rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,BOUNDARY COUNTY NURSING HOME,135004,6640 KANIKSU STREET,BONNERS FERRY,ID,83805,2019-01-31,689,D,0,1,N5WL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, manufacturers guidelines, policy review, and record review, it was determined the facility failed to ensure staff utilized mechanical lifts properly to reduce potential injuries. This was true for 2 of 2 residents (#1 and #6) reviewed for supervision and accidents. These failed practices placed residents at risk of bone fractures and other injuries related inappropriate use of a mechanical lift. Findings include: The facility's The use of Mechanical Lifts Policy, revised 12/13/18, documented staff utilized mechanical lift equipment when residents could no longer support their weight on their own. The policy documented the facility used a Arjo Maxi Move Mechanical lift device and staff needed to demonstrate and verbalize the correct procedure to operate the lift. The facility's Transfers Policy, revised 10/17/18, documented a resident's ability to transfer was assessed at the time of admission. The policy documented wheelchair brakes needed to be locked during all transfers. The Arjo Maxi Move Instructions for Use, dated (MONTH) 2010, documented the Arjo was designed for safe usage with one caregiver. The instructions documented there were circumstances that dictated the need for a two-person transfer such as combativeness, obesity, contractures etc The instructions documented it was the responsibility of the facility to determine if a one or two person transfer was more appropriate based on the task, resident load, environment, capability, and skill level of the staff members. a. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, dated 11/4/18, documented Resident #1 had severe cognitive impairment and she was dependent on one staff member for bed mobility, transfers, and toilet use. The MDS documented Resident #1 weighed 185 pounds. Resident #1's Care Area Assessment, dated 11/2/18, documented she was considered obese. The care plan area addressing Resident #1's Activities of Daily Living (ADL), revised 11/6/18, documented Resident #1 required extensive to total assistance with all ADL's and cares. The care plan documented Resident #1 had a history of [REDACTED]. The care plan documented she used a Geri chair for positioning. The care plan documented Resident #1 required the assistance of one to two staff with bed mobility depending on her cooperation, mood, or anxiety. The care plan documented Resident #1 required the assistance of one staff for all transfers with the Arjo lift, and the assistance of two staff when she was uncooperative or agitated. On 1/29/19 at 9:57 AM, CNA #7 was observed assisting Resident #1 to the bathroom with the use of the Arjo lift. CNA #7 was the only staff member in the bathroom. Resident #1's Geri chair was near the left-hand side wall approximately one inch from the wall. Resident #1's Geri chair brakes were not locked as CNA #7 raised Resident #1 off her seat. The Geri chair slid forward approximately two to three inches. After Resident #1 was free of the chair CNA #7 placed her onto the toilet. After Resident #1 finished using the restroom, CNA #7 raised her with the Arjo lift and assisted her back into her Geri chair. Resident #1's Geri chair brakes were not locked, and as Resident #1 was lowered into the Geri chair the chair moved back and forth and back again and rested against the wall as Resident #7 was situated into the chair. According to the Arjo's manufacturer instructions, the facility was to assess Resident #1 for the use of one to two staff personnel based on Resident #1's size. Resident #1's clinical record did not contain documentation the assessment was completed. Facility staff failed to complete an assessment according to the manufacturer's instructions. and ensure Resident #1's Geri chair brakes were locked prior to transferring Resident#1. b. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 11/3/18, documented Resident #6 had severe cognitive impairment and documented she was dependent on one staff member for dressing, transfers, and toilet use. The MDS documented Resident #6 had bilateral range of motion impairments to her lower extremities and a range of motion impairment to one of her upper extremities. The care plan area addressing Resident #6's ADLs, revised 8/7/18, documented Resident #6 required extensive to total assistance of one to two staff with all ADLs and cares, depending on her behaviors and resistance. The care plan documented Resident #6 required two staff personnel for all transfers with the Arjo lift if she was agitated or combative and she needed transferred. On 1/28/19 at 1:12 PM, CNA #6 was observed assisting Resident #6 from her wheelchair and into her bed with the use of the Arjo lift. Resident #6 was observed with severely contracted legs and left hand. CNA #6 attached Resident #6's sling onto the Arjo lift and after she finished attaching the sling, she moved to stand in front of the controller of the Arjo lift. CNA #6 did not lock Resident #6's wheelchair brakes. CNA #6 was standing near the controller of the Arjo lift while Resident #6 was lifted into the air with the lift. CNA #6 moved Resident #6 over to her bed and assisted her into bed. On 1/29/19 at 9:39 AM, CNA #5 was observed assisting Resident #6 from her wheelchair and into her bed with the use of the Arjo lift. CNA #5 attached Resident #6's sling onto the Arjo lift and then locked Resident #6's right brake of her wheelchair, the brake closest to her. CNA #5 moved to stand in front of the controller of the Arjo lift. CNA #5 did not lock Resident #6's left wheelchair brake. CNA #5 was standing near the controller of the Arjo lift while Resident #6 was lifted into the air with the lift. CNA #5 moved Resident #6 over to her bed and assisted her into bed. According to the Arjo's manufacturer instructions, based on Resident #6's contractures the facility was to assess Resident #6 to determine if one or two staff were needed to safely transfer her. Resident #6's clinical record did not contain documentation the assessment was completed. Resident #6's wheelchair brakes were not locked when she was transferred and she was not assessed consistent with Arjo's manufacturer's instructions, to determine if one or two staff were needed when transferring her. On 1/30/19 at 10:53 AM, Registered Nurse (RN) #1 stated residents' transfers plans were determined based on multiple factors. RN #1 stated staff assessed a residents' fall risk, if they could stand, if they were resistive with cares, and their body tone. RN #1 stated the assessment was on the care plan. On 1/30/19 at 11:00 AM, LPN #2 stated the facility did not have a documented assessment as to if residents were safe with one or two staff transfers. LPN #2 stated what was on the care plan was how residents should be transferred. LPN #2 stated Resident #1's and #6's care plans stated they could be assisted by one or two staff, and the CNAs had the option to use two people. LPN #2 stated Resident #1 and Resident #6 could be resistive with cares at times. LPN #2 stated the manufacturer guidelines for the Arjo lift documented only one person was required for use. LPN #2 stated staff competencies related to the proper mechanics of the Arjo lift were reviewed annually. On 1/30/19 at 2:28 PM, the DNS stated residents' wheelchair brakes should always be locked during transfers. The DNS stated the nurses assessed residents' needs often and the facility did not have documented assessment for the Arjo lift to determine if one or two staff were required to safely transfer the residents.",2020-09-01
2,BOUNDARY COUNTY NURSING HOME,135004,6640 KANIKSU STREET,BONNERS FERRY,ID,83805,2019-01-31,812,F,0,1,N5WL11,"Based on observation, review of facility policy and the (YEAR) FDA Food Code, and staff interview, it was determined the facility failed to ensure food was handled properly and maintained according to safe practices and proper hand hygiene was performed. This was true when Potentially Hazardous Food (PHF) cold food temperatures were not maintained at safe temperatures and/or were not assessed prior to service. The facility failed to ensure staff performed adequate hand hygiene to prevent possible cross-contamination of dirty to clean areas in the kitchen. These failed practices placed 12 of 12 residents (#1, #3, #4, #6, #7, #8, #9, #12, #13, #16, #18, and #72) reviewed who dined in the facility and the other 10 residents who dined in the facility, at risk of adverse health outcomes. Findings include: 1. The facility's Dietary Personal Hygiene Policy, revised 1/9/19, documented staff should wash their hands after handling soiled equipment or utensils. The policy documented staff should wet their hands, apply soap, rub their hands together for one minute and, rinse well and dry their hands. On 1/30/19 at 12:10 PM, Cook #1 was observed moving between tasks and she approached the sink, applied soap, rubbed her hands together under running water, banged her hands against the side of the sink, and obtained a paper towel to dry her hands. The whole process lasted 5 seconds. On 1/30/19 at 12:14 PM, Cook #1 repeated the steps above, and the process lasted four seconds. On 1/30/19 at 12:14 PM, the Certified Dietary Manager (CDM), who was present for the observation, stated she would expect staff to wash their hands minimally for 15-20 seconds. On 1/30/19 at 1:47 PM, Cook #2 was observed washing her hands in the dish room. She approached the sink, wet her hands, applied soap, rubbed her hands together, rinsed her hands off, and obtained a paper towel to dry her hands. The whole process lasted 6 seconds. The CDM, who was present for the observation, stated she did not see the staff member washing her hands because Cook #2 was so quick. The CDM stated she would in-service staff on proper hand hygiene. 2. The (YEAR) FDA Food Code, Chapter 3, Part 3-5, Limitation of Growth of Organisms of Public Health Concern, subpart 3-501.12 Time/Temperature Control for Safety Food, documents refrigerated foods are to be maintained at 5 C (41 F (Fahrenheit)) or less. On 1/30/19 at 11:45 AM, Cook #1 was observed assessing the temperatures of food items. Cook #1 approached a cooler and obtained cold roast beef sandwiches from the cooler. Cook #1 proceeded to obtain a temperature for roast beef sandwiches. The roast beef sandwiches were assessed to be 53.5 degrees F. The CDM placed the sandwiches into the freezer to cool down. On 1/30/19 at 12:10 AM, Cook #1 was observed obtaining chopped salads from the cooler and the cold roast beef sandwiches from the freezer, and placed them onto a cart to deliver them to the serving area. Cook #1 assessed the temperature of the cold roast beef sandwiches at 49 degrees F. Cook #1 did not assess the temperature of the chopped salads. The food was delivered upstairs to the serving area for lunch. On 1/30/19 at 12:17 PM, Cook #3 was observed assessing the temperature of food. items. Cook #3 proceeded to obtain a temperature for roast beef sandwiches. The roast beef sandwich was assessed to be 49.4 degrees F. Cook #3 did not obtain the temperature of the chopped salads and continued with service. Cook #3 served the roast beef sandwiches and the chopped salads to residents. On 1/30/19 at 12:37 PM, the CDM stated she did not feel right about serving the sandwiches, but the staff did so anyway. The CDM stated potentially hazardous foods should be at a temperature of less than 41 degrees F prior to service.",2020-09-01
3,BOUNDARY COUNTY NURSING HOME,135004,6640 KANIKSU STREET,BONNERS FERRY,ID,83805,2019-01-31,880,F,0,1,N5WL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and policy review, it was determined the facility failed to ensure infection control measures were consistently implemented as they related to laundry service practices, hand hygiene practices, and urinary catheter care. Failure to ensure staff processed and transported linens in a sanitary manner, had the potential to impact 12 of 12 residents (#1, #3, #4, #6, #7, #8, #9, #12, #13, #16, #18, and #72) reviewed who resided in the facility and the other 10 residents residing at the facility. Lapses in hand hygiene directly impacted 4 of 15 residents (#1, #6, #7, and #10) whose care was observed. Lapse in urinary catheter care directly impacted 1 of 1 resident (#9) reviewed who had a catheter. These deficient practices created the potential for harm by exposing residents to the risk of infection and cross contamination. Findings include: 1. The facility's Handwashing and Hand Hygiene policy, dated 9/3/17, documented staff should perform hand hygiene when they changed gloves and when moving from a unclean body site to a clean-body site during resident care. This policy was not followed. Examples include: a. On 1/28/19 at 11:15 AM, CNA #1 was observed providing peri care for Resident #7. After assisting Resident #7 with peri care CNA #1 removed her gloves but did not perform hand hygiene. CNA #1 continued to provide care for Resident #7 applying an incontinence pad, readjusting clothing, and transferring Resident #7 back to her recliner. On 1/28/19 at 11:34 AM, CNA #1 stated she should have performed hand hygiene after removing her gloves, prior to touching other items. b. On 1/28/19 at 1:15 PM, CNA #6 was observed assisting Resident #6 with peri care. CNA #6 was observed washing her hands and placing clean gloves onto her hands. CNA #6 retrieved clean supplies to change Resident #6's adult brief and prepared the supplies. CNA #6 began removing Resident #6's soiled pants and placed them into the dirty hamper. CNA #6 then looked around and grabbed the trash can with her hand and placed it next to her. CNA #6 removed Resident #6's soiled brief and threw it into the trash can. CNA #6 provided Resident #6 with peri care, applied a clean brief, placed pillows under and between Resident #6's contracted legs, and then removed her gloves. CNA #6 adjusted Resident #6's blanket and washed her hands. On 1/28/19 at 1:27 PM, CNA #6 stated she forgot to perform hand hygiene after she assisted Resident #6 with peri care. c. On 1/29/19 at 9:43 AM, CNA #5 and CNA #7 were observed assisting Resident #6 with peri care. CNA #5 washed her hands and placed clean gloves onto her hands. CNA #5 retrieved the clean supplies needed to assist Resident #6 with peri care. CNA #5 removed Resident #6's pants and soiled adult brief and began providing peri care. CNA #7 was assisting CNA #5 by holding Resident #6's contracted legs in place for peri care to be completed. CNA #5 stated she needed more wipes, removed her gloves, and left the room. CNA #5 returned with new wipes, opened the wipes, removed a few wipes, washed her hands, and placed clean gloves onto her hands. CNA #5 continued to assist with peri care and completed the task. After CNA #5 completed the task she placed a clean brief onto Resident #6 and placed pillows under and between her legs, and then removed her gloves and washed her hands. On 1/29/19 at 9:53 AM, CNA #5 stated she forgot to complete hand hygiene after she assisted Resident #6 with peri care. d. On 1/30/19 at 7:46 AM, CNA #3 was observed assisting Resident #10 with morning cares. CNA #3 cleaned Resident #10's legs, arms, chest, and back with wipes and then assisted Resident #10 with sitting up. CNA #3 placed a clean shirt and clean pants up to Resident #10's knees and rested an opened clean adult brief on the top of her pants. CNA #3 then stood Resident #10 up with the sit to stand, removed her soiled brief, and provided peri care. CNA #3 pulled up and fastened the clean brief, pulled Resident #10's pants over the clean brief, and lowered her into her wheelchair. CNA #3 removed her gloves and washed her hands. On 1/29/19 at 8:00 AM, CNA #3 stated she realized she did not change her gloves and perform hand hygiene after peri care was completed. On 1/31/19 at 12:54 PM, the DNS stated staff should be washing their hands after removing gloves and the staff were educated constantly about this. 2. According the Centers for Disease Control and Prevention, Guidelines for Prevention of Catheter Associated Urinary tract infections, updated 2/15/17, states the urinary collection bag should not rest on the floor. This guideline was not followed. Examples include: a. On 1/29/19 at 9:04 AM, Resident #9 was observed in the dining room, and he was stepping on his catheter tubing. On 1/29/19 at 9:06 AM, CNA #4 was asked if Resident #9's catheter tubing should be on the floor and she stated no. CNA #4 was observed washing her hands, placing gloves on, and adjusting Resident #9's catheter tubing off the floor. b. On 1/29/19 at 2:50 PM, Resident #9 was observed in bed and his catheter collection bag was inside a privacy bag and the privacy bag was resting on the floor. On 1/29/19 at 3:01 PM, LPN #1 stated the catheter collection bag should be off the floor, and the privacy bag was permeable to germs. LPN #1 adjusted Resident #9's collection bag off the floor. 3. The facility's Environmental Services Department Laundry policy, reviewed 9/12/18, documented staff were to wear a gown and gloves when working in the sorting room and whenever handling soiled linen. The policy documented the clean linens should be covered. This policy was not followed. Examples include: a. On 1/28/19 at 2:47 PM, CNA #2 was observed passing out clean clothes to different residents. The items were on two carts, one was a metal cart with shelves, and had the residents' names on the shelves, and one had hangers hanging from it. The cover for the metal cart was set on top of the cart and residents' undergarments were seen as the cart moved down the hall. The hanging cart's cover was thrown to the side and residents' clothes were seen as the cart moved down the hall. On 1/28/19 at 3:00 PM, CNA #2 stated the laundry came from the laundry department covered and the staff uncovered it when it reached the floor, so residents' names could be seen. b. On 1/31/19 at 2:25 PM, CNA #8 and CNA #9 were observed passing laundry with the covers off the carts. The DNS was present when the laundry was passed, and asked CNA #8 to please cover the undergarments with the covering. The covering on the metal cart was placed over the cart and the covering did not reach to the bottom of the cart, and half of the cart was still exposed. The DNS stated the cart needed a longer covering. On 1/31/19 at 2:25 PM, the DNS stated the laundry should be covered for infection control reasons. c. On 1/31/19 at 7:00 AM, Laundry Staff #1 stated when the staff sorted laundry in the dirty laundry room, they donned a protective [NAME]et. The [NAME]et used was a light weight porous material, not a moisture barrier type of material. Laundry Staff #1 stated the staff changed to a new [NAME]et throughout the day, depending on the task, but always used the same type of [NAME]et. She stated for example, the [NAME]et was changed if residents' bowel movements were on linens. Laundry Staff #1 stated the [NAME]ets sometimes got wet. When they changed the [NAME]ets, they removed them and put them in with the laundry load and got a new [NAME]et. Laundry Staff #1 stated she was responsible for sorting, washing, drying, and folding clothes. She stated she delivered the laundry to the floors. Laundry Staff #1 stated the staff did not normally wear goggles when sorting laundry, but they were available for use if they were needed. On 1/30/19 at 7:30 AM, the Environmental Services Manager, stated the training she received was that the current [NAME]ets were the proper PPE (personal protective equipment) for laundry. She stated the laundry staff were to change [NAME]ets after every sort and the goggles were for when they worked with [MEDICAL CONDITION]. ([MEDICAL CONDITION], is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon.) On 1/31/19 at 11:31 AM, the Infection Control Preventionist stated the facility followed the Association for Professionals in Infection Control and Epidemiology (APIC) guidelines. She stated the guideline recommended wearing barrier gowns and safety glasses. The 10/11/18 APIC Hygienically Clean Healthcare- Laundry Tour Planner for Healthcare Professionals guideline, posted on the APIC website on 10/11/18, documents employees should know what PPE was required in each function to guard against contamination and should be wearing barrier gowns, puncture resistant gloves, safety glasses/goggles, and face masks. A document 1910.1030 Bloodborne pathogens, provided by the Infection Control Preventionist, which she said she had printed from the Centers for Medicaid and Medicare Website documented, PPE would be considered appropriate only if it did not permit blood or other potentially infectious material to pass through to or reach the employee's work clothes, skin, eyes, mouth, or other mucous membranes under normal conditions of use, and for the duration of time which the PPE would be used. The document was researched on the internet and found to be from the Occupation Safety and Health Association's Bloodborne Pathogens Standard (29 CFR 1910.1030), which prescribes safeguards to protect workers against health hazards related to bloodborne pathogens",2020-09-01
4,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2020-01-24,578,E,0,1,JSJS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' advance directive information was periodically reviewed with the residents and/or their representatives and was accurate. This was true for 3 of 3 residents (#3, #13, and #14) whose records were reviewed for advance directives. This failed practice created the potential for harm if residents' wishes regarding end of life or emergent care were not honored if they became incapacitated. Findings include: The State Operations Manual, Appendix PP, defines an Advance Directive as .a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. The State Operations Manual also states a Physician order [REDACTED]. medical condition into consideration. A POLST [MEDICATION NAME] form is not an Advance Directive. The facility's Advance Directives policy, dated 8/31/19, documented the following: * Staff will inquire and document whether there is an existing Advanced Directive. If one is provided it will be scanned into the medical record. * Copies of the Advanced Directive should be documented in the medical record and communicated clearly to staff involved with cares. This policy was not followed. 1. Resident #3 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #3's admission orders [REDACTED]. Resident #3's admission orders [REDACTED]. A care plan dated 1/10/20, documented Resident #3 did not want to prolong his life and requested comfort measures only. Resident #3's admission orders [REDACTED]. On 1/22/20 at 3:16 PM, the DNS stated there was a discrepancy in the documentation of Resident #3's code status and it should have been changed to reflect the residents wishes. 2. Resident #13 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A Durable Power of Health Care dated 4/7/09, documented Resident #13 did not want efforts to prolong her life, and did not want life sustaining treatments or cardiopulmonary resuscitation. Resident #13's admission order, dated 11/30/18, documented her resuscitation status she was to be a full code. Resident #13's admission orders [REDACTED]. On 1/22/20 at 3:40 PM, the DNS stated Resident #13's code status was not documented to reflect her wishes and needed to be changed. 3. Resident #14 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #14's record did not include documentation of an Advance Directive, or that it was offered or discussed with him. On 1/24/20 at 11:05 AM, the Resident Services Advocate stated Resident #14's record did not have documentation Advance Directives were offered or discussed with him or his representative.",2020-09-01
5,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2020-01-24,641,E,0,1,JSJS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and resident and staff interview, the facility failed to ensure MDS assessments accurately reflected the resident's status. This was true for 5 of 8 residents (#1, #5, #8, #11, and #12) whose MDS assessments were reviewed for accuracy. This failure created the potential for harm should residents receive inappropriate care related to discrepancies in the MDS assessment. Findings include: The facility's Restraint Policy, revised on 9/20/19, stated, Physical Restraint/Hold: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his arms, legs, body or head freely and/or a measure to prevent patient from exiting the bed/chair (e.g., mitts tied down, soft or leather wrist or ankle straps. The CMS Resident Assessment Instrument (RAI) Manual, Version 3.0, dated (MONTH) 2019, which is used as an instruction manual for completing MDS assessments, defines physical restraints as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The use of bed rails in the facility did not meet the definition of a physical restraint as documented in residents' MDS assessments, as follows: a. Resident #1 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #1's MDS assessments, dated 11/26/18, 2/19/19, 5/17/19, 8/17/19, and 11/15/19, documented bed rails were used daily as physical restraints. Resident #1's bed rail assessments, dated 2/19/19, 5/17/19, 8/16/19 and 11/15/19, documented bed rails were medically necessary and used for bed mobility, entering and exiting the bed safely, turning side to side, and positioning and moving up and down. The assessments did not include documentation the bed rails were used as a restraint. On 1/22/20 at 5:00 PM, Resident #1 was observed laying in her bed with the left side against the wall and the bed rails were up. Resident #1 stated she used the bed rails to help her get in and out of bed. b. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Risks and Benefits of Side Rails consent for use of bed rails for Resident #5 was signed by a family member on 4/2/19. Resident #5's MDS assessments, dated 4/9/19, 10/2/19, and 1/2/20, documented bed rails were used daily as a physical restraint. The initial bed rail assessment, dated 5/22/19, documented bed rails were medically necessary to assist Resident #5 for bed mobility, moving up and down in bed, and for transfer exiting and entering the bed more safely. The assessment documented the bed rails would not impede Resident #5's freedom of movement. The assessment did not include documentation the bed rails were used as a restraint. Resident #5's quarterly bed rail assessments dated 7/9/19, 10/2/19, and 1/2/20, documented the bed rails were used for supporting herself, improving balance, transferring more safely, turning side to side, and pulling herself from a laying to a sitting position. The assessments documented the bed rails would not impede Resident #5's freedom of movement. The assessments did not include documentation the bed rails were used as a restraint. During an interview with Resident #5 on 1/22/20 at 3:15 PM, she stated she used the bed rails when she was in bed, so she could reposition herself and the bed rails did not prevent her from getting out of the bed. c. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Risks and Benefits of Side Rails consent for use of bed rails was signed by Resident #8 on 12/3/18. Resident #8's MDS assessments, dated 12/10/18, 3/4/19, 6/4/19, 9/4/19, and 12/3/19, documented bed rails were used daily as a physical restraint. Resident #8's initial bed rail assessment, dated 12/3/18, and the subsequent quarterly assessments dated 3/4/19, 6/4/19, 9/6/19, and 12/3/19, documented the bed rails were recommended due to Resident #8's bladder incontinence, assistance of one person for toileting, diuretic use, and orthostatic medication use. The assessments documented the bed rails would not impede Resident #8's freedom of movement and the right upper bed rail had the bed controls imbedded in the rail. The assessments did not include documentation the bed rails were used as a restraint. During an interview with Resident #8 on 1/23/20 at 9:38 AM, she stated she had one bed rail on her bed that was used because it had the bed controls on the rail. She stated the rail did not keep her from getting out of bed. d. Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Risks and Benefits of Side Rails consent for use of bed rails was signed by Resident #11 on 5/21/19. Resident #11's MDS assessments, dated 5/21/19, 8/21/19, and 11/21/19, documented bed rails were used daily as a physical restraint. Resident #11's initial bed rail assessment, dated 5/21/19, and the subsequent quarterly assessments for bed rails, dated 8/21/19, and 11/21/19, documented the bed rails were medically necessary to assist Resident #11 with bed mobility, for turning side to side, moving up and down in bed, pulling herself from a laying to a sitting position, and for transfer for improving balance and supporting herself. The assessments documented bed rails would not impede Resident #11's freedom of movement. The assessments did not include documentation the bed rails were used as a restraint. During an interview with Resident #11 on 1/23/20 at 3:15 PM, she stated she used the bed rails when she was in bed, so she could reposition herself and the bed rails did not prevent her from getting out of the bed. e. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #12's MDS assessments, dated 11/17/18, 2/7/19, 5/7/19, 8/7/19, and 11/7/19, documented bed rails were used daily as a physical restraint. A Risks and Benefits of Side Rails consent for use of bed rails for Resident #12 was signed by a family member on 6/15/17. Resident #12's bed rail assessments, dated 2/7/19. 5/7/19, 8/6/19, and 11/7/19, documented the bed rails were medically necessary to assist Resident #12 with bed mobility, turning side to side, and pulling herself from a laying to sitting position. The bed rail was recommended due to conditions of dementia, bladder incontinence, assistance of two people for toileting, and orthostatic medications (blood pressure medications). The assessments stated the bed rails would not impede Resident #12's freedom of movement. The assessments did not include documentation the bed rails were used as a restraint. During an interview with Resident #12 on 1/21/20 at 9:45 AM, she stated she had one bed rail on her bed and used it to help pull herself up in bed. Resident #12 was observed on 1/22/20 at 9:48 AM, in bed with the upper bed rail on the right side of the bed in the raised position, with a pillow propped against it. Resident #12 stated it did not keep her from getting out of bed and she could not get out of bed without assistance from staff. On 1/22/20 at 9:02 AM, the MDS Coordinator stated bed rails are not used to restrict the residents but allowed them bed mobility. She stated the bed rails were coded as restraints because the residents could not lower the bed rails by themselves. She stated the bed rails in use did not prevent any of the residents using them from getting out of bed or restrict their movement. On 1/23/19 at 2:00 PM, the Administrator brought forward the CMS RAI Manual, dated (MONTH) 2019, the reference used for coding bed rails as a positioning device. She referenced Section P: Physical Restraints, Bed rails used as positioning devices: If the use of bed rails (quarter-, half- or three-quarter, one or both, etc.) meet the definition of a physical restraint even though they may improve the resident's mobility in bed, the nursing home must code their use as a restraint at P0100[NAME] The surveyor explained to the Administrator the bed rails as used by the residents did not meet the definition of a physical restraint.",2020-09-01
6,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2020-01-24,657,D,0,1,JSJS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were regularly reviewed and revised for 1 of 16 residents (Resident #13) whose care plans were reviewed. This failure created the potential for harm if the resident was to receive inappropriate or inadequate care. Findings include: The facility's Resident Care Plan policy, dated 6/30/18, documented a comprehensive person-centered care plan was developed by an interdisciplinary team for each resident, and upon a change in status of the resident, the care plan was modified. This policy was not followed. Resident #13 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. On 1/21/20 at 3:31 PM, Resident #13 was observed in her room laying in bed with 2 bed rails up. A quarterly MDS assessment, dated 12/26/19, did not include documentation Resident #13 used bed rails. The next quarterly MDS assessments, dated 3/25/19, 6/25/19, and 9/25/19, documented Resident #13 used bed rails daily as a physical restraint. Resident #13's Care Plan did not include a revision for the use of bed rails or interventions why the resident needed them. On 1/23/20 at 5:15 PM, the DNS and MDS Coordinator were unable to locate a care plan for bed rails for Resident #13. On 1/24/20 at 10:45 AM, the Administrator stated Resident #13 did not have the use of bed rails documented on her care plan.",2020-09-01
7,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2020-01-24,700,D,0,1,JSJS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure a resident was appropriately assessed and a consent was obtained prior to installing bed rails. This was true for 1 of 8 residents (Resident #13) reviewed for bed rails. This failure created the potential for harm from entrapment or injury related to the use of bed rails. Findings include: Resident #13 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. On 1/21/20 at 3:31 PM, Resident #13 was observed in her room laying in bed with 2 bed rails up. Resident #13's MDS assessments, dated 3/25/19, 6/25/19, and 9/25/19, documented Resident #13 used bed rails daily as physical restraints. Resident #13's record included a bed rail assessment, dated 3/15/19, that was blank. Resident #13's chart did not include a current quarterly bed rail assessment. There was no risk versus benefit discussion documented in Resident #13's record or a consent for use of the bed rails by Resident #13. On 1/24/20 at 10:45 AM, the Administrator stated Resident #13 did not have a consent for the use of bed rails, the bed rails were not care planned, and her MDS assessment was inaccurate.",2020-09-01
8,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2017-07-27,280,D,0,1,V9TA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, it was determined the facility failed to ensure a resident's care plan was revised to reflect current needs. This was true for 1 of 7 (#4) sampled residents and had the potential for harm if residents did not receive appropriate incontinence care and interventions due to lack of direction on the care plan. Findings include: Resident #4 was readmitted to the facility on [DATE] with multiple diagnoses, including urinary obstruction. Resident #4's physician order, dated 9/29/16, documented an order for [REDACTED].>Resident #4's current bladder continence care plan, dated 6/12/17, documented an intervention, Condom catheter on at all times. Resident #4's quarterly Minimum Data Set assessment, dated 6/28/17, documented the resident was cognitively moderately impaired, required extensive two-person assistance with toileting, was incontinent of bowel and bladder, and had an external catheter. Resident #4's progress notes, dated 6/30/17, documented a small area of the skin of the meatus was missing from Resident #5's penis, the physician was notified, and ordered barrier cream to the affected area. Progress notes, dated 7/7/17, documented the resident's penis had healed and no new issues were noted and we will continue to keep the condom catheters off at this time. Resident #4's (MONTH) (YEAR) active orders documented an order for [REDACTED].>On 7/25/17 at 12:55 pm, Resident #4 was observed with an absorbent incontinent pad beneath him and the resident said there was also a pad covering the top of his peri area. He said he no longer used the condom catheter and did not like to wear incontinent briefs when in bed. On 7/24/17 at 3:00 pm, CNA #5 (Certified Nurse Assistant) said Resident #4 was incontinent of bowel and bladder and used incontinent pads while in bed because he did not like to wear incontinent briefs and the pads were checked every two hours and changed if they were wet or soiled. On 7/25/17 at 1:55 pm, CNA #6 said Resident #4 had used a condom catheter in the past, but had not used a catheter for amonth or two. She said the resident used incontinent pads under him and one on top of his peri area which were checked every two hours and changed if they were wet or soiled. On 7/25/17 at 2:20 pm, LPN #1 said Resident #4 did not use a condom catheter and was incontinent of bladder. On 7/26/17 at 1:50 pm, the DNS (Director of Nursing Services) said Resident #4 was incontinent of bowel and bladder and staff were to check and change the resident's incontinent pads while in bed. She said the bladder continent care plan was not updated when the resident's catheter was discontinued and it did not direct staff regarding the resident's incontinence care needs.",2020-09-01
9,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2017-07-27,281,D,0,1,V9TA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, it was determined the facility failed to ensure physician orders [REDACTED]. This was true for 1 of 7 sampled residents (#4) and had the potential for harm if residents received inappropriate incontinent care. Findings include: Resident #4 was readmitted to the facility on [DATE] with multiple diagnoses, including urinary obstruction. Resident #4's physician order, dated 9/29/16, documented an order for [REDACTED].>Resident #4's current bladder continence care plan, dated 6/12/17, documented an intervention, Condom catheter on at all times. Resident #4's quarterly Minimum Data Set assessment, dated 6/28/17, documented the resident was incontinent of bowel and bladder, and had an external catheter. Resident #4's nurse progress notes, dated 6/30/17, documented a small area of the skin of the meatus was missing from Resident #5's penis, the physician was notified and the resident received a barrier cream to the affected area. Nurse progress notes, dated 7/7/17, documented the resident's penis had healed with no new issues noted and the nurse documented, we will continue to keep the condom catheters off at this time. Resident #4's active physicians orders and treatment administration record from 7/1/17 to 7/27/17, documented a 9/29/16 physician order [REDACTED].>On 7/25/17 at 12:55 pm, Resident #4 said he no longer used the condom catheter and did not like to wear incontinent briefs when in bed. On 7/24/17 at 3:00 pm, CNA #5 (Certified Nurse Assistant) said Resident #4 was incontinent of bowel and bladder and used incontinent pads while in bed because he did not like to wear incontinent briefs. On 7/25/17 at 1:55 pm, CNA #6 said Resident #4 had used a condom catheter in the past, but had not used a catheter for a month or two. On 7/25/17 at 2:20 pm, LPN #1 said Resident #4 did not use a condom catheter. On 7/26/17 at 1:50 pm, the DNS (Director of Nursing Services) said the condom catheter had been a physician's orders [REDACTED].",2020-09-01
10,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2017-07-27,309,D,0,1,V9TA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure physician orders [REDACTED]. This was true for 1 of 7 residents (#2) reviewed for physician orders. The physician orders [REDACTED]. This deficient practice had the potential for harm if Resident #2 experienced high or low blood glucose levels. Findings include: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Physician order [REDACTED]. *Blood glucose testing 30 minutes before meals and at bedtime * [MEDICATION NAME], 50 units each morning * HumaLog insulin based on the pre-meal blood glucose results: Less than or equal to 150 mg/dL(milligrams per deciliter) = no insulin 151-200 mg/dL give 2 units 201-250 mg/dL give 4 units 251-300 mg/dL give 6 units 301-350 mg/dL give 8 units Greater than 350 mg/dL give 10 units Resident #2's orders also included the following: *[MEDICATION NAME] injection 1 mg intramuscular every 15 minutes as needed for low blood sugar. The Physician orders [REDACTED]. According to the American Diabetes Association, Standards of Medical Care in Diabetes - (YEAR), from the Diabetes Care Journal, Volume 39 Supplement 1, documented older adults with diabetes in a long term care (LTC) facility were at higher risk of experiencing hypoglycemic episodes, and providers should be called immediately in case of hypoglycemic episodes or when BG levels were less than 70 mg/dl. A position statement from the American Diabetes Association documented LTC facilities should increase the frequency of glucose monitoring, call the practitioner, and confirm high glucose values by laboratory testing. These steps were to be completed if residents experienced BG's greater than 300 during all or part of 2 consecutive days. (Munshi, M. N., Florez, H.,[NAME] E. S., et al. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care, vol. 39, Feb. (YEAR), pp. 308-318.) Resident #2's medical record, dated (MONTH) (YEAR), did not document blood glucose levels lower than 70 mg/dL or greater than 400 mg/dL. On 7/25/17 at 10:30 am, Resident #2 stated the facility was doing a great job managing his diabetes. Resident #2 stated his blood sugars have been good. On 7/26/17 at 2:10 pm, the facility provided a 7-page document titled Provider Orders. This document provided the physician multiple order choices for diabetic management and included nursing to notify provider if blood glucose is less than 70 or if greater than 400. Administration Staff #2 stated, The physicians' have been given the Provider's Order set to use, but, they have not been utilized by the physicians. The facility will be making changes. On 7/27/17 at 8:30 am, LN #1 was asked what she would do if a resident had high or low blood glucose levels. She stated she would address the resident needs and notify the physician.",2020-09-01
11,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2017-07-27,332,D,0,1,V9TA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure a medication error rate less than 5 percent. This was true for 2 of 37 medications (5.4%) administered during medication pass and effected 2 of 5 residents (#9 and #10) observed during medication pass. This failed practice placed residents at risk of not receiving medications as ordered by the physician and had the potential to lessen the effectiveness of the medications administered. Findings include: 1. Resident #9 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] reflux. Resident #9's Physician order [REDACTED].) On 7/25/17 at 8:25 am, LPN #1 (Licensed Practical Nurse) was observed as she administered morning medications to Resident #9, which included the medication [MEDICATION NAME]. The resident had completed her breakfast and was sitting in the activity room. The Medication Administration Record [REDACTED]. 2. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] reflux. Resident #10's Physician order [REDACTED]. On 7/25/17 at 8:35 am, LPN #1 was observed as she administered morning medications to Resident #10, which included [MEDICATION NAME]. The resident had completed his breakfast and was sitting in his wheelchair in activity room. On 7/26/17 at 1:25 pm, the Director of Nursing stated the delivery of [MEDICATION NAME] should be given on the 7:00 am medication pass.",2020-09-01
12,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2017-07-27,371,E,0,1,V9TA11,"Based on observation and staff interview, it was determined the facility failed to ensure 7 of 11 plastic coffee mugs were free of debris and 4 of 6 plastic cereal and soup bowls were free from scratches and grooves. This had the potential to affect 7 of 7 (#s 1-7) sampled residents and all residents who dined in the facility. This failure created the possibility for food-born illness if bacteria remained on unsanitary surfaces. Findings include: On 7/26/17 at 11:05 am, 7 of 11 plastic coffee mugs were observed to contain a white filmy residue inside the mugs. The Lead Food Service Worker (LFSW) said it looked and smelled like soap residue. The LFSW said he would have them rewashed and wiped clean. 4 of 6 plastic soup and cereal bowls were observed to have several scratches inside the bowls. The LFSW said they all had scratches and grooves in them and he took them out of service and said he would replace them with new bowls.",2020-09-01
13,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2017-07-27,431,D,0,1,V9TA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined the facility failed to ensure medications were labeled in accordance to Federal and State regulations and that discontinued medications were removed from the medication cart. This was true for 2 of 17 medication bins checked for labeled and discontinued medications. This failed practice created the potential for residents to receive medications not ordered for them and to receive medication that had been discontinued. Findings include: On [DATE] at 2:00pm, a resident's medication bin had a bottle of Nitrostat 0.4 mg that did not have a pharmacy label which identified the medication, strength, expiration date, resident 's name, route of administration, appropriate instructions or precautions (such as shake well, with meals, do not crush, special storage instructions). A tube of Nystatin creme, found in the same bin, had the name of the medication and the resident's name was handwritten on a piece of paper and taped to the tube. It did not have a pharmacy label that identified the medication, strength, expiration date, resident's name, route of administration, appropriate instructions or precautions (such as shake well, with meals, do not crush, special storage instructions). The resident's medical record documented the Nystatin creme had been discontinued on [DATE], however, the tube remained in the resident's medication bin. On [DATE] at 2:00 pm, LN #1 stated a pharmacist checked the medication cart each morning and removed expired and discontinued medications from the residents' medication bins. LN #1 stated she did not know why the medications were not labeled or why the discontinued medication was not removed. LN #1 stated they should have been labeled and/or removed when discontinued. On [DATE] at 2:30 pm, the Director of Nursing stated pharmacy labels would be common practice. The Pharmacist stated the labels should be on the medications. The Pharmacist stated he did not know why the discontinued medication was not removed from the resident's medication bin.",2020-09-01
14,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2017-07-27,526,D,0,1,V9TA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident, hospice staff and facility staff interview, it was determined the facility failed to ensure coordination of care, including development of a coordinated plan of care, between the hospice provider and the facility. This was true for 3 of 3 residents (#s 5, #6, #7) sampled for hospice care. This failure had the potential for harm if the residents received inadequate care from the facility and/or hospice agency due to a lack of care coordination. Findings include: Resident #'s 5 and 7 local hospice agency contract, dated 3/6/12, documented, The plan of care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the plan of care. Resident #6's local hospice agency contract, dated 5/13/14, documented, .hospice and facility shall jointly develop and agree upon the hospice patient's plan of care. 1. Resident #5 was readmitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION]. Resident #5's physician orders, dated 5/11/17, documented an order for [REDACTED].>Resident #5's Significant Change Minimum Data Set (MDS) assessment, dated 5/15/17, documented the resident was severely impaired, required extensive assistance from staff for all cares, and received hospice services. Resident #5's current facility Comfort Care (End of Life) care plan, dated 5/18/17, documented an intervention, (Hospice Agency) hospice to help maintain comfort for (Resident #5). No other information regarding hospice was documented in the care plan. Resident #5's record did not contain a delineation of duties between the hospice agency and the facility. On 7/26/17 at 9:25 am, Resident #5 was observed in his bed in his room. Hospice Nurse #1 was observed in the room who said she had just finished her assessment. Hospice Nurse #1 said she or another hospice nurse came into the facility at least once a week or as needed to assess the resident and a CNA (Certified Nurse Assistant) came in twice a week to bathe the resident and provide other ADLs (Activities of Daily Living) as needed. Hospice Nurse #1 said when she or another hospice staff member came into the facility they contacted the charge nurse before and after their visits and left a note in the hospice book which was located at the nurse's station. She said the facility staff was supposed to provide all cares and the hospice only provided additional support. On 7/26/17 at 9:35 am, CNA #1 said the hospice provided the resident showers and the facility provided all other ADL cares. She said if the hospice staff were unable to provide the resident a shower, the facility staff were to provide showers for Resident #5. On 7/26/17 at 9:45 and 10:15 am, RN #1 said hospice provided the resident showers and the facility provided all other ADL cares. She said if the hospice staff were unable to provide the resident a shower, the facility staff were to provide showers. RN #1 said this information should be in Resident #5's facility care plan, including frequency of visits by hospice staff. She said the hospice agency care plan for hospice staff, along with notes were located in a book at the nurses station. On 7/27/17 at 2:45 pm, the DNS (Director of Nursing Services) said Resident #5's facility hospice care plan lacked direction for facility staff regarding what services the hospice provided versus what facility provided and lacked information regarding frequency of hospice visits. The DNS said there was no delineation of duties for the resident. 2. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses, including terminal [MEDICAL CONDITION]. Resident #6's physician orders, dated 6/27/17, documented an order for [REDACTED].>Resident #6's Admission MDS, dated [DATE], documented the resident was cognitively intact, required limited assistance of one staff member for toileting, had an ostomy (a surgical opening in the body to discharge waste) and received hospice services. Resident #6's current facility Comfort Care (End of Life) care plan, dated 6/23/17, documented an intervention, Staff will collaborate with (Hospice Agency) on end of life cares. She will be encouraged to participate in activities that she enjoys. She will be able to attend spiritual services as she wishes. No other information regarding hospice was documented in the care plan. The resident's bowel care plan, dated 6/23/17, documented how facility staff were to assist the resident with her ostomy care. Resident #6's record did not contain a delineation of duties between the hospice agency and the facility. Resident #6's ADL flow sheet, dated 7/26/17, documented a Hospice CNA assisted the resident in changing her ostomy bag and wafer. On 7/26/17 at 4:00 pm, Resident #6 was observed in her bed in her room. Hospice CNA #3 was observed to offer the resident a mug of ice water and asked the resident if she needed anything else. On 7/26/17 at 4:05 pm, Hospice CNA #3 said hospice CNA staff came to the facility for Resident #6 at least once a week and as needed and provided various ADL cares and services for the resident. On 7/27/17 at 8:50 am, Resident #6 said she had just requested for hospice to come and give her a bath. She said when she requested a bath, the hospice or facility staff would provide a bath for her. On 7/27/17 at 8:55 am, CNA #2 said the CNA who was providing showers for that day was aware of the resident's request and would offer the resident a bath. CNA #2 said the facility provided all of the resident's ADL cares, including showers and hospice provided extra showers and cares. On 7/27/17 at 9:50 am, CNA #4 was observed to provide Resident #6 with a bed bath in the resident's room. On 7/27/17 at 9:55 am, LPN #1 said she had only been working in the facility for a few days. She said the resident's facility care plan should document which services the facility provided and which services the hospice provided. LPN #1 said hospice staff checked in with her when they visited the resident. On 7/27/17 at 11:05 am, CNA #3 said she had assisted Resident #6 and Hospice CNA #3 the day before with the ostomy bag change and said the hospice agency supplied the resident's ostomy supplies, which were kept in the resident's room. On 7/27/17 at 3:00 pm, the DNS said there was no delineation of duties for the resident. She said Resident #6's facility's hospice care plan lacked direction for facility staff regarding what services the hospice provided versus what facility provided, lacked information regarding frequency of hospice visits, and did not address who would provide the resident's ostomy supplies. 3. Resident # 7 admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #7's physician orders, dated 3/24/17 included hospice care. Resident #7's Admission MDS assessment, dated 3/31/17, documented the resident was severely cognitively impaired, required extensive assist of 2 or more staff for bed mobility, transfers, dressing, toileting, and personal hygiene with hospice care provided. Resident #7's facility care plan, dated 3/24/17, documented comfort care for end of life care. The goal documented for Resident #7 was to be free from pain. The care plan documented the facility and hospice staff would work together to manage the Resident's end of life care. Resident #7's hospice care plan documented weekly visits from the licensed nurse and the CNA and monthly visits from the social worker. A binder was located at the nurse's station which was entitled Hospice contained weekly notes that documented the care provided by the hospice Licensed Nurse and CN[NAME] On 7/27/17 at 2:45 pm, the DNS (Director of Nursing Services) said Resident #7's facility's hospice care plan lacked direction for facility staff regarding what services the hospice provided versus what facility provided and lacked information regarding frequency of hospice visits. The DNS said there was no delineation of duties for the resident.",2020-09-01
15,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2018-10-12,656,E,0,1,SC7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined the facility failed to develop and follow resident-specific care plans. This was true for 5 of 10 residents (#1, #5, #12, and #64) whose care plans were reviewed. The residents' care plans did not address the use of [MEDICAL CONDITION] medications, wheelchair positioning, preference to sleep in a recliner, and follow aspiration precaution interventions. This failure created the potential for residents to receive inappropriate or inadequate care with a subsequent decline in health. Findings include: A facility policy Nursing Assessment, effective 06/30/18, stated an individualized plan-of-care will be formulated as soon as possible upon admission and updated based on ongoing assessment and patient needs. The policy stated the plan of care will include goals and interventions established in collaboration with the patient, family/significant other/guardian, and care providers. The policy also stated an RN will review and revise the plan as warranted in collaboration with the other disciplines. This policy was not followed. 1. Resident #5 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #5's physician orders, dated 7/13/18, directed staff to provide [MEDICATION NAME] (an antianxiety medication) 0.5 mg by mouth nightly and 0.25 mg every morning. On 8/23/18, an order for [REDACTED]. Resident #5's care plan, dated 5/22/18, documented the antianxiety medication was to help with Resident #5's worries she experienced over her children and family. The care plan did not identify specific behaviors Resident #5 exhibited related to her anxiety. On 10/11/18 at 3:30 PM, the DON and RCA stated the medication was for anxiety but could not identify the specific behaviors exhibited. 2. Resident #64 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Physician orders, dated 10/1/18, documented Resident #64 was to receive [MEDICATION NAME] (an antidepressant) 20 mg by mouth daily, [MEDICATION NAME] (used to stabilize mood or for [MEDICAL CONDITION]) 100 mg by mouth daily, and [MEDICATION NAME] (an antianxiety) 0.5 mg by mouth 3 times daily as needed. A care plan, dated 10/11/18, documented Resident #64 had major [MEDICAL CONDITION] and was prescribed an antidepressant medication. The care plan documented the activities Resident #64 enjoyed and the common side effects of the medication, however, the care plan did not indicate the behaviors exhibited related to her depression. The care plan did not address the [MEDICATION NAME] or the [MEDICATION NAME]. On 10/11/18 at 3:30 PM, the DON stated Resident #64's [MEDICATION NAME] was used as a mood stabilizer. The DON stated Resident #64 asked for the [MEDICATION NAME] when she wanted it because she was cognitively intact. 3. Resident #12 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A physician progress notes [REDACTED].#12 had a [DIAGNOSES REDACTED]. Resident #12's physician orders, dated 10/5/18, directed staff to provide [MEDICATION NAME] (an antidepressant/sedative) 50 mg nightly. Resident #12's Care Plan did not identify [MEDICAL CONDITION]. There was no documentation of sleep monitoring in Resident #12's medical record. On 10/13/18 at 10:15 AM, the DON stated the facility did not monitor Resident #12's hours of sleep. 4. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 10/09/18 at 3:36 PM, Resident #1 was tilted back in his wheelchair at a table in the common area, with his feet dangling (no foot rests, and his legs could not reach the floor). At 3:39 PM, staff offered Resident #1 a shake drink, but did not reposition him. On 10/11/18 at 10:27 AM, Resident #1 was observed in the common area for a bowling activity. He was seated in his wheelchair and his feet did not reach the floor. Resident #1's care plan did not address a tilting wheelchair or positioning in the wheelchair, ie. a foot rest. On 10/11/18 at 4:40 PM, the Compliance Director stated Resident #1 refused the foot rests, so when he is tilted back, his feet did not touch the floor. She stated he just received a new wheelchair and it was not yet in the care plan. The Compliance Director was unsure of when Resident #1 received the new wheelchair. On 10/12/18 at 9:39 PM, the DON stated the expectation was Resident #1's refusal of wheelchair footrests and positioning were in the care plan. On 10/12/18 at 12:20 PM, RN #1 stated Resident #1's feet were usually on the floor or on the legs of the table, she had not seen them dangling. She stated he has had his new wheelchair for a couple months now.",2020-09-01
16,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2018-10-12,684,D,0,1,SC7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure physician orders [REDACTED].#3 and #7) whose records were reviewed. Resident #7's blood glucose physician orders [REDACTED].#3's aspiration precautions were not followed. These failed practices had the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practices. Findings include: 1. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An H&P, dated 8/28/18, documented Resident #7 received [MEDICATION NAME] (long-acting insulin) injections each morning, [MEDICATION NAME] (an oral diabetic medication) 50 mg once daily, and Humalog (a short-acting insulin) injections according to a sliding scale with each meal and at bedtime. The American Diabetes Association, website accessed 10/17/18, defines sliding scale as a set of instructions for adjusting insulin based on blood glucose test results, meals, or activity levels. Resident #7's MAR indicated [REDACTED]. The order was to check Resident #7's blood glucose at bedtime and 3:00 AM. The order stated if Humalog was given at bedtime to correct a high blood sugar, according to the ordered sliding scale, Resident #7's blood glucose was to be checked again at 3:00 AM. This order was not followed. Examples include: - On 9/2/18 at 9:21 PM, Resident #7 did not receive a Humalog injection. Her blood glucose was rechecked at 12:30 AM on 9/3/18, when it should not have been done per the orders, and it was not at 3:00 AM. - On 9/11/18 at 8:08 PM, Resident #7 received and injection of 1 unit of Humalog. At 2:52 AM, her blood glucose was not checked per physician order. At 4:36 PM on 10/11/18, the DON reviewed Resident #7's record and confirmed the blood glucose and insulin orders and stated they were not followed. 2. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Speech Evaluation, dated 6/13/18, documented Resident #3 was a high aspiration risk due to her progressive dementia and age. Aspiration is the risk of breathing foreign objects into the airway which can be food, saliva, or stomach contents when swallowing. Resident #3's care plan included Aspiration Precautions, initiated on 6/13/18. The care plan included interventions to keep her at a 90 degree angle for all oral intake and keeping the head of her bed greater than 30 degrees. On 10/9/18 at 11:10 AM and 1:52 PM, Resident #3 was observed laying in her bed and the head of her bed was flat. On 10/11/18 at 10:30 AM, Resident #3 was observed laying in her bed and the head of her bed was flat. On 10/11/18 at 4:36 PM, the DON confirmed Resident #3's care plan included elevating the head of her bed for aspiration precautions. She stated if the head of the bed was not elevated staff were not following the care plan.",2020-09-01
17,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2018-10-12,690,D,0,1,SC7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure the bowel protocol was followed and implemented for 1 of 2 residents (Resident #5) reviewed for bowel and bladder care. This had the potential to place residents at risk for fecal impaction and bowel blockage. Findings include: The facility's Bowel and Bladder Program policy, revised 4/9/18, directed staff to notify the physician for no bowel movement in 5 days. Resident #5 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A bowel continence care plan, dated 8/31/17, documented Resident #5's bowel movement pattern as one time a day 2 days apart. The care plan directed staff to refer to her medications for bowel care or call her physician to get an order if Resident #5 did not have a bowel movement by day 3. A physician order, dated 8/2/18, directed staff to provide Milk of Magnesia 30 mLs nightly as needed for constipation. A Pharmacy Review, dated 9/13/18, documented Resident #5 had not had a bowel movement for 3-4 days twice in the last 2 weeks. The bowel movement records, dated 9/9/18 through 9/22/18, documented Resident #5 did not have a bowel movement between 9/10/18 and 9/14/18 (5 days) and between 9/18/18 through 9/22/18 (5 days.) The Medication Administration Record [REDACTED]. A Pharmacy Review, dated 10/9/18, documented there were up to 5 days between bowel movements. The consultant pharmacist documented Resident #5 had Milk of Magnesia ordered as needed but none was given when Resident #5 went 5 days between bowel movements. On 10/12/18 at 2:30 PM, the DON stated residents received bowel care medication after 3 days without a bowel movement and the physician was notified on day 4. She confirmed the care plan and physician orders [REDACTED].#5.",2020-09-01
18,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2018-10-12,756,D,0,1,SC7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observation, and staff interview, the facility failed to ensure the pharmacy reported medication irregularities and were addressed by the atttending physician for an antibiotic ointment for 1 of 7 residents (Resident #1) whose medication records were reviewed for unnecessary medications and/or irregularities. This failure had the potential for Resident #1 to develop resistance to the antibiotic and result in lack of efficacy of future treatments for infections. Findings include: The facility's policy Medication Use in Long Term Care, effective 04/30/18, stated a pharmacy medication regimen review will occur for each skilled nursing facility patient at least monthly. The regimen review will include all prescribed medication orders and evaluated adequate indication for use, appropriateness of ongoing therapy, medical necessity, and duration. This policy was not followed. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1's MAR indicated [REDACTED]. The antibiotic ointment was last administered 10/10/18 at 7:21 PM. On 10/09/18 at 12:10 PM and 3:36 PM, and on 10/10/18 at 9:00 AM, Resident #1 was not observed with visible signs of eye redness, swelling, or drainage. On 10/11/18 at 2:34 PM, the Pharmacy Director stated he was unable to find documentation regarding the discontinuation or the need for continuation of the antibiotic ointment. He stated he had a discussion with the Consultant Pharmacist regarding the notation of None for antibiotics on the monthly review. The Pharmacy Director stated there was a [DIAGNOSES REDACTED]. The Pharmacy Director stated the expectation was the continued use of the antibiotic ointment should have been addressed. On 10/12/18 at 11:28 AM, the Compliance Director stated the facility policy does not address long term use of antibiotics. On 10/12/18 at 3:42 PM, the DON stated the expectation was the antibiotic ointment was reviewed related to 4 years of continued use.",2020-09-01
19,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2018-10-12,758,E,0,1,SC7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy and procedure review, it was determined the facility failed to ensure a.) residents' behaviors and potential side effects of [MEDICAL CONDITION] medications were routinely monitored b.) there was a clear indication for use of PRN [MEDICAL CONDITION] medication c.) non-pharmacological approaches were attempted prior to the use of PRN medications d.) physician orders for PRN antianxiety medications were time limited and e.) residents received PRN [MEDICAL CONDITION] medications only when clinically indicated for the treatment of [REDACTED].#5, #7, #9, #10, #11, #12, and #64) reviewed for unnecessary medications. This created the potential for harm should residents receive [MEDICAL CONDITION] medications that were unnecessary, ineffective, or used for excessive duration, and placed them at risk for adverse reactions from [MEDICAL CONDITION] medications. Findings include: The facility's policy for Medication Use in Long Term Care, revised 4/25/18, documented psychoactive medications are prescribed when necessary to treat specific medical conditions. When prescribed: * The [MEDICAL CONDITION] medications will have a documented indication for the medication in the medical record. * Psychoactive MEDICATION ORDERS FOR [REDACTED]. If there is a continued clinical need the prescriber will document in the medical record justification for continued use. * Each behavior monitoring record will identify the specific symptoms for which the drug is being used. The documentation of the behavior will be quantitative and objective. * Each resident will have care plan interventions specific to their mood, behavior, and activity. * Pharmacy medication regimen review will evaluate prescribed medications orders for an adequate indication for use, appropriateness of ongoing therapy, medical necessity, adverse drug reaction and side effects, and adequate monitoring of therapy. 1. Resident #12 was admitted to the facility on [DATE], with multiple diagnosed including: [DIAGNOSES REDACTED]. A physician's Inpatient Progress Note, dated 9/13/18, documented Resident #12 had a [DIAGNOSES REDACTED]. Resident #12's admission MDS assessment, dated 9/19/18, documented she was severely cognitively impaired, had moderately severe depression, exhibited behavioral symptoms not directed toward others, and received antipsychotic medications and antianxiety medications daily. Resident #12's physician orders, dated 10/5/18, directed staff to provide [MEDICATION NAME] (antipsychotic) 1 mg by mouth nightly and [MEDICATION NAME] (antidepressant/sedative) 50 mg nightly. The physician orders did not include the [DIAGNOSES REDACTED]. A care plan, dated 10/11/18, identified mood/behaviors and dementia with behavioral symptoms for Resident #12 and directed staff to monitor for side effects related to her antipsychotic medication. The care plan documented she could become tearful and bang her fist on the table because she could not live at home with her husband. The care plan did not provide specific behaviors for [DIAGNOSES REDACTED]. Resident #12's Care Plan did not identify [MEDICAL CONDITION]. There was no documentation in Resident #12's record her sleep was monitored. On 10/13/18 at 10:15 AM, the DON stated the facility did not monitor Resident #12's hours of sleep. 2. Resident #5 was admitted to the facility on [DATE], with multiple diagnosed including: [DIAGNOSES REDACTED].) Resident #5's annual MDS assessment, dated 8/21/18, documented she had moderately impaired cognition, had mild depression, exhibited delusional thoughts, verbal behavioral symptoms directed toward others, and received antianxiety medications daily. Resident #5's physician orders, dated 7/13/18, directed staff to provide [MEDICATION NAME] 0.5 mg by mouth nightly and 0.25 mg every morning. On 8/23/18, an order for [REDACTED]. The physician orders did not include the [DIAGNOSES REDACTED]. Resident #5's MAR indicated [REDACTED]. The PRN order for [MEDICATION NAME] documented This is an extra dose when she needs it. Resident #5's care plan, dated 5/22/18, documented interventions for sundowning behaviors, agitation, and [MEDICAL CONDITION]. The care plan documented the antianxiety medication was to help with Resident #5's worries she experienced over her children and family. The care plan did not identify specific behaviors exhibited by Resident #5 related to her anxiety. A Mood/Behavior of Cognitively Impaired care plan, dated 10/9/18, directed staff to monitor for side effects related to antianxiety medications. A Behavioral/Psychopharmacological Review, dated 9/6/18, documented Resident #5 received [MEDICATION NAME] 0.5 mg two times daily and 0.5 mg daily as needed. The review documented Resident #5's targeted behaviors were delusions, hallucinations concerning family and/or children, yelling at/threatening staff, residents, and visitors, wandering, exit seeking, and crying/yelling for help. Resident #5's Behavior Monitoring flowsheets, dated 7/14/18 through 10/11/18, documented Resident #5 exhibited disorientation, anxiety, was unwilling to follow instruction, yelling, screaming, restless, fearful, resistive to care, multiple requests, crying, and tearful. Resident #5's behavior monitoring did not indicate whether medications were given, what the indications were, what behaviors were being monitored, or why Resident #5 received the additional [MEDICATION NAME] or the effectiveness of the anti-anxiety medication. The documentation did not provide non-pharmacological interventions for staff to attempt prior to providing the PRN dose of [MEDICATION NAME]. The targeted behaviors identified for monitoring on the Behavioral/Psychopharmacological Review were inconsistant with the behaviors exhibited on the behavior monitoring. On 10/11/18 at 3:30 PM, the DON and RCA stated the medication was for anxiety but could not identify the specific behaviors exhibited. 3. Resident #64 was admitted to the facility 10/1/18, with multiple diagnosed including: [DIAGNOSES REDACTED]. Resident #64's admission MDS assessment, dated 10/1/18, documented she was cognitively intact, had mild depression, had no behaviors, and received antidepressant medication daily and antianxiety medications almost daily, 5 out of 7 days. Physician orders, dated 10/1/18, documented Resident #64 was to receive [MEDICATION NAME] (an antidepressant) 20 mg by mouth daily, [MEDICATION NAME] (a mood stabilizer) 100 mg by mouth daily, and [MEDICATION NAME] (an antianxiety medication) 0.5 mg by mouth 3 times daily as needed. The orders did not include a [DIAGNOSES REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A care plan, dated 10/11/18, documented Resident #64 had major [MEDICAL CONDITION] and was prescribed an antidepressant medication. The care plan documented the activities Resident #64 enjoyed and the common side effects of the medication, however, the care plan did not indicate the behaviors exhibited due to depression. The care plan did not address the [MEDICATION NAME] or the [MEDICATION NAME]. Resident #64's Behavior Monitoring flowsheet included sections to document whether she was able to express her needs, her feelings, her thoughts, and her ability to understand. The entries, from 10/1/18 through 10/11/18, documented Resident #64 was calm, cooperative, able to express her feelings, needs, thoughts, and understood others. Resident #64's behavior monitoring flowsheet did not include what medications were given, what the indications were, what behaviors were being monitored, and how many episodes were exhibited each shift. The monitoring flowsheet also did not include why Resident #64 requested [MEDICATION NAME] or the effectiveness of the medication. On 10/11/18 at 3:30 PM, the DON stated Resident #64 was cognitively intact and would request the [MEDICATION NAME] when she needed it. The DON stated the staff did not ask Resident #64 the reason she was requesting the antianxiety medication. 4. Resident #11 was admitted to the facility on [DATE], with multiple diagnosed including: [DIAGNOSES REDACTED]. Resident #11's Significant Change MDS assessment, dated 9/13/18, documented severe cognitive impairment, mild depression, hallucinations, she received antipsychotic and antidepressant medications daily. Resident #11's physician orders directed the staff to provide [MEDICATION NAME] (an antipsychotic) disintegrating tablet 15 mg by mouth nightly and [MEDICATION NAME] (an antidepressant) 20 mg by mouth daily. The orders did not provide a [DIAGNOSES REDACTED]. Resident #11's care plan, dated 5/29/18, documented a [DIAGNOSES REDACTED]. The care plan documented Resident #11 was taking medication to help with the delusions and hallucinations. A Mood/Behavior of Cognitively Impaired care plan, dated 10/9/18, directed staff to monitor for side effects related to antianxiety medications. A monthly Long-term Care Pharmacy Review, dated 6/15/18, documented Resident #11 continued to see worms and spiders in her food, picked bugs off her clothing and the floor, saw men in her room and talked with people that were not present. A monthly Long-term Care Pharmacy Review, dated 8/14/18, documented Resident #11's fear and paranoia were improved and her fear of men, paranoia, delusions, and hallucinations were improved with the combination of the antidepressant and antipsychotic medications. A monthly Long-term Care Pharmacy Review, dated 9/12/18, documented Resident #11's fear of men, paranoia, delusions, and hallucinations were improved with the combination of the antidepressant and antipsychotic medications. A Behavioral/Psychopharmacological Review, dated 9/6/18, documented Resident #11 received [MEDICATION NAME] 5 mg nightly and [MEDICATION NAME] 20 mg daily. The review documented Resident #11 continued to experience mild hallucinations but none that prevented care and nutrition as before. The facility's Behavior Monitoring flowsheet documented whether Resident #11 was able to express her needs, her feelings, her thoughts, and her ability to understand. The entries completed each shift, from 7/14/18 through 10/11/18, documented Resident #11 was calm, cooperative, able to express her feelings, needs, thoughts, and understood others. The Behavior Monitoring flowsheet did not document episodes of hallucinations or delusions. The behavior monitoring did not indicate what medications were given, what the indications for the medications were, what behaviors were being monitored, how many episodes were exhibited each shift, or provide non-pharmacological interventions to staff. On 10/11/18 at 3:30 PM, the DON stated that Resident #11 has continued to have hallucinations and delusions but they are not upseting to her now. 5. Resident #7 was admitted to the facility on [DATE], with diagnoses which included dementia with behavioral disturbance, Type II DM, HTN, and a history of stroke. An H&P, dated 8/28/18, documented Resident #7 was living in an Assisted Living Facility when she was sent to the local ER due to combativeness, striking other residents at the facility. Resident #7 was admitted to the hospital and subsequently admitted to the facility. The H&P stated Resident #7's combativeness continued at the hospital and she was treated with [MEDICATION NAME] 75 mg twice daily. The note documented the plan was to ensure the combativeness was well controlled and then attempt a reduction in the dose of [MEDICATION NAME]. A physician progress notes [REDACTED].#7 had not demonstrated behaviors which were a challenge to staff previously. The physician documented a plan to initiate a gradual medication reduction of [MEDICATION NAME] beginning 9/3/18. The MAR indicated [REDACTED]. On 9/3/18, Resident #7 received 2 routine doses of [MEDICATION NAME] 50 mg and a 1 time dose of 50 mg, a total of 150 mg. Resident #7's [MEDICATION NAME] dose was reduced on 9/3/18, however, she received an additional 1 time dose on that day, which equaled her original dose. On 9/4/18, Resident #7's [MEDICATION NAME] was increased back to 75 mg twice a day. The physician's plan to initiate a gradual medication reduction of [MEDICATION NAME] was not documented after the attempt on 9/3/18. Resident #7's care plan, dated 9/7/18, identified the need for management of her behaviors related to her dementia. The care plan documented Resident #7 may become physical when she is upset, banging her fist on the wall, or yelling at others. It also stated Resident #7 may become frustrated and angry when her daughter and/or husband leave without her after a visit, it is too noisy, or she believes people are lying to her. Interventions included redirection to another activity which involved music or games, removing Resident #7 from other residents if she was yelling at them, or have a staff member sit and talk quietly with her in a quiet place. Resident #7's record included a Behavior Monitoring flowsheet. The flowsheet included sections for documentation of the date and time, resident behaviors, expressed needs, the ability to express feelings, needs, and thoughts, and the resident's ability to understand others. The flowsheet for Resident #7 was dated 8/28/18 to 10/11/18. Staff entries varied from 1 to 5 times a day. The Behavior Monitoring flowsheet included the following: - On 8/30/18 at 6:38 PM, Resident #7's behavior was described as angry, she was able to express her feelings, needs, and thoughts, and understood others. There was no further description documented of how she displayed her anger. There was no documentation of interventions by staff. - On 9/1/18 at 3:00 PM, Resident #7's behavior was described as restless and impulsive. There was no further description of her behaviors. There was no documentation of interventions by staff. - On 9/2/18 at 10:00 AM, Resident #7's behavior was described as Cries/tearful. There was no further description of her behaviors. There was no documentation of interventions by staff. - On 9/5/18 at 5:00 PM, Resident #7's behavior was described as Anxious; Resistive to care; Restless. There was no further description of her behaviors. There was no documentation of interventions by staff. - On 9/8/18 at 6:34 PM, Resident #7's behavior was described as Angry; Anxious, she was able to express her feelings, needs, and thoughts, and understood others. There was no further description documented of how she displayed her anger. There was no documentation of interventions by staff. - On 9/10/18 at 6:49 PM, Resident #7's behavior was described as Anxious; Angry; Cooperative, she was able to express her feelings, needs, and thoughts, and understood others. There was no further description documented of how she displayed her anger or anxiety. There was no documentation of interventions by staff. - On 9/17/18 at 6:08 PM, Resident #7's behavior was described as Angry; Anxious, she was able to express her feelings, needs, and thoughts, and understood others. There was no further description documented of how she displayed her anger or anxiety. There was no documentation of interventions by staff. - On 9/18/18 at 6:11 PM, Resident #7's behavior was described as Angry; Anxious, she was able to express her feelings, needs, and thoughts, and understood others. There was no further description documented of how she displayed her anger or anxiety. There was no documentation of interventions by staff. - On 9/29/18 at 3:00 PM, Resident #7's behavior was described as Cooperative; Restless; Anxious. There was no further description documented of how she displayed her behaviors. There was no documentation of interventions by staff. - On 10/7/18 at 5:22 PM, Resident #7's behavior was described as Angry; Anxious, she was able to express her feelings, needs, and thoughts, and she understood others. There was no further description documented of how she displayed her anger or anxiety. There was no documentation of interventions by staff. - On 10/8/18 at 1:00 PM, Resident #7's behavior was described as Anxious; Restless. There was no further description documented of how she displayed her anxiety or restlessness. There was no documentation of interventions by staff. At 10:35 AM on 10/12/18, the DON stated when Resident #7 was admitted the physician changed her from [MEDICATION NAME] (an antipsychotic medication) to [MEDICATION NAME]. The DON stated a GDR was attempted but was unsuccessful. She stated when Resident #7 has behaviors staff will assess for pain or other causes. The DON stated the Behavior Monitoring flowsheet was completed once a shift. She confirmed the flowsheet did not include a further description for a specific mood and did not document interventions by staff. 6. Resident #9 was admitted to the facility on [DATE], with diagnoses which included [MEDICAL CONDITIONS], HTN, and Type II DM. Resident #9's physician orders, dated 10/1/18, included [MEDICATION NAME] 60 mg daily for neuropathic pain (a disease of the sensory system) and [MEDICATION NAME] 0.5 mg every 6 hours as needed for anxiety. There was no documentation in Resident #9's record she had diagnoses of [MEDICAL CONDITION] or anxiety. On 10/11/18 at 2:16 PM, the Pharmacy Director stated there was a Clinical Pharmacist who conducted monthly medication reviews. He stated he reviewed indications for medications with diagnoses and also looked for off-label indications. The Pharmacy Director stated if there was a discrepancy between indications for use and diagnoses he will review the record further. He confirmed Resident #9's record did not included diagnoses for [MEDICAL CONDITION], depression, or anxiety. On 10/11/18 at 4:24 PM, the DON was asked about Resident #9's order for [MEDICATION NAME] and what behaviors are staff monitoring for and she stated Resident #9 becomes tearful and repetitive if anxious. She confirmed there were no diagnoses of [MEDICAL CONDITION], depression or anxiety on Resident #9's list of diagnoses. 7. Resident #10 was admitted to the facility on [DATE], with diagnoses which included malaise, [MEDICAL CONDITION] (paralysis of one side of the body), HTN, and Type II DM. Resident #10's physician orders included [MEDICATION NAME] (an antidepressant/sedative medication) 100mg nightly starting 9/6/18 and [MEDICATION NAME] (an herbal sleep aid) 3 mg nightly for sleep trouble, starting 10/5/18. A consent for Psychoactive Medication, dated 09/16/18, documented the Trazadone was for sleep. Resident #10's care plan, dated 9/26/18, included interventions to increase his participation to maximize rehabilitation benefits, have consistent daily scheduling, and reduce the risk of escalation. The care plan included monitoring for side effects related to Resident #10's antidepressant medication including drowsiness, dry mouth, sedation, and agitation. The care plan included direction to report to the nurse and physician if the medication assisted with sleep and if any negative side effects were observed. On 10/12/18 at 9:35 AM, the DON stated We do not do a true monitor where staff note how many hours residents are awake/asleep. She stated the EMR documented whether sleep was adequate in the flow sheets, then the nurses write a note if the resident is up or having trouble sleeping. The DON stated the [MEDICATION NAME] was started during Resident #10's acute hospital stay.",2020-09-01
20,ST LUKE'S ELMORE LONG TERM CARE,135006,895 NORTH 6TH EAST,MOUNTAIN HOME,ID,83647,2018-10-12,759,D,0,1,SC7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure a medication error rate less than 5 percent. This was true for 2 of 33 medications (6.06%) administered during medication pass and effected 2 of 5 residents (#65 and #114) observed during medication pass. This failed practice placed residents at risk of not receiving medications as ordered by the physician and had the potential to lessen the effectiveness of the medications administered. Findings include: 1. Resident #114 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #114's physician orders, dated 9/27/18, included [MEDICATION NAME] (an acid reflux medication) 40 mg by mouth every morning before breakfast (served at 7:45 AM - 8:45 AM). On 10/12/18 at 8:45 AM, RN #1 was observed as she administered morning medications to Resident #114, which included the medication [MEDICATION NAME]. Resident #114 had finished her breakfast and was sitting in the activity room. 2. Resident #65 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #65's physician's orders [REDACTED]. On 10/12/18 at 9:11 AM, RN #1 was observed as she administered morning medications to Resident #65, which included [MEDICATION NAME]. Resident #65 had finished her breakfast and was sitting in her wheelchair in her room. On 10/12/18 at 9:30 AM, RN #1 stated she did not know why the [MEDICATION NAME] for Resident #114 and Resident #65 were scheduled for 8:00 AM. RN #1 stated [MEDICATION NAME] was usually scheduled for 7:00 AM. On 10/12/18 at 2:35 PM, the DON stated sometimes the medication delivery times in the EMR changed. The DON stated the [MEDICATION NAME] should be given during the 7:00 AM medication pass.",2020-09-01
21,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2019-03-01,568,E,0,1,U2XH11,"Based on facility policy review, staff interview, and record review, it was determined the facility failed to ensure resident personal funds were maintained in separate accounts and quarterly statements were provided for 7 of 8 residents (#3, #4, #5, #10, #18, #20, and #37) whose personal funds were reviewed. The failure created the potential for harm if the residents or their representatives had concerns about their personal fund account, including inaccuracies, that were not addressed. Findings include: The facility's policy for transactions involving resident funds, dated 2/20/19, documented the following: * The facility will establish and maintain a system that assures a complete and separate accounting of each resident's personal funds. * Quarterly statements will be provided in writing to the resident, or the resident's representative, within 30 days after the end of the quarter and upon request. * The facility will ensure resident funds are not comingled with facility funds or funds of someone other than a resident. On 2/28/19 at 9:40 AM, the facility's Patient Financial Counselor, stated she did not manage residents' personal fund accounts. She stated CNA #1 provided resident transportation and managed the personal funds accounts for the residents. On 3/1/19 at 11:03 AM, during an interview with CNA #1, the Administrator, and the Patient Financial Counselor, CNA #1 reviewed current personal funds accounts. CNA #1 stated all the resident funds were in a single account with a local bank. CNA #1 provided a printout of a Trust Account Balance Sheet as of 3/1/19. The ledger identified current balances for Residents #3, #4, #5, #10, #18, #20, and #37. The Administrator stated the residents' money was in one interest bearing account. He said the interest generated from the account went into a Bingham Memorial Hospital account. The Administrator said the interest was then paid out to the individual residents. CNA #1 stated she had not sent out monthly or quarterly statements to residents or families, but she was only in the position a few months. The Administrator stated he did not know the last time statements were sent out. The Patient Financial Counselor stated three residents received statements in (MONTH) (YEAR). Prior to that, she was unsure. The Patient Financial Counselor attempted to find previous statements provided for the other residents. She said, I think it might have been back in (MONTH) of (YEAR).",2020-09-01
22,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2019-03-01,623,D,0,1,U2XH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and family interview, facility policy review, and record review, it was determined the facility failed to ensure transfer notices were provided in writing to residents upon transfer. This was true for 2 of 2 residents (#12 and #25) reviewed for transfers. This deficient practice had the potential for harm if residents were not made aware of or able to exercise their rights related to transfers. Findings include: The facility's policy and procedure for Transfer and Discharge, dated 10/2018, directed staff to notify the resident/resident representative for facility initiated emergency transfers and/or discharges for medical reasons. 1. Resident #25 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A nurse's note, dated 2/11/19, documented Resident #25 was transferred to the emergency room for evaluation and treatment. The note documented Resident #25's wife was called and notified of the transfer. Resident #25's record did not include documentation he or his representative received a written notification of the reason for transfer to the hospital. On 2/27/19 at 1:23 PM, Resident #25's wife stated the facility did not provide written notification of her husband's transfer to the hospital. She stated the facility did not contact her. She stated she found out Resident #25 was transferred to the hospital when she came to see him. On 2/27/19 at 2:35 PM, RN #3 stated the family is called when a resident is transferred to the hospital but was not familiar with any transfer/discharge papers from the facility. On 2/27/19 at 2:50 PM, the LSW stated Social Services did not provide written notice of transfer and discharge to residents. On 2/27/19 at 3:15 PM, the Patient Financial Counselor stated she did not provide residents with written notice of transfer or discharge. 2. Resident #12 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. a. A nurse's note, dated 1/7/19, documented Resident #12 was observed to be anxious at the nurses' station. He was hitting his head with both fists. Resident #12 stated he was going to try and kill himself. Resident #12 agreed to physician notification and inpatient psychiatric observation if needed. A physician's orders [REDACTED].#12 to an inpatient hospital psychiatric unit for [MEDICAL CONDITION]. On 1/7/19, Resident #12 was transferred to a hospital psychiatric unit for treatment. b. A nurse's note, dated 2/3/19, documented Resident #12 verbalized suicidal intent to staff. A physician's orders [REDACTED].#12 to a hospital psychiatric unit for suicidal ideation. On 2/3/19, Resident #12 was transferred to a hospital psychiatric unit for treatment. Resident #12's record did not document Resident #12 or his representative were provided written notice of transfer for either transfer. On 2/27/19 at 2:35 PM, RN #3 stated when a resident was transferred, she called the family and sent the chart and a copy of the MAR indicated [REDACTED]. She stated she did not know about providing written transfer/discharge information. On 2/27/19 3:15 PM, the Patient Financial Counselor confirmed the facility did not give residents a written notice of transfer or discharge.",2020-09-01
23,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2019-03-01,625,D,0,1,U2XH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family and staff interview, policy review, and record review, it was determined the facility failed to ensure a bed-hold notice was provided to a resident and/or their representative upon transfer to the hospital. This was true for 2 of 2 residents (Resident #12 and #25) who were reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time and may cause psychosocial distress if not informed they may be charged to reserve their bed/room. Findings include: The facility's Bed-Hold Notice Upon Transfer policy, dated 8/2018, documented the following: * In the event of an emergency transfer of a resident, the facility will provide within 24 hours, written notice of the facility's bed-hold policies. * The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file. 1. Resident #25 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A progress note, dated 2/11/19, documented Resident #25 was transferred to the emergency room for evaluation and treatment. The note documented Resident #25's wife was called and notified of the transfer. Resident #25's record did not include documentation he or his representative received a bed-hold notification when he was transferred to the hospital. On 2/27/19 at 1:23 PM, Resident #25's wife stated the facility did not talk with her about holding her husband's bed for his return. She stated she did not remember having signed a bed-hold notice. A bed-hold notice was not found in Resident #25's record. On 2/27/19 at 3:15 PM, the Patient Financial Counselor stated, We tell the resident verbally that we will do a bed hold. We don't have anything in writing. 2. Resident #12 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. a. A progress note, dated 1/7/19, documented Resident #12 was observed to be anxious at the nurses' station. He was hitting his head with both fists. Resident #12 stated he was going to try and kill himself. Resident #12 agreed to physician notification and inpatient psychiatric observation, if needed. A physician's orders [REDACTED].#12 to an inpatient hospital psychiatric unit for [MEDICAL CONDITION]. On 1/7/19, Resident #12 was transferred to an inpatient hospital psychiatric unit for treatment. b. A progress note, dated 2/3/19, documented Resident #12 verbalized suicidal intent to staff. A physician's orders [REDACTED]. On 2/3/19, Resident #12 was transferred to an inpatient hospital psychiatric unit for treatment. Resident #12's record did not document Resident #12, or his representative was provided with the facility's bed-hold policy information for either transfer. On 2/27/19 at 2:35 PM, RN #3 stated when a resident was transferred, she called the family and sent the chart and a copy of the MAR indicated [REDACTED]. She stated she did not know about providing written bed-hold information. On 2/27/19 03:15 PM, the Patient Financial Counselor stated the facility told Resident #12 verbally about the bed hold policy at the time of the transfers. However, the facility did not have documentation Resident #12 was notified about the facility's bed hold policy for either transfer to the hospital.",2020-09-01
24,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2019-03-01,684,D,0,1,U2XH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff and resident interview, it was determined the facility failed to ensure professional standards of practice were followed for bowel care and medication administration. This was true for 3 of 9 residents (#10, #25, and #189) reviewed for medications. This failed practice created the potential for harm if residents did not receive medications to prevent constipation or received medications contrary to physicians' orders. Findings include: 1. Resident #25 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #25 was readmitted on [DATE] after a 3 day acute care stay for pneumonia. The 5 day MDS assessment, dated 2/21/19, documented Resident #25 had impaired cognition. Resident #25's admission physician's orders [REDACTED]. * If no BM day 2: Milk of Magnesia 30 cc by mouth 1 dose if not contraindicated, as needed. * If no BM day 2: [MEDICATION NAME] 10 mg by mouth 1 dose if no results from Milk of Magnesia, if not contraindicated, as needed. * If no BM day 3: [MEDICATION NAME] 10 mg rectal suppository 1 dose if not contraindicated, as needed. * If no BM day 3: Fleets enema per rectum 1 dose if not contraindicated, as needed. * If no BM day 3: If no results from enema, notify MD, as needed. The facility's policy and procedure for tracking bowel movements, dated 5/15/18, documented the following: * Bowel tracking protocol is to establish a system for the facility to track resident bowel movements, detect abnormalities of bowel movements, and implement appropriate interventions to prevent constipation and complications associated with constipation. * Bowel movement activity will be recorded in the vital section of the facility electronic record indicating whether the resident did or did not have a bowel movement on the shift and the size of the bowel movement. Resident #25's medical record documented the following: * From 2/1/19 - 2/6/19, for 6 days, there was no documentation of BMs. * From 2/8/19 - 2/11/19, for 4 days, there was no documentation of BMs. * From 2/11/19 - 2/14/19, Resident #25 was out of facility. * From 2/15/19 - 2/20/19, for 6 days, there was no documentation of BMs. * From 2/25/19 - 2/27/19, for 3 days, there was no documentation of BMs. Resident #25's MARs from 1/28/19 to 2/28/19, did not include documentation bowel care medications were provided as ordered by the MD. 2. Resident #189 was admitted to the facility on [DATE], following surgical repair of a left [MEDICAL CONDITION]. Resident #189's admission physician orders, dated 2/23/19, included the following: * If no BM day 2: Milk of Magnesia 30 cc by mouth x 1 dose if not contraindicated, as needed. * If no BM day 2: [MEDICATION NAME] 10 mg by mouth x 1 dose if no results from Milk of Magnesia, if not contraindicated, as needed. * If no BM day 3: [MEDICATION NAME] 10 mg rectal suppository x 1 dose if not contraindicated, as needed. * If no BM day 3: Fleets enema per rectum x 1 dose if not contraindicated, as needed. * If no BM day 3: If no results from enema, notify MD, as needed. Resident #189's medical record documented, he had 2 BMs on 2/23/19. Resident #189's MARs, dated 2/22/19 to 2/28/19, did not include documentation bowel care medications were provided as ordered by the physician. On 2/26/19 at 10:30 AM, Resident #189 stated he needed to find out the last time he had a bowel movement. He said, I think it has been awhile. On 2/27/19 at 10:51 AM, RN #2 stated the 2 BMs were the only documentation she could find for Resident #189. 3. Resident #10 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A (MONTH) 2019 physician order, directed staff to provide Resident #10 with [MEDICATION NAME] light powder (a medication used to treat chronic diarrhea) 4 grams by mouth twice a day. On 2/11/19, additional physician direction was provided to staff to ensure the [MEDICATION NAME] was not administered within 2 hours of other medications. Resident #10's MAR indicated [REDACTED]. Resident #10's (MONTH) 2019 MAR indicated [REDACTED]. The MAR indicated [REDACTED] * [MEDICATION NAME] for [MEDICAL CONDITION] (a diuretic) * [MEDICATION NAME] (a medication for [MEDICAL CONDITION]) * [MEDICATION NAME] (a medication for high blood sugars) * [MEDICATION NAME] (a medication for high blood pressure) * [MEDICATION NAME] Chloride (a medication for urinary incontinence) * Potassium Chloride (a potassium supplement) Resident #10's (MONTH) 2019 MAR indicated [REDACTED]. The MAR indicated [REDACTED] * [MEDICATION NAME] * Potassium Chloride * [MEDICATION NAME] * [MEDICATION NAME] (a medication for high blood cholesterol) On 2/28/19 at 5:11 PM, RN #1 stated the physician's orders [REDACTED].#10 continued to get other medications with the [MEDICATION NAME].",2020-09-01
25,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2019-03-01,695,E,0,1,U2XH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure staff changed and dated residents' oxygen tubing per physician orders [REDACTED].#6, #8, and #22) reviewed for oxygen use. This failure created the potential for harm from respiratory infections due to the growth of pathogens (organisms that cause illness) in oxygen humidifiers and cannulas. Findings include: The facility's policy and procedure for oxygen administration, dated 8/2018, directed staff to change oxygen tubing and the mask or cannula weekly and as needed if they became soiled or contaminated. Staff are directed to date and initial all oxygen tubing with the date of change. 1. Resident #8 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. On 2/25/19 at 1:00 PM, Resident #8 was observed sitting in his room at bedside with his oxygen on. The oxygen tubing was connected to a prefilled bubble humidifier which was connected to an oxygen system on the wall. The bubble humidifier was dated, the oxygen tubing was not. Resident #8's (MONTH) 2019 Treatment Administration Record (TAR) directed staff to change the oxygen tubing every Sunday on nightshift. The oxygen tubing was changed on 2/3/19, 2/10/19, 2/17/19, and 2/24/19. On 2/26/19 at 4:45 PM, RN #3 stated oxygen tubing should be changed weekly and as needed. She stated the tubing was changed every Sunday. RN #3 said nurses initialed on the TAR but did not date oxygen tubing. On 2/26/19 at 5:06 PM, the DON stated staff changed oxygen tubing every Sunday. The DON stated the staff should put a piece of tape on the tubing with the date changed and their signature to identify the date it was changed. The DON stated Resident #8's oxygen tubing was not dated. On 2/27/19 at 10:32 AM, Resident #8 was sitting in his wheelchair in his room. The oxygen tubing was connected to an oxygen delivery system. The oxygen tubing did not have a date. RN #2 stated she was not able to find a date on Resident #8's oxygen tubing. 2. Resident #22 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Resident #8's (MONTH) 2019 TAR directed staff to change the oxygen tubing every Sunday on nightshift. The oxygen tubing was changed on 2/3/19, 2/10/19, 2/17/19, and 2/24/19. On 2/26/19 at 3:50 PM, Resident #22 was sitting in her room with oxygen on. The DON stated she was not able to find a date on the oxygen tubing. 3. Resident #6 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#6 with oxygen at 4 liters a minute and to keep oxygen saturations (oxygen levels in blood) above 90%. Resident #6's care plan, dated 12/13/18, directed staff to change the oxygen tubing weekly. On 2/25/19 at 2:12 PM, Resident #6 was observed with oxygen on. The oxygen tubing was not dated. On 2/26/19 at 7:47 AM and 4:05 PM, Resident #6 was observed with oxygen on. The oxygen tubing was not dated. On 2/26/19 at 4:46 PM, RN #1 confirmed the oxygen tubing was not dated. She stated the oxygen tubing was usually changed every Sunday and the tubing should be dated at that time.",2020-09-01
26,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2019-03-01,756,D,0,1,U2XH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, staff interview, and record review, it was determined the facility failed to ensure the pharmacy recognized and reported medication irregularities. This was true for 3 of 3 residents (#6, #10, and #22) whose monthly pharmacy medication reviews were reviewed. This failure created the potential for harm should residents receive medications that were unnecessary, ineffective, or used for excessive duration, or should residents experience adverse reactions from medications. The facility's policy for use of [MEDICAL CONDITION] drugs, dated 11/2018, documented the following: * PRN orders for [MEDICAL CONDITION] drugs shall be used only when the medication is necessary to treat a diagnosed specific condition documented in the record, and for a limited duration (i.e. 14 days.) 1. Resident #22 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #22's 90-day MDS assessment, dated 2/25/19, documented she was cognitively intact and received antianxiety medications daily. Resident #22's physician orders, dated 11/27/18, directed staff to provide [MEDICATION NAME] 0.5 mg 4 times daily as needed for anxiety. The Pharmacist Medication Reviews, completed on 11/30/18, 12/30/18, 1/31/19, and 2/26/19 did not have comments or recommendations made by the Pharmacist. On 2/28/19 at 3:54 PM, the Pharmacist stated if he did not make recommendations, the Monthly Pharmacist Chart Review form had a zero in the comment section. He stated he put his recommendations in the comment section. On 2/28/19 at 4:13 PM, the Pharmacist stated he was not paying attention to the PRN [MEDICAL CONDITION] medications when he conducted the resident's monthly medication review. He stated he should have been reviewing them. On 3/1/19 at 11:30 AM, the DON confirmed she had not received any recommendations from the Pharmacist for Resident #22. The Pharmacist review of Resident #22 did not include review of PRN medications and whether the orders were in place for more than 14 days. 2. Resident #10 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#10 with [MEDICATION NAME] light powder (a medication used to treat chronic diarrhea) 4 grams by mouth twice a day. On 2/11/19, additional physician direction was provided to staff to ensure the [MEDICATION NAME] was not administered within 2 hours of other medications. Resident #10's MAR from (MONTH) (YEAR) through Feburary 2019, documented Resident #10 received the [MEDICATION NAME] medication twice a day at 7 AM and 8 PM with other medications. The Monthly Pharmacist Chart Review documented the Pharmacist reviewed Resident #10's medications on 9/28/18, 10/30/18, 11/30/18, 12/30/18, 1/31/19, and 2/26/19 with no recommendations documented. On 2/28/19 at 6:25 PM, RN #2 stated the Pharmacist should have identified the [MEDICATION NAME] was given with other medications with his monthly reviews. The Pharmacist review of Resident #10 did not include review of PRN medications and whether the orders were in place for more than 14 days. On 3/1/19 at 8:40 AM, the Pharmacist stated the administration of [MEDICATION NAME] should be separated by a couple of hours from other medications. He stated the medication interacts with [MEDICATION NAME] and the [MEDICATION NAME] Resident #10 was receiving and should be separated by a couple of hours. On 3/1/19 at 11:27 AM, the DON stated she had not received recommendations from the Pharmacist regarding the administration of [MEDICATION NAME] and the administration of Resident #10's other medications. 3. Resident #6 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. On 2/28/19 at 9:47 AM, RN #2 stated the Trazadone was ordered PRN. She stated the order should have only been written for 14 days. She stated she was unable to tell if the Trazadone was repeated in an hour or not because the order was written together on the MAR and the MAR did not have a space for the nurse to document if the Trazadone was repeated in one hour. The Monthly Pharmacy Chart Review documented Resident # 6's medications were reviewed monthly from 6/30/18 through 2/26/19. Resident #6's Pharmacy Chart Review did not include documentation of recommendations from the Pharmacist. On 02/28/19 at 3:54 PM, the Pharmacist stated he should have caught the Trazadone may be repeated in an hour as needed. On 2/28/19 at 4:13 PM, the Pharmacist stated he was not paying attention to the PRN [MEDICAL CONDITION] medications when he conducted the monthly medication review. He stated he should have been reviewing them. On 3/1/19 at 11:23 AM, the DON confirmed she had not received recommendations from the Pharmacist for Resident #6.",2020-09-01
27,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2019-03-01,812,D,0,1,U2XH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility policy, it was determined the facility failed to store and distribute food in a safe manner related to expired supplements and unlabeled and undated food for 1 of 1 food pantry. These failures had the potential to impact all the residents in the facility and created the potential for harm should residents experience adverse health outcomes from improperly stored or outdated food. Findings include: The facility's policy for Date Marking for Food Safety, dated [DATE], documented: * Food should be clearly marked to indicate the date or day, by which the food should be consumed or discarded. * The dietary staff are responsible for checking the refrigerator daily for food items that are expiring and discard accordingly. On [DATE] from 11:05 AM to 12:05 PM, an inspection of the nursing pantry was conducted with the Nutritional Production Coordinator. A cupboard in the pantry contained a box of 24 four-ounce bottles of Ensure. The expiration date was [DATE]. There were 4 four-ounce bottles of Ensure in the refrigerator with the expiration date of [DATE]. The refrigerator in the pantry had a bowl with what appeared to be ham. There was no label or date on the product. There was a bag of what appeared to be turkey. There was no label or date on the product. The Nutritional Production Coordinator stated the items should have been labeled and dated.",2020-09-01
28,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2016-06-17,155,E,0,1,J25411,"Based on observation, record review and staff interviews, it was determined the facility failed to ensure staff received training necessary to understand and follow the facility's advanced directive policies. This was true for 7 of 24 sampled residents (#1, #4, #5, #21-#24) with DNR status, and had the potential to impact all residents who had established advanced directives. This failed practice created the potential for staff to initiate, or not initiate, resuscitation, contrary to residents' wishes. Findings include: On 6/12/16 at 6:35 pm, during the initial tour of the facility, the rooms of Residents' #1, #4, #5, and #21 - #24 were observed to have a blue dot by the residents' names. At 6:40 pm on the 300 hallway, CNA #6 and CNA #7 were asked what the blue dots meant. CNA #7 stated she was not sure. CNA #6 stated she did not know, but believed it meant DNR. LN #1 stated the blue dot meant the resident was a DNR. At 6:45 pm on the 400 hallway, CNA #2 stated the blue dot meant the resident was a full code. CNA #3 stated she was not sure what the blue dot meant. LN #5 stated it was the residents' code status, but did not know which and would have to check. LN #9 stated she was not sure, it was probably a code status, but at a previous place she worked it referred to assistive devices. On 6/13/16, the medical records of Residents' #1, #4, #5, and #21 - #24 were reviewed. Each residents' medical record documented the resident's code status as DNR. On 6/14/16 at 12:00 pm, the DNS stated the blue dot by residents' names meant DNR, not a full code. The DNS stated she was in the process of changing the program because it was confusing. The DNS stated that usually a code blue, means resuscitation. The DNS stated the policy was for staff to look in the chart at the actual advance directives. The code status of each resident was found in the first section of the resident's chart.",2020-09-01
29,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2016-06-17,221,E,0,1,J25411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and resident interviews, it was determined the facility failed to ensure residents were not physically restrained. This was true for 3 of 10 sampled residents reviewed for side rails (#2, #3, and #10). This resulted in the use of half to full side rails for residents who did not have the ability to lower the side rails and had no identified medical symptoms that required restraint. Findings include: 1. Resident #10's MDS assessment, dated 4/11/16, documented he was moderately cognitively impaired and required total assistance with mobility and cares. The MDS documented Resident #10 did not have any physical or mechanical device, or equipment, that could easily be removed. On 6/16/16 at 4:00 pm, Resident #10 was observed lying in bed. The bed was against the wall to his right side, with 4 side rails up. Resident #10's left side was affected by a previous [MEDICAL CONDITION]. Resident #10 stated he felt trapped. Resident #10 did have consents for use of side rails for use related to bed mobility, bed control and assistance with transfers, however, he did not have the ability to use the side rails for positioning and bed control. 2. Resident #3's MDS assessment, dated 6/13/16, documented she was severely cognitively impaired, and required total assistance for mobility and cares. The MDS assessment documented Resident #3 did not have any physical or mechanical device, or equipment, that could easily be removed. On 6/16/16 at 4:00 pm, Resident #3 was observed in bed with bilateral lower side rails. Resident #3 was observed not to be able to lower her side rails. Resident #3 did have consents for use of side rails for use for assistance with repositioning in bed, however, she did not have the ability to use the side rails for positioning and bed control. 3. Resident #2's MDS assessment, dated 4/22/16, documented she was severely cognitively impaired, and required total assistance with mobility and all cares. The MDS assessment documented Resident #2 did not have a physical or mechanical device, or equipment, that could easily be removed. On 6/16/16 at 4:00 pm, Resident #2 was observed in bed with bilateral, full upper and lower side rails. Resident #2 was observed to not be able to lower her side rails. Resident #2 did have consents for use of side rails for use related to proper positioning and bed control, however, she lacked the ability to use the side rails for positioning or bed control. On 6/16/16 at 6:20 pm, the DNS stated the facility had old beds that had the bed controls on the side rails. The DNS agreed the residents did not have the ability to remove their side rails or use the bed controls.",2020-09-01
30,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2016-06-17,225,D,0,1,J25411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and resident, staff and family interview, it was determined the facility failed to ensure that for 1 of 2 investigations reviewed for abuse/neglect, the allegations were identified as potential neglect and investigated and processed as such. This was true for 1 of 2 residents (#7) whose allegations and investigations were reviewed. The facility failed to recognize an allegation as potential neglect and handled the investigation as a general care complaint. This compromised the ability of the facility to identify, thoroughly investigate, and initiate corrective actions necessary to protect residents from neglect. Findings include: Resident #7 was admitted to the facility on [DATE] for rehabilitation following a total knee replacement. She had an admission [DIAGNOSES REDACTED]. At the time of admission, Resident #7 required staff assistance for toileting and transfers. During an interview on [DATE] at 2:10 pm, Resident #7 stated that she had problems with her bladder when she was initially admitted after knee surgery. She stated it was hard for her to get to the bathroom on time. Resident #7 stated that initially, it took 2 to 3 staff to assist her with toileting because of her limited weight bearing status following surgery. She stated she was prescribed [MEDICATION NAME] and was incontinent the first couple days because staff did not help her. Resident #7 stated she waited an hour to an hour and a half to be toileted. Resident #7 reported staff came to her room and turned off her call light and said they would come back, but did not come back. She stated she remained in wet incontinence briefs for extended timeframes. Resident #7 stated staff got angry when they had to come and assist her to the toilet. It took several staff to do so and reported one staff member stated, Again? when she needed assistance to toilet. Resident #7 suggested the surveyor speak with her family member, Family Member #1, because this family member reported these concerns to administration and could provide the details. Family Member #1 was interviewed on [DATE] at 3:00 pm. Family Member #1 stated Resident #7 was admitted to the facility for rehab about a week and a half ago. Family Member #1 stated Family Member #2 was with Resident #7 during the day she was admitted ([DATE]) to the facility following surgery. Family Member #1 stated he was with Resident #7 during the second day ([DATE]) following Resident #7's admission and that both he and Family Member #2 went and spoke with the Administrator due to their concerns. Family Member #1 stated Resident #7 had been completely continent prior to the surgery and was aware when she needed to use the toilet. Family Member #1 stated Resident #7 had a catheter in the hospital but it was removed prior to her coming to the facility. He stated Resident #7 was put into incontinent briefs when she was admitted to the facility even though she was continent. Family Member #1 stated both he and Family Member #2 observed Resident #7 waiting too long for assistance and Resident #7 was incontinent, urinating in her brief, as a result. He stated he had medical training and helped Resident #7 to the toilet twice when he was visiting because staff did not come timely and Resident #7 had already been incontinent. Family Member #1 stated he was concerned because Resident #7 had what looked like skin breakdown to her bottom. Family Member #1 stated he and Family Member #2 spoke with the Administrator on Monday [DATE]. Concerns raised included Resident #7 being put in incontinence briefs, the long wait for toileting assistance, call light response time, and Resident #7 remaining in wet briefs for an extended time. Family Member #1 also reported an interaction with a nurse who forcefully stated, Bullshit when he reported a concern about whether Resident #7's skin had been assessed upon admission. Family Member #1 stated he was concerned when he observed Resident #7's skin as it looked like she had skin breakdown to her buttocks area. Family Member #1 stated the Administrator was concerned when the issues were reported on [DATE] and told both he and Family Member #2 that it would be handled as a state level complaint. Family Member #1 stated the Administrator had not followed up with him regarding the outcome of the investigation. A BMH Concern Form, dated on [DATE] at 1:30 pm, documented the concerns raised by Family Member #1 and Family Member #2. A Bowel and Bladder Continence Evaluation, dated [DATE], documented Resident #7 was incontinent of urine a total of 4 times on [DATE] and on [DATE]. On [DATE] and [DATE], there were no recorded incidents of incontinence; however, there was one incident of Resident #7 being wet. The SNRC Admission Assessment, dated [DATE], stated Resident #7's buttocks area were red and excoriated. Review of the Bingham Memorial Skilled Nursing and Rehabilitation Center and Bingham Memorial Hospital Abuse and Assault (Child Abuse/Neglect; Elder Abuse/Neglect; Domestic Battery, Sexual Assault) policy, created [DATE] and expired on [DATE], defined neglect as, The failure of a caretaker to provide food, clothing, shelter, or medical care necessary to sustain the life and health of a vulnerable adult . Examples of physical neglect were documented as, Inadequate provision of care .Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The abuse/neglect policy stated if an allegation of neglect was made for a resident in the facility that did not reach the level of serious, life threatening injury or death, staff must notify the Administrator and DNS. The Administrator was responsible to contact the SNRC Social Worker to proceed with reporting requirements of within 24 hours to the State Agency, Bureau of Facility Standards. The SNRC Social Worker or designee would then fax a written report to the Bureau of Facility Standards within 5 days. The Administrator was interviewed on [DATE] at 2:00 pm. He stated Family Member #1 and Family Member #2 came into his office on [DATE] and expressed their concerns regarding Resident #7's the lack of care. He stated he grabbed a complaint form and documented their concerns at that time. He stated he went to the charge nurse after the discussion and began investigating the concerns immediately. He stated that he found out Resident #7 was admitted with an incontinence brief on and that a skin assessment was completed upon admission. He stated he directed staff to respond timely to call lights and toileting assistance. He verified (nurse's name) said, Bullshit when Family Member #1 questioned whether an initial skin assessment was completed. The investigation did not include documentation of interviews with nursing staff members who worked with Resident #7 on [DATE] and [DATE] or any other method to determine whether adequate toileting assistance was provided. The investigation did not include interviews with other residents to determine whether their needs were met on those dates. The investigation did not include an interview with Resident #7 at that time; she was interviewed during the survey. When asked about reporting the incident as an allegation of potential neglect to the State Agency, the Administrator stated the incident should have been reported to the social worker. He stated he had not considered the allegation as potential neglect at the time, but could see how a failure to provide care and services (toileting) met the criteria. He verified the incident was not reported to the State Agency within 24 hours and a report was not faxed to the State Agency within 5 days.",2020-09-01
31,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2016-06-17,240,E,0,1,J25411,"Based on observations, record review, and resident and staff interviews, the facility failed to ensure the dining experience in the main dining room promoted the enhancement of quality of life for residents. This directly impacted 12 of 20 sampled residents (#3, #6, #8 - #10, and #14 - #20) who resided in the facility at the time of survey and 6 of 7 residents in the group interview. It also had the potential to impact all residents who ate in the main dining room. Specifically: residents waited lengthy time frames to be served; meals were not always served on time; condiments such as salt and pepper and sugar were not easily accessible to residents who dined in the main dining room; a sufficient amount of beverages was not consistently served, including water; and beverages were served in cans, cartons and plastic bottles without residents being offered the option of having the beverages poured into cups. Findings include: 1. Meal service start times were posted on the wall adjacent to the primary entrance into the main dining room as follows: breakfast 7:20 am, lunch 12:20 pm, and dinner 5:20 pm. Between 30 to 35 residents were observed to eat their meals in the main dining room during the survey. a. On 6/13/16, breakfast observations were made in the main dining room beginning at 7:05 am. At this time, approximately 20 residents were present in the dining room, sitting at their tables. The remaining residents (approximately 10 residents) arrived and were present in the dining room by 7:15 am. Although most residents had one beverage at their places on the tables, breakfast meal service did not start until 7:40 am. This was 20 minutes after the posted meal time and 40 minutes after two thirds of the residents had been present. Meal service concluded at 7:55 am. Approximately 20 of the residents had been in the dining room since prior to 7:05 am, when observations began. Specific examples include: * At 7:15 am, Resident #20 stated (in regards to meal service) It takes a while. * At 7:45 am, 3 of the 4 residents sitting at the assistance table (Residents #9, #15 and #16), were observed with their heads slumped and their eyes closed. The remaining resident, Resident #3, was observed intermittently fidgeting with her silverware and sitting and staring off from the time she was first observed seated in the dining room at 7:05 am, until she was served her meal. This table was served last at 7:55 am. * Resident #17 was in the dining room sleeping with her tray in front of her at 8:02 am. She continued to sleep and ate nothing. She was aroused by staff at 8:15 am, and wheeled out of the dining room for a scheduled hair appointment. b. Almost all the residents were present in the dining room at 12:20 pm, when the observations began. Lunch meal service started at 12:25 pm. Service was finished at 12:40 pm. During meal service there were two dietary staff behind the tray line serving meals. One staff served hot items and the other cold items. There were 6 nursing staff members taking residents' trays from the tray line and serving the meals to the residents. There were frequently 4 to 6 nursing staff members waiting at the tray line for dietary staff to dish up the plates. Dietary staff did not keep up with the pace of the nursing staff who were available to serve the meals. Another factor that slowed the meal service had to do with the option for residents to walk, wheel, or be wheeled up to the tray line to select the specific foods they wanted. Four residents were observed to go to the tray line to select their meals; it took between 2 and 5 minutes each for the residents to get through the tray line with their food selected. Meal service backed up more during these times with up to 6 nursing staff waiting at the tray line for dietary staff to serve additional trays. Four residents complained about waiting too long for meals. Specific examples include: * At 12:40 pm, Resident #19 was beginning to eat her meal. She stated, All meals are a half hour late. * At 12:40 pm, Resident #18, who was sitting near Resident #19, agreed with Resident #19's statement that the meals were served a half hour late. * At 12:40 pm, Resident #6, newly admitted and sitting near Residents #18 and #19, stated she did not understand why they waited. She stated they (residents) were in the dining room and ready to go at noon. * At 12:43 pm, Resident #8 stated all meals were late and that she was just served her meal at 12:40 pm. She stated part of the problem was that staff brought residents to the dining room quite a while before the meals were served. She stated she no longer allowed staff to bring her to the dining room early. The Dietitian was interviewed on 6/15/16 at 9:40 am, and stated nursing and social services directed meal times/meal service. She stated residents were able to go through the tray line and select what they wanted and verified meal service took longer when residents did so. She stated the facility was brainstorming how to speed up meal service and still retain the ability of residents to go through the tray line to select food choices. When asked what her expectations were for how many trays per minute should be served, she stated 2 trays per minute was the goal. If two trays per minute were served, all residents would be served within approximately 15 minutes which was not observed to occur during the meal observations noted above. The DNS was interviewed on 6/16/16 at 5:50 pm, and stated that they had tried changing the serving order in the dining room to meet the needs of residents; however, were still in the process of figuring out the best meal service plan. 2. Breakfast was observed on 6/13/16 in the main dining room from 7:05 am until 8:15 am. With the exception of 2 tables that had salt and pepper shakers (one set being provided after Resident #14 requested it), there were no condiments on the remaining 9 tables in the main dining room such as salt, pepper, sugar, etc. Condiments such as salt and pepper were not served unless residents asked for them. Specific examples include: * Resident #14 asked for salt and sugar when his meal was served; staff went and got him a salt and pepper shaker for the table and sugar packets. * An anonymous resident asked for sugar at 7:59 am; a staff member went and retrieved sugar packets for the resident. On 6/14/16 at 12:20 pm, the lunch meal dining room observations began and continued through 1:00 pm. No salt or pepper shakers or sugar was observed on the tables initially. At 12:15 pm, salt and pepper had been placed on one table; the other tables did not have it. Specific examples include: * Resident #8 stated the food was bland; she stated there was no salt available for her to use. No salt and pepper shakers were observed on her table. * An anonymous resident was interviewed at 12:47 pm, and stated salt and pepper were not available on the tables. She stated she could ask for it if she wanted it. The Dietitian was interviewed on 6/15/16 at 9:40 am, and verified salt and pepper were not put on the tables customarily at meals. She stated residents could ask for salt if they wanted it. The Director of Nutrition services was interviewed on 6/16/16 at 11:15 am, and stated the facility used to provide salt and pepper shakers on the tables. She stated the previous Administrator instructed staff to remove the salt and pepper shakers to prevent residents that should not have sodium from accessing it. This practice had continued since that time. 3. On 6/13/16, breakfast meal observations were made in the main dining room beginning at 7:05 am. At this time, approximately 20 residents were present in the dining room, sitting at their respective tables. A staff member was in the process of pushing a cart from table to table and pouring beverages for the residents. At 7:15 am, most residents had been served their beverages with the majority of them having only one beverage served to them. No water was observed to be present on the tables with the exception of 3 residents who had been served cups of water. Some residents were served additional beverages with their meals such as milk for cereal. Resident specific observations revealed the following beverages were served: * Resident #10 was served one chocolate beverage only; no water was served. * Resident #14 was served a cup of water on the table when he arrived at 7:30 am. Resident #14 mumbled that he would like coffee when he was assisted by staff to the table. He asked staff again for coffee when they served his meal at 7:45 am; staff then brought him a cup of coffee. * Resident #16 was served one 4 ounce (oz) beverage. No water or additional beverage was served. * Resident #17 was served one 4 oz beverage with breakfast. No additional beverage was served. The Dietitian was interviewed on 6/15/16 at 9:40 a.m. and stated water should be served at each meal and additional beverages in accordance with residents' preferences. She stated residents should be served a minimum of 2 beverages with meals. The Director of Nutrition services was interviewed on 6/16/16 at 11:15 am, and stated that CNAs served all the beverages to residents at meals. She stated dietary stocked and sent the beverages up in accordance with the menu and preferences from the kitchen in the basement to the first floor for meal service, but dietary staff did not serve beverages directly to residents. She stated she was not sure what the process was for nursing to determine the distribution of beverages to residents. 4. During observation of the breakfast meal on 6/13/15, it was noted that none of the residents were observed with their canned supplements or milk (in plastic bottles/cartons) poured into cups. These beverages were either not opened, opened with straws placed in the containers, or were opened without a cup or straw being offered, which left the only method of drinking by lifting the can, carton or bottle up and drinking from the container. Specific observations from 7:05 to 8:15 am included: * Resident #15 was served Glucerna supplement in a can, a straw or cup were not offered. She was observed, with some difficulty, lifting the can to her lips and drinking directly from it. Resident #15 sat at a table designated for residents who required meal assistance. * Resident #9 was served Nepro supplement in a can. A straw was placed into the can; Resident #9 was not offered the option of having the supplement poured into a cup. * Resident #14 was served Ensure Clear in the carton. A straw was placed in the carton; Resident #14 was not offered the option of having the supplement poured into a cup. He was also served milk in a plastic bottle with his meal; he was not offered the option of having it poured into a cup. * The table for residents requiring meal assistance was observed at the end of the meal with 2 unopened plastic bottles of milk, that had not been opened during the meal, remaining on the table. During observation of the lunch meal on 6/13/16, it was noted that none of the residents were observed with their canned supplements or milk (in plastic bottles/cartons) poured into cups. These beverages were opened with straws placed in the containers. Specific observations during lunch included: * Resident #15 was served Glucerna supplement in a can, with a straw. Resident #15 was not offered the option of having the supplement poured into a cup. * Resident #9 was served Nepro supplement in a can. A straw was placed into the can; Resident #9 was not offered the option of having the supplement poured into a cup. The Dietitian was interviewed on 6/15/16 at 9:40 am, and stated beverages served in cans, cartons and bottles should be poured into cups in accordance with residents' preferences. The Director of Nutrition services was interviewed on 6/16/16 at 11:15 am, and stated that beverages served in bottles, cans and cartons should be poured into cups. 5. On 6/15/16 at 10:20 am, during a group interview, the group stated there was not enough staff available during meals and during the night shifts. The group stated that after 10 pm, there were only 2 CNAs. The group stated they often had to wait up to 45 minutes for their call lights to be answered. The group stated the 400 and 500 halls were really short of staff. The group stated meal times took too long and did not understand why staff stood around the tray line waiting for trays. They stated that although they liked being able to go to the tray line to pick their meal, the process took too long. The group further stated they usually had to ask or wait for their meals to get something to drink. The group stated water was not served unless asked for, as well, as condiments. The group stated that not all the residents were able to eat what they wanted. If a resident was on a special diet, they could not get anything not on the diet especially if they were not able to voice their wishes. The group further stated fluids were not always offered in a glass or cups. They usually got drinks from a can. Resident Council Grievance meeting minutes from the last three months documented the following: * Review of (MONTH) Concerns - Meal service changed to improve flow and timing of meals and hall trays delivered before dining rooms and staff are unable to address residents' special needs or provide extra assistance due to being so busy. * (MONTH) - Residents need assistance in the rehab dining rooms during meals and in completing menus; too much Mexican food on menus; potatoes and fruit too hard. * (MONTH) - Salt and pepper over used in vegetables and gravies; potatoes under cooked; and meat overcooked and tough; meals cold in dining room; requests for smaller portions not provided; and drinks are not served timely at dinner meals. * (MONTH) - Staff continue to turn off call lights without providing care. They say they will return but often forget. Staff also need to be quicker in answering the red bathroom call lights. Staff are not helping as efficiently in the dining room during tray line as they could be. A Mini Inservice for staff, dated 5/10/16, documented that residents' continue to report drinks are not served timely at the dinner meal in the dining room. Residents are stating there are times they receive their meal and have yet to be served anything to drink. This concern has been expressed during several resident council meetings. The inservice directed that all residents should receive water, as well as, beverages of choice. The inservice stated CNAs are responsible to serve beverages at dinner meals and for staff to be aware of who is in the dining room to ensure drinks are passed prior to meal service.",2020-09-01
32,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2016-06-17,241,G,0,1,J25411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, family and staff interview, the facility failed to ensure 4 of 19 sampled residents (#1, #7, #12 and #13) were provided care and services in a manner enhancing their dignity and respect. This resulted in harm to Resident #1 when she experienced resentment and demoralization when a tab alarm was attached to her clothing and the loud alarm that sounded when she moved or stood. It also placed Resident #7 at risk of psychosocial harm when she was not provided with toileting assistance necessary to avoid incontinence and incontinence briefs were put on her when she had been continent previously. Residents #12 and #13 were administered insulin injections during meals in the main dining room, creating the potential of embarrassment and humiliation. Findings include: 1. Resident #1 was admitted to the facility on [DATE]; current [DIAGNOSES REDACTED]. Resident #1 received hospice care for end stage [MEDICAL CONDITION]. Review of the 4/20/16 quarterly MDS indicated Resident #1 was usually understood by others, had no behavioral symptoms, and had a history of [REDACTED]. Resident #1's Care Plan, reviewed and revised on 6/10/16, stated a tabs alarm was initiated to address the problem of potential for falls on 3/21/16. Documentation included, I may hide or disable it because the sound bothers me, remind me it alerts the staff that I may need help. Resident #1 was observed with large writhing movements, primarily of her arms and upper body, at various times during the survey (6/12/16 at 8:00 pm - 8:30 pm, 6/13/16 at 7:00 am and 9:30 am, and 6/14/16 at 6:10 pm). Resident #1 was interviewed on 6/13/16 at 9:30 am, and reported she had a history of [REDACTED]. She stated she resented the alarm due to the loud sound that emanated when it went off. She stated it was very important to remain independent as much as she could. Resident #1 was interviewed a second time on 6/14/16 at 9:50 am, and stated she was capable of disconnecting the alarm by unclipping it from her clothing. Resident #1 stated she had unclipped it at times because it bothered her, but was encouraged by staff to keep it connected. Resident #1 reported she had not disconnected it recently. Resident #1 concluded, stating the tab alarm use was upsetting and made her feel, Like a dog on a leash. Resident #1 was observed during the survey, between 6/12/16 and 6/17/16, a number of times without the alarm connected. She was also observed during the survey with the alarm connected. On 6/14/16 at 6:10 pm, Resident #1 was observed eating dinner in the dining room. Within a period of 5 minutes (6:10 pm - 6:15 pm), the alarm sounded with a loud, piercing beep, 4 times. Within 5 seconds of each incident, a staff member turned the sound off and reconnected the alarm to Resident #1's clothing. Resident #1 reached down once to pick something up off the floor; however, in the other 3 instances the alarm was set off by Resident #1's writhing movements of her upper body in the wheelchair. She was not attempting to stand, get out of the chair, or do something unsafe in 3 of the 4 instances the alarm sounded. CNA #1 was interviewed on 6/13/16 at 9:30 am, and stated Resident #1 was to have the tab alarm on when she was in the wheelchair and verified Resident #1 removed it at times. She stated Resident #1 had a history of [REDACTED]. The DNS was interviewed on 6/16/16 at 5:30 pm, and verified Resident #1 had a history of [REDACTED]. She verified Resident #1 was capable of removing the tab alarm and it was not an effective measure to prevent falls. She stated Resident #1 was stubborn, knew what she wanted, and desired independence. 2. Resident #7 was admitted to the facility on [DATE], for rehabilitation following a total knee replacement. She had an admission [DIAGNOSES REDACTED]. Resident #7 required staff assistance for toileting and transfers when admitted . During an interview on 6/13/16 at 2:10 pm, Resident #7 stated that she had problems with her bladder when she was initially admitted after knee replacement surgery. She stated it was hard for her to get to the bathroom on time. Resident #7 stated it took 2 to 3 staff to assist her with toileting initially, because of her limited weight bearing status following surgery. She stated she was prescribed [MEDICATION NAME] and was incontinent the first couple days because staff did not help her. Resident #7 stated she waited an hour to an hour and a half to be toileted. Resident #7 reported staff came to her room and turned off her call light and said they would come back but did not come back. She stated she remained in wet incontinence briefs for extended timeframes. Resident #7 stated staff got angry when they had to come and assist her to the toilet. It took several staff to do so and reported one staff member stated, Again? when she needed assistance to toilet. Family Member #1 was interviewed on 6/14/16 at 3:00 pm. Family Member #1 stated Resident #7 was admitted to the facility for rehab about a week and a half ago. Family Member #1 stated Family Member #2 was with Resident #7 during the day she was admitted (6/3/16) to the facility following surgery. Family Member #1 stated he was with Resident #7 during the second day (6/4/16) following Resident #7's admission and that both he and Family Member #2 went and spoke with the Administrator due to their concerns. Family Member #1 stated Resident #7 had been completely continent prior to the surgery and was aware when she needed to use the toilet. Family Member #1 stated Resident #7 had a catheter in the hospital but it was removed prior to her coming to the facility. He stated Resident #7 was put into incontinent briefs when she was admitted to the facility even though she was continent. Family Member #1 stated both he and Family Member #2 observed Resident #7 waiting too long for assistance and Resident #7 was incontinent, urinating in her brief, as a result. He stated he had medical training and helped Resident #7 to the toilet twice when he was visiting because staff did not come timely and Resident #7 had already been incontinent. Family Member #1 stated he was concerned because Resident #7 had what looked like skin breakdown to her bottom. A Bowel and Bladder Continence Evaluation, dated 6/8/16, documented Resident #7 was incontinent of urine a total of 4 times on 6/3/16 and on 6/4/16. On 6/5/16 and 6/6/16, there were no recorded incidents of incontinence; however, there was one incident of Resident #7 being wet. A SNRC Admission Assessment, dated 6/3/16, noted Resident #7's buttocks area was red and excoriated. The Administrator was interviewed on 6/16/16 at 2:00 p.m. He stated Family Member #1 and Family Member #2 came into his office on 6/6/16 and expressed their concerns regarding Resident #7's lack of care, including toileting. He stated he grabbed a complaint form and documented their concerns at that time. He stated he went to the charge nurse after the discussion and began investigating the concerns immediately. He stated that he found out Resident #7 was admitted with an incontinence brief on and had since been progressed to an incontinence pull up. He stated he directed staff to respond timely to call lights and toileting assistance after talking with Family Member #1 and Family Member #2. 3. On 6/13/16 at 7:00 am, Resident #12 was observed in the small dining room eating breakfast. LN #7 had administered Resident #12's oral medications. LN #7 then assisted Resident #12 in lifting the left corner of her shirt and administered Resident #12's insulin. On 6/16/16 at 9:30 am, Resident #12 stated she was not asked about getting her injection in the dining room, that it was just how it was done. 4. On 6/13/16 at 7:20 am, Resident #13 was observed in the small dining room eating breakfast. LN #7 had administered Resident #13's oral medications. LN #7 then assisted Resident #13 in lifting the right corner of his shirt and administered Resident #13's insulin. On 6/16/16 at 10:00 am, Resident #13 stated he was not asked about getting his medications in the dining room and he had always got his insulin in the dining room. Resident #13 stated he had not been asked.",2020-09-01
33,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2016-06-17,242,D,0,1,J25411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of Resident Council meeting minutes, review of an inservice record, and resident and staff interview, it was determined the facility failed to ensure 1 of 20 sampled residents (Resident #8), and 2 of 7 residents in the group meeting, were allowed to make choices regarding foods and condiments. This resulted in Resident #8, who was on a therapeutic diet, not being served foods she selected and wanted to eat, creating dissatisfaction. It also resulted in frustration of members of the resident group due to lack of response from the facility to their concerns. Findings include: 1. Resident #8 was admitted to the facility on [DATE], for rehabilitation following a fall at home. [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated 5/6/16, indicated Resident #8 was understood by others and could understand others, had no behavioral indicators; however, was depressed, tired and having a poor appetite. The MDS assessment documented Resident #8 as being on a therapeutic diet with an initial weight of 216 pounds (lbs). Review of Resident #8's care plan, dated 5/6/16, identified the problem of I have potential altered nutrition related to my vitamin deficiency, chronic pain, and reflux. The goal was defined as I will maintain nutritional status through my next review date. One of the care plan approaches documented, I need a therapeutic cardiac, regular texture, thin liquid diet for meals. Review of the Resident #8's initial admission orders [REDACTED]. The plan of care notes, dated 5/6/16, stated, Meal intakes of cardiac, regular texture diet are fair at 50-75% due to the food being 'bland' per (Resident #8). Therapeutic menu extensions were provided for the week of the survey. Review of the cardiac diet menus showed: omission of high sodium meats such as bacon, ham, and sausage for breakfast, 1% milk was served versus 2%, substitution of whole wheat bread for bread, low salt gravies and sauces, low salt soups, low salt grains (rice pilaf, whipped potatoes, risotto, Mexican rice), low salt meats (low salt chicken taco without cheese, low salt spaghetti with meatballs, low salt baked fish) for regular items, and half portions of some desserts were served (pudding, shortcake). Resident #8 was interviewed on 6/13/16 at 12:46 pm. She stated she was admitted to the facility for rehabilitation and was working to improve strength so she could return home. She stated she was prescribed a cardiac diet when she was admitted to the facility and she did not want to be on this diet. She stated she had not been on a therapeutic diet prior to admission to the facility. Resident #8 stated the food was bland, had no flavor and tasted, Like hell. Resident #8 stated she was provided with a written menu ahead of time that she could select from. She stated she frequently selected foods that she did not receive and was told by staff that she could not have them due to her diet restriction. She stated she recently selected pizza from the menu but was not allowed to have it; selected Mexican rice on 6/12/16 but was served plain rice instead, and was recently served plain noodles. Resident #8 stated she did not understand why there were foods listed on the menu for her to select from that she was not allowed to have. Observations during the survey noted salt, pepper, Mrs. Dash, and/or other seasonings or condiments were not available on the tables in the dining room, including on Resident #8's table. On 6/14/16, Resident #8 was observed eating lunch at 12:48 pm. She stated she was not served the tomato juice she ordered on her menu, but was served grape juice instead. Resident #8's menu was on the table and tomato juice was circled indicating her selection. Grape juice was not selected on the menu. The DNS was interviewed on 6/16/16 at 5:50 pm, and stated staff served foods to Resident #8 according to her therapeutic diet parameters. She stated staff met with Resident #8 on 5/4/16 and encouraged the use of Mrs. Dash (herb based seasoning without salt) for added flavor. The Dietitian was interviewed on 6/15/16 at 9:40 am, and verified salt and pepper were not put on the tables customarily at meals. She stated residents could ask for salt if they wanted it. She stated Resident #8 should be served the foods she selected from the menu that included allowable cardiac diet choices. The Dietitian stated Resident #8 had informed her of the diet being bland and that she did not want to be on the diet. The Dietitian was informed of Resident #8's selection of tomato juice, circled on her menu at lunch, and the resident being served grape juice instead. The dietitian stated Resident #8 should have been served low sodium tomato juice. The Director of Nutrition services was interviewed on 6/16/16 at 11:15 am, and stated the facility used to provide salt and pepper shakers on the tables. She stated the previous administrator instructed staff to remove the salt and pepper shakers to prevent residents that should not have sodium from accessing it. his practice had continued since that time. She further stated therapeutic diets were identified in the dietary software and tray cards with this information were printed prior to the meal. She stated dietary staff referred to the tray cards when serving and nursing served the beverages. The Practice Paper: Individualize Nutrition Approaches for Older Adults in Health Care Communities Volume 110, Issue 10, Pages 1554-1563, (MONTH) 2010, include, It is the position of the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) that the quality of life and nutritional status of older adults residing in health care communities can be enhanced by individualization to less-restrictive diets. Resident #8's food choices were not honored and respected. 2. On 6/15/16 at 10:20 am, the group of residents stated meal service took too long and they did not understand why staff stood around the tray line waiting for trays. They stated that although they liked being able to go to the tray line to pick their meal, the process took too long. The group further stated they usually had to ask or wait for their meals to get something to drink. The group stated water was not served unless asked for, as well as, condiments. The group stated that not all the residents were able to eat what they wanted. If a resident was on a special diet, they could not get anything not on the diet especially if they were not able to voice their wishes. The group further stated fluids were not always offered in a glass or cups. They usually got drinks from a can. Resident Council Grievance meeting minutes from the last three months documented the following: * Review of (MONTH) Concerns - Meal service changed to improve flow and timing of meals and hall trays delivered before dining rooms and staff are unable to address residents' special needs or provide extra assistance due to being so busy. * (MONTH) - Residents need assistance in the rehab dining rooms during meals and in completing menus; too much Mexican food on menus; potatoes and fruit too hard. *April - Salt and pepper over used in vegetables and gravies; potatoes under cooked; and meat overcooked and tough; meals cold in dining room; requests for smaller portions not provided; and drinks are not served timely at dinner meals. *May - Staff continue to turn off call lights without providing care. They say they will return but often forget. Staff also need to be quicker in answering the red bathroom call lights. Staff are not helping as efficiently in the dining room during tray line as they could be. A Mini Inservice for staff, dated 5/10/16, documented that residents' continue to report drinks are not served timely at the dinner meal in the dining room. Residents are stating there are times they receive their meal and have yet to be served anything to drink. This concern has been expressed during several resident council meetings. The inservice directed that all residents should receive water, as well as, beverages of choice. The inservice stated CNA are responsible to serve beverages at dinner meals and for staff to be aware of who is in the dining room to ensure drinks are passed prior to meal service.",2020-09-01
34,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2016-06-17,244,E,0,1,J25411,"Based on observation, record review, review of Resident Council meeting minutes, review of an inservice record, and staff, family, and resident interviews, it was determined the facility failed to ensure sufficient numbers of staff were available to meet the needs of residents. This was true for 5 of 19 sampled residents (#4, #5, #6, #7, and #8) and 6 of 7 residents in group interviews. This deficient practice resulted in residents experiencing incontinence due to lack of timely assistance with toileting placed residents at risk of psychosocial and physical harm due to unmet needs. Finding include: 1. On 6/12/16 at 6:00 pm, Resident #4 stated staff took over 30 minutes to answer call lights. Resident #4 stated staff would often just come in a turn off the call light without providing cares. Resident #4 stated there was not enough staff at night and during meals. Resident #4 stated, the facility pulled all the staff to the dining room to help with the meals so there was no one on the halls to answer the call lights. 2. On 6/13/16 at 12:30 pm, a family member stated she came to the facility several times a day because she felt she needed to be there because there was not enough staff. The family member stated the staff the facility had did a good job, but there was not enough of them. 3. On 6/14/16 at 10:10 am, Resident #6 stated the facility needed more help. Resident #6 stated she could push her call light and sometimes had to wait over 30 minutes for staff to respond or staff just ignored the call light. 4. On 6/15/16 at 10:20 am, during a group interview, the group stated there was not enough staff available during meals and during the night shifts. The group stated that after 10:00 pm, there were only 2 CNAs. The group stated they often had to wait up to 45 minutes for their call lights to be answered. The group stated the 400 and 500 halls were really short of staff. The group stated meal times took too long and did not understand why staff stood around the tray line waiting for trays. They stated that although they liked being able to go to the tray line to pick their meal, the process took too long. The group further stated they usually had to ask or wait for their meals to get something to drink. The group stated water was not served unless asked for as well as condiments. The group stated that not all the resident were able to eat what they wanted. If a resident was on a special diet, they could not get anything not on the diet especially if they were not able to voice their wishes. The group further stated fluids were not always offered in a glass or cups. They usually got drinks from a can. Resident Council Grievance meeting minutes from the last three months documented the following: *Review of (MONTH) Concerns- Meal service changed to improve flow and timing of meals and hall trays delivered before dining rooms and staff are unable to address residents' special needs or provide extra assistance due to being so busy. *March-Residents need assistance in the rehab dining rooms during meals and in completing menus; too much Mexican food on menus; potatoes and fruit too hard. *April-Salt and pepper over used in vegetables and gravies; potatoes under cooked; and meat overcooked and tough; meals cold in dining room; requests for smaller portions not provided; and drinks are not served timely at dinner meals. *May- Staff continue to turn off call lights without providing care. They say they will return but often forget. Staff also need to be quicker in answering the red bathroom call lights. Staff are not helping as efficiently in the dining room during tray line as they could be. A Mini Inservice for staff, dated 5/10/16, documented that residents' continue to report drinks are not served timely at the dinner meal in the dining room. Residents are stating there are times they receive their meal and have yet to be served anything to drink. This concern has been expressed during several resident council meetings. The inservice directed that all residents should receive water, as well as, beverages of choice. CNAs were identified as responsible to serve beverages at dinner meals and for staff to be aware of who is in the dining room to ensure drinks are passed prior to meal service. 5. Resident #7 reported insufficient staffing following her recent admission to the facility for rehabilitation due to total knee replacement surgery. During an interview on 6/13/16 at 2:10 pm, Resident #7 stated that it was hard for her to get to the bathroom on time and it took 2 to 3 staff to toilet her initially because of her non-weight bearing status. Resident #7 stated she waited an hour to an hour and a half to be toileted. Resident #7 reported staff came to her room and turned off her call light and said they would come back but did not. She stated she was incontinent the first couple days following her admission to the facility because she did not receive timely toileting assistance. Resident #7 reported nights were the worst for call light response time and that it still took 30-45 minutes when she turned on her call light. Resident #7 also stated, Forget it at meal time. Don't even put it (call light) on. Resident #7's family member was interviewed on 6/14/16 at 3:00 p.m. Family Member #1 stated Resident #7 was admitted to the facility for rehab about a week and a half ago following a total knee replacement. Family Member #1 stated Resident #7 had been completely continent prior to the surgery and was aware when she needed to use the toilet. Family Member #1 stated the resident had a catheter in the hospital but it was removed prior to her coming to the facility. He stated Resident #7 was put in incontinent briefs when she was admitted to the facility, although she was continent. Family Member #1 stated both he and Family Member #2 observed Resident #7 waiting too long for assistance and Resident #7 was incontinent and urinated in her briefs, as a result. He stated he had medical training and helped Resident #7 to the toilet twice when he was visiting because staff did not come timely and she had already been incontinent. 6. Resident #8 stated on 6/13/16 at 12:40 pm, that the facility was short staffed. Resident# 8 reported waiting up to 45 minutes at night for toileting. She reported Nights were the worst. She stated there was only one nurse aide routinely assigned to cover 2 halls (400 and 500). Resident #8 stated she was incontinent if she had to wait too long. 7. An Interview with Resident #5's family member (Family Member #3) was conducted on 6/15/16 at 5:30 pm. Family Member #3 stated Resident #5 was dependent on staff for all cares. Family Member #3 stated the facility was understaffed at times. She stated when the facility was understaffed, Resident #5 had to wait more than 2 hours to be repositioned and range of motion was not provided. She said she noticed longer wait times for assistance during meals.",2020-09-01
35,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2016-06-17,278,D,0,1,J25411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, it was determined the facility failed to ensure assessment documentation accurately reflected residents' abilities. This was true for 4 of 10 sampled residents reviewed for side rails (#2, #3, #6 and #10). This resulted in MDS assessment which did not accurately reflect the residents' ability to easily remove their side rails. Findings include: 1. Resident #10's MDS assessment, dated 4/11/16, documented he was moderately cognitively impaired and required total assistance with mobility and cares. The MDS assessment documented Resident #10 did not have any physical or mechanical device or equipment that could easily be removed. On 6/16/16 at 4:00 pm, Resident #10 was observed lying in bed. The bed was against the wall to his right side with 4 full side rails up. Resident #10's left side was affected by a previous [MEDICAL CONDITION]. Resident #10 stated he felt trapped. 2. Resident #6's MDS assessment, dated 6/13/16, documented she was cognitively intact, and required total assistance for mobility. The MDS assessment documented Resident #6 did not have any physical or mechanical device or equipment that could easily be removed. On 6/16/16 at 4:00 pm, Resident #6 was observed in bed with 4 full side rails up. Resident #6 stated she thought the side rails could be put down, but did not know if she could do it. Resident #6 stated,they (facility) just put them up, they (facility) did not ask. 3. Resident #3's MDS assessment, dated 6/13/16, documented Resident #3 was severely cognitively impaired, and required total assistance for mobility and cares. The MDS assessment documented Resident #3 did not have any physical or mechanical device, or equipment, that could easily be removed. On 6/16/16 at 4:00 pm, Resident #3 was observed in bed with bilateral lower side rails. Resident #3 was observed not to be able to lower her side rails. 4. Resident #2's MDS assessment, dated 4/22/16, documented Resident #2 was severely cognitively impaired, and required total assistance with mobility and all cares. The MDS assessment documented Resident #2 did not have any physical or mechanical device, or equipment, that could easily be removed. On 6/16/16 at 4:00 pm, Resident #2 was observed in bed with bilateral, full upper and lower side rails. Resident #2 was observed not to to be able to lower her side rails.",2020-09-01
36,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2016-06-17,281,D,0,1,J25411,"Based on observation, record review and staff interview, it was determined the facility failed to ensure professional standards of practice during medication administration were observed for 1 of 4 nurses reviewed for medication administration (LN #7). This directly impacted 2 of 4 residents (#12 and #13) sampled for medication administration. This resulted in residents' medications being pre-signed as given prior to actual administration. The practice placed residents at increased risk of adverse outcomes due to medication errors. Findings include: On 6/13/16 at 7:00 am, LN #7 was observed during medication administration to Resident #12 and Resident #13. LN #7 was observed to take the medication out of the cart, check the medication with the MAR, and then sign off the medication as given on the MAR. LN #7 then removed the medications from the cards and/or containers and administered the medications to the residents. Resident #12 was administered 16 different medications and Resident #13 was administered 12 different medications. During the observation, LN #7 was asked if those were her initials on the MAR for the medication she was about to administer. LN #7 confirmed her initials. The facility's Medication Administration Policy, dated 6/13/16, documented Medications are not signed off until the resident has received and/or swallowed the medication. Nursing: Scope and Standards of Practice (American Nurses Association, 2010), require documentation after the medication has been administered to avoid medication errors.",2020-09-01
37,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2016-06-17,309,D,0,1,J25411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, family and staff interviews, the facility failed to provide the necessary nursing care and services for 3 of 19 sampled residents (#5, #7 and #9). The facility's protocol to address [DIAGNOSES REDACTED], and physician orders [REDACTED].#5 and Resident #9, creating the potential for adverse health consequences. Resident #7's compression stockings were not applied in accordance with physician orders [REDACTED]. Findings include: 1. Resident #7 was admitted to the facility on [DATE] for rehabilitation following a total knee replacement surgery. She had admission [DIAGNOSES REDACTED]. Resident #7's TKA (total knee arthroplasty) Rehab Hospital Transfer Orders and Instructions, dated 6/3/16, documented thigh high compression stockings were to be to be worn throughout the day for [MEDICAL CONDITION], a stocking could be applied directly over the bandage, and the compression stockings should be removed at night and for showering. No documentation was found indicating compression stockings had been applied during Resident #7's admission to the facility. The Resident #7's Interim ADL (activities of daily living) Care Plan stated she had a self-care deficit related to the [DIAGNOSES REDACTED].#7 with ADLs, as needed, and to encourage her to complete ADLs as independently as possible. Compression stockings were not specifically addressed on the interim care plan. Resident #7 was observed in her room during the survey a total of 4 times. She was not wearing compression stockings during the following observations: * 6/12/16 at 6:50 pm * 6/13/16 at 11:25 am * 6:14;16 at 2:10 pm * 6/16/16 at 3:50 pm LN #1 was interviewed on 6/16/16 at 4:15 pm and stated Resident #7 was to wear compression stockings per physician's orders [REDACTED]. Resident #7 was interviewed on 6/16/16 at 3:50 pm. She stated her physician ordered compression stockings to be worn daily. She stated she was unable to put them on herself and needed staff assistance. She pointed to a towel rack on the wall and stated the compression stockings had been hanging there since the second or third day after admission. Compression stockings were observed hanging on the towel rack at this time. Resident #7 stated the compression stockings had not been applied since staff provided her initial shower, a couple days after she was admitted . Family Member #1 was interviewed on 6/14/16 at 3:00 pm. Family Member #1 stated Resident #7 was admitted to the facility for rehab about a week and a half ago following total knee replacement surgery. Family Member #1 stated he was employed in the medical profession and was concerned that Resident #7 was not wearing the compression stockings. Family Member #1 stated Resident #7 had a small sore under her knee cap on the back of her leg and that may have been why she was not wearing the stockings. He stated, It makes me nervous. I fear more for a blood clot than I do for skin breakdown. 2. Resident #9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #9 received [MEDICAL TREATMENT] 3 days a week. She was prescribed a pureed diet. Resident #9's 5/3/16 annual MDS assessment noted Resident #9 required extensive assistance of one staff for most ADLs, including eating. The MDS assessment also identified Resident #9 as having long and short term memory problems, disorganized thinking, and receiving insulin injections during each of the 7 days in the assessment period. Resident #9's 2/3/16 quarterly MDS assessment documented her weight as 142 lbs. Resident #9's weight was 134.4 lbs on 6/14/16, which was a 5.3% weight loss since 2/3/16. A Physician order [REDACTED]. The physician also prescribed Humalog insulin 100 unit/ml per sliding scale with blood sugars to be checked twice a day at 6:00 am and 5:00 pm. The sliding scale parameters stated: * If Resident #9's BG was less than 70, the MD was to be called. * If her BG level was 150-199, give 1 unit. * If her BG level was 200-249, give 3 units. * If her BG level was 250-299, give 5 units. * If her BG level was 300-349, give 7 units. * If her BG level was 350-399, give 9 units. * For a BG level greater than 399, call MD. [DIAGNOSES REDACTED] protocol, documented in the Physician order [REDACTED]. * Call MD if BG is less or equal to 70. * Give 4-6 oz of orange juice if resident is able to swallow. * If resident is not able to swallow start IV and give 50 ml D50W. * Recheck blood sugar after 15 minutes of treatment. * If resident is unconscious, cannot swallow, does not have IV access give 1 mg of [MEDICATION NAME] IM or subcutaneous x 1 dose only. * Recheck blood sugar in 15 minutes and notify MD if blood sugar is still less than 70. Resident #9's Medications Flowsheet for (MONTH) (YEAR), indicated she had 8 instances of BG levels of 70 or below recorded at 6:00 am, as follows: * 3/2/16 - 64 * 3/11/16 - 64 * 3/12/16 - 70 * 3/13/16 - 65 * 3/14/16 - 69 * 3/23/16 - 67 * 3/25/16 - 70 * 3/26/16 - 68 There was no documentation on the Medications Flowsheet or in nurses' notes that the physician was notified of the low BGs, whether orange juice or a different carbohydrate source was administered, that BG levels were rechecked, or that potential signs and symptoms of [DIAGNOSES REDACTED] were monitored. [MEDICATION NAME], 5 units scheduled at 7:00 am, was administered on all dates noted above except on 3/13/16. It was not signed off as being administered on that date. Resident #9's Medications Flowsheet for (MONTH) (YEAR), did not include documentation that her BG level was assessed at 5:00 pm on the following 6 dates: 3/10/16, 3/20/16, 3/21/16, 3/24/16, 3/27/16, and 3/31/16. In March, for the dates that Resident #9's BG level was assessed at 5:00 pm, she required administration of sliding scale insulin on 6 occasions. The Medications Flowsheet for (MONTH) (YEAR), documented Resident #9 had 3 instances of a BG level of 70 or below at 6:00 am, that lacked documentation of follow up: * 4/11/16 - 61 * 4/18/16 - 70 * 4/25/16 - 70 There was no documentation on the Medications Flowsheet or in nurses' notes to demonstrate the physician was notified of the low BG levels, whether orange juice or a different carbohydrate source was administered, that BG levels were rechecked, or that potential signs and symptoms of [DIAGNOSES REDACTED] were monitored. [MEDICATION NAME], 5 units scheduled at 7:00 am, was administered on all dates noted above. The Medications Flowsheet for (MONTH) (YEAR), showed Resident #9's BG level was not assessed at 5:00 pm, on the following 10 dates: 4/1/16, 4/3/16, 4/12/16, 4/17/16, 4/19/16, 4/24/16, 4/25/16, 4/26/16, 4/28/16, and 4/29/16. In April, for the dates her BG level was assessed at 5:00 pm, Resident #9 required administration of sliding scale insulin a third of the time (7 occasions). Resident #9's BG on 4/22/16 at 5:00 pm was 179. There was no documentation to indicate 1 unit of insulin was administered in accordance with the sliding scale parameters on that date. The Medications Flowsheet for (MONTH) (YEAR), documented Resident #9 had 1 instance of a BG level of 70 or below when assessed at 6:00 am (BG of 64 on 5/5/16). There was no documentation on the Medications Flowsheet or in nurses' notes to demonstrate the physician was notified of the low BG level, whether orange juice or a different carbohydrate source was administered, that her BG levels were rechecked, or that potential signs and symptoms of [DIAGNOSES REDACTED] were monitored. [MEDICATION NAME], 5 units scheduled at 7:00 am, was administered on 5/5/16. Review of the Medications Flowsheet for (MONTH) (YEAR), indicated Resident #9's BG level was not assessed at 5:00 pm, on the following 4 dates: 4/9/16, 4/12/16, 4/29/16, and 4/31/16. In May, for the dates in which her BG level was assessed at 5:00 pm, Resident #9 required administration of sliding scale insulin 11 times. Resident #9's BG level on 5/26/16 at 5:00 pm, was 239. There was no documentation to indicate 3 units of insulin was administered in accordance with the sliding scale parameters. Resident #9's BG level on 5/27/16 at 5:00 pm, was 164. There was no documentation that 1 unit of insulin was administered in accordance with the sliding scale parameters. LN #1 was interviewed on 6/16/16 at 4:15 pm, and stated Resident #9's food and fluid intake was often poor. Resident #9 was observed in the dining room during breakfast on 6/13/16 from 7:05 am - 8:15 am. She required staff assistance to eat and was not observed to initiate eating independently. The DNS was interviewed on 6/16/16 at 5:00 pm, and referred to the Diabetes Management Protocol noted above in the event of [DIAGNOSES REDACTED]. The DNS stated if blood sugar was less than 70, the physician should be notified. The DNS indicated documentation of physician notification, administration of carbohydrate, and rechecking blood sugar should be found in the Medication Administration Record [REDACTED]. None was provided beyond the nurses' notes which were reviewed above. 3. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #5 received all food and fluids via a gastrostomy (G) tube, had a [MEDICAL CONDITION], and received 9 liters of oxygen continuously [MEDICAL CONDITION]. Resident #5 was prescribed a total of 4 cans/day of Vital tube feeding formula administered via bolus feedings. Resident #5's 2/21/16 annual MDS documented Resident #5 was in a persistent vegetative state. Resident #5 observed during the survey from 6/12/16 - 6/17/16, to be non-responsive and totally dependent on staff for all cares. When the surveyor introduced herself to Resident #5 on 6/13/16 at 11:30 am, she did not respond in any manner. A Physician order [REDACTED]. The physician's orders [REDACTED]. [DIAGNOSES REDACTED] protocol documented in the Physician order [REDACTED]. * Call MD if BG is less or equal to 70. * Give 4-6 oz of orange juice if resident is able to swallow. * If resident is not able to swallow start IV and give 50 ml D50W. * Recheck blood sugar after 15 minutes of treatment. * If resident is unconscious, cannot swallow, does not have IV access give 1 mg of [MEDICATION NAME] IM or subcutaneous x 1 dose only. * Recheck blood sugar in 15 minutes and notify MD if blood sugar is still less than 70. The Medications Flowsheet for (MONTH) (YEAR), documented Resident #5 had a BG level of 61 on 5/27/16 at 9:00 pm. Documentation on the MAR indicated [REDACTED]. A nurses' note the next day, on 5/28/16 at 4:14 am, stated Resident #5's tube feeding was given in response to the BG of 61, with an improvement to 145 within an hour after the feeding was administered. There was no documentation that the physician was notified of the low BG level. No changes in Resident #5's diabetic medications were made in response to the low B[NAME] Resident #5's [MEDICATION NAME], 20 units, was administered at 10:00 pm on 5/27/16, per the Medications Flowsheet. Blood glucose levels were not consistently taken in accordance with physician's orders [REDACTED].#5's BG level was not assessed at 10:00 am on the following 6 dates: 5/5/16, 5/15/16, 5/23/16, 5/24/16, 5/30/16 and on 5/31/16. The Medications Flowsheet for (MONTH) (YEAR), documented Resident #5 had subsequent [DIAGNOSES REDACTED] incidents on 6/2/16 and 6/3/16, with a BG of 69 recorded at 9:00 pm. The Medications Flowsheet documented Resident #5's insulin scheduled to be given at 10:00 pm, was administered. According to the Medications Flowsheet, Resident #5's BG level was rechecked and was 120. A nurses' note the next day, on 6/3/16 at 6:30 am, documented Resident #5's tube feeding was given in response to the BG of 69 with prompt improvement to 120 noted after the feeding was administered. The nurses' note further documented Resident #5's BG was rechecked prior to the 4:00 am tube feeding and was 59, with an improvement to 124 after feeding. Documentation stated the physician was notified; however, it was not clear if the physician was notified twice for two separate incidents or notified once. It was unclear when the physician was notified. The physician reduced Resident #5's [MEDICATION NAME] to 15 units twice daily on 6/3/16 and again to 10 units twice daily on 6/9/16. Interview with Resident #5's family member (Family Member #3) was conducted on 6/15/16 at 5:30 pm. Family Member #3 stated Resident #5 was dependent on staff for care. She verified Resident #5 was in a persistent vegetative state, all nutrition was provided via a G tube, Resident #5 was a diabetic, and Resident #5 had been experiencing new onset of low blood sugar incidents. The DNS was interviewed on 6/16/16 at 5:00 pm and stated nursing staff should follow the diabetic protocol in the event of [DIAGNOSES REDACTED] incidents. The DNS stated if blood sugar was less than 70, the physician should be notified right away.",2020-09-01
38,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2016-06-17,325,D,0,1,J25411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and family interview, it was determined the facility failed to ensure 1 of 19 sampled residents (Resident #5) was provided with care and services to ensure maintenance of adequate nutritional parameters. Resident #5 was not assessed for nutritional requirements to ensure her tube feeding regimen met her nutritional needs, and her tube feeding regimen was not reassessed in light of a significant weight loss, risk for skin breakdown, constipation, and onset of [DIAGNOSES REDACTED]. Findings include: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #5 received all food and fluids via a gastrostomy (G) tube, had a [MEDICAL CONDITION], and received oxygen continuously [MEDICAL CONDITION]. Resident #5's 2/21/16 annual MDS assessment documented she was in a persistent vegetative state. Resident #5 was prescribed insulin and 2 medications daily for constipation. Resident #5 was observed during the survey from 6/12/16 - 6/17/16 to be non-responsive and totally dependent on staff for all cares. When the surveyor introduced herself to Resident #5 on 6/13/16 at 11:30 am, she did not respond in any manner. A Physician order [REDACTED].#5 was prescribed (on 12/10/14): Vital 1.0, 1 can, bolus feeding, twice a day at 4:00 am and 10:00 pm. This provided 20 grams (gm) of protein, 474 ml formula, and 474 calories a day. The amount of water the tube feeding formula provided was not documented. Resident #5 was also prescribed Vital High Protein, 1 can, bolus feeding, twice a day at 10:00 am and 4:00 pm. The Vital High Protein provided 42 gm protein, 474 ml formula, 474 calories. The amount of water the tube feeding formula provided was not documented. Resident #5 was also prescribed [MEDICATION NAME], one packet per day. Review of the nutritional analysis from Hormel Health Labs manufacturer, [MEDICATION NAME] instant whey protein supplement provided 8 gm protein and 30 calories. In regards to fluids, Resident #5 was prescribed (on 6/17/15): 100 cc water flush before and after the tube feed bolus to equal 800 cc/day four times a day at 10:00 am, 4:00 pm, 10:00 pm, and 4:00 am. Additional free water with medications equaled 780 ml per day. Calculations of the above nutrition plan (including water provided in the tube feeding formula per manufacturer's nutrition analysis) were completed. The calculations showed Resident #5 received a total of 978 calories, 70 gm protein, and 1977 ml of water per day. The Dietitian was interviewed on 6/15/16 at 9:30 am, and stated Resident #5 weighed 247 lbs in (MONTH) (YEAR) and the goal was for her to lose weight. Based on 247 lbs, Resident #5 lost 68.5 lbs over the past year and 5 months. Resident #5's most recent weight was 178.5 lbs on 6/2/16, recorded in the Matrix software, and her weight was 185.3 lbs on 3/10/16. Resident #5 lost 6.8 lbs, a 3.6% weight loss, in approximately 90 days, prior to the survey. The Medications Flowsheet for (MONTH) (YEAR), documented Resident #5 had a BG level of 61 on 5/27/16 at 9:00 pm. A nurse's note the next day, on 5/28/16 at 4:14 am, documented Resident #5's tube feeding was given in response to the BG of 61, with an improvement to 145 within an hour after the feeding was administered. There was no documentation demonstrating the physician or dietitian were notified of the low BG level on this date. The Medications Flowsheet for (MONTH) (YEAR), documented Resident #5 had subsequent [DIAGNOSES REDACTED] incidents on 6/2/16 and 6/3/16, with a BG of 69 recorded at 9:00 pm on 6/2/16. According to the Medications Flowsheet, Resident #5's BG level was rechecked and was 120. A nurse's note the next day, on 6/3/16 at 6:30 am, documented Resident #5's tube feeding was given in response to the BG of 69 with prompt improvement to 120 noted after the feeding was administered. The nurse's note further stated Resident #5's BG level was rechecked prior to the 4:00 am tube feeding and was 59, with an improvement to 124 noted after the feeding. Documentation showed the physician and dietitian were notified. Interview with Resident #5's family member (Family Member #3) was conducted on 6/15/16 at 5:30 pm. Family Member #3 stated Resident #5 was dependent on staff for care. She verified Resident #5 was in a persistent vegetative state, all nutrition was provided via a G tube, she was a diabetic and had been experiencing new onset of low blood sugar incidents, and had lost a lot of weight. She stated it had been the goal for Resident #5 to lose weight, but now (as of this week) the goal was for her weight to stabilize. When asked if there was anything else important to note at the conclusion of the interview, she stated she was concerned about the skin breakdown to Resident #5's buttocks. Resident #5's most recent protein level, [MEDICATION NAME], was obtained on 1/1/15. According to the Laboratory Detail report, Resident #5's [MEDICATION NAME] was 3.2, low, with a normal range of 3.4-5, according to the report. Her protein status had not been re-evaluated since 1/1/15, a year and 5 months prior, however, she had sustained a weight loss of 68 lbs since that time. On 6/15/16 at 9:00 am, Resident #5 was observed during a skin assessment to have an approximately 0.5 diameter open area surrounded by scar tissue on her left buttocks. Resident #5 had multiple areas on her buttock of resolved skin breakdown. Resident #5's care plan, with a start date of 5/26/16, identified the nutritional problem of, I have potential for altered nutritional needs secondary to not being able to feed myself and need a feeding tube for all foods and fluids to meet my nutritional needs. The goal was, I will maintain adequate nutritional status through next review and will continue to tolerate my feedings until the next review date. Resident #5's weight loss was not identified on the care plan and the goal did not identify weight loss as currently being a goal. Resident #5's risk of skin breakdown, most recent low protein level, and presence of constipation, were not identified on the nutrition care plan. The care plan included the approach of Vital 1.0 and Vital High Protein bolus feeding administration as noted above. Resident #5 had been on the same tube feeding regimen of Vital and Vital High Protein since 12/10/14, however, she had experienced a weight loss of 68.5 lbs in the past year and 5 months, experienced recent low blood sugar incidents, her protein level (prior to 68.5 lb weight loss) was low, had impaired skin integrity to her buttocks, and had a [DIAGNOSES REDACTED]. A nutritional assessment comparing Resident #5's nutritional needs for calories, protein, and fluid, to what the tube feeding regimen provided, was not found in Resident #5's record. The Observation Report for nutrition, dated 2/23/16, was identified by the Dietitian as being the most recent full nutritional assessment. The report did not identify what Resident #5's nutritional needs were or include a comparison and analysis in regards to what her tube feeding regimen provided. The Observation Report for nutrition, dated 2/23/16, documented 948 calories, 74 gm of protein, 906 ml of free water, and 800 ml of other water were provided daily by the tube feeding regimen. A calculation of the water provided from the tube feeding formula was not made on this assessment or anywhere else in Resident #5's record. The section for total water intake was not filled out and was blank; however, the box was checked indicating total water intake was sufficient. Per the surveyor's calculations, Resident #5 received a total of 1977 ml of water per day (water in the tube feeding formula 397 ml, free water 800 ml per physician's orders [REDACTED].#5's nutritional requirements for calories and protein were not documented. The Dietitian was interviewed on 6/15/16 at 9:30 am, and stated the Matrix nutrition assessment form (Observation Report) did not include a section for nutrition requirements and that was why it was not documented. Per surveyor's request, the Dietitian hand wrote on the Observation Report for nutrition, dated 2/23/16, Resident #5's daily nutritional requirements as: 1000-1200 calories, 70-84 gm protein, and 2100 ml water. Resident #5's tube feeding regimen provided 1977 ml of water which was less than her requirements of 2100 ml per the Dietitian's calculations. Resident #5's tube feeding regimen provided 948 calories which was less than her requirements of 1000-1200 calories per the Dietitian's calculations. Resident #5 was receiving less calories and fluid than her requirements, which had not been identified in the facility's nutrition assessment process. Per the Dietetics in Health Care Communities, Dietetic Practice Group of the Academy of Nutrition and Dietetics, Pocket Resource for Nutrition Assessment 2013 Edition, page 13, The first step in the Nutrition Care Process is the completion of a nutritional assessment and determination of nutrition needs.",2020-09-01
39,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2016-06-17,329,D,0,1,J25411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined the facility failed to ensure residents were not administered antibiotic medications without clinical rationale for continued use. This was true for 2 of 2 resident sampled for [MEDICATION NAME] antibiotic use (#1 and #4). This created the potential for residents to experience adverse outcomes resulting from unnecessary medications. Findings include: 1. Resident #4 was admitted on [DATE], with [DIAGNOSES REDACTED]. Recapitulated Physician Orders, dated 5/1/16, documented Resident #4 received [MEDICATION NAME] 500 mg every day for [MEDICATION NAME] treatment of [REDACTED]. A History and Physical, dated 11/9/14, documented Resident #4 had an indwelling suprapubic catheter and had experienced muliple urinary tract infections over the past several months. The History and Physical noted Resident #4 was likely colonized. Being colonized means you carry the infectious agent but are not actively sick with infection. Resident #4's Monthly Pharmacist Chart Review, dated 5/25/14-5/26/16, did not contain documentation regarding medication of any kind. 2. Resident #1 was admitted on [DATE], with end stage [MEDICAL CONDITION]. A History and Physical dated 6/30/15, documented Resident #1 was on Keflex 250 mg every day for [MEDICATION NAME] treatment of [REDACTED]. A subsequent History and Physical, dated 5/1/16, documented the continuation of Keflex due to a history of chronic UTI for patient comfort. Resident #1's Monthly Pharmacist Chart Review, dated 7/10/15-5/26/16, did not contain documentation regarding medication of any kind. Resident #1 and Resident #4's medical records did not contain documentation regarding reassessments, rationale for the antibiotic's continued use, and determination of the need for the continued use of the antibiotics. On 6/16/16 at 7:30 am, the DNS stated Resident #1 and Resident #4 were receiving antibiotic therapy for chronic UTIs, and the facility did not have other paperwork other that what had been provided. On 6/20/16, the facility faxed documentation for Resident #1 and Resident #4, however the fax did not provide new or additional information on [MEDICATION NAME] antibiotic treatments for Resident #1 or Resident #4.",2020-09-01
40,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2016-06-17,520,D,0,1,J25411,"Based on staff interview, it was determined the facility failed to ensure a physician was a member of the facility's Quality Assurance Committee. The lack of physician involvement on the committee had the potential to compromise the efficacy of the Qualtiy Assurance program, thereby, placing residents at risk of adverse outcomes. Findings include: On 6/9/16 at 5:45 pm, the Administrator stated the QAPI committee members consisted of: the Administrator, DNS, LSW, MDS Coordinator, Activity Director, and Pharmacist. The Administrator confirmed that a physician was not a member of the committee. The Administrator stated the facility's medical director was sent an update, but does not actually attend the quarterly meetings.",2020-09-01
41,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2017-09-21,311,D,0,1,ZCF511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, and medical record review, it was determined the facility failed to provide a restorative nursing program for 1 of 7 residents (Resident #5) sampled for restorative nursing programs. The deficient practice created the potential for harm if the resident experienced a functional decline when restorative services were not provided. Findings include: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's most recent quarterly Minimum Data Set (MDS) assessment, dated 7/22/17, documented the resident had moderate cognitive impairment, was dependent on two staff for bed mobility and transfers, and had limited use of his left arm and leg. Resident # 5's Activities of Daily Living care plan, dated 7/22/17, did not document the resident had a restorative nursing program, and no updates to add a restorative nursing program were documented. Resident #5's Physical Therapy Discharge Summary, dated 7/30/17, documented recommendations for restorative nursing services for strengthening and standing. The summary documented the resident's anticipated outcome was good with consistent staff follow through. On 9/19/17 at 9:15 am Resident #5 stated that he was told that the State said that he was no longer progressing and no longer eligible physical therapy, so he would be transferred to a restorative nursing program. Resident #5 stated it had been almost two months since his physical therapy ended, but he had not yet had any restorative nursing services. He stated he felt he may have lost some strength in his left leg by not being in a restorative program. On 9/19/17 at 10:10 am, Physical Therapist (PT) #2 stated she remembered Resident #5 and wrote a Restorative Plan for him as part of his discharge from skilled therapy 8/3/17. PT #2 stated she provided the Restorative Plan to the Director of Nursing (DON), as the DON oversaw the Restorative Nursing Program. She stated that she did not get any feedback on the Restorative Plan or told why it was not implemented. On 9/19/17 at 4:30 pm, CNA #1 stated she was the Restorative CNA, but was not aware of any restorative program for Resident #5 prior to 9/19/17, but had received a program that day. CNA #1 stated that Resident #5's spouse had inquired about when the resident's restorative program was going to start about a week and a half ago, and CNA #1 had asked the DON about it, but had not received a response until today. On 9/21/17 at 10:00 am PT #2 stated she re-evaluated the resident on 9/19/17 and did not believe the resident lost any strength or function since his discharge from physical therapy. On 9/19/17 at 4:35 pm the DON stated she could not find the Restorative Plan from 8/3/17. The DON stated if she had received a restorative referral from physical therapy she would have processed it the same day.",2020-09-01
42,BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION,135007,98 POPLAR STREET,BLACKFOOT,ID,83221,2017-09-21,441,D,0,1,ZCF511,"Based on observation, staff interview and policy review, it was determined the facility failed to ensure hand hygiene occurred for 1 of 10 residents (#5) observed for hand hygiene. The deficient practice created the potential for harm if the resident developed infection from unsanitary practices. Findings include: On 9/19/17 at 3:15 pm, during suprapubic catheter care for Resident #5, LPN #1 washed her hands, placed the supplies on the over bed table, and put on a pair of gloves. LPN #1 removed the soiled dressing that covered the ostomy (surgically created opening between an internal organ and the body surface), then removed her gloves and replaced them with a new pair of gloves. LPN #1 did not wash her hands or use hand sanitizer between glove changes. LPN #1 cleaned the ostomy with sterile normal saline solution and then applied a clean dressing. LPN #1 then repositioned Resident #5 and removed her gloves. Following the dressing change, LPN #1 walked to the sink and washed her hands. On 9/19/17 at 3:30 pm, LPN #1 stated she forgot to sanitize her hands between glove changes. The facility Policy and Procedure titled Handwashing, Hand Antisepsis and Surgical Hand Scrub, Reference #921, Version 9 with an effective date of 6/30/17 documented, Hand hygiene must be performed at a minimum upon arrival to the facility, before and after touching each patient, before clean/aseptic procedures, after body fluid exposure, putting on gloves (clean or sterile), and after removing gloves, after touching anything in the patient's environment, before and after eating, after using the restroom, and when hands are visible soiled. On 9/19/17 at 4:10 p.m. the Director of Nursing (DON) stated it was facility policy that hand hygiene must be performed anytime gloves were removed. The DON stated that LPN #1 not sanitizing her hands after removing soiled gloves and replacing them with clean gloves was not following facility infection control policy.",2020-09-01
43,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2018-06-15,583,D,0,1,GRQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and resident interview, it was determined the facility failed to ensure the resident's right to personal privacy was maintained during personal care. This was true for 1 of 1 resident (#1) observed during provision of personal care. The failure created the potential for Resident #1 to be embarrassed if her body was exposed to others unnecessarily. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's annual MDS assessment, dated 6/4/18, documented Resident #1 was cognitively intact. On 6/12/18 at 8:53 AM, CNA #5 provided morning care for Resident #1. CNA #5 was on the window side of the bed, and Resident #1 was in bed with her pants down to her knees. The window curtain was open and Resident #1's peri area was exposed. CNA #5 applied stockings and braces to Resident #1's legs prior to dressing her. CNA #4 arrived to assist with the transfer to the wheelchair with the Hoyer lift. Resident #1 was exposed for 3-5 minutes. No attempt was made by either CNA to cover Resident #1 or close the window curtain. On 6/14/18 at 1:32 PM, Resident #1 stated she tolerated the curtain being open. She stated she did not like it though. When asked if she told anyone about the open curtain, she shook her head no. and commented on how much she cared for facility staff. On 6/14/18 at 4:01 PM RN #2 stated she provided teaching on dignity and privacy to new hire staff. RN #2 stated the entire staff were expected to respect residents' privacy. RN #2 was not able to provide documentation regarding the teaching of personal privacy.",2020-09-01
44,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2018-06-15,657,D,0,1,GRQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy and procedure review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated to maintain consistency and accuracy. This was true for 1 of 12 sample residents (#29) whose care plans were reviewed. This had the potential for harm if appropriate cares and/or services were not provided due to incorrect information on the care plan. Findings include: The facility's policy and procedure for Care Plans, dated 11/28/17, documented the following: * A comprehensive care plan is developed consistent with the residents' specific conditions, risks, needs, behaviors, preferences and with standards of practice . * The comprehensive care plan addresses services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. * The care plan is revised and updated to demonstrate the resident's current status. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses, including age-related cognitive decline and dysphagia (a swallowing disorder). Resident #29's significant change MDS assessment dated [DATE] documented moderate cognitive impairment with signs and symptoms of [MEDICAL CONDITION], a mechanically altered diet, and speech therapy was in place during (MONTH) (YEAR). Resident #29's physician orders, active as of 6/13/18, documented a regular diet, pureed texture, regular consistency. Resident #29's care plan documented the following: * Altered texture: nectar thick puree solids, pudding thick puree solids to be thinned to honey thick (as a max consistency) via cream whole milk, gravy/sauce or butter to improve bolus flow through esophagus per speech therapist recommendation, initiated on 5/11/18 and revised on 6/7/18. * Diet ordered by physician: regular diet, pureed texture, thin liquids, initiated on 7/16/14 and revised on 4/18/18. A Progress Note, dated 6/1/18 at 9:13 AM, documented Resident #29 had a change of condition with a downgrade in her diet due to the decline. Resident #29 had difficulty swallowing medications whole. On 6/13/18 at 2:20 PM, the speech therapist said Resident #29's diet should be pureed with thin liquids. The speech therapist said the order and care plan were not congruent, and Resident #29 should be on puree solids that are no thicker than honey thick. The speech therapist said the diet order and care plan were confusing. On 6/13/18 at 3:45 PM, RN #3 said Resident #29's care plan needed to be updated regarding her diet order.",2020-09-01
45,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2018-06-15,684,E,0,1,GRQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure professional standards of practice were met related to neuro checks after resident falls, medication management, management of respiratory symptoms and not following physician orders. This was true for 2 of 3 residents (#12 and #16) reviewed for falls when neurological checks were not completed after resident falls, 3 of 12 residents (#2, #20, and #30) whose medications were reviewed when the recommended dose of Tylenol was exceeded and the ordered dose was exceeded for a nasal spray and antacid medication, 1 of 1 resident (#4) reviewed for respiratory symptoms and 1 of 16 residents (#132) where the nurses failed to follow physician orders. This failed practice created the potential for harm should residents experience undetected changes in neurological status after a fall, adverse side effects from excessive doses of medication, and undetected signs and symptoms of worsening respiratory status or [MEDICAL CONDITION]. Findings include: The facility's undated policy and procedure for nasal inhalers, sprays, and aerosols, documented the following: * Verify the physician's order, taking notice of the concentration of the medication and which nostril to treat. * Occlude one of the resident's nostrils, insert the tip into the open nostril and squeeze quickly and firmly one time. * Have the resident hold their breath for a few seconds then exhale through the mouth. * Repeat the ordered number of times in each nostril. The facility's policy and procedure for respiratory care, dated 11/28/17, documented the following: * Depending on the type of respiratory services the resident receives, physician orders and the individualized respiratory care plan, documentation should include, as appropriate: vital signs, respiratory rate, movement of the chest and respiratory effort, abnormal breath sounds, signs of dyspnea (shortness of breath), position change effects of breathing, the nature of sputum (mucous), signs of infection, changes in behavior that may signify [MEDICAL CONDITION] (low oxygen levels), and resident instruction regarding participating in respiratory treatments as appropriate. * The attending practitioner is immediately notified of significant changes in condition, and the medical record reflects the notification, response and interventions implemented to address the resident's condition. The facility's policy and procedure for Neurological Evaluation, dated 11/28/17, directed staff to perform neuro checks every 15 minutes for one hour, then every 30 minutes for one hour, then every hour for two hours, then every 4 hours until (the) physician states it is no longer necessary or in 72 hours if (the) resident's condition is stable and showing no signs and symptoms of neurological injury. The facility's policy and procedure for Fall Response and Management, dated 11/28/17, directed staff to perform neuro checks per the physician's orders, or monitor every 15 minutes for 1 hour, then every 30 minutes for one hour, then every hour for 2 hours or until the resident's status stabilizes if the resident hit their head. According to the Lippincott NursingCenter website, accessed on 6/21/18, and the Nursing (YEAR) Drug Handbook, there are eight Rights of medication administration: 1. Right patient. 2. Right medication. 3. Right dose. 4. Right route. 5. Right time. 6. Right documentation. 7. Right reason. 8. Right response. 1. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] reflux disease and acute sinusitis. Resident #2's physician orders, active as of 6/14/18, documented the following: * [MEDICATION NAME] Proprionate Suspension (a nasal steroid spray) 50 mcg 2 sprays each nostril twice a day for chronic rhinosinusitis. * [MEDICATION NAME] Suspension 200-200-20 mg /5 ml 2 tsp every 6 hours as needed for stomach upset. Resident #2's (MONTH) (YEAR) MAR indicated [REDACTED] * The [MEDICATION NAME] nasal spray was administered each day from 6/1/18-6/14/18. * The [MEDICATION NAME] was administered on 6/8/18, 6/10/18, 6/12/18, and 6/14/18. On 6/14/18 at 9:19 AM, RN #1 administered medications to Resident #2. RN #1 administered two sprays of [MEDICATION NAME] nasal spray to Resident #2's right nostril and left nostril. RN #1 then administered three additional sprays of [MEDICATION NAME] to Resident #2's right nostril and two additional sprays to the left nostril. When asked how many sprays should be administered, RN #1 said it was two sprays in each nostril. When the surveyor brought it to RN #1's attention that she had administered 5 sprays in the right nostril and 4 sprays in the left nostril, RN #1 said Oh. On 6/14/18 at 12:05 PM, RN #1 said sometimes it appeared Resident #2 did not sniff up all the nasal spray, so she gave more sprays. RN #1 said she normally would not give that many sprays. On 6/14/18 at 9:20 AM, RN #1 administered Advanced Antacid (a generic form of [MEDICATION NAME]) 30 ml to Resident #2. On 6/14/18 at 2:50 PM, RN #1 said the order for [MEDICATION NAME] was 2 tsp, which equaled 10 mls. RN #1 said she administered 30 mls of [MEDICATION NAME] to Resident #2 and was thinking it was tablespoons. 2. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including heart failure and [MEDICAL CONDITION] (a lung disease). Resident #4's physician orders, active as of 6/15/18, documented the following: * [MEDICATION NAME] sulfate HFA aerosol solution 108 (an inhaled medication to open the resident's breathing tubes) inhale 1 puff every 6 hours as needed for shortness of breath. * [MEDICATION NAME] sulfate nebulization solution 2.5 mg/3 mls inhale 3 mls via nebulizer every 4 hours as needed for shortness of breath and wheezing. * Breo Ellipta 14 dose 100-25 mcg (an inhaled medication to open the resident' breathing tubes plus an inhaled steroid) inhale 1 puff once daily for shortness of breath/wheezing. * [MEDICATION NAME] capsule 18 mcg (an inhaled medication to open the breathing tubes) inhale one capsule once daily for breathing. Resident #4's current care plan directed staff to administer nebulizer treatments as ordered and Check breath sounds and monitor/document for labored breathing. Monitor/document for the use of accessory muscles while breathing. Resident #4's Progress Notes documented the following: * On 6/6/18 at 1:42 PM, he had a cough with expiratory wheezing, thick white to yellow sputum, he was just not feeling good, weak, and with fatigue, and a chest x-ray was ordered by the physician. * On 6/8/18 at 3:42 PM, Resident #4 was improved with a slight cough and some wheezing. The x-ray was done and the report was not back yet. * On 6/13/18 at 3:25 PM, Resident #4 was more confused for the past few days, complained of feeling weaker and needed more help. The chest x-ray was normal. There was no documentation Resident #4's lung sounds were re-assessed after 6/8/18. There was no documentation the oxygen saturation level was checked. Resident #4's MAR indicated [REDACTED] * The [MEDICATION NAME] inhaler was last administered on 6/6/18 and was the only dose administered in (MONTH) (YEAR) and (MONTH) (YEAR). * The [MEDICATION NAME] via nebulizer was not administered in (MONTH) or (MONTH) (YEAR). On 6/12/18 at 9:37 AM, Resident #4 said he recently went to the emergency room due to a cough, he had a chest x-ray, and was still coughing. On 6/15/18 at 11:41 AM, LPN (Licensed Practical Nurse) #1 said Resident #4's lungs were clear with some wheezing. LPN #1 said the last [MEDICATION NAME] nebulizer was given in (MONTH) (YEAR) and the last [MEDICATION NAME] inhaler was given on 6/6/18. LPN #1 said he had not listened to Resident #4's lungs on that morning. LPN #1 said the lung bases were a little diminished and sounded clear. On 6/15/18 at 11:24 AM, RN #2 said Resident #4 had wheezing and coughing on 6/6/18 and was given an antibiotic. RN #2 said the physician may have seen Resident #4 on 6/14/18 at his office and she could call to find out if a note was available. The facility did not provide documentation of Resident #4 being evaluated by the physician on 6/14/18. On 6/15/18 at 12:10 PM, the DON said the staff usually checked oxygen saturation as part of vital signs and did not know why it was not recorded for Resident #4. The DON said she thought the nebulizer and inhaler would have been given when the resident was still complaining of coughing. 3. Resident #16 was admitted to the facility on [DATE] with multiple diagnoses, including other abnormalities of gait and mobility and muscle wasting and atrophy. Resident #16's current care plan documented the following: * He was at high risk for falls and had a fall on 5/31/18. * Two person assist for transfers with a Hoyer lift. * Anticipate Resident #16's needs. * Ensure the call light was in reach. * Provide non-skid footwear, and the resident was to wear gripper socks while in bed. * PT (physical therapy)/OT (occupational therapy) to evaluate and treat as ordered or as needed. * Place the recliner chair controller in the side pocket of the chair for resident safety. A Fall Risk Assessment Tool, dated 4/3/18 at 6:19 PM, documented Resident #16's fall risk score was 5, which indicated he was at risk for falling. A Progress Note, dated 5/31/18 at 1:39 PM, documented Resident #16 was adjusting his power recliner and could not take his finger off the control button. He was found on the floor, face down, in front of the power recliner. A 5-cm skin tear was present to the left forearm with mild bruising and a small swollen area was noted on the center of his forehead. An A and I Report, dated 5/31/18 at 11:15 AM, documented Resident #16 fell from his chair and was face down on the floor in front of the fully raised recliner. Resident #16's Neurological Assessment sheet, dated 5/31/18-6/1/18, documented neuro checks were performed at the following times: * On 5/31/18: 11:15 AM, 11:30 AM, 12:00 PM, 12:15 PM, 12:45 PM, 1:15 PM, 1:45 PM, 2:15 PM, 3:15 PM, 4:15 PM, 5:15 PM, 6:15 PM, 7:15 PM, and 11:15 PM. * On 6/1/18: 3:15 AM, 7:15 AM, 11:15 AM, and 7:00 PM. * On 6/2/18 at 11:00 AM and 10:00 PM. The neurological checks were not completed through 6/3/18 at 11:15 AM (72 hours). On 6/14/18 at 4:31 PM, the DON said the facility policy indicated neuro checks were for 72 hours, and the physician did not say the neuro checks were no longer necessary prior to that for Resident #16. The DON said there should have been one more day of neuro checks. 4. Resident #30 was admitted to the facility on [DATE] with multiple diagnoses, including gangrene to his left below knee amputation surgical site and [MEDICAL CONDITION]. Resident #30's Admission Physician orders, dated 2/26/18, documented he was to receive [MEDICATION NAME] 10/325 mg ([MEDICATION NAME]/[MEDICATION NAME]) 1 tablet by mouth every 6 hours as needed for pain. It was also noted Resident #30 was not to take Tylenol ([MEDICATION NAME]) while he was taking the medication. The order documented the maximum dose of [MEDICATION NAME] was 4000 mg in 24 hours. Resident #30's Physician order, dated 6/13/18, documented he was to receive [MEDICATION NAME] 10/325 mg 1 tablet by mouth every 6 hours as needed for pain. The order did not include the precaution for the maximum [MEDICATION NAME] dosage in a 24 hour period. The website for the U.S Food and Drug Administration, announced new measures to reduce the risk of severe liver injury with [MEDICATION NAME] on 1/13/11. On 7/28/11, the maker of Tylenol announced new instructions to lower the maximum daily dose from 4000 mg to 3000 mg. On 6/14/18 at 4:38 PM, the DON stated some of the physicians did not reduce the maximum dosage of [MEDICATION NAME] from 4000 mg to 3000 mg. 5. Resident #12 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The USA Food and Drug Administration announced on 1/13/11, new measures to reduce the risk of severe liver injury with [MEDICATION NAME]. On 7/28/11, the maker of Tylenol ([MEDICATION NAME]) announced new instructions to lower the maximum daily dosage from 4000 mg to 3000 mg. A Medication Administration Record [REDACTED]. A physician's order dated 5/9/17, documented Resident #12 was to not to receive more than a maximum dose of 4000 mg, of [MEDICATION NAME] in 24 hours. This was not consistent with the 3000 mg limit recommended by the maker of Tylenol. 6. Resident #20 was readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #20's admission MDS assessment dated [DATE], documented she was moderately cognitively impaired. a) A Post Fall Investigation dated 4/3/18 at 12:35 AM, documented Resident #20 was in bed under a weighted blanket. Resident #20 was out of bed when the floor alarm sounded. Resident #20 fell and hit her head on the corner of her night stand. Resident #20 was transported to a hospital emergency roiagnom on [DATE] at 1:00 AM and returned to the facility at 3:30 AM. Documentation of neurological checks for the fall dated 4/3/18 were not found in Resident #20's medical record. b) A Post Fall Investigation, dated 4/21/18 at 9:45 PM, documented Resident #20 stood up from her wheelchair and fell on her right side. She hit her head on the door frame. She sustained a bump on her right forehead and two small skin lacerations on her arm. Resident #20's Neurological Check form, dated 4/21/18, documented completed neurological assessments performed by nursing on 19 of 24 opportunities. The other 5 neuro checks lacked each the following: * Pupil Response * Eye Response * Level of Consciousness * Motor Response c) A Post Fall Investigation, dated 4/30/18 at 7:30 PM, documented Resident #20 was found on the floor in her room. She was on her right side and found to have a cut over her right eye. She stated she hurt her head. A Neurological Check form, dated 4/30/18, documented neurological assessments were completed nursing staff from 4/30/18 at 7:45 PM through 5/1/18 at 7:45 AM. Resident #20 did not receive neurological checks for 72 hours. There was no physician order to stop the neurological checks earlier than 72 hours. On 6/15/18 at 11:36 AM, the DON stated she was aware that some neurological checks were incomplete. The facility's policy and procedure for Diabetes Mellitus, dated 10/31/17, documented the following: * Notify the physician for blood sugar levels below or above the established ranges and carry out any new orders. * Monitor the resident and notify the physician if the blood sugar level is above 240 despite extra insulin being administered. * Document in the chart the physician was notified of the change in condition and/or the diagnostic results, and any new orders. 7. Resident #132 was admitted to the facility on [DATE] with multiple diagnoses, including Type 2 diabetes mellitus. Resident #132's physician orders, active as of 6/14/18, documented the following: * Blood sugar checks four times a day and as needed. * Basaglar KwikPen (Insulin [MEDICATION NAME]) inject 30 units at bedtime. * Insulin [MEDICATION NAME] inject 14 units with meals. * Insulin [MEDICATION NAME] inject per sliding scale: if blood sugar Greater than 350 give 5 units and call MD . Resident #132's current care plan directed staff to administer diabetes medication as ordered and monitor/document/report to the physician for signs/symptoms of [MEDICAL CONDITION] (elevated blood sugar). Resident #132's Weights and Vitals Summary documented blood sugar readings as follows: * 6/6/18 at 10:14 PM = 359 * 6/7/18 at 7:55 AM = 307 * 6/7/18 at 12:06 = 324 * 6/7/18 at 4:49 PM = 413 * 6/7/18 at 5:03 PM = 413 Resident #132's (MONTH) (YEAR) MAR indicated [REDACTED] * On 6/6/18 at 5:00 PM, Insulin [MEDICATION NAME] inject per sliding scale: if blood sugar Greater than 350 give 5 units and call MD . was initialed NN, DPQ, and R. There was no documentation of units administered. * On 6/7/18 at 8:00 AM, the blood sugar was 307 and 4 units of insulin were administered. * On 6/7/18 at 12:00, the blood sugar was 324 and 4 units of insulin were administered. * On 6/7/18 at 5:00 PM, the blood sugar was 413 and 5 units of insulin were administered. Resident #132's Progress Notes documented the following: * On 6/6/18 at 9:35 PM: He arrived at the facility at approximately 7:10 PM via facility van. He was very hungry and a meal was provided. * On 6/7/18 at 12:18 PM: Blood sugars since admission were 304-359. * On 6/7/18 at 10:00 PM: His blood sugar was 413, insulin was administered, and the physician was notified. An order was received to increase the Basaglar insulin to 30 units at bedtime. *There was no documentation the physician was notified when the blood sugar was 359 on 6/6/18 at 10:14 PM. On 6/14/18 at 10:29 AM, the DON said she did not see it documented that the physician was notified of the blood sugar of 359 on 6/6/18 at 10:14 PM, and the nurse should have notified the doctor.",2020-09-01
46,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2018-06-15,686,G,0,1,GRQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policies, resident records, and I and A Reports, it was determined the facility failed to prevent the development and worsening of a pressure ulcer. This was true for 1 of 1 sampled residents (#29) reviewed for pressure ulcers. This deficient practice caused harm to Resident #29 when she developed a blister on her coccyx (tailbone area) that deteriorated and became an unstageable pressure ulcer. Findings include: The facility's policy and procedure for Prevention and treatment of [REDACTED]. * Residents at risk for developing pressure ulcers are identified by using the Braden Scale. * Interventions for pressure ulcers and other wound and skin issues are developed by collaborating with the interdisciplinary team and are implemented to identify, prevent, or decrease the risk of developing pressure and/or non-pressure wounds. * Basic or routine care could include but was not limited to: redistribute pressure, minimize moisture contact with the skin and keep the skin clean, provide appropriate, pressure-redistributing, support surfaces, providing surfaces that are not irritating to skin, and maintain or improve nutrition and hydration status, where feasible. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses, including other abnormalities of gait and mobility, and muscle wasting atrophy. Resident #29's quarterly MDS assessment, dated 4/26/18, documented she was at risk for developing pressure ulcers and no pressure ulcers were present. Resident #29's Braden Scale for Predicting Pressure Sore risk, dated 5/1/18 at 11:33 AM, documented a moderate risk for developing pressures sores. Resident #29's significant change MDS assessment, dated 5/23/18, documented she was at risk for developing pressure ulcers and had one unstageable pressure ulcer measuring 2.0 (length) by 2.0 (width) by 0.2 deep. Resident #29's physician orders [REDACTED]. Resident #29's current care plan directed staff to provide the following interventions: * Assess skin weekly and as needed, and was initiated on 7/9/14. * A pressure relieving mattress to the bed and a pressure reducing cushion to the wheelchair, and was initiated on 2/16/17. * Reposition the resident in bed during rounds and as needed, and was initiated on 2/11/15. * When out of bed, change the resident's position by toileting, uploading, shifting weight, ambulating or return to bed for rest. When in bed, turn and reposition q (every) 2 hours, and was was initiated on 7/30/15. The following interventions were initiated on 5/22/18: * Assess for pain every shift/as needed before changing the dressing, and give medication per the physician's orders [REDACTED]. * Complete the Daily Monitoring Pressure Ulcer Report. * Encourage frequent position changes every 2 hours. * Follow physician's orders [REDACTED]. * Specialty mattress-air mattress. * Resident #29 out of bed only for meals, initiated on 5/25/18. Resident #29's Weekly Skin Checks documented the following: * On 5/15/18 at 9:27 PM: No skin conditions, changes, ulcers, or injuries. * On 5/22/18 at 12:27 PM: An open wound on the coccyx with slough (yellow, devitalized tissue). * On 5/29/18 at 11:36 PM: Skin warm, dry and very fragile. Cont(inue) present treatment to wound on coccyx, dressing clean dry and intact. * On 6/6/18 at 3:17 AM: Skin warm and dry but at times moist due to incontinence. Coccyx area red . * On 6/12/18 at 11:17 PM: Skin warm, dry and very fragile. Wound on coccyx covered with dressing. Dressing clean, dry and intact. Resident #29's Weekly Skin Alteration Reports documented the following: * On 5/11/18 at 1:46 PM: A fluid-filled blister below the coccyx, circular in shape and measuring 2 cm in diameter. It was first observed on 5/11/18. * On 5/25/18 at 1:46 PM: A 2 cm by 2 cm wound on the coccyx was first observed on 5/18/18, it was healing slowly, and calcium alginate and [MEDICATION NAME] dressing were continued daily. Resident #29's Weekly Pressure Ulcer BWAT Reports documented the following: * On 5/21/18 at 10:36 AM: A new onset pressure ulcer on the coccyx, measuring 2 cm (length) by 2 cm (width) by 0.2 cm (depth) and was unstageable. The ulcer was first observed on 5/11/18 and required the following treatment: wound cleanser, skin prep to surround tissue, [MEDICATION NAME] alginate to the wound bed, and cover with a [MEDICATION NAME] foam dressing. * On 5/28/18 at 10:36 AM: The pressure wound on the coccyx measured 2 cm by 2.1 cm by 0.8 cm and was Stage 2. Wound care was updated to [MEDICATION NAME] ointment on the wound bed and cover with an Alevyn dressing. * On 5/31/18 at 1:57 PM: The pressure wound to the coccyx measured 2 cm by 1.8 cm by 0.5 cm and was Stage 2. The wound was healing nicely, bed visible, beefy red. Size decreasing . *On 6/7/18 at 1:57 PM: The pressure wound to the coccyx measured 1.2 cm by 1.6 cm by 0.4 cm and was Stage 2. The Treatment/Evaluation of Effectiveness was to continue the current plan of care. Resident #29's I and A Reports documented the following: * An I and A Investigation, dated 5/11/18, documented a small fluid-filled blister was discovered below the coccyx, the site was cleansed, and a dressing was applied. The event was described as a shear/rub causing a blister. It was recommended to use a cushioned dressing and change the dressing routinely. * On 5/21/18, a stage 3 pressure sore measuring 2 cm by 2 cm by 0.2 cm was present on the coccyx. The Pressure Ulcer Investigation documented the following: (A) clear blister on (the) coccyx (was) reported on 5/13/18, (a) foam/sponge drsg (dressing) (was) applied and staff cont(inue) turning q 2 hours. Family to come and pick up recliner. Over (the) wkend (weekend) (the) wound changed to (a) pressure wound 2 cm-2cm by 0.2 cm with off white slough across (the wound) bed. Surrounding tissue (was) intact, no adipose tissue (fat) noted between skin and bone, tissue loose and moveable. It was recommended to use a dressing, remove the recliner, use an air mattress, change the wheelchair, provide incontinence care, reposition side to side, and strongly encourage fluids. Resident #29's Progress Notes documented the following: * On 5/11/18 at 1:13 PM, a small fluid-filled blister was noted below the coccyx measuring 2 cm in diameter and was circular in shape. * On 5/11/18 at 4:53 PM, a fluid-filled blister was noted in the coccyx area, and it appeared to be caused by the incontinence brief pinching the tissue. The area was cleansed and a [MEDICATION NAME] dressing was applied. The wound measured 2.1 cm by 1.8 cm. * On 5/14/18 at 8:47 AM, the fluid-filled blister remained and was discussed by the event committee. The area was cleansed and a cushioned dressing was applied. Will continue to monitor and change dressing via altered skin evaluations. Nurse supervisor to do this. * On 5/15/18 at 1:30 PM, A blister was present on the buttock area and it measured 1.2 cm by 1 cm. The site was cleansed and a foam dressing was applied. An order was requested for physical therapy because the resident was no longer bearing weight during transfers. She required one person assistance to transfer a month prior. * On 5/16/18 at 7:17 PM, the physician was notified regarding the blister on the buttocks and continued care with a cushioned dressing. The nurse supervisor was to change the dressing. * On 5/21/18 at 1:36 PM, staff reported a change in the coccyx wound over the weekend. The wound depth had increased to 0.2 cm and it was 2 cm in length. The wound bed was filled with slough except for a small area at the base of the wound. The wound was round, crater-like with definite edges, no undermining. Wound care was provided including wound cleanser, skin prep to the surrounding intact tissue, [MEDICATION NAME] Alginate to the wound bed, and a [MEDICATION NAME] sponge dressing was applied to cover the wound. Will inform Dr (doctor) of change. * On 5/22/18 at 9:20 AM, the event committee discussed the blister to the coccyx that was noted on 5/11/18 and a foam dressing was applied. The area was now an unstageable pressure ulcer. The family was to remove the resident's recliner from her room, treatments were in place for wound care, and an air mattress was to be applied to the bed. The dietician was to review nutritional interventions and the wheelchair cushion was changed. The care plan was updated and physician were to be notified. * On 5/22/18 at 5:15 PM, the slough was separating from the wound bed on the right side, pink tissue was visible underneath, and the wound measured 2 cm by 2 cm and was a Stage 2 pressure wound. * On 5/28/18 at 10:36 AM, the pressure ulcer on the coccyx measured 2 cm by 2.1 cm by 0.8 cm and was Stage 2. The dressing was updated to [MEDICATION NAME] ointment on the wound bed and Alevyn dressing to cover the wound. * On 5/30/18 at 1:32 PM, the resident cried out quite often, ate poorly, and was medicated with [MEDICATION NAME] (narcotic pain medication) twice for pain. The dressing was changed on the coccyx by the nurse supervisor. * On 5/31/18 at 1:57 PM, the pressure ulcer to the coccyx measured 2 cm by 1.8 cm by 0.5 cm. The wound was healing nicely, the wound bed was visible and beefy red. * On 6/1/18 at 12:44 PM, a new order was received for a [MEDICATION NAME] (narcotic pain medication) patch 25 mcg. * On 6/1/18 at 2:24 PM, the wound dressing was changed, the wound was red and beefy, the edge of the wound was pink, and the wound bed measured .02 deep. * On 6/4/18 at 4:03 PM, the pressure ulcer continued to improve with [MEDICATION NAME] and an Alevyn dressing, and it measured 1.8 cm by 1.4 cm by 0.6 cm. * On 6/6/18 at 10:24 AM, the wound dressing regimen was changed to include Alginate to a small area on the right side of the wound bed due to slough, and the wound measured 1.7 by 1.8 by 0.4 cm. * On 6/6/18 at 11:06 AM, there was a care plan conference that discussed the resident was declining, now required total assistance for cares, exhibited worrying, nervousness, and yelling, and increased antidepressant medication in May. A medication patch was ordered for pain management. Resident #29's family member believed she was trying to pass away. She lost 6.2 pounds in a month, oral intake was refused to 25%, and nutrition interventions were in place. Other than getting up for meals, Resident #29 was on bed rest and the coccyx wound was being monitored for healing. * On 6/7/18 at 1:57 PM, the coccyx wound measured 1.2 cm by 1.6 cm by 0.4 cm and was Stage 2. * On 6/10/18 at 11:08 AM, the dressing was changed to the coccyx and the area was red with signs of healing. [MEDICATION NAME] was applied to the wound and an Alevyn dressing was applied. [MEDICATION NAME] was administered twice for pain and the [MEDICATION NAME] was continued. * On 6/11/18 at 3:09 PM, the dressing was changed to the coccyx. The wound bed was red and beefy without slough and the edge was pink. New tissue was noted throughout the wound. The current dressing order was continued. * On 6/12/18 at 2:20 PM, the dressing was changed and the wound measured 1.2 cm by 2 cm by 0.4 cm. The wound bed was red, beefy and signs of healing were present. Resident #29's (MONTH) (YEAR) TAR (Treatment Administration Record) documented a daily dressing change to the coccyx was performed each day from 5/22/18 through 5/31/18, except for 5/29/18. Resident #29's (MONTH) (YEAR) TAR documented a daily dressing change to the coccyx was performed each day from 6/1/18 through 6/5/18 and on 6/11 and 6/12/18. On 6/12/18 at 1:52 PM, RN #2 was observed changing the dressing on Resident #29's coccyx. An ulcer was present that measured 1.2 cm by 2 cm by 0.4 cm. RN #2 said the wound was healing. On 6/13/18 at 1:59 PM, CNA #3 said Resident #29 was more alert at the end of (MONTH) and would feed herself. CNA #3 said they reposition Resident #29 every two hours and it should be documented but it was not. On 6/13/18 at 2:48 PM, RN #2 said Resident #29 was doing fairly well until she got a blister on her bottom. It started as a clear blister and she did not know what caused it. The cushion was changed in her wheelchair in case it had pinched her skin, and a dressing was applied to the coccyx. RN #2 said the next time she saw the wound it was an open wound with slough. RN #2 said she applied silver alginate, and in two days the slough was gone and it was a stage 2 ulcer. The dressing was then changed to [MEDICATION NAME] and Alevyn. RN #2 said a blister could be from pressure, and when it was first brought to her attention that Resident #29 had a blister on her coccyx the staff was instructed to change the cushion in her wheelchair and keep the wrinkles out of her sheets. RN #2 said the first time she saw Resident #29's blister she thought it from being pinched, and she assumed if she put a clear dressing on it would absorb and she depended on the nurses to check on it. RN #2 said the next time she saw the blister it was an ulcer and she was not aware until sometime after the weekend that it had changed. RN #2 said she thought it was appropriate to initiate the air mattress 11 days after the blister was noticed on Resident #29's coccyx, after it became an unstageable ulcer. On 6/14/18 at 1:48 PM, RN #3 said CNAs do not document repositioning residents every two hours, and the only way to know it was done was by observation. On 6/15/18 at 9:23 AM, the DON said when Resident #29 developed a blister on her coccyx, the blanket and chair were removed. The DON said there were concerns about the incontinence briefs causing the blister, and they tried putting her in bed to keep pressure off the area. The DON said a good mattress was being used and the blister was not thought to be pressure related, and once the wound was determined to be pressure related an air mattress was implemented. The DON said an incident form was completed when the skin issue was first noticed, then another incident form was done when the wound changed.",2020-09-01
47,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2018-06-15,689,G,0,1,GRQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and record review, it was determined the facility failed to provide sufficient supervision to meet resident's needs. This was true for 2 of 3 residents (#4 and #20) reviewed for supervision and accidents. Resident #20 was harmed when she sustained multiple injuries requiring medical evauation and care when the facility failed to implement interventions to prevent reoccurring falls. Resident #4 had multiple falls related to failure to implement the plan of care, ensure the bariatric extenders were locked . Findings include: The facility's policy and procedure for Fall Response and Management dated 11/28/17, directed staff to implement immediate interventions to prevent a repeat fall, to complete a post-fall investigation and event report, to review the post-fall evaluation and investigation, determine the cause, and to revise the care plan with interventions. The facility's policy and procedure for Accidents and Supervision to Prevent Accidents, dated 11/18/17, documented the following: *The facility staff observed, identified, and resolved potential hazards in the environment, while they took into consideration the unique characteristics and abilities of each resident. * The staff examined hazard and accident risk information for potential causes of accidents, and created interventions to reduce the risk of the hazard. * The facility monitored to confirm interventions were in place, evaluated interventions for efficacy, and changes and/or replaced interventions that were not effective. * The facility provided sufficient supervision to avoid accidents. The above policies were not followed. Examples include: 1. Resident #20 was readmitted to the facility 2/5/18 with multiple [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE], documented Resident #20 was moderately cognitively impaired. Resident #20 experienced four falls in (MONTH) (YEAR). a) A Post Fall Investigation, dated 4/3/18 at 12:35 AM, documented Resident #20 was in bed under a weighted blanket. Resident #20 got out of bed and the floor alarm sounded. Resident #20 fell and hit her head on the corner of her night stand. A Progress Note dated 4/3/18 at 12:35 AM, documented Resident #20 had an unwitnessed fall. She was found in her room at 12:35 AM, lying on her left side. Resident #20 was bleeding from a laceration to her left forehead. Resident #20 complained of left hip pain and neck pain. She was sent to the emergency room . A Progress Note dated 4/3/18 at 3:30 AM documented Resident #20 returned to the facility at 3:30 AM with negative x-ray results and that her head was glued and ster stripped. A progress note dated 4/4/18 at 10:02 AM, documented Resident #20 sustained a laceration to her left forehead and bruising to her left face as result of the 4/3/18 fall. A Resident Monitoring Tool dated 4/3/18, documented Resident #20 was observed at 12:15 AM and 12:30 AM in bed and asleep. An Event Committee Follow Up Note dated 4/3/18 at 10:02 AM, documented Resident #20 was wearing regular socks, and the facility would re-educate staff to provide Resident #20 with no-skid socks. A care plan, dated 2/5/18, documented Resident #20 had no-skid socks were initiated on 2/26/18. b) A Post Fall Investigation dated 4/21/18 at 9:45 PM, documented Resident #20 stood up from her wheelchair and fell on her right side. She hit her head on the door frame, sustained a bump on her right forehead, and sustained two small skin lacerations on her arm. A progress note dated 4/22/18 at 9:00 AM, documented Resident #20 was transported to a clinic due to complaints of side pain. The physician diagnosed a right rib fracture and pneumonia. A Resident Monitoring Tool dated 4/21/18, documented Resident #20 was not monitored with 15-minute checks from 6:00 PM to 10:00 PM. An Event Committee Follow Up Note, dated 4/23/18 at 9:37 AM, documented checks would be done every 15 minutes from 6:00 PM to 6:00 AM. Resident #20's care plan dated 2/5/18, directed staff to perform 15-minute checks from 6:00 PM to 6:00 AM, and was initiated on 2/26/18. c) A Post Fall Investigation dated 4/26/18 at 7:45 PM, documented Resident #20 was found in a seated position near her bed. Resident #20 stood up at the bedside from her wheelchair and the wheelchair rolled backwards. She was uninjured. Resident #20 was last seen at 7:00 PM. A Resident Monitoring tool dated 4/26/18, documented Resident #20 was in the bathroom and engaged with staff from 7:30 PM to 8:15 PM. The documentation was written over to say in bed and engaged with staff. This was inconsistent with the Post Fall Investigation which stated Resident #20 was last seen by staff at 7:00 PM. Resident #20's care plan dated 2/5/18, documented anti-roll back brakes were initiated for Resident #20 on 4/27/18. d) A Post Fall Investigation dated 4/30/18 at 7:30 PM, documented Resident #20 had an unwitnessed fall with significant injury. Resident #20 was found on the floor in her room. She was on her right side and found to have a cut over her right eye. She stated she hurt her head. She had been in her wheelchair. A Resident Monitoring tool dated 4/30/18, documented Resident #20 was seated in her chair from 6:30 PM until her fall at 7:45 PM. Resident #20 was engaged with staff while seated in her chair at 7:00 PM. On 6/14/18 at 9:43 AM, the DON stated to prevent falls, the facility would place the resident on the Falling Star Program, place them on every 15-minute checks, and/or use a weighted blanket to help residents feel safer in bed. 2. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including a history of falling, other abnormalities of gait and mobility, and [MEDICAL CONDITION] without behavioral disturbance. Resident #4's annual MDS assessment, dated 12/26/17, documented a moderate cognitive impairment, setup help only with transfers, one person physical assistance with ambulation, and one fall since the prior assessment. Resident #4's quarterly MDS assessment, dated 3/22/18, documented a moderate cognitive impairment, two person physical assistance with transfers, one person physical assistance with ambulation, and two or more falls since the prior assessment. Resident #4's current care plan documented he was at risk for falls, and had a history of [REDACTED]. * Assess his fall risk, completing assessments to identify the risk for falls. * Ensure the call light is within reach and encourage him to use it. * Encourage him to request assistance with ambulating. * Follow the facility fall protocol was initiated on 2/20/17. * The falling star program to identify his fall risk was initiated on 2/20/17 and revised on 4/24/18. * Non-skid footwear, non-skid socks was initiated on 2/20/17 and revised on 1/3/18. * PT to evaluate and treat and non-skid strips by the bed were initiated on 1/3/18. * Self-locking brakes to his wheelchair and non-skid strips on the bathroom floor were initiated on 3/21/18. * Encourage him to sit in the wheelchair while bedding is changed was initiated on 6/5/18. Resident #4's I and A reports documented the following: * A fall on 1/2/18 at 9:15 PM when he was in the wheelchair, attempted to remove his socks, and his feet slipped. * A fall on 2/8/18 at 7:00 AM when he fell out of bed while trying to reach the television's remote control. * A fall on 3/20/18 at 10:25 AM when he was unattended in the bathroom and lost his balance after standing up from the toilet. * A fall on 3/20/18 at 9:05 PM, when he attempted to self-transfer from the wheelchair to bed, forgot to lock the wheelchair brakes, and the wheelchair slid out of under him. * A fall on 6/5/18 at 5:15 AM when he was sitting on the edge of the bed as the CNA changed the bedding and he slipped off the edge of the bed. Resident #4's Progress Notes documented the following: * On 1/3/18 at 9:18 AM: He fell on [DATE] at 9:15 PM when standing by his bed to turn down the bedding. He was wearing socks and no shoes. Non-skid strips were added by the bed, non-skid socks were provided, and therapy was to continue. * On 2/9/18 at 7:04 AM: A large abrasion and red area were present on his abdomen. Neuro checks were good and he continued to self-transfer. On 2/9/18 at 2:38 PM: An environmental review was performed by the maintenance supervisor, and it was found the bariatric extenders were not locked into place. Will educate housekeepers and all staff when moving bed from one room to another to ensure (the) frame (is) locked into position on bariatric beds. * On 3/20/18 at 11:20 AM: The nurse was notified at 10:25 AM that the resident was found sitting on the bathroom floor, and he said he slipped when getting up from using the bathroom. Staff reported the resident was depressed the day before and was slightly confused. * On 3/20/18 at 9:05 PM: He was found on the floor between the wheelchair and bed, and said he attempted to transfer from the wheelchair to the bed, forgot to lock the wheelchair brakes, and the wheelchair rolled out from under him. He was asked to wait for assistance with transfers. * On 3/21/18 at 9:34 AM: The event committee discussed the falls on 3/20/18. Non-skid strips were added to the floor in front of the toilet, self-locking brakes were added to the wheelchair, therapy was to continue, and the resident was educated to wait for assistance with transfers. * On 6/5/18 at 7:09 AM: He was assisted to the floor by a CNA as she was changing his bed. * On 6/5/18 at 7:29 AM: The nurse was called to the resident's room and the resident was sitting/kneeling on his knees. He was assisted back to bed with 3 person assistance and a Hoyer lift. * on 6/5/18 at 9:02 AM: The event committee discussed the fall on 6/5/18. Resident #4 slid off the side of the bed and the CNA assisted him to his knees. Staff were inserviced regarding having the resident sit in the wheelchair while changing the bedding, the resident was encouraged to sit in the wheelchair while staff change his bedding, and therapy was continue. On 6/12/18 at 9:38 AM, Resident #4 said a couple of weeks ago and his legs gave out, and he had fallen quite a bit since being admitted to the facility. On 6/15/18 at 10:54 AM, CNA #6 said Resident #4 had fallen, one time from his chair and one time out of bed. CNA #6 said staff was helping him in the morning, made sure he was scooted back in his bed, therapy was working with him, and the staff walked with him at meal times. On 6/15/18 at 11:24 AM, RN #2 said Resident #4 had fallen, he slid to the floor during the previous week and he was kneeling next to his bed. RN #2 said the CNA was there when the resident slid to the floor, and RN #2 thought he was out too far on the bed. Staff were educated that sitting on the edge of the bed was not the best place for the resident when making the bed. RN #2 said Resident #4 had issues with spontaneity, non-skid strips were added next to the toilet, and the resident was educated about wearing non-skid socks. RN #2 said there was another fall when Resident #4's wheelchair rolled out from under him, and non-rolling brakes were added to the wheelchair. On 6/15/18 at 12:10 PM, the DON said Resident #4 fell on [DATE] and the physician should have been notified. The DON acknowledged there were blank areas on the Accident and Investigations and said there were blank areas that should have been filled in. The DON said staff were inserviced after the fall on 2/8/18 to make sure Resident #4 could reach the remote control.",2020-09-01
48,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2018-06-15,693,D,0,1,GRQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of clinical records and policies, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 2 sample residents (#182) reviewed for medications through a feeding tube. This failure created the potential for harm if complications developed from improper feeding tube practices. Findings include: The facility's policy and procedure for Administering of Medication through an Enteral Feeding Tube, dated 5/28/15, directed staff that if a pump was not being used, check the tube for placement and patency using a 60 ml syringe, then flush with 15 to 30 mls of warm tap water prior to administering medication. Resident #182 was admitted to the facility on [DATE] with multiple diagnoses, including pneumonitis due to inhalation of food and vomit and dysphagia (a swallowing disorder). Resident #182's physician orders, dated 6/14/18 at 5:46 PM, documented the following: * [MEDICATION NAME] sodium tablet (a stool softener) give 100 mg through the tube twice a day. * [MEDICATION NAME] Fast-Max Congest Cough (a decongestant) 2.5-5-100 mg/5 ml give 10 ml through the tube twice a day. * Apixaban (Eliquis) tablet (a blood thinner) give 2.5 mg through the tube twice a day. Resident #182's current care plan documented he had a feeding tube related to dysphagia and directed staff to do the following: Monitor/document/report to physician as needed: aspiration (inhaling material into lungs), fever, shortness of breath, tube dislodged, infection of the tube site, self-removal of the tube, disturbance or malfunction of the tube, abnormal breathing or lung sounds, abnormal lab results, abdominal pain, distension, or soreness, constipation or impaction, diarrhea, nausea/vomiting, or dehydration. On 6/14/18 at 5:30 PM, RN #5 was observed administering medication to Resident #182 through his feeding tube. RN #5 briefly turned the valve on the stopcock to the feeding tube, observed a small amount of mostly clear liquid return in the tube and turned the stopcock back. RN #5 then administered the following medications through the feeding tube: [MEDICATION NAME] 10 mls, [MEDICATION NAME] 10 mls, and Eliquis 2.5 mg. RN #5 did not verify placement or patency of the feeding tube prior to administering medications through the tube. On 6/14/18 at 5:56 PM, RN #5 said she should have checked placement of the feeding tube prior to giving medications, and sometimes she just watched the tube to check placement by turning the stopcock to see return (of stomach contents).",2020-09-01
49,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2018-06-15,759,D,0,1,GRQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 of 25 medications (8%) which affected 1 of 7 residents (#2) whose medication passes were observed. This failure created the potential for harm when Resident #2 received doses in excess of physician orders [REDACTED]. Findings include: The facility's undated policy and procedure for nasal inhalers, sprays, and aerosols, documented the following: * Verify the physician's orders [REDACTED]. * Occlude one of the resident's nostrils, insert the tip into the open nostril and squeeze quickly and firmly one time. * Have the resident hold their breath for a few seconds then exhale through the mouth. * Repeat the ordered number of times in each nostril. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] reflux disease and acute sinusitis. Resident #2's physician orders, active as of 6/14/18, documented the following: * [MEDICATION NAME] Proprionate Suspension (a nasal steroid spray) 50 mcg 2 sprays each nostril twice a day for chronic rhinosinusitis. * [MEDICATION NAME] Suspension 200-200-20 mg/5 ml give 2 tsp every 6 hours as needed for stomach upset. Resident #2's (MONTH) (YEAR) MAR indicated [REDACTED] * The [MEDICATION NAME] nasal spray was administered each day from 6/1/18-6/14/18. * The [MEDICATION NAME] was administered on 6/8/18, 6/10/18, 6/12/18, and 6/14/18. On 6/14/18 at 9:19 AM, RN #1 administered medications to Resident #2. RN #1 administered two sprays of [MEDICATION NAME] nasal spray to Resident #2's right nostril and left nostril. RN #1 then administered three additional sprays of [MEDICATION NAME] to Resident #2's right nostril and two additional sprays to the left nostril. When asked how many sprays should be administered, RN #1 said it was two sprays in each nostril. When the surveyor pointed out to RN #1 that she administered 5 sprays in right nostril and 4 sprays in the left nostril, RN #1 said Oh. On 6/14/18 at 12:05 PM, RN #1 said sometimes Resident #2 appeared like he didn't sniff up all the nasal spray so she gave more sprays. RN #1 said she normally would not give that many sprays. On 6/14/18 at 9:20 AM, RN #1 administered Advanced Antacid (a generic form of [MEDICATION NAME]) 30 mls to Resident #2. On 6/14/18 at 2:50 PM, RN #1 said the order for [MEDICATION NAME] was 2 tsp, which equaled 10 mls. RN #1 said she administered 30 mls of [MEDICATION NAME] to Resident #2 and was thinking it was tablespoons.",2020-09-01
50,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2018-06-15,761,E,0,1,GRQ011,"Based on observation, policy review, and staff interview, it was determined the facility failed to ensure expired medications were not available for administration to residents. This was true for 1 of 2 medication storage rooms with expired Pneumococcal vaccine. This failed practice had the potential to effect 12 of 12 sampled residents who could receive expired medications (#2, #3, #4, #7, #8, #9, #16, #19, #20, #29, #30, and #132) and other 23 residents who resided in the facility. This failed practice created the potential for harm should residents receive expired vaccinations with decreased efficiency. Findings include: The facility Medication Management policy dated 11/28/17, documented medications were discarded by the expiration date unless indicated by the pharmacy and/or the manufacturer's instructions to discard sooner. On 6/14/18 at 10:58 AM, a medication room was inspected with RN #4. An unopened multi-dose vial of Pneumococcal vaccine with an expiration date of 9/27/17, was found in the refrigerator. At the time of inspection, RN #4 verified the expiration date and disposed of the expired medication. On 6/14/18 at 11:08 AM, the DON stated it was the staff and administration's responsibility to monitor for expired medications. Residents #2, #3, #4, #7, #8, #9, #16, #19, #20, #29, #30, and #132 and the other 23 residents residing in the facility were at risk of receiving expired Pneumococcal vaccine.",2020-09-01
51,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2018-06-15,883,F,0,1,GRQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, policy review, and record review, it was determined the facility failed to ensure a) implementation of an immunization program to ensure residents' Pneumococcal (bacterial) pneumonia vaccine status were being tracked with receiving or declining the Pneumococcal vaccines PCV 13 and PPSV 23, consistent with current Centers for Disease Control and Prevention (CDC) recommendations, and b) residents who consented to administration of the Pneumococcal vaccinations, received the vaccinations. This is true for 9 of 9 residents (#2, #4, #7, #9, #12, #16, #19, #29, and #30) reviewed for Pneumococcal vaccinations, and had the potential to impact the other 26 residents residing in the facility. These deficient practices placed residents at risk of developing Pneumococcal pneumonia and developing subsequent serious, potentially life threatening, complications. Findings include: The Centers for Disease Control and Prevention (CDC) website, updated 11/22/16, documented recommendations for Pneumococcal vaccination (PCV 13 or Prevnar 13(R), and PPSV 23 or [MEDICATION NAME] 23(R)) for all adults [AGE] years or older: * Adults who were [AGE] years or older, who had not previously received PCV 13, should receive a dose of PCV 13 first, should follow 1 year later by a dose of PPSV 23. * If the patient already received one or more doses of PPSV 23, the dose of PCV 13 should be given at least 1 year after they received the most recent dose of PPSV 23. The facility's policy and procedure Patient Immunization Program dated 4/27/15, documented the facility would ensure all patients were offered appropriate Pneumococcal vaccinations in accordance with recommendations set forth by the Centers for Disease Control (CDC). The facility's policy Pneumococcal Program dated 10/31/17, documented vaccinations were available that could prevent two kinds of pneumonia: Pneumococcal conjugate vaccine (PCV 13 or Prevnar 13) and Pneumococcal [MEDICATION NAME] vaccine (PPSV 23 or [MEDICATION NAME] 23) included the following: * If not previously received, the facility would provide residents the PCV 13 vaccine upon admission. The facility would follow in at least 8 weeks for high risk residents, and in at least 1 year for other residents, with the Pneumococcal PPSV 23. * If a resident was previously vaccinated with either PCV 13 or PPSV 23, then the facility would follow with the alternate immunization upon admission. * Residents should receive both Pneumococcal immunizations in at least weeks apart for high risk residents and in at least 1 year for other residents. * Revaccination of PPSV 23 is recommended in at least 5 years after PPSV 23. The above policy was not followed. Examples include: a) Resident #7 was admitted to the facility on [DATE] with multiple diagnoses, including dementia, [MEDICAL CONDITION] disorder, anxiety, and depression. Resident #7's Quarterly MDS assessment dated [DATE] documented Resident #7 was offered and declined the Pneumococcal vaccination. The facility Vaccine Information Sheet Acknowledgement and Consent dated 10/11/17, documented Resident #7 wanted to receive the Pneumococcal vaccination. Resident #7's record did not contain documentation she received the [MEDICATION NAME] consented to on 10/11/17. The facility Audit Report for Vaccinations dated 6/13/18, documented Resident #7 received the [MEDICATION NAME] (PPSV 23), on 1/1/08. Resident #7's order summary report dated 6/13/18, did not include a standing order for the Pneumococcal vaccination. b) Resident #12 was readmitted to the facility on [DATE] with multiple diagnoses, including pneumonia, anxiety, and depression. An MDS dated [DATE], documented Resident #12 was given the Pneumococcal vaccination. A Vaccine Information Sheet Acknowledgement and Consent dated 10/11/17, documented Resident #12 consented to receiving the Pneumococcal vaccines. The facility Immunization Report dated 6/2/18, documented Resident #12 received a [MEDICATION NAME] (PPSV 23) on 11/1/17. The reason PPSV 23 was administered prior to the PCV 13 vaccine was not documented. c) Resident #2 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A Physician order, dated 1/19/16, documented Resident #2 may have [MEDICATION NAME] vaccine if no history of vaccine. Resident #2's quarterly MDS assessment, dated 6/6/18, documented Resident #2 was up to date with the Pneumococcal vaccination. Resident #2's signed Vaccine Information Sheet Acknowledgement and Consent, dated 10/11/17, documented he would like to receive the Pneumococcal Vaccine. The form documented Resident #2 was provided with vaccine information on 10/11/17. The consent did not provide the dates the vaccines were administered prior to admission. Resident #2's Immunization Report, date range 6/1/00 -6/30/18, documented a [MEDICATION NAME] dose was provided on 1/1/02. d) Resident #9 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A Physician order, dated 8/6/14, documented Resident #9 may have [MEDICATION NAME] vaccine if no history of vaccine. Resident #9's quarterly MDS assessment, dated 4/6/18, documented Resident #9 was offered and declined the Pneumococcal vaccination. Resident #9's signed Vaccine Information Sheet Acknowledgement and Consent, dated 10/11/17, documented he did not wish to receive the Pneumococcal Vaccine at that time. The form documented Resident #9 was provided with vaccine information on 10/11/17. The consent did not document when, or if, the vaccine was administered prior to admission. Resident #9's Immunization Report, date range 6/6/13 -6/30/18, documented a [MEDICATION NAME] dose was administered on 11/6/14. The Immunization Report also documented Resident #9 refused Prevnar 13 but did not document a date of the refusal. e) Resident #19 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #19's Physician order, dated 2/2/18, documented Do not give [MEDICATION NAME] vaccine. Resident #19's quarterly MDS assessment, dated 5/2/18, documented Resident #19 was up to date with the Pneumococcal vaccination. Resident #19's signed Vaccine Information Sheet Acknowledgement and Consent, dated 2/2/18, documented he did not wish to receive the Pneumococcal Vaccine at that time. The form did not document if vaccine information was provided or when, or if, the vaccine was administered prior to admission. f) Resident #30 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A Physician order, dated 2/26/18, documented Resident #30 may have [MEDICATION NAME] vaccine if no history of vaccine. Resident #30's quarterly MDS assessment, dated 5/29/18, documented Resident #30 was up to date with the Pneumococcal vaccination. Resident #30's signed Vaccine Information Sheet Acknowledgement and Consent, dated 2/26/18, documented he did not wish to receive the Pneumococcal Vaccine at that time. The form did not document if vaccine information was provided or when, or if, the vaccine was administered prior to admission. g) Resident #29 was admitted to the facility on [DATE], with multiple diagnoses, including chronic [MEDICAL CONDITION] (irregular heart rhythm) and hypertensive (high blood pressure) [MEDICAL CONDITION]. Resident #29's physician orders, active as of 6/13/18, documented (MONTH) have flu shot annually in season. Influenza vaccine 0.5 ml injected IM (intramuscular) annually as [MEDICATION NAME] for influenza and (MONTH) have [MEDICATION NAME] Vaccine if no history of vaccine. Resident #29's Significant Change MDS assessment, dated 5/23/18, documented the Pneumococcal vaccination was up to date. Resident #29's immunization report documented the Pneumococcal vaccine, historical type unknown, was given on 4/18/13. There was no documentation that efforts were made to provide additional doses of the pneumonia vaccine. h) Resident #16 was admitted to the facility on [DATE] with multiple diagnoses, including unspecified [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #16's physician orders, active as of 6/14/18, documented (MONTH) have flu shot annually in season if not allergic to eggs. Influenza vaccine 0.5 ml injected IM (intramuscular) annually as [MEDICATION NAME] for influenza and (MONTH) have [MEDICATION NAME] Vaccine if no history of vaccine. Resident #16's quarterly MDS assessment, dated 4/18/18, documented the Pneumococcal vaccine was up to date. Resident #16's Immunization Report documented the Pneumococcal PPSV 23 vaccine was administered on 1/1/13. There was no documentation that efforts were made to provide additional doses of the pneumonia vaccine. i) Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including heart failure and [MEDICAL CONDITION]. Resident #4's physician orders, active as of 6/15/18, documented (MONTH) have [MEDICATION NAME] Vaccine if no history of vaccine. Resident #4's quarterly MDS assessment, dated 3/22/18, documented the Pneumococcal vaccine was up to date. Resident #4's Immunization Report documented the Pneumococcal vaccine, historical type unknown, was given on 9/30/14. There was no documentation that efforts were made to provide additional doses of pneumonia vaccine. On 6/13/18 at 2:21 PM, RN #2 stated she was unable to show a system in place for tracking immunizations. On 6/13/18 at 3:19 PM, the DON stated residents were admitted to the facility with an order or standing order for immunization. She stated the facility had a check system in place, which was the MDS assessments.",2020-09-01
52,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2019-10-04,578,D,0,1,VWS011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' records included an Advanced Directive or documentation of discussion regarding Advance Directives and their decision not to formulate one. This was true for 2 of 12 residents (#1 and #30) reviewed for Advance Directives. The deficient practice created the potential for harm should residents' wishes regarding end of life care not be honored when they are unable to make or communicate their health care preference. Findings include: The State Operations Manual (SOM) defined an Advance Directive as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. The SOM defined a Physician order [REDACTED]. medical condition into consideration. A POLST [MEDICATION NAME] form is not an advance directive.If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether he or she has executed an advance directive or not, the facility may give advance directive information to the individual's resident representative in accordance with State Law. The facility's Advance Directives/Health Care Decisions policy and procedure, dated 10/1/17, documented Residents have the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate Advance Directives. In states with governance surrounding Advance Directives, facilities are to follow the State's specific requirements. This policy was not followed. 1. Resident #1 was admitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #1's record did not include an Advance Directive or documentation Advance Directives were discussed with her. On 10/3/19 at 10:35 AM, the Resident Support Services Manager (RSSM) said within 48-72 hours after admission a conference with a resident and/or a resident's representative was scheduled. She said during the conference the facility reviewed a resident's living will or provided the Idaho Advance Directive information, and if needed, the facility offered Advance Directive completion assistance. The RSSM said if the Advance Directive was not completed at the next conference, the facility reminded the resident and/or resident's representative to complete and provide it to the facility. On 10/3/19 at 10:45 AM and 11:52 AM, the DON confirmed the review process described above was correct and said unless an Advance Directive was scanned into a resident's chart, the resident and/or resident's representative had not provided it. The DON said Resident #1's record did not include an Advance Directive and there was no discussion with Resident #1 and/or her representatives about Advance Directives documented. 2. Resident #30 was admitted to the facility on [DATE] and was readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #30's record included a Multidisciplinary Care Conference note, dated 9/3/19, which documented Advance Directive - continue. Resident #30's record did not include an Advance Directive or documentation information was discussed with her about Advance Directives. On 10/3/19 at 10:35 AM, the RSSM said within 48-72 hours after residents are admitted , a care conference was scheduled for residents and/or their representatives. The RSSM said Advance Directives were discussed during the care conference, and the resident and/or their representatives were asked to provide a copy of the resident's Advance Directive if they had one. The RSSM said the facility offered to help the resident to complete an Advance Directive if they did not have one. The RSSM also said Advance Directives were reviewed with the residents and/or their representatives quarterly. On 10/3/19 at 11:39 AM, the DON said Advance Directive - continue meant to continue what was on Resident #30's Physician order [REDACTED]. The DON said she was unable to find documentation Advance Directives were discussed with Resident #30.",2020-09-01
53,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2019-10-04,625,D,0,1,VWS011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interview, it was determined the facility failed to ensure a notice of their bed-hold policy was provided to residents or their representatives upon transfer to the hospital. This was true for 1 of 1 resident (Resident #17) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time and may cause psychosocial distress if not informed they may be charged to reserve their bed/room. Findings include: The facility's Bed-Hold Readmission policy and procedure, dated 11/28/17, documented the facility provided written information to the resident, or the resident's representative, about holding a resident's bed prior to or upon transfer to a hospital, and in cases of emergency transfer within 24 hours of transfer. This policy was not followed. Resident #17 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. A progress note documented Resident #17 was transferred to the hospital for evaluation on 9/26/19, when she exhibited increased weakness and had stopped eating and drinking. Resident #17's record did not include documentation a written notice of the facility's bed-hold policy was provided to her. On 10/4/19 at 2:03 PM, Resident #17 said she did not remember if she was given a bed-hold notice. On 10/4/19 at 3:10 PM, The DON said Resident #17's record did not include documentation she was provided written notice of the facility's bed-hold policy.",2020-09-01
54,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2019-10-04,677,D,0,1,VWS011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were assisted with hand hygiene. This was true for 1 of 12 residents (Resident #40) reviewed for ADL care. This failure created the potential for harm by potentially exposing residents to the risk of infection. Findings include: Resident #40 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 9/18/19, documented Resident #40 was cognitively intact and she required extensive assistance from one person for most activities of daily living. On 10/2/19 at 1:22 PM, CNA #4 was observed as she provided pericare to Resident #40. CNA #4 unfastened Resident #40's incontinence brief and Resident #40 scratched her genitalia vigorously using her right hand. CNA #4 asked Resident #40 to stop scratching and gave the resident a wet wipe. Resident #40 held onto the wipe, but did not clean her hands. CNA #4 proceeded to clean Resident #40's periarea and wiped it from front to back. CNA #4 then cleansed around Resident #40's catheter insertion site. Resident #40 then scratched her genitalia again using her right hand and her fingers were observed going to her catheter insertion site. CNA #4 reminded Resident #40 to stop scratching and gave Resident #40 another wet wipe. Resident #40 held onto the wipe, but did not clean her hands. CNA #4 then removed her gloves, performed hand hygiene, and applied new gloves. While CNA #4 was applying a new incontinence brief Resident #40 was observed to scratch her genitalia again. CNA #4 asked Resident #40 to stop scratching and said she was going to let the nurse know to check Resident #40's periarea. CNA #4 then assisted Resident #40 to sit on the edge of the bed and helped her to transfer to her wheelchair. As CNA #4 was helping Resident #40 to transfer to the wheelchair, Resident #40 scratched her nose and then wiped her mouth using her right hand. CNA #4 did not assist Resident #40 with hand hygiene after she touched her periarea. On 10/2/19 at 1:38 PM, CNA #4 said she should have cleaned Resident #40's hand when she finished with her pericare.",2020-09-01
55,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2019-10-04,684,D,0,1,VWS011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure professional standards of nursing practice were followed for medication administration, bowel care, and skin care. This was true for 3 of 12 residents (#9, #16, and #30) reviewed for quality of care. These failed practices created the potential for harm should residents experience adverse effects from medications, constipation or fecal impaction, and skin breakdown. Findings include: 1. The facility's undated policy for Oral Inhalant Administration, directed staff to instruct residents receiving steroid inhalers to rinse their mouth thoroughly with water immediately following inhalation to wash away steroid residue in the mouth. This policy was not followed. Resident #9 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 7/22/19, documented Resident #9 had moderate cognitive impairment. Resident #9's (MONTH) 2019 physician's orders [REDACTED]. The order included special instructions for Resident #9 to rinse their mouth out with water and spit after administration. On 10/3/19 at 7:29 AM, RN #1 was observed when she administered Resident #9's medications which included the inhaled medication Breo Ellipta. Resident #9 was observed to take one puff of the Breo Ellipta orally, and then gave the inhaler back to RN #1. RN #1 then asked Resident #9 to take a sip of water. Resident #9 did not rinse his mouth after inhaling the Breo Ellipta. On 10/3/19 at 9:08 AM, RN #1 said she forgot to ask Resident #9 to rinse his mouth after administering the Breo Ellipta. RN #1 said she should have told Resident #9 to rinse his mouth with water and spit it out. 2. The facility's Bowel Care protocol, updated on (MONTH) (YEAR), documented the following: *Follow specific physician's orders [REDACTED]. * If the resident was 24-48 hours without a bowel movement documented, staff were to administer 30 cc (cubic centimeter) of Milk of Magnesia (MOM) orally. *If the resident was 72 hours without a bowel movement documented, staff were to administer a [MEDICATION NAME] suppository rectally as per physician's orders [REDACTED].>*If no bowel movement was documented by the following morning, staff were to administer a fleet enema rectally as per physician's orders [REDACTED].>*If no bowel movement within 2 hours, staff were to call the physician for additional orders. This policy was not followed. Resident #16 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 8/17/19, documented Resident #16 had severe cognitive impairment, required extensive assistance of two people for toileting, and was always incontinent of bowel. Resident #16's physician's orders [REDACTED]. *Fruiteze (laxative) 30 cc as needed for bowel care *MOM suspension, give 30 ml (milliliters) by mouth as needed for bowel care if no bowel movement in 24 - 48 hours. *[MEDICATION NAME] Adult Suppository, insert one suppository rectally as needed for bowel care if no bowel movement in 72 hours. *Fleet Enema 7-19 gm (grams)/118 ml, insert one unit rectally as needed for bowel care if no bowel movement in 72 hours. Resident #16's Bowel Movement Records, dated 9/5/19 through 10/3/19, documented she did not have a bowel movement between 9/5/19 and 9/7/19 (3 days) and between 9/20/19 and 9/22/19 (3 days). Resident #16's Medication Administration Record (MAR), dated 9/1/19 through 9/30/19, documented bowel medications were not administered as ordered when she did not have a bowel movement from 9/5/19 to 9/7/19 and 9/20/19 to 9/22/19. On 10/3/19 at 1:27 PM, LPN #1 said he was not aware of the facility's bowel protocol. LPN #1 said physician's orders [REDACTED]. LPN #1 reviewed Resident #16's MAR and said Resident #16 was not provided the bowel medications as ordered. 3. Resident #30 was admitted to the facility on [DATE] and was readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #30's (MONTH) 2019 physician's orders [REDACTED]. Resident #30's care plan included interventions for Prevalon boots to each lower extremity when in bed and to have a pillow between her knees. On 10/3/19 at 2:03 PM, CNA #1 and CNA #2 assisted Resident #30 to transfer from her wheelchair to her bed. CNA #1 pulled the bed sheet up to Resident #30's waist and both CNAs left the room. Resident #30 was not provided with a pillow between her knees when she was repositioned in bed, and Prevalon boots were not applied to her lower extremities. On 10/3/19 at 2:27 PM, CNA #2 reviewed the care instructions for Resident #30 and said she did not know Resident #30 needed a pillow between her knees when she was being repositioned in bed. CNA #2 was also not aware Resident #30 also was to wear Prevalon boots while in bed.",2020-09-01
56,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,159,E,0,1,224111,"Based on resident and staff interview and review of the Resident Trust Fund Account, it was determined the facility failed to ensure quarterly trust account statements were provided to residents and/or their responsible parties. This was true for the 13 of 13 residents who had trust accounts, including 3 of 3 residents who participated in the resident group interview and had trust accounts. This created the potential for harm if residents and/or their responsible parties were unable monitor their trust fund accounts. Findings include: The Resident Trust Fund Account, reviewed on 10/20/16 at 12:27 pm, did not include documented evidence quarterly account statements were provided to 13 residents and/or their responsible parties, to make them aware of the balances and transactions in their trust accounts. During a resident group interview conducted on 10/18/16 at 11:00 am, 3 residents who had trust accounts reported not receiving quarterly statements to inform them or their responsible parties of balances or transactions. During an interview with the Business Office Manager on 10/20/16 at 12:27 pm, she reported 13 residents authorized the facility to manage their trust accounts. She confirmed she did not provide quarterly statements to the residents or their responsible parties, and added she sent out a monthly billing statement. She further stated she had not thought of sending out quarterly trust account statements because a monthly bill was provided, although the billing statement did not include information about the trust account activity, balance or transactions.",2020-09-01
57,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,166,E,0,1,224111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview and review of facility policies, it was determined the facility failed ensure grievances regarding lost items were resolved. This was true for 3 of 18 sampled residents (#15, #16 and #18). This deficient practice placed residents at risk of psychosocial harm due to lack of control over their belongings and inability to resolve their concerns through established processes. Findings include: 1. During the resident group interview on 10/19/16 at 11:00 am, Resident #15 reported several months ago he sent 3 pairs of pajamas to the laundry to be washed and only the tops of the pajamas were returned to him. He informed nursing staff immediately when his bottoms were not returned and nothing had been done. During an interview with the Assistant Social Worker (ASW) on 10/20/16 at 11:30 am, she reported the missing items were just brought to her attention yesterday on 10/19/16, after the group meeting ended at 12 noon and since then she had already ordered replacements for 4 sets of flannel pajamas from a local clothing store. She further stated she had since then informed Resident #15 the pajamas had been ordered and were scheduled for delivery in 7 days. 2. Resident #16 reported in the resident group interview on 10/19/16 at 11 am, that he had diabetes and [MEDICAL CONDITION]. He said he went to appointments at the [MEDICAL TREATMENT] clinic 3 times per week. Resident #16 reported he brought a blood sugar monitoring accu-check machine from home to the facility so he could check his blood sugar while away from the facility. Resident #16 reported the machine was kept in the nurse's medication cart and when needed he would request his machine. Approximately 2 weeks ago he requested his machine and the nurse informed him the machine was missing. He said he spoke with the supervisor immediately, however, no one to date had gotten back with him even though a concern/ grievance form was completed. During a subsequent interview with the ASW on 10/20/16 at 11:40 am, she reported she did not remember a concern/ grievance form, but yesterday (10/19/16) she placed a written request for the hospital next door to provide Resident #16 with a new machine. The ASW provided a form from the physician and the hospital next door approving the replacement of the blood sugar machine. 3. Resident #18 reported in the resident group interview on 10/19/16 at 11:20 am, she sent her pajama top and bottom down to the laundry to be washed, but they were never returned to her. She indicated she informed the ASW approximately 1 month ago but she had heard nothing on the status of her lost items. During an interview with the ASW on 10/20/16 at 11:30 am, she reported the missing items were just brought to her attention yesterday on 10/19/16, after the group meeting ended at 12 noon and she had since then already ordered a replacement of 1 set of cotton pajamas from a clothing store. She further stated she had since then informed Resident #18 the pajamas had been ordered and were scheduled for delivery in 7 days. During an interview with the ASW on 10/20/16 at 1:30 pm, she confirmed the resident concerns/ grievances must have gotten lost in the shuffle. 4. Following the resident group meeting conducted on 10/19/16 at 11:00 am, a review of the facility's policy titled Grievance Policy and Procedure was completed. The policy stated when a resident and/or family voiced a concern, staff or the complainant should document the concern on the form labeled Grievance/Concern Form and forward the form to the ASW. The facility's Grievance file and Resident Council meeting minutes for (YEAR) were reviewed. No grievances had been transferred to paper, although staff were informed of the residents' grievances.",2020-09-01
58,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,176,D,0,1,224111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, review of facility policies, and record review it was determined the facility failed to ensure 1 of 2 (#19) random residents was assessed to safely self-administer medications. This deficient practice created the potential for medication errors and harm if Resident #19 did not take his medications timely. Findings include: Resident #19 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Physician orders, dated (MONTH) (YEAR), included: * Aspirin 81 mg tablet once a day for the heart * [MEDICATION NAME] Extended Release (ER) 20 meq by mouth every day as a supplement * [MEDICATION NAME] HCl 2 mg once a day for pain * [MEDICATION NAME] 100 mg give half a tablet once a day for [MEDICAL CONDITION] Resident #19's physician orders [REDACTED]. The facility's Self-Administration of Medications policy documented, if the Interdisciplinary Team (IDT) and the attending physician determine the resident is safe to self-administer medications a physician order [REDACTED]. The licensed nurses are responsible for following-up with the resident to validate the resident has taken the medication and should be documented on the resident's Medication Administration Record [REDACTED]. On 10/18/16 at 10:15 am, LN #4 was observed to dispense the above medications into a medication cup and enter Resident #19's room. Resident #19 refused to take the medications and stated, You know that I don't take my medications this early. He directed the nurse to place the dispensed medication in his lock box located in the closet. When the nurse asked him if he had the key for the box Resident #19 stated, No it is in my sock drawer. LN #4 was observed to remove the key from the drawer, unlock the box, place the medication inside the box, lock the box, and return the key to the sock drawer. Resident #19 stated he would take them later. The Electronic Medication Administration Record [REDACTED]. On 10/18/16 at 10:20 am, LN #4 stated Resident #19 was cognitively aware and he could identify each medication and the reason for taking them. LN #4 stated she locked Resident #19's medications in his box every day and he would take them during the day. LN #4 stated Resident #19 kept the key with him until he took all of his medications and then placed the key back in the drawer.",2020-09-01
59,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,242,D,0,1,224111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, family member, and staff interviews, it was determined the facility failed to ensure that 1 of 18 sampled residents (Resident #4), choice of when to arise in the morning was respected. This placed Resident #4 at risk for a decline in his psychosocial well-being. Findings include: Resident #4 was admitted to the facility on [DATE]. Resident #4's MDS assessment, dated 3/4/16, included [DIAGNOSES REDACTED]. The assessment further documented Resident #4 had functional impairment on both sides of his upper and lower limbs. This consequently caused him to depend on 2 staff for extensive assistance in all transfers. Resident #4's 10/1/16 active physician orders [REDACTED]. On 10/18/16 at 9:30 am, Resident #4 was observed in bed. As he was lying in bed, with some assistance from Family Member #1, he frequently suctioned copious amounts of clear thick sputum. Resident #4 shared that he wanted to get up earlier in the day, when other residents who eat in the dining room were assisted up. He said when he sits up he has less phlegm, and therefore, less need for suctioning. Resident #4 said Family Member #1 comes early morning every day to help him shave and brush his teeth, before he has to go to speech therapy. Family Member #1, present for the interview, stated she offered to get Resident #4 ready to get up, if staff would assist with getting him out of bed earlier. On 10/18/16 at 4:50 pm, Resident #4 was observed slowly wheeling himself, independently, in his wheelchair. He stated at that time that he tried to do 3 laps around the inside of the facility as exercise. On 10/18/19 at 3:00 pm, the DON was asked if she was aware of Resident #4's desire to get up for breakfast when other residents get up. She said he used to get up earlier than his current rising, but staff was getting rushed trying to get him up. She said in the interest of safety, his transfer time was changed to after breakfast. The DON said a meeting was held with Resident #4 and Family Member #1, and both agreed to the change. The DON attempted to explain the census and staffing issues. She said she was afraid the staff would rush through Resident #4's transfer, placing him at risk for injury. When the DON was told Resident #4 continued to desire the previous early rise time, the DON said she would have to think about how that could happen. When asked what she would do if Resident #4 received oral nourishment, she had no answer.",2020-09-01
60,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,280,D,0,1,224111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined the facility failed ensure interventions on residents' care plans related to mobility/ transfer status were reviewed and revised to reflect their current status. This was true for 2 of 18 sampled residents (#4 and #6). This deficient practice placed residents at risk for injuries related to improper transfers. Findings include: 1. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The assessment further documented Resident #4 had functional impairment to both sides of his upper and lower limbs. According to Resident #4's quarterly MDS assessment, dated 8/29/16, he required extensive assistance of 2 staff for transfers and was totally dependent on 2 staff for bed mobility. The assessment further stated Resident #4 had impaired range of motion to all limbs. On 10/18/16 at 9:30 am, in Resident #4's room, he was observed during a transfer from his bed to the wheelchair. LN #1 and CNA #5 utilized a sit-to-stand device to perform the transfer. During preparation for the transfer the previously mentioned staff positioned Resident #4 in a seated position on the edge of the bed, while the bed was in a raised position. While they were working with the harness (harness is secured around the resident to assist in supporting the resident), they were discussing how they needed to apply the harness. Resident #4, who later said he was 6 feet and 1 inches tall, abruptly fell backward across the bed. Resident #4 yelled as he fell backward onto the bed. The staff returned him to sitting on the edge of the bed. They then assisted Resident #4 to grab the sit-to-stand handgrip, and applied the harness. After securing Resident #4, the staff engaged the lift and transported him to his wheelchair. During the transfer Resident #4 did not stand. He was transferred in a squat like position. Resident #4's care plan dated 5/21/16 and revised on 10/7/16, with a focus on Impaired physical mobility related [MEDICAL CONDITION] a goal that Resident #4 would maintain independence in wheelchair locomotion. There was no mention of transferring him utilizing the sit-to-stand. The only mention of a sit-to-stand in Resident #4's care plan was related to his potential for skin impairment. The intervention documented the use of Geri-sleeves during the sit-to-stand transfers to protect his skin from abrasions and lacerations. Resident #4 did not have Geri-sleeves on during the aforementioned observation of his transfer. The care plan was not revised to include current interventions. 2. Resident #6, according to her admission MDS dated [DATE], was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/19/16 at 1:17 pm, in Resident #6's room, CNA #3 and CNA #4 were observed transferring Resident #6 to provide incontinence care. As Resident #6 was lifted from the wheelchair, her legs remained bent and she never stood or bore weight on her legs. Her bottom remained at the level of the chair or below as the 2 aides provided incontinence care. At one moment during the care, Resident #6 moaned out loud. CNA #4 told her they were almost done with the care and they were hurrying. As Resident #6 dangled from the sit-to-stand, her bottom was at or below the level of the wheelchair she had just been removed from. The harness was up around the upper chest area and her arms were extended up above her chest. After the care was completed, Resident #6 was assisted back to the wheelchair. Resident #6's care plan, dated 4/14/16 and revised on 9/26/16, that focused on ADL (activities of daily living) Self Care Performance deficit r/t (related to) end stage [MEDICAL CONDITION] with [MEDICAL TREATMENT] included a goal to improve transfers. However, the care plan had not been revised to include use of the sit-to-stand device for transfers. On 10/20/16 around 8:30 am, the SDC provided updated care plans, with revision dates of 10/19/16, for Resident #4 related to his impaired mobility, which now included an intervention for a mechanical lift Hoyer with sling until therapy recommended transfer changes, and for Resident #6 related to her need for the use of a Hoyer lift for transfers. An Occupational Therapy (OT) Treatment Note, dated 10/20/16, documented Resident 6's sit-to-stand mechanical transfer safety assessment had been performed. The note confirmed Resident #6 demonstrated a poor performance with transfer secondary to decrease in range and strength during transfers.",2020-09-01
61,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,281,D,0,1,224111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure a) staff followed policies and procedures for medication administration, The failure to provide services that met or exceeded professional standards, directly impacted 1 of 18 sampled residents (#15). These deficient practices created the potential for residents not receive the appropriate mediation or other residents to have access to unsecured medications. Findings include: During initial tour of the facility on 10/17/16 at 10:05 am, Resident #15 was observed sitting upright in a chair in his room. On the bedside table were 2 round pills in a small plastic medication cup. Resident #15 made no attempt to take the medication. At 10:10 am, LN #1 entered Resident #15's room. During an interview with LN #1 at that time, she reported Resident #15 did not self-administer his medication and she left the medications at his bedside in error. LN #1 reported the 2 pills were TUMS and administered the 2 pills to Resident #15 at 10:13 am. Resident #15's physician orders, reviewed at 11:00 am on 10/17/16, included an order for [REDACTED]. The facility policy and procedure titled Medication Administration documented that during medication administration the licensed nurse was to remain at the bedside and observe the resident take the medication as prescribed. Leaving medications at the bedside was an infraction of facility standards of practice.",2020-09-01
62,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,309,D,0,1,224111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review it was determined the facility failed to ensure a) a resident received rapid acting insulin at the correct time, and that the amount of insulin administered was based on accurate blood sugar levels and b) physician orders [REDACTED]. This was true for 1 of 5 (Resident #2) residents observed during medication administration. This placed Resident #2 at risk of [MEDICAL CONDITION] when he was administered rapid acting insulin greater than one hour after the lunch meal. Findings include: Resident #2 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Resident #2's physician orders, dated 10/10/16, included [MEDICATION NAME] solution 100 units/ml - Inject as per sliding scale subcutaneously before meals and at bedtime for diabetes mellitus. The sliding scale was as follows: 0-149 = 0 units 150-200 = 3 units 201-250 = 6 units 251-300 = 9 units 301-350 = 12 units 351-400 = 15 units 401-450 = 18 units For blood sugar greater than 450 give 21 units and notify the medical doctor. The FDA's specifications for use state [MEDICATION NAME] subcutaneous injections should, generally be given immediately (within 5-10 minutes) prior to the start of a meal. On 10/18/16 at 11:50 am, Resident #2's blood sugar reading was 219 mg/dl, indicating he should receive 6 units of [MEDICATION NAME] per the sliding scale. LN #6 told Resident #2 she would administer his sliding scale insulin after lunch. On 10/18/16 at 1:00 pm, LN #6 was observed to administer 6 units of [MEDICATION NAME] to Resident #2. LN #6 stated she routinely administered Resident #2's sliding scale insulin after meals. When asked if she checked Resident #2's blood sugar after lunch prior to administering the sliding scale insulin, LN #6 stated she did not and gave the sliding scale insulin based on what Resident #2's blood sugar was prior to lunch. LN #6 stated Resident #2's physician was not aware she had been holding the sliding scale insulin until after meals. LN #6 then reviewed the physician's orders [REDACTED].",2020-09-01
63,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,323,J,0,1,224111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and review of manufacturer's recommendations, and staff interviews, it was determined the facility failed to ensure 2 of 3 residents (#4 and #6) requiring the use of mechanical devices for assistance with transfers, were monitored and re-evaluated for the continued appropriateness and safety of the devices; and staff were trained how to use the devices. These failures placed the health and safety of Residents #4 and #6, who required the use of a sit-to-stand device for transfers, in immediate jeopardy of serious injury, harm, or death. Findings include: 1. Resident #4 was admitted to the facility on [DATE]. Resident #4's MDS assessment, dated 3/4/16, included [DIAGNOSES REDACTED]. The assessment further noted Resident #4 had functional impairment to both sides of his upper and lower limbs. On 10/18/16 at 9:30 am, in Resident #4's room, he was observed during a transfer from his bed to the wheelchair. LN #1 and CNA #5 utilized a sit-to-stand device to perform the transfer. During preparation for the transfer the previously mentioned staff positioned Resident #4 in a seated position on the edge of the bed, while the bed was in a raised position. While they were working with the harness (harness is secured around the resident to assist in supporting the resident), they were discussing how they needed to apply the harness. Resident #4, who later said he was 6 feet and 1 inches tall, abruptly fell backward across the bed. Resident #4 yelled as he fell backward onto the bed. The staff returned him to sitting on the edge of the bed. They then assisted Resident #4 to grab the sit-to-stand handgrip, and applied the harness. After securing Resident #4, the staff engaged the lift and transported him to his wheelchair. During the transfer Resident #4 did not stand. He was transferred in a squat like position. LN #1 was present during the above transfer of Resident #4 on 10/18/16 at 9:30 am, utilizing the sit-to-stand device. LN #1 did not provide guidance to the CNA related to supporting Resident #4 during the preparation for transfer, appropriate height of the bed, or the inappropriateness of Resident #4's transfer position on the lift. An incident investigation, dated 8/7/16, involving Resident #4, documented 2 aides (CNA #6 and CNA #7) were assisting Resident #4 to sit on the edge of the bed to attach the (sling) harness, when he fell backward on the bed. According to the report, Resident #4, at that time, complained of mild ache-like pain between his shoulder blades. The PI (Performance Improvement) Recommendations noted on the incident documented no change to plan of care, CNA re-education. Resident #4's care plan, revised on 10/7/16, included a focus on Impaired physical mobility related to CV[NAME] An accompanying goal was for Resident #4 to maintain independence in wheelchair locomotion. There was no mention of transferring him utilizing the sit-to-stand. During an interview with the Physical Therapy Director, on 10/18/16 at 2:38 pm, the therapist said the sit-to-stand was still the appropriate method of transfer for Resident #4. She said after the staff told her about the transfer observed at 9:30 am earlier on the same day, she provided training on the correct way to transfer Resident #4. When the surveyor asked if she observed the staff perform the transfer prior to providing the training, she said she had not. The therapist was asked if she was aware of the resident's previous (8/7/16) accident resulting in the same outcome during a transfer. The therapist said she was not aware that this type of accident had occurred before with Resident #4. During an interview on 10/19/16 at 6:30 pm, the SDC stated the licensed nursing staff were not required to complete a competency evaluation for the use of the sit-to-stand mechanical lift. The SDC further shared the licensed nursing staff were responsible for signing off the CNAs for the use of the sit-to-stand. LNs having no evaluation of their own competency for the use of the sit-to-stand, were required to evaluate competency for the CNAs. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/19/16 at 1:17 pm, in Resident #6's room, CNA #3 and CNA #4 were observed transferring Resident #6 to provide incontinence care. Prior to the transfer, Resident #6 was observed sitting in a wheelchair at bedside. The staff placed the sit-to-stand device in front of Resident #6 and proceeded to secure the harness. They instructed Resident #6 to hold onto the handgrips on the device. After securing Resident #6, the sit-to-stand was engaged to lift her from the wheelchair. As she was lifted from the wheelchair, her legs remained bent and she never stood or bore weight on her legs. Her bottom remained at the level of the chair or below as the 2 CNAs provided incontinence care. At one moment during the care, Resident #6 moaned out loud. CNA #4 told her they were almost done with the care and they were hurrying. As Resident #6 dangled from the sit-to-stand, her bottom was at or below the level of the wheelchair she had just been removed from. The harness was up around the upper chest area and her arms were extended up above her chest. After the care was completed, Resident #6 was assisted back to the wheelchair. Resident #6's care plan, dated 4/14/16 and revised on 9/26/16, included a focus on ADL (activities of daily living) Self Care Performance deficit r/t (related to) end stage renal failure with hemodialysis. A related goal was to improve transfers. The care plan not include interventions related to the sit-to-stand device used for the transfer. On 10/19/16 at 6:30 pm, an interview was conducted with the Staff Development Coordinator (SDC). During the interview the SDC was informed of the observations of Resident #4 and Resident #6's transfers with the sit-to-stand. The SDC stated the CNAs would be the first to notice a decline in residents' transfer status. She indicated an assessment to determine appropriateness of a transfer method or a change in that method, would depend on the CNAs or nurses noticing and reporting a decline. The SDC further stated if injuries were noted, part of the investigation would be a review of the transfer equipment. She was unaware of any consistent follow-up observations of the aides demonstrating competency of the mechanical devices, specifically the sit-to-stand, or to determine the continued appropriateness for the device for the residents. The manufacturer's handbook for the sit-to-stand, copyright 2014, stated the sit-to-stand device should only be used for residents/patients who can support at least 20% of their body weight. The manual further instructed the facility to assure only trained personnel was permitted to operate the lift. The manual further noted Untrained operators can cause injury or be injured. The manufacturer's instruction were not followed prior to 10/20/16. The SDC was not trained in the use of the device until 10/20/16 and competencies with return demonstrations were not completed for LNs or CNAs prior to 10/20/16. Removal of Immediate Jeopardy: The Administrator, DON, SDC, and Corporate Representative were informed of the Immediate Jeopardy on 10/20/16 at 12:23 pm. Subsequently, the facility responded by providing a performance improvement action plan for removal of the Immediate Jeopardy situation. The plan included: * The Rehabilitation Program Director to oversee lift transfer program. Rehabilitation Program Director will train the SDC on the sit-to-stand transfer. * The SDC will complete training to 1 LN and 1 CNA with return demonstration with satisfactory outcome. The trained LN and CNA to assist in training other LN and CNA staff. Therapy to assist. Staff will be able to verbalize what to do if a patient (resident) is not able to complete a sit to stand transfer safely. * The SDC and RN Supervisors will train LNs and CNAs on sit-to-stand transfer prior to their next scheduled shift, utilizing the skills checklist. LNs and CNAs will complete a return demonstration and must complete all areas as satisfactory before competency is completed. Staff will be able to verbalize what to do if the patient (resident) is not able to complete a sit to stand transfer safely (10/20/16 start and will continue until all staff are trained). * Surveillance observations to occur during sit-to-stand transfer at least weekly for 4 months, bi-weekly for 2 month, monthly for 6 month by SDC or RN Supervisor. * Sit-to-stand competencies for CNAs and LNs will be completed on hire, annually, and as needed, by SDC or designee. * The Rehabilitation Program Director or therapy designee will assess the competencies of trainers annually. * Residents transferred using a sit-to-stand will be observed quarterly, and as needed with change of condition, by physical therapy and SDC or RN Supervisor. * Training for new hires will utilize skills checklist and include return demonstration with satisfactory outcome from SDC or RN Supervisor. * Therapy will provide demonstration to new hires in general orientation and quarterly x2 during general staff meetings on how to complete a sit-to-stand transfer and what to do when a sit-to-stand transfer does not go well. * Unsafe sit-to-stand observations will be reported to the physical therapist and/or designee for immediate review and intervention. * Sit-to-stand competencies and surveillance outcomes will be reviewed at monthly performance improvement meetings for 6 months. Along with the action plan, the facility provided proof of competencies for all staff, and return demonstrations of competencies. The plan was reviewed, the evening shift was trained prior to working, and the night/day shifts were called in for training and told they would not be able to work until the training/competency was completed. The SDC was trained and completed return demonstration. Surveyors then observed her as she trained staff. The SDC was observed performing a sit-to-stand transfer with a CN[NAME] All nursing staff were required to take a competency test prior to working their next shift. After everything was validated, the Administrator, DON, and Regional Nurse Consultant, were informed the Immediate Jeopardy was removed on 10/20/16 at 4:40 pm.",2020-09-01
64,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,328,E,0,1,224111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and resident, staff, and outside service provider interview, the facility failed to ensure the maintenance on the oxygen (O2) concentrators was current for 2 of 3 residents in the facility that were using oxygen (#1 and #14). The lack of maintenance placed residents at risk of injury and/or adverse health outcomes due to malfunctioning O2 concentrators. Findings include: 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 had a physician's orders [REDACTED]. During an interview on 10/17/16 at 2:30 pm, Resident #1 showed the surveyor his oxygen concentrator. The back of the plastic case showed signs the machine had gotten hot and the plastic was partially melted. Observation of the filter in the machine showed there was buildup of material. Resident #1 stated he had told staff about the problem and that he could not remember when the plastic case melted. The maintenance sticker on the front of the machine showed the last maintenance was 11/13/13 and was due again 11/13/14. There was a physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The Administrator was informed on 10/17/16 at 4:00 pm, and removed the machine from Resident #1's room. 2. Resident #14 was admitted to the facility 5/15/15, with [DIAGNOSES REDACTED]. Resident #14's physician's orders [REDACTED]. A physician's orders [REDACTED]. On 10/17/16 at 4:15 pm, Resident #14's O2 concentrator was examined. The filter was in need of cleaning and the last maintenance performed was 9/21/14, and noted maintenance was due to be performed on 9/21/15. Resident #14 stated, at that time, he used the machine every night with his [MEDICAL CONDITION] machine and was not aware of the maintenance issue. The Administrator was notified of the maintenance issues on 10/17/16 at 4:00 pm. At 4:15 pm, the Administrator was observed removing concentrators from oxygen storage room. There were five machines that were removed. Each had different maintenance expiration dates as follows: * Concentrator #1 - Service date: 2/15/15, and service due: 2/15/16 * Concentrator #2 - Service date: 11/13/13, and due date: 11/13/14 * Concentrator #3 - Service date: 11/13/13, and due date: 11/13/14 * Concentrator #4 - Service date: 9/21/14, and due date: 9/21/15 * Concentrator #5 - Service date: 11/9/14, due date: 11/9/15 The Administrator was interviewed on 10/17/16 at 4:15 pm, and stated that the facility had a contract with an outside agency to service the machines. On 10/17/16 at 5:20 pm, the maintenance person from the outside agency was in the facility collecting the seven outdated concentrators and replacing them with serviceable ones. The outside agency's maintenance person was interviewed and stated he came to the facility on Mondays and Thursdays to service the liquid oxygen and replace tanks. He was not aware he was to look at, remove, and replace the concentrators for maintenance. The Administrator, District Director of Clinical Services, and Staff Development Coordinator, were interviewed 10/18/16 at 3:00 pm about the failed maintenance on the concentrators and a maintenance schedule. The Administrator indicated there was not currently (10/18/16) a scheduled maintenance plan for the oxygen concentrators in place.",2020-09-01
65,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,332,E,0,1,224112,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interview, it was determined the facility failed to ensure a medication error rate less than 5 percent. This was true for 5 of 33 medications (15%) during medication pass observations which affected 4 of 12 sampled residents (#14, #16, #20 and #21). The failure created the potential for [DIAGNOSES REDACTED] when rapid acting insulin was administered too early before a meal and for oral [MEDICAL CONDITION](thrush) to develop from lack of rinsing and spiting after inhalation of a corticosteroid medication. Findings include: The manufacturer's documented [MEDICATION NAME] (Insulin [MEDICATION NAME]) as a rapid acting insulin and that an injection of [MEDICATION NAME] should immediately be followed by a meal within 5-10 minutes. On 12/14/16 at 11:10 am, the Administrator provided the facility's Insulin Quick Reference, dated 2002, which documented [MEDICATION NAME] insulin, Should be given just prior to .eating. The Nursing (YEAR) Drug Handbook patient teaching regarding [MEDICATION NAME]documented, .give insulin at appropriate time around a meal . 1. Resident #14 was readmitted to the facility in (MONTH) (YEAR) with multiple diagnoses, including DMII, asthma and [MEDICAL CONDITION]. Resident #14's Active Orders As Of: 12/14/16 included a 4/6/16 order for [MEDICATION NAME]per sliding scale SQ before meals and at bedtime and a 7/24/16 order for [MEDICATION NAME] suspension inhaled twice a day. a. On 12/13/16 at 11:10 am, LN #3 was observed as she administered Resident #14's rapid acting [MEDICATION NAME] insulin. At 11:15 am, the LN said lunch was scheduled for 12:00 pm and that she usually waits to give sliding scale insulin 30 minutes or less before meals. Resident #14's rapid acting insulin was administered 50 minutes before the meal. b. On 12/14/16 at 8:55 am, LN #1 was observed as administered an inhaler medication, 6 oral medications then [MEDICATION NAME] (corticosteroid) inhalation suspension via nebulizer to Resident #14. After the [MEDICATION NAME] nebulizer treatment, LN #1 did not encourage or instruct Resident #14 to rinse his mouth and spit or provide water for him to do so. On 12/14/16 at 9:25 am, LN #1 said she did not have Resident #14 rinse his mouth and spit after the [MEDICATION NAME] nebulizer treatment but she would go and do it right then. 2. Resident #16 was admitted to the facility in 2013, with multiple [DIAGNOSES REDACTED]. Resident #16's Active Orders As Of: 12/14/16 included orders for [MEDICATION NAME]per sliding scale SQ with meals every day, ordered 8/3/16. On 12/13/16 at 11:15 am, LN #3 said the lunch meal was scheduled for 12:00 pm and that she usually waits to give sliding scale insulin 30 minutes or less before meals. On 12/13/16 at 11:30 am, Resident #16 told LN #3 that he may not eat lunch. LN #3 told Resident #16 his sliding scale called for 4 units of [MEDICATION NAME]. Resident #16 said he would take 2 units of insulin but not 4 units. Resident #16 also refused 2 oral medications and said he was not going to eat at lunch time. On 12/13/16 at 11:35 pm, the LN was observed as she administered [MEDICATION NAME] 2 units SQ into Resident #16's left abdomen. Resident #16's rapid acting insulin was administered 25 minutes before the lunch meal which he said he was not going to eat and the dose was decreased without a physician's orders [REDACTED].>3. Resident #21 was readmitted to the facility in (MONTH) (YEAR) with multiple diagnoses, including DMII. Resident #21's Active Orders As Of: 12/14/16 included [MEDICATION NAME]per sliding scale SQ before meals, dated 11/22/16. On 12/13/16 at 11:15 am, LN #3 said the lunch meal was scheduled for 12:00 pm and that she usually waits to give sliding scale insulin 30 minutes or less before meals. On 12/13/16 at 11:20 am, LN #3 was observed as she administered Resident #21's rapid acting [MEDICATION NAME] insulin. Resident #21's rapid acting insulin was administered 40 minutes before the meal. On 12/14/16 at 2:40 pm, the DNS said [MEDICATION NAME]should be administered 15 minutes or less before a meal. On 12/14/16 at 4:15 pm, the DNS said the facility references the Nursing (YEAR) Drug Handbook and their pharmacy regarding medications. 4. Resident #20 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #20's (MONTH) (YEAR) physician orders [REDACTED]. The [MEDICATION NAME] dose was to be held if Resident #20 was unable to eat the corresponding meal. The sliding scale was as follows: 0 - 69 = 0 units, refer to hypoglycemic policy 70 - 80 = 0 units 81 - 100 = 3 units 101 - 150 = 12 units 151 - 200 =19 units 201 - 250 = 28 units 251 - 300 = 33 units 301 - 350 = 36 units 351 - 400 = 40 units 401+ - 35 units and notify MD if greater than sliding scale range. On 12/14/16 the following observations were made: *11:10 am, LN #1 checked Resident #20's blood sugar. It was 234. *11:17 am, LN #1 administered 28 units of [MEDICATION NAME]to Resident #20. *12:05 pm, Resident #20 was at a dining room table waiting for his meal to be served. *12:10 pm, the food trays were being delivered to residents in the dining room. *12:20 pm, Resident #20 was being assisted to eat. On 12/14/16 at 2:16 pm, the DNS said, she believed [MEDICATION NAME] should be given 15 minutes before meals.",2020-09-01
66,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,333,E,0,1,224112,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility's Insulin Quick Reference, and resident and staff interview, it was determined the facility failed to ensure there were no significant medication errors for 4 of 12 sampled residents (#14, #16, #20 and #21) during medication pass observations. The failure created the potential for the residents to experience [DIAGNOSES REDACTED] when rapid acting insulin was administered too early before meals and after Resident #16 said he was not going to eat a meal. In addition, Resident #16's insulin dose was changed without a physician's orders [REDACTED].>The manufacturer documented [MEDICATION NAME] (Insulin [MEDICATION NAME]) as a rapid acting insulin and that an injection of [MEDICATION NAME] should immediately be followed by a meal within 5-10 minutes. On 12/14/16 at 11:10 am, the Administrator provided the facility's Insulin Quick Reference, dated 2002, which documented [MEDICATION NAME] insulin, Should be given just prior to .eating. Regarding [MEDICATION NAME] insulin, the Nursing (YEAR) Drug Handbook patient teaching documented, .give insulin at appropriate time around a meal . 1. Resident #16 was admitted to the facility in 2013 with multiple [DIAGNOSES REDACTED]. Resident #16's Active Orders As Of: 12/14/16 included orders for [MEDICATION NAME]per sliding scale SQ with meals every day, dated 8/3/16. On 12/13/16 at 11:15 am, LN #3 said the lunch meal was scheduled for 12:00 pm and that she usually waits to give sliding scale insulin 30 minutes or less before meals. On 12/13/16 at 11:30 am, Resident #16 told LN #3 that he may not eat lunch. LN #3 told Resident #16 his sliding scale called for 4 units of [MEDICATION NAME]. Resident #16 said he would take 2 units of insulin but not 4 units. Resident #16 also refused 2 oral medications and said he was not going to eat at lunch time. On 12/13/16 at 11:35 pm, the LN was observed as she administered [MEDICATION NAME] 2 units SQ into Resident #16's left abdomen. Resident #16's rapid acting insulin was administered 25 minutes before the lunch meal which he said he was not going to eat and the dose was decreased without a physician's orders [REDACTED].>2. Resident #14 was readmitted to the facility in (MONTH) (YEAR), with multiple diagnoses, including DMII, asthma, and [MEDICAL CONDITION]. Resident #14's Active Orders As Of: 12/14/16 included a 4/6/16 order for [MEDICATION NAME]per sliding scale SQ before meals and at bedtime and a 7/24/16 order for [MEDICATION NAME] suspension inhaled twice a day. On 12/13/16 at 11:10 am, LN #3 was observed as she administered Resident #14's rapid acting [MEDICATION NAME] insulin. At 11:15 am, the LN said lunch was scheduled for 12:00 pm and that she usually waits to give sliding scale insulin 30 minutes or less before meals. Resident #14's rapid acting insulin was administered 50 minutes before the meal. 3. Resident #21 was readmitted to the facility in (MONTH) (YEAR) with multiple diagnoses, including Dm II. Resident #21's Active Orders As Of: 6 included [MEDICATION NAME]per sliding scale SQ before meals, dated 11/22/16. On 12/13/16 at 11:15 am, LN #3 said the lunch meal was scheduled for 12:00 pm and that she usually waits to give sliding scale insulin 30 minutes or less before meals. On 12/13/16 at 11:20 am, LN #3 was observed as she administered Resident #21's rapid acting [MEDICATION NAME] insulin. Resident #21's rapid acting insulin was administered 40 minutes before the meal. On 12/14/16 at 2:40 pm, the DNS said [MEDICATION NAME]should be administered 15 minutes or less before a meal. 4. Resident #20 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #20's (MONTH) (YEAR) physician orders [REDACTED]. The [MEDICATION NAME] dose was to be held if Resident #20 was unable to eat the corresponding meal. The sliding scale was as follows: 0 - 69 = 0 units, refer to hypoglycemic policy 70 - 80 = 0 units 81 - 100 = 3 units 101 - 150 = 12 units 151 - 200 =19 units 201 - 250 = 28 units 251 - 300 = 33 units 301 - 350 = 36 units 351 - 400 = 40 units 401+ - 35 units and notify MD if greater than sliding scale range. On 12/14/16 the following observation were made: *11:10 am, LN #1 checked Resident #20's blood sugar level. It was 234. *11:17 am, LN #1 administered 28 units of [MEDICATION NAME]to Resident #20. *12:05 pm, Resident #20 was in the dining room waiting for his meal to be served. *12:10 pm, the food trays was being delivered to residents in the dining room. *12:20 pm, Resident #20 was being assisted to eat The [MEDICATION NAME] manufacturer documented [MEDICATION NAME] (Insulin [MEDICATION NAME]) as a rapid acting insulin and an injection of [MEDICATION NAME] should immediately be followed by a meal within 5-10 minutes. On 12/14/16 at 2:16 pm, the DNS said, she believed [MEDICATION NAME] should be given 15 minutes before meals.",2020-09-01
67,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,456,D,0,1,224111,"Based on observations, review of the facility maintenance log, and staff interview, it was determined the facility failed to ensure resident care equipment was maintained and serviced for 1 of 18 sampled residents (Resident #4). This failure to monitor and maintain equipment allowed staff to continue to use pertinent care equipment for the critical management of a resident requiring frequent suctioning, and placed the resident at risk of aspiration if the machine malfunctioned. Findings include: 1. On 10/18/16 at 8:45 am, a suction machine in Resident #4's room was observed to have a canister attached with approximately 100 cc of clear sputum. The inspection safety test was documented as most recently completed on 2/5/15. The label indicated the next date for the machine to be evaluated was 2/2016. A second suction machine in the room contained an inspection safety test label that documented the last time the machine was evaluated was 2/15/15 and required another inspection to be completed in 2/2016. 2. During the Environmental Tour On 10/18/16 at 10:00 am, with the Maintenance Director, he confirmed not all equipment was checked routinely as required. The Maintenance Director could offer no explanation of the facility's failure to ensure the necessary inspections were completed. Review of the Maintenance Log at this time showed the following items were due for inspection in (MONTH) (YEAR), but were not inspected: * Dining Room Suction Machine * Bath Patient lift/scale * 2 Patient Suction Machines",2020-09-01
68,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,463,D,0,1,224111,"Based on observation and resident and staff interview, it was determined the facility failed to ensure the resident call system was functional and equipped to receive resident Emergency calls from private bathrooms for 2 of 30 residents residing in the facility (#12 and #13). This created the potential for harm when residents were unable to summon staff assistance when needed. Findings include: Resident #12 who resided in room 204, and Resident #13 who resided in room 206, shared an adjoining bathroom. During environmental rounds with the Maintenance Director on 10/19/16 at 10:50 am, the emergency call bells for residents who resided in rooms 204 and 206 were tested for proper functioning. When the bathroom emergency call bell was pulled for testing, the Maintenance Director immediately reported this call bell has not worked since 10/6/16. The Maintenance Director provided the following information: On the morning of 10/6/16, a CNA presented him with a detached pull cord from the emergency call bell that serviced rooms 204 and 206. It was observed that the call light was not illuminating at the nurses' station or over the door of either resident's room, even when the call bell was pulled manually. On 10/6/16, electric company representatives came to the facility to assess the problem. They were unable to fix the call bell. Cordless doorbells were placed in the residents' bathroom for them to push when they needed assistance while in the bathroom. The doorbells sounded at the nurses' station through a cordless speaker. A TABS (trademark) Alarm was also placed for the 2 residents to use in the event they fell and could not reach the doorbell. Resident #12 resided in room 204. Her MDS assessement, dated 9/15/16, documented she had the ability to express her ideas and the ability to understand others. On 10/19/16 at 10:55 am, she was asked how she would call for help if she were in her bathroom and required assistance. She reported she was mostly independent but would use the call bell in the bathroom. Resident #12 reported she knew nothing of a door bell or that her call bell was non-functional. On 10/20/16 at 10:50 am, the doorbell in the bathroom of room 204/206 was pushed for testing in the presence of the Maintenance Director. During an interview with CNA #1, who was also in the room, CNA #1 reported I do not know what that sound is. I think it means it is time to exercise the residents. The Maintenance Director confirmed facility staff had not received education or in-service regarding the broken emergency call bell in rooms 204 and 206, nor had they been educated on the placement of the doorbell, sound of the doorbell, or placement of the TABS alarm. The electric company's report, dated 10/6/16, included a notation indicating the system was old with replacement parts not normally available. On 10/20/16, at approximately noon, the Administrator presented a written document that indicated a cordless doorbell was installed on the left side of the toilet with a speaker placed at the nurses' station to inform nursing staff that help was needed in the bathroom serving rooms 204 and 206, due to no visual cue at the nurses' station. On 10/20/16, at approximately noon, the Administrator reported staff would be educated, Resident #13 in room 206 was being discharged home, and Resident #12 in room 204 would be moved to a room with a functional call bell, and the electric company would make a return visit today (10/20/16) to make another attempt to fix the broken call bell.",2020-09-01
69,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,490,F,0,1,224111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff, resident, and outside service provider interview, review of manufacturer's recommendations, and record review, the facility failed to ensure it was administered in such a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 6 of 18 sampled residents (#1, #4, #6, #12, #13, and #14). The administration failed to ensure a) LNs and CNAs were competent for the safe transfer of residents with mechanical lifts, b) oxygen concentrator equipment was safe for resident use, and c) suction equipment, call lights, and mechanical lifts were inspected and maintained in manner that protected residents from harm. Findings include: 1. Refer to F323 (Immediate Jeopardy) as it relates to the failure of the facility to ensure residents requiring the use of mechanical sit-to-stand lifts for assistance with transfers, were monitored and re-evaluated for the continued appropriateness and safety of the devices; and that staff were trained how to use the devices. This deficient practice placed 2 residents at risk of serious harm, injury, or death. The Administrator was questioned on 10/20/16 at 11:00 am, about competency of the staff who used the sit-to-stand lifts on residents. He indicated competencies were to be reviewed annually by an outside agency who monitored the facility. The Administrator said the Staff Development Coordinator was to report to the QA (Quality Assurance Committee) on the progress of the competencies. The Administer confirmed he was not aware staff competency evaluations for the use of sit-to-stand lifts were not being completed. 2. Refer to F328 as it relates to the failure of facility administration to ensure the maintenance on the oxygen (O2) concentrators was current. The Administrator, District Director of Clinical Services, and Staff Development Coordinator were interviewed 10/18/16 at 3:00 pm, about the failed maintenance on the concentrators and a maintenance schedule. The Administrator indicated there was no scheduled maintenance plan for the oxygen concentrators in place. 3. Refer to F456 as it relates to the failure of the facility to ensure suctioning machines and resident lifts/scales were inspected within required time frames to avoid harm to residents due to their malfunction. During the Environmental Tour On 10/18/16 at 10:00 am, with the Maintenance Director, he confirmed not all equipment was checked routinely as required. The Maintenance Director could offer no explanation of the facility's failure to ensure the necessary inspections were completed. 4. Refer to F463 as it relates to the failure of the facility to ensure the resident call system was functional and equipped to receive resident Emergency calls from private bathrooms. Resident #12 who resided in room [ROOM NUMBER], and Resident #13 who resided in room [ROOM NUMBER], shared an adjoining bathroom. During environmental rounds with the Maintenance Director on 10/19/16 at 10:50 am, the emergency call bells for residents who resided in rooms [ROOM NUMBERS] were tested for proper functioning. When the bathroom emergency call bell was pulled for testing, the Maintenance Director immediately reported this call bell has not worked since 10/6/16.",2020-09-01
70,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,498,F,0,1,224111,"Based on review of staff training records and staff interviews, it was determined the facility failed to ensure 17 of 17 CNAs (#1-#5 and #7-18) whose competency evaluations were reviewed, were verified as competent to appropriately and safely transfer residents using a sit-to-stand mechanical lift. This resulted in the unsafe transfer of 2 residents requiring the use of a sit-to-stand mechanical lift. Findings include: 1. CNA skills competencies were reviewed for CNAs #1-#5 and #7-18. None of the new hire core competencies or the annual competencies for these staff included a demonstration of competency with the sit-to-stand mechanical lift. During an interview with the SDC, on 10/19/16 at 6:30 pm, she stated newly hired CNAs received, as part of their orientation, training on the Hoyer lift and the sit-to-stand. She said the new employee was paired with a CNA mentor for orientation on the floor. The SDC said the new employee would perform a return demonstration with the mentor (using the mechanical lifts) and the mentor then notified the nurse if the new employee was competent or needed more training. The nurse then signed off the core clinical competency based on the verbal report from the mentor. The SDC said she only followed-up on training of the mechanical lifts if there were concerns. The SDC said nurses were not required to complete the training or competencies for the mechanical lifts. Nurses, whose competency with the sit-to-stand mechanical lift was not verified, were responsible for checking off the competency of CNAs. The SDC provided an in-service, dated 7/8/16, for the sit-to stand. The in-service was a table top in-service where staff read the information and signed that they read it. It did not include a return demonstration. 2. Refer to F323 (Immediate Jeopardy) as it relates to the failure of the facility to ensure residents requiring the use of mechanical sit-to-stand lifts for assistance with transfers, were monitored and re-evaluated for the continued appropriateness and safety of the devices; and staff were trained how to use the devices. This deficient practice placed the health and safety of Residents #4 and #6 in immediate jeopardy of serious harm, injury, or death.",2020-09-01
71,WEISER CARE OF CASCADIA,135010,331 EAST PARK STREET,WEISER,ID,83672,2016-10-21,520,E,0,1,224111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, review of manufacturer's instructions, and record review, it was determined the facility failed to have a Quality Assurance and Assessment (QAA) program that identified resident safety issues requiring the development and implementation of appropriate plans of action to correct the issues. This deficient practice directly impacted 6 of 18 sampled residents (#1, #4, #6, #12, #13, and #14). These deficient practice placed residents at risk of harm due to unsafe mechanical lift transfers and ill-maintained oxygen concentrators, suction machines, call lights, and bath/scale lift. Findings include: 1. Staff were observed unsafely transferring Resident #4 and Resident #6 without following the manufacturer's instructions when using the sit-to-stand mechanical lift. a. Resident #4 was admitted to the facility on [DATE]. Resident #4's MDS assessment, dated 3/4/16, included [DIAGNOSES REDACTED]. The assessment further noted Resident #4 had functional impairment to both sides of his upper and lower limbs. On 10/18/16 at 9:30 am, in Resident #4's room, he was observed during a transfer from his bed to the wheelchair. LN #1 and CNA #5 utilized a sit-to-stand device to perform the transfer. During preparation for the transfer the previously mentioned staff positioned Resident #4 in a seated position on the edge of the bed, while the bed was in a raised position. While they were working with the harness (harness is secured around the resident to assist in supporting the resident), they were discussing how they needed to apply the harness. Resident #4, who later said he was 6 feet and 1 inches tall, abruptly fell backward across the bed. Resident #4 yelled as he fell backward onto the bed. The staff recovered him and returned him to sitting on the edge of the bed. They then assisted Resident #4 to grab the sit-to-stand handgrip, and applied the harness. After securing Resident #4, the staff engaged the lift and transported him to his wheelchair. During the transfer Resident #4 did not stand. He was transferred in a squat like position. An incident investigation, dated 8/7/16, involving Resident #4, documented 2 aides (CNA #6 and CNA #7) were assisting Resident #4 to sit on the edge of the bed to attach the (sling) harness, when he fell backward on the bed. According to the report, Resident #4, at that time, complained of mild ache-like pain between his shoulder blades. The PI (Performance Improvement) Recommendations noted on the incident documented no change to plan of care, CNA re-education. During an interview with the Physical Therapy Director, on 10/18/16 at 2:38 pm, the therapist said the sit-to-stand was still the appropriate method of transfer for Resident #4. She said after the staff told her about the transfer observed at 9:30 am earlier on the same day, she provided training on the correct way to transfer Resident #4. When the surveyor asked if she observed the staff perform the transfer prior to providing the training, she said she had not. The therapist was asked if she was aware of the resident's previous (8/7/16) accident resulting in the same outcome during a transfer. The therapist said she was not aware that this type of accident had occurred before with Resident #4. LN #1 was present during the above transfer of Resident #4 on 10/18/16 at 9:30 am, utilizing the sit-to-stand device. LN #1 did not provide guidance to the CNA related to supporting Resident #4 during the preparation for transfer, appropriate height of the bed, or the inappropriateness of Resident #4's transfer position on the lift. During an interview on 10/19/16 at 6:30 pm, the SDC stated the licensed nursing staff were not required to complete a competency evaluation for the use of the sit-to-stand mechanical lift. The SDC further shared the licensed nursing staff were responsible for signing off the CNAs for the use of the sit-to-stand. b. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/19/16 at 1:17 pm, in Resident #6's room, CNA #3 and CNA #4 were observed transferring Resident #6 to provide incontinence care. Prior to the transfer, Resident #6 was observed sitting in a wheelchair at bedside. The staff placed the sit-to-stand device in front of Resident #6 and proceeded to secure the harness. They instructed Resident #6 to hold onto the handgrips on the device. After securing Resident #6, the sit-to-stand was engaged to lift her from the wheelchair. As she was lifted from the wheelchair, her legs remained bent and she never stood or bore weight on her legs. Her bottom remained at the level of the chair or below as the 2 CNAs provided incontinence care. At one moment during the care, Resident #6 moaned out loud. CNA #4 told her they were almost done with the care and they were hurrying. As Resident #6 dangled from the sit-to-stand, her bottom was at or below the level of the wheelchair she had just been removed from. The harness was up around the upper chest area and her arms were extended up above her chest. After the care was completed, Resident #6 was assisted back to the wheelchair. The manufacturer's handbook for the sit-to-stand, copyright 2014, stated the sit-to-stand device should only be used for residents/patients who can support at least 20% of their body weight. The manual further instructed the facility to assure only trained personnel was permitted to operate the lift. The manual further noted Untrained operators can cause injury or be injured. The manufacturer's instruction were not followed prior to 10/20/16. The SDC was not trained in the use of the device until 10/20/16 and competencies with return demonstrations were not completed for CNAs, nor the LNs, prior to 10/20/16. 2. Untimely and unsafe maintenance issues were identified with oxygen concentrators. Through investigation it was determined that there was no plan for preventative maintenance or servicing of the oxygen concentrators for two residents (Resident #1 and Resident #14) in the sample that were using the oxygen concentrators. a. Resident #1 had a physician's orders [REDACTED]. During an interview on 10/17/16 at 2:30 pm, Resident #1 showed the surveyor his oxygen concentrator. The back of the plastic case showed signs the machine had gotten hot and the plastic was partially melted. Observation of the filter in the machine showed there was buildup of material. Resident #1 stated he had told staff about the problem and that he could not remember when the plastic case melted. The maintenance sticker on the front of the machine showed the last maintenance was 11/13/13 and was due again 11/13/14. The Administrator was informed on 10/17/16 at 4:00 pm, and removed the machine from Resident #1's room. He confirmed he was previously unaware the machine was partially melted and overdue for routine maintenance. b. Resident #14 was admitted to the facility 5/15/15 with [DIAGNOSES REDACTED]. On 10/17/16 at 4:15 pm, Resident #14's O2 concentrator was examined. The filter was in need of cleaning and the last maintenance performed was 9/21/14, and noted maintenance was due to be performed on 9/21/15. Resident #14 stated, at that time, he used the machine every night with his [MEDICAL CONDITION] machine and was not aware of the maintenance issue. The Administrator was notified of the maintenance issues on 10/17/16 at 4:00 pm. At 4:15 pm, the Administrator was observed removing concentrators from oxygen storage room. There were five machines that were removed. Each had different maintenance expiration dates as follows: * Concentrator #1 - Service date: 2/15/15, and service due: 2/15/16 * Concentrator #2 - Service date: 11/13/13, and due date: 11/13/14 * Concentrator #3 - Service date: 11/13/13, and due date: 11/13/14 * Concentrator #4 - Service date: 9/21/14, and due date: 9/21/15 * Concentrator #5 - Service date: 11/9/14, due date: 11/9/15 The Administrator was interviewed on 10/17/16 at 4:15 pm, and stated that the facility had a contract with an outside agency to service the machines. On 10/17/16 at 5:20 pm, the maintenance person from the outside agency was in the facility collecting the seven outdated concentrators and replacing them with serviceable ones. The outside agency's maintenance person was interviewed and stated he came to the facility on Mondays and Thursdays to service the liquid oxygen and replace tanks. He was not aware he was to look at, remove, and replace the concentrators for maintenance. The Administrator, District Director of Clinical Services, and Staff Development Coordinator, were interviewed 10/18/16 at 3:00 pm about the failed maintenance on the concentrators and a maintenance schedule. The Administrator indicated there was not currently (10/18/16) a scheduled maintenance plan for the oxygen concentrators in place. 3. Resident #12 who resided in room [ROOM NUMBER], and Resident #13 who resided in room [ROOM NUMBER], shared an adjoining bathroom. During environmental rounds with the Maintenance Director on 10/19/16 at 10:50 am, the emergency call bells for residents who resided in rooms [ROOM NUMBERS] were tested for proper functioning. When the bathroom emergency call bell was pulled for testing, the Maintenance Director immediately reported this call bell has not worked since 10/6/16. The Maintenance Director provided the following information: On the morning of 10/6/16, a CNA presented him with a detached pull cord from the emergency call bell that serviced rooms [ROOM NUMBERS]. It was observed that the call light was not illuminating at the nurses' station or over the door of either resident's room, even when the call bell was pulled manually. On 10/6/16, electric company representatives came to the facility to assess the problem. They were unable to fix the call bell. Cordless doorbells were placed in the residents' bathroom for them to push when they needed assistance while in the bathroom. The doorbells sounded at the nurses' station through a cordless speaker. A TABS (trademark) Alarm was also placed for the 2 residents to use in the event they fell and could not reach the doorbell. Resident #12 resided in room [ROOM NUMBER]. Her MDS assessement, dated 9/15/16, documented she had the ability to express her ideas and the ability to understand others. On 10/19/16 at 10:55 am, she was asked how she would call for help if she were in her bathroom and required assistance. She reported she was mostly independent but would use the call bell in the bathroom. Resident #12 reported she knew nothing of a door bell or that her call bell was non-functional. On 10/20/16 at 10:50 am, the doorbell in the bathroom of room [ROOM NUMBER]/206 was pushed for testing in the presence of the Maintenance Director. During an interview with CNA #1, who was also in the room, CNA #1 reported I do not know what that sound is. I think it means it is time to exercise the residents. The Maintenance Director confirmed facility staff had not received education or in-service regarding the broken emergency call bell in rooms [ROOM NUMBERS], nor had they been educated on the placement of the doorbell, sound of the doorbell, or placement of the TABS alarm. The electric company's report, dated 10/6/16, included a notation indicating the system was old with replacement parts not normally available. On 10/20/16, at approximately noon, the Administrator presented a written document that indicated a cordless doorbell was installed on the left side of the toilet with a speaker placed at the nurses' station to inform nursing staff that help was needed in the bathroom serving rooms [ROOM NUMBERS], due to no visual cue at the nurses' station. On 10/20/16, at approximately noon, the Administrator reported staff would be educated, Resident #13 in room [ROOM NUMBER] was being discharged home, and Resident #12 in room [ROOM NUMBER] would be moved to a room with a functional call bell, and the electric company would make a return visit today (10/20/16) to make another attempt to fix the broken call bell. 4. On 10/18/16 at 8:45 am, a suction machine in Resident #4's room was observed to have a canister attached with approximately 100 cc of clear sputum. The inspection safety test was documented as most recently completed on 2/5/15. The label indicated the next date for the machine to be evaluated was 2/2016. A second suction machine in the room contained an inspection safety test label that documented the last time the machine was evaluated was 2/15/15 and required another inspection to be completed in 2/2016. During the Environmental Tour On 10/18/16 at 10:00 am, with the Maintenance Director, he confirmed not all equipment was checked routinely as required. The Maintenance Director could offer no explanation of the facility's failure to ensure the necessary inspections were completed. Review of the Maintenance Log at this time showed the following items were due for inspection in (MONTH) (YEAR), but were not inspected: * Dining Room Suction Machine * Bath Patient lift/scale * 2 Patient Suction Machines 5. On 10/20/16 at 11:00 am, the Administrator stated there was an annual calendar provided from the corporate office that identified the QA activities to be completed each month. He indicated the facility also used survey deficiencies and the CMS Casper reports for potential QA issues to review. The Administrator said the QA program was doing some quality monitoring, but was unable to explain what that included. The Administrator was unable to explain how the facility's QA process identified issues in the facility that were not listed on the corporate calendar, Casper reports, or survey deficiencies. There was no evidence of the staff identifying and reporting issues to the QA committee for review. The Administrator was questioned about competency of the staff who used the sit-to-stand lifts on residents. He indicated competencies were to be reviewed annually by an outside agency who monitored the facility. The Administrator said the SDC was to report to the QA Committee on the progress of the competencies. The Administer was told the sit-to-stand competencies were not being reviewed, and he confirmed he was not previously aware they were not being done as expected in the facility policy. The Administrator confirmed there was no QA being done to ensure quality care was provided with transfers. The Administrator was asked about the lack of QA involvement by the Maintenance Director, given he was aware of so many safety concerns, and he was not able to explain why the Maintenance Director was not included in the QA process.",2020-09-01
72,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2018-04-12,602,D,1,0,0IO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and review of policies, clinical records, employee time records, and facility investigations, it was determined the facility failed to ensure 1 of 7 sampled residents (#9) was free from misappropriation of a controlled pain medication. This failed practice resulted in misappropriation of Resident #9's [MEDICATION NAME] by Staff #[NAME] It also created the potential for other residents to experience uncontrolled pain if misappropriation of their controlled pain medications was undetected. Findings include: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses, including end stage liver disease. A physician's orders [REDACTED]. A subsequent physician's orders [REDACTED]. Resident #9's (MONTH) (YEAR) MAR indicated [REDACTED]. There was no documentation that [MEDICATION NAME] was administered to Resident #9 in the (MONTH) (YEAR) MAR. There was no documentation in the progress notes, dated 11/7/17 through 11/30/17, that [MEDICATION NAME] was administered to Resident #9. Resident #9's narcotic count sheet, dated 11/14/17, documented 42 doses of [MEDICATION NAME] 10 mg were delivered to the facility. The narcotic count sheet documented Staff #A signed that she administered 15 of 16 doses between 11/14/17 and 11/20/17. One dose, dated 11/19/17 at 12:00 PM, documented different initials in the Administered By column, but was the same handwriting as Staff #A's in all the other documentation. After the [MEDICATION NAME] was discontinued on 11/21/17, Staff #A signed that she administered 15 of 15 doses between 11/22/17 to 11/26/17. The narcotic count sheet documented 11 doses remained in the bubble pack card. An undated summary of the facility's investigation, signed by the Administrator, DNS, and ADON on 12/8/17, documented, On 11/27/17 it was reported to the DNS that during an attempt to waste a discontinued narcotic, one of the medication cards on (Resident #9's name) had medications taped back into the card. The investigation documented (Staff A's name) had signed out the medications to this resident and that the medications taped in did not correlate, in appearance, with what was described on the Pharmacy identification tag. The summary documented the remaining 11 doses in the bubble pack card were [MEDICATION NAME], not [MEDICATION NAME]. The investigation summary documented Staff #A was not available for interview until 11/30/17 at 2:00 PM. Staff #A admitted to taking Resident #9's [MEDICATION NAME] and replacing the remaining 11 doses in the bubble pack card with [MEDICATION NAME]. The investigation documented Staff #A was taking the [MEDICATION NAME] from Resident #9 for personal use since the beginning of November. Staff #A was suspended pending investigation. The investigation summary documented, Per the results of this investigation we feel this was an isolated incident that began in the beginning of November, involved one resident, and did not result in bodily harm or any adverse effect to the identified resident or other residents. The identified nurse was suspended, reported to the nursing board, and local Police were notified . The investigation summary documented the Board of Nursing and the Police Department were both notified on 12/1/17, four days after the facility knew about the misappropriation of the controlled medication by Staff #[NAME] The Bureau of Facility Standards Long Term Care Reporting System documented the facility notified the State Survey Agency on 12/1/17 at 11:25 AM, four days after the facility knew about the misappropriation of the controlled medication by Staff #[NAME] On 4/11/18 at 1:00 PM, the facility provided a current employee job profile that listed Staff #A as an LPN. On 4/11/18 at 4:25 PM, the DNS stated Staff #A told him that she was in a program for recovering nurses. The DNS was unable to provide documentation about the recovering nurses program and was unaware of any restrictions or limitations for Staff #[NAME] The DNS stated Staff #A returned to work under his supervision and her job duties entailed filing paperwork. The DNS stated Staff #A was not working as a nurse, was not providing direct patient care, did not have access to the electronic medication records, and did not have keys to access the medication carts or medication rooms. On 4/12/18 at 8:30 AM, the Administrator stated the facility did not press charges against Staff #A with the police department. The Administrator stated he did not have a copy of the police report and it would take 3 business days to get a copy of the police report. On 4/12/18 at 10:00 AM, the DNS provided a Program For Recovering Nurses (PRN) contract for Staff #A dated 1/7/18. The PRN contract documented, I shall not return to work until I receive written approval from the PRN and support of my treatment provider. In the event that I change positions or seek new employment, I shall obtain approval from the PRN at least two weeks prior to accepting the position. To begin working, I must first have a work monitor in place and all releases must be signed for the hiring facility. The PRN contract was signed by Staff #A on 1/7/18 and a witness signed the contract five days later on 1/12/18. The DNS stated he did not have the PRN contract until 4/12/18 and he was unaware that written approval from the PRN program was required for Staff #A to return to work in any capacity. The DNS stated Staff #A filed paperwork in his office or the charge nurse room within the conference room and only worked when he was in the building. Staff #A's employee time record documented Staff #A worked 4-6 days per week between 2/12/18 to 4/9/18, including 3 Saturdays in (MONTH) (YEAR) (3/17/18, 3/24/18, and 3/31/18). On 4/12/18 at 10:30 AM, the DNS stated he was not aware Staff #A had worked on Saturdays. The DNS stated he was not in the building and Staff #A was not supervised on those dates.",2020-09-01
73,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2018-04-12,608,D,1,0,0IO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review, and review of facility investigations and a police report, it was determined the facility failed to report misappropriation of a controlled medication to law enforcement within 24 hours. This was true for 1 of 7 residents (#9) whose medications were reviewed. The delay in reporting created the potential for misappropriation of controlled medication to continue without detection. Findings include: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses, including end stage liver disease. A physician's orders [REDACTED]. A subsequent physician's orders [REDACTED]. An undated summary of a facility investigation, signed by the Administrator, DNS, and ADON on 12/8/17, documented, On 11/27/17 it was reported to the DNS that during an attempt to waste a discontinued narcotic, one of the medication cards on (Resident #9's name) had medications taped back into the card. The investigation documented (Staff A's name) had signed out the medications to this resident and that the medications taped in did not correlate, in appearance, with what was described on the Pharmacy identification tag. The summary documented the remaining 11 doses in the bubble pack card were [MEDICATION NAME], not [MEDICATION NAME]. The investigation summary documented the police department was notified on 12/1/17, four days after the misappropriation of Resident #9's controlled medication by Staff #A was reported to the DNS on 11/27/17. On 4/16/18, the facility provided a Police Department Detail Incident Report, dated 12/1/17. The report documented a police officer responded to the facility regarding a reported theft of medication. The police report documented a police officer spoke to Staff #A on 12/2/17 and Staff #A, .admitted to taking the pills between 11/14/17 and 11/17/17 .she had taken at least eleven [MEDICATION NAME] pills, possible (sic) more, though she did not remember the exact amount .she had taken the pills for personal use, and had already consumed them. The report documented the incident was forwarded to the narcotics division. The police report documented on 12/21/17 the narcotics division was not mandated to press a charge for the theft of the [MEDICATION NAME].",2020-09-01
74,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2018-04-12,609,D,1,0,0IO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, review of facility investigations, and review of the Bureau of Facility Standards Long Term Care Reporting System, it was determined the facility failed to report misappropriation of a controlled medication to the State Survey Agency within 24 hours. This was true for 1 of 9 residents (#9) whose medications were reviewed. The delay in reporting created the potential for misappropriation of controlled medication to continue without detection. Findings include: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses, including end stage liver disease. A physician's orders [REDACTED]. A subsequent physician's orders [REDACTED]. An undated summary of a facility investigation, signed by the Administrator, DNS, and ADON on 12/8/17, documented, On 11/27/17 it was reported to the DNS that during an attempt to waste a discontinued narcotic, one of the medication cards on (Resident #9's name) had medications taped back into the card. The investigation documented (Staff A's name) had signed out the medications to this resident and that the medications taped in did not correlate, in appearance, with what was described on the Pharmacy identification tag. The summary documented the remaining 11 doses in the bubble pack card were [MEDICATION NAME], not [MEDICATION NAME]. The Bureau of Facility Standards Long Term Care Reporting System documented the facility notified the State Survey Agency on 12/1/17 at 11:25 AM, four days after the facility knew about the misappropriation of the controlled medication by Staff #[NAME]",2020-09-01
75,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2018-04-12,655,D,1,0,0IO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it was determined the facility failed to ensure a baseline care plan included the instructions needed to provide effective and person-centered care. This was true for 1 of 3 sample residents (#4) whose baseline care plans were reviewed. This deficient practice created the potential for Resident #4 to experience hyper/hypoglycemic (high/low blood sugar) events without the implementation of corrective interventions. Findings include: Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including diabetes mellitus. Resident #4's 4/2/18 hospital discharge medication list and the resident's (MONTH) (YEAR) facility recapitulation of orders, documented the following medications for diabetes: * insulin [MEDICATION NAME] solution 12 units by subcutaneous injection two times a day; * insulin [MEDICATION NAME] solution per sliding scale before meals and at bedtime, notify the physician if the resident's BG was less than 60 and if the BG was greater than 500, give 12 units of insulin and notify the physician; * [MEDICATION NAME] 1 mg by intramuscular injection as needed for [DIAGNOSES REDACTED] (low blood sugar). Resident #4's care plan documented the potential for nutritional problems related to diabetes. The care plan did not include further reference or interventions related to diabetes. On 4/12/18 at 9:15 AM, the DNS provided the facility's Diabetic Protocol policy and procedure, revised (MONTH) (YEAR), which documented the following: * Call the physician if the diabetic resident has a fever, low blood pressure, lethargy or confusion, abdominal or chest pain, respiratory distress, or functional and/or mental decline. * If the BG is 0-65 and the resident is conscious and able to swallow: give juice, 2% milk or 1 pouch of glucose gel combined with a protein snack, notify the supervisor, recheck the BG in 15 minutes, repeat the intervention and BG check 15 minutes later if the BG is still less than 65 and the resident is alert, notify the physician non-urgently versus STAT (immediately), if the resident becomes unresponsive at any time or becomes extremely lethargic call 911. * If the BG is 0-65 and the resident is unconscious or unable to swallow: give [MEDICATION NAME] 1 mg by subcutaneous or intramuscular injection, notify the physician STAT and notify your supervisor, recheck the BG in 15 minutes, if BG still less than 60 call 911, if BG 65 or over and resident is conscious and talking, offer a protein snack, recheck the BG in 1 hour and resume previous testing orders. * If the blood sugar is over 500: give the maximum units of insulin per the sliding scale orders, notify the physician, recheck the blood sugar in 1 hour, and follow new orders if they are given. * If the blood sugar is over 600: give the maximum units of insulin per the sliding scale orders, notify the physician, recheck the blood sugar in 1 hour, if still Hi notify the physician and do a BMP (basic metabolic profile lab test) STAT, and follow new orders if they are given. On 4/12/18 at 5:40 PM, the ADON said residents who are diabetic should have a care plan for diabetes from the beginning of their stay in the facility.",2020-09-01
76,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2018-04-12,656,D,1,0,0IO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it was determined the facility failed to implement comprehensive resident-centered care plans. This was true for 2 of 4 (#3 and #6) residents reviewed for diabetes management care plans and had the potential for harm if residents experienced hyper/hypoglycemic (high/low blood sugar) events. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses, including diabetes mellitus. An admission MDS assessment, dated 2/12/18, documented Resident #3 was cognitively intact and required extensive assistance of 1-2 staff members for cares. The care plan addressing diabetes mellitus, dated 2/20/18, documented signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. The care plan did not include instructions for staff on how to treat hypoglycemic events or hyperglycemic events. On 4/12/18 at 5:35 PM, the ADON stated the care plan should have documented staff were to follow the facility's diabetic protocol. The ADON stated the diabetic protocol was located on the nursing medication carts for all the nurses to reference. 2. Resident #6 was admitted to the facility in (YEAR) and readmitted on [DATE] with multiple diagnoses, including diabetes mellitus. The care plan addressing diabetes mellitus, dated 3/7/18, documented staff were to assess Resident #6 for signs of skin breakdown and provide diabetic medications as ordered. The care plan did not include instructions for staff on how to treat hypoglycemic or hyperglycemic events and the symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] staff were to monitor for. On 4/12/18 at 5:35 PM, the ADON stated the care plan should have documented staff were to follow the facility's diabetic protocol.",2020-09-01
77,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2018-04-12,684,D,1,0,0IO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and review of policies, resident records, facility investigations, it was determined the facility failed to ensure professional standards of practice for medication management were followed for 3 of 9 sample residents (#3, #8, and #9) whose medications were reviewed. Resident #8 continued to receive an IV antibiotic after she may have experienced an allergic reaction to the medication. Resident #9's narcotic medication was discontinued and not destroyed in a timely manner, which contributed to the misappropriation of Resident #9's narcotic medication. Resident #3 did not receive ordered IV antibiotic medications, placing her at risk of ineffective antibiotic therapy. Findings include: 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment, dated 2/4/18, documented Resident #8 was cognitively intact and received IV antibiotics. a. Resident #8 began a six-week treatment of [REDACTED]. The facility continued to administer [MEDICATION NAME] to Resident #8 after she experienced possible signs and symptoms of an allergic reaction to the antibiotic as follows: The care plan addressing Resident #8's septic arthritis, dated 1/29/18, documented staff members were to obtain and monitor her lab work, as ordered, and report these results to the Infectious Disease (ID) physician. The care plan documented Resident #8 was on IV [MEDICATION NAME] for the infection. Physician orders [REDACTED].#8 received daily doses of IV [MEDICATION NAME], varying from 450 mg to 500 mg, [MEDICAL CONDITION]. Resident #8's MAR indicated [REDACTED]. During this period, Progress Notes included communication from the Nurse Practitioner (NP) to nursing staff, dated 2/20/18 at 10:30 AM, Resident #8 had a bilateral rash and swelling to her lower extremities that may be related to a possible reaction to [MEDICATION NAME]. The NP documented he would re-assess the rash after the [MEDICATION NAME] was discontinued and after Resident #8 finished a 5-day course of [MEDICATION NAME]. The NP did not suggest stopping the [MEDICATION NAME] at that time. The communication documented the NP also ordered as needed [MEDICATION NAME]. There was no documentation the NP nor facility staff notified the ID physician of Resident #8's 2/20/18 possible reaction to the [MEDICATION NAME]. A 2/21/18 Progress Note documented the NP evaluated Resident #8 and noted that she had a rash to lower extremities that might be reaction to an ABX (antibiotic). There was no documentation the facility reported the possible allergic reaction from the [MEDICATION NAME] to the ID physician at that time. A Progress Note, dated 3/2/18 at 5:20 AM, documented Resident #8 continued to receive [MEDICATION NAME] and continues to have a rash on legs and arms. Two Progress Notes, dated 3/2/18 at 11:10 AM and 3/5/18 at 12:22 PM, documented Resident #8 was administered 25 mg of as needed [MEDICATION NAME] for a rash and itchiness. There was no documentation the facility reported the possible allergic reaction from the [MEDICATION NAME] to the ID physician when signs and symptoms were identified on 3/2/18. A Progress Note, dated 3/6/18 at 2:03 PM, documented staff were to monitor Resident #8 for adverse side effects of [MEDICATION NAME] related to increased [MEDICAL CONDITION] (excess fluid buildup), rash, and pain every 8 hours for 72 hours and report the results to the physician. The note documented Resident #8 was sent to the emergency room for evaluation related to possible signs and symptoms of side effects to [MEDICATION NAME]. A Progress Note, dated 3/6/18 at 5:52 PM, documented Resident #8 had non-[MEDICAL CONDITION] located on her right arm and around the left side of her face. The note documented it was possibly related to [MEDICATION NAME]. The note documented Resident #8 had acute pain, a rash to all extremities, itching, and [MEDICAL CONDITION]. The note documented Resident #8 was admitted to the hospital for evaluation of the adverse reaction to the medication. A Progress Note, dated 3/6/18 at 5:57 PM, documented the facility notified the NP on 3/5/18 at 7:00 AM of a change in condition of new or worsening [MEDICAL CONDITION] to Resident #8. A 3/8/18 Progress Note documented the following communications between a nurse and the NP between 3/5/18 and 3/8/18. A summary of the LPN #1's communication on 3/5/18 at 1:31 PM, documented Resident #8 had a 6.4 critical lab value of potassium. A summary of LPN #1's communication on 3/5/18 at 3:28 PM, documented Resident #8 was having side effects from the [MEDICATION NAME] and the LPN was trying to contact the ID physician for instructions for what to do with the [MEDICATION NAME] order. A summary of LPN #1's communication on 3/5/18 at 4:23 PM, documented the ID physician's office was contacted about the signs and symptoms and they were relayed to the ID physician. The communication documented the office was under the impression the [MEDICATION NAME] was supposed to end on 3/2 but our orders end 3/6. A summary of LPN #1's communication on 3/5/18 at 4:24 PM, documented the ID physician agreed to hold the [MEDICATION NAME] and ordered [MEDICATION NAME] and [MEDICATION NAME]. A summary of LPN #1's communication on 3/6/18 at 7:01 PM, documented Resident #8's potassium level was elevated to 6.6. A summary of the NP's communication on 3/8/18 at 9:38 AM, thanked the LPN for the updates. On 4/12/18 at 5:35 PM, the ADON stated the facility called the NP when Resident #8 experienced signs and symptoms of a possible allergic reaction to the [MEDICATION NAME]. The ADON was unable to provide documentation the facility notified the ID physician who ordered the [MEDICATION NAME], or if the NP contacted the ID physician when Resident #8 experienced signs and symptoms of an allergic reaction to the [MEDICATION NAME] on 2/20/18 or 3/2/18. The ADON stated she would expect there to be communication between the provider or the facility if the resident was experiencing an allergic reaction from a prescribed medication. The ADON stated she would expect staff to stop the medication promptly and call the prescribing physician and wait for further instructions. The facility failed to report the signs and symptoms of possible allergic reaction to the ID physician who had been ordering and monitoring the [MEDICATION NAME]. Resident #8 was transported to the hospital to treat a critically high level of potassium and a possible signs and symptoms of an allergic reaction to [MEDICATION NAME]. b. Resident #8's interventions were not implemented fully after possible allergic reaction occurred on 2/20/18 as follows: Resident #8's Physician orders [REDACTED]. Resident #8's 2/20/18 through 2/26/18 MAR indicated [REDACTED]. Resident #8 missed two doses of the [MEDICATION NAME] on 2/21/18 and 2/25/18. The reason documented on 2/21/18 was documented as absent from the facility. Resident #8 was to receive the [MEDICATION NAME] at 7:00 AM in the morning, she was to receive 13 additional medications and/or treatments during that timeframe. The 2/21/18 MAR indicated [REDACTED]. The reason documented on 2/25/18 was Resident Spit out. There was no documentation the NP was notified that Resident #8 did not receive two doses of her [MEDICATION NAME] or that other attempts to administer the medication were attempted. Resident #8's Physician orders [REDACTED]. Resident #8's 2/20/18 through 3/6/18 MAR indicated [REDACTED]. On 4/12/18 at 5:35 PM, the ADON stated she would look into why the medications were not given. The facility did not provide information prior to exit of the survey. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment, dated 2/12/18, documented Resident #3 was cognitively intact and required extensive assistance of 1-2 staff members for cares. Resident #3's (MONTH) (YEAR) Physician orders [REDACTED]. Resident #3's 4/1/18 through 4/12/18 MAR indicated [REDACTED]. A Progress Note dated 4/11/18 at 10:48 AM, documented the reason for the missing dose was the medication was on order from the pharmacy. Resident #3's Pharmacy Delivery Records documented the facility received 3 doses of IV meropenem on 4/9/18, 4/10/18, and 4/11/18. On 4/12/18 at 2:03 PM, the ADON stated on 4/11/18 the facility was short staffed and had staff members call out sick. The ADON stated that she and three other nurses LPN #1, LPN #3, and LPN #4, covered the R-Hall medication cart on the morning of 4/11/18. The ADON stated the shift started with LPN #1 working the cart and the ADON relieved LPN #1. The ADON stated Resident #3's 6:00 AM meropenem dose was not administered and she did not know why, but was told the medication was not available. The ADON stated LPN #3 relieved her and then LPN #4 relieved LPN #3. The ADON stated Resident #3 received 2 of 3 doses of meropenem on 4/11/18 like the MAR indicated [REDACTED]. On 4/12/18 at 2:20 PM, the ADON was observed locating 3 IV bags of meropenem dated 4/12/18 with Resident #3's name on it. The ADON stated she did not open the refrigerator on 4/11/18 in the morning to check for the meropenem. On 4/12/18 at 2:30 PM, LPN #1 stated he could not locate Resident #3's IV meropenem in the refrigerator on 4/11/18 at 6:00 AM. He stated he called the physician and wait for further instructions. LPN #1 stated the physician did not call back on 4/11/18. LPN #1 stated the ADON and DNS instructed him to waited until the medication was located until providing the medication to the resident. On 4/12/18 at 2:33 PM, LPN #4 stated LPN #3 asked her to please administer Resident #3's 2:00 PM IV meropenem on 4/11/18. LPN #4 stated she located the IV meropenem in the refrigerator on 4/11/18, and she did not recall how many bags were in the refrigerator. LPN #4 stated she administered the 2:00 PM dose of meropenem. On 4/12/18 at 3:03 PM, LPN #3 stated on 4/11/18 around 2:00 PM, she located Resident #3's IV meropenem in the medication refrigerator and asked LPN #4 to please administer the medication. LPN #3 did not recall how many IV bags were in the refrigerator on 4/11/18. LPN #3 stated she did not recall pharmacy delivering any meropenem that morning or not. LPN #3 stated when she looked in the refrigerator the meropenem was there. On 4/12/18 at 6:25 PM, the DNS stated if an IV antibiotic dose was missed the nurse would call the physician for orders. The DNS stated if the physician added orders the nurse would call the pharmacy and the pharmacy would mix the medication and deliver the medication. The DNS stated he would expect the nurse to document the conversation. 3. According to the Drug Enforcement Agency Disposal of Controlled Substances Act, dated 9/9/14, Long-Term Care Facilities (LTCF) are required to dispose of controlled substances immediately, and no longer than three business days after the discontinuation of use by the LTCF resident. The facility's Narcotic Destruction Policy, dated 4/12/18, documented when a narcotic medication was needing to be wasted a witness would be present. The policy did not define when narcotics were to be disposed of. The policy was not signed off as reviewed by the medical director. Resident #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 3/26/18, documented Resident #9 was cognitively intact and exhibited no pain. Resident #9's (MONTH) (YEAR) MAR indicated [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. A physician's orders [REDACTED].#9's [MEDICATION NAME] 10 mg as needed was discontinued. Resident #9's narcotic count sheet, dated 11/14/17, documented 42 doses of [MEDICATION NAME] 10 mg. The narcotic count sheet documented Staff #A signed that she administered 16 of 16 doses between 11/14/17 and 11/20/17, before the [MEDICATION NAME] was discontinued on 11/21/17. After the [MEDICATION NAME] was discontinued on 11/21/17, Staff #A continued to sign that she administered 15 of 15 doses between 11/22/17 to 11/26/17. Resident #9's narcotic count sheet for [MEDICATION NAME] documented 11 doses remaining in the bubble pack card. An undated summary of the facility's investigation, signed by the Administrator, DNS, and ADON on 12/8/17, documented that on 11/27/17 it was reported to the DNS that during an attempt to waste a discontinued narcotic, one of Resident #9's medication cards had, medications taped back into the card. The DNS identified Staff #A was the only nurse signing the narcotic count sheet for Resident #9 and discovered the remaining 11 doses in the bubble pack card were [MEDICATION NAME], not [MEDICATION NAME]. The investigation summary documented that Staff #A was interviewed on 11/30/17 at 2:00 PM, at which time Staff #A admitted to taking Resident #9's [MEDICATION NAME] and replaced the remaining 11 doses in the bubble pack card with [MEDICATION NAME]. The investigation documented Staff #A was taking the [MEDICATION NAME] from Resident #9 for personal use since the beginning of November. Staff #A was suspended pending investigation. The facility began the destruction process 6 days after the [MEDICATION NAME] was discontinued by the physician. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment, dated 2/12/18, documented Resident #3 was cognitively intact and required extensive assistance of 1-2 staff members for cares. Resident #3's (MONTH) (YEAR) Physician orders [REDACTED]. Resident #3's 4/1/18 through 4/12/18 MAR indicated [REDACTED]. A Progress Note dated 4/11/18 at 10:48 AM, documented the reason for the missing dose was the medication was on order from the pharmacy. Resident #3's Pharmacy Delivery Records documented the facility received 3 doses of IV meropenem on 4/9/18, 4/10/18, and 4/11/18. On 4/12/18 at 2:03 PM, the ADON stated on 4/11/18 the facility was short staffed and had staff members call out sick. The ADON stated that she and three other nurses LPN #1, LPN #3, and LPN #4, covered the R-Hall medication cart on the morning of 4/11/18. The ADON stated the shift started with LPN #1 working the cart and the ADON relieved LPN #1. The ADON stated Resident #3's 6:00 AM meropenem dose was not administered and she did not know why, but was told the medication was not available. The ADON stated LPN #3 relieved her and then LPN #4 relieved LPN #3. The ADON stated Resident #3 received 2 of 3 doses of meropenem on 4/11/18 like the MAR indicated [REDACTED]. On 4/12/18 at 2:20 PM, the ADON was observed locating 3 IV bags of meropenem dated 4/12/18 with Resident #3's name on it. The ADON stated she did not open the refrigerator on 4/11/18 in the morning to check for the meropenem. On 4/12/18 at 2:30 PM, LPN #1 stated he could not locate Resident #3's IV meropenem in the refrigerator on 4/11/18 at 6:00 AM. He stated he called the physician and wait for further instructions. LPN #1 stated the physician did not call back on 4/11/18. LPN #1 stated the ADON and DNS instructed him to waited until the medication was located until providing the medication to the resident. On 4/12/18 at 2:33 PM, LPN #4 stated LPN #3 asked her to please administer Resident #3's 2:00 PM IV meropenem on 4/11/18. LPN #4 stated she located the IV meropenem in the refrigerator on 4/11/18, and she did not recall how many bags were in the refrigerator. LPN #4 stated she administered the 2:00 PM dose of meropenem. On 4/12/18 at 3:03 PM, LPN #3 stated on 4/11/18 around 2:00 PM, she located Resident #3's IV meropenem in the medication refrigerator and asked LPN #4 to please administer the medication. LPN #3 did not recall how many IV bags were in the refrigerator on 4/11/18. LPN #3 stated she did not recall pharmacy delivering any meropenem that morning or not. LPN #3 stated when she looked in the refrigerator the meropenem was there. On 4/12/18 at 6:25 PM, the DNS stated if an IV antibiotic dose was missed the nurse would call the physician for orders. The DNS stated if the physician added orders the nurse would call the pharmacy and the pharmacy would mix the medication and deliver the medication. The DNS stated he would expect the nurse to document the conversation. 3. According to the Drug Enforcement Agency Disposal of Controlled Substances Act, dated 9/9/14, Long-Term Care Facilities (LTCF) are required to dispose of controlled substances immediately, and no longer than three business days after the discontinuation of use by the LTCF resident. The facility's Narcotic Destruction Policy, dated 4/12/18, documented when a narcotic medication was needing to be wasted a witness would be present. The policy did not define when narcotics were to be disposed of. The policy was not signed off as reviewed by the medical director. Resident #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 3/26/18, documented Resident #9 was cognitively intact and exhibited no pain. Resident #9's (MONTH) (YEAR) MAR indicated [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. A physician's orders [REDACTED].#9's [MEDICATION NAME] 10 mg as needed was discontinued. Resident #9's narcotic count sheet, dated 11/14/17, documented 42 doses of [MEDICATION NAME] 10 mg. The narcotic count sheet documented Staff #A signed that she administered 16 of 16 doses between 11/14/17 and 11/20/17, before the [MEDICATION NAME] was discontinued on 11/21/17. After the [MEDICATION NAME] was discontinued on 11/21/17, Staff #A continued to sign that she administered 15 of 15 doses between 11/22/17 to 11/26/17. Resident #9's narcotic count sheet for [MEDICATION NAME] documented 11 doses remaining in the bubble pack card. An undated summary of the facility's investigation, signed by the Administrator, DNS, and ADON on 12/8/17, documented that on 11/27/17 it was reported to the DNS that during an attempt to waste a discontinued narcotic, one of Resident #9's medication cards had, medications taped back into the card. The DNS identified Staff #A was the only nurse signing the narcotic count sheet for Resident #9 and discovered the remaining 11 doses in the bubble pack card were [MEDICATION NAME], not [MEDICATION NAME]. The investigation summary documented that Staff #A was interviewed on 11/30/17 at 2:00 PM, at which time Staff #A admitted to taking Resident #9's [MEDICATION NAME] and replaced the remaining 11 doses in the bubble pack card with [MEDICATION NAME]. The investigation documented Staff #A was taking the [MEDICATION NAME] from Resident #9 for personal use since the beginning of November. Staff #A was suspended pending investigation. The facility began the destruction process 6 days after the [MEDICATION NAME] was discontinued by the physician.",2020-09-01
78,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2018-04-12,726,D,1,0,0IO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the Idaho Board of Nursing rules, and staff interview, it was determined the facility failed to ensure residents' care plans were developed and revised by licensed nurses. This was true for 3 of 9 sample residents (#1, #3, & #6) whose care plans were reviewed. The failure created the potential for harm if the residents' needs and/or wishes were not competently and comprehensively addressed in their care plans. Findings include: The Idaho Board of Nursing rules at IDAPA (Idaho Administrative Procedures Act) 23.01.01.401, state one of the functions of a Registered Nurse is to develop and document a plan for nursing intervention based on assessment, analysis of data, identified nursing [DIAGNOSES REDACTED]. The Idaho Board of Nursing rules at IDAPA 23.01.01.460, state one function of a Licensed Practical Nurse is to participate in the development and modification of the plan of care. The Idaho Board of Nursing rules at IDAPA 23.01.01.490, Unlicensed Assistive Personnel, documented, The term unlicensed assistive personnel .is used to designate unlicensed personnel employed to perform nursing care services under the direction and supervision of licensed nurses . and, unlicensed assistive personnel may complement the licensed nurse in the performance of nursing functions, but may not substitute for the licensed nurse . The rules do not allow Unlicensed Assistive Personnel to develop and document nursing care plans or make modifications to the plans. 1. Resident #6 was admitted to the facility in (YEAR) and readmitted on [DATE] with multiple diagnoses, including metabolic [MEDICAL CONDITION], dementia, altered mental status, urinary tract infection, [MEDICAL CONDITIONS] bladder, right [MEDICAL CONDITION], diabetes mellitus, [MEDICAL CONDITION], kidney disease, right eye [MEDICAL CONDITION], and hypertension. All of Resident #6's care plan Focus areas, goals, and interventions/tasks dated 3/7/18, were documented as created, initiated, and revised by CNA #1. These care plans were for diabetes mellitus, oxygen therapy, hypertension, acute/chronic pain related to diabetic [MEDICAL CONDITION], alteration in neurological status, kidney disease, [MEDICAL CONDITION], the risk for [MEDICAL CONDITION] or confusion, the risk for impaired cognitive function or thought processes related to dementia, impaired visual function, ADL self care performance deficit, suprapubic catheter/[MEDICAL CONDITION] bladder, and the risk for falls. On 4/12/18 at 4:11 PM, LPN #3 identified herself as an MDS nurse and said that MDS assessments help staff develop care plans. The LPN said the IDT, including CNA #1, work on care plans. LPN #3 said a CNA cannot open and create care plans and that care plans should be created by licensed professionals. 2. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITIONS] and [MEDICAL CONDITION] following cerebral infarction (stroke), presence of a cerebrospinal fluid drainage device, and generalized muscle weakness. Resident #3's ADL self care performance deficit care plan, initiated 2/20/18, documented CNA #1 created and revised an intervention regarding the use a bedpan every 2 hours. The fall risk care plan, initiated 2/20/18, documented CNA #1 created 2 interventions and revised 1 intervention on the plan. On 4/12/18 at 6:25 PM, the DNS said CNA #1 transcribes during IDT care plan meetings and the nurse who signs the MDS is responsible for the care plan. 3. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] and muscle weakness related to [DIAGNOSES REDACTED]. Resident #1's ADL self care performance deficit care plan, initiated 10/1/8, documented CNA #1 created 4 nursing rehab interventions. On 4/12/18 at 7:50 PM, the Administrator said the IDT, including CNA #1, develop and revise care plans. The Administrator said CNA #1 might be scribing for the IDT, but the CNA did not create care plans in a vacuum.",2020-09-01
79,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2018-04-12,755,D,1,0,0IO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, facility policy review, and staff interviews, it was determined the facility failed to ensure prescription medications were available for administration to 1 of 9 residents (#8) whose medications were reviewed. This failure had the potential to compromise Resident #8's respiratory status and allow exacerbation of her [MEDICAL CONDITION] reflux disease. The facility also failed to ensure medications were secured and locked, including controlled medications. This was true for 8 of 8 bubble pack medication cards left unsecured on the counter at a nurses' station. This failure created the potential for residents, staff, and visitors to access medications not prescribed for them, including controlled medications. Findings include: 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment, dated 2/4/18, documented Resident #8 was cognitively intact and received IV antibiotics. a. Resident #8's physician orders [REDACTED]. * 40 mg [MEDICATION NAME] by mouth for [MEDICAL CONDITION] reflux disease, ordered 2/7/18, * 1 inhalation orally of 18 microgram (mcg) dose of [MEDICATION NAME] every day for asthma, ordered 1/28/18 and discontinued 3/8/18, and * 1 inhalation orally of 100-50 mcg/dose [MEDICATION NAME] every 12 hours for asthma, ordered 1/28/18 and discontinued 3/8/18. Resident #8's (MONTH) (YEAR) MAR indicated [REDACTED] * [MEDICATION NAME] was not administered on 2/9/18 at 8:00 PM and on 2/13/18 and 2/14/18 at 8:00 AM and 8:00 PM. * [MEDICATION NAME] was not administered on 2/26/18 at 7:00 AM. * [MEDICATION NAME] was not administered on 2/26/18 at 7:00 AM. A Progress Note, dated 2/9/18 at 10:34 PM, documented Resident #8's [MEDICATION NAME] was on order from the pharmacy. Two Progress Notes, dated 2/13/18 at 9:54 AM and 9:47 PM, documented Resident #8's [MEDICATION NAME] was ordered from the pharmacy during the morning shift and it had not arrived. The notes documented the physician had not provided further instructions. Two Progress Notes, dated 2/14/18 at 8:09 AM and 9:24 PM, documented the facility was waiting for Resident #8's [MEDICATION NAME] to arrive from pharmacy. The notes documented the physician had not provided further instructions. A Progress Note, dated 2/26/18 at 8:17 AM, documented Resident #8's [MEDICATION NAME] was not found in the medication cart and the pharmacy and physician were notified. A Progress Note, dated 2/26/18 at 8:17 AM, documented Resident #8's [MEDICATION NAME] was not found in the medication cart and the pharmacy and physician were notified. On 4/12/18 at 5:35 PM, the ADON stated she would look into why the medications were not given. The facility did not provide information prior to exit of the survey. b. Inconsistent ordering and delivering of medications: [REDACTED] On 4/12/18 at 2:03 PM, the ADON stated the facility did not have written policy and procedures for ordering and receiving of medications. The ADON stated the process for delivering medications was the pharmacy delivered medications to the A/B nurses' station and the nurses from the other respective nurses' stations were called to collect the medications that belonged in their carts. The ADON stated if time allowed, the A/B nurse delivered the medications to the other nursing stations if the other nurses did not have time to pick them up at the A/B nursing station. The ADON stated if nurses at the other nursing stations did not have time to collect or deliver the medication, then the A/B nurse locked the medications in the A/B drug room until time allowed for delivery or collection. The ADON stated sometimes the pharmacy delivered the medications to the different nursing stations if they had time. On 4/12/18 at 2:20 PM, the ADON and surveyor arrived at the R-Hall nurses' station and observed a stack of eight medication bubble packs including 1 controlled medication sitting unattended on the counter. The ADON obtained the medication packs from the counter and called the nurse over her head-set to the nurses' station. On 4/11/18 at 2:23 PM, LPN #1 arrived at the nurses' station and the ADON handed him the stack of medication bubble packs to store in the medication cart. While the ADON handed the nurse the medication bubble packs she told the nurse not leave the medications unattended. On 4/12/18 at 2:25 PM, the ADON stated the medications should not have been delivered to the R-Hall nurses' station as they were. The ADON stated the nurse who delivered the medications should have hand delivered them directly to the nurse who should have put them in the medication cart. The ADON stated the delivering nurse should not have left the medications on the counter when LPN #1 was not available, as it appears to have happened. The ADON stated the medications should not have been left unattended. On 4/12/18 at 2:33 PM, LPN #1 stated the medications found on the counter included eight bubble packs, including one controlled medication. LPN #1 stated he normally received a phone call when pharmacy delivered medications to the A/B-Hall nurses' station, and he would retrieve the medications. LPN #1 stated he did not receive a phone call 4/12/18 and did not know the medications were delivered to the R-Hall nurses' station. LPN #1 stated the pharmacy did not deliver the medication in a timely manner and some residents missed doses of medications. LPN #1 stated a few months ago it would take 2-3 days for medications to be ordered and delivered to the facility. LPN #1 stated the timeline for deliveries now was 6-7 days after the orders were placed. LPN #1 stated there was not a written process to assist nurses with ordering medications and when to order medications. LPN #1 stated he was unsure why there was a change in the turn around of the medication deliveries from the pharmacy. On 4/12/18 at 6:25 PM, the DNS stated when a medication was low, a couple days left, and needed ordered, there were stickers on the back of the medication bubble pack cards that were faxed to pharmacy. The DNS stated when a nurse noticed a medication beginning to dwindle down they ordered the medication. The DNS said any nurse could order medications and the responsibility was not designated to a specific shift. The DNS stated if a medication was needed immediately, nurses could call the pharmacy for emergent needs. On 4/12/18 at 7:51 PM, the Administrator stated the medication delivery system in place could use improvement. The Administrator was unaware the facility did not have a written policy and procedure for medication ordering and delivery. The pharmacy services policy and procedure was requested from the Administrator at this time. This policy was not provided for review.",2020-09-01
80,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2018-04-12,835,F,1,0,0IO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review, and review of personnel files, a police report, and facility investigations, it was determined facility administration allowed a staff member, who was suspended from the facility for diversion of narcotics, to return to work when the administration had knowledge the staff member had misappropriated a resident's medication. This was true for 1 of 2 employees (Staff #A) whose personnel files were reviewed. The failure directly impacted 1 of 7 (#9) sample residents residing in the facility and placed the other 74 residents residing in the facility at risk of misappropriation of medications. Findings include: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses, including end stage liver disease. A physician's orders [REDACTED]. A Physician's verbal order, dated 11/21/17, documented Resident #9's [MEDICATION NAME] 10 mg every four hours as needed for pain was discontinued. Resident #9's narcotic count sheet, dated 11/14/17, documented 42 doses of [MEDICATION NAME] 10 mg. The narcotic count sheet documented Staff #A signed that she administered 16 of 16 doses between 11/14/17 and 11/20/17, before the [MEDICATION NAME] was discontinued on 11/21/17. After the [MEDICATION NAME] was discontinued on 11/21/17, Staff #A continued to sign that she administered 15 of 15 doses between 11/22/17 to 11/26/17. Resident #9's narcotic count sheet for [MEDICATION NAME] documented 11 doses remaining in the bubble pack card. An undated summary of the facility's investigation, signed by the Administrator, DNS, and ADON on 12/8/17, documented that on 11/27/17 it was reported to the DNS that during an attempt to dispose of a discontinued narcotic, one of Resident #9's medication cards had medications taped back into the card. The DNS identified Staff #A as the only nurse signing the narcotic count sheet for Resident #9 and discovered the remaining 11 doses in the bubble pack card were [MEDICATION NAME], not [MEDICATION NAME]. The investigation summary documented that Staff #A was interviewed on 11/30/17 at 2:00 PM, at which time Staff #A admitted to taking Resident #9's [MEDICATION NAME] and replaced the remaining 11 doses in the bubble pack card with [MEDICATION NAME]. The investigation documented Staff #A was taking the [MEDICATION NAME] from Resident #9 for personal use since the beginning of November. Staff #A was suspended pending investigation. On 4/11/18 at 1:00 PM, the facility provided a current employee job profile that listed Staff #A as an LPN. The investigation summary documented the police department was notified on 12/1/17, four days after the misappropriation of Resident #9's controlled medication by Staff #A was reported to the DNS on 11/27/17. On 4/16/18, the facility provided a Police Department Detail Incident Report, dated 12/1/17. The report documented a police officer responded to the facility regarding a reported theft of medication. The police report documented a police officer spoke to Staff #A on 12/2/17 and Staff #A, .admitted to taking the pills between 11/14/17 and 11/17/17 .she had taken at least eleven [MEDICATION NAME] pills, possible (sic) more, though she did not remember the exact amount .she had taken the pills for personal use, and had already consumed them. The report documented the incident was forwarded to the narcotics division. The police report documented on 12/21/17 the narcotics division was not mandated to press a charge for the theft of the [MEDICATION NAME]. On 4/11/18 at 4:25 PM, the DNS stated Staff #A told him that she was in a program for recovering nurses. The DNS was unable to provide documentation about the recovering nurses' program and was unaware of any restrictions or limitations for Staff #[NAME] The DNS stated Staff #A was not working as a nurse, was not providing direct patient care, did not have access to the electronic medication records, and did not have keys to access the medication carts or medication rooms. The DNS stated Staff #A returned to work in (MONTH) under his supervision and her job duties were filing paperwork. Staff #A's employee time record documented Staff #A returned to work 2/12/18 through 4/9/18 and worked 4-5 days per week. On 4/12/18 at 10:00 AM, the DNS stated Staff #A filed paperwork in his office or in the charge nurse room within the conference room when he was in the building. The DNS provided a Program For Recovering Nurses (PRN) contract for Staff #A dated 1/7/18. Staff #A signed the contract on 1/7/18 and the witness signed the contract five days later on 1/12/18. The DNS stated he did not have the PRN contract until 4/12/18 and he was unaware that written approval from the PRN program was required for Staff #A to return to work in any capacity. The PRN contract signed by Staff #A documented, I shall not return to work until I receive written approval from the PRN and support of my treatment provider. In the event that I change positions or seek new employment, I shall obtain approval from the PRN at least two weeks prior to accepting the position. To begin working, I must first have a work monitor in place and all releases must be signed for the hiring facility. On 4/12/18 at 10:30 AM, the DNS stated he was unaware Staff #A had worked 3 of 5 Saturdays in (MONTH) (YEAR) (3/17/18, 3/24/18, and 3/31/18). The DNS stated he was not in the facility and Staff #A was not supervised on those dates. The untitled facility's investigation, dated 12/8/17, documented the results of the investigation determined, we feel this was an isolated incident that began in the beginning of November, involved one resident, and did not result in bodily harm or any adverse effect to the identified resident or other residents. The identified nurse was suspended, reported to the nursing board, and police were notified. The investigation was signed by the Administrator, DNS, and ADON. On 4/11/18 at 4:25 PM, the DNS stated Staff #A told him that she was in a rehab program for recovering nurses. The DNS did not recall the exact date and had no documentation when Staff #A shared this information with him. The DNS stated Staff #A returned to work on 2/12/18 to file paperwork only and was not providing direct patient care, did not have access to the electronic medication records, and did not have keys to access the medication carts or medication rooms. The DNS was unable to provide documentation of communication with the PRN program. The facility's current employee job profile documented Staff #A was listed as Licensed Practical Nurse. Staff #A's employee time records documented Staff #A returned to work on 2/12/18. On 4/12/18 at 8:45 AM, the DNS stated he called the rehab program on 4/11/18 and received a copy of the recovering nursing program for Staff #[NAME] The DNS provided a job description for Staff #A, dated 4/12/18, documented, Staff #A will do mostly clerical duties including but not limited to, filing paperwork for the director of nurses the assistant director of nurses, ward clerk, medical records and Human Resources. Staff #A will continue with these job descriptions/restrictions until further documentation can be verified that Staff #A has been approved and is improving with her monitoring program for the program of recovery nurses and the Idaho State Board of Nursing. The untitled document was signed by the Administrator and the DNS. The DNS stated Staff #A had not reviewed or signed the job description. On 4/12/18 at 10:00 AM, the DNS stated Staff #A verbally told the DNS she was in PRN program and she returned to work on 2/12/18, filing paperwork with under direct supervision with the ADON or DNS in the their office. The DNS stated he did not receive documentation or have communication from the recovering nursing program. The DNS provided a contract from the PRN program that he received on 4/12/18. On 4/12/18 at 7:50 PM, the Administrator stated the DNS notified the Board of Nursing via phone on 12/1/17 regarding the misappropriation of Resident #9's [MEDICATION NAME] by Staff #[NAME] The Administrator was unable to provide documentation the Board of Nursing was notified. The Administrator was not aware Staff #A was working in the facility unsupervised on 3/17/18, 3/24/18, and 3/31/18. The Administrator was unable to provide documentation of communication with the PRN program regarding Staff #[NAME] The Administrator stated the investigation was completed under the direction of their corporation and he thought it was complete. The Administrator stated the investigation could use some improvement looking back on it now. 2. Also refer to: * F602 as it relates to the facility's failure to ensure residents were free from misappropriation of a controlled medication. * F608 as it relates to the facility's failure to ensure the facility reported misappropriation of medications to law enforcement within 24 hours. * F609 as it relates to the facility's failure to ensure the facility failed to report the misappropriation of medications to the State Survey Agency within 24 hours.",2020-09-01
81,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2019-04-12,565,E,1,1,WTPU11,"> Based on Resident Council meeting minutes, Resident Group interview, policy review, and staff interview, it was determined the facility failed to address Resident Council concerns. This was true for 8 of 8 residents (#3, #8, #17, #26, #36, #45, #60, and #64) who participated in the Resident Group interview. The deficient practice had the potential to cause psychosocial harm for residents frustrated by the perception their concerns were not valued or addressed by the facility. Findings include: The facility's Grievance policy, revised on 1/2018, documented the facility would make prompt efforts to resolve grievances, including Resident Council concerns, and to keep residents notified of progress toward resolution. Resident Council minutes, dated 2/28/19, documented complaints of cold meals and coffee, and long wait times for response to call lights. Resident Council minutes, dated 3/28/19, documented the residents wanted follow through with the issues they talked about in the meetings and still wanted hot coffee. The facility did not document what actions were taken to resolve the concerns identified at the 2/28/19 meeting. On 4/10/19 at 10:10 AM, during the Resident Group interview, Residents #3, #8, #17, #26, #36, #45, #60, and #64 said the food concerns were not addressed, the food was still cold, and did not taste good. Residents #3, #26, #36, #45, #60, and #64 said the call light concern was not addressed and was still an issue. On 4/11/19 at 8:52 AM, the Resident Council Liaison said she emailed the Resident Council minutes and concerns to the department head so they could respond back to her. She said not all of the department heads responded back to the concerns. On 4/11/19 at 2:18 PM, the DM said she received the Resident Council minutes, attempted to fix the concerns, but did not respond to the emails or notify the Resident Council Liaison or the Resident Council of her response. On 4/11/19 at 2:44 PM, the DON said he received the Resident Council minutes, had completed call light audits due to the concerns, and verbally reported the results to the Resident Council Liaison and to the Resident Council President. The DON said he had not considered the concerns from the Resident Council as grievances.",2020-09-01
82,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2019-04-12,585,D,1,1,WTPU11,"> Based on record review, policy review, resident, resident representative, and staff interview, it was determined the facility failed to document, investigate, and report complaints expressed by 1 of 19 residents (Resident #227) whose complaints were reviewed. This failure created the potential for harm if residents' verbal grievances were not acted upon and residents did not receive appropriate care or were at risk for abuse or neglect. Findings include: The facility's Grievance Policy, dated 1/2018, documented residents had the right to file a grievance orally or in writing and the right to obtain a review in writing; and when a grievance was voiced to a staff member a grievance form would be completed and the grievance would be evaluated and investigated. The facility's Grievance file did not include a grievance for Resident #227. On 4/10/19 at 9:56 AM, Resident #227 and his representative stated they reported incidents to the facility staff, as well as other concerns that were medical in nature, as follows: - A nurse answered the call light and said she could not help Resident #227 but was going to get a CNA to help. The CNA never came, and Resident #227 had to sit in urine and feces for an extended period of time causing skin issues in his peri-area. - A nurse yelled at Resident #227 and chewed him out when his representative called the DON to complain about the care the nurse had given to Resident #227. The representative said she used her cell phone and a land line phone to connect the DON directly to Resident #227's room so the DON could hear the way Resident #227 was treated by a particular nurse. - Resident #227 received rough care by a CNA who had transferred him, unassisted, using a Hoyer lift (a mechanical lift). During the transfer, Resident #227 was bumped against the Hoyer lift and the foot board of the bed which caused damage to his knee, which was the site of a recent surgical procedure. Resident #227 reported the same CNA picked up his leg, jerked the stump away from his body and dropped his stump on the bed causing extreme pain. Resident #227 said this same CNA also positioned his urinal in a rough manner, which caused him pain. On 4/9/19 at 11:09 AM, the DON said he had not documented the complaints made by Resident #227 and said Resident #227 was very particular in his care needs. The DON said when Resident #227 made complaints, the staff tried to meet his needs. The DON recalled the partial conversation he overheard by phone between Resident #227 and the nurse, and said he could not substantiate that abuse had occurred. The DON said he had not conducted a formal investigation into the nurse's behavior but had reassigned the nurse to prevent other complaints and incidents. The DON said he had not documented any of the incidents reported by Resident #227, nor had he documented the resolution of the complaints and he was not aware of some of the complaints. The DON said he had responded to several complaints by the resident but had not felt the complaints had risen to the level of abuse or neglect. The facility failed to provide documented evidence Resident #227's concerns reported by him and/or his representative were investigated, reported, and acted upon.",2020-09-01
83,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2019-04-12,657,D,0,1,WTPU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, resident interview, and staff interview, it was determined the facility failed to ensure residents' care plans were revised as needed. This was true for 1 of 21 residents (Resident #67) whose care plans were reviewed. This failure had the potential for harm if cares and/or services were not provided due to inaccurate information. Findings include: The facility's Care Planning policy, undated, directed staff to develop a comprehensive care plan for each resident and care plans were to be updated quarterly and as needed. Resident #67 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. a. Resident #67's quarterly MDS assessment, dated 3/21/19, documented she required the assistance of two staff with toilet use and transfers, and the assistance of one person with eating. Resident #67's care plan documented she required one-person assist with toilet use and transfers. The care plan was not consistent with the MDS assessment for Resident #67 which documented she required the assistance of two staff with toilet use and transfers and the assistance of one staff for eating. b. An Incident and Accident report, dated 1/21/19, documented Resident #67 had a fall and fractured her right shoulder. A hospital evaluation, dated 1/21/19, documented Resident #67 had a right shoulder fracture and directed staff to provide a sling for comfort. Resident #67's MAR, dated 1/30/19 through 3/18/19, documented a sheepskin sleeve was to be placed around the strap of the sling, in the neck area, for comfort. Resident #67's physician's progress notes, dated 2/6/19, 3/6/19, and 4/3/19, directed staff to provide a sling for her right shoulder fracture. Resident #67's care plan, documented she was at risk for falls and had a history of [REDACTED]. Resident #67's care plan did not include documentation she fractured her right shoulder and she required the use of a shoulder sling with a sheepskin sleeve over the strap of the sling. c. Resident #67's progress notes, dated 3/21/19, documented she received counseling services through a local mental health provider. The notes documented she was treated for [REDACTED]. Resident #67's care plan did not include she received counseling services. On 4/12/19 at 8:28 AM and 10:52 AM, The ADON stated Resident #67's ADLs care plan should have been revised to include her need for two-person assistance related to toilet use and transfers and one person assistance with eating. The ADON stated Resident #67's care plan was not revised to include her fractured right shoulder and her need for a sling with a sheepskin cover. The ADON stated Resident #67 continued to receive counseling from a local counseling provider and the care plan did not include this service.",2020-09-01
84,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2019-04-12,804,E,0,1,WTPU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, review of Resident Council minutes, resident interview, Resident Group interview, test tray evaluation, and staff interview, it was determined the facility failed to ensure palatable food was served. This was true for 15 of 18 residents (#1, #3, #8, #17, #20, #26, #27, #36, #38, #41, #45, #53, #54, #60, and #64) reviewed for food and nutrition. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include: The facility's Food Quality and Palatability policy, revised 9/2017, documented food will be palatable and served at an appetizing temperature. Resident Council minutes, dated 2/28/19, documented complaints of cold meals and coffee. Resident Council minutes, dated 3/28/19, documented the residents wanted follow through with the issues they talked about in the meetings and still wanted hot coffee. The facility did not document what actions were taken to resolve the concerns identified at the 2/28/19 meeting. On 4/10/19 at 10:10 AM, during the Resident Group interview, Residents #3, #8, #17, #26, #36, #45, #60, and #64 said the previously mentioned food concerns were not addressed, the food was still cold, and did not taste good. Residents were interviewed regarding the food served at the facility. Examples include: * On 4/8/19 at 4:18 PM, Resident #38 stated she did not like the greasy noodles that were served by the facility. * On 4/8/19 at 4:30 PM, Resident #54 stated the facility put Mrs. Dash and garlic on everything, and the food was lukewarm 90 percent of the time. * On 4/8/19 at 4:44 PM, Resident #27 stated the chicken was pasty. She stated the only fruit the facility had were apples, canned peaches, and fruit cocktail, and they were not very flavorful. She stated she told the DM her concerns with the food, and the DM told her everyone had told her that they liked the food. * On 4/8/19 at 5:58 PM, Resident #53 stated he did not like the food. * On 4/8/19 at 6:11 PM, Resident #41 stated the food was monotonous. * On 4/9/19 at 8:23 AM, Resident #17 stated the food could be better. She stated the broccoli and carrots were not cooked through and were rubbery. She said the pasta was also rubbery. * On 4/9/19 at 8:29 AM and on 4/11/19 at 9:20 AM, Resident #20 stated the food was cold sometimes. She stated she had tried to voice her concerns with kitchen staff but they did not address her food concerns. She stated she had difficulty eating her pancake the morning of 4/11/19, because part of the crust was too hard to cut. * On 4/9/19 at 10:45 AM, Resident #26 stated the food sucks! He said the food quality was poor and was often cold. * On 4/9/19 at 11:10 AM, Resident #36 stated the regular and alternate meals were served lukewarm and tasted terrible. * On 4/9/19 at 11:55 AM, Resident #1 stated the food was always the same and they put too much pepper on the food. On 4/10/19 at 11:45 AM, two test tray lunch meals were requested for the regular and alternate meals. The DM plated residents' meals and took one plate and one warming pellet at a time out of the top of the unplugged plate warmer which was opened at the top. At 12:07 PM, the last of the warming pellets were used and the DM plugged in the plate warmer and asked DA #2 to place new pellets into the warmer. DA #2 took a stack of pellets that had been on a nearby counter and placed them in the warmer. The DM then plated two more residents' meals and the two test tray meals with the new warming pellets underneath them and were delivered down the C and D hallways. On 4/10/19 at 12:15 PM, the two test trays were evaluated by three surveyors along with the District Manager of Dietary (DMD). The alternate meal included Swedish meatballs which had a temperature of 129 degrees F (Fahrenheit), parsley noodles which were 106 degrees F, and broccoli which was 93.5 degrees F. The regular meal included garlic and [MEDICATION NAME] roasted red potatoes which were 111 degrees F and sauteed zucchini which was 110 degrees F. The DMD said the noodles, broccoli, potatoes, and zucchini were lukewarm. The surveyors evaluated the meals and found the meatballs to lack flavor, the noodles were cool and greasy, the broccoli was cool and tough, the potatoes were lukewarm, and the zucchini was lukewarm and chewy.",2020-09-01
85,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2019-04-12,812,F,0,1,WTPU11,"Based on observation, policy review, and staff interview, it was determined the facility failed to a) date items in the freezer and refrigerator, b) ensure staff contained all hair with a hair net, c) ensure infection control practices were implemented when gathering ice to be used to keep foods cool and d) clean and maintain the kitchen floor. These deficient practices placed 18 of 18 sample residents (#1, #2, #11, #22, #23, #26, #27, #36, #42, #43, #44, #62, #65, #67, #71, #76, #228, and #229) who dined in the facility, and the other 61 residents who dined in the facility, at risk food borne illness or other disease-causing pathogens. Findings include: The facility's food labeling and dating policy, dated (YEAR), directed staff to date food upon receipt before being stored. The policy also documented food moved from the freezer to the refrigerator for thawing was to be labeled with the removal date and a use by date. The facility's Staff Attire policy, dated 9/2017, directed staff members to have their hair off the shoulders and confined in a hair net or cap. On 4/8/19 from 4:00 to 4:30 PM, during a tour of the kitchen the following were observed: * An open half bag of brussel sprouts was in the freezer. The bag was not dated when it was opened. Five other bags of brussel sprouts were found in the refrigerator without labels or dates as to when they were moved from the freezer to the refrigerator. * DA #1 had on a baseball cap in the kitchen. The lower half of her hair was loose and hung almost to her shoulders. * A plastic pitcher was face down on top of the ice machine. DA #1 took the plastic pitcher and filled it with ice and walked across the kitchen to a plastic tub with milk and juice cartons in it and poured the ice into the plastic tub. At that time, the DM told DA #1 to use the ice scoop and not the pitcher. The DM then instructed DA #1 to place the plastic pitcher in the dish washing area. * The floor throughout the kitchen and storage areas was dirty, with grime build up along the walls, door frames, drains, and stationary equipment. Various cracks and divots were observed in the flooring in multiple areas throughout the kitchen and storage areas. On 4/8/19 at 4:00, 4:26, and 4:30 PM, the DM said the brussel sprouts found in the freezer should have been dated when they were opened, and the brussel sprouts found in the refrigerator should have been dated when they were moved from the freezer to the refrigerator. She said the brussel sprouts were thawing for the next day's meal and said she moved them from the freezer to the refrigerator and had not dated them because she was in a hurry. The DM said she believed dietary staff could either wear a hair net or a baseball cap, and hair in a cap could reach the shoulders. The DM said she expected staff to use the ice scoop next to the ice machine instead of the plastic pitcher. On 4/9/19 at 8:22 AM, the kitchen floor was not completely clean. There was build up along all the walls and around legs of stoves, cabinets, preparation tables, ice machine, and almost all items stationary in the kitchen. The floor tile had divots and cracks throughout the kitchen, especially in the grill area. All areas of the kitchen and storage areas had tiles that were worn and cracked. On 4/9/19 at 8:22 AM, the DM said the facility was aware of the condition of the floor and planned to replace the floor last (MONTH) but had not completed that project. She said the surface of the floor was uncleanable and they did the best that we can to keep it clean. On 4/9/19 at 8:56 AM, the Facility Operations Manager said the kitchen floor had been identified for replacement last (MONTH) and he believed the floor would be replaced in (MONTH) or (MONTH) of this year. He said a solid plan for when the floor would be replaced would depend on the facility's ability to hire a mobile kitchen to use for the period the floor would be replaced.",2020-09-01
86,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2019-04-12,880,E,1,1,WTPU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, policy review, and staff interview, it was determined the facility failed to implement appropriate infection control practices when assisting residents during dining and after a Hoyer lift transfer of a resident on contact precautions. This was true for 2 of 6 residents (#33 and #42) observed in the assisted dining room and 1 of 4 residents (Resident #16) in contact precaution rooms. These deficient practices created the potential for harm by exposing residents to the risk of infection and cross contamination. Findings include: The facility's Infection Control policy, dated 9/29/17, directed staff to disinfect equipment after each use for residents in contact precaution rooms. 1. Resident #16 was admitted to the facility on [DATE]. Resident #16's record included a physician's orders [REDACTED]. On 4/11/19 at 2:00 PM, CNA #2 and CNA #3 assisted Resident #16 in a Hoyer lift transfer. All staff persons in the room wore personal protective equipment during the transfer. After the task was completed, CNA #2 removed the Hoyer lift from the room and took it down the hall to the shower room. CNA #2 placed the Hoyer lift in the shower room and left the room. On 4/11/19 at 2:30 PM, CNA #2 said she did not cleaned the Hoyer lift after it was used to transfer Resident #16. CNA #2 said she should have cleaned it as the Hoyer lift could have been used for other residents. The Hoyer lift was left in the shower room for use by other staff for other residents without being properly sanitized between uses. On 4/11/19 at 3:10 PM, RN #1 said the Hoyer lift should be disinfected after each use. On 4/11/19 at 3:15 PM, LPN #2 said she thought the Hoyer lift should be cleaned before and after use with each resident. On 4/11/19 at 4:00 PM, the DON said he expected staff to clean the Hoyer lift between resident use. 2. On 4/9/19 at 12:19 PM, CNA #1 sat between Resident #33 and Resident #42 at the assisted dining table in the dining room. CNA #1 assisted both residents using her gloved right hand on the residents' utensils to offer bites of food. She then picked up each resident's napkins from the table and wiped their mouths with their napkins, using her right hand. CNA #1 then continued to assist both residents with the utensils. This process continued through-out the entire meal. CNA #1 did not change her gloves or sanitize her hands when moving between the two residents. On 4/10/19 at 08:38 AM, CNA #1 said she should not have assisted Resident #33 and Resident #42 with wiping their mouths without sanitizing her hands. On 4/10/19 at 9:12 AM, the DON said when assisting residents, he expected staff to only use the left side of their body to assist the person on the left, and the right side their body to assist the person on the right.",2020-09-01
87,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2019-04-12,883,D,0,1,WTPU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff and resident interview, it was determined the facility failed to ensure residents were offered the pneumococcal vaccine and information and education consistent with current Centers for Disease Control and Prevention recommendations. This was true for 1 of 7 residents (Resident #23) reviewed for pneumococcal immunizations. This failure created the potential for harm to residents should they acquire, transmit, or experience complications from pneumococcal pneumonia. Findings include: The Centers for Disease Control and Prevention (CDC) website, updated 11/22/16, documented recommendations for Pneumococcal vaccination (PCV 13 or Prevnar13(R), and PPSV 23 or [MEDICATION NAME](R)) for all adults [AGE] years or older: * Adults [AGE] years or older who have not previously received PCV 13, should receive a dose of PCV 13 first, followed 1 year later by a dose of PPSV 23. *If the patient already received one or more doses of PPSV 23, the dose of PCV 13 should be given at least 1 year after they received the most recent dose of PPSV 23. The facility's Immunizations policy and procedures, dated 9/2018, directed staff to minimize the risk of residents acquiring, transmitting, or experiencing complications from pneumococcal pneumonia by assuring that each resident was informed about the benefits and risks of immunizations and had the opportunity to receive, unless medically contraindicated or refused or already immunized, the pneumococcal vaccine. Resident #23 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #23's quarterly MDS assessment, dated 2/1/19, documented her cognition was intact, and her pneumococcal vaccination was up to date. Resident #23's record documented she received [MEDICATION NAME] 23 pneumococcal vaccine on 10/10/14. Resident #23's record did not include documentation she received the Prevnar 13 pneumococcal vaccine, consent, or information about the benefits and risks of pneumococcal immunization. On 4/11/19 at 8:10 AM, the ADON stated Resident #23's record did not include documentation she was offered or educated on the Prevnar 13 vaccine and stated she should have been offered and provided the education. On 4/12/19 at 9:17 AM, Resident #23 stated she was not offered the pneumococcal vaccination or informed about the benefits and risks of immunizations on admission or otherwise during her stay in the facility.",2020-09-01
88,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2016-06-24,167,C,0,1,X31E11,"Based on observation and visitor and staff interview, it was determined the facility failed to ensure the results of the most recent surveys were readily accessible to residents. This deficient practice was true for any resident or their representative or visitors who may want to review the survey results, including 13 of 13 sample residents (#s 1-13). Findings included: On 6/20/16 at 1:55 pm, a survey results binder was observed on the wall near the nurses' station in Hallway C. The binder contained the results of the last annual recertification survey, dated 6/13/14. The results of two complaint surveys, dated 1/27/15 and 2/11/15, were not located in the binder. On 6/21/16 at 9:10 am, the DON said he did not see the two complaint surveys in the binder. On 6/22/16 at 12:30 pm, Visitor A was observed to read the survey results, which also included the two newly placed complaint surveys. She said she had been visiting facilities and reading survey results in order to make a decision on where to find the right home for a family member. The complaint survey results were not available to Residents #1 - #13, or others who may wish to review the results.",2020-09-01
89,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2016-06-24,309,D,0,1,X31E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility's hospice agreement, and staff and resident interview, it was determined the facility failed to ensure hospice communications were available for staff, and physician orders were clarified regarding catheter size and catheter balloon fill amounts. This was true for 1 of 2 (#11) residents reviewed for hospice care and 2 of 3 (#1 & #14) residents reviewed for catheters. This failure had the potential for more than minimal harm if residents did not receive appropriate services based on lack of coordination of hospice care or experienced pain due to improper catheter size or improper inflation of catheter balloons: Findings include: 1. The facility's Hospice Agreement, dated 10/1/06, stated: Documentation of Services. Both parties shall maintain appropriate documentation of services provided under this Agreement in accordance with applicable state and federal laws and regulations .Patient medical records and documentation maintained by each Party shall be available for review and inspection by the other Party . Resident #11 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #11's 10/12/15 physician's orders documented an ongoing order for hospice services. Resident #11's hospice care plan documented an intervention, dated 7/15/15 of, Work cooperatively with hospice team to ensure (Resident #11's) spiritual, emotional, intellectual, physical and social needs are met . Resident #11's clinical record did not contain hospice visit notes from 5/21/16 to 6/22/16. On 6/23/16 at 11:35 am, LN #3 said she coordinated with hospice staff when they provided services for residents on hospice. She said if she did not receive a verbal update from the hospice staff, she would review hospice nurse and CNA visit notes. On 6/23/16 at 11:40 am, the DON said the hospice notes from 5/21/16 through 6/22/16 were just received from Resident #11's hospice agency and had not been available to staff until that morning. 2. Resident #14 was admitted to the facility on [DATE] with multiple diagnoses, including neuromuscular dysfunction of the bladder. Resident #14's 10/6/15 physician's orders documented, Change suprapubic catheter monthly and PRN every . every 30 day(s) . Resident #14's 10/9/15 physician's progress note documented, She has had several incidents of catheter pulling, which has increased tissue damage in the past. Resident #14's (MONTH) and (MONTH) (YEAR) TARs documented the catheter was changed as ordered. On 6/23/16 at 3:30 pm, LN #4 said when changing a catheter she would determine the size of the catheter and how full to fill up the balloon with water by checking the size written on the order. LN #4 showed the surveyor various sizes of catheter packages in a storage room. Each package documented the size and how many CC's to fill the catheter balloon, which is inserted into the bladder. On 6/23/16 at 3:40 pm, the DON reviewed Resident #14's catheter order and said the order was not clear regarding the size or how many CC's of water were to be used to fill the balloon. The DON said the order should have been clarified. 3. Resident #1 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was readmitted to the facility from the hospital on [DATE] post back surgery. Resident #1's annual MDS assessment, dated 8/8/15, and quarterly MDS assessment, dated 3/7/16, documented he had a BIMS of 15, did not ambulate, used a wheelchair for locomotion with the assistance of 1 person, and had a suprapubic catheter. The 6/2016 Physician's Orders included an order to change the suprapubic catheter every month (every 30 days) on the night shift. The order did not specify the size of the catheter or the amount of water to be instilled to inflate the balloon of the suprapubic catheter. A Nurses' Progress Note, dated 6/1/16, did not include documentation of changing Resident #1's suprapubic catheter, the size of the suprapubic catheter that was inserted, or the amount of water instilled. Resident #1's 6/2016 TAR documented his suprapubic catheter was changed on 6/1/16. There was no note regarding the size of the catheter used or the amount of water instilled to inflate the balloon of the suprapubic catheter. Resident #1's record included a Care Plan for the Suprapubic Catheter, with the Focus Area Titled: Has Suprapubic Catheter, [DIAGNOSES REDACTED]. The goals were: Resident #1 will show no signs or symptoms of urinary infection through the review date, and Resident #1 will remain free from catheter related trauma through the review date. A Care Plan intervention documented to change the suprapubic catheter monthly and as necessary, however, the size of the suprapubic catheter and the amount of water to instill to inflate the balloon of the catheter were not documented. During an interview with Resident #1 on 6/23/16, at approximately 2:00 pm, he stated he may have an occasional small amount of leakage from the suprapubic catheter when he was having some spasms. In addition, he stated there had been no problems or pain when the suprapubic catheter was changed. LN #2 who changed the suprapubic catheter on 6/1/16, was not available for interview. During an interview on 6/23/15, at approximately 5:00 pm with LN #1, who said she took care of the resident in the past, stated if the physician's order did not specify what size catheter to use or the amount of water to instill, she would check the size of the catheter to be removed and instill the amount of water documented on the bulb connector of the suprapubic catheter. LN #1 also stated if the resident was complaining of pain or having a problem with leakage (unrelated to presence of spasms) or the suprapubic catheter was not draining, she would notify the physician and obtain an order for [REDACTED]. During an interview with the ADON on 6/24/16, at approximately 9:30 am, the ADON stated the Physician's Order documented for the month of 6/2016, did not include the size of the suprapubic catheter or the amount of water to instill to inflate the balloon of the suprapubic catheter. The ADON showed the surveyor several different sized catheters used as suprapubic catheters and said the amount to be instilled is listed on the catheter.",2020-09-01
90,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2016-06-24,431,E,0,1,X31E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the safe and secure storage of drugs including narcotics and Schedule 2 controlled drugs in a locked storage area, and failed to permit only authorized personnel to have access to the keys. This created the potential for more than minimal harm to residents if they were to ingest the medications, and for diversion of medications by individuals present in the facility. Findings include: The medication cart on R Hall on 6/22/16 at 11:00 am, was observed to be was unattended with the keys left in the lock of the medication cart. The key to gain access to the medication cart and a separate/different key to gain access to narcotics and other controlled drugs in a locked drawer were kept on the same key ring holder. The medication cart was left in the hallway of R Hall near room [ROOM NUMBER], which was a few feet away from the R Hall doorway leading into the facility lobby. There were no residents, visitors, or staff observed in the R Hall at the time. After observing the medication cart continuously for 3 minutes, LPN #2 was observed walking at a rapid pace from the lobby to the medication cart, then removing the keys and locking the medication cart. During an interview with LN #2 on 6/22/16 at 11:05 am, LN #2 stated that she had left the medication cart to take a medication to a resident who was in the Physical Therapy/Occupational Therapy Department. LN #2 stated that she was away from the medication cart for approximately 3 minutes and that while she was in the therapy department she realized she left the keys in the lock of the medication cart when she reached into her pocket and the keys were not in her pocket. LPN #2 also stated the keys to the medication cart and the locked drawer were never to be left in the lock of the medication cart except when the nurse was pouring medications and if she had to leave the medication cart, the medication cart was to be locked and the keys removed. During an interview with the DON on 6/22/16 at approximately 1:00 pm, the DON stated the medication cart ws to be locked when unattended and the keys were never to be left in the lock.",2020-09-01
91,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2018-08-09,660,D,1,0,1TM511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents received an adequate and/or updated discharge plan, timely referrals to home health services, and/or involve residents in the discharge planning process. This was true for 3 of 4 residents (#1, #3 and #4) reviewed for discharge planning. This failure created the potential for harm if residents' various discharge needs were not met. Findings include: The facility's Discharge Planning Process policy, dated (MONTH) (YEAR), documented: *Provide and document sufficient preparation to ensure a safe and orderly discharge. *Identify changes that require modification of the discharge plan.The discharge plan must be updated, as needed, to reflect these changes. *Involve the IDT, residents and resident's representative in developing the discharge plan. *Document the evaluation of the resident's discharge needs. 1. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses, including malignant neoplasm of the esophagus [MEDICAL CONDITION] (breathing tube), gastrostomy (feeding tube), and muscle weakness. Resident #3 was discharged from the facility on 5/29/18. Resident #3's discharge area of the care plan, dated 4/10/18, directed staff to: * Establish a pre-discharge plan with the resident. * Evaluate the resident's progress and revise the discharge plan. * Make arrangements with required community resources to support independence post-discharge. * Did not have a preferred home health provider. The discharge area of the care plan did not document Resident #3's needs regarding his [MEDICAL CONDITION] and PEG tube. Resident #3's Weekly Skilled Review meeting, dated 5/24/18, documented several staff attended without the resident present. The notes documented Resident #3's progress towards discharge, including his PEG (feeding tube) tube and [MEDICAL CONDITION] management status. Resident #3's Family Meeting and Social Service notes, dated 5/25/18, documented he and a family member were present. The notes documented Resident #3 wanted to discharge from the facility and agreed to be discharge on 5/29/18, after he was able to independently manage his [MEDICAL CONDITION] and PEG tube. Resident #3's Social Service notes, dated 5/29/18, documented, Resident approached discharge planner multiple times throughout the day to discuss discharge .Discharge orders were obtained and reviewed with resident .referral was sent to (Local Home Health Agency). Discharge planner stated it could take a few days for services to begin but resident could expedite process by contacting the home health agency and setting up an appointment that worked for both the home health and resident. A facility's Fax status page, dated 5/30/18 at 8:57 AM, documented Resident #3's medical information was sent to the HH[NAME] On 8/9/18 at 11:05 AM, the Social Worker said Resident #3's discharge portion of the care plan did not include updates discussed in the Weekly Skilled Review meeting or in the Family Meeting, did not document the resident's [MEDICAL CONDITION] and PEG tube needs at discharge, and did not document which HHA the resident had chosen. The Social Worker said she had made a verbal referral to the HHA and did not know why the resident's medical information was sent to the HHA the day after he was discharged . The Social Worker said she had contacted the HHA on 6/1/18 and had been informed that Resident #3 had been seen for the first time by the HHA that day. Resident #3's first visist from the HHA was completed 3 days after his discharge from the facility on 5/29/18. 2. The [DIAGNOSES REDACTED].#1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Discharge Plan dated 5/23/18, located in the electronic medical record and attached to the care plan documented: Resident #1 anticipates returning to (name) ALF (Assisted Living Facility) in (town) The discharge plan interventions included: * Encourage to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress. * Establish a pre-discharge plan with the resident, family/caregivers and evaluate progress and revise plan. * Evaluate and discuss with resident/family/caregivers the prognosis for independent or assisted living. Identify, discuss and address limitation, risks, benefits and need for maximum independence. * Make arrangements with required community resources to support independence post-discharge. (Resident #1) prefers (name) Home Health. * Provide a list of any upcoming appointments post discharge to (Resident #1) and (name) assisted living facility. On 6/4/18 at 2:00 PM, the Discharge Coordinator documented a family meeting was held that included the resident, resident's son, Discharge Coordinator, business office manager, therapy and nursing. The meeting addressed Resident #1's need for oxygen, walker, wheelchair, and power scooter. After the family meeting, Resident #1's 5/23/18 Discharge Plan was not updated to reflect his need for oxygen, walker, wheelchair, and power scooter after discharge. Resident #1's medical record, electronic and paper versions, was reviewed. Resident #1's medical record did not include documentation of an additional meeting, after 6/4/18 with him or his family about his discharge and discharge needs. On 8/9/18 at 11:50 AM, the Discharge Coordinator confirmed Resident #1's discharge plan was not updated with his current discharge information. 3. The [DIAGNOSES REDACTED].#4 was admitted to the facility 5/4/18 with [DIAGNOSES REDACTED]. The documentation further identified Resident #4 was discharged on [DATE]. Resident #4's Discharge Plan, dated 5/9/18, located in the electronic medical record and attached to the residents' care plan documented: (Resident #4) lives alone in a 2-level home with 4 - 5 steps to enter. There are 11 steps to the basement. The discharge plan interventions included: * Encourage to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress. * Establish a pre-discharge plan with the resident, family/caregivers and evaluate progress and revise plan. * Evaluate and discuss with resident/family/caregivers the prognosis for independent or assisted living. Identify, discuss and address limitation, risks, benefits and need for maximum independence. * Make arrangements with required community resources to support independence post-discharge. (Resident #4) prefers (name) Home Health. * Provide a list of any upcoming appointments post discharge. On 6/15/18 at 1:00 PM, the Discharge Coordinator documented a family meeting was held that included Resident #4, her brother, Discharge Coordinator, social service, therapy and nursing staff. The meeting addressed Resident #4's need for nutrition assistance, such as Meals-on-Wheels after discharge. After the family meeting Resident #4's 5/9/18 Discharge Plan was not updated to reflect her need for nutritional assistance post-discharge. Resident #4's medical record, electronic and paper versions, was reviewed and did not reflect an additional meeting with her or her family about her discharge. On 8/9/18 at 11:50 AM, the Discharge Coordinator confirmed Resident #4's Discharge Plan was not updated with current discharge information.",2020-09-01
92,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2018-08-09,661,D,1,0,1TM511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' records contained a complete discharge summary. This was true for 2 of 2 residents (#3 and #4) reviewed who were discharge from the facility. This failure created the potential for harm and inappropriate care due to incomplete documentation related to residents' discharge. Findings include: The facility's Discharge Summary policy, dated (MONTH) (YEAR), documented a recapitulation of residents stay included diagnoses, course of illness/treatment or therapy, pertinent lab, radiology, and consultation results. The policy did not address the need to include other care areas listed on the resident's most recent comprehensive assessment. 1. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses, including malignant neoplasm of the esophagus [MEDICAL CONDITION] (breathing tube), gastrostomy (feeding tube), and muscle weakness. Resident #3 was discharged from the facility on 5/29/18. Resident #3's Weekly Skilled Review meeting, dated 5/24/18, documented several staff attended without the resident present. The notes documented Resident #3's progress towards discharge, including his PEG tube and [MEDICAL CONDITION] management status. Resident #3's Family Meeting and Social Service notes, dated 5/25/18, documented he and a family member were present. The notes documented Resident #3 wanted to discharge from the facility and agreed to be discharge on 5/29/18, after he was able to independently manage his [MEDICAL CONDITION] and PEG tube. Resident #3's Social Service notes, dated 5/29/18, documented, Resident approached discharge planner multiple times throughout the day to discuss discharge .Discharge orders were obtained and reviewed with resident .referral was sent to (Local Home Health Agency). Discharge planner stated it could take a few days for services to begin but resident could expedite process by contacting the home health agency and setting up an appointment that worked for both the home health and resident. A facility's Fax status page, dated 5/30/18 at 8:57 AM, documented Resident #3's medical information was sent to the HH[NAME] Resident #3's Discharge Summary, dated 5/29/18, documented he was admitted to the facility with a [MEDICAL CONDITION] and a feeding tube. The summary of stay included Resident #1 was assisted with therapies related to strengthening, gait/balance and speech, pain management, medication management and assistance with his activity of daily living. The summary did not document Resident #3 was discharged with the services of an HHA and his management status regarding his [MEDICAL CONDITION] and PEG tube. On 8/9/18 at 11:05 AM, the Social Worker and the Discharge Coordinator said nursing completed the discharge summaries and were not aware of what was required on the discharge summary. The Social Worker said the summary did not include documentation Resident #1 went home with services from an HH[NAME] On 8/9/18 at 12:10 PM, the DON said Resident #3's discharge summary did not include documentation he was discharged with HHA services and the DON was not aware of what was required on the discharge summary. 2. The [DIAGNOSES REDACTED].#4 was admitted to the facility 5/4/18 with [DIAGNOSES REDACTED]. The documentation further identified Resident #4 was discharged [DATE]. Resident #4 had a paper medical record in addition to an electronic medical record. Resident #4's Discharge Summary, which was handwritten by a Licensed Nurse on 6/21/18 documented: Pt (patient) admitted to GTC (Gateway Transitional Care) for left knee after surgery care. Pt received assistance (with) ADLs (activity of daily living), medication management, Labs (bloodwork) and Vitals (vital signs), PT/OT/SP (Physical, Occupational, Speech Therapy) for strength training balance and gait training, cognition training. No additional discharge summary information was found in the medical record. The Discharge Summary did not include the following required information: * Identification and demographic information * Customary routine * Cognitive patterns * Communication * Vision * Mood and Behavior patterns * Psychosocial well-being * Physical functioning and structural problems * Continence * Disease [DIAGNOSES REDACTED]. * Dental and nutritional status * Skin condition * Activity pursuit * Medications * Special treatments and procedures * Most recent discharge care plan * Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the MDS. * Documentation of participation in assessment. This refers to documentation of who participated in the assessment process. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care/direct access staff members on all shifts. On 8/9/18 at 11:05 AM, the Discharge Coordinator was interviewed about the contents of the Discharge Summary. The Discharge Coordinator stated she was not aware of the federal discharge summary requirements.",2020-09-01
93,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2019-10-03,551,D,1,0,4YWP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it was determined the facility failed to ensure a resident's rights were not delegated to an unauthorized person for 1 of 8 residents (Resident #3) whose records were reviewed. This resulted in the potential for a resident's rights to be violated. The findings include: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 9/12/19, documented Resident #3's BIMS score was 12, indicating she had mild cognitive impairment. The assessment also documented Resident #3 had the ability to express ideas and wants, she had clear comprehension, and she had the ability to understand others. An Advance Beneficiary Notice of Non-coverage (ABN), dated 7/8/19, documented Resident #3 had reached her maximum level of potential with her Physical and Occupational therapies and would benefit from restorative nursing. The ABN stated, Talked on phone to POA (Power of Attorney) (name of daughter) on 7/8/19 at 2:30 p.m. and is in agreement with plan. Resident #3's Face Sheet, dated 8/2/18, listed her daughter as an emergency contact, not PO[NAME] Resident #3's record included a document which stated her end of life treatment wishes and was signed by Resident #3 and dated 12/5/87. The document included a section to designate a representative for Resident #3 if she was unable to make her own decisions, which was left blank. On 10/3/19 at 7:25 AM, the DON was asked whether Resident #3 had a PO[NAME] The DON stated the facility was trying to figure it out. The facility failed to ensure Resident #3's rights were not delegated to an unauthorized person.",2020-09-01
94,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2019-10-03,559,D,1,0,4YWP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined the facility failed to ensure residents received a written notice prior to a change in their room for 1 of 1 resident (Resident #3) who was reviewed for a room change. This resulted in a lack of information being provided to a resident necessary to make an informed decision. Findings include: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 9/12/19, documented Resident #3's BIMS score was 12, indicating she had a mild cognitive impairment. The assessment also documented Resident #3 had the ability to express ideas and wants, she had clear comprehension, and she had the ability to understand others. Resident #3's record included an untitled document, dated 9/1/19, which stated Resident #3 was moved to a different hall and room that day. The comments section of the document stated DON requested due to Resident altercation. Family notified & patient agreed. An investigation report, dated 9/6/19, included a statement from an RN about an incident which occurred on 9/1/19. The RN statement documented (Resident #3) was moved into a different room on another hall around 10am (sic). (Resident #3) is confused as to what is going on and where her new room is. On 10/3/19 at 7:25 AM, the DON stated there was no additional information related to Resident #3's room change. The facility failed to ensure Resident #3 received a written notice prior to her room change.",2020-09-01
95,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2019-10-03,578,D,1,0,4YWP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it was determined the facility failed to ensure a resident's advance directives were recognized and her physician's orders [REDACTED].#3) whose advance directives were reviewed. This resulted in the potential for a resident's choices for end of life treatment not being honored. Findings include: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3's record included a document which stated her end of life treatment wishes and was signed by Resident #3 and dated 12/5/87. The document stated Resident #3 did not want electrical or mechanical resuscitation if her heart stopped beating, naso-gastric tube feeding if she was unable to take nourishment by mouth, mechanical respirations if she was unable to sustain breathing, and if she was declared brain dead, she did not want mechanical means to prolong her life. Resident #3's current Physician order [REDACTED]. On 10/3/19 at 7:25 AM, the DON was asked about Resident #3's code status. The DON stated the facility was trying to figure it out. The facility failed to ensure Resident #3's advance directives were honored.",2020-09-01
96,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2019-10-03,657,D,1,0,4YWP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, it was determined the facility failed to ensure resident care plans were appropriately revised for 2 of 8 residents (#1 and #3) whose care plans were reviewed. This failure had the potential for residents to not receive care and services which met their needs. Findings include: 1. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 9/12/19, documented Resident #3's BIMS score was 12, indicating she had a mild cognitive impairment. The MDS documented Resident #3 had no behaviors. An investigation, dated 9/6/19, stated on 9/1/19 at 3:00 AM, Resident #5 reported to a CNA on duty Resident #3 was yelling out and he (Resident #5) went into Resident #3's room and found her without covers. The investigation stated Resident #5 replaced the covers on Resident #3 and then reported it to the CN[NAME] The investigation included 3 statements from residents, dated 9/1/19, whose rooms were near Resident #3. The statements documented the following: - One resident (Room B21) statement documented Resident reported he is often awake at night and can hear (Resident #3) yell out frequently throughout the night. Resident stated she (Resident #3) often repeats 'help me, help me.' - The second resident (Room B18) statement documented Resident stated her neighbor (Resident #3), often yells at night and will often yell 'help me, help me.' Resident stated she and (Resident #5) have visited with this resident (Resident #3) at night to help calm her down. - The third resident (Room B23) statement documented Resident stated there is a resident (Resident #3) who calls out throughout the night. Resident stated .she yells out for a long time. Resident #3's care plan did not include a care area or interventions related to nighttime behaviors. On 10/3/19 at 7:25 AM, the DON stated Resident #3's care plan did not address nighttime behaviors and no concerns were reported by the staff. The facility staff did not revise and update Resident #3's care plan to include her nighttime behaviors. 2. Resident #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1's care plan related to falls, dated 5/21/19, stated Do not leave (Resident #1) in room in chair unattended. Resident #1 was observed to be sitting in his wheelchair in his room, watching television. No staff were present in the room with him. On 10/3/19 at 7:25 AM, the DON stated Resident #1 could be left alone in his room and his care plan needed to be revised. The facility failed to ensure Resident #1's care plan was revised to meet his current needs.",2020-09-01
97,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2019-10-03,684,D,1,0,4YWP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, it was determined the facility failed to ensure a resident's care plan was implemented for 1 of 8 residents (Resident #3) whose care plans were reviewed. This resulted in a resident not consuming most of her lunch meal. Findings include: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3's care plan related to eating, dated 2/27/19, stated Resident #3 was to be provided with frequent cueing to eat as much as possible of her meals. Resident #3 was oserved eating lunch on 10/2/19 from 12:15 PM to 12:40 PM. The lunch consisted of a tuna salad sandwich, pasta salad, water, juice, and ice cream. At 12:20 PM, Resident #3 was sitting at the table in the dining room for lunch service. She picked up her tuna salad sandwich. As she was moving the sandwich to her mouth, the contents of the sandwich fell on to her clothing protector. Resident #3 appeared to be unaware that the tuna salad had fallen from the sandwich and she proceeded to eat the bread. Resident #3 then placed her bowl of pasta salad on her plate and a styrofoam container of ice cream on her plate. Resident #3 picked up both her fork and spoon and held them in her right hand, the utensils were held in a crisscrossed position. She then used her fork, which was upside down, to scoop ice cream from the cup. Resident #3 was noted to obtain approximately 1/2 teaspoon of ice cream on her fork and eat it. She repeated this a second time. On the third scoop, 2 tines of the fork became inserted and stuck into the side of the styrofoam cup. Resident #3 let go of the fork and it remained stuck in the side of the cup. Resident #3 then used her spoon and retrieved a large scoop of ice cream. As she lifted the spoon to her mouth, the ice cream fell on to her lap. Resident #3 retrieved a second scoop of ice cream from the cup and as she lifted the spoon to her mouth, the ice cream fell on to her lap. At 12:40 PM, Resident #3 requested help to leave the dining room. A nearby SLP assisted Resident #3 to remove her clothing protector and then used a cloth napkin to wipe the ice cream from Resident #3's lap. The SLP then requested a CNA be paged to help Resident #3 leave the dining room and get cleaned up. At 12:42 PM, the DON came into the dining room and assisted Resident #3 to her room. During the lunch meal, a CNA was observed sitting across from Resident #3 and the CNA was feeding two other residents. The SLP was observed approximately 10 feet from Resident #3 during the lunch meal. The CNA and the SLP did not assist or cue Resident #3 during her lunch. On 10/3/19 at 7:25 AM, the DON stated Resident #3's care plan was not implemented and she should have been assisted with her lunch. The facility failed to ensure Resident #3's care plan was implemented.",2020-09-01
98,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2017-10-13,157,D,0,1,247411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview, it was determined the facility failed to ensure a resident's physician was notified of significant changes in the resident's clinical condition. This was true for 1 of 17 (#2) sample residents and had the potential for more than minimal harm when the facility failed to notify Resident #2's physician of the resident's low blood sugar readings. Findings include: Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's diabetes mellitus care plan documented Monitor/document/report to MD (Medical Doctor) PRN (as needed) signs and symptoms of [DIAGNOSES REDACTED] (low blood sugar). Resident #2's 10/2/17 Order Summary Report documented Humalog (Insulin [MEDICATION NAME]): .If BG (blood glucose) is 70 or below notify MD. Resident #2's 8/1-8/31/17 Medication Administration Record [REDACTED]. Resident #2's 9/1-9/30/17 MAR indicated [REDACTED]. Resident #2's 10/1/17-10/31/17 Medication Administration Record [REDACTED]. On 10/12/17 at 1:05 pm, Resident #2 said he did not notice any symptoms when his blood glucose was low. He did not know if his physician was notified when this occurred. On 10/13/17 at 9:24 am the DON (Director of Nursing) said there was no documentation Resident #2's physician was notified, he did not recall if the physician was notified. The DON stated the nurse should follow physician's orders [REDACTED].",2020-09-01
99,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2017-10-13,164,D,0,1,247411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure a resident's privacy during peri care (cleaning between the resident's legs.) This was true for 1 of 17 sample residents (#4). This deficient practice created the potential for harm should Resident #4 become embarrassed if others observed her receiving peri care and her exposed body was seen by others. Findings include: Resident #4 was admitted to the facility on [DATE] and re-admitted on [DATE] and 7/3/17 with [DIAGNOSES REDACTED]. On 10/11/17 at 4:55 pm, Resident #4 was lying in bed and CNA (Certified Nursing Assistant) #3 entered the resident's room. CNA #3 told the resident she was going to change her disposable briefs and pulled the privacy curtain between the bed and the door. The window blinds were in the open position on the other side of the resident's bed. It was possible to see through the resident's window into a grassy courtyard with a bench facing towards the resident's window. The Courtyard was an open area for staff, visitors, and residents to walk around and sit on the bench. CNA #3 proceeded to pull down Resident #4's pants to her knees, exposing the abdomen, disposable brief, and upper legs. When asked if the resident's privacy was protected, CNA #3 looked at the window and said she should have closed the blinds.",2020-09-01
100,GATEWAY TRANSITIONAL CARE CENTER,135011,527 MEMORIAL DRIVE,POCATELLO,ID,83201,2017-10-13,241,D,0,1,247411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, it was determined the facility failed to ensure residents were treated with dignity and respect during their dining experience when staff stood over a resident while assisting the resident to eat. This was true for 1 of 17 sample residents (#7) and created the potential for harm if residents' sense of self-worth or self-esteem was negatively affected. Findings include: Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #7's 9/8/17 quarterly (Minimum Data Set) assessment documented severe cognitive impairment, and supervision was required for eating. On 10/12/17 at 12:35 pm, CNA (Certified Nursing Assistant) #4 was observed feeding Resident #7 in his room as he sat up in bed. CNA #4 stood on the left side of the resident as she fed him. The resident occasionally opened his eyes to verbal stimuli as CNA #4 fed him a sandwich and potato and assisted him to drink water. On 10/12/17 at 12:45 pm, when asked about how to ensure the resident is treated with respect and dignity during meals, CNA #4 said she should have been sitting down as she fed the resident and she forgot.",2020-09-01