maintained in a separate database accessible only by designated staff person who had the administrative rights to print the documents. (Reference Residents 1 through 5, Resident 7 through 11).",2020-09-01
30,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,315,D,0,1,H7FJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the resident's comprehensive assessment, the facility must ensure that a resident who entered the facility without an indwelling catheter was not catheterized unless the resident's clinical condition demonstrated that catheterization was necessary; and a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. (Reference Residents 2 and 9) Finding includes: 1. Resident 9 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The most current MDS dated [DATE] described the resident as having short or long-term memory problems, with severely impaired cognitive skills for daily decision making, and was dependent on staff for most activities of daily living (ADLs). The MDS indicated that the resident did not have an indwelling catheter. During the initial tour on 9/26/16, Resident 9 was observed in bed with a urinary tubing and drainage bag at the bedside. In an interview after the tour (on 9/26/16) a licensed staff (LN6) stated that Resident 9 had an indwelling catheter. Review of the medical record revealed a physician's orders [REDACTED]. Review of progress notes revealed that the resident had an episode of [MEDICAL CONDITION] prompting insertion of the catheter. Further record review however revealed the lack of indication that an evaluation of the use of the indwelling catheter was conducted or that a referral to appropriate health care professionals was considered to determine the cause of the retention and whether continued use of the device was warranted. A physician's progress note dated 5/25/16 revealed the lack of mention of the catheter or any other urinary problems. In addition, the MDS dated [DATE] revealed the lack of an active urinary problem (or diagnoses) that required use of the catheter. Review of the medical record further revealed that a care plan for the use of the indwelling catheter was not developed until 8/29/16. While one Outcome of the care care plan noted that the resident will tolerate discontinuation of the catheter with at least 250 ml. of output every shift, there was no indication that a trial removal was conducted. During an interview on 9/28/16, a licensed nurse (LN1) stated that an attempt to remove the catheter might have been conducted but was unsuccessful. When a request was made to provide documented evidence, LN1 responded that the information could not be located. 2. Resident 2 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE] revealed that the resident had severe cognitive impairment with a BIMS (brief interview of mental status) score of 3, and that she was dependent on staff for all activities of daily living. The same MDS noted that the resident was admitted with an indwelling urinary catheter. Review of the medical record revealed the lack of documentation of the indication for the use of the catheter. The was no mention of an active [DIAGNOSES REDACTED]. During an interview on 9/27/16, a licensed staff (LN8) stated that a pressure sore might have been the indication for the use of the catheter. Review of the medical record however revealed that while a pressure sore was described as healing in nurses progress notes on 8/26/16, there was no evidence that an evaluation of the continued use of the catheter was conducted. In the same interview on 9/27/16, LN8 stated that a trial to discontinue the catheter might have been conducted; but further review of the medical record revealed that lack of documentation of the attempt or of any outcome.",2020-09-01
31,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,322,D,0,1,H7FJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that a resident who was fed by a gastrostomy tube received the appropriate treatment and services to restore normal eating skills for one of 10 sampled residents (Resident 5). Finding includes: Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the latest MDS assessment dated [DATE] revealed the resident had a BIMS of 15 indicating that he was cognitively intact and totally dependent and required one person physical assist with bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. On 9/26/16 at 10:50 a.m., during the initial tour, the resident was observed in bed inside a dark resident room with all window curtains drawn. The resident was awake and communicated by text messages using his personal cell phone. The resident was observed with right upper extremity contracture and able to move his left hand. On 9/27/16 at 8:30 a.m. during breakfast meal observation, Resident 5 was observed in his room eating pureed diet with foamy liquid at the side of his mouth. A nurse at the hallway was notified and assisted the resident in suctioning his mouth. Review of the latest quarterly assessment dated [DATE] revealed the resident had a BIMS of 15 indicating that he was cognitively intact and he was totally dependent with one person physical assist with eating. The active [DIAGNOSES REDACTED]. He was noted as having no signs and symptoms of swallowing disorder and had no weight loss in the last 6 months. He was described as having an abdominal feeding tube (PEG) and was receiving mechanically altered diet (pureed food). The resident received 51% or more proportion of total calories and an average fluid intake of 500 cc/day or more through tube feeding. Review of the dietetic technician's latest documentation dated 9/12/16 revealed the following: Recommended enteral feeding: Glucerna at 4 cans per day and pureed diet with honey-like liquids for pleasure feeding. Patient receiving an average of 4 cans per day from 9/2/16 per MAR (medication administration record). Total calories consumed 1000 kcal/day from [MEDICATION NAME] d/t (due to) NIS (not in stock) Glucerna and additional kcal from pleasure feeding meals. Total protein consumed 44 gm/day [MEDICATION NAME] d/t NIS Glucerna and additional protein from pleasure feeding meals. Additional documentation revealed that the estimated nutrient needs according to the registered dietitian (RD) was: 1525 - 1830 kcal (25-30 kcal/kg actual body wt. 61 kg); 49-61 gram protein (1.2 g pro/kg); and that based on the CNA flowsheet, the patient consumed 25% of pleasure eating. Further review of the resident's electronic record revealed that the resident was last seen by the RD on 11/29/15. The RD notes stated: Current weight 58.2 kgs. Patient remains to be nutritionally stable. On [MEDICATION NAME] 4 cartons per day plus puree diet per orem. Weight is considered stable. No issues with BM (bowel movement) and no sick day for the month. To continue with same diet regimen. The date of the last RD1 evaluation was confirmed by RD2 after making a telephone call with RD1 on 9/29/16. Review of the speech therapist's (ST) evaluations in the hospital were last conducted on 2013 and 2014. As of 11/12/13 the ST notes indicated that the resident did well, tolerated oral trials of puree and oral trials of regular thin liquids with no overt s/s (signs and symptoms) of laryngeal penetration, and that swallowing appeared to be intact. The speech therapy weekly note dated 1/02/14 indicated the patient continued to improve. The last hospital speech therapy note dated 1/17/14 revealed documentation on working with the resident's speech and how the patient continues to prefer pad and pen to communicate. Review of the resident's care plan dated 7/12/15 revealed a problem: Patient has been on TF (tube feeding) for several months and still not weaned from it. Outcome: reduce the amount of tube feeding and increase oral feeding. Intervention: will increase puree items in tray and monitor oral intake. On 5/16/16, the speech-language initial note revealed that the rehab order for swallow re-evaluation was acknowledged. However, the resident refused to attempt the evaluation to advance his diet. Gestured by holding throat that the current diet is ok and didn't want to try nectar like thickened liquids as well as the mechanically chopped solids. Pt. (patient) currently has Peg. Will defer BSA when Pt complies to participate in test at next work session. On 9/28/16 at 10:00 a.m. interview with LN1 revealed that the resident received a pureed diet for oral pleasure in addition to tube feedings four times a day. She also indicated the resident was currently capable of eating independently once the tray was set up next to him and had not exhibited any signs and symptoms of aspiration. LN1 stated that the resident continued to have the tube feeding because the resident did not get enough calories from the pureed diet served for pleasure meals. However, it was confirmed that there were no attempts to reduce the tube feeding solution given and increase the amount of puree items in his meal tray to increase his oral intake as indicated in the resident's care plan.",2020-09-01
32,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,325,D,0,1,H7FJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that the resident maintained acceptable parameters of nutritional status, such as body weight unless the resident's clinical condition demonstrated that this was not possible. Finding includes: Resident 3 was readmitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The most current quarterly MDS (minimum data set) assessment dated [DATE] described the resident as having no short or long term memory problems, had intact cognitive skills for daily decision making, and had no mood, [MEDICAL CONDITION], or behavioral problems. During the initial tour on 9/26/16, a licensed facility staff (LN6) described the resident as alert and oriented but non-verbal as a result of the stroke, and able to communicate or make his needs known by gestures. Review of the quarterly MDS (dated 8/04/16) revealed that Resident 3 was noted to weigh 119 lbs (with height of 65 ins). Review of dietary notes including dietary tech notes dated 8/24/16 revealed that Resident 3 consumed between 75 - 100% of his meals. During two meal observations conducted on 9/27/16 and 9/28/16, the resident was observed eating without need for any assistance and consumed most of his meals, a 2000 Kcal, 75-gm carbohydrate controlled diet. In an interview on 9/27/16, a dietary staff member (DT10) stated that Resident 3 had no problem eating in spite of his [MEDICAL CONDITION] and usually consumed most of his meals. Review of the medical record revealed that while weights were being taken and recorded, there was no documentation during the current admission that an acceptable parameter for determining nutritional adequacy, such as body weight, was established for Resident 3. Review of the dietary tech note dated 7/13/16, for example, noted Resident 3's weight as being 127 lbs on 3/02/16; 122 on 4/16/16; 138 on 4/26/16; 130 on 6/01/16; 118 on 6/16/16; and 123 lbs on 7/09/16. While the same note added that the fluctuating weight changes (were) based on the height and weight flowsheet, and the patient's good food intake, determining whether Resident 3 had achieved an adequate or desired level of nutritional status could not be made. And while care plans were developed for the problem that Resident 3 needs a therapeutic diet (dated 6/15/16), and decreased ability to chew and/or swallowing (dated 6/15/16), whether or not Resident 3's body weight was ideal and was his highest practicable level, was not addressed because a parameter had not been identified. Review of the medical record from a previous admission revealed that during an assessment by the registered dietitian on 12/24/13, Resident 3's ideal body weight (IBW) was noted to be 140 lbs. Further review revealed that Resident 3 had not been evaluated by a registered dietitian since 11/29/15.",2020-09-01
33,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,329,D,0,1,H7FJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used without adequate monitoring or without adequate indication for its use or in the presence of adverse consequences which indicate the dose should be reduced or discontinued, or any combinations of the reasons above. (Reference Residents 4 and 8) Findings include: 1. Resident 8 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the discharge summary from the hospital dated 5/17/16 revealed that the resident had a history of [REDACTED]. One of the discharge medications listed from the hospital was [MEDICATION NAME] (an antipsychotic drug) 1 milligram (mg.) three times a day as needed for agitation. Review of the initial admission minimum data set (MDS) - an assessment tool dated 5/24/16 revealed that the resident had short and long term memory problems, and that his cognitive skills for daily decision making was severely impaired. The resident had unclear speech and was rarely/never understood, however, he sometimes understands. He also had severely impaired vision and had no corrective lenses. The resident exhibited no mood or behavior problems. The resident was identified as totally dependent with one person physical assist for all activities of daily living (ADL). He was also noted as always incontinent of bowel and had an indwelling urinary catheter due to Stage IV pressure ulcer in the sacrum. He was admitted with multiple pressure ulcer acquired from home and had post debridement of the ulcer from the hospital. The latest quarterly MDS dated [DATE] revealed no significant change from the admission MDS. On 9/26/16 at 10:40 a.m., during the initial tour, Resident 8 was in bed and non-verbal and had an indwelling urinary catheter with clear urinary output. LN1 indicated that the resident was getting ready for discharge to home. The resident had a history of [REDACTED]. On the same day, 9/26/16, Resident 8's yelling was heard in the hallway and nurses station. Review of nurses notes dated 6/15/16 revealed that Resident 8 was agitated at 2:00 a.m., and that staff repositioned patient (pt.), offered milk and adjust lighting in room, still talking in loud voice, [MEDICATION NAME] 1 mg. po PRN given, with relief. pt able to sleep. On 7/6/16, the pharmacist's medication regimen review (MRR) revealed that the agitation/[MEDICAL CONDITION] medication, was dose appropriate for indication, behavior monitoring in MAR indicated [REDACTED]. The active medication order as of 7/6/16 was [MEDICATION NAME] ([MEDICATION NAME]) 1 mg. by mouth (po) three times a day (TID) as needed (PRN) for agitation. Gradual dose reduction (GDR) was recommended by the pharmacist and the physician agreed with the GDR to [MEDICATION NAME] 1 mg. po once daily (QD) PRN for agitation. On 8/18/16 the MRR revealed the GDR was complete to no active order. 1 dose since admit, continue behavior monitoring in Medication Administration Record [REDACTED]. On 9/26/16 the MRR timed at 8:02 a.m. revealed that GDR [MEDICATION NAME] was completed and the resident had no active order for [MEDICAL CONDITION] medications. Care conference was scheduled for next week for discharge planning. Review of the pharmacy notes dated 9/26/16 revealed that the resident had a history of [REDACTED]. po TID PRN on admission, and history of behavioral health patient. The GDR for [MEDICATION NAME] was completed on 8/18/16 and no active order since then. Recent episodes last 3 days shouting, agitation (see MAR behavior monitoring), non-pharmacological measures attempted - food, fluids, change position. Continue behavior/intervention monthly flow record in MAR, goal- positive outcomes with non-pharmacological interventions, medication secondary intervention, no history of dementia documented. [MEDICATION NAME] 1 mg. po QD PRN agitation - new order obtained on 9/26/16. Assessment/Plan: Agitation becoming more frequent, recommended put [MEDICATION NAME] back on order for [MEDICATION NAME] 1 mg. po daily PRN agitation. Continue monitoring with appropriate tracking in MAR indicated [REDACTED]. Review of the Behavior/Intervention Monthly Flow Record for (MONTH) (YEAR) revealed the behavior monitored for [MEDICATION NAME] administration was agitation. The record also revealed that the listed behaviors with asterisk sign (*) were behaviors which by themselves don't justify antipsychotic (AP) drugs. One of the specific behaviors listed was #2. agitated On 9/28/16 at 9:00 a.m., interview with the pharmacist revealed that facility staff had been monitoring the resident's agitated behavior since the resident was admitted with prescribed [MEDICATION NAME]. She confirmed that there were no specific agitated behaviors exclusively identified as manifested by Resident 8. Interview with the resident's caregiver revealed that the resident was non-verbal when he was admitted and now he started yelling again. Interview with LN1 revealed that they have noted the increase in yelling episodes after the discharge plan was initiated by the the interdisciplinary (IDT) team. LN1 confirmed that the resident was initially non-verbal and started talking in loud voice and had episodes of yelling for three days. However, LN1 acknowledged that IDT should have looked closely at the reason for resident's yelling than putting him back on [MEDICATION NAME] PRN medication for agitation. 2. Resident 4 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident 4's latest quarterly Minimum Data Set (MDS) - assessment tool dated 7/02/16 revealed the resident had a brief interview of mental status score (BIMS) of 9 indicating moderate impairment of cognitive skills. The resident mood interview revealed that the resident was feeling down, depressed, or hopeless for several days. Also the resident exhibited verbal behavioral symptoms directed toward others that occurred 4-6 days. The resident also exhibited rejection of care for 4 to 6 days. The depressed behaviors and refusal of care at intervals were confirmed by LN1 during the initial tour of the facility on 9/26/16 at 10:40 a.m. On 9/26/16 at 2:30 p.m., during an interview, Resident 4 stated that he wanted to talk to his ex-wife to discuss about the pending surgery to amputate the gangrenous left foot. Review of the physician's orders [REDACTED]. Review of the behavior/intervention monthly flow record for (MONTH) (YEAR) revealed depression as behavior being monitored for [MEDICATION NAME] 50 mg. po. daily. This record also revealed that the listed behaviors with asterisk sign (*) were behaviors which by themselves don't justify antipsychotic (AP) drugs. One of the specific behaviors listed was #12. Depressed/withdrawn On 9/26/16 at 10:45 a.m. LN1 confirmed the resident's depressed behavior but was unable to provide the specific behavioral manifestations of Resident 4's depressed status that needed to be monitored quantitatively in the behavior flow record. Although the flow record provided the potential side effects of the general drug category such as antidepressant, the flow record did not indicate the potential side effects of a specific classification of antidepressant such as [MEDICATION NAME] that was classified as a selective serotonin reuptake inhibitor (SSRI), and any information related to the black box warning. According to the manufacturer's information regarding antidepressants and suicidality (Labeling/Pfizer.com) patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Review of the resident's care plan dated 9/12/16 revealed a problem of [MEDICAL CONDITION] drug use with outcome: Patient will be free of complications associated with [MEDICAL CONDITION] drug use. Interventions included: assess and record benefit side effects, drug related complications, or drug related cognitive-behavior or impairment; assess for drug related gait disturbances, drug related [MEDICAL CONDITION], or movement disorder; assess need of continued potential use for less restrictive alternative approach. The plan of care was generalized for [MEDICAL CONDITION] drugs and not specific to the antidepressant that was newly prescribed for Resident 4.",2020-09-01
34,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,354,F,0,1,H7FJ11,"Based on observation, interviews and record review, the facility failed to designate a registered nurse as the director of nursing of the skilled nursing unit (SNU) on a full time basis as required. Finding includes: On 9/26/16 at 9:00 a.m. during the entrance conference, an administrative staff member (AA1) identified the associate administrator of nursing services (AANS1) as the director of nursing at the facility (skilled nursing unit) which was about 7 miles away from the hospital. On 9/27/16 at 10:00 a.m., the AANS1 introduced herself to the survey team as the SNU's director of nursing and provided her business card with an official title as the Associate Administrator of Nursing Services. Further interview revealed that she had oversight responsibility of nursing services at the acute hospital and at the skilled nursing unit. AANS1 added that she also oversaw the unit supervisor of the SNU because the unit supervisor (LN1) was new at her position. Review of facility documents however revealed the lack of documented evidence of the appointment. In addition, while a registered nurse, AANS1 was hospital-based and worked full-time at the hospital as an assistant administrator for hospital nursing services. In addition, review of the facility's brochure given to newly admitted residents to the SNU made reference about the SNU Inter-disciplinary team; however, the composition of the team did not identify a director of nursing (as member) but the SNU's unit supervisor which also had the title of SNU Hospital Supervisor of Nursing. Further, review of the facility's Daily Assignment sheet revealed the name SNU's unit supervisor listed as SNU Head Nurse. On 9/28/16 at 10:00 a.m., interview with the SNU's unit supervisor (LN1) revealed that she had several responsibilities since the former DON left the SNU. She added that some of her responsibilities included coordination and supervision of nursing services at the SNU, conducting weekly meetings with other members of the interdisciplinary team, creating staffing work schedules, and representing the SNU at the hospital's quality improvement meetings monthly. LN1 confirmed that she reported to the hospital's assistant administrator of nursing services since she assumed the position of the SNU's supervisor. She also stated she was not aware of who the designated DON for the SNU was, and denied that she was the designated DON. LN1 later confirmed that there has been no official appointment or designation of a DON for SNU. Review of the survey forms required to be completed and submitted by the facility further revealed the lack of identification of a DON as well as work hours by the DON at the SNU. The CMS Form-671 (Long Term Care Facility Application for Medicare and Medicaid) for example, revealed the lack of hours (zero hours) worked by the DON at the SNU after the form was revised and submitted to the survey team on 9/27/16.",2020-09-01
35,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,361,F,0,1,H7FJ11,"Based on observation, interview, and record review, the facility did not designate a person as food service director who received frequently scheduled consultation from a qualified dietitian. Findings include: 1. During the initial kitchen tour at 9:10 a.m. on 9/26/16, a dietary staff (DS11) stated that while he was the designated individual in charge of the kitchen for the day, he was, however, not the director of food service. In the same interview, DS11 added that the facility had dietary technicians available two times a week, as well as a registered dietitian who worked part time and was available only on Saturdays. During a separate interview at 10:45 a.m. on 9/26/16, a dietary technician (DS12) stated that she and another technician (DS13) shared coverage and that one of them was available in the facility two days a week on Monday and Wednesday. DS12 stated that she allocated some time in the kitchen but most of her time was spent on direct patient care conducting screening and follow-ups. Review of the position description (PD) revealed that while the dietary technician can assist in the supervision of the department, it did not identify either technicians (DS12, DS13) as director of food service with inherent duties and responsibilities. 2. While the position description noted that the dietary technician could perform basic nutritional screening of patients under the supervision of the clinical dietitian, there was no documentation available indicating that the screening process as well as the provision of nutritional care were being supervised by the registered dietitian. In addition, there was no documentation that consultations were being regularly scheduled between dietary technicians and the registered dietitian. While the facility maintained a communication log documenting tasks by the dietary technicians that were accomplished or were pending, there was no indication that the log was being reviewed by the registered dietitian to ensure that screening or progress notes, for example, were conducted timely and addressed the residents' identified needs. 3. Review of medical records revealed the lack of indication of dietary staff involvement in the development of care plans for nutritionally compromised residents. Review of the medical records of Residents 3 and 9, for example, revealed that licensed nursing staff were developing care plans and interventions for residents identified to be at nutritional risk. Review of Resident 3's medical record, for instance, revealed that for the most current admission on 6/08/15, the clinical dietitian had not identified an acceptable parameter of nutritional status (such as weight) even while the resident was described as having fluctuating weights. Record review also noted that the last progress note by the clinical dietitian was on 11/29/15. (Cross-refer to F325) 4. There was no indication that food complaints from residents were being elicited and addressed. In several confidential interviews, residents stated that meals served, including alternates and evening snacks were repetitive. One resident stated that eggs were a frequent occurrence, and that you get tired of chicken after a while. During an interview on 9/28/16, an administrative staff for hospital food services (Admin 01) stated that she could not remember when the facility's menu cycles were last reviewed and revised, adding that the review might have been done a long time ago.",2020-09-01
36,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,441,E,0,1,H7FJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility did not establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of diseases and infection. Findings include: 1. Random Sample Resident (RSR)11 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the physician's order dated 9/13/16 revealed an order for [REDACTED].; 0.125% IR starting on 9/13/16 twice daily for 30 days. Special Instructions: wet to dry dressing change with Dakin's solution 0.125% twice a day (BID) after cleaning with Normal Saline Solution (NSS) on sacrum and back area. Review of the Medication Administration Record from 9/19/16 to 9/27/16 revealed that wet to dry dressing change with Dakin's solution 0.125% BID after cleaning with normal saline solution on sacrum and back BID On 9/27/16 at 9:45 a.m., a licensed nurse (LN)2 was observed for pressure ulcer dressing change for Random Sample Resident (RSR)11. The nurse wore an isolation gown, pair of clean gloves and mask. She stated the resident is currently on contact isolation due to MRSA of the wound. she then prepared the two packs of 4x4 gauze she was going to use. The first pack of gauze was opened in the top and the nurse poured normal saline solution to wet the gauze and the second pack of gauze was opened to the top and Dakin's solution was poured in the gauze inside the packet. The resident's pressure ulcers were observed to be located in the sacral and mid lower back. LN2 changed the dressing one site at a time. She removed the old dressing with minimal to moderate amount of bloody drainage and proceeded to the sink area to remove the used gloves. She proceeded to use the hand sanitizer before wearing a new pair of gloves. She proceeded to clean the pressure sore area with one of 4x4 gauze in the packet that was observed to be slightly wet and not soaked with normal saline solution (NSS). Interview of LN2 on the same day revealed that she acknowledged that the gauze she used were not fully saturated with NSS. Review of the facility Policy No. 6580-D18 on Wet to Dry Wound Care dated (MONTH) 2009 stated, 12. Saturate the 4x4 gauze pads with the prescribed cleaning agent. Pick up the moistened 4x4 gauze pad, and squeeze out the excess solution. After the pressure ulcer area was cleaned with the NSS, another gauze with Dakin's solution was inserted into the Stage IV pressure ulcer in the sacrum and the area was covered with a dry dressing. Review of the facility Policy No. 6580-D18 on Wet to Dry Wound Care dated (MONTH) 2009 stated, #16. Use sterile cotton-tipped applicators for efficient cleaning of tight fitting sutures, deep and narrow wounds, or wounds with pockets. Review of the wound assessment sheet dated 9/21/16 revealed a healing Stage 4 in the sacrum measuring 1.3 cm. long, 1 cm. wide and 1.5 cm in depth with sero-sanguinous discharge and mild odor. The wound assessment sheet dated 9/23/16 described the other pressure ulcer as healing Stage 3 in the mid lower back that measured 1.5 cm. long, 6.1 cm wide and 0.2 cm in depth with scanty red drainage and no odor. On 9/27/16 at 2 p.m. during an interview, LN2 stated that she used to use the cotton-tipped applicators when the wounds were deeper but now that the wounds are healing she has not been using them lately. LN2 removed the contaminated gloves and used the hand sanitizer before she wore a clean pair of gloves. She repeated the same dressing change procedure to the Stage 3 pressure ulcer in the lower back. Review of the facility Policy No. 6580-D18 on Wet to Dry Wound Care dated (MONTH) 2009 stated, #9. Discard the soiled dressing and gloves in the trash can. 10. Wash hands. #26. Dispose of all soiled equipment and supplies appropriately, and wash your hands. 2. Review of the hospital wide policy #7202-130 titled, Employee Health Services (EHS)Immunizations with an effective date of 05/22/2008 and revised on 09/2011 revealed that all employees (initial and existing) will be assessed for vaccination history and immune status for the required vaccine-preventable diseases. The required vaccination (except Varivax) are offered via EHS free of charge. Documentation of declination/refusal of vaccination is required for employees that refuse to participate in vaccination. This refusal form will be filed with the employee's health record. Out of the 37 names listed as staff in the SNU, 6 employees refused 10/28/15 flu vaccination and 6 staff refused the 2/6/16 flu vaccination offer. Review of the hospital wide policy #6202-180 titled: Methods of improving influenza vaccination rates amongst hospital employees and licensed independent practitioners with effective date of 5/22/13 revealed the presence of an Attachment III form related to influenza vaccination/declination surveillance. Although the form details the the information in tracking the reasons for the declination of the the influenza vaccine as part of performance improvement in infection control area, the policy did not address the preventive measures to protect the residents in SNU. On 9/28/16 at 3:30 p.m., interview with the EHS staff revealed that there was no facility policy on how health care workers who declined the influenza vaccination should take care of residents in SNU to reduce the potential of transmission of influenza and subsequent influenza-related complications during the vaccination period. 3. During the initial tour of the kitchen on 9/26/16, a sign on the cover of the ice machine noted, Not available for consumption. In an interview during the tour, DS11 stated that dietary staff were waiting for the results of a laboratory test on a culture that was recently obtained. Until then, DS11 stated, the ice can't be use. DS11 added that tests were conducted monthly. During the kitchen observation on 9/28/16, dietary staff stated that ice from the machine was safe to use and so the sign was removed. When a request was made to review the culture results, the staff stated that maintenance staff (MS1) had the information. During an interview on 9/28/16, the maintenance staff (MS1) stated a recent test revealed microbial growth so that the machine had to be cleaned, disinfected, and retested . The retest, according to MS1, noted no growth. Review of microbiology results provided by MS1 revealed that no growth was identified for tests from (MONTH) through (MONTH) (YEAR). In August, culture results from the ice machine dated 8/07/16 revealed the presence of 60 org/ml of non-fermenting gram-negative rods (that were) not Pseudomonas. In September, culture results dated 9/16/16 and 9/17/16 revealed the presence of 400 org/ml of Pseudomonas Stutzeri and 20 org/ml of Coagulase negative staph (staphylococcus), a gram-negative bacteria that can cause fever, chills, nausea, vomiting and other symptoms. There was no indication that the positive results were reported to infection control for appropriate surveillance and investigation, evaluation of safe food handling practices, and/or effectiveness of cleaning and maintenance service.",2020-09-01
37,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,456,F,0,1,H7FJ11,"Based on observation, interview, and record review, the facility did not maintain all essential mechanical and electrical equipment in safe operating condition. Findings include: 1. During the initial tour on 9/26/16, a dietary staff (DS11) stated that the kitchen's dishwasher, a high temperature washer, was out of service. DS11 added that as a consequence, residents were being served disposable Styrofoam, plates, cups, and plastic eating forks, knives, spoons. According to DS11, the machine been out of order since the beginning of the year (2016) because of a broken booster pump. During an interview on 9/28/16, a maintenance staff member (MS1) stated that the dishwasher had been out of order since (MONTH) (YEAR). MS1 explained that the heater booster was broken and could not reached the (high) temperature required for washing and sanitation. MS1 further added that since the machine was old, a decision was made not to replace the booster but purchase a new unit. Review of maintenance records revealed the lack of documentation evidencing inspection and/or service maintenance provided on the dishwasher. In the same interview, MS1 stated that preventive maintenance was provided by a vendor regularly but was discontinued in 2012 when the contract was not renewed because of the lack of funds. Since then, according to MS1, maintenance staff did what they could do, replacing parts that were broken. In the interview, MS1 added that the contract agreement would have been for the inspection, testing, maintenance, troubleshooting, and repairs for its (the facility's) commercial cooking equipment and ice machine at the skilled nursing unit. Review of the document however did not include the dishwasher. (Cross-refer to F490.) 2. During the initial tour of the kitchen on 9/26/16, a sign on the cover of the ice machine noted, Not available for consumption. In an interview during the tour, DS11 stated that dietary staff were waiting for the results of a laboratory test on a culture that was recently obtained. Review of test results provided by MS1 revealed that no growth was identified for tests from (MONTH) through (MONTH) (YEAR). In August, the results of a culture from the ice machine dated 8/07/16 noted the presence of 60 org/ml of non-fermenting gram-negative rods (that were) not Pseudomonas. In September, the culture results dated 9/16/16 and 9/17/16 revealed the presence of 400 org/ml of Pseudomonas Stutzeri and 20 org/ml of Coagulase negative staph (staphylococcus), a gram-negative bacteria that can cause fever, chills, nausea, vomiting and other symptoms. There was no indication that an investigation was conducted to determine the cause of contamination. During the same kitchen observation on 9/28/16 a, brown colored container identified by MS1 as a water filter was observed connected to the back of the ice machine from the water supply. MS1 added that the filter was installed with the ice machine. Review of the ice machine ' s user manual revealed that water filters are recommended to remove suspended solids. When asked when the filter cartridge was last replaced, MS1 could not recall but stated that the cartridge had been removed years ago and had not been replaced. Review of the preventive maintenance checklist revealed that while replacing the water filter was part of the checklist, there was no indication that the water filter was being checked and that the filter cartridge was replaced as recommended. The ice machine's user manual noted that the water filter was to be changed if it had been installed more than 6 months. 3. During the initial kitchen tour on 9/26/16, the following observations were also made: a. The upper compartment of the steamer had a sign indicating it was out of order. b. Ice build-up was noted around the door to the walk-in freezer. The door did not easily close and had to be pushed firmly in order for it to close properly to prevent condensation. c. One of two reach-in windows of the walk-in refrigerator was noted to have been taped heavily on the outside. In an interview, DS1 explained that the tape was there to secure the window and prevent it from opening when the walk-in refrigerator door is closed.",2020-09-01
38,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,490,F,0,1,H7FJ11,"Based on observation, interview and record review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to enable residents to maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings include: 1. During the survey, a food services director was not hired by the facility to ensure oversight and supervision of dietary services. Interview with staff revealed that while two dietetic technicians were available to the facility to provide coverage for two days of the week on Monday and Wednesday, it was unclear as to whether the technicians fulfilled the position of food services director. In addition, there was no documentation available to indicate that the technicians had adequate training and experience; that a food services director position description (or its equivalent) had been developed, and whether the dietetic technicians met the requirements. Further, while the facility had the services of a registered dietitian one day a week on Saturdays, there was no documentation that there was regularly scheduled consultations between the dietetic technicians and the registered dietitian to ensure effective communication; and that the needs of residents were being assessed and identified, and dietary outcomes were being met. (Cross-refer to F325 and F363.) 2. There was no indication that the facility had used its resources to ensure that vital appliances used in the kitchen to cook, prepare, and store food were in good operating condition. The kitchen's dishwashing machine, for example, had been out of order according to dietary staff, since the beginning of the year because of a broken booster pump. Review on 9/28/16 of the departmental requisition (dated 3/28/16) for the replacement of the dishwasher revealed that it was unprocessed and was returned (to Admin5) because of incomplete documentation and the amount of money requested that required additional information. During an interview on 9/28/16, an administrative staff member for hospital food services (Admin5) explained the many delays in procurement including the lack of bids received from vendors and her lack of familiarity with the requisition process and other requirements. In a letter dated 9/20/16, however, according to Admin5, a response from the supply management administrator revealed that the requisition was again returned (unprocessed) because of incomplete information on requisition and to prepare Scope of Work/Services and submit for FY2017. In the same interview, Admin 5 added that because of the impending fiscal year ending (on 9/30/16), the revised requisition will unlikely be acted upon until after the start of the fiscal year (YEAR) resulting in further delay. Admin5 added that the lack of funding was a major issue. Review of facility records revealed the lack of involvement by facility administrative staff in the requisition process so that procurement of a replacement dishwasher could be expedited. Review of a supplemental attachment dated 3/16/16 to the initial departmental requisition made revealed that the current dishwasher had exceeded (its) functional life and the booster heater is irreparable. The attachment noted further that the facility had been cited by Public Health because it (dishwasher) does not work properly. Repeat citations could force SNU (the facility) to close their kitchen. The delay in getting a replacement dishwasher had also resulted in residents of the facility being served meals using disposable food containers and plates and Styrofoam cups, and using plastic forks, spoons, and knives to eat over a extended period of time. In a separate interview on 9/28/16, MS1 stated that the dishwasher may have been broken in (MONTH) (YEAR), and remained out of order since. (Cross-refer to F241 and F456.) 3. Review of the personnel record revealed that the job description of the recreation therapy coordinator lacked documentation of training and experience to prepare and enable her to effectively coordinate the facility's activity program, supervise recreational technicians, and ensure that activities provided to residents were meaningful and met the residents' needs. 4. Review of facility documents including the organizational chart revealed that the facility (the skilled nursing distinct part) was a unit under the assistant administrator of nursing service, which was also under the associate administrator for clinical services. Further document review however revealed that the facility did not have an appointed facility administrator, as required under 483.75(d). While facility staff interviewed during the survey identified the hospital CEO as the administrator of the facility, the position description (of the hospital CEO) did not include specific duties and responsibilities for the facility, including ensuring that the facility was administered in a manner that allowed it to use its resources effectively and efficiently to enable residents to maintain their highest practicable level of physical, mental, and psychosocial well-being; and participation in quality assessment and performance improvement activities. 5. The facility did not have any documentation to indicate that an appointment was made to designate the director of nursing service. (Cross-refer to F354)",2020-09-01
39,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,493,F,0,1,H7FJ11,"Based on observation, record review, and interview, the governing body did not appoint an administrator who was responsible for the management of the facility. Finding includes: Review of hospital documents pertaining to governing body responsibility specific to the skilled nursing unit revealed that the governing body appoints the Administrator that is responsible for the management of the facility. While facility staff interviewed during the survey identified the hospital CEO as the administrator of the facility, the position description (of the hospital administrator) did not include specific duties and responsibilities by the CEO to ensure that facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure that residents attained or maintained their highest practicable level of physical, mental, and psychosocial well-being. (Cross-refer to F241, F354, F361, F456 and F490.)",2020-09-01
40,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,501,F,0,1,H7FJ11,"Based on record review and interview, the facility failed to designate a physician to serve as medical director for the facility who was responsible for implementation of resident care policies, and the coordination of medical care in the facility. Finding includes: On 9/28/16 at 9:15 a.m., interview with LN1 revealed that there was no position description for the current medical director assigned to skilled nursing unit (SNU). During the survey, an interview with the medical director was not conducted because he was off-island, according to LN1. On 9/28/16 at 2:15 p.m., following a request to review the position description for the medical director of the SNU, a human resources staff person responded with a note to the surveyor indicating that the facility did not have position description. The following day on 9/29/16 at 9:00 a.m., a document, Hospital Staff Physician - Skilled Nursing Unit (SNU) with collateral duties and work tasks as Director, Skilled Nursing Unit, Responsibilities was provided by the administrative assistant (AA1). The document described the scope of work for the facility's medical director to include the following: Directs the day-to-day functions of the Skilled Nursing Facility/Skilled Nursing Unit (SNF/SNU) in accordance with current federal, state and local standards, guidelines, and regulations that govern, hospital-based long term care units to assure the highest degree of quality of care is provided to all residents, at all times. Assures that there is continuous monitoring and evaluation of the quality and appropriateness of the medical care provided as part of the overall quality assurance program. Develops and directs educational programs related to medical activities such as, but not limited to, results from Quality Assurance monitoring and evaluation activities. Provides consultation to the Medical Records Department on the development and maintenance of an adequate medical record. (Cross-refer to F322, F329, F441 and F520.)",2020-09-01
41,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,514,F,0,1,H7FJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; and progress notes. Findings include: 1. On 9/26/16 to 9/27/16, access to electronic medical record was not readily accessible. Interview with administrative and nursing unit supervisor on 9/26/16 at 2:00 p.m. revealed that surveyors will not be allowed to access the electronic records unless the Optimum RN/LPN Clinical User Request Form was signed to ensure privacy and protection of Patient Information, under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Multiple exchanges of information with the hospital's Information Technology (IT) staff were held to explain that surveyors were exempt from the HIPAA law. Access was granted only on 9/26/15 at 3:00 p.m. On 9/27/16 at 9:00 a.m. Minimum Data Set (MDS) information - an assessment tool for residents in skilled nursing facilities, was requested from nursing staff to evaluate facility's regulatory compliance. The surveyors were granted limited access to electronic record until requests were made to print all the MDS and resident care plans that needed to be reviewed. 2. Resident 3 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the medical record on 9/27/16 revealed that Resident 3 had a progress note dated 8/09/16 by the attending physician describing the resident as still intubated, was off pressors, and being on a [MEDICATION NAME] drip for pain. Interview with a licensed staff (LN1) on 9/27/16 revealed that the progress note entry was not applicable to Resident 3 following her admission to the facility, and not for any of the other residents in the skilled nursing facility. 3. Review of medical records revealed that minimum data set assessments (MDS) including admission and quarterly assessment were not easily retrievable. When a request was made on 9/26/16 to have them available for review, facility staff stated that they cannot be reviewed electronically but can only be printed by a designated staff member from a separate database so they can be reviewed. Copies of the requested assessments were not made available for review until 3:00 p.m. on 9/27/16.",2020-09-01
42,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,517,F,0,1,H7FJ11,"Based on observation, interview, and record review, the facility did not have a detailed plan and procedures to meet all potential emergencies and disasters. Finding includes: During the survey, several documents were presented evidencing the facility's emergency/disaster preparedness plan. A review of the the facility's emergency preparedness contingency plan for a tropical cyclone (revised (MONTH) (YEAR)) which defined the role dietetic services for the skilled nursing facility was conducted. While the document outlined responsibilities of dietetic staff as well as for the cook to conduct a preliminary assessment of food supplies on hand; and coordinating at least a 2-day food supply to supplement the existing 3-day emergency food supply already kept stocked and rotated at the facility, the plan did not include the amount of drinking water allocations for the number of residents, staff, and other individuals who may be at the facility; as well as for the number of days of the emergency or disaster. Review of the facility's emergency water distribution plan also revealed that dietetic services shall support the provision of drinking water supply for patients and emergency responders during times of emergency at the hospital. Admin5 stated that the policy was a revision and was unsigned, but being circulated for signatures. The policy did not include contingency plans for an emergency or disaster but outlined procedures to be undertaken during an emergency. The policy (emergency water distribution) revealed that while procedures were outlined including conducting an inventory of available bottled drinking water at the SNU, completion of requisition forms, ordering and anticipating delivery of bottled drinking, and rationing of drinking water to patients and first responders, the policy also did not specify the amount of drinking water to be stored on-site, including at the SNU which was located about 7 miles away from the hospital, especially when the emergency or disaster involved road closures causing delivery delays, power failures, and breakdown or interruption in communications for several days.",2020-09-01
43,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2016-09-29,520,F,0,1,H7FJ11,"Based on interviews and record review, the facility failed to maintain a quality assessment and assurance (QAA) committee consisting of the director of nursing services; a physician designated by the facility; and at least 3 other members of the facility's staff. The quality assessment and assurance committee failed to meet at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and failed to develop and implement appropriate plans of action to correct identified quality deficiencies. Findings include: On 9/28/16 at 10:00 a.m. during an interview with licensed nurse (LN1), it was revealed that the facility did not have a quality assurance program although she represented the SNU in program improvement (PI) meetings at the hospital on a monthly basis. According to LN1, quality assurance consisted of collecting SNU-specific data and reporting this to the hospital PI meetings. LN1 added that the SNU was part of the hospital's overall PI meetings. LN1 further explained that ever since the last SNU's director of nursing/administrator left last May, (YEAR), the facility had not conducted a formal quality assessment and assurance (QAA) meeting exclusive to SNU. LN1 added that while each licensed nurse was assigned a specific quality indicator to monitor, such as incidence of pressure sores, the data collected was sent to the facility's administrative assistant for compilation. Target goals not met continue to be monitored on the list of key indicators. There was no evidence if analysis of data collected was conducted or not. In another interview on 9/29/16 at 1:30 p.m. the administrative assistant (AA1) stated that she worked closely with LN1 to establish and maintain the SNU's QAA program. She stated that while quarterly QAA meetings were held with the medical director and the department heads, no other meetings were convened since March, (YEAR) when the former director of nursing/acting administrator left and the former medical director retired. She recalled that the last official QAA meeting in the SNU that was attended by the medical director was (MONTH) (YEAR). In the same interview, AA1 confirmed that there was no evidence of an existing QAA committee for the SNU except for the PI program in the hospital. However, AA1 stated that the facility will reconvene and plan to start QAA meetings in SNU on 10/15/16 with the new medical director and heads of the each department.",2020-09-01
44,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2014-09-19,164,B,0,1,OCYD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure that residents were afforded personal privacy when nursing staff failed to announce or knock before entering three resident rooms (resident rooms [ROOM NUMBER]). Failing to announce or knock before entering into a resident's room is an infringement of the resident's right to privacy. Finding includes: During the meal service observation on 9/16/2014, one certified nursing assistant (CNA) was observed walking into 3 residents rooms without knocking or announcing their entrance into the rooms. Later, after being questioned, the CNA acknowledged that knocking or announcing their entrance into the resident room was what should have occurred rather than just entering into the resident rooms.",2019-04-01
45,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2014-09-19,279,E,0,1,OCYD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure ongoing resident's assessment data was used to develop and revise the comprehensive plan of care for 2 of 8 sample residents (Residents 1 and 4). Failing to use ongoing assessment data to develop and revise the resident's plan of care can lead to potential declines in resident functioning. Finding include: 1. The medical records of Resident 1 were reviewed on 9/18/2014. The resident sustained [REDACTED]. The nursing documentation for that incident reads, Was informed by assigned nurse that patient was found on floor near bed at around 2020. No injuries noted. Assisted patient back to wheelchair by three staff members. MD informed. No new orders obtained. During two separate interviews and record reviews with licensed nurses (LN1 and LN2) it was determined that the records did not reflect an investigation for the circumstances surrounding or contributing to the fall. The licensed nurses acknowledged that investigating or assessing the circumstances contributing to the fall could potentially prevent future falls. Additionally, both nurses acknowledged the fall occurred on 7/22/14 and that the last time the Potential for Fall care plan had been updated was 7/03/2014; 19 days before the fall. 2. Resident 4 was admitted to the facility on [DATE] with a medical [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment Section D (Mood) was completed by the facility social worker. The resident was assessed to be feeling down, depressed, or hopeless. During an interview with the Resident and family member, he stated that he was tired of being at the facility, and tired of being in the shape I am now. The family member stated that the resident was depressed about his condition because he wants to enjoy his retirement like everyone else, not like this. The Resident added I am tired of the pain, and just feel frustrated about having to be here (in the facility), and I just want to go home. It's depressing. review of the resident's medical record revealed [REDACTED]. The LN of the Resident stated she was not aware if the Resident was depressed or sad. The facility administrator was interviewed on 9/17/14 at approximately 3:30PM, and stated that he was aware that the Resident was not happy about having to be in the facility. When I talk to him, I try to redirect him, and remind him that he will be going home soon. When asked if a care plan addressing the emotional/psycho-social needs of the Resident would be appropriate, the administrator stated that even though he was mindful of the Resident's condition, it would be a good idea to address it in a nursing care plan so that staff would be aware, and what interventions to utilize to help the Resident cope with his depression.",2019-04-01
46,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2014-09-19,309,D,0,1,OCYD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that the resident received care and services to enable him to meet the highest practicable physical and psychosocial well-being. Finding includes: Resident 2 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The resident was also noted as having a right below-knee amputation and described in the initial minimum data set ((MDS) dated [DATE] as having no cognitive impairments and dependent on staff for most activities of daily living with one-person physical assist. During an interview on 9/16/14 at about 3:20 p.m., Resident 2 stated that he had been having irregular bowel movements and that while he receives milk of magnesia (MOM) when he hasn't had a bowel movement for several days, he added that by the time, he feels loaded and uncomfortable. Review of the electronic medical record revealed that while Resident 2's bowel movements were being monitored, the frequency however was such that he would have none for three or more days, including on 9/14/14 - 9/16/14 (3 days); 8/28/14 - 9/01/14 (5 days); and 8/16/14 - 8/19/14 (4 days). In light of this, there was no documentation that Resident 2 was always given MOM as needed. Review of the Medication Administration Record [REDACTED]. During an interview on 9/18/14 at 11:00 a.m., a licensed staff (Admin 1) stated that facility protocol was to give 30 ccs of MOM if a resident had no BMs for 3 days. Further record review revealed that while the facility developed a plan of care dated 4/23/14 for constipation with the goal to maintain regular bowel pattern, there was no indication that the care plan was reviewed to determine if interventions were being implemented, were effective, or needed to be revised. While the care plan, for example, noted encourage high fiber intake and coordinate with the dietitian, there was no evidence of any coordination or that the resident's diet order (Cardiac 2000 cal bite-sized) was modified, or that consideration was made for the use of daily stool softener or addition of fiber to the resident's drug regimen. In a follow-up interview on 9/18/14, Resident 2 stated that while waiting 3 days for a laxative (MOM) might be good for other residents, it was too long of a wait for him.",2019-04-01
47,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2014-09-19,329,D,0,1,OCYD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that each resident's drug regimen must be free of unnecessary drugs for 2 of 8 sampled residents (Residents 1 and 2). Failure to secure appropriate physician orders [REDACTED]. Findings include: 1. On 9/17/14, Resident 1's medical records were reviewed with licensed nurse (LN) 1 and 2. Both nurses acknowledged the resident's current medications orders included [MEDICATION NAME] and [MEDICATION NAME]. The current [MEDICATION NAME] order dated 9/01/14 was written as [MEDICATION NAME] 2 mg orally twice to day. The current [MEDICATION NAME] order dated 9/09/14 was 0.5 mg orally twice a day. Both licensed nurses acknowledged the [MEDICATION NAME] nor the [MEDICATION NAME] contained indications for the use of the medications. During further investigation it was determined that Resident 1 was receiving the [MEDICATION NAME] and [MEDICATION NAME] related to behaviors. The minimum data set for Resident 1 listed behaviors such hitting, scratching, and screaming. When the licensed nurses were questioned how staff would document the number of behaviors per day, week, or month, the licensed nurses stated one would have to read all the nurses notes for the day, week, or month to quantify the number of behaviors for any specific time period. When the licensed nurses were questioned how they would document and quantify the number of adverse events for the [MEDICATION NAME] or [MEDICATION NAME] it was determined that once again one would have to read the nurses notes for that specific period of time. Furthermore, LN 1 stated that the facility was relying on the nurse's professional judgment to determine if adverse effects were occurring or not. That is, there was no list of specific adverse effects that may be associated with [MEDICATION NAME] or [MEDICATION NAME] that may facilitate a nursing action if a specific adverse affect was noted to be occurring. The licensed nurses concurred the current system for monitoring behaviors or adverse effects was not conducive to quantifying the number of adverse effects or behaviors in a day, week, or month and the aforementioned could potentially subject the residents to the use of unnecessary drugs. 2. Resident 2 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The resident was also noted as having a right below-knee amputation and described in the initial minimum data set ((MDS) dated [DATE] as having no cognitive impairments and dependent on staff for most activities of daily living with one-person physical assist. Review of the medical record revealed that Resident 2 had a physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. Further review revealed that the medication had been re-ordered monthly since 6/27/14. Review of the medical record revealed that while the resident was being given Klonopin, there was no documentation of attempts to determine the cause of the [MEDICAL CONDITION] and how these could be minimized or addressed by the use of non-drug interventions. In addition, a care plan for the problem of [MEDICAL CONDITION] was not developed outlining interventions that might help promote sleep. While nurses notes at times documented that non-drug interventions did not help, the notes however did not identify specific care plan interventions that were used or why they were ineffective. During an interview on 9/16/14, Resident 2 stated that there were nights when he felt uncomfortable from pain on his back and buttocks; and that noise at night, especially during shift change kept him awake. In the same interview, the resident added that because he also worked as a night shift security guard for 4 years that his circadian rhythm had been turned around. There was no documentation in the medical records that these factors were considered prior to the use of Klonopin. Further review of the medical record revealed the lack of evidence that monitoring of the cause and incidence of [MEDICAL CONDITION] was being conducted as well as the potential adverse effects of Klonopin, a benzodiazepine used to control [MEDICAL CONDITION] in [MEDICAL CONDITION] and for the treatment of [REDACTED]. Without monitoring and supporting documentation, the use of the Klonopin is rendered unnecessary because of the lack of indication and monitoring.",2019-04-01
48,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2014-09-19,371,C,0,1,OCYD11,"Based on observations and interviews, the facility failed to store and prepare food under sanitary conditions. Findings included: 1. During an observation of the lunch meal preparation on 9/17/14 at approximately 10:50AM, the top service of the steamer/oven located next to the stove had a notable thick layer of grease/grime build-up that included dust debris. The cook looked at the top of the steamer/oven and concurred that there was a build-up of debris, and stated that it should be cleaned. Yeah, that should not be there, and be cleaned. He stated he did not recall when the surface had been cleaned. 2. During the initial tour a cup was observed to be in the dry macaroni storage bin. The Dietary Food Service manager acknowledged the cup should not be stored with the dry cereal/macaroni and removed the cup.",2019-04-01
49,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2014-09-19,428,D,0,1,OCYD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a drug regimen review monthly for 2 of 8 sample residents (Residents 1 & 2). Failure to complete the drug regimen has the potential subject the residents to unnecessary medications. Findings include 1. On 9/18, 14, during a concurrent interview and record review for Resident 1 with the consulting pharmacist she acknowledged there was no documentation to reflect drug regimen reviews were completed for the months of (MONTH) through (MONTH) 2014. During a concurrent interview and medical record review with a licensed nurse (LN1), there was acknowledgement that the record did not reflect the drug regimen reviews were completed since (MONTH) 2014. The facility policy titled Skilled Nursing Unit Drug Regimen Review, last revised (MONTH) 2012, indicated drug regimen reviews will be conducted monthly to ensure that each resident will not receive unnecessary drugs. 2. Resident 2 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The resident was also noted as having a right below-knee amputation and described in the initial minimum data set ((MDS) dated [DATE] as having no cognitive impairments and dependent on staff for most activities of daily living with one-person physical assist. Review of the medical record revealed that Resident 2 had a physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. Further review revealed that the medication had been re-ordered monthly since 6/27/14. The medical record revealed that while the pharmacist conducted a review of the resident's drug regimen in (MONTH) and (MONTH) 2014, to identify and report any irregularities, no reviews were conducted monthly thereafter, as required. During an interview on 9/18/14, a pharmacy staff member (PH1) acknowledged that drug regimen reviews were not conducted monthly and that she needed to allocate time amongst other competing workload obligations to conduct and document the reviews.",2019-04-01
50,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2014-09-19,431,E,0,1,OCYD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that drugs and biologicals stored in the facility's only medication storage room in use were discarded when expired; and also properly disposed/returned to the pharmacy or resident after discharge. Findings included: During a tour of the medication room on [DATE] at approximately 2:20PM with the LN, the following was observed: 1. A 30cc vial of Heparin flush mixed/prepared and labeled by the facility pharmacy with a label reading that the Heparin flush vial was mixed/prepared on [DATE] with a disposal/expiration date of [DATE] was stored with other medications actively being used by the facility. The LN stated that the vial should have been disposed and/or returned to the pharmacy by the expiration date (,[DATE]) and not stored with other medications. It is unknown if any of the Heparin flush preparation had been administered to a resident after it's expiration date. 2. Seven (7) Lantis insulin pens labeled with the name of a previously discharged resident were being stored in the refrigerator with other medications currently being administered to residents in the facility. The LN stated the pens should have either been sent home with the resident/family when they were discharged , or sent to the pharmacy for disposal. The pens should have been sent home with the resident, or we sometimes will call the resident's family to come pick them up.",2019-04-01
51,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2014-09-19,441,D,0,1,OCYD11,"Based on interview and record review the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of disease and infection. Finding includes: On 9/16/14 during the initial tour of Resident 3's room with a licensed nurse (LN3), the nurse acknowledged the normal saline solution and irrigation set use for the dressing changes was not dated nor timed. During further interview the licensed nurse stated that irrigation solution was good for 28 days after the bottle was opened but acknowledged it would be difficult to determine when the current bottle was opened since there was no date or time on it. On 9/17/14 during a wound care observation for Resident 3 with LN 3 the normal saline solution was observed to be labeled with the date and time opened; however the irrigation set was not dated nor timed as to when it was initially opened. The wound for Resident 3 was a large pressure ulcer which extended from above the anus to the coccyx area. LN3 executed the following steps before and during the dressing change: hands were washed and clean gloves applied; the old dressing was removed; original gloves removed and the hands washed then a new set of clean gloves were applied; the wound site was irrigated with normal saline solution; then the wound was pat dried from the anus to the superior aspect of the wound; the gloves were removed, the hands were washed and new set of clean gloves were applied; Hydrogel was applied to the fresh dressing then the wound was covered and tape applied to secure the dressing. The licensed nurse was question about the drying technique and acknowledged the wound should've been dried from the clean superior aspect to the dirtiest aspect of the wound (the anus). On 9/17/14 during an interview with LN1 it was ascertained that the normal saline irrigation solution is good for only 24 hours after being open and that the container of solution should be dated and timed. Furthermore, during a concurrent observation with LN1 of the manufacturer's label on the irrigation set it was determined that the irrigation set was a single use item. That is, the irrigation set was not intended to be used multiple times within a 24 hour period.",2019-04-01
52,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2014-09-19,463,E,0,1,OCYD11,"Based on interview and record review the facility failed to ensure the resident call system was working in all restrooms (rooms 127, 130, and 131) and in one resident room (room number 101A). Failure to have a functioning call system can put the resident at risk for potential harm when he/she is unable to communicate with the staff during times of need. Findings include: 1. On 9/16/14 during the initial tour with a licensed nurse (LN3), the visual aspect of the call system for rooms 127 and 130 where observed not to be working. LN 3 acknowledged he could hear the call system however the visual component of the system was not working. 2. During the initial tour on 9/16/14, the call light inside the bathroom in room 131 did not activate when the button was pressed. The was no visual indicator observed or audio signal heard to alert staff about the call for assistance. During an interview, a licensed staff stated that once the call light button was pressed, an audio signal should have been heard and an indicator light in the hallway on the wall outside the resident's room should have been lit. 3. During the initial tour, the nursing call light for sampled resident 4 was at his bedside within reach. However, the call light was not functional when the call light button was pressed. The resident stated It's been like that for a while. When I need them (facility staff), and can't call them or let them know I need help, so my (family member) has to go to the nursing station to get help for me if I need to go to the bathroom or need my pain medication. Thank goodness my (family member) stays with me most of the time.",2019-04-01
53,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2014-09-19,465,B,0,1,OCYD11,"Based on observation and interview, the facility did not provide a safe and functional environment for its staff. Finding includes: During the food storage observation on 9/17/14, a puddle of water was observed inside the walk-in refrigerator's sheet-metal flooring in an area adjacent to the door leading into the walk-in freezer compartment. The puddle which covered an area about a foot-and-a-half from the wall separating the freezer and refrigerator was slippery and could potentially cause anyone to slide and fall, especially in the dim lighting inside the refrigerator that rendered the puddle difficult to notice. There were no warning cones or anti-slip devices noted. During an interview on 7/17/14, a dietary staff member stated that the puddle was from melted ice inside the freezer that had flowed into the refrigerator compartment. The staff who thereafter secured warning cones added that maintenance personnel had recently been inside the freezer to break-up the ice build-up inside the freezer.",2019-04-01
54,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2014-09-19,514,D,0,1,OCYD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, and the facility failed to ensure that all verbal and telephone orders obtained related to the urgent or emergent situations, and that all clinical records were legible, dated, timed, and signed. Persistent over use of verbal and or telephone orders, that are handwritten or re-transcribed on the monthly basis, has the potential for increased transcription error. Findings include: 1. On 9/19/14 the medical records for Residents 1 and 3 were reviewed with a licensed nurse (LN4). The nurse acknowledged that the monthly reoccurring orders for Resident 1 for the months of (MONTH) and (MONTH) 2014 were telephone orders. The records reflected that there were five physician's orders [REDACTED]. LN 4 acknowledged that the following orders were possibly not related to an emergent or urgent situations: [MEDICATION NAME] 100 milligrams orally two times a day; and [MEDICATION NAME] cream to hemorrhoids two times a day as needed. 2. Resident 3 was admitted on [DATE] with hand written telephone orders. Between 8/23/14 to 8/26/14, there were 8 physician's orders [REDACTED]. 3. On 9/19/14, the Guam Memorial Hospital Authority Nursing Services Manual addressing Physician order [REDACTED]. The policy indicated, All physician orders [REDACTED]. Additionally, The policy reflected Use of verbal and telephone orders must be minimized in all nursing units. Verbal or telephone orders must be taken by an RN only. Use of verbal orders must be limited to urgent and emergent situations 4. Resident 2 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The resident was also noted as having a right below-knee amputation and described in the initial minimum data set ((MDS) dated [DATE] as having no cognitive impairments and dependent on staff for most activities of daily living with one-person physical assist. Review of the medical record revealed that the resident had a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. elevated temperature), or result or effect, if any, after the medication was given.",2019-04-01
55,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2014-09-19,517,B,0,1,OCYD11,"Based on observation and document review, the facility did not have a written plan and procedure to ensure availability of water supply for all residents, staff, visitors, and family members in the event of an emergency or disaster. Finding includes: Review of the facility's plan regarding availability and storage of drinking water supply during an emergency revealed that forty-five gallons of drinking water would be made available in the dietary department for the use of residents. During an interview on 9/17/18, a dietary staff member explained that the allocated water supply should allow 30 residents (the number of residents being planned for) to each have 2 quarts of drinking water each day for three days of the anticipated duration of the emergency. Further review of the plan however revealed the lack of consideration for the number of employees, visitors, and family members who may be stranded in the facility during the emergency and would therefore have no access to drinking water. During the kitchen tour on 9/17/14, forty-eight gallons of drinking water were observed in the dietary department storage room. In the same interview, the staff member stated that the available water supply was sufficient to meet the drinking water needs of 30 residents for three days of emergency, but not those of staff, family members, and/or visitors.",2019-04-01
56,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2013-09-20,157,E,0,1,JK1T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the primary attending physician regarding a change in medical condition for Resident 5 and 8 related to reports of the residents wanting to hurt/harm themselves. 1. Resident #5 was readmitted to the facility on June13, 2013 with a [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. According to an interview with LN 1 during the initial tour of the facility on (MONTH) 18, 2013 at approximately 9:23 AM, the resident was recently moved to a room closer to the nursing station because the facility became aware that the resident 'might want to hurt or kill' themselves. During the tour, the resident was not observed to be in their assigned resident room. An interview was done with LN 3 on (MONTH) 19 at approximately 5:10 PM. The staff person stated that she was not the assigned staff for the resident that shift, and that near the end of the shift (3 PM - 11 PM) she took a phone call from the friend of the resident on (MONTH) 13, 2013. Staff 3 said the caller sounded worried and like they were about to cry, and asked for nursing staff to go check on Resident 5 in their room because I (the caller) think (the resident) may have, or may be trying to cut herself with a knife. The caller told LN 3 that they were worried about the resident because they (the caller and the resident) had just been arguing on the phone. LN 3 reported that earlier during the shift they had observed Resident 5 to be restless and about to cry, and looked mad. LN 3 said they then reported this information to the shift Charge Nurse, and then they went to check on the resident and took the knife away from the resident. LN 3 stated that she was not aware of the resident ever doing this in the past to her knowledge. Review of the nursing notes on (MONTH) 13, 2013 timed at 11:20PM read, The (friend) of this patient called and said Can you go see (resident) in her room, she might slice her wrist. CNA and other nurse went to patient's room. Patient still awake, CNA found a kitchen knife and removed the knife in her room. Patient was up in wheelchair and went upstairs. I went upstairs and give knife to security and told him to watch this patient. On (MONTH) 14, 2013 at 10PM, an entry in the nursing notes read, Called Dr. (attending) informed him about the patients mental state last night. Was informed of suicidal ideation and acting out last night. Incident report was filed. Dr. (attending) ordering to have mental consult and monitor patient and on Level 1 suicide protocol until seen by mental health personnel . . An interview with LN 2 on (MONTH) 19, 2013 at 5:10PM was done related to the resident's change in condition/emotionsl status that took place on (MONTH) 13, 2013. There were several disconnects that should not have happened after the incident took place. The residents' physician should have been contacted the night the incident happened rather than the next day. 2. Resident 8 was admitted to the facility on (MONTH) 10, 2013 with a [DIAGNOSES REDACTED]. During an interview with the resident while completing the initial tour on (MONTH) 18, 2013, he was returning from physical therapy, and stated that he was 'sore, but okay.' Review of the residents medical record indicated that the SW 2 had documented an interview with the resident on (MONTH) 18, 2013 at 3:19PM that Resident stated that he had been feeling sad due to his present medical condition and severe pain to both legs. He noted that he has thoughts of hurting himself when he experiences severe pain .This worker discussed counseling at GBHWC (Guam Behavioral Health and Wellness Clinic) .And he agreed. Review of the Medication Administration Record [REDACTED]. Further record review on (MONTH) 20, 2013 revealed that the resident was transferred to and seen by a mental health professional on (MONTH) 19, 2013. Nursing notes revealed that the patient returned from GBHWC at 6PM. There was no documentation from GBHWC regarding the evaluation. The only documentation from GBHWC was a one-page document titled Discharge Instructions that said to Return to GBHWC if you feel like harming yourself or others, and to Call the crises line if you feel you need to talk to somebody . Review of the SNU Resident Appointment Communication Form revealed that it had been completed by Guam Memorial Hospital Skilled Nursing Unit, but the part for the treating physician/clinician to whom the resident was transferred to be seen for evaluation was blank. Review of nursing notes did not include any reference to or assessments related to suicide ideation or risks factors for suicide prior to being evaluated at GBHWC. An interview was done with SW 2 on (MONTH) 20, 2013 at approximately 11:57AM regarding her interaction with the resident and the notes she documented in the medical record on (MONTH) 18, 2013. SW 2 stated that the resident reported to her thoughts of suicide. I was interviewing the resident, and he told me of his thoughts to hurt and harm himself. That's when I made sure the referral was made for him to be seen by GBHWC. She added, I didn't tell the charge nurse about the suicide ideation, only his depression. I should have told her so they would have been watching him closely, and not just made the note in his record. There was no documentation in the medical record that the resident's physician was notified about the encounter the resident had with facility staff on Septamber 18, 2013 regarding his desire to hurt/harm himself until (MONTH) 20, 2013 at 12:40PM",2018-07-01
57,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2013-09-20,167,C,0,1,JK1T11,"Based on interviews, the facility failed to inform residents and their families of their right, or location, to view/examine the results of the most recent survey of the facility conducted by Federal surveyors and any plan of correction with respect to the facility. During the resident group interview that took place on (MONTH) 19, 2013 at 10:00AM, four of four residents in attendance, and a family member of sampled Resident 1 who was not in attendance (total of five responses) verbalized that they were not informed at admission, or anytime subsequent to their respective admitted s, of the location and their right to view the survey results from the previous Medicare recertification survey. Further, three of the four residents and a family member of Resident 1 verbalized their desire to want to view the results of the previous Medicare recertification survey.",2018-07-01
58,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2013-09-20,252,C,0,1,JK1T11,"Based on observations and interviews, the facility failed to provide a safe, clean, comfortable and homelike environment. Finding 1: During the resident group interview on (MONTH) 19, 2013 at 10 AM, three of four residents and also the family member of a sampled resident not in attendance reported that the outdoor courtyard was frequently overrun with cats, and that they have begun to not go out onto the patio due to the strong odor of cat urine and feces. Respondents stated that they enjoyed going outside for fresh air when able, but cannot do so because of the objectionable odor. Respondents also said that they have previously reported this to facility representatives, but nothing has been done to date. Finding 2: During the same interview, the same respondents stated that they would like to go out onto the courtyard more often, but there are concerned and fearful of their safety (accident hazard) due to the excessive amounts of mold and algae in the courtyard. Unsamped Resident 11 stated that his wheelchair has limited traction on the algae, and also that his visitors are afraid of slipping and falling when pushing him outdoors on the courtyard, it needs a good cleaning and power washing out there . Finding 3: During the initial tour of the facility on (MONTH) 18, 2013, and on subsequent visits to various resident rooms, observations were made of disposable window coverings covering resident room windows. The material of these window coverings were light blue disposable material, and appeared to be modifications of privacy treatment curtains used to provide resident privacy during delivery of care that had been cut to fit the curtain rod and window covering. These window coverings in resident rooms 102, 107, 108, 110, 111, 125, 130, and 131 all had various colored permanent stains of varying sizes. Finding 4: On (MONTH) 19, 2013, there was inclement weather and it rained the entire day. At approximately 5:10 PM that same day during the evening dinner meal service, several water leaks were observed coming from the ceiling in the resident dining room and resident activities room. Specifically, there were four leaks in the resident dining room along the east wall and ceiling of the dining room just above the windows and resident dining tables. There were two residents dining in the room at the time, and they were moved from the areas where the water leakage was occurring, and plastic containers and linen/towels were placed on the floor to catch and/or absorb the water. Resident dining tables were moved to avoid being exposed to the leaking water. The ceiling leak in the resident activities room was located on the south-east end of the room, and the leaking water was being collected by a container and linen. On (MONTH) 20, 2013 at approximately 12:35 PM, Staff 4 was interviewed and stated, I know where these leaks are coming from. There are some exhaust vents coming from this way (points to the ceiling), and the water is probably coming from the edges of the vents, and running down to the edge of the building roof, and leaking along here (points to leaking areas along ceiling-wall junction). It's leaked here before whenever it rains bad. Finding 5: On (MONTH) 20, 2013 at approximately 11:37 AM, a water leak was noted coming from the ceiling above the first floor atrium over the sub-ground floor hallway between the dining room and the hallway going to the resident rehabilitation area. There was also multiple cracks high up on the west concrete wall that was also leaking water. Finding 6: On (MONTH) 20, 2013, at approximately 10:27 AM there were two episodes of electrical power failure. During the power failure, emergency back-up lighting became operative via the external power generator. However, there was no electrical power or lighting in resident rooms 102, 107, and 111. During an interview with Staff 4 on (MONTH) 20, 2013 at approximately at 12:35 PM, he stated that all the rooms should have back-up emergency power and lighting, and did not know why the affected rooms did not have such during the power outage. The whole building is under the emergency power system .I think one of the main breakers may have tripped, and that ' s why there may be no power to those rooms. There is an electrician here trying to troubleshoot the problem right now .",2018-07-01
59,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2013-09-20,274,D,0,1,JK1T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to conduct a comprehensive assessment of Resident 5 after there was a significant change in the resident's medical/mental condition. Resident 5 was readmitted to the facility on June13, 2013 with a [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. According to an interview with LN 1 during the initial tour of the facility on (MONTH) 18, 2013 at approximately 9:23 AM, the resident was recently moved to a room closer to the nursing station because the facility became aware that the resident 'might want to hurt or kill' themselves. During the tour, the resident was not observed to be in their assigned resident room. Throughout the morning and early afternoon of (MONTH) 18, the resident was observed to be self-propelling herself throughout the facility and outside to the patio located at the front entrance of the facility. An interview with Resident 5 at approximately 1:30 PM on (MONTH) 18, 2013 was done, and they indicated they would be going to an off-campus appointment at 2:30 PM for the remainder of the afternoon. The resident said they felt okay ', and enjoyed going outdoors for fresh air. When asked about their mood, they indicated that they had recently been moved to another room, because a friend called the facility and reported that they (the resident) was trying to cut and kill myself with a knife. She added that it was 'a misunderstanding', and that she was okay now. An interview was done with LN 3 on (MONTH) 19, 2013 at approximately 5:10 PM. The staff person stated that they were not the assigned staff for the resident that shift, and that toward the end of the shift (3 PM - 11 PM) they took a phone call from the friend of the resident on (MONTH) 13, 2013. LN 3 said the caller sounded worried and like they were about to cry, and asked for nursing staff to go check on Resident 5 in their room because I (the caller) think (the resident) may have, or may be trying to cut herself with a knife. The caller told LN 3 that they were worried about the resident because they (the caller and the resident) had just been arguing on the phone. LN 3 reported that earlier during the shift they had observed Resident 5 to be restless and about to cry, and looked mad. LN 3 said they then reported this information to the shift Charge Nurse, and then they went to check on the resident and took the knife away from the resident. LN 3 said that she heard the staff say that the door was locked, and responded to other staff that the door can't be locked because there is no lock on the doors. Staff 3 said that staff then thought that the resident might have barricaded the door closed. Staff 3 said the door was finally opened and they checked on the resident. Staff 3 stated that she was not aware of the resident ever doing this in the past to her knowledge. The staff person added that security was informed to watch her just in case (the resident) does something else. Record review of the Resident's 5 medical record revealed that the primary attending physician was notified on (MONTH) 14, 2013 at 10 PM, at which time the resident was placed on Level-One Suicide Watch precautions. During an interview with LN 5 on (MONTH) 20, 2013 at approximately 10:57 AM, they indicated they had not done a MDS re-assessment related to the change in condition in Resident 5. The staff person stated they believed the event(s) that took place on (MONTH) 13, 2013 did constitute a significant change in the condition of the resident, and that a MDS assessment would probably be indicated. The staff person stated that they became aware of the incident on (MONTH) 18, 2013, and that she asked LN 1 for guidance if an MDS assessment would be needed (LN 5 said they had been mentored by LN 1 related to their role). LN 5 said that LN1 responded by saying that they (the facility) needs to figure out a process for that. LN 5 reported that they have never completed a MDS when there has been a significant change in a resident condition during her tenure in her position at the facility I have never tried that yet. We have only done MDS assessments when they are scheduled .Like at 30 and 60 days. LN 1 was interviewed on (MONTH) 20, 2013 at approximately 11:04 AM and asked if the event(s) involving Resident 5 that took place on (MONTH) 13, 2013 would constitute a significant change in resident condition necessitating a MDS assessment. LN 1 stated that 'we rely on the social worker, and we (the facility) know (the residents) baseline behavior. LN was then asked what guidelines the facility is using to determine what constitutes or qualifies as a significant change in condition, and their response was there is no policy, we follow the MDS 3.0 guidelines. When asked if there should have been an MDS assessment completed, LN 1 said most of the time we focus on the physical changes of the resident, and sometimes not the mental changes .",2018-07-01
60,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2013-09-20,315,D,0,1,JK1T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review the facility failed to ensure one of eight sample residents (Resident #3) that was admitted into the facility with an indwelling urinary catheter had a medical justification for the catheter. Failure to substantiate the need for the indwelling urinary catheter has the potential to contribute to urinary tract and or other facility acquired infections. Findings include: On (MONTH) 20, 2013 the medical record for Resident #3 was reviewed with LN #5. She acknowledged both Minimum Data Sets for the resident dated (MONTH) 6 and (MONTH) 13, 2013 indicated the resident was admitted into the facility with a foley catheter. On further investigation she acknowledged there was no medical justification for the urinary catheter and there was no plan for bladder training or attempt to discontinue the foley. Later that same day LN#5 obtained physician's orders [REDACTED].",2018-07-01
61,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2013-09-20,319,E,0,1,JK1T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on inerviews and record reviews, the facility must ensure that a resident (Residents 5 and 8) who displays mental or psychosicial adjustment difficulty receives appropriate treatment and services to correct the assessed problem. Resident 5 was readmitted to the facility on June13, 2013 with a [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. According to an interview with LN 1 during the initial tour of the facility on (MONTH) 18, 2013 at approximately 9:23 AM, the resident was recently moved to a room closer to the nursing station because the facility became aware that the resident ' might want to hurt or kill ' themselves. During the tour, the resident was not observed to be in their assigned resident room. Throughout the morning and early afternoon of (MONTH) 18, the resident was observed to be self-propelling herself throughout the facility and outside to the patio located at the front entrance of the facility. An interview with the resident at approximately 1:30 PM on (MONTH) 18, 2013 was done, and they indicated they would be going to an off-campus appointment at 2:30 PM for the remainder of the afternoon. The resident said they felt okay' , and enjoyed going outdoors for fresh air. When asked about their mood, they indicated that they had recently been moved to another room, because a friend called the facility and reported that they (the resident) was trying to cut and kill myself with a knife . She added that it was 'a misunderstanding ', and that she was okay now. An interview was done with LN 3 on (MONTH) 19, 2013 at approximately 5:10 PM. The staff person stated that they were not the assigned staff for the resident that shift, and that toward the end of the shift (3 PM - 11 PM) they took a phone call from the friend of the resident on (MONTH) 13, 2013. LN 3 said the caller sounded worried and like they were about to cry , and asked for nursing staff to go check on Resident 5 in their room because I (the caller) think (the resident) may have, or may be trying to cut herself with a knife. The caller told LN 3 that they were worried about the resident because they (the caller and the resident) had just been arguing on the phone. LN 3 reported that earlier during the shift they had observed Resident 5 to be restless and about to cry, and looked mad . LN 3 said they then reported this information to the shift Charge Nurse, and then they went to check on the resident and took the knife away from the resident. LN 3 said that she heard the staff say that the door was locked , and responded to other staff that the door can't be locked because there is no lock on the doors . LN 3 said that staff then thought that the resident might have barricaded the door closed. LN 3 said the door was finally opened and they checked on the resident. LN 3 stated that she was not aware of the resident ever doing this in the past to her knowledge. The staff person added that security was informed to watch her just in case (the resident) does something else. Review of the nursing notes on (MONTH) 13, 2013 timed at 11:20PM read, The girlfriend of this patient called and said Can you go see (resident) in her room, she might slice her wrist. CNA and other nurse went to patient's room. Patient still awake, CNA found a kitchen knife and removed the knife in her room. Patient was up in wheelchair and went upstairs. I went upstairsand give knife to security and told him to watch this patient. On (MONTH) 14, 2013 at 10PM, an entry in the nursing notes read, Called Dr. (attending) informed him about the patients mental state last night. Was informed of suicidal ideation and acting out last night. Incident report was filed. Dr. (attending) ordering to have mental consult and monitor patient and on Level 1 suicide protocol until seen by mental health personnel . . Review of the physician's order [REDACTED]. However, there was also a telephone order by the physician dated (MONTH) 14, 2013 3:15PM obtained from the 3PM-11PM shift (MONTH) go out on pass today with friends for 3-4 hours. This order was obtained apparently prior to the physician being notified of the subsequent request for Suicide Watch order related to the events taking place the previous day. Further record review indicated that the physician's orders [REDACTED]. The order also stated, Initiate the Physical Environment Safety for Suicidal Patient (involve Safety, Security, and Facilities Maintenance). The physician order [REDACTED]. The physician also indicated Patient Transfers (staff must remain in constant attendance of the patient during transfers) 1:1 escorts on transfers (Level 1 & 2), Psychiatric/Behavioral Health Consultation, and Provide patient/family education on suicide precautions. Subsequent daily orders did not include 1:1 escorts on transfers. Based on review of the physician's order [REDACTED]. Review of the nursing notes revealed that the following assessments of the resident were documented related to her being on Suicide Watch Precautions ordered on (MONTH) 14, 2013 at 10PM from the event that took place on (MONTH) 13, 2013 (Note: Assessments were to have been made and documented every two hours, per physician's order [REDACTED].>September 15, 2013 -12:15AM -2:38AM -4:32AM -7:04AM -1:57PM -2:06PM -2:10PM -3:00PM -5:58PM -8:08PM -10:08PM September 16, 2013 -12:45AM -2:44AM -6:11AM -7:41PM -7:46PM -7:49PM -10:07PM September 17, 2013 -1:03AM -4:13AM -6:44AM -10:21AM -10:24AM -5:00PM -8:00PM September 18, 2013 -12:56AM -3:05AM -5:07AM -11:22AM -11:26AM -11:28AM -1:32PM -10:22PM September 19, 2013 -1:13 AM -3:07AM -5:06AM -1:39PM -1:42PM -1:44PM -4:30PM -6:40PM -8:35PM -10:22PM An interview with LN 2 on (MONTH) 19, 2013 at 5:10PM was done related to the resident and suicide watch. She stated that the assessments that were ordered by the physician as part of the Suicide Watch every two hours should have been completed and documented every two hours. When asked about the resident leaving the facility with a 'pass' , she also says that should not have taken place in light of the resident event on (MONTH) 13, 2013 precipitating the Suicide Watch on (MONTH) 14, 2103 at 10PM. She also added that the resident should not have been allowed to leave the facility on a 'pass' if the physician had been notified timely on (MONTH) 13, 2013. There were several disconnects that should not have happened after the incident took place. She should not have been allowed to leave the facility, and the nurses should be doing the assessments every two hours and documenting them as long as the order is in place . She was unclear as to why the initial suicide protocol order stipulated escorts on transfers, but subsequent orders did not. Finding 2: Resident 8 was admitted to the facility on (MONTH) 10, 2013 with a [DIAGNOSES REDACTED]. During an interview with the resident while completing the initial tour on (MONTH) 18, 2013, he was returning from physical therapy, and stated that he was 'sore, but okay' Review of the residents medical record indicated that the Social Worker had documented an interview with the resident on (MONTH) 18, 2013 at 3:19PM that Resident stated that he had been feeling sad due to his present medical condition and severe pain to both legs. He noted that he has thoughts of hurting himself when he experiences severe pain .This worker discussed counseling at GBHWC (Guam Behavioral Health and Wellness Clinic) .And he agreed. Review of the Medication Administration Record [REDACTED]. Further record review on (MONTH) 20, 2013 revealed that the resident was transferred to and seen by a mental health professional on (MONTH) 19, 2013. Nursing notes revealed that the patient returned from GBHWC at 6PM. There was no documentation from GBHWC regarding the evaluation. The only documentation from GBHWC was a one-page document titled Discharge Instructions that said to Return to GBHWC if you feel like harming yourself or others , and to Call the crises line if you feel you need to talk to somebody . Review of the SNU Resident Appointment Communication Form had been completed by Guam Memorial Hospital Skilled Nursing Unit, but the part for the treating physician/clinician to whom the resident was transferred to be seen for evaluation was blank. Review of nursing notes did not include any reference to or assessments related to suicide ideation or risks factors for suicide. An interview with LN 2 was done on (MONTH) 20, 2013 at 11:37AM. She stated that whenever a resident goes out to another facility for treatment or referral, the treating facility at which the resident was seen is supposed to forward a copy of any clinical notes or assessments done while at the treating facility, as well as completion of a SNU Resident Appointment Communication Form . She concurred that there was nothing in the resident ' s medical record from GBHWC other than the one-page discharge instructions addressed to the resident. When asked the behavioral/mental status of the resident related to the potential suicide ideation they were evaluated for, as well as continued plan of care, she responded I will need to have the social worker contact GBHWC to find out what their discharge instructions were and whether or not he still needs to be observed per the suicide watch protocol. An interview was done with SW 2 on (MONTH) 20, 2013 at approximately 11:57AM related to her interaction with resident and the notes she documented in the medical record on (MONTH) 18, 2013. She indicated that the resident reported to her thoughts of suicide. I was interviewing the resident, and he told me of his thoughts to hurt and harm himself. That's when I made sure the referral was made for him to be seen by GBHWC. She added, I didn ' t tell the charge nurse about the suicide ideation, only his depression. I should have told her so they would have been watching him closely, and not just made the note in his record.",2018-07-01
62,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2013-09-20,328,D,0,1,JK1T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure one of eight sample residents (resident #1) with special needs received the proper [MEDICAL CONDITION] suctioning care in accordance with facility policy. Failure to suction the resident's [MEDICAL CONDITION] in accordance with facility policy could potentially lead to lung tissue damage, [MEDICAL CONDITION], or the collection of [MEDICAL CONDITION] sections near or at the [MEDICAL CONDITION] stoma. Findings include: On (MONTH) 20, 2013 at approximately 12:00PM Resident #1, who has a [MEDICAL CONDITION], was observed having several dressings changed; she was logged rolled during the process. The log rolling activity possibly contributed to the loosening of [MEDICAL CONDITION] sections which could be heard as air moved in and out of the [MEDICAL CONDITION]. LN #7 acknowledged the need to suction the resident and suctioning finally occurred at 12:30PM. According to LN#7, the suction should be between negative 240 to a negative 26 milliliters mercury (mmhg). The nursing supervisor (LN2) was requested to provide the [MEDICAL CONDITION] Suctioning policy. LN#2 provided the Naso-tracheal Suctioning policy and it was reviewed concurrently with her. The facility policy states (sic)Lowes possible vacuum pressures are preferred. The higher the negative pressure the greater the possibility for trauma to the tracheal mucosa. Suction pressure should be set at -60 to -80 mmhg in neonates, and -80 to -100 mmhg in adults. LN#2 acknowledged that LN#7 failed to suction the resident in accordance with facility policy.",2018-07-01
63,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2013-09-20,367,D,0,1,JK1T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review the facility failed to ensure one random resident (Resident #10) received his therapeutic diet as prescribed by the attending physician. Failure to receive a prescribed therapeutic diet could potentially contribute to chocking and/or aspiration of food products into the lungs. Findings include: On (MONTH) 20, 2013 Medication Pass was being completed for Resident #10 at approximately 8:30AM. He was admitted on (MONTH) 14, 2013 with a [DIAGNOSES REDACTED]. The resident was finishing his breakfast and agreed to take his AM medications. The medications were administered in accordance with the physician's orders [REDACTED]. LN#7 asked the resident to open his mouth several times to ascertain if all the medications had been swallowed. When the resident opened his mouth there were no medications observed in his oral cavity. He had no permanent teeth or dentures but was attempting to chew on a piece of pear from a fruit cup. The pears on his tray were not chopped. The meal card indicated the resident was to receive a Low Salt Mechanical Soft Chopped Diet-Regular Liquids. Nursing staff called the Dietary department and they were requested to bring a cup of mechanical soft pears to the resident. When the dietary staff member arrived she acknowledged original cup of pears was not chopped. The resident was able to eat the cup of chopped pears without difficulty. In a review of the medical record the physician had prescribed a Low Salt Mechanical Soft Chopped Diet- (with) Regular Liquids.",2018-07-01
64,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2013-09-20,371,C,0,1,JK1T11,"Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. During the initial tour of the facility kitchen on (MONTH) 18, 2013 at approximately 9:05 AM, the following observations were made: 1. An open beverage container and two packages of personal food items belonging to Staff 13 was observed to be opened and partially consumed, and were located on a metal shelf above and to the far right (but not over) the dietary steam table where resident food is stored and kept warm prior to assembling meal trays. Upon observation, Staff 13 removed the personal opened beverage and food items, and placed them in the dietary staff refrigerator. The staff person stated that they realized the opened beverage and food items should not have been placed on the shelf. 2. A container on the shelf in the walk-in refrigerator of cooked white rice that was covered but not dated as to when it had been cooked, when it had been placed in the refrigerator, or an expiration date for discard. Staff 13 stated that the container of cooked rice should have been dated appropriately. 3. A container of peeled ripen bananas was on a shelf in the walk-in freezer was not dated as to when it had been cooked, when it had been placed in the refrigerator, or an expiration date for discard. Staff 13 stated that the container of cooked peeled bananas should have been dated appropriately. 4. During the dietary service observation on (MONTH) 19, 2013 at 4PM, Staff 13 that was preparing for residents of the facility was observed at the stove cooking/heating items for the dinner menu. During the observation Staff 13 repeatedly would put his hands into his pockets and then continue preparing food items without hand washing. 5. During the dietary service observation on (MONTH) 19, 2013 at 4:17PM, Staff 13 was preparing for residents of the facility was observed at the stove cooking/heating items for the dinner menu. The worker would go to the covered trash container located near the stove and across from the steam table, lift (open) the cover, dispose of substances, return the trash container cover (close), and then resume preparing food items for the dinner service without hand washing. 6. An inspection of the dried food storage pantry revealed the following canned items with dents near the top/seal of the canned items: - One 107-once can of mandarin oranges - One six-pound can of pear halves - One 107-once can of pear halves Staff 13 stated that food containers received from food service delivery are inspected upon receipt, and that the pantry storage area is also inspected by facility staff on a weekly basis to ensure that stored food items are in intact containers.",2018-07-01
65,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2013-09-20,441,E,0,1,JK1T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infections. Failure to prevent the development and transmission of disease and infections could potentially contribute to facility acquired infections for all residents and staff. Findings include: 1. Resident 5 was readmitted to the facility on June13, 2013 with a [DIAGNOSES REDACTED]. The facility placed the resident of Contact Isolation precautions. These precautions included, per policy and the sign on the door of the resident's room, that gloves and gown be worn when entering the room, as well as hand washing before entering and after exiting. An observation of a wound ulcer dressing change was made on (MONTH) 19, 2013 at approximately 11:50AM. The resident (Resident 5) had bilateral skin ulcers to both feet/lower extremity. LN 6 stated that the resident was on contact precautions due to the ulcer wounds being MRSA positive. LN 6 assembled the items necessary to do the dressing change, placed them in the room on a mayo stand, and then proceeded to wash his hands and don the appropriate protective equipment as stated in the facility policy. As LN 6 was preparing to remove the current wound dressing, he realized that he needed additional supplies, and left the room wearing his gloves and gown without removing them. He went to the medication cart to retrieve an ointment, and then returned to the room to resume the procedure. As LN 6 was trying to remove the current dressing by pulling away the tape securing to the area, he decided to use his personal scissors from a pocket in his uniform, and proceeded to cut away the current dressing covering the wounds with the scissors. As he was changing the dressings on the various ulcers wounds, LN 6 used the same glove to grasp the prescribed ointment to be applied to the new dressing, and then place it back on the mayo stand. At the completion of the dressing change, LN 6 used an alcohol wipe to clean the scissors, and then placed them back in his pocket. When asked whether or not if he knew if alcohol was an effective disinfectant to use on his scissors that were used on a resident with MRSA, he responded that he wasn ' t sure, I will have to look into that. LN 6 was observed putting the ointment container that he used on the patient ' s wounds back into the medication cart that contains and stores medication for residents throughout the facility that is accessed by all licensed staff. 2. Resident 4 was readmitted to the facility on (MONTH) 3, 2013 with a [DIAGNOSES REDACTED]. The resident had been placed on contact precautions, and there was a placard taped outside the room indicating such, and that visitors and staff need to wear gloves and gowns when in the room, and wash hands upon entry and exit of the room. During the initial tour of the facility (MONTH) 18, 2013 at approximately 9:10AM, LN 1 entered the room of the resident. A family member of the resident was sitting at the bedside playing cards, and was not observed to be wearing gloves. The family member was also observed throughout the remainder of the day to not be wearing gloves while in the resident room, nor washing hands when exiting. After the tour was completed, LN 1 was interviewed regarding what contact isolation was. He indicated that all staff and visitors need to at least wear gloves, regardless of what they do in the room. He added that if there was going to be close contact between the resident and staff or visitors, those individuals would also have to wear a gown. On a different observation on (MONTH) 19, 2013 at approximately 11:10AM the family member was observed to be arranging the blanket that was covering the patients torso and legs (upper extremities). Again, the family member was not wearing gloves. On (MONTH) 19, 2013 at approximately 1:50PM, the family member of the resident was interviewed and asked if he had been educated regarding the resident ' s condition, why they were on contact precautions, and what the interventions were (as posted on the placard taped near the doorway). The family member stated they didn't recall, but said they would start. 3. An observation of a dressing wound change of Resident 4 was observed at approximately 12:10PM on (MONTH) 19, 2013. Prior to the dressing change, the nurse pulled the privacy curtain around the bed of the resident to protect the privacy of the resident during the procedure. When the light blue drape made of disposable material was pulled around the patient, there were darkened spots on the drape where some fluid that was dark in color had splashed or spilled, and subsequently dried on the material. After the wound dressing was complete, LN 10 was interviewed at approximately 12:40PM. When asked about the dried substance, she stated she didn't know what it was or how long it had been there, but it looked gross . When asked how often the curtains are changed, she wasn't sure, but responded sometimes not often enough . 4. Resident 6 was admitted to the facility on (MONTH) 4, 2013 with a [DIAGNOSES REDACTED]. The resident was placed on contact precautions, and there was a placard taped outside the room indicating such, and that visitors and staff need to wear gloves and gowns when in the room, and wash hands upon entry and exit of the room. During the initial tour of the facility with LN 1, a family member was observed asleep in a chair at the bedside of the resident. The family member was observed to not be wearing gloves (or a gown). On (MONTH) 20, 2013 at approximately 10:05AM, a different family member was observed at the bedside of the resident. The family member was observed to not be wearing of the protective equipment that was stipulated on the placard for staff and visitors. The family member was then asked if they knew why the resident was on contact precautions. The family member responded saying that they thought was due to an infection in the urine of the resident, but not certain. When asked if they had been educated about the precautions, he responded 'not really' . The family member went on to say that sometimes staff wore gloves, sometimes they didn't. While interviewing the family member, an area of dried fluid appearing white in color was observed on the disposable drape window covering. The bottoms of the light-blue disposable curtain was also frayed, torn, and appeared dirty. That looks terrible the family member said. Can't they afford to change them (the disposable drapes)? 5. On (MONTH) 18, 2013 LN#14 was observed administering a gastric-tube feeding to Resident #1. The nurse stated the resident was on contact isolation precautions due to multidrug resistance and the presence of Methicillin-resistant Staphylococcus aureus. He used a gown, gloves and mask during the gastric tube feeding. On (MONTH) 20, 2013 at approximately 12:00PM Resident #1 was observed having several dressings changed by LN#7; aside from the gastric feeding tube the resident also has a tracheostomy and a pressure ulcer dressing. The nurse was using a gown, gloves and mask; gloves were changed several times during the dressing changes. The resident was log rolled during the dressing changes which may have loosed up some pulmonary secretions which necessitated tracheostomy suctioning. While waiting to suction the tracheostomy LN#7 was observed entering into and out of the room into the hall with the same gown and mask. The nursing supervisor (LN #2) was requested to provide the facility policy regarding contact precautions. LN#2 provided the policy addressing Expanded Precautions dated 12/2009. Under item #I of the Expanded Precautions the policy addressed Contact Precautions. Sub item f of the Contact Precautions indicates . Gloves, mask and gowns should not be worn outside the resident's room once care of the resident has been initiated. That same section of the Contact Precautions section was reviewed with the Nursing Supervisor and she affirmed she would have expected LN #7 to remove her gloves, mask and gown if she was exiting the resident's room.",2018-07-01
66,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2013-09-20,456,D,0,1,JK1T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure all essential patient care equipment was in safe operating condition. Failure to have safe and operational portable suction equipment could potentially lead to a blocked airway for any resident dependent on staff to clear their airway. Findings include: On (MONTH) 20, 2013 at approximately 12:00PM Resident #1, who has a [MEDICAL CONDITION], was observed having several dressings changed; she was logged rolled during the process. The log rolling activity possibly contributed to the loosening of [MEDICAL CONDITION] sections which could be heard as air moved in and out of the [MEDICAL CONDITION]. LN#7 acknowledged the need to suction the resident and she attempted suctioning by using the wall suction piped into the resident room. The wall suction failed possibly due to the power outages that were occurring related to heavy rains. LN#7 obtained the portable suction equipment as an alternative to the wall suction. The portable suction would not go past five on the suction dial and the nurse acknowledge the portable suction was not working in-spite of several attempts to adjust the suction dial. Careful inspection of the portable suction device revealed the last time the equipment was check for safety was on (MONTH) 12, 2011. The safety inspection sticker revealed the next projected safety check was suppose to occur in (MONTH) 2012. The LN#7 acknowledged the portable suction was not inspected in 2012 nor 2013. The last dated safety inspection sticker on portable suction was dated (MONTH) 12, 2011. The wall suctioning mechanism was finally fixed by 12:30PM and the resident was suctioned by LN#7.",2018-07-01
67,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2013-09-20,518,D,0,1,JK1T11,"Based on interview the facility failed to train all employees on emergency fire procedures. Failure to have all staff trained on fire alarm procedures could potentially compromise all residents and staff. Findings include: On (MONTH) 19, 2013 CNA #15 was interviewed at 4:00PM regarding her response to a situational fire and the use of a fire extinguisher. The facility has wall mounted single action fire alarm boxes that have a key hole. She was not sure how to use the wall mounted single action fire alarm box. She stated she would need to use a key to activate the wall mounted single action fire alarm box. On (MONTH) 19, 2013 CNA #16 was interviewed at 4:20PM regarding her response to a situational fire and the use of a fire extinguisher. The facility has wall mounted single action fire alarm boxes that have a key hole. She was not sure how to use the wall mounted single action fire alarm box. She stated she would need to use a key to activate the wall mounted single action fire alarm box. On (MONTH) 19, 2013 the Maintenance Supervisor as was interviewed at 4:35PM regarding the appropriate use of the wall mounted single action fire alarm boxes which have a key hole. He affirmed no key was needed to activate the wall mounted single action fire alarm boxes.",2018-07-01
68,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,157,D,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to immediately inform/consult with the resident ' s physician when there is a significant change in the resident ' s physical status and when there is a need to alter treatment significantly for one sampled and one non-sampled residents. (4 and 11) Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of initial assessment dated [DATE] identified the resident as totally dependent on staff with all activities of daily living except eating. The resident had surgery to repair the fractured left hip (open reduction internal fixation) on 12/18/11. The initial assessment identified the resident with frequent hip pain daily. The admission notes dated 12/21/12 at 22:41 revealed the resident had a surgical wound that measured 15 ? centimeters (cm) scar incision in the left hip/thigh and a sore in the left hand in between the second and third finger. The Braden scale for pressure sore identified the resident as moderate risk to develop pressure sores. Upon admission the resident did not have any pressure sores but the resident was bedfast and required moderate to maximum assistance. Review of the nurses ' progress notes revealed that on 12/25/11 at 21:30, the left inner buttock 3 small 1-0.5 cm next to the sacrum, about an inch below it, small 0.5 cmx0.6 cm and the larger one at the bottom 2.0 cm L(length) x 1.0 cm W(width). dry, no drainage. Duoderm applied. On 1/25/12 at 4:00 p.m. in an interview with the licensed nurse who documented the pressure sore discovery, she revealed that she reported the skin breakdown to the charge nurse and was verbally told to apply the Duoderm. However, she was not sure if the physician was notified on the same day. She indicated that only the registered nurses (RNs) notify the physicians if there is a need to initiate or change a treatment for [REDACTED]. [REDACTED]. Review of the physician's orders [REDACTED]. 2. Resident 11 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial assessment nursing notes revealed no skin breakdown. On 1/25/12 at 9 a.m. Resident 11 was observed during morning care rendered by a certified nursing assistant. During the bedbath, the resident's back had three areas of persistent redness: a raised reddened area in the mid-back, flat reddened area on the right side of the back and a blackish red abraded area on the sacrum. The licensed nurse indicated that A&D ointment is applied as a preventive measure, however, the CNA did not apply the ointment because it was unavailable. The nurses' notes dated 1/24/12 revealed that the certified nursing assistant notified the licensed nurse of redness on the buttocks, raised reddish patches on the sacral area. On 1/25/12 on 11 pm-7 am shift, a licensed nurse documented red raised area mid-upper back still present, hard to touch. Charge nurse (CN) made aware. On 1/25/12, the 7 am-3 pm shift nurses notes revealed a reddened tender area size-like a quarter still present at mid upper back. Notified CN. Review of the resident's medical record showed no documented evidence that the physician was notified of the reddened skin areas at the back. On 1/25/12 at 4 p.m. interview with the resident's husband revealed a concern of the reddened raised area on the resident's back if it was a growing cyst. He was also concerned about the resident's peeling skin in the hands and feet from the allergic reactions incurred from antibiotics infused in the hospital. On 1/25/12 after discussions with the licensed nurse of Resident 11's skin condition, the charge nurse notified the physician and obtained orders for warm compress to mid-upper back. The physician also held the [MEDICATION NAME] and [MEDICATION NAME] doses for that day.",2017-01-01
69,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,164,E,0,1,J2NN11,"Based on observation, interviews, and record review, the facility failed to ensure the resident's right to personal privacy for three residents in the sample (3, 4, and 11) and confidentiality of his or her clinical records. Findings include: 1. On 1/23/12 at 3 p.m., during the initial tour, a licensed nurse did not provide visual privacy when she checked Resident 3's diaper exposing the resident's lower body to anyone passing in the hallway. 2. On 1/25/12 at 2:45 p.m., during a treatment observation, the blue window drape was partially covering the resident's window in the room. While the licensed nurse treated the Resident 4's sacral pressure ulcer, the resident pointed to the partially draped window upon seeing two male residents pass by in wheelchair to the outside grounds. Interview with the nurse revealed she did not notice the window was partially draped and that the resident refuses male caregivers be assigned to care for her. 3. On 1/26/12 at 9 a.m., the privacy curtain was partially pulled around the resident ' s bed, exposing the resident's upper body to the hallway while a certified nursing assistant was giving Resident 11 a bath while in bed. 4. On 1/26/12 at 8:15 a.m., during medication pass observation, one licensed nurse left the log book that contained the medication administration records (MAR) open to anyone passing in the hallway. This happened a couple of times when the licensed nurse left the medication cart unattended while she administered medications to the residents who were eating breakfast in the dining room.",2017-01-01
70,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,242,D,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to 1. Allow a resident (Resident 5) to make choices regarding her bath time when staff bathed the resident at 5 AM. 2. Ensure the right to choose bathing schedule when Resident 3's wound care was scheduled for staff convenience. The above deficient practices effected the quality of life for 2 of 10 sampled residents (Residents 5 and 3). Findings: 1. Resident 5 was admitted with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) for feeding. The resident was alert and responsive with eye movement and required total care for activities of daily living (ADLs). A family member was with the resident 24 hours per day. During Family interviews on 1/24/2012 at 3:45 PM, Resident 5's family stated they had informed the facility of this on admission that Resident 5 had always preferred bathing later in the day. The facility did not give the resident a bath until the family asked them too, three days after admission, and then the staff woke the resident up at 5 AM to give her a bath. The family said that although the resident was unable to speak and was bedbound as a result of a recent stroke she still knew what was going on. During an interview on 1/26/2012 at 11:15 AM, The head nurse stated the admitting nurse did ask the resident's preference for bathing; however bedbound residents received their baths on the night shift, as the day and evening shift was too busy to bathe everyone. 2. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Recent hospital admission was due to urinary tract infection, dysuria and infected left leg. Urine cultures showed Escherichia (E.) Coli and leg wounds with heavy growth of pseudomonas aeruginosa (1/17/12). On 1/23/12 at 3:10 pm, during the initial tour, Resident 3's left lower leg dressing was observed soaked with bright red drainage. The licensed nurse stated that the physician has just changed the resident's leg ulcer dressing at the bedside. Review of the Patient Progress Notes record dated 1/12/12 revealed the left leg wounds were debrided. On the same day, the physician ordered wound care daily alternate wet to dry with [MEDICATION NAME]. On 1/25/12, in an interview, the morning charge nurse indicated that the leg treatments were done by the night shift nurses because the resident belonged to the list of residents scheduled for early morning showers and dressing changes can be done after the shower. On 1/26/12 at 8:15 a.m. Resident 3 was observed up in wheelchair eating breakfast in the common dining room. Upon surveyor request, a treatment observation was done after the resident finished breakfast meal and returned to room. The treatment nurse assessed the multiple sites of debrided pressure sores and found inaccuracies in the wound measurements and identification of a black eschar in the left ankle that was not reported to the physician.",2017-01-01
71,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,246,D,0,1,J2NN11,"Based on observation, interview and record review the facility did not accommodate the resident needs when staff delayed the provision of care for up to 1 hour after 2 of 15 residents (sampled resident 8 and unsampled resident 13) used the call bell system to request assistance for personal needs. Findings: During interviews on 1/24/2012 beginning at 2 PM, Resident 8 stated she needed help to use a walker to get to the bathroom. The night shift staff were slow to answer the call light, which caused the resident distress at getting to the bathroom in time. Resident 13 stated she need help to get to the bathroom. When she used the call light to call for help, the staff would come in and turn off the call light stating they would be return; however she would have to wait for up to one hour to get help. She stated only the CNA's would answer the call lights. During an interview on 1/26/2012 beginning at 11:15 AM, the head nurse stated she expected all staff to answer the call lights and they should be answered within five minutes. Review of the Policy and Procedure titled Use of Call Light #6580 read as follows: Procedure: 1. All facility personnel must be aware of call lighted at all times. 2. Answer ALL call lights promptly whether or not you are assigned to the resident . 6. Answer all call lights in a prompt, calm, courteous manner; turn off the call light as soon as you enter the room. 7. Never make the resident feel you are too busy to give assistance; offer further assistance before you leave the room . 14. Limit the call light response time up to 5 minutes.",2017-01-01
72,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,253,B,0,1,J2NN11,"Based on observation and interview, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Findings include: 1. During the initial tour on 1/23/12, at 3:15 p.m., two rolls of toilet paper were observed on top of the toilet water tank cover in room 106. Further observation revealed that the roller pin was missing from the toilet paper dispenser that was on the wall adjacent to the toilet. In addition, a hamper for dirty linen was observed inside the bathroom. 2. During the environmental tour on 1/24/12, the ventilator screen in the main hallway above the door leading to the recreation room was observed heavily laden with dust. Another ventilator screen inside the recreation room on the wall adjacent to the door was also noted with a thick accumulation of dust. During an interview on 1/25/11, a maintenance staff stated that the cleaning of ventilator screens were ongoing but that there were other screens in the facility that staff have yet to get to that were not clean.",2017-01-01
73,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,279,D,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the assessment. Findings include: 1. Resident 2 was admitted on [DATE] with several [DIAGNOSES REDACTED]. Review of the Mini Nutritional Assessment dated 1/07/12, revealed that Resident 2 was nutritionally at high risk and with increased nutrient needs related to severe malnutrition (as evidenced by) severe protein depletion with [MEDICATION NAME], and cachexia . The assessment also noted that his height was 5 feet and 5.75 inches and that he weighed 96 lbs. Initial nutritional recommendations dated 1/07/12 included providing Resident 2 with enteral feedings of [MEDICATION NAME] 1 can every 6 hours for 24 hours increasing to 1 can every 4 hours, and 150 ccs water for flush. This regimen, accordingly, would provide the resident with 1500 kcal and 61 gms of protein per day. The recommendation further noted monitoring of tube feeding residuals, monthly weights, weekly laboratory tests, and hydration status. Further review of the medical record revealed that while a care plan was written for special needs--providing nutritional support, the plan however was developed relative to the risk for aspiration and not the resident's need for nutritional support. The care plan, for example, did not identify goals that needed to be met or indicators that needed to be monitored to help ensure that Resident 2 met established nutritional benchmarks such as weight and [MEDICATION NAME] levels. Further review of the care plan revealed the lack of identification of a desired or target weight and did not specify if the current enteral feeding regimen allowed for weight gain. While the resident was described in a dietary note dated 1/16/12 as being underweight (weight noted on admission was 96 lbs), no other weight measurements were obtained until 1/25/12 when a weight of 95.2 was recorded. Further review of the medical record revealed that an [MEDICATION NAME] level (a measure of protein stores; normal limit 3.5 - 5 gm/dl) of 2.2 was obtained at the acute care hospital on [DATE]. Review of Resident 2's medical record at the facility however revealed that while laboratory tests including chemistry panels were available, there was no indication that an [MEDICATION NAME] level however was obtained as a measure of outcome to help determine if current interventions were effective or needed to be adjusted. 2. Resident 1 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the minimum data set ((MDS) dated [DATE] revealed that the resident was alert and oriented, dependent on staff for most activities of daily living, and continent of bladder function. The care area assessment (CAA) summary for the current admission noted that urinary incontinence will not be care planned because the resident is continent. Review of nurses notes including on 1/16/12 revealed that Resident 2 was incontinent of bladder. On 1/18/12, for example, the resident was documented as incontinent of bladder and bowel. 1/20/12, the resident was also noted as being incontinent of urine. In addition, SNU (skilled nursing unit) nurse aide flowsheets dated 1/20/12 through 1/23/12 described Resident 2 as incontinent of bladder function. In spite of the documentation of incontinence, review of the medical record revealed the lack of indication that a care plan was developed to address the change in bladder status which included goals and outcomes as well as interventions to prevent further diminishment of function. During an interview on 1/24/11, Resident 2 stated that while he had been having episodes of urinary incontinence which required him to wear briefs, that he however still feels the urge if he has to urinate. The resident added that he had been having accidents because of the increasing urgency and the delay and difficulty of getting him to the bathroom. 3. There was no evidence that the interdisciplinary team developed a comprehensive care plan to address the individual needs of a [MEDICAL TREATMENT] resident. For example: Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/24/12 at 3:30 p.m., Resident 8's husband expressed concern regarding the coordination of [MEDICAL TREATMENT] treatments related to schedules and transportation. He indicated that post surgery, Resident 8 was moved to the Tuesday, Thursday, Saturday last shift schedule due unavailability of the M-W-F slot. The [MEDICAL TREATMENT] facility would call them if ever there was an available chair to dialyze earlier than scheduled. However, at times, the [MEDICAL TREATMENT] schedule would change and they remain waiting for hours on standby until the first available chair would be available. This also affects arrangements with transportation services. Interview with the social service designee on 1/25/12 at 10:30 a.m. revealed that they discussed these issues with the husband. review of the resident's medical record revealed [REDACTED].",2017-01-01
74,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,281,D,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that services provided by the facility meet the professional standards of quality for one of non-sample resident (12). Finding includes: On 1/25/12 at 8:30 a.m. a licensed nurse was observed to administer two inhalers for Resident 12: [MEDICATION NAME] 220 mcg. 2 puffs and [MEDICATION NAME] 90 mcg. 2 puffs. The manufacturer's recommendation for [MEDICATION NAME] revealed that after taking the medication, the mouth should be rinsed with water and to spit out the water. There was no evidence that the resident rinsed his mouth after 2 puffs of [MEDICATION NAME] was administered. This was confirmed by the medication nurse.",2017-01-01
75,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,309,D,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record and review, the facility failed to provide the necessary care and services to attain or maintain the highrest practicable physical, mental, and psycho-social well-being, in accordance with the comprehensive assessment and plan of care for two of 10 sampled residents. (4 and 8) 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of initial assessment dated [DATE] identified the resident as totally dependent on staff with all activities of daily living except eating. The resident had surgery to repair the fractured left hip (open reduction internal fixation) on 12/18/11. The initial assessment identified the resident with frequent hip pain daily. For pain management, Resident 4 was prescribed [MEDICATION NAME] tablets. Also, she was received one tablet of [MEDICATION NAME] 5/325 on 12/22/11 twice that same day and once on 12/24/11. One of the side effects of [MEDICATION NAME] is constipation. The Medication Administration Record [REDACTED]. one tablet daily. Review of the vital signs log and MAR indicated [REDACTED]. On 12/25/11 at 2:15 p.m., the physician ordered [MEDICATION NAME] suppository as needed (PRN) for constipation and milk of magnesia (MOM) 30 milliliters (ml) by mouth three times a day PRN for constipation. Review of the MAR indicated [REDACTED]. The second episode of 3 consecutive days of no BM for 3 shifts was from 12/26/11 to 12/28/11. The MAR indicated [REDACTED]. was administered with results as followed: On 7 a.m.-3p.m. shift, the resident had large BM 3x and on 3 p.m.-11a.m. had one extra large BM. The third episode of no BM episode was from 12/30/11 to 1/2/12. Review of the MAR indicated [REDACTED]. without results. On 1/3/12 at 7:30 a.m., MOM 30 ml was administered. On the same day during the 3p.m.-11p.m. shift, the resident had medium size BM twice and on 1/4/12 during the 3p.m.-11p.m. shift had one large BM. On 1/25/12 at 11:45 a.m., in an interview, the administrator and former director of nursing confirmed the inconsistencies in the implementation of PRN medications for constipation. He further explained that the facility no longer implement the old bowel protocol because each resident should have an individualized bowel program. He added that the expectation is for the nurses to administer the oral medication first and to administer the suppository if the oral medication ordered did not work. 2. Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/24/12 at 3:30 p.m., Resident 8's husband expressed concern regarding the coordination of [MEDICAL TREATMENT] treatments related to schedules and transportation. He indicated that post surgery, Resident 8 was moved to the Tuesday, Thursday, Saturday last shift schedule due unavailability of the M-W-F slot. The [MEDICAL TREATMENT] facility would call them if ever there was an available chair to dialyze earlier than scheduled. However, at times, the [MEDICAL TREATMENT] schedule would change and they remain waiting for hours on standby until the first available chair would be available. This also affects arrangements with transportation services. Interview with the social service designee on 1/25/12 at 10:30 a.m. revealed that they discuss these issues with the husband. review of the resident's medical record revealed [REDACTED]. There was no interdisciplinary plan of care on how to care for residents residing in the facility and dialyze outside of the facility in terms of accountability in care and emergency services.",2017-01-01
76,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,312,D,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene for one of 10 sampled residents (Resident 5) and one non-sampled resident (Resident 11) who were unable to to carry out activities of daily living. Findings include: 1. Resident 11 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial assessment nursing notes revealed no skin breakdown. The initial assessment dated [DATE] revealed that the resident was totally dependent on staff with one person physical support for personal hygiene and bathing. On 1/25/12 at 9 a.m. Resident 11 was observed during morning care rendered by a certified nursing assistant (CNA). During the bedbath, the resident's fingernails were observed an quarter of an inch long with black substance under the nail bed in the right hand. There were also three areas of persistent redness observed in the resident's back: a raised reddened area in the mid-back, flat reddened area on the right side of the back and a blackish red abraded area on the sacrum. The licensed nurse indicated that the resident scratches herself at times. The nurse also indicated the resident had a history of [REDACTED]. The resident's bilateral hands and feet were observed dry and had significant amount of peeling skin. On the same day at 10 am, upon interview, the resident stated that she wanted her fingernails trimmed. On 1/25/12 at 4 p.m. interview with the resident's husband revealed a concern of the reddened raised area on the resident's back if it was a growing cyst. He was also concerned about the resident's peeling skin in the hands and feet from the allergic reactions incurred from antibiotics infused in the hospital. 2. Resident 5 was admitted with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) for feeding. The resident was alert and responsive with eye movement and required total care for activities of daily living (ADLs). A family member was with the resident 24 hours per day. During Family interviews on 1/24/2012 at 3:45 PM, Resident 5's family stated they had informed the facility of this on admission that Resident 5 had always preferred bathing later in the day. The facility did not give the resident a bath until the family asked them too, three days after admission, and then the staff woke the resident up at 5 AM to give her a bath. The family said that although the resident was unable to speak and was bedbound as a result of a recent stroke she still knew what was going on.",2017-01-01
77,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,314,G,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interviews, and record review, the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they are unavoidable for one of 10 sampled residents, (Resident 4) and one of 5 unsampled residents (Resident (11); and failed to provide necessary treatment to promote healing and prevent infection for one of 10 sampled residents (Resident 6) a resident who entered the facility with pressure ulcers. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) for feeding and a urinary catheter for elimination. The resident required total assistance for activities of daily living (ADLs). The resident's family member was with the resident most of the time. Review of the facility Pressure Ulcer Management Policy # 6301-II C-15 identifies pressure ulcers as follows: Stage 1: An observable, pressure-related alteration of intact skin. Skin changes in one or more of the following parameters: a. Skin temperature (warmth or coolness) b. Tissue consistence (firm or boggy) c. Sensation (pain, itching) d. A defined area of persistent redness in lightly pigmented skin, whereas in darker skin-tones, the ulcer may appear with persistent red, blue or purple hues. Stage 2: Partial thickness skin loss involving epidermis, dermis or both. the ulcer is superficial and presents clinically as an abrasion, or shallow crater. Stage 3: full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underling fascia. The ulcer presents clinically as a deep crater with or without undermining adjacent tissue. Stage 4: full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (e.g., tendon, joint capsule). Undermining an sinus tracts also may be associated with Stage 4 pressure ulcers. unstageable: When the wound is mostly covered with necrotic tissue, it can not be staged until it is debrided. During observations on 1/24/2012 at 1:30 PM, a licensed nurse (LN) and a certified nursing assistant (CNA) were providing care to Resident 6. The resident was positioned on her right side. The CNA removed the resident's soiled brief. The urinary catheter bag was attached to the right side of the bed, causing the catheter tube to pull from the resident's urethra over the stool and down to the collection bag. Neither the nurse nor the CNA were observed moving the collection bag to the left side of the bed, nearer to the resident and out of area where the staff were working. The CNA used hand that was gloved to clean the resident while pouring water with the other hand over the perineum and the catheter tubing- spreading the stool over the entire perineum including the opening of the urethra, which increased the risk of urinary infection and infection of the sacral pressure ulcer. After the area was cleaned, the nurse removed the dressing from a Stage 4 pressure ulcer on the resident's sacrum. She cleansed the wound, and dressed it as ordered by the physician; however when she tried to secure the dressing, she taped the lower end of the dressing very near the anus where the tape would not stick. The dressing was not secure to prevent fecal cross contamination. The staff stated they had completed the resident's care. Resident 6's heels were covered with socks and heel protectors (a foam bootie). The surveyor asked to see the resident's heels. The right heel had a black circular pressure ulcer with reddened area surrounding the ulcer. The measurements were 4.0 cm x 2.0 cm. The wound bed could not be visualized as it was covered with hard black necrotic (dead) tissue termed Eschar. No treatment was provided for the heel pressure ulcer. When asked why the heel wound was not treated the LN stated she did not know. When asked the Head Nurse, she stated she did not know, however she would contact the doctor to find out. When asked about the method of cleaning the resident, the CNA stated We do not have enough wash cloths to go around. When asked about the catheter pulling the CNA and the LN stated, We should have moved it to the other side. Review of the electronic medical record Wound Assessment revealed the following: 10/22/2011 - Right heel- Stage 1 pressure ulcer, size 1 cm Length (L) x 0.75 cm Width (W) appearance -black skin noted. Treatment- Heel protectors and elevate heels. Sacrum- Stage 3 pressure ulcer size 6 cm L x 7 cm W appearance - 70% red, 30 % brown. Treatment - wet to dry (dressing) with normal saline. 11/8/2011- Right heel- Stage 1 size 1 cm L x 1 cm W appearance - black hard necrotic. Treatment- heel protectors and elevate heels. Comment- improvement. However the size had increased and necrotic tissue was present. Sacrum - Stage 2 size 6 cm L x 4.7 cm W appearance - pinkish/read surrounding, serous (yellowish fluid) discharge center of the wound is yellow brown color. Treatment- wet to dry dressing with normal saline. The standard of practice is not to down Stage a pressure ulcer - 11/25/2011 - Right heel - Stage 2 size 2 cm L x 1 cm W appearance - blackish. Treatment heel protectors and leg elevated. Sacrum- Stage 3 size 6.5 cm L x 5 cm W appearance- center - yellow/surrounding red. Serosanginous (yellowish/bloody) drainage. Treatment- wet to dry dressing with normal saline. 12/16/2011 - Right heel - Stage 2 size 2 cm L x 2.5 W cm hard black scab. Treatment heel protectors and leg elevated. Note - patient unable to reposition leg. Sacrum- Stage 3 size 7 cm L x 5.5 cm W x 2 cm D (deep), appearance- center - pinkish/ grayish yellow. yellowish drainage, mild odor and with grayish necrotic tissue. Treatment- wet to dry dressing with normal saline. Reposition every 2 hours side to side. The type of treatment to the sacral wound was not changed despite evidence that the wound was getting worse. 12/22/2011 - Right heel - No assessment documented. Sacrum - Stage 3 size 5.2 cm L x 7.7 cm W x 2.5 cm D appearance pinkish with yellowish tissue - wound debrided. Treatment- hydrogen dressing. 12/31/2011- Right heel - Stage 2 size 2 cm L x 2.3 cm W, appearance blackish, hard and dry. Treatment elevate on the pillow, heel of the bed. Sacrum - Stage 4 size 5.2 cm L x 7.7 cm W x 3.2 cm D with 2.5 cm undermining at 8 o'clock. Appearance - pinkish with yellowish tissue, yellowish drainage, mild odor. Treatment- hydrogel and [MEDICATION NAME] dressing after cleaning with normal saline. 1/24/2012 - (Observed by surveyor) Right heel- Stage 2 size 4 cm L x 2 cm Appearance - black with reddish surrounding. Treatment: heel protector, heel off the bed. Comment both lower extremities elevated on the pillow. Sacrum - Stage 3 size 4.6 cm L x 6 cm W x 3 cm D. No appearance documented. Treatment - wet to dry clean with normal saline, [MEDICATION NAME] wash and hydrogel applied to inner area of the wound. The heel wound was unstageable due to the presence of eschar covering the entire wound. There was no documentation as to why the right heel wound was not treated. The sacral wound started out as a Stage 3 and progressed to a Stage 4 involving bone and muscle. Undermining was documented one time. Review of the laboratory reports for the sacral wound were as follows: A swab sample of the sacral wound drainage was collected on 12/29/2011 source: deep wound sacral decubiti Stage 4 - Culture and Sensitivity (C&S) final results dated 1/3/2012 showed infection with four multi-drug resistant organisms (MDROs) Pseudomonas aeruginosa, Cirtobacter freundii, Acinetobacter baumannii [DIAGNOSES REDACTED] pneumoniae. The resident had prior infections of the [DEVICE] site collected C&S 11/9/11 with [DIAGNOSES REDACTED] pneumoniae and Pseudomonas aeruginosa; Two urinary tract infection [MEDICAL CONDITION] collected C&S 11/16/11 with Escherichia coli (E.coli- an organism found in feces) and 12/6/11 with Pseudomonas aeruginosa; and Peripherally inserted central catheter (PICC-line) infection C&S collected 12/6/11 with [DIAGNOSES REDACTED] pneumonia. The sacral wound was infected 12/29/2011 with two of the bacterium found in three other sites of the body. Review of the Care Plan Conference Summary dated 12/5/2011 and 12/7/2011 revealed the resident had a stage 3 pressure ulcer on 12/5/2011 and 2 pressure ulcer on 12/7/2011. A summary of the Interdisciplinary care conference and the staff's recommendations were faxed to the physician on 12/9/2011. The summary did not include complete or accurate identification or treatment of [REDACTED]. There was no documentation of discussion of the location of the pressure ulcers, or the progression in size or the infections of the pressure ulcers or the treatment of [REDACTED]. Review of the facility Pressure Ulcer Management Policy # 6301-II C-15 under section III. Wound Prevention/Management Interventions part C. reads as follows: For patients who have a pressure ulcer, document on the weekly Braden Scale Assessment, or when there is a change in the pressure ulcer and intervene appropriately (based on the stage level of the wound), as follows: .Stage II - Air Mattress .[MEDICATION NAME] Cleansing Spray . [MEDICATION NAME] Cream (moisture barrier) .Duoderm, changed every 3 days or as needed, OR Transparent film dressing, changed every 2 days or as needed, turning schedule every 2 hours. Stage III - Air Mattress, .[MEDICATION NAME] Cleansing Spray .[MEDICATION NAME] Cream . Normal Saline wet to dry dressing 2-3 times per day, cover with gauze using [MEDICATION NAME] tampe to secure to skin. [MEDICATION NAME] gel (to keep wound bed moist and promote (new cell growth), cover with gauze using [MEDICATION NAME] tape to secure to skin .Turning schedule every 2 hours .Stage III with necrotic tissue .Santyl Ointment (enzymatic Debridement) daily application, cover with guaze using [MEDICATION NAME] tape to secure to skin. Stage IV- Same as Stage III. There were no guidelines for how to manage unstageable pressure ulcers. There were no guidelines for Deep Tissue injury. The facility did not follow their policy in using [MEDICATION NAME] Cleansing Spray, [MEDICATION NAME] Cream, Duoderm or Transparent film dressing for Resident 6's right heel Stage II pressure ulcer (This pressure ulcer was unstageable because it was covered with Eschar) The Facility did not follow their policy in using Santyl (or any other enzymatic [MEDICATION NAME] agent) for Resident 6's Sacral Stage III pressure ulcer when eschar formed. Surgical debridement ended up revealing a deep Stage IV pressure ulcer. 2. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital history and physical record dated 1/8/12 revealed the resident was admitted due to [MEDICAL CONDITION] Recent admission with urinary tract infection, dysuria and infected left leg. Urine cultures showed Escherichia (E.) Coli and leg wounds with heavy growth of pseudomonas aeruginosa (1/17/12). Review of the Patient Progress Notes record dated 1/12/12 revealed the left leg wounds were debrided. On the same day, the physician ordered wound care daily alternate wet to dry with [MEDICATION NAME]. On 1/23/12 at 3:10 pm, during the initial tour, Resident 3's left lower leg dressing was observed soaked with bright red drainage. The licensed nurse stated that the physician has just changed the resident's leg ulcer dressing at the bedside. The Wound Care Flowsheet dated 1/8/12 revealed the resident's left lower leg had an irregular size pressure sore with a length of 25 cm x 4 cm in width with sero-sanguinous, odorless drainage. On 1/24/12 the left lower leg Stage II pressure sore was described as pale/pink in color and measured 19 cm L x 6 cm W with no depth. On the same day, the flowsheet also revealed a new pressure area in the left ankle described as Stage II with a length of 1 cm x 1 cm in width, yellow in color, with no drainage and no odor. The management was to elevate the legs on a pillow, and wet to dry dressing as prescribed. On 1/25/12, in an interview, the morning charge nurse indicated that the leg treatments were done by the night shift nurses because wound treatment and dressing changes can be done after the showers. On 1/26/12 at 8:15 a.m. Resident 3 was observed up in wheelchair eating breakfast in the common dining room. Upon surveyor request, a treatment observation was done after the resident finished breakfast meal and returned to the room. The treatment nurse assessed the multiple sites of debrided pressure sores: Left inner leg with irregular shaped open areas: upper area measured 11.5cm L x 4 cm W x 1 cm in depth (D); the middle area measured 4 cm L x 2 cm W with undermining and lower area measured 9.5 cm L x 3 cm W. The Stage II left ankle pressure sore measured 1.5 cm L x 1.0 cm W The black eschar on the lower lateral side of the left ankle measured 3.0 cm L x 2.0 cm W A dry scab on the upper lateral side of the left ankle measured 05. cm L x 0.5 cm W After the treatment nurse measured the pressure sore areas, she indicated that accuracy in measuring the debrided areas was inconsistent due to irregular open areas. Also the three open areas were measured as one in length as documented in the wound care. However, the undermining in the middle portion of the left inner leg was not identified. The black eschar area in the left ankle was not identified in the assessment on 1/24/12, two days prior to assessment conducted by the day shift treatment nurse. On the same day at 9:30 a.m., the director of nurses (DON) was made aware of the inaccuracies of pressure sore assessments and observed the newly discovered black eschar on the lateral side of the left ankle. 3. Resident 11 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial assessment nursing notes revealed no skin breakdown. On 1/25/12 at 9 a.m. Resident 11 was observed during morning care rendered by a certified nursing assistant. During the bedbath, the resident's back had three areas of persistent redness: a raised reddened area in the mid-back, flat reddened area on the right side of the back and a blackish red abraded area on the sacrum. The licensed nurse indicated that A&D ointment is applied as a preventive measure, however, the CNA did not apply the ointment because it was unavailable. The nurses' notes dated 1/24/12 revealed that the certified nursing assistant notified the licensed nurse of redness on the buttocks, raised reddish patches on the sacral area. On 1/25/12 on 11 pm-7 am shift, a licensed nurse documented red raised area mid-upper back still present, hard to touch. Charge nurse (CN) made aware. On 1/25/12, the 7 am-3 pm shift nurses notes revealed a reddened tender area size-like a quarter still present at mid upper back. Notified CN. There was no documented evidence in the medical record that the physician was notified of the reddened skin areas at the back. On 1/25/12 at 4 p.m. interview with the resident's husband revealed a concern of the reddened raised area on the resident's back if it was a growing cyst. He was also concerned about the resident's peeling skin in the hands and feet from the allergic reactions incurred from antibiotics infused in the hospital. On 1/25/12 after discussions with the licensed nurse about Resident 11's skin condition, the charge nurse notified the physician and obtained orders for warm compress to mid-upper back. The physician also held the [MEDICATION NAME] and [MEDICATION NAME] doses for that day. 4. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of initial assessment dated [DATE] identified the resident as totally dependent on staff with all activities of daily living except eating. The resident had surgery to repair the fractured left hip (open reduction internal fixation) on 12/18/11. The initial assessment identified the resident with frequent hip pain daily. The admission notes dated 12/21/12 at 22:41 revealed the resident had a surgical wound that measured 15 ? centimeters (cm) scar incision in the left hip/thigh and a sore in the left hand in between the second and third finger. The Braden scale for pressure sore identified the resident as moderate risk to develop pressure sores. Upon admission the resident did not have any pressure sores but the resident was bedfast and required moderate to maximum assistance. Review of the nurses' progress notes revealed that on 12/25/11, the left inner buttock 3 small 1-0.5 cm next to the sacrum, about an inch below it, small 0.5 cmx0.6 cm and the larger one at the bottom 2.0 cm L(length) x 1.0 cm W(width). dry, no drainage. Duoderm applied. The Wound Assessment form confirmed that on 12/25/11 , the resident's left inner buttock had an open area next to the sacrum, measured 0.5 cm. below the first 1.0 cm x 0.5 cm down below the next one 2.0 cm x 1.0 cm W On 12/29/11 the Stage II pressure sore in the left inner buttock increased in size 2.0 cm to 7.0 cm in length and from 1.0 cm to 4 cm in width. Also, on 12/29/11 two other pressure sores were identified: A Stage II pressure sore in the right inner buttock that measured 5 cm in length and 4 cm in width and Stage II pressure sore in the sacrum that measured 3 cm L x 0.5 cm W. On 1/25/12 at 4:00 p.m. the licensed nurse who documented the pressure sore discovery revealed that she reported the skin breakdown to the charge nurse and was verbally told to apply the Duoderm. Review of the physician's orders [REDACTED]. On 1/26/12 at 7:20 a.m., interview with the charge nurse revealed that she might have told the other licensed nurse to apply the Duoderm and she was not sure if Duoderm required a physician's orders [REDACTED].>Review of the plan of care dated 12/29/11 revealed the resident was assisted to turn to sides; explained to resident the importance of repositioning and turning to sides every two hours. The social service designee notes revealed the resident has mood problems, feisty and needs special approach. On 1/25/12 at 2:45 p.m. during a treatment observation, Resident 4's sacral pressure sore was noted dry without drainage. The treatment nurse stated that the other pressure sores healed because the resident started getting out of bed and goes to the courtyard most of the time.",2017-01-01
78,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,315,G,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections [MEDICAL CONDITION] and to restore as much normal bladder function as possible; 1. When the facility did assess or refer a resident for bladder training or adaptive equipment resulting in accidental incontinence for one of 10 residents (Resident 2), and 2. When the facility did not prevent the development of UTIs for one of 10 residents (Resident 6). Findings include: 1. Resident 1 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the minimum data set ((MDS) dated [DATE] revealed that the resident was alert and oriented, dependent on staff for most activities of daily living, and continent of bladder function. The care area assessment (CAA) summary for the current admission noted that urinary incontinence will not be care planned because the resident is continent. Review of the medical record revealed that on 1/16/12, Resident 2 was described in nurses notes as being incontinent of bladder. On 1/18/12, the resident was also documented in nurses notes as incontinent of bladder and bowel, and on 1/20/12, as being incontinent of urine. In addition, SNU (skilled nursing unit) nurse aide flowsheets dated 1/20/12 through 1/23/12 described Resident 2 as being incontinent of bladder function. Notwithstanding the documentation, review of the medical record revealed the lack of documented evidence that the physician was notified and that an assessment of the resident's bladder status was conducted to identify the cause of the incontinence and determine whether or not the resident could benefit from a bladder training program. In addition, review of the medical record revealed the lack of indication that a care plan was developed to address the change in bladder status which included goals and outcomes as well as interventions to prevent further diminishment of function. During an interview on 1/24/11, Resident 2 stated that while he had been having episodes of urinary incontinence which required him to wear briefs, that he however still feels the urge if he has to urinate. The resident added that he had been having accidents because of the increasing urgency and the delay and difficulty of getting him to the bathroom. In light of this, there was no documentation of any referral to determine if the resident could benefit from therapy services or use of adaptive equipment. 2. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) for feeding and a urinary catheter for elimination. The resident required total assistance for activities of daily living (ADLs). The resident's family member was with the resident most of the time. During observations and subsequent interviews on 1/24/2012 beginning at 1:30 PM, a licensed nurse (LN) and a certified nursing assistant (CNA) were providing care to Resident 6. The resident was positioned on her right side. The CNA removed the resident's soiled brief. The urinary catheter bag was attached to the right side of the bed, causing the catheter tube to pull from the resident's urethra over the stool and down to the collection bag. Neither the nurse nor the CNA moved the collection bag to the left side of the bed, nearer to the resident and out of area where the staff were working. The CNA used a gloved hand to clean the resident while pouring water over the perineum and the catheter tubing- spreading the stool over the entire perineum including the opening of the urethra, increasing the risk of urinary tract infection [MEDICAL CONDITION]. When asked how often catheter care was provided to Resident 6 and about the method of cleaning the resident, the CNA stated We do it (catheter care) every shift and we not have enough wash cloths to go around so we just use our gloved hand and water. When asked about the catheter pulling the CNA and the LN stated, We should have moved it to the other side. When asked what the procedure was to do catheter care, the LN stated they cleaned the perineum beginning close to the body using soap and water, cleaning around the catheter and then clean the tube from close to the body down the tube. The LN stated they usually use some gauze if a wash cloth was not available. When told of the surveyors observation of potential contamination of the Urethra (opening of the urinary tract) due to the method of cleaning and allowing the catheter tube to be in touch with the anus and stool. The LN stated she would be sure to observe the resident for signs of infection. Review of laboratory results revealed the resident had two previous urinary tract infections [MEDICAL CONDITION] collected C&S 11/16/11 with Escherichia coli (E. coli- an organism found in feces) and 12/6/11 with Pseudomanas aeruginosa; The resident had prior infections of the [DEVICE] site collected C&S 11/9/11 with [DIAGNOSES REDACTED] pneumoniae and Pseudomanas aeruginosa; Review of the Care Plan for SNU-Foley Catheter Use initiated 10/22/2011 and updated 1/20/2012, included the following direction: Clean urinary meatus (opening of the Urethra) .every shift.",2017-01-01
79,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,325,G,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutrition for weight for 2 of 10 sampled residents ( resident 2 and 6); when 1.) Resident 6 lost 18.5 % of her body weight due to a leaking gastrostomy tube ([DEVICE]) and 2.) Resident 2 did not receive follow up care for weight maintenance. Findings: 1. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) for feeding and a Urinary catheter for elimination. The resident required total assistance for activities of daily living (ADLs). The resident's family member was with the resident most of the time. Observations of the resident on 1/24/2012 during personal care revealed the resident was cachectic (ill health and very thin). During an interview on 1/24/2011 at 10 AM, the resident's family member stated the resident had a feeding tube that leaked for a long time before the facility replaced it. The family member stated the resident lost a lot of weight. During an interview and record on 1/24/2011 at 10:45 AM, the day shift charge nurse stated the [DEVICE] had been leaking almost from admission to Christmas. She stated she was not sure why it took so long for the tube to be changed. Review of Resident 6's record from the Monthly Weight Log read as follows: 10/22/2011 - 103 pounds (lbs) 11/14/2011 - 89.6 lbs 12/10/2011 - 85 lbs ([DEVICE] replaced 12/14/2011) 01/10/2012 - 87.9 lbs The resident lost 18 lbs in approximately 2 months. A summary of the review of the staff and physician notes revealed the following time line: 10/22/2011 - Admission; 10/28/2011 - minimal amount of drainage around the feeding tube; 10/29/2011- greenish discharge from the feeding tube. 11/15/2011 - MD noted added suture at the [DEVICE] site to help reduce leakage. 11/16/2011 - MD noted to request surgeon to revise or change the [DEVICE]. 11/28/2011- feeding tube leaking; 11/30/2011- MD noted the [DEVICE] needed to be changed. 12/3/2011 - feeding tube still leaking, 12/9/2011 - feeding tube still leaking. 12/14/2011- Surgeon replaced [DEVICE] with same size tube, 24 french. 12/27/201 - MD noted [DEVICE] still leaking. Resident to have tube replaced again the next day (12/28) with a 28 french [DEVICE]. 1/13/2012 - MD noted [DEVICE] leak is fixed. During this time frame the MD began the resident on [MEDICATION NAME] one half can every 6 hours then increased to one can every 6 hours. Nurses notes between 10/22 and 11/6/2011 revealed the resident did not tolerate one can, so the feeding was reduced to [MEDICATION NAME] one half can every 6 hours on 11/6/2011 - 31 days after the [DEVICE] leak began. A physician's orders [REDACTED]. On 12/19/2011 the dietician recommended pleasure feeding 1/2 teaspoon puree food and 1/2 teaspoon water at a time. There was no documentation whether or not the resident received this oral feeding or how/if the resident tolerated it. On 12/31/2011 the dietitian recommended and the physician changed the feeding to Nepro 1/2 can every 4 hours. On 1/7/2012 - the physician changed the feeding to Fibersource 1/2 can every 4 hours. Review of the registered dietician (RD) notes dated 1/18/2012 revealed the residents lab results for Serum [MEDICATION NAME] was low at 2.0 grams/deciliter (gms/dcl)- Normal range was 3.4 - 5.0 gms/dcl. Decreased [MEDICATION NAME] may occur when your body does not get or absorb enough nutrients and reduces the body's ability to heal. During an interview on 1/25/2011 at 2 P.M., the RD stated the resident developed diarrhea from the Nepro, therefore the feeding was changed to Fibersource. She stated the weight loss was due to the leaking [DEVICE]. She said the resident was receiving maybe 60% of what was fed to her. When asked if any other means of nutrition was discussed or considered, she stated no. When asked if she was involved in the interdisciplinary care conferences, she stated no, the dietary manager attended and let her know if there were problems. Review of the Care Conference notes dated 12/5&7/2011 indicated the current type and amount of feeding, and a note that the [DEVICE] was leaking. There was no other Care Conference noted provided and no other documentation on what the facility would do to enhance the resident's nutrition to prevent weight loss and improve wound healing during the 69 days that the [DEVICE] was leaking. 2. Resident 2 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the Mini Nutritional Assessment dated 1/07/12, revealed that Resident 2 was nutritionally at high risk and with increased nutrient needs related to severe malnutrition (as evidenced by) severe protein depletion with [MEDICATION NAME], and cachexia . The assessment also noted that weighed 96 lbs and had a height of 5 feet and 5.75 inches. Recommendations made by the dietitian dated 1/07/12 included providing Resident 2 with enteral feedings of [MEDICATION NAME] 1 can every 6 hours for 24 hours increasing to 1 can every 4 hours, and 150 ccs water for flush. This, according to the recommendation would provide the resident with 1500 kcal and 61 gms of protein per day. The recommendation also included monitoring of tube feeding residuals, monthly weights, weekly laboratory tests, and hydration status. During an interview on 1/25/12, a nutritional support staff stated that because of Resident 2's [MEDICAL CONDITIONS] and consideration for a carbohydrate controlled formula, that [MEDICATION NAME] was an appropriate substitute for another solution he was to receive but was unavailable. Review of the medical record however revealed the lack of monitoring of Resident 2 to ensure that identified nutritional risks were being addressed or that interventions were effective. While the resident, for example, was described in a dietary note dated 1/16/12 as being underweight (weight noted on admission on 1/07/12 was 96 lbs), no other weight measurements were obtained until 1/25/12 when a weight of 95.2 was recorded. In addition, there was no documentation if the current enteral feeding regimen, calculated to provide 1500 kcal per day, allowed for weight gain or maintenance of current weight. While the enteral feeding was to provide 61 gms of protein, no measurements of protein stores ([MEDICATION NAME] level) were available following Resident 2's admission to the facility. Review of laboratory results dated [DATE] when Resident 2 was in the hospital revealed an [MEDICATION NAME] level of 2.2 gms/dl (normal limit 3.4 - 5 gms/dl). Further review of the medical record revealed that while a care plan was written for special needs--providing nutritional support, the plan however was developed relative to the risk for aspiration. The care plan, for example, did not identify nutritional goals that needed to be met or indicators that needed to be monitored to help ensure that Resident 2 met established nutritional benchmarks such as weight and/or [MEDICATION NAME] levels. Further review of the care plan revealed the lack of identification of a desired or target weight as a baseline from which the effectiveness of nutritional interventions can be measured.",2017-01-01
80,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,334,E,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not develop policies and procedures that ensured that before offering influenza and/or pneumococcal immunizations, each resident or the resident's legal representative received education regarding the benefits and potential side effects of the immunization; that each resident was offered an influenza immunization October 1 through March 31 annually, unless the immunization was medically contraindicated or the resident had already been immunized during this time period; and that the resident's medical record included documentation that indicated, at a minimum, that the resident or resident's legal representative was provided education regarding the benefits and potential side effects of influenza or pneumococcal immunization. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the minimum data set ((MDS) dated [DATE] revealed that the resident was alert and oriented, and dependent on staff for most activities of daily living. Further review of the MDS revealed that Resident 1 did not receive the influenza vaccine at the facility for this year's influenza season and that it was offered but that the resident had declined. In addition, the MDS noted that the resident's pneumococcal vaccine was not up to date and that it was also offered but that the resident had also declined. During an interview on 1/25/12, Resident 1 stated that he had been informed about the influenza and pneumococcal vaccines but that he declined because he had heard of problems associated with them. When asked to give examples of problems he had previously heard, the resident was unable to state any. When asked if he was given any informational handouts about the influenza (for 2011 - 2012) and pneumococcal vaccines, Resident 1 was unable to respond. In a separate interview on 1/25/12, a licensed nursing staff stated that residents were screened for influenza and pneumococcal vaccinations within one week after admission, and that informational What you need to know handouts were provided to the each resident to educate them about the risk and benefits of both vaccines. The staff added that the vaccines were then given only after the resident had given consent. In the same interview on 1/25/12, Resident 1 was shown copies of handouts for both the influenza and pneumococcal vaccines. When asked if he was familiar with them, the resident responded that he had not seen the handouts before. After reading the the copies, Resident 1 stated that it would have been a good idea to receive the influenza vaccine at least. Review of Resident 1's medical record revealed the lack of documentation indicating that the resident had been provided education regarding the risks and benefits of the influenza and pneumococcal vaccines. 2. Resident 2 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. During the initial tour on 1/23/12, a licensed nursing staff described the resident as able to makes needs known with mumbled speech, and that he occasionally had family members and a significant other visiting. Review of the minimum data set ((MDS) dated [DATE] indicated that the resident was dependent on staff for all activities of daily living. Review of the MDS dated [DATE] revealed that Resident 2 did not receive the influenza vaccine at the facility for the current influenza season and that it was not offered. In addition, the MDS noted that the resident's pneumococcal vaccination was not up to date and that the vaccine was also not offered. In spite of this, the facility tracking log for influenza and pneumococcal vaccinations revealed that Resident 2 received the influenza vaccine on 1/11/12, and that he refused the pneumococcal vaccine. Further review of medical record however revealed the lack of documentation that the resident or the resident's legal guardian was provided education about the risks and benefits of both the influenza and pneumococcal vaccines. 3. Review of the facility's policy and procedures on Administering Influenza Vaccines (revised 08/2009) revealed that the policy did not meet certain elements specified under 483.25)(n) including that: a. before offering the influenza immunization, each resident, or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; b. that each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; c. that the resident or the resident's legal representative has the opportunity to refuse immunization; and d. that the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's legal representative was provided education regarding the benefits and potential side effects of influenza immunization; and that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. Further, the facility did not have policies and procedures in place specific to pneumococcal vaccinations to ensure that: a. before offering the pneumococcal immunization, each resident, or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; b. each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; c. the resident or the resident's legal representative has the opportunity to refuse immunization; and that d. the resident's medical record includes documentation that indicated, at a minimum, the following: the resident or resident's legal representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. During the same interview on 1/25/12, the licensed nursing staff stated that the facility had policy and procedures for Administering Influenza Vaccines. Review of the document however revealed that while the document clarified licensed nursing staff responsibility in the assessment of high-risk target groups and the administration of the influenza vaccine, it did not include pneumococcal vaccinations and how this was to be monitored and offered to residents. In addition, the policy did not have provisions that included the elements referenced above.",2017-01-01
81,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,367,D,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not ensure that therapeutic diets was prescribed by the attending physician. Finding includes: Resident 1 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the minimum data set ((MDS) dated [DATE] revealed that the resident was alert and oriented and because of obesity, was dependent on staff for most activities of daily living. Review of the medical record revealed that on admission on 1/04/12, a physician's orders [REDACTED]. On 1/18/12, this diet order was changed to a low sodium. During meal observations conducted on 1/24/12 and 1/25/12, Resident 2's meal tray was observed to be regular and also contained a salt packet. In an interview during the lunch meal observation 1/24/12, Resident 1 stated that he appreciated the salt packet because it helped improve the flavor of his food. During an interview on 1/25/12, a dietary staff was asked to clarify Resident 1's diet order because his meal trays contained a salt packet and his diet order was supposed to be low sodium. The dietary staff went to the facility's electronic database and stated that the regular diet order had not been changed when the new order for a low sodium was made on 1/18/12. When asked if the salt packet would significantly alter a low sodium diet, the staff stated that it would especially depending on the resident's medical condition.",2017-01-01
82,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,431,E,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys. Finding includes: During the environmental observation on 1/24/12, two medication carts identified as 1 and 2 were noted inside the clean linen room which was unlocked. While medication cart 1 was locked, cart 2 however was unlocked so that all medications designated for residents in room [ROOM NUMBER] through 125 were readily accessible to unauthorized individuals. In addition, several house supply medications including Atrovent and Albuterol nebulizer solutions, an injectable vial of Dextrose 50% solution, and an assortment of syringes and needles were kept in other unlocked compartments of the cart. During an interview on 1/24/12, an administrative nursing staff stated that because of the lack of space, the clean linen room was being used to store the medications carts to keep the hallways free from obstruction. The staff added however that the medication carts should be locked at all times when unattended by staff.",2017-01-01
83,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,441,G,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection, when the facility did not prevent the development of infections for 3 of 15 residents (sampled Resident 6, 3, and unsampled Resident 14.); failed to provide adequate supplies of PPE to prevent cross contamination where seven resident rooms had contact isolation precautions in place; Staff inconsistently follow infection control techniques; and the infection control designee was not trained for infection control management nor given the time to conduct infection control assignments and the facility did not have an effective tracking and monitoring system to ensure the vaccination status of all residents. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) for feeding and a urinary catheter for elimination. The resident required total assistance for activities of daily living (ADLs). The resident's family member was with the resident most of the time. During the initial tour on 1/23/2012 at 4:30 PM, Resident 6 was observed lying in bed. Her family member was sitting next to the resident's bed without wear Personal Protective Equipment (PPE). When asked what the facility had taught him about the use of PPE, and he looked at the sign, he said he had not noticed the sign and though he did notice the staff usually wore a yellow gown and gloves, they told him he did not need to, just to wash his hands frequently. He stated the staff taught him to feed the resident through the feeding tube and how to clean the resident's privates, and how to change the dressing on the wound. When he did those things he stated he wore gloves, but not a gown. The resident stated he did interact with other residents and visitors and sat in common areas of the facility. There was a sign on the resident's door indicating the resident was on: Contact Precautions Isolation an Standard Precautions; Gown and Glove When Entering (these are called (PPE)); Clean hands before entering room and upon exiting, wash hands thoroughly for at least 15 seconds or use Alcohol hand foam. A staff member was seen exiting the resident's room wearing a yellow gown, she took off the gown and hung it on a pole attached to the drawers where the clean PPE were outside the door of the room. Then she reentered the room to wash her hands in the resident's bathroom. The resident's urinary catheter bag was on the floor. During observations of care provided on 1/24/2012 at 1:30 PM, a licensed nurse (LN) and a certified nursing assistant (CNA) donned PPE then went into Resident 6's room to provide care. The resident was positioned on her right side. The CNA removed the resident's soiled brief. The urinary catheter bag was attached to the right side of the bed, causing the catheter tube to pull from the resident's urethra over the stool and down to the collection bag. Neither the LN nor the CNA moved the collection bag to the left side of the bed, nearer to the resident and out of area where the staff were working. The CNA used a gloved hand to clean the resident while pouring water over the perineum and the catheter tubing- spreading the stool over the entire perineum including the opening of the urethra, which increased the risk of urinary infection. After the area was cleaned the LN removed the dressing from a Stage 4 pressure ulcer on the resident's sacrum. She cleansed the wound, and dressed it as ordered by the physician; however when she tried to secure the dressing, she taped the lower end of the dressing very near the anus and the tap would not stick. The LN stuffed extra gauze under the tape, to prevent any stool from getting in the wound. The staff stated they had completed the resident's care. Resident 6's heels were covered with socks and heel protectors (a foam bootie). The surveyor asked to see the resident's heels. The right heel had a black circular pressure ulcer with reddened area surrounding the ulcer. The measurements were 4.0 cm x 2.0 cm. The wound bed could not be visualized as it was covered with hard black necrotic (dead) tissue termed Eschar. No treatment was provided for the heel pressure ulcer. The LN and CNA removed their gloves, washed their hands then exited the room where they removed their gowns. The CNA threw away the gown and the LN hung her gown on the pole attached to the drawers where clean PPE was stored. When asked about the method of cleaning the resident, the CNA stated We do not have enough wash cloths to go around. When asked about the catheter pulling the CNA and the LN stated, We should have moved it to the other side. When asked why she hung the soiled gown on the pole outside the resident's room, the LN stated they run out of gowns if they throw them out each time. Review of the record revealed the following: A summary of the review of the staff and physician notes revealed the following: 10/22/2011 - Admission; 10/28/2011 - minimal amount of drainage around the feeding tube; 10/29/2011- greenish discharge from the feeding tube site. On 11/9/11- staff collected C&S from [DEVICE] site results showed infection with MDROs- [DIAGNOSES REDACTED] pneumoniae and Pseudomanas aeruginosa; On 11/8/2011 LN noted there was pus at the Peripherally inserted central catheter (PICC) site on the resident's right upper arm. In the physicians notes and orders dated 11/30/2012 the MD ordered RN to remove the PICC and send the tip for C&S. The physician also ordered IV fluids for two days. However there was no order for replacement of the PICC or to insert any other type of IV. On 12/5/2012 and MD ordered at 9 PM, Please remove PICC now- send cath (catheter) tip for C&S. Lab result showed C&S collected 12/6/11 with PICC site infection with MDRO - [DIAGNOSES REDACTED] pneumonia. During an interview on 1/24/2011 at 3: 35 PM, when asked about the infection of the PICC site and why the PICC was removed five days after the MD's order, a LN familiar with the patient stated the infection was bad at the site and there was pus all around it. The MD ordered antibiotics on the same day and (the LN on duty) was afraid to remove it (the PICC). Review of the laboratory reports also revealed the following time lines of infections for Resident 6: [DEVICE] site - staff collected Culture and Sensitivity (C&S) on 11/9/2011 results showed infection with MDROs- [DIAGNOSES REDACTED] pneumoniae and Pseudomanas aeruginosa; Two urinary tract infections (UTI) collected C&S 11/16/11 with Escherichia coli (E.coli- an organism found in feces) and 12/6/11 with Pseudomanas aeruginosa; and Peripherally inserted central catheter (PICC) site infection C&S collected 12/6/11 with [DIAGNOSES REDACTED] pneumonia. The sacral wound was infected 12/29/2011 with two of the bacterium found in three other sites of the body. A swab sample of the sacral wound drainage was collected on 12/29/2011 source: deep wound sacral pressure ulcer Stage 4. A C&S final results dated 1/3/2012 showed infection with four multi-drug resistant organisms (MDROs): Pseudomonas aeruginosa, Cirtobacter freundii, Acinetobacter baumannii, and [DIAGNOSES REDACTED] pneumoniae. Two of these organisms, [DIAGNOSES REDACTED] pneumoniae and Pseudomanas aeruginosa, were found in the infections of the three sites listed above. The resident had been on numerous antibiotics since admission: 11/ 9/2011 -[MEDICATION NAME] mg via feeding tube daily for two weeks. 11/19/2011 - [MEDICATION NAME] 1 Gram (gm) IV daily for 7 days; 12/8/11 [MEDICATION NAME] 3.375 mg IV every 12 hours for two weeks and [MEDICATION NAME] 500 mg IV daily for 2 weeks; 12/10/11 Impenem 250 mg IV every 12 hours for 7 days and Amikrein 240 Mg IVPB every 24 hours for three days. 12/29/11 [MEDICATION NAME] 3.375 gms in 50 ml of normal sa IV every 12 hours for 7 days; 12/30/11 [MEDICATION NAME] 1 gm IV daily for 7 days; and 1/2/12 [MEDICATION NAME] 1 gm IV every 12 hours for 10 days and Imipenem 250 mg IV every 6 hours for six weeks. 2. During a tour of the residents rooms with the acting administrator and the head nurse on 1/26/2012 beginning at 8:45 AM, the following was observed: room [ROOM NUMBER] a contact precaution sign for a resident infected with Clostridium Difficile (C.Diff)- the sign instructed those entering and exiting to wear PPE and to wash hands with soap and water. There was a yellow gown hanging on the pole attached to the drawers where the clean PPE were located outside the resident's room. room [ROOM NUMBER] the resident was infected with MDRO infections; room [ROOM NUMBER] the resident was infected with Methicillin Resistant Staphylococcus Aureus (MRSA); room [ROOM NUMBER] the resident was infected with [DIAGNOSES REDACTED] (flesh eating bacteria) and C.Diff. The contact precaution signs outside each of these rooms were the same, Contact Precautions Isolation an Standard Precautions; Gown and Glove When Entering (these are called Personal Protective Equipment (PPE)) Clean hands before entering room and upon exiting, wash hands thoroughly for at least 15 seconds or use Alcohol hand foam. On 1/26/2012 at 8:50 AM, room [ROOM NUMBER] the resident was infected with MRSA. There was an occupational therapist (OT) working with the resident in the room. The OT had on a yellow gown that was loosely tied at the neck and not at the waist potentially exposing parts of the OT's personal clothing to the MRSA organism. A CNA exited the room, removed her yellow gown and hung it on the pole attached to the drawers where the clean PPE were located outside the resident's room; she then washed her hands. room [ROOM NUMBER] - the resident was infected with MRSA - the contact precaution sign indicated visitors did not need to wear PPE. The assistant administrator and the head nurse stated the resident had a wound so the visitors did not need to wear PPE. room [ROOM NUMBER] - the resident was infected with MDRO, and had a different contact precaution sign. room [ROOM NUMBER] - the resident was infected with MRSA and had the following sign: Contact Precautions Isolation an Standard Precautions; Gown and Glove When Entering (these are called Personal Protective Equipment (PPE)) Clean hands before entering room and upon exiting, wash hands thoroughly for at least 15 seconds or use Alcohol hand foam. During interviews 1/26/2012 beginning at 8:45 AM, When asked why the staff hung the contaminated yellow gowns on the pole outside the residents' rooms that had isolation precautions, the acting administrator and the head nurse stated the facility had limited resources. The acting administrator stated if they threw away the gowns after each use they would run out in one day. He stated the hospital administration was aware of this problem, however no changes had been made. When asked why the LN continued to instill IV fluids into an infected PICC site, the acting administrator stated the LN should have removed the PICC the first time the MD order the removal or obtained a clarification order to continue IV fluids via the PICC site or to insert a peripheral IV . 3. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital history and physical record dated 1/8/12 revealed the resident was admitted due to sepsis Recent admission with urinary tract infection, dysuria and infected left leg. Urine cultures showed Escherichia (E.) Coli and leg wounds with heavy growth of pseudomonas aeruginosa (1/17/12). Review of the Patient Progress Notes record dated 1/12/12 revealed the left leg wounds were debrided. On the same day, the physician ordered wound care daily alternate wet to dry with [MEDICATION NAME]. On 1/23/12 at 3:10 PM, during the initial tour, a posting outside the resident's room stated Contact Isolation. Resident 3's left lower leg dressing was observed soaked with bright red drainage. The licensed nurse stated that the physician has just changed the resident's leg ulcer dressing at the bedside. The licensed nurse went inside the resident's room without wearing an isolation gown. With a pair of gloves on, the licensed nurse repositioned the resident's leg to check the dressing moderately saturated with fresh blood. She changed her gloves, and without washing her hands, the licensed nurse proceeded to get a new disposable pad from the resident's closet. She placed the disposable pad under the resident's left leg to protect to line the resident's linen be saturated with the drainage. She then checked on the resident who was pointing to her disposable diaper. The resident is a known deaf and mute to the facility staff. The licensed nurse continued to check on the resident's diaper for tightness without changing her gloves. Review of the resident's plan of care showed no evidence of precautions to be taken while resident is on contact isolation. 4. On 1/23/12 at 3 PM, during the initial tour non-sample Resident 14's room had a posting, Contact isolation A licensed nurse was observed inside the resident's room wearing gloves and no isolation gown. Interview with the nurse revealed that she was assisting and cleaning the resident's face to wipe off the sputum. When asked what kind of infection the resident has, the licensed nurse stated the resident has methicillin-resistant staphylococcus aureus (MRSA) of the sputum. Review of sputum culture dated 7/17/11 revealed heavy growth of MRSA. Interview with the charge nurse on 1/25/12 revealed that the physician does not want to re-culture. Review of the resident care plan showed no evidence of precautions to be taken while the Contact Isolation is still being enforced. On the same day and time, Resident 14's Foley catheter drainage bag was also observed lying on the floor. There was no effort to get the bag off the floor in the presence of a licensed nurse in the room. 5. Interview with nursing administrative staff revealed that the facility did not have a qualified infection control coordinator responsible for investigating, controlling, and preventing infections in the facility. Review of the facility's infection control manual revealed several duties of the infection control representative including the ability to demonstrate knowledge of complete infection control process in the healthcare setting; demonstrating understanding of standard and isolation precautions set forth by the CDC; attending continuing education program and maintaining current knowledge of all aspects of infection control; demonstrating knowledge of microbiology and modes of transmission of disease entities, conferring with staff nurses on a regular basis to determine occurrence of healthcare associated infections; and communicating infection control activities to the infection control practitioner at the hospital. During an interview on 1/25/12, an administrative staff member stated that the facility's infection control coordinator was a licensed nursing staff who worked full-time on the evening shift (3:00 PM - 11:00 PM). When asked if the number of hours allocated for infection control duties and responsibilities by the staff could be determined, the administrative staff stated that the time was not captured because the licensed staff, when regularly scheduled, provided direct patient care. The administrative staff added that the licensed nursing staff could not work during her days off to conduct infection control activities because overtime pay was not being authorized. In the same interview, the administrative staff stated that the facility's infection control coordinator did not have training in infection control but that she consulted with the hospital infection control coordinator on a regular basis. When asked if meeting minutes were maintained during these consultation, the staff stated that he was not aware. During a separate interview on 1/25/12, the hospital's infection control coordinator stated that there were regular consultations between her and the facility's infection control representative. When asked if documentation was maintained detailing when these consultations occurred and what topics were discussed, none was provided. 6. The facility did not have an effective tracking and monitoring system to ensure that the vaccination status of residents in the facility could be determined so that the influenza and pneumococcal vaccines could be offered. In addition, the facility did not have policy and procedures that included provisions required under 483.25(n)(1)&(2). (Cross-refer to F334.)",2017-01-01
84,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,490,E,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to enable the residents to attain or maintain their highest practicable physical, mental and psychosocial well-being. Finding includes: 1. The facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they are unavoidable for one of 10 sampled residents, (Resident 4) and one of 5 unsampled residents (Resident (11); and failed to provide necessary treatment to promote healing and prevent infection for one of 10 sampled residents (Resident 6) a resident who entered the facility with pressure ulcers. (Cross-refer to F314.) 2. The facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections [MEDICAL CONDITION] and to restore as much normal bladder function as possible; 1. When the facility did not assess or refer a resident for bladder training or adaptive equipment resulting in accidental incontinence for one of 10 residents (Resident 2), and 2. When the facility did not prevent the development of UTIs for one of 10 residents (Resident 6). (Cross-refer to F315) 3. The facility did not ensure that a resident maintained acceptable parameters of nutritional status, such as body weight and protein levels when the facility did not promptly provide necessary equipment or supplies to ensure that 1 of 10 residents (Resident 6) received adequate nutrition when her feeding tube leaked for six weeks resulting in an 18% weight loss; and Resident 2 did not receive follow up care for weight maintenance. (Cross-refer to F325) 4. The facility did not have an effective infection control program coordinated by a trained and qualified infection control practitioner who was allowed sufficient time and resources in infection control activities including collecting, analyzing, and providing infection control data and trends to nursing staff and health care practitioners; consulting on infection risks and assessment, prevention, and control activities; providing education and training; and implementing infection control practices. (Cross-refer to F441.)",2017-01-01
85,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,493,E,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not have a governing body that was legally responsible for establishing and implementing policies regarding the management and operation of the facility, and did not ensure that the appointed administrator was responsible for management of the facility. Findings include: 1. The facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they are unavoidable for one of 10 sampled residents, (Resident 4) and one of 5 unsampled residents (Resident (11); and failed to provide necessary treatment to promote healing and prevent infection for one of 10 sampled residents (Resident 6) a resident who entered the facility with pressure ulcers. (Cross-refer to F314.) 2. The facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections [MEDICAL CONDITION] and to restore as much normal bladder function as possible; 1. When the facility did not assess or refer a resident for bladder training or adaptive equipment resulting in accidental incontinence for one of 10 residents (Resident 2), and 2. When the facility did not prevent the development of UTIs for one of 10 residents (Resident 6). (Cross-refer to F315) 3. The facility did not ensure that a resident maintained acceptable parameters of nutritional status, such as body weight and protein levels when the facility did not promptly provide necessary equipment or supplies to ensure that 1 of 10 residents (Resident 6) received adequate nutrition when her feeding tube leaked for six weeks resulting in an 18% weight loss; and Resident 2 did not receive follow up care for weight maintenance. (Cross-refer to F325) 4. The facility did not have an effective infection control program coordinated by a trained and qualified infection control practitioner who was allowed sufficient time and resources in infection control activities. (Cross-refer to F441.) 5. The administrative manual pertaining to the governing body noted that the facility must have a governing body that is legally responsible for establishing and implementing policies regarding the management and operation of the Skilled Nursing Unit. In addition, the purpose of the administrative manual was to identify the governing body of the Unit. The administrative manual however did not identify a responsible governing body or designated individuals with authority and control over the facility. Further review of facility documents revealed the lack of documented evidence that the duties and responsibilities of the governing body, and that of the appointed administrator responsible for the day-to-day operation of the facility, were delineated. On 1/25/12, for example, following a request for a copy of the job description of the facility administrator, a copy identified as draft was presented.",2017-01-01
86,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-01-26,501,E,0,1,J2NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not ensure that the medical director was responsible for the implementation of resident care policies and the coordination of medical care in the facility. Findings include: 1. During the survey, the medical director did not ensure that facility staff complied with and implemented patient care policies and procedures regarding the provision of care and services for residents who were admitted without pressures to ensure that they did not develop pressure sores and for residents with pressure ulcers to promote healing and prevent infection of the pressure sores. (Cross-refer to F314.) 2. The Medical Director did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections [MEDICAL CONDITION] and to restore as much normal bladder function as possible. (Cross-refer to F315) 3. The Medical Director did not ensure that a resident maintained acceptable parameters of nutritional status, such as body weight and protein levels when the facility did not promptly provide necessary equipment or supplies to ensure that residents received adequate nutrition.(Cross-refer to F325) 4. The medical director did not ensure that facility staff complied with facility policies and procedures on infection control and prevention. (Cross-refer to F441.) Review of the responsibilities of the medical director revealed several specific responsibilities including developing and recommending policies and procedures to ensure that care is appropriately delivered to the patients and to assure a smooth operation; providing consultation to the administrator, administrator of nursing, and social services on the ability of the facility in providing for the psychosocial, medical, and physical needs of the patients; and contributing to assuring a safe and sanitary environment for patients and staff.",2017-01-01
87,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2012-09-27,520,E,1,0,KXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record and document review, the facility failed to consistently implement and evaluate plans of action related to the identified quality deficiencies in infection control practices to prevent the development and transmission of infection and communicable diseases as evidenced by: 1. Failure to follow posted instructions for residents placed in contact isolation precautions. 2. Failure to inform and educate residents, families, and visitors of the necessary precautions 3. Failure to ensure adequate personal protective equipment was available and accessible when needed. 1. On 9/26/12 at approximately 3:50p.m., an RN staff member was observed going from room-to-room checking on residents. The nurse entered the room of sampled Resident #6 who was identified as being on 'Contact Isolation' precautions as evidenced by the sign posted at the entry outside of the resident's room. The sign stated that a staff member or visitor was to wear a protective gown and gloves (Personal Protective Equipment - (PPE)) when entering the resident room, as well as washing hands before entering and after exiting the room. Upon entering, the staff member did not wash her hands or put on a protection gown or gloves as indicated on the contact isolation precaution sign posted at the doorway. While in the room, the resident complained of left flank discomfort. The staff member proceeded to pull-up the resident's gown and palpated/examined the left side of the resident' s torso. After she finished the encounter with the resident, she left the room without washing her hands and continued to enter other resident rooms interviewing and assessing residents after the start of the evening shift. At approximately 4:32 p.m. the RN staff member was interviewed. She stated that she was doing her 'rounds' to check on residents as she normally does after the start of her shift. The staff member acknowledged that she did not wear a protective gown or gloves when entering the resident room. She also acknowledged that she did not wash her hands before or after the encounter with the resident and should have adhered to the instructions on the posted contact isolation precaution sign. Resident #6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's medical record indicated that the resident was placed on contact isolation related to the [DIAGNOSES REDACTED]. On 9/26/12 at approximately 10:15 a.m., a staff member was observed entering into Resident room [ROOM NUMBER] that had contact isolation precautions signage posted at the entry door. The sign read that staff and visitors were to wear a protective gown and gloves (Personal Protective Equipment - (PPE)) when entering the resident room, as well as washing hands before entering and after exiting the resident room. The staff member did not wash her hands prior to entering, did not put on gloves or a protective gown (all of which were located outside the resident room in a storage cart marked PPE (Personal Protective Equipment). She then proceeded to examine the resident making contact and moved the IV pole located at bedside of the resident who was sitting in a wheelchair at the time. She then left the room (without washing her hands), and proceeded to go enter a different room (107) without washing her hands and had direct contact with her hands to the resident in that room. After staying in that room for about one minute, she then returned to room [ROOM NUMBER] without washing hands, putting on gloves, or wearing protective gown and removed the IV medication tubing that was connected to the arm of the patient. She then touched and checked the IV site on the patient, and then exited the room. After disposing of the IV tubing, she went directly to the nursing station, where she still did not wash her hands. During an interview at approximately 10:30 a.m., the staff member was asked about the resident being on contact isolation precautions. She stated that most of the patients that are admitted with amputations or skin ulcers are placed on contact isolation precautions when admitted to the facility as a precaution. Further, she stated that she did not realize she had not washed her hands. 2. Unsampled Resident #7 was in room [ROOM NUMBER] and had been admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was assessed to be alert and oriented by the facility. During an interview with the unsampled resident on 9/26/12 at approximately 11:30 a.m., he stated that he did not know why he had been placed on isolation precautions, and that no one from the facility had told him why he was on contact isolation precautions. On 9/26/12 at approximately 10:00 a.m., unsampled Resident #8 was observed in his room with a visitor. The resident had been placed on contact isolation precautions as indicated by the sign on at the entrance of his room. The sign stated that staff and visitors were to wear a protective gown and gloves (Personal Protective Equipment) when entering the resident room, as well as washing hands before entering and after exiting the resident room. The visitor was sitting in a facility wheelchair at the bedside of the resident talking to the resident who was in bed, and was sharing a telephone conversation via the visitor's cell phone. At approximately 10:45 a.m., the resident was interviewed and stated that he did not realize he was on contact isolation precautions. He had no idea what the term meant, and that no one at the facility had told him or his brother that had been visiting. The resident said he routinely receives visits from family members and friends daily, and that no one wears gowns or gloves when visiting because they don't know they are supposed to. According to the medical record, the resident had been admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was assessed to be alert and oriented by the facility, and had been placed on isolation precautions at the time of admission. 3. On 09/26/2012, beginning at 9:30a.m., during a tour, a sign was observed posted at the doorway of room [ROOM NUMBER]. The sign indicated Contact Isolation and listed instructions to gown and glove before entering the room, clean hands before entering room and upon exiting clean hands with soap and water, no gel soap can be used. Contact Precautions (Isolation) are intended to prevent transmission of infectious agents. which are spread by direct or indirect contact with the patient or the patient's environment . The application of Contact Precautions is for patients infected or colonized with multiple drug resistant organisms (MOROs). Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission .Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. 2007. Pdf> A cart (bedside table) was in front of room [ROOM NUMBER]. The staff member identified the cart as an isolation cart to store PPE (personal protective equipment) such as gowns, gloves, and masks and protective eyewear. When the three drawers on the cart were opened, the first drawer had two yellow gowns, the second drawer was empty and the third drawer had a half full12 ounce bottle of drinking water. The staff member removed the bottle of water immediately and validated only PPE should be stored in the cart. The staff member also stated the nurses did not stock the isolation carts. The nursing assistants were expected to restock when needed. Medical record review on 9/26/2012 at 2 p.m., revealed the resident in room [ROOM NUMBER] had a physician order for [REDACTED]. Based on the 2007 CDC guidelines for isolation techniques, the contact isolation sign for this resident should have indicated hand washing with soap and water or alcohol based hand rub. During an interview on 9/27/2012, beginning at 11 a.m., the administrative staff indicated they had developed two signs for contact isolation. One sign was for regular contact isolation and the second sign was for special contact isolation. The special contact isolation was designated to identify those patients who had contagious infections affecting the intestines causing frequent cramping and watery diarrhea. These infections could potentially be spread from one resident to another without good hand washing with soap and water only. The administrative staff had removed the incorrect isolation signs and replaced them with the correct instructions for staff by the following day. On 9/27/2012, a nutrition aide came to unit A at 12:15 p.m. to deliver the lunch trays. The first lunch tray was delivered to an isolation room. The nutrition aide was observed from the time she entered the unit. She walked directly to the food cart, removed a tray, delivered it to the resident in the isolation room, placed it on the table at bedside, left the room and immediately went back to the food cart to deliver the next tray. The next tray was delivered to a resident who required set up (opening of containers). As the aide was walking toward the food cart again, she was asked if this is the normal routine for her to pass all the trays on unit A. She indicated it was a daily routine and that they try to deliver the trays as soon as they arrive on the unit. When the aide was asked about hand hygiene between residents with or without isolation, she stated she does not touch the residents. No hand washing was observed prior to the start of serving the trays, before entering, or after leaving the residents rooms. The aide was observed washing her hands at the nurse station before the next tray was delivered. Review of the facility policy ' Personal Protective Equipment (SNU SPECIFIC) ' identified the types of personal protective equipment and appropriateness of use. Under suggested use for examination gloves, the policy directs the staff to use vinyl synthetic examination gloves for short term tasks such as handling and preparing food.Review of the facility policy 'Rationale for Isolation Precautions' identified indirect contact as the most frequent mode of transmission (spreading infection) .through a contaminated inanimate object and subsequently touch another resident without performing hand hygiene between resident contacts. The policy further indicated, Unwashed hands are the most frequent cause of pathogen (germ) transfer resulting HAIs (hospital/facility acquired infections). Review of the facility infection control skills validation and training list completed on 4/3/2012 identified 5 of 14 staff members were observed during a training scenario to perform a dirty procedure prior to performing a clean procedure (bowel/perineal care then oral care). 5 of 14 staff members failed to change gloves after first procedure. 2 of 14 staff members failed to perform hand hygiene between procedures. There was no evidence of remediation or further observations to ensure consistent, effective infection control staff practices.",2015-09-01
88,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2010-09-17,226,D,0,1,7DPX11,"Based on interview and document review, the facility failed to develop and implement policies and procedures that prohibited abuse when one staff member interviewed was unable to identify the different kinds of abuse. Findings include: 1. On 9/16/10, CNA 1 (certified nursing assistant) was interviewed regarding abuse and emergency preparedness. CNA1 stated that she had received abuse training earlier this year (2010) but could not recall the month when the training was conducted. When asked to identify the different forms of abuse she could only recall physical and verbal abuse and not other forms of abuse such as sexual, mental, involuntary seclusion and corporal punishment. 2. A review of the facility's policy and procedure on abuse training revealed that ""Hospital/SNU (Skilled Nursing Unit) staff shall be educated regarding recognition of abuse, identification of victims of abuse, and the mandatory reporting duties. Staff education will take place during employee orientation, as well as in unit-specific in-service training programs and other hospital-wide training sessions. These training sessions shall include information on the role of the hospital/SNU staff in situations of abuse, criteria for identifying victims, statutory reporting requirements, and referrals for appropriate services."" The ""General Orientation Checklist/Agenda"" from the education department included watching a video from social services regarding Referrals: Identifying Victims of Abuse (video). A sign-in sheet was provided for an inservice on ""Reporting Adult Abuse"" conducted by DPHSS Adult Protective Services on 9/3/10. The informational material provided by the educational department regarding the video however was related to ""Domestic Abuse.""",2014-12-01
89,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2010-09-17,244,E,0,1,7DPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to listen to and act on the views, grievances and recommendations of a resident's family concerning decisions affecting residents care and life in the facility. This failure has the potential impact quality of life for residents and could lead to a potential delay in staff response to an emergent or urgent resident situation in the dining room if a resident started choking. Finding includes: On [DATE], during the noon meal observation there were 3 residents observed eating in the dining room. Two residents were feeding themselves and the other was being fed by a family member. No nursing or dietary staff was observed in attendance during the meal service. On [DATE], during the dinner meal observation there were 3 residents observed eating in the dining room. Two residents were feeding themselves and the other was being fed by a family member. No nursing or dietary staff members were observed in attendance during the meal service. During the meal observation, the nurse call light was activated by this surveyor at 5:00 p.m. From 5:00 p.m. to 5:25 p.m. there was no dietary or nursing staff response to the dining room call light. The call light was deactivated by an upstairs front desk security staff member. On [DATE], A licensed staff (LN3) was interviewed. She stated that there was usually a CNA (certified nursing assistant) or dietary staff member present in the dining room during the meal service; however, the CNAs may return to the rooms to assist the residents in need of feeding assistance. She stated all staff had CPR (cardiopulmonary resuscitation training) with First Aid and therefore the dietary staff should know what to do in the event a resident was choking. LN3 acknowledged a choking resident may not be able to speak and with the doors closed to the dining room, shouts for help by family members or other residents may not be heard by the staff. On further investigation LN3 acknowledged that there was no system to ensure nursing or dietary staff members had been, or were currently, assigned to the dining room to provide potential resident assistance during meal times. On [DATE], the Grievances/ Complaints policy dated [DATE] was reviewed. The policy defined a complaint as ""Any concern expressed by the patient or family member concerning care or services that can be addressed relatively quickly, on the spot, by the staff or managers present. No written response is needed."" On [DATE], the family of Resident 9 was interviewed. The father and the mother stated that on [DATE], they had discussed the concern about the lack of staff in the dining room to address potential resident needs with LN 2. Accordingly, the facility had not responded to their concern by placing a staff member in the dining room during the meal times; nor had they received a written or verbal response to the concern.",2014-12-01
90,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2010-09-17,248,E,0,1,7DPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not provide for an ongoing program of activities designed to meet the interest and the physical, mental, and psychosocial well-being of each resident for 6 of 10 sample residents (Residents 2, 3, 5, 6, 7 & 9). Failure to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well being of each resident has the potential to affect their quality of life. Finding includes: 1. Resident 3 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] described the resident as having short-term memory problem, with moderately impaired cognitive skills for decision-making, and was dependent on staff for all activities of daily living (ADL). Throughout the survey, Resident 3 was observed in bed and not engaged in any type of activity. Review of the medical record revealed that while there was no contraindication for her getting out of bed, there was no indication that an evaluation was conducted to determine the appropriate type and level of program that Resident 3 could benefit from in consideration of her cognitive status, frequent calling out, and physical limitations. The care plan on cognitive loss dated 8/25/10, for example, noted that staff would ""assess, monitor, and record the patient's decision making: memory problem understanding;"" and ""provide program of activities: that accommodates patient problem."" This notwithstanding, review of the medical record revealed the lack of documentation that an individualized program of activities was developed for Resident 3. There was no documentation of ""patient problem"" or attempts to engage Resident 3 in different types of activities or settings to determine if these could provide for a meaningful diversion, minimize behaviors of repeated calling out, or address her needs for comfort and companionship. Throughout the survey, Resident 3 was observed in bed and when awake was frequently heard calling out to staff for assistance to get out of bed or to the bathroom. On 9/15/10 at 1:30 p.m. for example, the resident was heard from the hallway calling out ""nurse ...nurse"" repeatedly. When asked what she wanted, the resident replied, ""Help me up...help me up. I want to go to the bathroom."" At 3:30 p.m. on 9/15/10, Resident 3 was again observed calling out, ""get me up ...I want to get up."" At 10:35 a.m. on 9/16/10, the resident was heard, saying repeatedly, ""I want to get up ...I want to get up."" When asked what she wanted to do, the resident replied that she wanted to get out of bed. When asked if Resident 3 could get out of bed, a facility staff interviewed stated that she did not know. 2. Resident 7 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Nursing admission notes dated 9/05/10 described Resident 7 as ""alert and oriented (times) 2;"" and that she was ""verbally responsive but confused."" Throughout the survey, Resident 7 was observed in her room never leaving her bed. Information provided by the facility concerning Resident 7 noted that she was ""bedfast."" Review of the medical record however revealed the lack of contraindication for her getting out of bed. Indeed, admission orders [REDACTED]."" In spite of this, Resident 7 was not observed assisted out of her room to any organized activity. A recreational therapy evaluation dated 9/08/10 described Resident 7 as able to interact ""with staff to express needs, (patient) is pleasant towards peers, but would need to attend group to observe peer interaction."" The evaluation further noted therapy goals which included participating ""in a 1:1 activity with staff..;"" that she will be ""brought out of the room via (wheelchair) for Sunshine and Socialization to increase Leisure performance;"" and ""will participate in light (wheelchair) Exercise group to increase strength and endurance. Interventions to meet the goals included providing emotional and spiritual support and providing Resident 7 ""with Arts and Crafts and Card Games;"" ""attend group at least 1 - 2 (times) a week,"" and will be ""brought out of the room at least 2 - 3 (times) a week, and participate in a 1 to 1 activity at least once a week. "" During the survey however, Resident 7 was always observed in bed neither engaged in Arts and Crafts and Card Games nor brought out of the room to attend group activities as planned. 3. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's minimum data set ((MDS) dated [DATE] revealed that the resident was awake, alert, and verbally responsive. The resident's activity pursuit patterns included her preferred activity settings as her room and the activity room. The MDS revealed that the general activity preferences of Resident 5 include the following: cards/other games, crafts/arts, exercise/sports, music, reading/writing, spiritual/religious activities, trips/shopping, walking/wheeling outdoors, watching tv, gardening or plants, talking or conversing, and helping others. The progress notes by the recreational therapy staff dated 8/26/10 identified an issue of ""decreased leisure activity performance"" The progress note further revealed a plan for the resident to be brought to a group activity via wheelchair to participate in exercise activity and sunshine stroll at least three times a week and 1-1 activity at least once a week. A social services summary form dated 9/1/10 revealed that the social worker was informed by the facility's unit nursing supervisor that the resident was on ""suicidal watch."" The social worker met with the resident who assured her that she would not harm herself and that she was joking with one of the nurse aides that she would kill herself using the cord line in her room. The social worker noted the resident was emotional during the interview and stated that she was depressed and was concerned about her placement upon discharge. A review of the physician orders [REDACTED]. one tablet daily for depression. A patient note dated 9/6/10 stated, ""Resident is being treated for [REDACTED]."" A plan of care last updated on 8/31/10 noted a mood state problem with a goal that the resident would have improved mood with an approach to encourage her to participate in diversional recreational activities for socialization with groups. Interview with the recreational therapy staff on 9/16/10 indicated that the resident was brought to the day/activity room for group activities and stayed outside when she has visitors. Review of the progress notes and plan of care showed no documentation that the activities provided were designed to meet the interests of Resident 5 whose depressed mood had deteriorated to suicidal thoughts within a one-month period. Also there was no provision for adapting the recreational needs of the resident when she was placed on contact isolation on 9/15/10 the first day of the survey. Review of the activity calendar for September 2010 revealed scheduled activities twice a day at 10 or 10:30 a.m.; and the second activity at 1:30 p.m. or 2:00 p.m. In an interview with two facility staff member acting as recreational therapy staff, they have stated that there had been no recreational therapy director for two years. Both revealed that they work together with a recreational therapy consultant to create an activity calendar that best addressed the recreational needs of the residents in the facility. 4. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/15/10 at 10:20 a.m., during the initial tour, the Resident 6 went out of the facility for her [MEDICAL TREATMENT] treatment in an acute hospital facility. The resident room had contact isolation precautions posted outside the door. Interview with the licensed nurse indicated that she was not sure of the cause of isolation. The licensed nurse added that the resident has either (MRSA) [MEDICAL CONDITION]-resistant staphylococcus aureus or (MDR) multi drug resistant infection from the wound in the right stump. A review of the MDS dated [DATE] revealed that Resident 6's cognition was moderately impaired and with periods of lethargy, e.g. sluggish staring into space, difficult to arouse with little body movements. The resident's preferred activity settings include her own room and the day/activity room. The MDS also revealed that the resident's general activity preferences include cards/other games, crafts/arts, exercise/sports, music, reading/writing, spiritual/religious activities, trips/shopping, walking/wheeling outdoors, watching tv, gardening or plants, talking or conversing, and helping others. The plan of care related to a problem with communication revealed a goal for the resident to maintain communication skills as evidence by making sounds, pointing, using gestures, responding with appropriate yes or a head nod. The plan of care related to cognitive loss included approaches such as provision of program of activities that accommodates patient problem. Also provision of reality orientation validation therapy: use of communication technique such as using patient's name, using smile and simple brief words. On 9/15/10 at 2:30 p.m. Resident 6 was observed resting in bed after coming back from [MEDICAL TREATMENT] unit. At 4:45 p.m., the resident was observed in bed radio was on with music playing. Except for this music, there were no other activities that were offered to the resident on the days of the survey. 5. Resident 2 is a [AGE] year old male admitted on [DATE]. His primary [DIAGNOSES REDACTED]. Review of the medical record revealed that he had a stroke on 7/16/10 and had made some recovery from a previous vegetative state. According to his minimum data set ((MDS) dated [DATE], Resident 2 was identified as being totally dependent for most physical functioning and had some involvement in activities. His preferred activities were assessed to be in the room or within the activity/day room and the activities generally occurred within the nursing home. His recreational therapy evaluation identified a problem of ""Decreased participation in leisure activity."" Expected outcomes/goals based on the recreational therapy evaluation indicated the resident ""will participate in sunshine stroll, group conversation for socialization."" Specific interventions identified for the problem were: ""staff to offer and organize a group/small setting for cooking and encourage the pt. (patient) to join and staff to provide some materials for him to use, or any activity functional depending on his level of function."" The document indicated that ""the pt. (patient) will attend group activity at least 3X a week and 1:1 activity at least 2X/week."" A review of the facility September 2010 resident activity calendar showed that for most day of the month there were 2 group activities per day; one activity occurring in the morning and one activity in the afternoon. Several in-room care observations were made for Resident 2 between survey dates of 9/15/10 and 9/17/10. No activity calendar was observed to be posted in the room. The brother of Resident 2 was noted to be visiting and assisting with care during the morning and the wife was visiting and assisting with care in the afternoon. Resident 2 was not observed to participate in any in-room or group activities during the observation period. During an interview on 9/16/10, the wife stated that during the afternoons when she was present she had not observed the staff provide her husband any form of reorientation or divisional activity aside from regular care. On 9/17/10, during an interview with the brother he stated during the mornings when he was present that he had not observed his brother participate in any form of in-room or group activity aside from the expected care such as turning, cleaning, or feeding. Neither the bother nor the wife acknowledged seeing the September 2010 activity calendar. On 9/16/10, Resident 2's medical record was reviewed with the facility activity representatives. The recreational therapy evaluation dated 8/20/10 was reviewed for assessment data, problem identification, goals, interventions, and frequency (i.e., plan of care). The daily treatment record was reviewed as well. The activity representative acknowledged that from 9/01/10 to 9/07/10 the form lacked documentation demonstrating group or in-room activities occurred for the resident. Additionally, she acknowledged the resident's assessment did not take into consideration the resident's [DIAGNOSES REDACTED]. 6. Resident 9 is a [AGE] year old male admitted into the facility on [DATE]. His [DIAGNOSES REDACTED]. The medical record reflected that ""the Mom is the primary caregiver"" of the patient. According to his minimum data set ((MDS) dated [DATE], he was identified as being totally dependent for most of his physical functioning and had some involvement in activities. His communication pattern was assessed as having unclear speech, rarely/never understood, rarely/never understands and speaks with signs/gestures/sounds. His preferred activities were assessed to be in the room or within the activity/day room. His recreational therapy evaluation form dated 8/23/10 was reviewed. It identified a problem of ""Decreased leisure activity participation."" The evaluation identified the expected outcome/goal as, ""Pt (patient = resident) will participate in group activity to increase his strength and safer mobility. Pt will participate in sunshine stroll, group conversation for socialization to increase social participation."" Specific interventions identified for the problem included ""staff to inform patient and family of current events, recreational therapy (RT) staff to offer the pt to try to use the piano in RT room to play and RT staff to offer or provide different functional activities appropriate for his level."" The document indicated that ""the pt will attend group activity at least 3X a week and 1:1 activity at least once a week."" Several in-room care observations were made for Resident 9 between survey dates of 9/15/10 and 9/17/10. No activity calendar was observed to be posted in the room. of Resident 9. Both the mother and father were observed interacting with the resident during most of the observation period. Resident 9 was not observed to participate in any in-room or group activities during the observation period. During an interview with the mother and father on 9/17/10, they stated that they had not observed the staff provide their son any form of individualized divisional activity aside for regular care. Neither of the parents acknowledged receipt of the September activity calendar. Three activities were documented on the recreational therapy daily treatment record for the week of 9/09/10 through 9/16/10. During the aforementioned time period the activities were documented as (1) Dining, (2) Being wheeled around in wheel chair by mother, and (3) watching TV in room. The goals, frequency and types of interventions specific to the facility identified problem for this resident were not met.",2014-12-01
91,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2010-09-17,278,B,0,1,7DPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that the assessment of one of 10 sample residents (Resident 1) accurately reflected the resident's status. Accurate assessment provides the basis for care and failure to obtain accurate assessments could result in inadvertent acts of omission or commission when planning the resident's care. Finding includes: Resident 1 is a [AGE] year old female admitted to the facility on [DATE]. Her admission [DIAGNOSES REDACTED]. Several in-room care observations were made for Resident 1 between survey dates of 9/15/10 and 9/17/10. On 9/15/10, she was observed to be responsive to both tactile and verbal communication with her family. During a skin observation on 9/16/10, her eyes were open and she appeared to acknowledge the verbal direction of her family member and the certified nursing assistant facilitating the skin observation. During the observation attempts were made to communicate with Resident 1, she never communicated clearly with her family or the staff. On 9/16/10, the MDS (minimum data s) dated 8/21/10 and the most recent weekly assessment was reviewed with LN4, a licensed nurse. The MDS identified communication patterns exhibited by Resident 1 during the assessment period were signs, gestures or sounds. The MDS also identified that she makes herself understood, that her speech was clear and that she was independent for cognitive skills for daily decision-making. A review of the facility admission form dated 8/15/10 reflected that the resident was disoriented to time and place and that she had a speech deficit. A review of the weekly assessment dated [DATE] identified the resident's speech as ""Signs/Gestures used."" LN 4 acknowledged the discrepancies in the assessments provided on the MDS, the admission sheet, and the most recent weekly assessment.",2014-12-01
92,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2010-09-17,314,E,0,1,7DPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents having pressure sores received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 4 of 10 sample residents (Residents 1, 2, 4, and 6). These failures have the potential to contribute to delayed wound healing or the development of new sores. Findings include: 1. Resident 1 is a [AGE] year old female admitted to the facility on [DATE]. Her admission [DIAGNOSES REDACTED]. The medical record indicated the family/resident was requesting end of life terminal care and that [MEDICAL TREATMENT] had been declined. On 9/16/10, a skin observation was completed and all the skin was intact. On 9/17/10, the medical record was reviewed with LN4. She acknowledged the wound assessment dated [DATE] reflected the previously documented stage II pressure ulcer was recorded as healed. Additionally, she validated the nursing care plan was still being implemented to prevent the development of new pressure ulcers. One of the interventions listed on the potential pressure ulcer care plan was ""SNU (Skilled Nursing Unit) - Turn and Reposition every two hours."" That is, the facility staff would be turning the resident every 2 hours to help prevent pressure ulcer development. On 9/18/10, the wound assessment data, nursing care plan and certified nurse assistant (CNA) turning schedule was reviewed with LN 5. She acknowledged the turning schedule indicated the turning was to occur every 2 hours. A review of the CNA turning schedule documentation from 8/16/10 to 8/29/10 indicated the resident was being turned every 4 hours not every 2 hours as identified in the nursing care plan. She also acknowledged that the CNA turning documentation from 8/30/10 to 9/11/10 reflected that there were periods where the records noted the failure to turn the resident or document the turning event for the resident. The Pressure Ulcer Management Policy dated September 1987 indicated the staff should ""implement the written turning schedule changing position at least every 2 hours while in bed"" which did not always occur for this resident as per the record review. 2. Resident 2 is a [AGE] year old male admitted on [DATE]. His primary [DIAGNOSES REDACTED]. He experienced the stroke on 7?26/10 and had made some recovery from a previous vegetative state. His medical record indicated he developed a sacral pressure ulcer prior to admission in to the facility and that the pressure ulcer was debrided on 9/02/10. Wound care was observed on 9/16/10 and the nurse described the stage IV wound to be improving after the debridement. On 9/17/10, the physician orders, nursing care plan and CNA turning schedule were reviewed with LN5. She validated that the physician's orders [REDACTED]."" The nursing care plan indicated one of the interventions listed on the pressure ulcer care plan was ""SNU - Positioning intervention as turning and repositioning the client. The intervention did not reflect that the patient would be turned every 2 hours to help promote would healing and prevent additional pressure ulcer development. After reviewing the CNA turning schedule documentation from 8/18/10 to 9/16/10, LN5 acknowledged the turning records did not always reflect that resident 2 was turned every 2 hours. She also acknowledged that the CNA turning documentation reflected there were periods where the records demonstrated there was a failure to turn the resident or there was failure to document the turning event for the resident. The pressure ulcer management policy dated September 1987 indicated the staff should ""implement the written turning schedule changing position at least every 2 hours while in bed"" which did not always occur for this resident. 3. Resident 7 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Nursing admission notes dated 9/05/10 described Resident 7 as ""alert and oriented (times) 2;"" that she was ""verbally responsive but confused;"" and that she was incontinent of bowel and bladder functions and was ""using adult diaper."" Review of the medical record revealed that Resident was admitted with a wound on the left lateral knee. A wound assessment dated [DATE] described the would as being a stage 2 with a length and width of 3 cms by 3 cms respectively. The wound was also noted as being ""pinkish"" with ""serosanguinous"" drainage. A nurses note dated 9/05/10 also noted that the resident had a ""pressure sore on left lateral knee 3 cm X 3 cm."" Accordingly, the wound was cleaned with saline solution and Duoderm (a moisture barrier occlusive dressing) was applied. On 9/05/10, a physicians order to apply DuoDerm to the left lateral knee was made. The same order noted to have the Duoderm changed every 72 hours. While a care plan dated 9/05/10 required staff to ""assess, document, or report skin status or any appearance or blister or redness,"" further record review however revealed the lack of evidence of continuing assessment as a basis for determining if the treatment regimen and other interventions were effective or needed to be adjusted. On 9/17/10 at 9:35 a.m. wound care observation was made. While the left lateral knee dressing was removed by the treatment nurse, there was no Duoderm applied to the wound so that bleeding was noted around the edges of the wound. During the procedure, the treatment nurse stated that the wound should have been covered by Duoderm as was currently ordered by the physician. 4. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/15/10 at 10:20 a.m., during the initial tour, the Resident 6 went out of the facility for her [MEDICAL TREATMENT] treatment in an acute hospital facility. The resident room had contact isolation precautions posted outside the door. Interview with the licensed nurse indicated that she was not sure of the cause of isolation. The licensed nurse added that the resident has either (MRSA) [MEDICAL CONDITION]-resistant staphylococcus aureus or (MDR) multi drug resistant infection from the wound in the right stump. A review of the MDS dated [DATE] revealed that Resident 6's cognition was moderately impaired and with periods of lethargy, e.g. sluggish staring into space, difficult to arouse with little body movements. The resident was identified with two (2) pressure ulcers, one of which was described as Stage II pressure ulcer. The skin treatments listed in the MDS were turning/repositioning program, nutrition or hydration intervention to manage skin problems, surgical wound care, application of dressings other than feet, application of ointments/medications (other than feet) and other preventative or protective skin care (other than feet). The resident's MDS also described infection of the foot - [MEDICAL CONDITION], purulent discharge, open [MEDICAL CONDITION] of the foot, received preventative or protective foot care (e.g. used special shoes, inserts, pads, toe separators), and application of dressings (with or without topical medications) The admission nurse's notes dated 7/15/10 at 23:30 stated that Resident 6 had a ""Duoderm dressing over the sacral area which was still new. Size is small. Did not open it anymore."" The wound assessment form dated 7/15/10 - 9/16/10 described the Stage II pressure ulcer in the sacral area that initially measured 2.0 cm long and 1.0 cm wide with no depth, odor or drainage on 7/29/10. As of 9/12/10, the Stage II pressure ulcer measured 5.0 cm long and 4.0 cm wide with no depth, odor or drainage. The nurses notes dated 8/9/10 at 1715 read: ""Back from [MEDICAL TREATMENT] via hospital transport ...Dressing soaked with urine. Dressing of sacral wound changed."" Nurse's notes dated 7/30/10 at 1800 stated: ""Back from [MEDICAL TREATMENT] via hospital transport ...Cleaned and kept comfortable."" On 9/14/10, the physician ordered wet to dry dressing with normal saline solution daily to sacral area. On 9/16/10 at 3:30 p.m. a licensed nurse was observed changing the dressing on Resident 6's pressure ulcer in the sacral area. The resident had to be cleaned twice due to bowel incontinence. The licensed nurse identified the pressure ulcer as Stage II with areas of pink and white. Wet to dry dressing with saline was applied in the sacral area. There was no in-depth assessment of the factors that led to the increase in the size of the Stage II pressure ulcer in the sacral area.",2014-12-01
93,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2010-09-17,325,D,0,1,7DPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure the maintenance of acceptable parameters of nutritional status for 1 of 10 sampled residents (Resident 2). Failure to maintain acceptable parameters of nutrition can contribute to weight loss and low protein levels which may delay wound healing. Finding includes: Resident 2 is a [AGE] year old male admitted on [DATE]. His primary [DIAGNOSES REDACTED]. He experienced the stroke on 7/26/10 but had made some recovery from a previous vegetative state. His medical record indicated he developed a sacral pressure ulcer prior to admission in to the facility and that the pressure ulcer was debrided on 9/02/10. Wound care was observed on 9/16/10 and the nurse described the stage IV wound to be improving after the debridement. On 8/17/10, his diet was ordered as Ensure 1 can every 6 hours via gastric tube. On 8/24/10, his diet was changed to ""Fiber-source one can every 6 hours then increase to 1 can every 3 hours as tolerated, then change to 2 cans every 6 hours 2 days prior to discharge."" On 8/26/10, his diet gastric tube feeding was changed again to Fiber-source 1 can every 6 hours. On 9/02/10, his diet was changed to Fiber-source 1 can every 6 hours. On 9/15/10, during a tube feeding observation, and concurrent interview, LN6 (licensed nurse) stated Resident 2 was still receiving Fiber-source 1 can every 6 hours. LN6 acknowledged Resident 2 had not been tolerating the increasing volume of the Fiber-source and had residual gastric contents and therefore his tube feedings had never advanced as described in the physician orders. The medical records were reviewed on that same date and LN6 acknowledged Resident 2 had a low [MEDICATION NAME] level. She continued to indicate that the physician had been informed of all lab results. LN6 validated that the [MEDICATION NAME] level on 8/18/10 was sub-therapeutic at 2.8 gm/dl (normal is 3.4 to 5.0 gm/dl) and confirmed that throughout Resident 2's admission his [MEDICATION NAME] level remained sub-therapeutic. On 9/15/10, his [MEDICATION NAME] level was 2.7 gm/dl. On 9/16/10, the medical record was reviewed with the registered dietician (RD). Her documentation recognized Resident 2's sub-therapeutic [MEDICATION NAME] levels. She indicated the reason the diet had been initially changed was because Fiber-source had higher [MEDICATION NAME] content than Ensure. She stated Resident 2 had not been tolerating the increasing volume of Fiber-source and supplemental [MEDICATION NAME] sources had not been ordered since they were not on the current formulary. The RD agreed increasing the [MEDICATION NAME] level may promote Resident 2's pressure ulcer wound healing.",2014-12-01
94,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2010-09-17,166,E,0,1,7DPX11,"Based on interviews and record review, the facility failed to ensure that prompt efforts were made to resolve grievances the residents may have. Findings include: 1. On 9/16/10 at 10:15 a.m., during the resident group meeting, two of ten residents complained of noise from screaming patients at night. Resident 8 revealed that he was told to to shut his door to reduce the noise level. He also stated that it takes a long time for the nurses to attend to the screaming residents at night resulting his inability to fall asleep. Another resident confirmed that the screaming residents affected her ability to sleep at night. 2. On 9/16/10 during the same resident group meeting, three residents complained about the nurses' slow response to patient calls, especially on the night shift. One patient indicated that the facility needed more staff to attend to patients' needs at night. Also the slow response to residents' calls for assistance occur during early morning when residents needed to use the restroom. A review of the resident council meeting minutes for May - July, 2010 revealed that the same issue of staff's slow response to call lights was identified in the minutes: For example: a. 5/28/10 - ""Response time for help calls from nurses is too long. Sometimes more than 10 - 15 minutes which is dangerous if this is a life saving call."" The corrective actions documented were: ""to conduct test time it takes to answer call lights. All nursing staff instructed to ask patients what they need and inform the patients if they will be delayed in providing care."" Another entry in the meeting minutes dated 5/28/10 noted, ""There is this one CNA (certified nursing assistant) at the time my sister soiled herself and needed changing that came to the room, then told us she'll have to call the assigned CNA to help her change her. I stood at the door watching her and she walked down to the other end of the hallway but did not inform anyone that we needed help. Why did she even bother to come to our room and then do nothing?"" The corrective action read: ""Head Nurse counseled CNA. All nurses reminded to assist patients in timely fashion. If busy, the assigned CNA shall inform the patient of the delay and ask for assistance from the assigned RN."" b. The resident council meeting minutes dated 7/30/10 revealed, ""resident continued to comment about the nurses slow response time to patient calls and observing nurses always chit-chatting instead of attending to patients (90% of the attendees agreed with the comments of slow response time and constant chit-chatting going on)."" The facility's corrective action was for the head nurse to further investigate this incident with staff. Another entry in the 7/30/10 minutes revealed that a resident called to the nurses and was told to wait. The resident noticed the nurses have mood problems, if ""they don't like you, you don't get any service right away. (50% of the attendees agreed with this comment)."" The corrective action was for the head nurse to educate staff to improve customer service in upcoming emergency staff meeting. Another entry in the 7/30/10 minutes stated, ""The response time when I called to be position changed and diaper changed took four hours for a nurse to come."" The corrective action was for the head nurse to investigate this incident and re-educate staff to use buddy system. Although the slow response to call lights remain to be a topic in the resident council meetings since 5/2010, the issue remained unresolved as evidenced by concerns raised by the residents during the group meeting on 9/16/10.",2014-12-01
95,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2010-09-17,253,D,0,1,7DPX11,"Based on observations and interviews, the facility failed to maintain maintenance services necessary to maintain the integrity of the roof over the expansion joints located above the double doors in corridor D100 and cleanliness of C115 day room.. Findings include: During the facility tour on 9/16/10 at 2:10 p.m., observations included brownish/yellowish discoloration above the D100 corridor double doors extending down the walls outside the C115 day room and the wall next to room A125. A wall vent located near the double doors on the day room corridor side was removed and exposed a gap between the two walls, observations of the gap inside the two walls included dead insects and moist blackish debris on the floor area. In an interview during the observation, the facilities maintenance supervisor stated that the roof leaks at the expansion joints and the stains on the walls are water marks. The double doors replaced an accordion wall and the area behind the vent was used for the accordion wall. At this approximate time observations of the C115 day room included walls with brownish/yellow stains and a layer of dust over the television set. The above findings were verified with the GMHA safety administrator and SNU facilities maintenance supervisor who accompanied the surveyor during the tour.",2014-12-01
96,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2010-09-17,246,D,0,1,7DPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not ensure that the resident had the right to reside and receive services with reasonable accommodation of individual needs and preferences for two of 10 sampled residents. Findings include: 1. Resident 3 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the medical record revealed that the resident was admitted from the hospital where she was treated for [REDACTED]. The minimum data set ((MDS) dated [DATE] described the resident as having short-term memory problem, with moderately impaired cognitive skills for decision-making, and was dependent on staff for all activities of daily living (ADL). Throughout the survey, Resident 3 was frequently heard calling out to staff for assistance to get out of bed or to the bathroom. On 9/15/10 at 1:30 p.m. for example, the resident was heard from the hallway calling out ""nurse ...nurse"" repeatedly. When asked what she wanted, the resident replied, ""Help me up ...help me up. I want to go to the bathroom."" At 3:30 p.m. on 9/15/10, Resident 3 was again observed calling out, ""get me up ...I want to get up."" At 10:35 a.m. on 9/16/10, the resident was heard, saying repeatedly, ""I want to get up ...I want to get up."" When asked what she wanted to do, the resident replied that she wanted to get out of bed. When asked if Resident 3 could get out of bed, a facility staff interviewed stated that she did not know. Review of the medical record revealed the lack of contraindication for Resident 3's requests to get out of bed. physician's orders [REDACTED]."" Further review revealed the lack of indication that the facility had considered Resident 3's request and took steps to accommodate her preference. During the survey, Resident 3 was observed in bed and remained bed-bound in spite of her frequent calling out to get out of bed. 2. On 9/16/10 at 10:15 a.m., a resident's family member indicated that the telephone line was not working in the room that Resident 5 was transferred to. The resident stated that she wanted to talk to her granddaughter every afternoon when she returns from school. Accordingly, the nursing staff was made aware of the concern and have notified the maintenance department. However, they were told that maintenance will fix the telephone line later. Review of the medical record revealed that Resident 5 was transferred because she needed to be on contact isolation. On 9/16/10 at 4:30 p.m., the charge nurse stated that the telephone line in Resident 5's room was inoperable per maintenance staff. The charge nurse added however that the resident will be moved to another room soon, possibly back to her former room where she can have telephone access. The charge explained that the resident's physician had been notified and that based on a recent lab report contact isolation precaution could now be discontinued. The charge nurse revealed that the resident can go back to her former room where she can have access to the telephone.",2014-12-01
97,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2010-09-17,241,E,0,1,7DPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility did not promote care for residents in a manner and in an environment that maintained or enhanced the resident ' s dignity and self-respect. Findings include: 1. During the survey, bed-bound residents were repeatedly heard calling out to staff for assistance before receiving a response. In several instances, staff had to be summoned to the resident's room to ensure that the resident received assistance. For example: a. Resident 3 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the medical record revealed that the resident was admitted from the hospital where she was treated for [REDACTED]. The minimum data set ((MDS) dated [DATE] described the resident as having short-term memory problem, with moderately impaired cognitive skills for decision-making, and was dependent on staff for all activities of daily living (ADL). Throughout the survey, Resident 3 was frequently heard calling out to staff for assistance to get out of bed or to the bathroom. On 9/15/10 at 1:30 p.m. for example, the resident was heard from the hallway calling out ""nurse ...nurse"" repeatedly. When asked what she wanted, the resident replied, ""Help me up ...help me up. I want to go to the bathroom."" At 3:30 p.m. on 9/15/10, Resident 3 was again observed calling out, ""get me up ...I want to get up."" At 10:35 a.m. on 9/16/10, the resident was heard, saying repeatedly, ""I want to get up ...I want to get up."" When asked what she wanted to do, the resident replied that she wanted to get out of bed. When asked if Resident 3 could get out of bed, a facility staff interviewed stated that she did not know. b. Resident 7 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Nursing admission notes dated 9/05/10 described Resident 7 as ""alert and oriented (times) 2;"" that she was ""verbally responsive but confused;"" and that she was incontinent of bowel and bladder function and was ""using adult diaper."" Review of additional nurses notes indicated that Resident 7 had behaviors of calling out including on 9/05/10 when she was described ""calling her sister mama;"" on 9/12/10, when she was noted as ""confused at times"" and ""calling names;"" on 9/14/10 with ""on and off shouting;"" and on 9/16/19 when she was described as ""kept on yelling asking for help."" During the initial tour at 9:55 a.m. on 9/15/10, Resident 7 was heard from outside her door repeatedly calling out to staff for assistance. When asked what she wanted, the resident replied, ""I want to change my pampers. It's wet."" The resident continued to state, ""Please, please, ask the girls."" When this was brought to attention, a facility staff on the tour with the surveyor summoned a CNA (certified nurse aide) who thereafter attended to the resident's needs. During the survey, Resident 7 was heard calling out several more times and in all these, staff were not observed to promptly check on the resident to determine the reasons for calling out. On 9/16/10 at 9:05 a.m., for example, Resident 7 was heard calling out, ""I want to turn, I want to turn."" At 3:05 p.m. on 9/16/10, Resident 7 was heard calling out, ""I want to get up, I want to get up."" When asked what she wanted, the resident stated that she wanted ""to move."" When asked if she knew to use the call light for assistance, the resident did not reply. When approached, the staff stated that the resident was confused and that sometimes she does not know what she wants. 2. During the group interview on 9/16/10, several residents complained about the slow response from facility staff regarding summons made for assistance. In the same meeting, three residents complained that staff were slow to respond to call lights especially on the night shift. One patient indicated that the facility needed more staff to attend to patients' needs at night. Also the slow response to residents' calls for assistance occur during early morning when residents needed to use the restroom. (Cross-refer to F241.)",2014-12-01
98,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2010-09-17,250,D,0,1,7DPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of three residents in the sample described as receiving psychoactive medications. Finding includes: 1. Resident 3 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the medical record revealed that the resident was admitted from the hospital where she was treated for [REDACTED]. The minimum data set ((MDS) dated [DATE] described the resident as having short-term memory problem, with moderately impaired cognitive skills for decision-making, and was dependent on staff for all activities of daily living (ADL). Review of the medical record revealed nurses notes that documented Resident 3 as being confused and ""restless,"" including on 8/21/10, 8/29/10, 8/30/10, 9/01/10 and 9/02/10; as well as ""yelling""and being ""agitated"" including on 8/16/10, 8/29/10 and 9/15/10. Review of the medical record revealed that on 8/15/10, physician's orders [REDACTED]. days."" Review of the MAR (medication administration record) and nurses notes revealed that Resident 3 was given Haldol for the behaviors. Further record review however revealed that in light of this, there was no evidence of social services participation in assessing the underlying cause of the resident's agitation or restlessness and whether this could be eliminated or minimized. In addition, there was no documentation of social service involvement in the development of interventions to address the behavior or decrease their frequency without the use of antipsychotic drugs (or use of the least dose possible). While a social service summary dated 8/24/10 referenced the resident as being ""sometimes confused,"" there was no mention of any of the behaviors manifested by Resident 3 requiring treatment with antipsychotic drugs. During the survey, Resident 3 was frequently heard calling out to staff for assistance to get out of bed or to the bathroom including on 9/15/10 at 1:30 p.m. when the she was heard from the hallway calling out ""nurse ...nurse"" repeatedly. When asked what she wanted, Resident 3 replied, ""Help me up ...help me up. I want to go to the bathroom."" At 3:30 p.m. on 9/15/10, Resident 3 was again observed calling out, ""get me up ...I want to get up."" At 10:35 a.m. on 9/16/10, the resident was heard, saying repeatedly, ""I want to get up ...I want to get up."" When asked what she wanted to do, the resident replied that she wanted to get out of bed. Review of nurses notes including on 8/21/10 revealed that Resident 3 was given Haldol because ""she dangles her legs over the bed and attempts to get down."" There was no documentation available to indicate why the resident wants to get out of bed and why this could not be accommodated by staff. Medical record review revealed the lack of contraindication to Resident 3's getting out of bed. 2. Resident 5 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident's MDS dated [DATE] revealed the resident is awake, alert, and verbally responsive. A social services summary form dated 9/1/10 revealed that the social worker was informed by the facility's unit nursing supervisor that the resident is on ""suicidal watch"" The social worker met with the resident who assured her that she will not harm herself and that she was joking with one of the nurse aides that she will kill herself using the cord line in her room. The social worker noted the resident was emotional during the interview and she stated that she is depressed and she is concerned about her placement upon discharge. Interviews with direct care givers of the resident indicated that they are not aware that the resident is on suicidal watch. There was no thorough assessment and plan of care for a resident on ""suicidal watch"" specific to Resident 5. A review of the admission orders [REDACTED]. A patient note dated 9/6/10 stated, ""Resident is being treated for [REDACTED]."" A plan of care last updated on 8/31/10 indicated a mood state problem with a goal that the resident will have improved mood with an approach to encourage her to participate in diversional recreational activities for socialization with groups. The occupational therapy indicated that she had been involved in resident activities. However, neither of the activity staff acting as activity director had any documentation that the activities provided were designed to meet the interests of Resident 5 whose depressed mood has deteriorated to suicidal thoughts within one month period. A review of the physician's orders [REDACTED]. The MAR (medication administration record) for medications administered as needed only showed that Halcion 0.125 mg was given to Resident 5 on 9/3, 9/6 and 9/8 twice - at 0030 and 2100. Also Halcion 0.25 mg. was administered on 9/4, 9/5, 9/9, 9/10, 9/11, 9/12, 9/13, 9/14, 9/15, and 9/16/10. The medical record showed no documentation of non-drug intervention prior to administering a hypnotic. There was no documentation of attempts to determine the cause of Resident 5's inability to fall asleep without the use of hypnotic.",2014-12-01
99,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2010-09-17,309,D,0,1,7DPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not provide the necessary care and services to enable the resident to attain or maintain the highest practicable physical well-being for three of 10 sampled residents. (Residents 3, 5, and 6). Findings include: 1. Resident 3 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the medical record revealed that the resident was admitted from the hospital where she was treated for [REDACTED]. The minimum data set ((MDS) dated [DATE] described the resident as having short-term memory problem, with moderately impaired cognitive skills for decision-making, and was dependent on staff for all activities of daily living (ADL). Review of the medical record revealed that Resident 3 had undergone a left arm exploration on 8/31/10 for a possible abscess and that after the procedure, the physician had made an order that no dressing on the arm was required. During skin care observation at 10:45 a.m. on 9/17/10, the left arm wound was observed uncovered but the area around it was noted to reddened and had slight swelling. Review of the medical record revealed that while a care plan was available for the prevention and treatment of [REDACTED]. In addition, there was no evidence that continuing assessments were conducted to determine progress or lack of wound healing. The treatment nurse stated that the no treatment orders were made by the physician but observed that the would indeed appeared reddened. Further review revealed that while wound assessments dated 8/15/10 and 8/24/10 noted wounds on the resident's upper buttocks, sacral area, and left hip, there was no evidence that monitoring was being conducted on [MEDICAL CONDITION] that were on the lateral aspect of the resident's lower legs to determine whether or not interventions were necessary. During the same skin care observation, both [MEDICAL CONDITION] appeared to have black eschar that were dry and intact. No measurements of the lesion were available and no mention of them were made in the nurses notes or in the wound assessment sheets. 2. Resident 5 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Occupational therapist's initial evaluation dated 8/23/10 revealed that the resident was admitted to the acute hospital on [DATE] following a month stay at the naval hospital with [DIAGNOSES REDACTED]. The resident's MDS dated [DATE] revealed the resident was awake, alert, and verbally responsive. A review of the rehab daily treatment record dated 9/1/10 revealed that a sharp debridement of the left hand wound was done by physical therapist (PT). The physical therapy summary note detail dated 9/1/10 revealed that the left hand dorsal aspect wound was covered 100% with black, thick, necrotic tissue with a length of 6.5 cm and 6 cm wide and undetermined depth. PT's treatment included removal of 100% necrotic tissue. The note further read: ""Wound now covered in 90% with yellow firmly adhering tissue with mod. (moderate) purulent drainage mainly from lat. (lateral) aspect of wound."" On 9/16/10 at 5:30 p.m., the resident was more alert and conversant. On the same day at 5:40 p.m., the resident's left hand dressing change was observed. Upon surveyor request, the licensed nurse measured the debrided area as 10 cm long and 10 cm wide and described the area with 85% yellow and 15% pink. The licensed nurse cleansed the debrided area in the left hand with normal saline. A wet to dry dressing was applied after the saline flush. Review of all the progress notes revealed that there was no documentation of an assessment of the necrotic area in left dorsal hand on admission (on 8/21/10) until the necrotic area was debrided by PT on 9/1/10. Thereafter, the debrided area was not thoroughly assessed until 9/16/10 when the surveyor addressed the issue with charge nurse. 3. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/15/10 at 10:20 a.m., during the initial tour, the Resident 6 went out of the facility for her [MEDICAL TREATMENT] treatment in an acute hospital facility. The resident room had contact isolation precautions posted outside the door. Interview with the licensed nurse indicated that she was not sure of the cause of isolation. The licensed nurse added that the resident has either (MRSA) [MEDICAL CONDITION]-resistant staphylococcus aureus or (MDR) multi drug resistant infection from the wound in the right stump. The admission nurses notes dated 7/15/10 revealed that the ""right mid-foot amputation dressing wet-dry done. Area is reddish pink with evidence of granulation. There is presence of tunneling about 1 inch on the 1700 side. No foul odor noted. Plantar surface slightly red in color."" The physical therapy (PT) initial evaluation dated 7/20/10 revealed the resident was admitted to the acute hospital on [DATE] with right foot gangrene and underwent right metatarsal amputation. The main barrier to therapy was resident's ""not cooperating with PT."" The post amputated wound site was not always thoroughly assessed and addressed accordingly. On 7/23/10 at 22:28 the nurses notes revealed an open sore at the bottom of the right foot and when pressed, a sero-sanguinous drainage came out from the amputated site. On the same day at 04:43 wound care to the right foot was done and was noted as, ""remains open and noted some necrotic tissue posterior portion of the open area and draining sore in the sole part."" On 7/30/10, the wound was ""Noted some sero-sanguinous drainage from the [MEDICAL CONDITION] site. Bottom sore packed with small gauze."" On 8/12/10, the wound was described ""with evidence of granulation but there is presence of tunneling at the 1800 site below the wound. On 8/17/10, nurses notes revealed, ""2x2 wound noted at arch area, redness and swelling noted as well. Wound is also with foul odor."" On 8/21/10, the wound was ""with evidence of granulation on wound but still with tunneling on 1800 about ? inch deep and measures 1x1 cm on the surface with slight pus like drainage."" On 8/24/10, nurses notes revealed that ""Wound care done to (R ) forefoot and arch area, foul odor noted; on 9/04/10, ""Right foot dressing done with [MEDICATION NAME] gel as ordered;"" on 9/8/10, ""Stump wound reddish in color but plantar wound with foul odor and yellowish discharge. Right heel blackish in color;"" and on 9/16/10, ""Open area with red wound base with granulation tissue no drainage."" On 9/16/10 at 3:15 p.m. a licensed nurse was observed doing a dressing change in Resident 6's post amputated right forefoot area. The dressing removed was heavily soaked with red drainage. The licensed nurse irrigated the top beefy red area with saline and applied Hydrogel. The licensed nurse indicated that the night shift does the measurement of the wounds and pressure ulcers when they do the dressing change in their shift. However, the licensed nurse measured the tunneling on 1800 site at 2 cm deep. The nurse applied the Hydrogel and wet dressing on the top and middle tunneling open areas. A dry 4x4 gauze was applied on the necrotic bottom right heel and wrapped the foot with Kerlix. In an interview, the licensed nurse stated that the resident's physician was informed when there were changes in the post surgical wound. She also stated that the resident's white blood count remained high and the physician ordered another dose of [MEDICATION NAME]. A review of all the nurses' progress notes revealed that there was no documentation that nurses were notifying the physician when there was a change in the wound area such as increase in drainage, foul odor or the onset of the necrotic area at the bottom heel of the right foot.",2014-12-01
100,GUAM MEMORIAL HOSPITAL AUTHORITY,655000,499 NORTH SABANA DRIVE,BARRIGADA,GU,96913,2010-09-17,312,D,0,1,7DPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition. Findings include: 1. Resident 3 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the medical record revealed that the resident was admitted from the hospital where she was treated for [REDACTED]. The minimum data set ((MDS) dated [DATE] described the resident as having short-term memory problem, with moderately impaired cognitive skills for decision-making, and was dependent on staff for all activities of daily living (ADL) including eating. Review of the care plan dated 8/15/10 pertaining to ""Imbalanced nutrition--less than body requirements"" revealed several interventions including ""do not hurry patient"" when eating; that Resident 3's ""head is flexed slightly forward"" and that ""if not contraindicated, position patient in a chair or elevate head of bed as high as possible."" During several meal observations including lunch on 9/15/10 and dinner on 9/16/10, Resident 3 was observed in bed sleeping while her meal tray was at the bedside on the overbed table. Once the tray was delivered, staff were observed setting up the tray and then leave the room to attend to other tasks. On 9/15/10. for example, Resident 3's meal tray was served at 12:15 p.m. while she was sleeping in bed. On one occasion, a staff was observed in the room and asked if the resident wanted to eat. Getting no response, the staff left the room. At 12:40 p.m.. a dietary staff was observed removing the tray which was largely uneaten from the resident's room. When asked how much the resident ate, the staff stated that the resident ""refused to eat."" During dinner observation at 5:10 p.m. on 9/16/10, an unlicensed staff was observed feeding Resident 3 who was hardly awake in bed. While encouraging the resident to eat and waking her up, the staff however was observed leaving the room every now and then to attend to other residents. At 5:40 p.m. the resident's tray was removed when the staff determined that the resident was no longer going to eat. In these two instances, staff were not observed to implement care plan interventions to help Resident 3 eat. She was not repositioned, assisted to a chair, or given sufficient time to eat. 2. Resident 7 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Nursing admission notes dated 9/05/10 described Resident 7 as ""alert and oriented (times) 2"" and that she was ""verbally responsive but confused."" A nutritional assessment dated [DATE] described Resident 7 as requiring feeding assistance. During lunch and dinner observations on 9/16/10, facility staff were observed setting up the meal tray for Resident 7 as soon as it was served. Thereafter, staff would leave the room and return later to check on the resident's progress. During lunch meal observation on 9/16/10, a facility staff was observed feeding the resident but stopped when the resident refused to eat further. Staff were not observed to reposition the resident to facilitate eating or encourage or take time to assist the resident. When the tray was removed, it was largely uneaten. Review of nurses notes including on 9/07/10 revealed that ""patient did not eat much."" On 9/14/10, Patient 7 was noted to ""only ate 10%."" Review of the medical record revealed that while care plans were available for constipation and ""Dehydration due to fluid maintenance,"" there was no documentation that a care plan was developed outlining interventions and strategies to ensure that Resident 7 had sufficient meal intake and prevent unplanned weight loss. The same nutritional assessment dated [DATE] noted that Resident 7 triggered care planning for ""nutrition and dehydration due to (potential) for inadequate calorie and protein intake (related to) dementia, decreased inability to self-feed."" During an interview on 9/17/10, a dietary staff stated that residents who required assistance with eating could be referred to rehab services where staff could assist and supervised them through their meals in the dining room. When asked if Residents 3 and 7 were referred and when the referral was made, the dietary staff stated that referrals were made verbally and not documented. During the survey Residents 3 and 7 were not observed participating in any assisted or supervised feeding program or transported out of their room to the dining room.",2014-12-01