rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,JEFFERSON DAVIS COMMUNITY HOSPITAL ECF,255050,1320 WINFIELD STREET,PRENTISS,MS,39474,2017-07-26,225,D,0,1,UP3C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interview, the facility failed to ensure an unusual occurrence was reported and investigated to ensure serial exposure/abuse didn't occur, for one (1) of 10 sampled residents, Resident #5. Findings include: Review of the facility policy for Reporting Abuse to Facility Management, revised 2014, revealed it is the responsibility of employees and others to promptly report any incident or suspected incident of resident neglect or abuse to facility management. Sexual Abuse is defined as, but is not limited to, sexual harassment, sexual coercion , or sexual assault. 5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, Director of Nursing Service, or Charge Nurse .8. The Administrator or Director of Nursing Services must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or must be paged and informed of such incident. Review of the nurses notes revealed Resident #5 had been exhibiting new inappropriate sexual behavior starting 07/18/17, such as undressing, holding his penis in his hands and asking staff for sex. The nurse's notes dated 7/24/17 at 1:11 AM, 5:43 AM, and 5:50 AM, revealed Resident #5 had been found in two (2) female residents room taking his clothes off and looking at a female in the lobby with his penis in his hands saying come here. In an interview on 07/24/17, during the initial tour, Nurse #4 revealed that Resident #5 had a problem during the last night shift with undressing and going into two (2) female resident rooms. In an interview on 7/24/17 at 10:55 AM, RN #2 stated that Resident #5 had sexually inappropriate behavior during the night shift with staff and two (2) female residents. When asked if this was investigated or reported, RN #2 did not answer. RN #2 stated Resident #5 was in his room at this time awaiting discharge for his behavior. On 07/24/17 at 3:30 PM, Licensed Practical Nurse #1 was asked what happened with Resident #5 on the night shift. She revealed the resident had been found with his pants down standing outside of Resident #3's room and a little later Resident #6 called to ask nurse to come to her room because #5 was in her room. When asked if there was an incident report or investigation to determine if abuse had occurred, she stated the Administrator was made aware later that morning after she reported the incident. She further revealed the Direction of Nursing nor Administrator had been made aware during the night, and no investigation was initiated. Interview with RN #1, Abuse Coordinator, revealed she did not know why the sexually inappropriate behavior of Resident #5 wasn't reported during the night to the Administrator or DON as it should have been. Resident #5 was not available for interview or observation after the tour on 7/24/17, due to discharge related to behaviors. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/28/17, revealed Resident #5 scored 9 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment.",2020-09-01
2,JEFFERSON DAVIS COMMUNITY HOSPITAL ECF,255050,1320 WINFIELD STREET,PRENTISS,MS,39474,2017-07-26,431,E,0,1,UP3C11,"Based on observation, staff interview, record review and facility policy review, the facility failed to discard expired medications from one (1) of two (2) medication carts checked; Medication Cart for 700 and 800 Hall. Findings include: A review of the facility's policy entitled Storage of Medications with a revision date of (MONTH) 2007, reads, the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Observation on 7/25/17 at 9:15 AM, revealed Medication Cart for 700 and 800 Hall had an expired medication of Q-Pap (Acetaminophen) Oral Solution 16 ounces with the bottle remaining one-half ( 1/2) full, with an expiration date of 12/2016. During an interview on 7/26/17 at 2:35 PM, the Director of Nursing (DON) stated that every medication nurse is responsible for ensuring no expired medications are on the medication cart. The DON also stated the Pharmacist checks the medication carts at least once a month. The DON stated: My clinical judgement is the medication would be ineffective, because it is only good for the dates indicated. Interview on 7/26/17 at 2:45 PM, with the Pharmacist, revealed, I think that the drug needed to be pulled and discarded, the drug may not be as effective, it depends on the drug itself. The pharmacist also stated, I spot check the medications once a month, but I don't check every individual medication.",2020-09-01
3,JEFFERSON DAVIS COMMUNITY HOSPITAL ECF,255050,1320 WINFIELD STREET,PRENTISS,MS,39474,2017-07-26,441,E,0,1,UP3C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to provide care in a manner to prevent the possibility of cross contamination for one (1) of four (4) care observations; Resident #2. Findings include: A review of the facility's policy entitled Wound Care revised (MONTH) (YEAR) revealed: Do not directly touch any item that will come in contact with the wound. Discard soiled materials in plastic bag. Remove soiled material from room. A review of the facility's policy entitled Infection Control Guidelines for all Nursing Procedures, revised (MONTH) (YEAR), revealed: Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. Resident #2 Observation on 7/24/17 at 10:35 AM, revealed when RN #3 attempted to place the gauze dressing and her soiled gloves into the wound trash bag, four (4) of the blood-stained gauze dressings and a soiled pair of gloves was noted to fall out of the trash bag onto the Resident's floor, leaving two (2) dime-sized blood stains and [MEDICATION NAME] on the floor. Observation on 7/24/17 at 11:15 AM, revealed RN #3 picked up a wedge cushion off Resident #3's floor and place it underneath Resident #3's right leg. After RN #3 cleaned Resident #2's right great toe, she then reached into the clean normal saline soaked gauze tray and squeezed the excess normal saline from the gauze back into the tray. RN #3 left the two (2) dime-sized blood stains and [MEDICATION NAME] on Resident #2's floor. Observation on 7/24/17 at 2:50 PM, revealed two (2) dime-sized blood stains and [MEDICATION NAME] remaining on Resident #2's floor. In an interview on 7/24/17 at 11:20 AM, RN #3 stated, I had already wiped the wedge cushion off. In an interview on 7/26/17 at 11:45 AM, the Director of Nursing (DON) stated there were germicidal wipes to get initial blood up and then housekeeping had blood spill kits. In an interview on 7/24/17 at 11:45 AM, RN #3 stated, I was not thinking, just not thinking, that's putting the germs back into it (referring to the clean normal saline gauze soaked tray), and that's contamination of the whole thing. A review of the Face Sheet revealed the facility admitted Resident #2 on 6/7/17, with a [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 6/14/17, revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment.",2020-09-01
4,JEFFERSON DAVIS COMMUNITY HOSPITAL ECF,255050,1320 WINFIELD STREET,PRENTISS,MS,39474,2019-09-19,622,D,0,1,S8KJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to convey to the receiving provider, the basis for the transfer from the facility for one (1) of six (6) residents with hospital transfers, Resident #3 Findings Include: Review of a statement on facility letterhead, dated 9/19/19, and signed by the Director of Nursing (DON) revealed,We do not have a policy and procedure that specifically addresses the information that is sent out with the resident to the hospital at time of discharge/transfer. Review of a document, provided by the facility, and signed by the DON, dated 9/19/19, revealed Sending residents to the ER- Transfer/discharge sheet once you fill it out in the computer (print). Record review of physician's orders [REDACTED].#3 was transferred from the facility to the hospital for evaluations. Record review of Resident #3's paper and computer chart revealed no documentation that a transfer summary containing Resident #3's medical status/ Resident Representative Contact information was sent to the receiving facility when Resident #3 was transferred to the hospital three (3) times. An interview on 09/17/19 at 1:25 PM, with the Director of Nursing (DON), revealed, We do not have a transfer summary that was sent to the hospital for Resident #3. We are supposed to send a transfer summary including the reason for transfer to the hospital, Medication Administration Record, [REDACTED].",2020-09-01
5,JEFFERSON DAVIS COMMUNITY HOSPITAL ECF,255050,1320 WINFIELD STREET,PRENTISS,MS,39474,2019-09-19,623,E,0,1,S8KJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to provide written documentation to the resident and/or resident's representative, of the reason for transfer/discharge to the hospital, for six (6) of six (6) hospitalization s reviewed out of 18 residents sampled, Residents #3, #21, #23, #28, #30, and #36. Findings include: A review of the facility's policy titled, Bed-Holds and Returns, with a revision date of (MONTH) (YEAR), revealed: Prior to a transfer, written information will be given to the residents and the resident representatives that explains the details of the transfer. Resident #36 Record review of the physician orders, dated 9/4/19, revealed an order to send Resident #36 to a local Behavior Hospital. The Nurse Progress Note, dated 9/4/19, indicated Resident #36 was observed walking up and down the hallway yelling and cursing staff, and when staff was trying to get the resident back to her room, the resident refused to put clothing on and refused to take medications as well. There was no documented evidence that a written notice was provided to the resident/resident representative regarding information of Resident #36's transfer to the hospital on [DATE]. On 9/17/19 at 1:45 PM, an interview with the Director of Nurses (DON) revealed the facility had not been notifying the resident or the Resident Representatives, in writing, of the reason for transfer to the hospital. On 9/17/19 at 2:07 PM, an interview with Resident #36's Resident Representative revealed no written notice of the reason for transfer to the behavior facility was provided. Resident #3 Record review of physician's orders [REDACTED].#3 was transferred from the facility to the hospital for evaluations. Review of Resident #3's medical record revealed no documentation of a transfer letter to the Resident Representative regarding Resident #3's transfers from the facility to the hospital, prior, during, or shortly after the transfers. The facility failed to provide proof of a written transfer letter mailed to Resident #3's Resident Representative (RR). An interview on 09/17/19 at 11:45 AM, with the Business Office Director (BOD) revealed, We have no documentation that we mailed the Resident Representative written notice of the hospital transfer on any of the days. An interview on 09/17/19 at 11:55 AM, with the DON revealed, The process is that the hospital written transfer sheet should be mailed out the next day after a Resident is transferred out of the facility. It should be mailed by the Social Service Department. An interview on 09/17/19 at 12:00 PM, with the Social Service Director (SSD), confirmed that she did not know of any transfer/bed hold letter that the facility mailed to the Resident Representative when the resident was transferred to the hospital. An interview on 09/17/19 at 1:25 PM, with the DON, revealed the facility did not have a transfer/bed hold sheet for Resident #3 for transfers to the hospital. The DON stated, We don't have any written transfer/bed hold letters that were mailed to the Resident Representative. We don't have proof we mailed anything. Res #23 Review of a physician's orders [REDACTED].#23 was transferred from the facility to the hospital. Review of Resident #23's medical record revealed no written transfer letter to the Resident Representative regarding Resident #23's transfer from the facility. The facility failed to provide proof of a written transfer letter mailed to Resident #23's Resident Representative. Res #30 Review of a physician's orders [REDACTED].#30 was transferred from the facility to the hospital. Review of Resident #30's medical record revealed no written transfer letter to the Resident Representative regarding Resident #30's transfer out of the facility. The facility failed to provide proof of a written transfer letter mailed to Resident #30's Resident Representative. Resident #21 Review of Resident #21's medical record revealed the resident was transferred to the hospital on [DATE], and returned to facility on 5/31/2019, for observation of Pneumonia. Review of Resident #21's medical record revealed no documented evidence of a written transfer notice to the Resident and/or Resident Representative for the 5/27/19 transfer to the hospital. During an interview on 09/17/19 at 1:37 PM, the DON confirmed the facility did not notify the Responsible Party of Resident #2, in writing, for transfer to hospital on [DATE]. Resident #28 Record review revealed Resident #28 was transferred to the hospital on [DATE], and returned on 9/7/2019, for [DIAGNOSES REDACTED]. Review of Resident #28's medical record revealed no documented evidence of a written notice of transfer to the Resident and/or Resident Representative. On 09/18/19 at 3:03 PM, interview with the DON revealed a written notice of transfer was not provided to the Resident Representative regarding the transfer to the hospital on [DATE].",2020-09-01
6,JEFFERSON DAVIS COMMUNITY HOSPITAL ECF,255050,1320 WINFIELD STREET,PRENTISS,MS,39474,2019-09-19,625,D,0,1,S8KJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to notify the resident and/or resident representative of the facility policy for bed hold, for two (2) of six (6) hospitalization s reviewed, Resident #23, and Resident #30. Findings Include: A review of facility policy titled Bed-Holds and Returns, dated (MONTH) (YEAR), revealed Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Resident #23 Record review of a physician's orders [REDACTED].#23 was transferred from the facility to the hospital. Record review of Resident #23's medical record revealed no evidence of a bed hold letter delivered to Resident #23 or the Resident Representative. The facility failed to provide evidence of a documented bed hold letter for Resident #23. Res #30 Record review of a physician's orders [REDACTED].#30 was transferred from the facility to the hospital. Record review of Resident #30's medical record revealed no documented evidence of a bed hold letter delivered to Resident #30 or the Resident Representative. The facility failed to provide evidence of a bed hold letter for Resident #30. An interview on 09/17/19 at 12:00 PM, with the Social Service Director, regarding Resident #23 and Resident #30's transfers, revealed that she did not know of any transfer/bed hold letter that the facility mailed to the Resident Representative when the resident was transferred to the hospital. An interview on 09/17/19 at 1:25 PM, with the Director of Nursing (DON), regarding Resident #23 and Resident #30's transfers, revealed there was no documented transfer/bed hold sheet for the residents for when they went out of the facility to the hospital. The DON stated, We don't have any written transfer/bed hold letters that were given to the resident or mailed to the Resident Representative. We don't have proof we mailed anything.",2020-09-01
7,JEFFERSON DAVIS COMMUNITY HOSPITAL ECF,255050,1320 WINFIELD STREET,PRENTISS,MS,39474,2019-09-19,641,D,0,1,S8KJ11,"Based on record review, staff interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for one (1) of 18 MDS assessments reviewed, Resident #21. Findings include: Review of a facility statement, regarding the Resident Assessment Instrument (RAI) Policy: A comprehensive assessment of a resident's needs shall be made within 14 days of the resident's admission. According to the M0210: RAI Version 3.0 Manual, If a resident had a pressure ulcer/injury that healed during the look-back period of the current assessment, do no code the ulcer/injury on the assessment. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2019, Section M revealed documentation that Resident #21 had a Stage 2 Pressure Ulcer. Record review of the Physician's Progress note, revealed documentation that the Pressure Ulcer for Resident #21 was Healed on 6/20/19. Record Review of the Wound/Skin Management Documentation Record, revealed on 06/24/2019, the wound for Resident #21 was intact. On 09/17/19 at 11:24 AM, an interview with Director of Nursing (DON) revealed Resident #21 had no Pressure Ulcer. During an interview on 09/17/19 at 11:25 AM, Register Nurse #1 confirmed Resident #21's physician documented that #21's Stage 2 ulcer was healed on 6/20/19. On 09/17/19 at 3:30 PM, observation of Resident #21 revealed no pressure ulcers. On 09/18/19 at 09:08 AM, an interview with Licensed Practical Nurse #1/MDS Coordinator, and the Director of Nursing, revealed the Stage 2 wound for Resident #21 healed on 6/20/2019, and the MDS was inaccurately coded. Licensed Practical Nurse #1, stated, I did not observe the wound. On 09/18/19 at 10:56 AM, an interview with Resident #21's Physician revealed Resident #21's wound had healed on 6/20/2019, and orders should have been written to discontinue the treatment.",2020-09-01
8,JEFFERSON DAVIS COMMUNITY HOSPITAL ECF,255050,1320 WINFIELD STREET,PRENTISS,MS,39474,2019-09-19,657,D,0,1,S8KJ11,"Based on record review, facility policy review, and staff interview, the facility failed to revise the Comprehensive Care Plan to reflect a soft wrist splint and interventions, for Resident #3 and the use of an indwelling catheter for Resident #38, for two (2) of 18 care plans reviewed. Findings Include: A review of facility policy titled, Care Plans-Comprehensive, (no date) revealed, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care-Planning interdisciplinary team is responsible for the review and updating of care plans. Resident #3 Record review of the Working Care Plan on the chart, and the most current care plan, initiated 12/12/18, through the review date of 9/30/19, revealed Resident #3's care plan was not revised to include a soft wrist splint and/or interventions related to the splint. Review of an incident report timeline, provided by the facility, revealed Resident #3 had a right wrist splint placed, per Primary Care Provider, on 8/13/19, for a non-displaced distal radial fracture. An observation on 09/16/19 at 8:53 AM, revealed a soft wrist splint noted on Resident #3's right wrist. During an interview on 09/18/19 at 11:07 AM, the Director of Nursing (DON) stated, after reviewing the current care plan and the working care plan on the chart, The right wrist splint interventions are not on the Resident's current care plan or on the working care plan in the chart. An interview on 09/18/19 at 11:20 AM, with LPN #1 MDS/Care Plan Nurse, revealed the soft wrist splint and interventions were not care planned, and they should have been. LPN #1 stated, The nurse who checks the orders when a resident returns from an appointment, is responsible to write the order and care plan the order if needed. An interview on 09/18/19 at 1:37 PM, with the DON, revealed, It is the RN Supervisor or the LPN's responsibility to check a resident back in after an appointment and they are supposed to write any orders that return with the resident. Then, whoever writes the order, is supposed do to create or update the care plan specific to the order. Resident #38 Review of Resident #38's comprehensive care plan, with a target date of 11/30/19, revealed a care plan related to the resident's incontinence, however, there was no care plan for an indwelling urinary catheter. On 9/17/19 at 9:19 AM, an observation revealed Certified Nursing Assistant (CNA) #1, assisted by CNA #2, performed catheter care for Resident #38. The resident was observed to have an indwelling urinary catheter. On 9/17/19 at 11:00 AM, an interview with the Director of Nurses (DON) revealed there was no physician's order or care plan for the indwelling urinary catheter for Resident #38. On 9/17/19 at 11:10 AM, an interview with Licensed Practical Nurse (LPN) #1 revealed a care plan had not been developed for the resident's indwelling urinary catheter. She also stated the current care plan did not reflect the resident's current status regarding the indwelling urinary catheter. During an interview on 09/18/19 at 8:54 AM, Registered Nurse (RN) #3 revealed Resident #38 returned from the hospital (8/19/19) with the catheter and had not had any complications from the urinary catheter.",2020-09-01
9,JEFFERSON DAVIS COMMUNITY HOSPITAL ECF,255050,1320 WINFIELD STREET,PRENTISS,MS,39474,2019-09-19,842,D,0,1,S8KJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and facility policy review, the facility failed to ensure accuracy of the medical record, related to a soft wrist splint and an indwelling urinary catheter, for two (2) of 18 resident medical records reviewed, Resident #3 and Resident #38. Findings include: A review of the facility's policy titled Medication Orders with a revision date of (MONTH) 2014, revealed a current list of orders must be maintained in the clinical record of each resident. A review of the facility's documented statement, signed by the Director of Nursing (DON), not dated, revealed the facility does not have a policy and procedure that specifically addresses the input of orders after a hospital return. Resident #38 A record review of the physician's orders for (MONTH) 2019, revealed there was no order for Resident #38's indwelling urinary catheter. The most recent Discharge-Return Anticipated Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/27/19, was coded to include an indwelling urinary catheter. The resident had a catheter for entire seven (7) day look-back period. On 9/17/19 at 9:15 AM, an observation revealed Resident #38 lying in bed with his eyes open. Resident #38 was observed with an indwelling urinary catheter. On 9/17/19 at 11:00 AM, an interview, with the Director of Nurses (DON), confirmed the medical record was inaccurate related to no physician's order for the indwelling urinary catheter for Resident #38. She also stated the physician orders did not reflect the resident's current status regarding the indwelling urinary catheter. The DON stated Resident #38 had the catheter upon his hospital return (8/19/19). On 9/18/19 at 8:54 AM, an interview, with Registered Nurse (RN) #3, revealed the resident returned from the hospital with the catheter, had poor kidney function, and is unable to urinate on his own. She also stated she would have to look at the chart to make sure of the diagnoses. She stated the resident had not had any complications from the urinary catheter that she is aware of. Resident #3 Review of Physician orders for (MONTH) 2019, revealed no Physician's order for a soft wrist splint to Resident #3's right wrist on 8/13/19. Review of an incident report timeline, provided by the facility, documented on 8/13/19, revealed Resident #3 received a right soft wrist splint, placed per Primary Care Provider, due to a nondisplaced distal radial fracture. An observation on 09/16/19 at 8:53 AM, revealed a soft wrist splint noted on Resident #3's right wrist. An interview on 09/18/19 at 11:00 AM, with the facility Medical Director, revealed he applied the soft splint to Resident #3's wrist in the emergency roiagnom on [DATE]. An interview on 09/18/19 at 11:07 AM, with the Director of Nursing (DON), revealed there should have been an order written [REDACTED]. The DON confirmed the medical record was inaccurate because there was no order written for the wrist splint. An interview on 09/18/19 at 1:37 PM, with the DON, revealed the RN Supervisor or the LPN who checks a resident back in after an appointment are supposed to write any orders that return with the resident. She stated whoever writes the order, is supposed to create or update the care plan, specific to the order. The DON confirmed there was no Physician's order written for Resident #3's splint, nor a care plan updated with written interventions for the soft right wrist splint.",2020-09-01
10,JEFFERSON DAVIS COMMUNITY HOSPITAL ECF,255050,1320 WINFIELD STREET,PRENTISS,MS,39474,2019-09-19,880,E,0,1,S8KJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of observation, record review, staff interview, and facility policy review, the facility failed to provide a Percutaneous Endoscopic Gastrostomy (PEG) tube dressing change in a manner to prevent cross contamination for two (2) of two (2) resident PEG tube care sites observed, for Resident #23 and Resident #38. This was evidenced by allowing resident clothing to touch/cover the PEG site, after cleaning and prior to applying a dressing, during treatment for [REDACTED].#38. The facility also failed to provide wound care in a manner to prevent cross contamination for one (1) of four (4) resident wound care observations, Resident #31. This was evidenced by the RN touching items with ungloved hands prior to performing the treatment. Findings include: A review of the facility's policy titled, Infection Control Guidelines for all Nursing Procedures, with a revision date of (MONTH) (YEAR), revealed: Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. A review of Perry and Potter Nursing Skills and Procedures, eighth edition, page 123, revealed: use of personal protective equipment reduces transmission of microorganisms. A review of facility policy titled, Policies and Practices-Infection control, dated (MONTH) (YEAR), revealed, The facility's infection control policies are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. A review of facility policy titled, Gastrostomy/Jejunostomy Site Care, dated (MONTH) (YEAR), revealed: The purpose of this procedure is to promote cleanliness and to protect the Gastrostomy or Jejunostomy site from irritation, breakdown and infection. Resident #31 On 9/18/19 at 9:48 AM, observation of wound care revealed RN #1 used her ungloved hands to place 10 dry 4 x 4 gauze dressings on a Styrofoam plate, sprayed the dressings with normal saline that she had gotten out of her treatment cart, then gloved and performed the wound care on Resident #31, using the 4 x 4 gauze. Resident #31's soiled dressing was observed to have a moderate amount serosanguious drainage. Resident #31's wound bed was pink with scattered red tissue. Resident #38 On 9/18/19 at 11:28 AM, an observation revealed, while RN #1 set up her supplies, she retrieved the 4 x 4 gauze dressings with her ungloved hands and placed them on a Styrofoam plate. She washed her hands, turned on the overbed light, and applied clean gloves, without washing her hands. She removed the soiled tube feeding dressing, washed her hands, applied clean gloves and performed the site care. On 9/18/19 at 11:48 AM, an interview with RN #1 revealed it was a habit for her to retrieve the 4 x 4 gauze with her bare hands and not use gloves. She also stated it made total common sense, that not wearing gloves while handling the 4 x 4 gauze dressings with bare hands, would cause cross contamination. On 9/18/19 at 11:50 AM, an interview with the Director of Nurses (DON) revealed RN #1 should have used gloves, because she had touched a lot of other things in her treatment cart. The DON stated not using gloves to handle the 4 x 4's could cause cross contamination. On 9/19/19 at 9:56 AM, an interview with RN #2 revealed that RN #1 should have used gloves and not her bare hands, while handling the 4 x 4 gauze dressings, to prevent hand to hand contact with the supplies. She also stated RN #1 could pass germs to the residents by using her bare hands to handle the 4 x 4 gauze dressings. Resident #23 An observation on 09/17/19 at 9:45 AM, revealed RN #1/Wound Care Nurse, entered Resident #23's room, washed and dried her hands, and then turned the faucet off with her clean hand. RN #1 left the room, pulled keys out of her pocket, and opened the wound care cart, then returned the keys to her pocket. RN #1 placed several gauze dressings onto a Styrofoam plate, using her bare hands, then opened the drawer of the wound cart, took out a spray bottle of wound cleanser, wet the gauze, and returned the cleanser to the drawer. RN #1 sanitized her hands, gloved, grabbed the side of Resident #23's geri-chair, and pushed the chair to the side, so she could get to the Resident's stoma. RN #1 pulled up Resident #23's shirt, removed the soiled dressing, and cleaned and dried the resident's stoma. RN #1 pulled the resident's shirt over the stoma between intervals, allowing the shirt to touch the dirty and clean stoma. With gloves on, RN #1 pulled Resident #23's shirt down after applying a new dressing, then, picked up Resident #23's baby doll and handed it to the resident, prior to removing her gloves and washing her hands. An interview on 09/18/19 at 11:50 AM, with RN #1 revealed, I do remember reaching in and getting the gauze with my ungloved hands. It is an infection control issue. RN #1 stated she remembered pulling the shirt back down over the cleaned wound, and stated I mean, what's the point of cleaning the wound if your going to put the shirt back on it. It was contaminated and should have been re-cleaned after the shirt touched it, and before putting a clean dressing on it. I know you probably seen me move the chair with my gloves on, but I don't remember it. I probably did it self-consciously. The wound definitely should have been re-cleaned, prior to putting a clean dressing on. An interview on 09/18/19 at 12:06 PM, with the Director of Nursing (DON), revealed the nurse should not have gotten the gauze with her bare hands, because of cross contamination. The DON stated, If she pulled the shirt back over the wound after cleaning it, and before applying a clean dressing, it was cross contamination also. An interview on 09/19/19 at 9:45 AM, with RN #2, revealed she would possibly consider it an infection control issue with the nurse pulling the shirt back over a cleaned stoma, before applying a clean dressing. She stated she would also consider it a possible infection control issue with the nurse picking up the 4 x 4 gauze with her ungloved hands and placing it onto the plate. She stated, You need a barrier between the clean gauze and your hands. You wouldn't want hand to hand contact with something you're going to use on a resident. You could pass germs to a resident. Record review of a facility document titled, JD-ECF treatment check log Nurse Check off, dated 3/16/16, revealed RN #1 received training in Any cross contamination with treatment.",2020-09-01
11,JEFFERSON DAVIS COMMUNITY HOSPITAL ECF,255050,1320 WINFIELD STREET,PRENTISS,MS,39474,2018-10-31,641,D,0,1,63N611,"Based on record review, facility policy review, and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for falls for one (1) of 12 Resident MDS assessments reviewed, Resident #25 Findings Include: Review of the policy documentation on facility letterhead, provided by the facility, dated 10/31/2018, no signature, revealed the facility followed the Resident Assessment Instrument (RAI) for Minimum Data Set (MDS) coding. Review of Resident #25's Quarterly MDS with an Assessment Reference Date (ARD) of 09/27/2018, revealed Section J1800 coded that no falls, with or without injury, had occurred. Resident #25 had a prior MDS assessment, with an ARD of 07/03/2018, where no falls were coded. Review of a Resident Incident Report, dated 08/17/2018, signed by the Administrator, revealed Resident #25 had a fall with head injury on 08/16/2018. Review of Departmental Notes, dated 08/16/2018 at 1:14 PM, revealed that Resident #25 fell when attempting to go to the bathroom unassisted. During an interview with the Director of Nursing (DON), on 10/30/2018 at 02:15 PM, the DON confirmed that Resident #25 had a fall with head injury on 08/16/2018. An interview with Licensed Practical Nurse (LPN) #1/MDS Coordinator, on 10/31/2018 at 10:40 AM, confirmed that Resident #25's MDS Assessment on 09/27/2018 had been miscoded relating to Resident #25's fall on 08/16/2018. LPN #1 stated that there was nursing documentation on Resident #25's fall with a major injury after the 07/27/2018 MDS assessment and before the 09/27/2018 MDS assessment. LPN #1 stated she agreed that Section J1800 of the 09/27/2018 MDS assessment should have been coded Yes indicating Resident #25 indeed had a fall on 08/16/2018. During an interview on 10/31/2018 at 11:08 AM, the Director of Nursing (DON) confirmed that Resident #25's 09/27/2018 MDS assessment had been miscoded, because of Resident #25's fall on 08/16/2018.",2020-09-01
12,JEFFERSON DAVIS COMMUNITY HOSPITAL ECF,255050,1320 WINFIELD STREET,PRENTISS,MS,39474,2018-10-31,644,D,0,1,63N611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to refer a resident to the appropriate state designated authority for level 2 Pre-Admission Screening Resident Review (PASSR) evaluation and determination for one (1) of three (3) residents reviewed for PASSR, Resident # 4 Findings Include: A record review of the resident's physician's orders [REDACTED]. Resident #4 was not taking [MEDICAL CONDITION] medication upon admission. During an Interview on 10/31/2108 at 10:50 AM, Licensed Practical Nurse (LPN) #1 stated that she's responsible for the PASSR. LPN #1 stated that all newly diagnosed residents with mental or intellectual disorders should be sent to the appropriate agency (Agency Named) to decide whether a level 2 should be done, however, she was unable to get to it at this time. She stated she will take care of the PASSR for Resident #4 as soon as possible (ASAP). LPN #1 stated that the facility does not have a policy on PASSRs, but it is part of her job duty to make sure they are done correctly and timely. A review of the facility's face sheet revealed the facility admitted Resident #4 on 08/24/2017, with [DIAGNOSES REDACTED].",2020-09-01
13,JEFFERSON DAVIS COMMUNITY HOSPITAL ECF,255050,1320 WINFIELD STREET,PRENTISS,MS,39474,2018-10-31,656,D,0,1,63N611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and staff interview, the facility failed to develop a comprehensive care plan to include interventions of a catheter securing device to prevent tension and trauma; and failed to implement the care plan of providing catheter care in a manner to help prevent infection for one (1) of four (4) care plans reviewed, Resident #30. Findings include: Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised (MONTH) (YEAR), revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the facility policy, Perineal Care, revised (MONTH) 2010, revealed that the facility policy, if a resident had a catheter, was to gently wash the juncture of the tubing from the Urethra down the catheter about three (3) inches. The facility policy also noted that the catheter tubing should be held to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. Review of the facility policy, Catheter Care, Urinary, revised (MONTH) 2014, revealed the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. The policy also included documentation to ensure that the catheter remains secure with a leg strap to reduce friction aandmovement at the insertion site. Record review revealed Resident #30's care plan, with an on-set date of 10/8/18, revealed a potential for complications related to an indwelling urinary catheter. Interventions included to keep the catheter and drainage bag lower than the bladder at all times and to provide catheter care with soap and water every shift. The care plan did not address the use of a securing device (leg strap). Review of Resident #30's face sheet revealed that she was admitted on [DATE], with a [DIAGNOSES REDACTED]. Observation on 10/31/18 at 10:36 AM, revealed Certified Nursing Assistant (CNA) #1 provided catheter care for Resident #30, along with assistance of CNA #2. Both CNA's were observed to wash hands prior to providing catheter care. Observation revealed there was no leg band to secure the catheter tubing to prevent the catheter from pulling at the Urethra. CNA #2 held the catheter bag above the Resident's bladder and was holding the catheter at the junction of where it meets the bag tubing, instead of securing it at the Urethra. Then, CNA #1 wiped toward the Urethra, instead of away from it. On 10/31/18 at 12:00 PM, interview with CNA#1 revealed that she knew that she wiped incorrectly when she cleaned Resident #30's Foley catheter. The CNA reported she was not sure about a catheter strap, today was her first day to take care of the resident. On 10/31/18 at 12:34 PM, interview with CNA #2 revealed Resident #30 had a leg strap on the day prior. The CNA reported that the resident should have a catheter strap on at all times to help prevent trauma from pulling. The CNA reported that she knew to hold the catheter at the closest point to the Urethra as possible and that CNA #1 should have wiped away from the Urethra, instead of toward it, while providing catheter care. On 10/31/18 at 11:27 AM, interview with the Director of Nursing (DON) revealed that she expected the resident to have a leg strap to secure the catheter. The DON stated that she expected the CNA to wipe the resident from front to back when providing perineal/catheter care and for staff to clean the catheter by wiping away from the Urethra. The DON reported that she expected the CNA to follow the care plan, which included providing care per the policy. Review of the staff education training, dated (MONTH) (YEAR), on incontinent catheter and peri- care, revealed that staff was trained on assuring that the catheter must be below the bladder at all times to prevent urine from flowing back into the bladder. The training also revealed that the catheter should have a secure leg band on and the catheter should be cleaned from the insertion site to approximately four (4) inches outward.",2020-09-01
14,JEFFERSON DAVIS COMMUNITY HOSPITAL ECF,255050,1320 WINFIELD STREET,PRENTISS,MS,39474,2018-10-31,690,D,0,1,63N611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, and staff interview, the facility failed to provide catheter care in a manner that would prevent infection and/or trauma for one (1) of two (2) resident observations of perineal care, Resident #30. Findings include: Review of Resident #30's face sheet revealed the facility admitted the resident on 9/27/18, with [DIAGNOSES REDACTED]. Review of the facility policy, Perineal Care, revised (MONTH) 2010, revealed if a resident had a catheter, to gently wash the juncture of the tubing from the Urethra down the catheter about three (3) inches. The facility policy also noted that the catheter tubing should be held to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. Review of the facility policy, Catheter Care, Urinary, revised (MONTH) 2014, revealed the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. The policy also included documentation to ensure that the catheter remained secure with a leg strap to reduce friction and movement at the insertion site. On 10/31/18 at 10:36 AM, observation of catheter care for Resident #30, revealed Certified Nursing Assistant (CNA) #1 provided catheter care, along with assistance of CNA #2. There was no leg strap or catheter securing device observed, to prevent the catheter from pulling at the Urethra. CNA #2 held the catheter bag above the resident's bladder and was holding the catheter at the junction of where it meets the bag tubing, instead of securing it at the Urethra. Then observed CNA #1 wiped toward the Urethra, or urinary Meatus, instead of away from it. On 10/31/18 at 11:27 AM, an interview with the Director of Nursing (DON) revealed that she expected Resident #30 to have a leg strap to secure the catheter. The DON stated that she also expected the CNA to clean the catheter tubing by wiping away from the Urethra, instead of toward the Urethra/Urinary Meatus. The DON stated that she expected the CNA to follow their policy for catheter care. On 10/31/18 at 12:00 PM, an interview with CNA #1 confirmed that she wiped incorrectly when she cleaned the Foley catheter for Resident #30. The CNA stated that she wasn't sure about the catheter securing device, because this was the first day she'd provided care for Resident #30. On 10/31/18 at 12:34 PM, an interview with CNA #2 revealed that she had observed the resident to have a leg strap the day before and that the resident should have a catheter strap on at all times to keep from pulling. The CNA reported that she knew to hold the catheter at the closest point to the urethra as possible. The CNA reported that CNA #1 should have wiped the tubing away from the Urethra while providing catheter care. Record review revealed that Resident #30 completed Intravenous (IV) [MEDICATION NAME], an antibiotic, on 10/16/18 for a UTI. The resident had a urinalysis with culture and sensitivity completed on 10/24/18, with no antibiotics prescribed for a UTI at this time. An interview with the DON on 10/29/18 at 3:49 PM, revealed they are waiting on the culture and sensitivity for the Physician to decide if Resident #30 needed treatment with antibiotics. Review of the staff education training, dated (MONTH) (YEAR), on incontinent catheter and peri- care, revealed that staff was trained on assuring that the catheter must be below the bladder at all times to prevent urine from flowing back into the bladder. The training also revealed that the catheter should have a secure leg band, and should be cleaned from the insertion site to approximately four (4) inches outward.",2020-09-01
15,WINSTON COUNTY NURSING HOME,255072,17560 EAST MAIN STREET,LOUISVILLE,MS,39339,2016-02-24,221,D,0,1,MMRK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility policy review, record review and resident interview, the facility failed to ensure that a resident was free from physical restraints as evidenced by Resident #11 had a self release seat belt that she was unable to release upon command for one (1) of three (3) residents reviewed with a self release seat belt. (Resident #11). Findings Include: Facility policy titled, Restraint Use, with a revision date of 8/29/14 revealed, the purpose is to provide residents with physical safety if the resident is at risk to cause harm to themselves. Procedure #3 stated, physical restraints may be defined as a waist belt, roll belt, lap buddy or geri-chair with a tray. During an interview at 9:30 AM on 2/24/16, the Director of Nursing (DON) stated, Resident #11 can release the seat belt, so the facility does not consider it a restraint. At 10:40 AM on 2/24/16, an observation revealed Resident #11 sitting in her wheelchair in her room with the self release seat belt across her waist, attached to the wheelchair. LPN #1 asked Resident #11 to release the self release seat belt. Resident #11 stated, I rarely ever am able to release it. LPN #1 instructed resident to unhook the belt. Resident #11 stated, No. Resident #11 was observed pushing and pulling on the belt and buckle. Resident #11 stated, I can't do it, I'll give it to you, you do it. LPN #1 instructed Resident # 11 to push red button. Resident #11 attempted to push release button, but was unable to push in enough to release belt. Resident #11 attempted for four (4) minutes without releasing belt. LPN #1 stated, She is not going to be able today. She's having a bad day. A review of Resident #11's signed physician's orders [REDACTED]. At 10:45 AM on 2/24/16 an interview with the facility Administrator revealed, some days Resident #11 can remove the seat belt and some days she cannot. Administrator stated the facility is going to do a restraint reduction attempt to see if Resident #11 still needs the belt and will document belt as a restraint. At 11:15 AM on 2/24/16, an interview with the Minimum Data Set (MDS) Coordinator revealed, that if the resident is not able to release the self release seat belt, it should be considered a restraint. At 11:30 AM on 2/24/16, an interview with the DON revealed, if the resident cannot release the belt by herself, it should be considered a restraint. The facility consent for restraints form for Resident #11, dated 5/20/15, lists the self releasing seat belt as a type of restraint to be used. The consent form was signed by Resident #11's responsible party and two (2) witnesses. The Plan of Care Kardex for Resident #11, dated (MONTH) (YEAR), revealed, under the title of restraints, the self release seat belt. The manufacturer's guidelines for the seat belt revealed, Product is not intended to be used as a restraint .Seat belts are not considered to be restraints as long as the individual is capable of releasing the closures themselves. The facility admitted Resident #11 on 5/19/15 with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 1/31/16, revealed a Brief Interview of Mental Status (BIMS) score of one (1), indicating that Resident #11 had severely impaired cognition.",2020-09-01
16,WINSTON COUNTY NURSING HOME,255072,17560 EAST MAIN STREET,LOUISVILLE,MS,39339,2016-02-24,224,D,0,1,MMRK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and the facility's policy review, the facility failed to properly screen new employees for abuse and neglect through the appropriate state agencies as evidenced by lack of fingerprints for one (1) of five (5) new employee records reviewed; (Employee #1). Findings Include: Review of the facility's policy titled, Abuse, Neglect, and Mistreatment of [REDACTED]. Record review for new hires revealed Employee #1 had a fingerprint background check for abuse and neglect through the Mississippi State Department of Health (MSDH) Criminal History Record Check Unit (MCIC) on 12/23/15. Review of a Letter from MCIC, dated 12/29/15, revealed, The fingerprints of (Employee #1) failed to meet quality standards and have been returned from MCIC. Please re-fingerprint and re-submit for processing. During an interview on 02/23/16 at 1:50 PM, the facility's Human Resources Employee (HR) stated she had not re- fingerprinted the Employee #1. It fell through the cracks. On 3/23/16 at 2:25 PM, an interview with the facility's Human Resource Employee revealed, I am leaving a note at the nurses' desk to be reprinted today, she (Employee #1) works 3-11. Review of the facility's Employee checklist, not dated, revealed, Employee fingerprinted and copy received.",2020-09-01
17,WINSTON COUNTY NURSING HOME,255072,17560 EAST MAIN STREET,LOUISVILLE,MS,39339,2016-02-24,252,E,0,1,MMRK11,"Based on observation, staff interview, resident interview, and record review, the facility failed to (a) ensure a resident's wheelchair was maintained in good repair for one (1) of seven (7) sampled residents who utilized a wheelchair for locomotion and (b) ensure foam padding placed on resident beds was maintained in good repair for seven (7) of eight (8) beds with foam padding attached to side rails. Findings Include: On 02/24/16 at 11:45 AM, the Director of Nursing (DON) stated the facility did not have a policy related to the maintenance or repair of resident wheelchairs or foam padding secured to resident bed side rails. Observations on environmental tours of the facility on 02/22/16 from 10:30 AM to 11:40 AM and 02/23/16 from 9:30 AM to 10:00 AM revealed eight (8) beds identified to have gray foam attached to side rails secured with black electrical tape. Of the eight beds identified with foam attached, seven had torn, ripped foam including the A beds in Rooms 11, 14, 17, 23, the A and B beds in room 39, and the A bed in room 48. An observation and interview with Resident #12 on 02/23/16 at 11:25 AM revealed the resident was seated in his room in his wheelchair. The end of the left arm of the wheelchair was broken off and underlying cushion was exposed. The resident stated the arm had been broken for at least a month and he had reported it to staff. Resident #12, who is blind, stated he was unsure who he reported it to. Resident #12 stated the footrest was [NAME]ed up too; demonstrating that the right foot rest when pulled up would not stay up, but flopped back down making it difficult for resident to rise when transferring. An interview on 02/23/16 and 11:15 AM with Maintenance Staff #1 (MS #1) revealed the maintenance staff did rounds in the facility daily. Each of the two nurses' stations (B hall and C hall) had a work order book that the nurses or Director of Nursing (DON) would write work requests in for repair or maintenance. Wheelchair arm replacements or foam attached to side rails would be requested for repair or maintenance. MS #1 did not recall any orders to replace or put on foam on side rails in the past couple of months. MS #1 did not recall any requests regarding wheelchairs in the past month. A review of the work order log revealed there was no work order to repair Resident #12's wheelchair over the past two months. There were also no work orders to replace or repair foam padding attached to bedrails. An interview on 02/23/16 at 11:45 AM with Registered Nurse (RN) #1 on the C Hall revealed she was not aware of any wheelchair or foam on side rails to be in need of repair. RN #1 stated if repairs were needed it would be reported to her or any other nurse on the floor to write in the maintenance work order book and a maintenance worker would review the book to see what needed repair. An interview on 02/23/16 at 2:30 PM with RN #2 on the B Hall revealed she had not been notified of any foam on side rails in need of repair and had not noticed any foam on side rails in need of repair. An interview on 02/23/16 at 3:00 PM with Certified Nurse Assistant (CNA) #4 revealed she had not noticed any problems with wheelchairs or foam on side rails but would report to nurse if she had seen. An interview on 02/23/16 at 3:10 PM with CNA #3 revealed she had not noticed any problems with wheelchairs or foam on side rails. An environmental tour and interview on 02/23/16 at 2:45 PM with the Director of Maintenance (DOM) of the facility revealed confirmation of torn, ripped foam attached to side rails in rooms 11, 14, 17, 23, 39, and 48. The broken wheelchair arm and footrest of Resident #12's wheelchair was also confirmed. The DOM stated that the foam attached to side rails and the wheelchair in need of repair should have been reported to maintenance and had not been. An interview on 02/24/16 at 9:30 AM with the Director of Nurses (DON) and the Administrator revealed that neither was aware of the foam being in disrepair on side rails of resident beds or the wheelchair being in need of repair for Resident #12. The DON stated the floor nurses were to write work orders as repair needs were identified. An interview on 02/24/16 at 9:45 AM with CNA #5 revealed she had seen that Resident #12's wheelchair was in need of repair. She acknowledged it had a broken left arm and the right footrest would not stay up when pulled up. CNA #5 stated she notified the nurses when she saw it and they should have written a work order to have it fixed. CNA #5 declined to identify the nurses she reported to. An interview on 02/24/16 at 9:50 AM with Licensed Practical Nurse (LPN) #2 revealed she had not been notified and had not noticed any problems with Resident #12's wheelchair or foam on side rails of resident beds.",2020-09-01
18,WINSTON COUNTY NURSING HOME,255072,17560 EAST MAIN STREET,LOUISVILLE,MS,39339,2016-02-24,253,D,0,1,MMRK11,"Based on observation, staff interview, and facility policy review, the facility failed to properly store and label resident personal care items for five (5) of ten (10) shared resident bathrooms on B Hall. Findings Include: Review of the facility's policy, titled, Labeling Resident Items, dated 2/22/16 revealed, Purpose: Identify items for personal use to avoid sharing of personal items. Maintain personal items labeled for resident use. During the initial environmental tour on B Hall on 2/22/16 with Licensed Practical Nurse (LPN) #1 at 10:30 AM to 11:45 AM, the following shared bathrooms contained personal items that were unlabeled and not bagged. Room B1 shared bathroom contained all unlabeled: dishwashing detergent, hand sanitizer, mouthwash, two tubes of toothpaste, two toothbrushes, and a hairbrush on the lavatory. Room B3 shared bathroom contained an unlabeled toothbrush and drinking cup. Room B6 shared bathroom contained an unlabeled toothbrush and toothpaste. Room B10 shared bathroom contained all unlabeled: bottle of shampoo, shaving cream, urinal, perineal cleanser, and toothbrush. Room B16 shared bathroom contained an unlabeled urinal. Interview with LPN #1 on 02/22/16 at 10:30 AM revealed these items should not be in these bathrooms. LPN #1 stated these bathrooms are shared by two residents and we need to get the personal items out. Interview with the Administrator on 2/23/16 at 10:00 AM stated staff have been trained to label all personal items when placed in resident rooms. Stated personal items should not be shared.",2020-09-01
19,WINSTON COUNTY NURSING HOME,255072,17560 EAST MAIN STREET,LOUISVILLE,MS,39339,2016-02-24,278,D,0,1,MMRK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure an accurate comprehensive assessment related to coding of a restraint for one (1) of three (3) resident's Minimum Data Set's (MDS) reviewed for restraint use. Resident #11 Findings Include: Facility policy titled MDS Scheduling And Care Plan Updates, with revision date of 8/27/14 revealed: each discipline performs assessment related to their specific sections and address care area assessment (CAA) and related care planning for resident being assessed and changes are discussed with interdisciplinary team to determine if significant change of status has occurred and need of additional assessment with care plan review is required. At 10:40 AM on 2/24/16, an observation of Resident #11 revealed, resident in her room, sitting in her wheelchair with the self release seat belt across Resident #11's waist and attached to the wheelchair. Licensed Practical Nurse (LPN) #1 asked Resident #11 to release self release seat belt. Resident #11 stated I rarely ever am able to release it. Resident #11 attempted to release belt without success. LPN #1 instructed resident to unhook the self release seat belt. Resident #11 stated, NO. Resident #11 pushed in and pulled on belt and buckle without success. Resident #11 stated, I can't do it, I'll give it to you, you do it. LPN #1 instructed resident to push red release button. Resident #11 attempted to push red button on belt buckle but was unable to push in enough to release. Resident #11 attempted for four (4) minutes without success. LPN #1 stated, She's not going to be able to today. She's having a bad day. Review of Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/31/16 for Resident #11, revealed, in section P - Restraints, no restraints were coded. At 11:15 AM on 2/24/16 an interview with MDS Coordinator revealed that she did not see anything in the nurse's notes to indicate Resident #11 was able to remove self release seat belt. MDS Coordinator stated for it not to be coded as a restraint there would have to be documentation to support her ability to release the seat belt. At 11:30 AM on 2/24/16 an interview with Director of Nursing (DON) revealed, if she can't release it by herself then it should be coded as a restraint. The DON confirmed the MDS was not accurately coded for the restraint. The facility admitted Resident #11 on 5/19/15 with [DIAGNOSES REDACTED]. A review of the Quarterly MDS with an ARD of 1/31/16 revealed a Brief Interview for Mental Status (BIMS) score of one (1), which indicated Resident #11 had severely impaired cognition.",2020-09-01
20,WINSTON COUNTY NURSING HOME,255072,17560 EAST MAIN STREET,LOUISVILLE,MS,39339,2016-02-24,279,D,0,1,MMRK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to develop a comprehensive care plan related to use of a restraint for one (1) of 14 comprehensive care plans reviewed. (Resident #11). Findings Include: Review of the facility's policy titled, Care Plan, with a revision date of 9/4/14, revealed a purpose statement of: To direct resident care from admission to discharge. The policy stated: Revision of care plan is ongoing with updates by nursing staff as changes occur throughout the resident's stay, customize the care plan to address the resident's individual concerns and needs, and as changes occur, revise care plan as needed. Review of Resident #11's current care plans revealed the absence of a care plan to address the resident's self release seat belt. At 11:15 AM on 2/24/16, an interview with the Minimum Data Set (MDS) Coordinator revealed, the self release seat belt should have been included in Resident #11's care plan. At 11:30 AM on 2/24/16, an interview with Director of Nursing (DON)revealed a care plan for self release belt should have been developed for Resident #11. The facility admitted Resident #11 on 5/19/15 with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/31/16, revealed a Brief Interview for Mental Status (BIMS) score of one (1), which indicated severely impaired cognition.",2020-09-01
21,WINSTON COUNTY NURSING HOME,255072,17560 EAST MAIN STREET,LOUISVILLE,MS,39339,2016-02-24,282,D,0,1,MMRK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to follow the comprehensive care plan for incontinent care for two (2) of 14 resident care plans reviewed. (Resident #2 and #8). Findings Include: Review of the facility's policy titled Care Plan, dated 10/14, revealed the purpose was to direct care from admission to discharge. Resident #2 At 9:55 AM on 2/23/16, observation revealed Certified Nursing Assistant (CNA) #2 performing incontinent care on Resident #2. CNA #2 performed incontinent care on Resident #2's perineal area, but failed to turn the resident to his side to clean his buttocks before placing his clean brief. A review of Resident #2's comprehensive care plan titled, Bowel and Bladder Deficit, with a 1/18/16 revision date, revealed a goal that the resident was to be kept clean, dry and odor free. Interventions included to check resident every 2 hours to assure needs are being met. During an interview on 2/23/16 at 2:15 PM, CNA # 2 confirmed she failed to clean Resident # 2's buttocks while performing incontinent care. The facility admitted Resident #2 on 6/29/11, readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/14/16, revealed a Brief Interview of Mental Status (BIMS) score of nine (9), which indicated that Resident #2 had moderately impaired cognition. Resident #8 At 9:35 AM on 2/23/16, an observation revealed CNA #1 performing incontinent care on Resident #8. CNA #1 cleaned Resident #8's perineal area, but failed to clean his buttocks before putting a clean brief on the resident. A review of Resident #8's comprehensive care plan titled Bowel and Bladder Deficit, with a 1/6/16 revision date, revealed a goal that stated the resident was to be kept clean, dry and odor free. Interventions included to check resident every 2 hours to assure needs are being met. At 2:00 PM on 2/23/16, an interview with CNA #1 revealed that she realized she had skipped cleaning Resident #8's buttocks and stated she knew what she should have done. At 2:20 PM on 2/23/16 an interview with Director of Nursing (DON) revealed that if the CNAs did not turn the residents on their side and clean their bottom, they did not follow the care plan. The face sheet revealed the facility admitted Resident #8 on 12/23/14 with [DIAGNOSES REDACTED]. A review of the Quarterly MDS, with an ARD of 1/1/16, revealed a BIMS score of four (4), which indicated that Resident #8 is severely impaired, cognitively.",2020-09-01
22,WINSTON COUNTY NURSING HOME,255072,17560 EAST MAIN STREET,LOUISVILLE,MS,39339,2016-02-24,315,E,0,1,MMRK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility policy review, and record review, the facility failed to provide proper incontinent care as evidenced by buttocks not being cleaned during incontinent care for two (2) of four (4) observations for incontinent care. (Resident #2 and Resident #8.) Findings Included: The facility policy titled Incontinent/Perineal Care, with a revision date of 3/2/15 and the purpose stated to cleanse the perineum and provide comfort. The policy stated, It is the policy of this facility that incontinent care will be provided at a minimum of every 2 hours and after episodes of incontinence. Care will include a thorough cleansing of the perineal area. Resident #2 At 9:55 AM on 2/23/16, an observation of incontinent care revealed CNA #2's failure to cleanse the Resident #2's buttocks before putting on a clean brief. During an interview on 2/23/16 at 2:15 PM, CNA #2 confirmed she forgot to clean Resident #2's buttocks. CNA #2 stated she usually turns resident onto his side and cleans his buttocks but failed to do so this time due to being nervous. CNA #2 stated she has been checked off on incontinent care and nurses have observed her perform incontinent care. The face sheet revealed the facility admitted Resident #2 on 6/29/11 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/16, for Resident #2, revealed a Brief Interview of Mental Status (BIMS) score of nine (9), which indicated moderately impaired cognition. Resident #8 On 2/23/16 at 9:35 AM, while performing incontinent care, Certified Nursing Assistant (CNA) #1 failed to cleanse Resident #8's buttocks. At 2:00 PM on 2/23/16 an interview with CNA #1 revealed she knew she had failed to cleanse Resident #8's buttocks. She stated she had attended inservices and had been checked off. At 2:20 PM on 2/23/16, an interview with the Director of Nursing (DON) revealed, the facility provides inservice and checks related to incontinent care to all CNAs. She stated, if they did not turn the residents on their side and clean their buttocks, they did not do what they were taught. Review of facility inservice titled, Peri Care, dated 11/9/15, revealed CNA #1 and CNA #2 were in attendance. The face sheet revealed the facility admitted Resident #8 on 12/23/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/1/16, revealed resident #8 had a Brief Interview of Mental Status (BIMS) score of four (4), which indicated the resident had severely impaired cognition.",2020-09-01
23,WINSTON COUNTY NURSING HOME,255072,17560 EAST MAIN STREET,LOUISVILLE,MS,39339,2016-02-24,323,D,0,1,MMRK11,"Based on observation, staff interview, and facility policy review, the facility failed to ensure proper storage of chemicals, as evidenced by, bleach cleanser stored in unlocked cabinet in resident care area on B hall; one (1) of two (2) resident care halls; B Hall. Findings Include: Review of facility policy, titled, Hazardous Chemical Storage, effective date 2/22/16, revealed, Purpose: Environmental services shall maintain all hazardous chemicals in a safe, clean, and locked location when not in use. All hazardous chemical shall be in control of facility personnel while being used. Procedure: Hazardous chemicals will be maintained in a locked storage area at all times. During the initial environmental tour on 2/22/16 at 10:40 AM, with Licensed Practical Nurse (LPN) #1, an observation revealed a double cabinet with locking mechanisms on each cabinet to be unlocked. The left side cabinet contained resident personal care items for daily care and the cabinet on the right side contained personal care items and a bottle of capped bleach cleanser on the bottom shelf. The weight of the bottle indicated it was near full. A blue ice chest was noted in front of the cabinet containing the bleach cleanser and was partially blocking the cabinet but was easily moved to gain access to the cabinet contents. Interview with LPN #1 on 2/22/16 at 10:40 AM, revealed the cabinets should be locked at all times. LPN #1 stated all Certified Nursing Assistants (CNAs) have access to the cabinet and know to keep it locked at all times. LPN #1 stated there are no wandering residents on B Hall at this time. Stated all residents are both alert and oriented or wheelchair bound requiring assistance. An interview with the Administrator on 2/22/16, at 12:00 Noon, revealed the CNA's washed wheelchairs last night and used the bleach cleanser to clean the wheelchairs. The Administrator stated more than likely one of the CNAs put the cleanser in the cabinet instead of giving it to the nurse. The Administrator stated staff are trained to not put any chemicals in cabinets and they should be kept behind locked doors. She also stated the facility had an inservice regarding proper chemical storage last week. Interview with Certified Nursing Assistant (CNA) #1 on 2/22/16, at 1:30 PM, revealed when she came in to work this morning she opened the left side of the cabinet to get some personal items out. CNA #1 stated both cabinets were locked at that time. CNA #1 stated she did not open the right side of the cabinet and did not see the bleach cleanser. An interview with the Administrator on 2/22/16, at 2:00 PM, revealed she had not been able to determine who placed the bleach cleanser in the cabinet but knew it had to be one of two CNAs that worked the previous night. The Administrator stated one on one inservice was done with both CNAs and the Nurse working. She stated she did not know who unlocked the cabinet and failed to lock it back but she has started inservice training with all staff on the floor. An interview with Licensed Practical Nurse (LPN) #3 on 2/23/16 at 4:40 PM, stated the CNAs usually bring the bleach cleanser back to her to lock up, but they didn't that night. She stated the Administrator called her on 2/22/16 and inserviced her to be sure she always gets the cleanser from the CNAs and locks it up. LPN #3 stated there were no residents on B Hall that wander at night. An interview with Certified Nursing Assistant (CNA) #6 on 2/24/16 at 5:00 PM, revealed she had the bleach cleanser in her hand when a resident called for assistance. She placed it in the cabinet to take care of the resident. She stated she intended to go back and get the cleanser, but forgot. CNA #6 stated the Administrator called her day before yesterday and told her to always be sure to return the cleanser to the nurse. Stated she would not forget again.",2020-09-01
24,WINSTON COUNTY NURSING HOME,255072,17560 EAST MAIN STREET,LOUISVILLE,MS,39339,2016-02-24,441,D,0,1,MMRK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to prevent the possible spread of infection, as evidenced by, Certified Nursing Assistant failed to change gloves and wash hands properly while providing incontinent care for one (1) of four (4) Residents receiving incontinent care; Resident #2. Facility policy titled Hand Washing, with revision date of 8/19/14, revealed the purpose was to remove germs and prevent the spread of infection. The procedure included to vigorously scrub for 10 seconds (longer if soiled) all areas of the hands and hands would be washed before and after providing care to the residents. Facility policy titled Incontinent/Perineal Care, with revision date of 3/2/15, instructed CNA after cleaning the resident to discard soiled gloves and apply a clean pair of gloves and the next step was to apply clean brief and assist resident with clothing. While observing incontinent care of Resident #2 on 2/23/16 at 2:15 PM, Certified Nursing Assistant (CNA) #2 did not change her gloves for the entire care observation. She continued to place a clean brief on the resident, reposition, arrange bed linens, and raise bed rails with soiled gloves. At 2:15 PM on 2/23/16, an interview with CNA #2 revealed she failed to change her gloves properly after cleaning the resident. CNA #2 stated she wore contaminated gloves when she should have washed her hands and put clean gloves on. At 2:20 PM on 2/23/16, an interview with the Director of Nursing (DON) revealed, Certified Nursing Assistants (CNAs) are inserviced on incontinent care. The DON stated the CNAs have been inserviced on changing gloves when they finish cleaning the resident and definitely before putting the clean diaper on and repositioning the resident. At 2:30 PM on 2/23/16 an interview with the Staff Development Nurse revealed, they have incontinent care inservice every six (6) months, the CNAs have access to the policies, and we cover incontinent care with the CNAs step by step. On 11/9/15 an inservice was provided by the Staff Development Nurse titled Peri Care, and documentation showed CNA #2 attended. The face sheet revealed the facility admitted Resident #2 on 6/29/11, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS), with an Assessment Data Set (ARD) of 1/14/16, revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of nine (9) which indicated moderately impaired cognition.",2020-09-01
25,WINSTON COUNTY NURSING HOME,255072,17560 EAST MAIN STREET,LOUISVILLE,MS,39339,2017-04-20,279,D,0,1,09RC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and facility policy review, the facility failed to implement a care plan related to wound care for Resident #8. This was for one (1) of 15 care plan reviewed. Findings Include: Review of the facility policy titled, Nursing Care Plan, stated, Customize the care plan to address the Resident's individual concerns and needs. Review of the resident's care plan revealed the absence of a care plan to address the wound care to the area on the left buttock. Record review revealed a physician's order dated 10/28/16 that stated, Cleanse abrasion to left buttock with normal saline, apply duoderm every three days. Interview with Registered Nurse (RN) #1 on 04/19/17 at 11:10 AM confirmed that she had not implemented a care plan for the skin concern area to the left buttock that developed on 10/28/16. RN #1 also confirmed that it was her responsibility to develop a care plan when the wound care began on Resident #8 and stated that she just failed to do it. Resident #8 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. status was severely impaired and she was unable to complete the assessment.",2020-09-01
26,WINSTON COUNTY NURSING HOME,255072,17560 EAST MAIN STREET,LOUISVILLE,MS,39339,2017-04-20,371,F,0,1,09RC11,"Based on observation, staff interview, record review, and facility policy review the facility failed to store and serve food in a safe and sanitary manner as evidenced by wet nesting of dishware, excessive temperature in dry storage area, and excessive build-up of grease inside the Combi/ convection oven. Findings include: Facility policy titled Storage of Pots, Dishes, Flatware, and Utensils, dated 5/95 and revised 1/14, revealed it is the policy of the facility that pots, dishes and flatware are stored in such a way as to prevent contamination by splash, dust, pests, or other means. Procedures revealed dish handlers and tray-line associates are to air dry all food contact surfaces, including pots, dishes, flatware and utensils before storage or store in a self-draining position. Do not stack or store wet. Facility policy titled Food and Supply Storage Procedures, dated 5/95 and revised 1/14, revealed it is the policy of the facility that all food, nonfood items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. The procedure for dry storage revealed to maintain the temperature of dry storage areas between 50 and 70 degrees Fahrenheit. Review of the Production Cleaning Matrix, undated, revealed daily cleaning duties included to clean Combi/Convection oven inside and out to include insides of the oven, inside and outside glass. The Cleaning Procedure for Convection Oven revealed the cleaning frequency to be: Daily: Exterior, handles, doors, knobs, top, and side using a multi-purpose cleaner and monthly using a heavy duty oven cleaner. Observation of the dietary department on initial tour 4/18/17 at 10:15 AM and subsequent observations on 4/19/17 and 4/20/17 revealed four (4) ounce glasses, eight (8) ounce glasses, and tulip serving bowls stacked in a storage tray with visible moisture present. Observation at these times also revealed a light and dark brown build-up of grease covering the inside walls, racks, drip pan, and door of the Combi/Convection oven and extremely warm temperature inside the room containing the Combi/Convection oven and dry food storage. Foods stored included canned foods, spices, oatmeal, instant mashed potatoes, pasta, and white and brown sugar. Interview with the Dietary Manager (DM) on 4/18/17 at 10:20 AM and on 4/20/17 at 10:20 AM confirmed there was a problem due to wet nesting on the three (3) days of dietary observation. DM confirmed that wet nesting can allow bacteria to grow and cause problems. DM informed staff and dishware was rewashed. Interview with DM on 4/20/17 at 10:15 AM revealed the oven is cleaned every month and is due for a cleaning this week-end. DM confirmed the heavy build-up and oven probably should be cleaned more often. DM confirmed there were no employee log-in sheets for cleaning the oven. DM confirmed the heavy build-up could be a source of contamination and a potential fire hazard. Interview with DM on 4/20/17 at 10:30 AM revealed it was so hot and the circulation was poor in the cooking room because the air conditioner burned out about three (3) months ago. DM stated the fire extinguisher had to be used and all the food stored in the room at that time was thrown away. DM confirmed the temperature in the cooking room was 86 degrees. Interview with the Administrator (ADM) on 4/20/17 at 10:35 AM confirmed the food should have been moved out because it was so hot in the room. ADM confirmed the air conditioner malfunctioned on 3/4/17 making it inoperable and a new control panel was ordered and was currently in stock. ADM stated Maintenance was scheduled to begin replacement on 4/21/17.",2020-09-01
27,WINSTON COUNTY NURSING HOME,255072,17560 EAST MAIN STREET,LOUISVILLE,MS,39339,2017-04-20,441,F,0,1,09RC11,"Based on observation, staff interview, facility policy review and record review the facility failed to clean glucometer and use a surface barrier when performing fingerstick glucose testing to prevent the potential spread of infection for three (3) of 3 finger sticks observed on one (1) of three 3 Units; C unit. Findings include: Record review of the facility policy titled Blood Glucose Monitor with a dated revision date of 3/6/15 revealed, no instructions to clean the glucometer or using a barrier for supplies to prevent the potential spread of infection. Observation on 4/19/17 at 11:10 AM revealed a finger stick performed during med pass by Licensed Practical Nurse (LPN) #1 in room C47[NAME] LPN#1 gathered supplies (glucometer, lancet, gauze, alcohol prep, strip, sharps container, wipes container and a box of gloves) at the med cart and carried them into the resident's room holding supplies against her scrubs top. LPN #1 laid all the supplies on the top of the over bed table, without cleaning the table or using a barrier. LPN #1 gathered all the supplies, carried them against her scrub top and returned them to her med cart without cleaning. An interview on 4/20/17 at 8:15 AM with LPN #1 confirmed she did carry the supplies up against her scrub top into the resident's room and laid them on an uncleaned table top and without a barrier. After the finger stick she gathered the supplies, carried against her scrub top and returned them to the med cart without cleaning. LPN #1 revealed she had been trained to use a barrier but was nervous. LPN #1 confirmed by not using a barrier for supplies, bringing supplies back to the med cart without cleaning could cause cross contamination and infection. Observation on 4/19/17 at 3:45 PM revealed a finger stick performed during med pass by LPN #2. LPN #2 gathered supplies at the med cart (glucometer, gauze, alcohol prep, lancet and strip), did not clean the glucometer before entering room C47A or before performing the finger stick. LPN #2 laid the supplies on the top of the over bed table without cleaning the table top or using a barrier. After performing the finger stick LPN #2 did not clean the glucometer with an approved antibacterial and antiviral cleaner, before placing in the med cart drawer and disposing of the lancet, gauze and strip. Interview on 4/19/17 at 4:30 PM with LPN #2 confirmed she did not clean the glucometer before or after using on the resident in room C47A and did not place a barrier under the supplies placed on the table top. LPN #2 revealed she knew she should clean before and after use of the glucometer because it could cause cross contamination and an infection. Observation on 4/19/17 at 4:20 PM revealed a finger stick performed during med pass by LPN #3. LPN #3 gathered supplies (glucometer, lancet, gauze, strip and alcohol strip) entered room C56 and performed the finger stick without cleaning the glucometer prior to using on the resident. LPN #3 returned to the med cart and returned the supplies and did not clean the glucometer before placing in the med cart drawer. Interview on 4/19/17 at 4:30 PM with LPN #3 confirmed she did not clean the glucometer before or after using on the resident in room C56. LPN #3 revealed she learned in nursing school to always clean the glucometer before and after using on a resident to prevent an infection, but was very nervous. Interview on 4/19/17 at 4:50 PM with the Director of Nursing (DON) revealed she and another nurse are responsible for providing training to the nurses on finger sticks. The DON revealed the nurses should know the process in finger sticks and it could be an infection control issue. Record review of the in-service, dated (MONTH) (YEAR), contained instruction on finger stick blood sugar (Accucheck) which revealed the signature of LPN #2 but did not contain the signatures of LPN #1 or LPN #3.",2020-09-01
28,WINSTON COUNTY NURSING HOME,255072,17560 EAST MAIN STREET,LOUISVILLE,MS,39339,2017-04-20,456,D,0,1,09RC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that resident's Geri chair was maintained in good repair for one (1) of eight (8) residents sampled who required a wheelchair or Geri chair for locomotion, Resident # 6. Findings include: Observation on 4/18/17 at 10:40 AM revealed a brown, vinyl covered Geri chair with nine (9), four (4) to five (5) inch rips in the chair's seat with exposed foam padding, in Resident #6's room. The tears in the covering were sharp and rough to the touch. An interview with the Director of Nursing (DON) on 4/20/17 at 10:30 AM revealed that a maintenance log is kept at each nurse's station, the nurses are to log any needed repairs and maintenance checks the log daily. The log sheet is taken to the maintenance supervisor when repairs are completed. Nurses are instructed to report any equipment or furniture needing repair or replacement. An interview on 4/20/17 at 10:35 AM with Maintenance Staff #1 (MS#1) revealed he does not have a policy addressing the repair or replacement of resident equipment. MS #1 revealed he makes rounds in and out of all the rooms and checks the maintenance logs at the nurse's stations all day. MS #1 stated he was unaware of the tears in the seat of the Geri chair in Resident #6's room. An interview on 4/20/17 at 10:40 AM with the DON in Resident #6's room confirmed the Geri chair had tears in the seat bottom with exposed foam padding that could cause skin tears to the resident if sitting in the chair and is an infection control problem. The DON revealed she was not aware of the condition of the chair. Review of the facility face sheet revealed the facility admitted Resident #6 initially on 4/25/14 and readmitted on [DATE] with [DIAGNOSES REDACTED]. not ambulate but used a wheelchair for mobility.",2020-09-01
29,WINSTON COUNTY NURSING HOME,255072,17560 EAST MAIN STREET,LOUISVILLE,MS,39339,2019-06-06,812,F,0,1,XJRB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to ensure that all staff who were responsible for food and nutrition service, could safely and effectively carry out these functions. This included consistent monitoring of all freezer temperatures; dating Mighty Shakes (nutritional shakes) with thawing date to indicate when to discard per manufacturer's recommendations; ensuring food to be served was at holding temperatures and reheated; documentation of food temperatures prior to serving meals; and ensuring that food is stored away from soiled surfaces. This deficient practice affected four (4) of six (6) resident cottages. Findings include: Review of the facility policy titled Food Storage and Labeling, which became effective on [DATE], revealed the procedures included the following: 1. All food items that are not in their original containers must be labeled and date marked to indicate use by date. 2. Suggested labeling includes: a. Common Name b. Date of preparation or use by date 3. Monitoring Storage Temperatures a. A thermometer is kept in storage areas. b. Temperatures in food storage units are monitored daily. c. Documentation of Temp is recorded on appropriate form. Review of the facility policy #B007 titled Food Handling Guidelines (HACCP), revealed the following procedures: - Hot Holding Temperatures - Foods should be held hot for service at a temperature of 140 F or higher. - Cold Holding Temperatures - Foods should be held cold for service at a temperature of 41 F or less. - Reheating - If a food is being held hot for service falls below 140 F, corrective action is taken and documented, as described on the Production Station Worksheet Report. - Internal temperature of potentially hazardous foods being held hot must be maintained at 135 F according to the 2013 FDA Food Code. The Company's standard for hot holding is 140 F. Review of the facility manual for hot food holding drop-in electric wells (model 500-HWI/D6) called Alto Shaam Halo Heat, revealed the following information was provided for operating instructions: - 2. Place pan dividers and empty pans in the wells. NOTICE: No matter what type of pan configuration chooses, pan separator bars or dividers must be used to close all gaps between pans and edges of the wells. If these gaps are not closed, heat will escape, heat distribution will be uneven, and uniform temperature will be very difficult to maintain. This is a VERY important requirement to follow whenever using this appliance is in use. 3. Preheat - a preheat set is built into the control. When knob is turned to desired setting the appliance will automatically preheat for a predetermined time and then begins to cycle on and off based on the setting selected. The pilot light (green) is on whenever the dial is turned to a number. 4. Load hot foods into the appliance - After preheating, place hot foods into the preheated pans located in the appliance or exchange pans with prefilled product pans. This appliance is designed for hot food holding. Only hot foods should be placed into the appliance. Potentially hazardous foods should be held in the appliance at setting 10. If lower settings are used, ensure the food has maintained safe food temperatures. Lower settings should be tested by user to ensure food has maintained safe food temperatures between 140 and 160 F. All pan divider bars required must be utilized at all times with the pan configuration chosen. Before loading food into the appliance, use a pocket-type thermometer to make certain all products have reached an internal temperature of 140 F to 180 F. Reset thermostat(s) as needed - After all products are loaded into the appliance, it is necessary to reset the thermostat(s). Since proper temperature range depends on the type of products and the quantities being held, it is necessary to periodically use a pocket thermometer to check each item to make certain the correct temperatures range is between a minimum of 140 and 180 F. Cypress Cottage Observation: Initial tour of the Cypress Cottage kitchen area, accompanied by Licensed Practical Nurse (LPN) #13 on [DATE] at approximately 10:05 AM, revealed the internal temperature of the French door refrigerator with ice maker was 40 degrees Fahrenheit (F). Further observation of the refrigerator revealed there was an eight (8) ounce carton of whole milk on the refrigerator door shelf which had been opened and not dated. A re-sealable storage plastic bag with pieces of watermelon was not labeled or dated. Five (5) 8-ounce cartons of fat free milk which expired on [DATE]. And no thaw date on three (3) regular and 11 no sugar added 4-ounce mighty shakes cartons good for 14 days after thawed. During further observation of the Cypress Cottage kitchen on [DATE] at approximately 10:12 AM, with the LPN #13, revealed a form entitled Refrigeration Temperature Record was noted attached to the side of the refrigerator which showed no monitoring of the freezer temperatures were being documented. Observation of lunch meal service in the Cypress Cottage kitchen on [DATE] at 11:34 AM, revealed the Alto Shamm five (5) pan drop in hot holding electric wells had all five (5) knobs at a setting of 7. During that observation it was noted all the wells were uncovered and on the last well on the right, staff had serving utensils including scoops and main entree plates. Continuation of the observation in the Cypress Cottage kitchen on [DATE] at 11:55 AM, revealed a contract Dietary Staff Worker (DSW) #14 arrived with the hot food to be served in an insulated box. All the foods were in different sized pans and covered with plastic. All the food pans were placed into the hot wells except for the one (1) that contained the plates and serving utensils and second one to the left. Small pans of the pureed and chopped meat were noted to be left on the back edge of the hot well near the wall with no access to any heating element. Since the pans were not big enough, they did not cover the entire wells leaving spaces in which the heat could escape. At approximately 11:58 AM, DSW #14 left the kitchen area and CNA #8 calibrated her digital thermometer to 33 F. Once she calibrated her thermometer she began to take the food temperatures. She first started with the pureed and chopped which were both noted to still be by the back edge of the hot holding heated electric wells. The temperature of the pureed chicken was noted to be 113.2 F and the ground chicken was 119.7 F at approximately 12:04 PM. CNA #8 was asked what the food temperature should be when reheated to which she reported it should reach 165 F when reheated. An interview with CNA #15 on [DATE] at approximately 10:10 AM, in the Cypress Cottage kitchen area by the refrigerator, revealed she was not aware that the manufacturer's instructions for the Mighty Shakes, which indicated they were to be used within 14 days of the item being thawed. CNA #15 indicated the Mighty Shakes came already thawed from the Dietary Department and placed in the refrigerator. Interview with CNA #8 on [DATE] at 11:52 AM, in the Cypress Cottage kitchen, revealed the only time she had received any training regarding the kitchen area responsibilities and use of equipment was upon hire during orientation, where she was able to shadow another CN[NAME] She indicated that a CNA would be allowed to shadow another CNA until they themselves told them they were comfortable to start working on their own. The CNA also stated that there were two (2) CNA shifts and each one is supposed to monitor the temperatures for the refrigerator and freezer in the kitchen and monitor for expired items in them. On [DATE] at 12:34 PM, CNA #8 was asked if the heated wells were supposed to have covers and she reported that as far as he knew they had never had any covers for the wells here in Cypress Cottage. CNA #8 stated that she usually kept knob settings at a setting of 7 to 9 for the food, area and in the well where the plates are stored, she had it set to five 5, because at a setting of 10, the plates would get too hot to touch. Per CNA #8, regarding who was responsible to clean the wells, she stated it was the responsibility of the Dietary Department. Interview on [DATE] at approximately at 9:16 AM, with DSW #10, revealed the Dietary staff delivered the food to the cottage kitchens and placed the food pans into the hot holding wells. The CNAs were responsible for serving the food and determining the setting of the temperature knobs for the hot holding electric wells. Interview with the Dietary Manager (DM) on [DATE] at 9:22 AM, revealed the food temperatures were taken prior to delivering the food delivered to the cottages. If they were out of temperature range, then they would heat the food until within an acceptable temperature range. The food was then delivered to each cottage in insulated hot boxes called Cambros. She reported that prior to all this happening, the CNAs were supposed make sure to turn on the hot holding electric wells in the morning to high so that when the food was brought it would stay hot, and at least 30 minutes prior to serving they should lower the temperature to half the setting. The DM stated that the wells were also supposed to have lids, but she just found out yesterday that only one (1) cottage had lids to be used for the hot holding electric wells. The DM also stated the staff was supposed to report to her if they needed any equipment for the wells, so she could order items needed such as the lids. DM further stated the responsibility fell upon the nurse to educate the CNAs on the kitchen tasks. The DM was not sure who trained the nurses on the kitchen tasks. She reported she only provided them with forms for them to use such as temperature logs for refrigerators, food serving temperature logs, etc. The DM further stated that a case of Mighty Shakes was thawed prior to delivery to the cottages, but no date was written on the shakes to identify when they were thawed once they were delivered to the cottages and placed in the refrigerators. Once the items were delivered to the cottages the CNAs were responsible for placing them and all other items delivered to them in the appropriate refrigeration unit. Interview with Nursing Home Administrator (NHA) on [DATE] at approximately 9:43 AM, revealed upon hire during orientation, all CNAs were trained on what was to be done in the kitchen at the cottages by lead educator CNA #7. She indicated the lead educator CNA was Servsafe approved. This meant the lead educator CNA had been trained and certified on food and beverage safety. Elm Cottage - Observations: Observation of the Elm Cottage kitchen on [DATE] at approximately 10:49 AM, with LPN #13, revealed CNA #9 was present. During the observation the French door refrigerator with ice maker was noted to have an internal temperature of 38 degrees F. When the refrigerator was opened it contained four (4) regular and two (2) no sugar added vanilla Mighty Shakes on the top shelf with no thawing date identified. An interview with the CNA #9 during that observation revealed she was not sure how long the Mighty Shakes had been thawed out. Further observation of the French door refrigerator revealed the freezer contained two (2) large re-sealable bags containing two (2) 4-ounce orange sherbet foam cups and ten (10) 4-ounce vanilla ice cream foam cups, frozen to touch, but no thermometer was observed inside to monitor the internal temperature of the freezer. Observation on [DATE] at 11:21 AM, of the Elm Cottage kitchen, revealed the drop in hot holding electric wells currently had a pan of rolls covered with plastic in one well and in the last well towards the right were the plates and serving utensils. Observation of the Elm Cottage kitchen on [DATE] at approximately 11:51 AM, revealed DSW#14 brought the food in the insulated box and placed items in the drop in hot holding electric wells leaving multiple spaces which would let the heat escape. At approximately 11:58 AM, the two (2) CNAs (CNA #11 and CNA #12) in Elm Cottage were observed placing multiple sized pans on the countertop containing the following: 1) salad made with lettuce, cherry tomatoes, and shredded cheddar cheese; 2) ranch dressing; 3) chocolate mousse; 4) angel food cake with a side of strawberry sauce. CNA #11 was observed taking the temperatures of the cold items on the counter at approximately 12:11 PM, which were as follows: - salad - 60.9 F - salad dressing - 63.2 F - chocolate mousse - 49.1 F - angel food cake - 54.7 F When CNA #11 was asked what she would do, she responded she would place the items back in the refrigerator and let dietary know. She did not place the items in the refrigerator at the time. Observation of the temperature for the hot food items on the hot holding heating electric wells prior to the lunch meal service by CNA #11 at 12:16 PM, revealed the following: - mechanical soft meat - 127 F - pureed peas - 116.8 F - pureed sweet potatoes - 133.7 F - mashed potatoes - 124.1 F - hamburger patty - 118.6 F CNA #11 was noted to plate the meals for the residents as per ticket, and if items had not reached the appropriate temperatures, she would reheat the plate with the food and the temperatures were re-documented. During this observation CNA #11 was noted to sanitize the thermometer in between temperatures and then place it in a cup of ice water each time after each was done. When asked why she did this, she said that this was how she was taught. Interview with CNA #11, in the Elm Cottage kitchen on [DATE] at approximately 11:30 AM, revealed she would normally place the hot holding heating electric wells temperature knobs between 8 or 9 setting. CNA #11 stated that she was trained by another CN[NAME] CNA #11 reported the food should be between 147 F - 177 F. CNA #11 also stated that she was supposed to reheat the food in the microwave until it reached a temperature of 145 F or 150 F or something. CNA #11 added that for the year she had worked at the facility, they never had any lids to use for the hot holding electric wells. Review of the documentation provided for both kitchenettes for the Cypress and Elm Cottages provided on [DATE], revealed (MONTH) 2019 through (MONTH) 3, 2019, staff had not been monitoring the internal temperatures of the French door refrigerator freezers. Review of several food temperature logs for the Cypress cottage revealed the following was documented: [DATE] - Lunch: Puree peas - 100.1 F - Dinner: Sweet peas - 134.6 F [DATE] - Lunch: Creamed corn - 120 F and Chicken - 120 F - Dinner: Green salad - 42 F and Pineapple - 48 F [DATE] - No hot or cold food temperatures documented for lunch or dinner [DATE] - Lunch: meat sauce -110 F and no temperature for the green beans - Dinner: no temperatures were documented for either cold or hot foods [DATE] - Lunch: Peaches - 48.8 F Review of several food temperature logs for the Elm cottage revealed the following was documented: [DATE] - Breakfast: Eggs - 134.2 F, Bacon - 107.5 F, French Toast - 122.3 F - Lunch: Baked Chicken - 129.7 F and Puree Meat - 118.1 F - Dinner: Curly fries - 130.4 F, Puree Meat - 125.5 F, Pineapples - 70.1 F [DATE] - Breakfast: Eggs - 132.6 F, Sausage - 128.2? F, Bacon - 102.1 F - Lunch - Mashed potatoes - 122.7 F and Chopped Meat - 120.8 F - Dinner: Grilled Cheese - 90.2 F [DATE] - No documentation done for cold or hot items for dinner [DATE] - Dinner: Potato salad - 62.1 F [DATE] - Breakfast: Puree meat - 112.2 F and Chopped meat - 115.5 F - Lunch: Puree meat - 130.5 F - Dinner: Broccoli - 134.8 F [DATE] - Breakfast: Sausage - 129.6 F and Bacon - 119.2 F - Lunch: Puree Meat - 81.6 F and Chopped Meat - 46.4 F - Dinner: no temperatures documented for either cold or hot [DATE] - Breakfast: Sausage - 134.5 F, Chopped meat - 100.6 F, Puree meat - 106.2 F - Lunch: Chopped meat - 128.2 F and Key lime pie - 50.1 F - Dinner: Puree meat - 98.2 F and Chopped meat - 98.1 F Further review of the Cypress and Elm Cottages food temperature logs revealed the staff filling out the document had not initialed or documented if corrective actions were taken. Hickory Cottage Observations: On [DATE] 11:11 AM, during observation of the Hickory Cottage lunch meal service, revealed the Dietary staff delivered metal pans of food items and placed some of the items inside the heated wells of the food service table and some of the food items on the outer edge of the food service table in an area which was not heated. CNA #1 was observed using a digital thermometer to take food temperatures from the heated food service table and record them on the Temperature Log and Checklist: The - String beans - 144.1 F - Chopped turkey - 114.6 F - Sliced turkey-120.9 F - Cornbread dressing- 143.6 F The following food items were stored on the outer edges of the food service table and not in the heated wells: - Chopped hot dog-106.0 F - Brown gravy- 133.8 F - Hot dog -106.0 F Food items stored on counter top in the kitchen were: - Grapes & strawberries - 68.0 F - Custard pie- 49.2 F There were no lids on the metal pans placed in the heated wells. There was an acrylic sneeze guard covering attached to the heat tables, above the food. On [DATE] 11:16 AM, after taking the temperatures of the food, CNA #1 was asked if she knew what the correct serving temperatures were. CNA #1 replied I know some of them, I don't know all of them. CNA, #2, who was assisting in the kitchen, was asked the same question and replied Yeah. I think it's at the bottom of the page, (referring to the Temperature Log and checklist). The meal service table was set at 3. When asked, how do you know what the heated food service table should be set at, CNA #1 replied The other Manager (he doesn't work here anymore) told us to turn the dials to 3. Without bringing the turkey and gravy up to a safe holding temperature, CNA #1 prepared a plate containing corn bread dressing with gravy, turkey and green beans for Resident #12, and was ready to serve the meal to the resident. Staff was asked to not serve and to have the Dietary Manager come over to the cottage before serving. On [DATE] at 12:34 PM, the Hickory Cottage refrigerator was observed to have multiple areas in the bottom freezer had food debris, melted brown ice cream droppings, and red stains on bottom food shelf. There were ice cream, frozen dinners and multiple bags of frozen fruit stored on wire racks above that area of the freezer. On [DATE] at 2:30 PM, in Hickory Cottage, Dietitian #6 was speaking with the CNA's concerning the use of the heated food service table. Dietitian #6 told the CNA's, You don't put water in them. When asked how the hot food service tables should be set-up, Dietitian #6 replied, We are looking into that now. On [DATE] at 11:25 AM, the Dietary Manager entered the kitchen and was made aware of the low holding temperatures on some of the food items being served for lunch. The Dietary Manager reviewed the temperature log and checklist and looked at the heated food service table and stated, There should be water in those containers on the table. When asked if she makes rounds to ensure the food items being served were at safe holding temperatures, the Dietary Manger replied, I make rounds and they use water in the other cottages. Oak Cottage - Observation: On [DATE] at 10:54 AM, during observation of the Oak Cottage kitchen refrigerator, there were scattered food particles in the bottom freezer storage area. The freezer area stored ice cream and snack bars. The glass drawer cover of the bottom drawer had a caked brown substance on it. Butter and other condiments were stored in the drawer. The stainless-steel garbage can at the entrance of kitchen had a heavy amount of brown, yellow, and white colored food residue on the lid. The wall behind the garbage can had multiple spill/drip marks on it. On [DATE] at 11:49 AM, observation of the Oak Cottage meal service, with the Dietary Manager, revealed there was no water in the food wells of the heated food service table. The cornbread dressing and turkey pans were uncovered on the counter in the kitchen. Residents were seated at the table eating their lunch. Review of the temperature log and checklist for [DATE], revealed the following recorded temperatures: - Chopped meat (turkey) - 139 F - Cornbread dressing- 158 F - Turkey- 134 F - Green beans- 150 F - Pureed: carrots- 134 F - Pureed meat (turkey) -130 F - Pureed green beans -104 F - Pureed gravy-130 F During an interview on [DATE] approximately at 11:49 AM, Licensed Practical Nurse (LPN) #4 stated, The Dietary Manager who use to work here before, told us we didn't need any water because there was no way to get the water out, we were just told to turn it on. During an interview on [DATE] approximately at 11:49 AM, CNA #3 and CNA #5 both stated, We were never told to put water in that table, because if we were told we would have done it that way. The Dietary Manager replied, No one ever told you to put water in there, if you don't put water in it, it can't keep the food hot. I need to get pans for you to put water in them, I guess. During the continued interview on [DATE], CNA #3 was asked what she would consider to be safe temperatures to serve the food during review of the temperature log and checklist. CNA #3 replied, I would say 130 degrees. Located in the lower left-hand corner of the temperature was the following information Minimum Holding Standards: Hot Beverages & Soups >/= 150 degrees, Hot food items: 140 - 165 degrees, Cold food & Beverage CNA #3 and CNA #5 were queried about who taught them how to set-up the heated food service table. CNA #3 replied, The CNA who use to work over here showed me. CNA #5 nodded her head in agreement. The CNAs did not identify CNA #7 (CNA trainer) as the person that provided their training. An interview at 11:00 AM on [DATE], with CNA #5, revealed housekeeping mops the floor. An observation of the cottage kitchen area, during the interview, revealed soiled areas inside of the refrigerator. Both CNA #3 and CNA #5 responded, Oh that needs to be clean, the night shift is supposed to do that when they clean the wheelchairs. When asked if there was a cleaning schedule, CNA #3 looked around the kitchen and then replied I don't know anything about a cleaning schedule. During an interview on [DATE] at 9:23 AM, the Dietary Manager stated, We prepare and deliver the food from our kitchen. We temp our food before we deliver the food to make sure it is at the right temperature. Our staff is not responsible for setting the heat tables up and temping the food after they are delivered to the cottages. Our staff is not responsible for putting the food in the wells. The CNAs are to do that. Staff is supposed to turn the wells on high when they first get in and once they get hot, turn it down to medium heat. We are responsible for the lids and the dividers. Only one (1) of the cottages had the lids, they are supposing to tell me if they don't have lids or dividers. We bring the temp logs over to the main kitchen and I keep them and review them. We do the dishes after the meal. I don't do the education for staff, they are responsible for that. I have just done what my boss have done in the past. I guess I need to speak to the Administrator and talk about what her expectations of us are. On [DATE] at 10:00 AM, Dietitian #6 was queried as to what his responsibilities were as far as food service and training of staff at the nursing home. Dietitian #6 replied, I am mostly clinical, I am involved in the food service, but the training and the set-up is mostly done by the Food Service Director and Manager who is relatively new in her position, a little over a month. On [DATE] at 9:43 AM, in an interview, the Administrator stated, When they are first hired, our Dietitian teaches them about safe-serve, portion sizes and food temps. The Nurse Educator does safe-serve education and the CNA is paired with another CNA who also trains them about the kitchen duties. The Dietitian does cottage visits. The Administrator further stated, Staff knows I have high standards. CNA's should be cleaning out the refrigerators, we don't have a cleaning schedule. Ice machines, garbage cans and the kitchen walls are done by housekeeping. These areas are cleaned monthly by housekeeping. An interview was conducted on [DATE] at 1:04 PM, with CNA #7, who is also responsible for CNA training. CNA #7 stated, I was trained by the on previous Dietitian. I do a walk through in the kitchen and show them how the heat tables work, how to take the temperatures, and I let them know the temperatures for the hot food should be at 140 degrees F and the cold food items should be at 41-degrees F or below. I tell them if the food doesn't reach those temps, call Dietary and inform them that the food is not correct. I tell them to turn the heat tables on an hour or so before the food comes; the setting on the tables should be between 5 and 6. Dietary comes and set the food up, do the food temps, and serve, and keep the food covered up until then. In some of the cottages they had covers, I was always told that the food had to be covered. Only time I go over to the cottages is if I get a complaint that someone doesn't know what they are doing.",2020-09-01
30,"LEXINGTON MANOR SENIOR CARE, LLC",255091,56 ROCKPORT ROAD,LEXINGTON,MS,39095,2017-06-28,280,D,0,1,YQ7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and the facility policy review, the facility failed to revise the comprehensive care plans as evidenced by omission of heel protectors, as ordered by the physician to prevent possible skin breakdown, for one (1) of nine (9) resident records reviewed (Resident #4). Findings include: Review of the facility's Comprehensive Care Plan policy, revised 2/2017, revealed: The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment. Review of the facility's Pressure Injury Prevention policy, dated 04/2017, revealed, To prevent the formation of avoidable pressure injuries, interventions will be documented in the care plan and communicated to all relevant staff. Review of the comprehensive care plans, potential for skin breakdown and self care deficit, dated 5/9/17, did not include applying heel protectors to Resident #4 while in bed. Observation of Resident #4 on 6/26/17 at 1:50 PM, revealed the resident did not have heel protectors while in bed. Review of Resident #4's (MONTH) 2014 physician's orders [REDACTED]. On 06/26/17 at 2:55 PM, an interview with Registered Nurse (RN) #1 revealed, I do the care plans. The heel protectors should have been on the care plans. Review of the facility's face sheet revealed, the facility admitted Resident #4 on 9/24/13. Resident #4's [DIAGNOSES REDACTED]. Review of Annual Minimum Data Set with an Assessment Reference Date of 05/09/17, revealed Resident #4 had a brief Interview of Mental status (BIMS) score of 6, indicating the resident had severely impaired cognition.",2020-09-01
31,"LEXINGTON MANOR SENIOR CARE, LLC",255091,56 ROCKPORT ROAD,LEXINGTON,MS,39095,2017-06-28,282,D,0,1,YQ7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and the facility policy review, the facility failed to follow the care plan for the problem of [MEDICAL CONDITION] related to unspecified [MEDICAL CONDITION], for one (1) of nine (9) records reviewed for care plans, Unsampled Resident #D, as evidenced by not administering medications as ordered, which included, per policy and recommended guidelines, waiting at least five (5) minutes between eye drops. Findings include: Review of the facility's Comprehensive Care Plans policy, with a revision date of 2/2017, revealed, 9. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of the Nursing (YEAR) Drug Handbook, page 233, for [MEDICATION NAME] eye drops, revealed, If more than on ophthalmic product is being used, give them at least 5 minutes apart. Page 468 of the Nursing (YEAR) Drug Handbook, for Dorzolamide ([MEDICATION NAME]) eye drops, revealed if more than one ophthalmic drug was being used, give at least 10 minutes apart. Review of the care plan for Unsampled Resident D revealed a problem onset date of 11/29/2016. The care plan stated Unsampled Resident D was legally blind and could only see shadows and outlines of figures, did not wear glasses, and had a history of [REDACTED]. Review of a Specific Medication Administration Procedures policy, dated 5/1/09, revealed Wait at least five (5) minutes before applying additional medications in the eyes. Observation on 6/27/17 at 8:30 AM, during medication pass to Unsampled Resident #D, revealed Licensed Practical Nurse (LPN) #5 instilled [MEDICATION NAME] 0.15%, one (1) drop, in each eye, followed by [MEDICATION NAME] eye drops, one (1) drop in each eye, without waiting between each medication, per policy and care plan of medications as ordered, which includes the correct procedures. Interview with LPN #5 on 6/27/17 at 8:32 AM, revealed she had not waited three (3) to five (5) minutes, per manufacture guidelines (and care plan to give medications as ordered), between each eye drop for Unsampled Resident #D. Interview on 6/27/2017 at 11:10 AM, with Registered Nurse (RN) #1 revealed she was the only care plan/assessment nurse and had missed some things on the care plan.",2020-09-01
32,"LEXINGTON MANOR SENIOR CARE, LLC",255091,56 ROCKPORT ROAD,LEXINGTON,MS,39095,2017-06-28,314,D,0,1,YQ7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and the facility policy review, the facility failed to prevent possible skin breakdown as evidenced by not applying heel protectors as ordered by the Physician for one (1) of nine (9) resident observations (Resident #4). Findings include: Review of the facility's Pressure injury Prevention policy, dated 04/2014, revealed: To prevent the formation of avoidable pressure injuries, interventions will be implemented in accordance with Physician orders. Review of the facility's Transcribing Physician order [REDACTED]. Review of the physician's orders [REDACTED]. On 06/26/17 at 1:50 PM, during an observation/interview of Resident #4, with Certified Nursing Assistant (CNA)#1 present, revealed Resident #4 laying supine in bed with bilateral heel protectors not in use. CNA #1 stated, They aren't in here, I should have gone to the laundry and got some. I put them on all the time, yes ma'am except today. On 06/26/17 at 3:20 PM, an interview with CNA #2 revealed, I did check his (Resident #4) heel protectors because they told me he didn't have them on, I don't know what time it was. He had them on then. On 06/26/17 at 2:10 PM, an interview with the Director of Nursing (DON) revealed, The orders should pull to the kiosk but the CNA's have a kardex (what the CNAs use as a care guide to care for the residents) they check everyday for changes. During an interview on 06/26/17 at 3:30 PM, the Administrator stated that the CNA's look at the kiosk, they only look at the kardex if there is a power failure. Everything for the care of the resident in on the kiosk and should be done. Review of the facility's face sheet revealed the facility admitted the resident on 9/24/13. Resident #4's [DIAGNOSES REDACTED]. Review of Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/09/17, revealed Resident #4 had a brief Interview of Mental status (BIMS) score of 6, indicating the resident had severely impaired cognition. The MDS revealed Resident #4 was totally dependent for bed mobility, and transfers to wheelchair. The resident was at risk for developing pressure ulcers and a Stage I present ulcer. The Care Area Assessment (CAA) for Resident #4 included a trigger for pressure ulcers.",2020-09-01
33,"LEXINGTON MANOR SENIOR CARE, LLC",255091,56 ROCKPORT ROAD,LEXINGTON,MS,39095,2017-06-28,332,D,0,1,YQ7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and the facility policy review, the facility failed to maintain a less than five (5) percent (%) medication error rate for two (2) of 34 medications administered, which caused an error rate of 5.8%, as evidenced by failure to wait at least five (5) minutes between eye drops for Unsampled Resident D. Findings include: Review of the facility's Specific Medication Administration Procedures policy, with an effective date of 05/01/2009, revealed K. Wait at least five (5) minutes before applying additional medication to the eye. Review of the Nursing (YEAR) Drug Handbook, page 233, for [MEDICATION NAME] eye drops, revealed, If more than on ophthalmic product is being used, give them at least five (5) minutes apart. Page 468 of the Nursing (YEAR) Drug Handbook, for Dorzolamide eye drops, revealed if more than one ophthalmic drug was being used, give at least 10 minutes apart. During medication pass observation on 6/27/2017 at 8:30 AM, Licensed Practical Nurse (LPN) #5 administered eye drops for Unsampled Resident D. LPN #5 placed one (1) drop of Dorzolamide ([MEDICATION NAME]) into each eye. LPN #5 then placed an addition drop of [MEDICATION NAME] at 8:32 AM, into each eye. The time sequence between eye medications was two (2) minutes. Review of the (MONTH) (YEAR) Physician Orders, for Unsampled Resident D, revealed an order dated 2/10/2015, for [MEDICATION NAME] for one (1) drop into both eyes twice a day and an order dated 4/10/2015, for Dorzolamide ([MEDICATION NAME]) one (1) drop in each eye twice a day. Interview on 6/27/2017 at 8:35 AM, with LPN #5, revealed she had not waited five (5) minutes between the eye medications but stated she should have. Registered Nurse (RN) #2, was also present during the administration of the eye medications, and when asked if giving both eye medications close together was a problem, she stated, I don't even know what they were. Interview on 6/28/2017 at 2:40 PM, with LPN #3, revealed there had been no in-service specific for eye drop administration. Interview on 6/28/2017 at 3:00 PM, with the Registered Pharmacist Consultant, revealed the statement, I tell them to wait five (5) minutes between eye drops.",2020-09-01
34,"LEXINGTON MANOR SENIOR CARE, LLC",255091,56 ROCKPORT ROAD,LEXINGTON,MS,39095,2017-06-28,356,C,0,1,YQ7Y11,"Based on record review, staff interview and the facility policy review, the facility failed to accurately post daily staffing as evidenced by posted staffing included scheduled, but not actual working staff for one (1) of three (3) days of survey. Findings include: Review of the facility's Posting Direct Care Daily Staffing Numbers policy, dated 04/2017, revealed: Within two (2) hours of the beginning of each shift the number of available staff will be posted. The posting will include the nursing staff working during that shift. On 6/28/17 at 10:40 AM, a review of the facility's Daily Nurses Staffing Form for 06/28/17, revealed the facility included the actual staff hours worked for 24 hours: Day shift 7:00 AM-7:00 PM and Evening Shift 7:00 PM-7:00 AM. On 6/28/17 at 10:50 AM, an interview with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) #3 documents the daily staffing sheet. On 6/28/17 at 10:55 AM, an interview with LPN #3 revealed she had been told the year before that it was okay to document the staffing sheet for the whole time period and if it wasn't right just to mark it out. On 6/28/17 at 11:00 AM, an interview with the Administrator revealed, We had two (2) complaint surveys about staffing and they were okay.",2020-09-01
35,"LEXINGTON MANOR SENIOR CARE, LLC",255091,56 ROCKPORT ROAD,LEXINGTON,MS,39095,2017-06-28,431,E,0,1,YQ7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and the facility policy review, the facility failed to remove discontinued medications from Medication Cart #2, for one (1) of two (2) medication carts observed. Findings include: Review of the facility's Discontinued Medication Review policy, with a revision date of ,[DATE], revealed, It is the policy of this facility to monitor the med cart and med room for discontinued medication and ensure that discontinued medications are destroyed timely. Review of the Nurses Meeting, (MONTH) (YEAR) in-service record, revealed: Make sure carts are clean, everything open has a date and remove any discontinued medication on cart. Observation with Licensed Practical Nurse (LPN) #4, of Medication Cart #2 on [DATE] at 9:20 AM, revealed one (1) bottle of [NAME]fen Cough Syrup dated [DATE], with the label instructions to give three (3) times a day for seven (7) days, one (1) bottle of Ondansetron dated [DATE], with label instructions to give every six (6) hours for two (2) days, one (1) bottle of Nystatin dated [DATE], with label instructions to give four (4) times per day for five (5) days, one (1) bottle of Geri-Tussin Cough Syrup dated [DATE], with instructions to give every four (4) hours as needed for cough, and two (2) bottles of Megestrol dated [DATE], with label instructions to give twice per day for 30 days. LPN #4 stated the medications were no longer in use and should not have been on the Medication Cart. She further stated it was all the nurses' responsibility to remove discontinued medications. Interview on [DATE] at 2:40 PM, with Staff Development Nurse LPN #3, revealed she didn't have an explanation as to why the discontinued medications were still on the medication cart. Interview on [DATE] at 3:00 PM, with the Pharmacy Consultant, revealed she told the facility nursing staff to destroy the medications as soon as they were expired.",2020-09-01
36,"LEXINGTON MANOR SENIOR CARE, LLC",255091,56 ROCKPORT ROAD,LEXINGTON,MS,39095,2017-06-28,441,D,0,1,YQ7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility policy review, the facility failed to prevent the possible spread of infection as evidenced by failure to wash hands when removing gloves, completing incontinent care without performing hand hygiene upon leaving resident's room, and when disposing of soiled care items in between residents for two (2) of six (6) care observations (Residents #1 and #2) Findings include: Review of the facility's Hand Hygiene Policy, with a revision date of 02/17, revealed staff involved in direct contact with the resident will perform proper hand hygiene procedures to prevent the spread of infection to residents. Hand hygiene refers to either hand washing or the use of an antiseptic hand rub, also known as alcohol based hand rub. The use of gloves does not replace hand hygiene. Wash hands after removing gloves. Antiseptic solution may be applied to hands after proper hand washing. Review of the facility's Hand Hygiene Table, not dated, revealed use either antimicrobial soap and water or alcohol based hand rub between residents, before applying and after removing protective equipment (PPE), including gloves, before and after handling clean or soiled linens, after assistance with personal body functions (elimination), and when in doubt. Observation during incontinent care on Resident #2, on 06/27/17 at 10:25 AM, with Certified Nursing Assistants (CNAs) #3 and #4, revealed CNA #3 removed her gloves after providing incontinent care, left the resident's room and went to the hallway where she obtained clean care supplies and a trash bag from the clean linen cart. CNA #3 took the clean items into Resident #1's room and left them on the night stand. She then went to another resident's room and retrieved a bedside table, then re-entered Resident #1's room to perform incontinent care, all without performing hand hygiene. Observation during incontinent care on Resident #1, on 06/27/17 at 10:40 AM, with CNAs #3 and #4, revealed them completing incontinent care on the resident. Each CNA bagged the soiled items in trash bags and carried them to the trash bins in the hallway. Each CNA lifted the trash can tops, disposed of the soiled bags and re-entered Resident #1's room without performing hand hygiene between residents or after disposing of soiled care items. Staff interview with CNA #3 and #4, on 06/27/17 at 2:30 PM, confirmed they failed to perform hand hygiene after disposing of used care items in the garbage cans in the hallway and prior to re-entering Resident #1's room. CNA #3 confirmed she did not perform hand hygiene after assisting with incontinent care on Resident #2 or before obtaining clean care supplies prior to entering Resident #1's room to perform incontinent care. Staff interview with License Practical Nurse (LPN), Staff Development Nurse/Infection Control Nurse #3, on 06/28/17 at 10:00 AM, confirmed the break in infection control when CNA #3 and #4 failed to perform hand hygiene after they disposed of soiled care items used during incontinent care on Resident #1, and when CNA #3 failed to perform hand hygiene after she assisted CNA #4 with incontinent care on Resident #2, then left the room to obtain clean supplies from the clean linen cart, which she took into Resident #1's room to prepare for incontinent care. LPN #3 stated the most important thing for them to do is wash their hands, especially when in doubt and to always wash their hands when gloves are removed. Interview with the Director of Nursing on 6/26/17 at 11:25 AM, confirmed CNAs should wash their hands when gloves are removed and when entering and exiting the resident's rooms. Review of the facility's face sheet revealed, the facility admitted Resident #1 on 10/25/16. Resident #1's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of the Admission Assessment, dated 04/17/17, revealed Resident #1 had a Brief Interview Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment Review of the facility's face sheet revealed, the facility admitted Resident #2 on 04/08/08. Resident #2's [DIAGNOSES REDACTED].#2 had a BIMS score of 7, indicating the resident had severe cognitive impairment.",2020-09-01
37,"LEXINGTON MANOR SENIOR CARE, LLC",255091,56 ROCKPORT ROAD,LEXINGTON,MS,39095,2016-08-17,246,D,0,1,BYHQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review, the facility failed to place call light within reach of a dependent resident for one (1) of 13 residents observed. (Resident #4) Findings include: Review of the facility's Call Lights policy, dated 7/14, revealed, the purpose of the procedure is to respond to the resident's requests and needs. While the resident is in bed or confined to a chair, the call light should be within easy reach. Observation of Resident #4 on 8/15/15, at 3:58 PM, revealed the resident in bed, alert and oriented. Resident #4 complained of itching all over and began feeling on top of his chest and around his bed with his hands, and was not able to locate his call light, which was located above his head, to the outer right edge of his pillow. Resident #4 said, I can't find it (call light), and confirmed he was completely blind. Staff interview and observation of Resident #4, with LPN (Licensed Practical Nurse) Staff Development Nurse #3 on 8/15/16 at 3:58 PM, confirmed the resident was not able to locate his call light. Staff interview with the Administrator on 8/15/16, at 4:05 PM, confirmed call lights should always be within reach of the resident, and confirmed that Resident #4 was blind. The Administrator said the staff who put the resident back to bed should have placed the call light within reach of the resident. Staff interview/observation with the Dietary Manager (DM) on 8/17/16, at 2:00 PM, revealed Resident #4 lying in bed, with his call light located to the upper right edge of his mattress. The DM asked the resident if he knew where his call light was located. The resident began feeling around his bed with his hands, and said, I can't find it. The DM asked him to reach up high over his bed pillow. Resident #4 held his right arm up onto his pillow and began feeling for the call light. The DM confirmed the resident was not able to locate his call light and that the call light was out of the resident's reach. Staff interview with the Director of Nursing (DON), on 8/17/16 at 2:15 PM, confirmed Resident #4's call light should always be within reach. Review of the facility's face sheet revealed the facility readmitted Resident #4 on 7/05/15, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 7/12/16, Section B 1000: Vision, revealed, 4. Severely Impaired - no vision or sees only light. Section G 0400 B: ROM (Range of Motion) triggered for Impairment on Both Sides. The Assessment revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 8, indicating Resident #4 had moderate cognitive impairment.",2020-09-01
38,"LEXINGTON MANOR SENIOR CARE, LLC",255091,56 ROCKPORT ROAD,LEXINGTON,MS,39095,2016-08-17,278,E,0,1,BYHQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to Activities of Daily Living (ADL) for Residents #1, #9, #10, #12; Hospice Services for Resident #13, for five (5) of 13 MDS assessments reviewed. Findings include: Review of the facility's Minimum Data Set (MDS) 3.0 Assessment Completion, Transmission and Validation policy, dated 07/14, revealed the facility uses an interdisciplinary approach to complete a comprehensive assessment of each resident's functional capacity. Members of the Interdisciplinary Team (IDT) will complete their assigned MDS sections and corresponding Care Area Assessments (CAA) within the specifications and timelines established by the Resident Assessment Instrument (RAI) Manual. Each IDT member is expected to use the RAI Manual as a resource during the assessment coding process. A review of the Centers for Medicare and Medicaid (CMS) RAI 3.0 Manual, dated 10/15, revealed under the section 1.3 Completion of the RAI, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Sources must include the resident, direct care staff on all shifts, the resident's medical record, physician and family. Information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy by the IDT completing the assessment. A review of the RAI 3.0 Manual under Section G0110 Activities of Daily Living (ADL) Assistance, revealed to code total dependence, the resident must be unwilling or unable to perform any part of the activity over the entire 7 day look-back period. Resident #1 A review for Resident #1 revealed a quarterly MDS assessment with an Assessment Reference Date (ARD) of 05/16/16. Section G 120 revealed Resident #1 was totally dependent with bathing and required two (2) or more persons for physical assistance. Review of the five (5) day admission MDS assessment with an ARD of 02/24/16 revealed Section G 120 was also coded totally dependent of two persons with bathing. Review of the ADL charting during the seven (7) day look-back period (05/10/16 - 05/16/16) for the quarterly 5/16/16 MDS assessment, revealed Resident #1 required only physical help in part of bathing with assist of one person on 05/13/16. A review of the ADL charting during the 7 day look-back period (02/19/16-02/24/16) for the 2/24/16 MDS, revealed Resident #1 required physical help in part of bathing with one person on 02/20/16. Interview on 08/17/16 at 2:00 PM, with Certified Nursing Assistants (CNA) #6 and #7 revealed that Resident #1 does not assist staff when he gets his bath. CNA #6 stated He is dependent on 2 staff for bathing. Interview on 08/17/16 at 6:00 PM, with egistered Nurse (RN) #1, revealed that she completed the quarterly MDS assessment for Resident #1 and had coded total dependence for bathing with two (2) persons assist. RN #1 confirmed that the RAI Manual is used as a reference guide when completing the MDS assessment. RN #1 further revealed that total dependence cannot be coded unless the resident has required total assist from staff every shift during the 7 day look-back period of the MDS assessment completed. Review of the Face Sheet revealed the facility admitted Resident #1 on 02/17/16, with [DIAGNOSES REDACTED]. A review of the most recent quarterly MDS assessment with an ARD of 05/16/16, revealed Resident #1 scored 8 on the Brief Interview for Mental Status (BIMS), which indicated moderately impaired cognitive skills. Resident #9 Record review for Resident #9 revealed a quarterly MDS assessment with an ARD of 07/05/16. Section G 120 revealed Resident #9 coded as being totally dependent with bathing and required two (2) or more persons for physical assistance. A review of the ADL charting during the seven (7) day look-back period (06/29/16 - 07/15/16) for the quarterly 7/5/16 MDS assessment revealed Resident #9 required physical help limited to transfer only with assist of one (1) person for bathing on 06/30/16; physical help in part of bathing with one (1) staff assist on 07/02/16 and 07/04/16. Interview on 08/16/16 at 8:35 AM, with Resident #9 revealed she is able to wash herself but the CNA washes her back because I can't reach back there. Interview on 08/16/16 at 3:15 PM, with CNA #1 revealed Resident #9 required limited assistance of one (1) person for bathing. CNA #1 further revealed that Resident #9 receives her bath on the night shift. Interview on 08/17/16 at 4:45 PM, with RN #2 confirmed Resident #9 was not dependent for bathing. RN #2 revealed Resident #9 can do a lot for herself. RN #2 stated staff sets up for bathing, stays with her while she bathes, and probably assists with washing areas that she can't reach. Interview on 08/17/16 at 6:05 PM, with RN #1, revealed that Resident #9 was not dependent with bathing and required two (2) staff for assistance. RN #1 confirmed that she completed the MDS assessment for Resident #9. RN #1 further revealed that she codes the MDS assessment for ADL care based on the information that the CNAs chart in the computer. A review of the Face Sheet revealed the facility readmitted Resident #9 on 07/11/13, with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment with an ARD of 07/05/15, revealed Resident #9 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated no cognitive impairment. Resident #10 A review of the annual MDS assessment with an ARD of 07/11/16, for Resident #10, revealed Section G 120 was coded as total dependent of two (2) of more staff for bathing. A review of the ADL charting during the seven (7) day look-back period (07/05/16 - 07/11/16) for the annual MDS assessment revealed Resident #10 required supervision and setup help only with bathing on 07/11/16. Interview on 08/17/16 at 4:40 PM, with RN #2, revealed Resident #10 was not totally dependent with bathing. Interview on 08/17/16 at 6:08 PM, RN #1 confirmed by stating No regarding whether Resident #10 was totally dependent upon two staff for bathing. RN #1 stated the MDS was coded wrong for bathing. Review of the Face Sheet revealed the facility admitted Resident #10 on 03/17/08 with [DIAGNOSES REDACTED]. A review of the annual MDS assessment with an ARD of 07/11/16, revealed Resident #10 scored 15 on the BIMS, which indicated Resident #10 was cognitively intact. Resident #12: Review of Resident #12's MDS with an ARD of 5/31/16, Section G 120, coded the resident with total dependence with the assistance of two (2) or more persons for bathing. The MDS with an ARD of 3/4/16, coded Resident #12 for total assistance with two (2) or more persons required for bathing. Record review of the Certified Nursing Assistants (CNA) computer documentation during the seven (7) day look-back period for the 3/4/16 MDS, from 2/26/16 through 3/4/16, revealed only three (3) of the seven (7) days reflected total assistance required for Resident #12's bathing. Computer documentation for the Quarterly 5/31/16 MDS, dates of 5/25/16 through 5/31/16, revealed only four (4) days where Resident #12 required two (2) person physical assist with bathing. An observation and interview of Resident #12 on 8/17/16 at 11:30 AM, revealed Resident #12 lying in her bed. She stated she was not feeling well today. She said she is normally up, washes her face before every meal, ambulates about the facility using her walker and usually bathes at the sink herself. An interview on 8/17/16 at 12:00 PM, with Registered Nurse (RN) #2, who serves as Monday through Friday, day charge nurse, revealed Resident #12 likes to stand at the sink and wash her face, brush her teeth and bathe. RN #2 said Resident #12 is not totally dependent upon staff for ADLs most days. In an interview on 8/17/16 at 6:00 PM, RN #1 revealed Resident #12 is not totally dependent for ADLs, and could help with some assistance from staff. She said she had miscoded the MDS for bathing on the Annual MDS assessment dated [DATE] and again on the Quarterly assessment dated [DATE]. The facility admitted Resident #12 on 7/3/12. Resident #12's [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 5/31/16, revealed Resident #12 had a BIMS score of 15, indicating the resident was cognitively intact. Resident #13: Record review revealed Resident #13's physician orders [REDACTED].>Review of the MDS assessments with ARDs of 9/30/15 and 12/21/15 did not reflect Hospice Care Services. An observation of Resident #13, with CNA #6 on 8/17/16 at 12:00 PM, revealed the resident sleeping soundly on and air mattress with the head of the bed slightly elevated and several positioning devices noted under her coverings. CNA #6 stated Resident #13 received Hospice services daily Monday through Friday. An interview with RN #1, the MDS Coordinator, revealed her acknowledgment of a coding error on both the 9/30/15 and 12/21/15 MDS submissions. She stated she failed to code Hospice services on both MDS assessments. Review of the facility's face sheet revealed, the facility admitted Resident #13 on 4/4/06. Resident #13's [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 5/31/16, revealed Resident #13 had a BIMS score of 3, indicating the resident had severely impaired cognition.",2020-09-01
39,"LEXINGTON MANOR SENIOR CARE, LLC",255091,56 ROCKPORT ROAD,LEXINGTON,MS,39095,2016-08-17,280,E,0,1,BYHQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review, the facility failed to revise the comprehensive care plan to reflect the conditions of the resident related to Foley Catheter Care and Oxygen use for Resident #4, and bathing for Residents #2, #9 and #10, for four (4) of the 13 resident records reviewed. Findings include: A review of the facility's Care Plans-Comprehensive policy, dated (MONTH) (YEAR), revealed the facility develops a plan of care through the interdisciplinary team to coordinate and communicate care approaches and goals for the resident related to clinical [DIAGNOSES REDACTED]. Outcome objectives are reflective and the facility staff uses the objectives to monitor the resident's progress. The purpose includes the development and modification based on the resident's status. Review of the facility's Comprehensive Care Plans policy, dated 07/14, revealed the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to a meet a resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment. The care plan will be reviewed and revised quarterly, annually, with significant change of status and as needed to enhance the residents ability's to meet his/her objectives. The facility also provided a document signed by the Administrator stating, It is our facility's policy to use the guidance from the CMS RAI manual for care planning. The RAI Manual, dated (MONTH) 2012, provided by the facility, revealed under section 4.4: Facilities use the findings from the comprehensive assessment to develop an individualized care plan to meet each resident's needs. Resident #4 Record review of Resident #4's physician's orders [REDACTED]. An order, dated 7/28/16, noted to irrigate Foley catheter with 30 to 60 milliliters (ml) of sterile water as needed for leakage or obstruction. Review of Resident #4's incontinent care plan with an onset date of 7/05/16, revealed, the elder (resident) is continent of bowel, and had a Foley catheter. A care plan for the Stage 4 sacral wound dated 7/5/16, documented Resident #4's Foley catheter. There was no care plan intervention for providing catheter care daily and as needed or for the irrigation of the Foley for either care plan. Record review of Resident #4's physician's orders [REDACTED]. Review of Resident #4's care plan for shortness of breath, dated 7/5/16, did not reveal an intervention/approach for the resident to have two (2) liters of oxygen by nasal cannula as needed. Interview with Registered Nurse/Minimum Data Set Nurse (RN/MDS) #1 on 8/16/16 at 3:58 PM, confirmed she should have revised the care plans to reflect the physician's orders [REDACTED].#4's condition. She said she is responsible for initiating and updating the residents care plans. Review of the facility's face sheet revealed the facility readmitted Resident #4 on 7/05/15, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 7/12/16, revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 8, indicating Resident #4 had moderate cognitive impairment. Resident #2 Review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/11/16 for Resident #2, Section G 120 revealed Resident #2 was totally dependent with bathing and required two (2) or more persons for physical assistance. A review of the comprehensive care plan for Resident #2 revealed a problem related to the resident's need for assistance with Activities of Daily Living (ADL) due to weakness secondary to [MEDICAL CONDITIONS] and [MEDICAL CONDITION],dated 11/5/15. Interventions for this problem did not address bathing. Interview on 08/17/16 at 6:08 PM, with Registered Nurse (RN) #1 revealed the MDS assessment should match the care plan. Review of the Face Sheet revealed the facility readmitted Resident #2 on 01/09/14, with [DIAGNOSES REDACTED]. A review of the most recent quarterly MDS assessment with an ARD of 07/11/16, revealed Resident #2 scored 15 on the BIMS, which indicated no cognitive impairment. Resident #9 Review of the quarterly MDS assessment with an ARD of 07/05/16 for Resident #9 revealed Section G 120 was coded totally dependent with bathing with two (2) or more persons for physical assistance. A review of the comprehensive care plan for Resident #9, dated 4/11/16, revealed a problem that addressed resident requiring limited assistance with ADL related to weakness. Interventions for that problem did not address bathing for Resident #9. Review of the Face Sheet revealed the facility readmitted Resident #9 on 07/11/13, with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment with an ARD of 07/05/15 revealed Resident #9 scored 15 on the BIMS, which indicated the resident was cognitively intact. Resident #10 Review of the annual MDS assessment with an ARD of 07/11/16, for Resident #10, revealed Section G 120 was coded as total dependent of two (2) of more staff for bathing. A review of the comprehensive care plan for Resident #10, dated 7/11/16, revealed a problem to address the resident requiring limited assistance with ADLs related to an old [MEDICAL CONDITION]. Interventions for this problem did not address bathing for Resident #10. A review of the Face Sheet revealed the facility admitted Resident #10 on 03/17/08, with [DIAGNOSES REDACTED]. Review of the annual MDS assessment with an ARD of 07/11/16, revealed Resident #10 scored 15 on the BIMS, which indicated the resident was cognitively intact.",2020-09-01
40,"LEXINGTON MANOR SENIOR CARE, LLC",255091,56 ROCKPORT ROAD,LEXINGTON,MS,39095,2016-08-17,441,E,0,1,BYHQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review, the facility failed to provide Foley/incontinent care in a manner to prevent the possible spread of infection, for two (2) of five (5) care observations. (Residents #4 and #8) Findings include: Observation of Foley catheter care on Resident #4, on 8/17/16 at 2:33 PM, with Certified Nursing Assistant (CNA) #2 and CNA #3, revealed CNA #3 removed the Foley catheter draining bag from the resident's bed frame and placed it on the resident's bed, adjusted the bed frame with bare hands, then donned gloves without hand hygiene. She then repositioned the Foley catheter bag on the bed and removed the catheter strap from the resident's left thigh. CNA #3 provided Foley catheter care. CNA #3 applied the leg strap back onto the resident's left thigh, while CNA #2 applied the Foley catheter tubing to the leg strap, and picked up the Foley catheter drainage bag from the bed linens, and hung it to the bed frame. CNA #2 and CNA #3 repositioned the resident in bed with the cotton pad without changing gloves and performing hand hygiene. CNA #3 pulled up the bed frame with while wearing the same soiled gloves used to clean the resident's perianal area. Staff interview with CNA #2 and CNA #3 on 8/17/16, at 2:50 PM, revealed both CNAs confirmed having a break in infection control during Resident #4's Foley catheter care. CNA #2 and CNA #3 both confirmed repositioning the bed rail, Foley catheter, resident and bed linens with soiled gloves. Staff interview with LPN #3/Staff Development Nurse, on 8/17/16 at 3:05 PM, confirmed there was a break in infection control when CNA #2 and CNA #3 provided Foley catheter care on Resident #4. She said CNA #2, and CNA #3, should have washed their hands when going from dirty to clean care during the resident's Foley catheter care. Review of the facility's face sheet revealed the facility readmitted Resident #4 on 7/05/15, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 7/12/16, revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 8, indicating Resident #4 had moderate cognitive impairment. Resident #8 Observation of incontinent care on Resident #8, on 8/16/16 at 10:32 AM, with CNA #4 and CNA #5, revealed CNA #4 pulled back the resident's bed covers, without washing her hands, then pulled clean wet wipes from the wipes container and placed them on the towel atop the bedside table. CNA #5 used the wipes which were laid upon the bedside table to perform incontinent care on the resident. After completion of incontinent care, CNA #4, and CNA #5 placed a clean cloth pad underneath the resident, repositioned the resident and her linens without the use of hand hygiene or change of gloves. Staff interview with CNA #4 on 8/17/16 at 3:20 PM, confirmed she had a break in infection control when she pulled back Resident #8's bed covers and proceeded to pull wet wipes from the wipes container and placed them on the bedside table for CNA #3 to use for incontinent care on the resident. She confirmed not washing her hands and changing gloves after incontinent care, and before repositioning the resident and her bed covers. Staff interview with CNA #5, on 8/17/16, at 3:25 PM, confirmed she had a break in infection control when she used the wet wipes which CNA #4 pulled from the wipes container and placed them on the bedside table for her to use for incontinent care on Resident #8. She confirmed not washing her hands and changing gloves after incontinent care, and before repositioning the resident and her bed covers. Review of the facility's face sheet revealed the facility admitted Resident #8 on 5/11/16, with [DIAGNOSES REDACTED]. Resident #8's most recent MDS with an ARD of 8/9/16, revealed a BIMS score of 2, indicating Resident #8 had severe cognitive impairment.",2020-09-01
41,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-01-13,164,D,0,1,QXQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to provide privacy by not closing the window blinds during incontinent care for one (1) of five (5) incontinent care observations, Resident # 13. Findings include: Review of the facility's policy titled, Perineal Care, dated 8/2014, revealed avoid unnecessary exposure of the resident's body. Review of the facility's Resident's Rights, no date, revealed the resident had the right to personal privacy. During an observation of an incontinent care for Resident #13 on 01/12/17 at 11:00 AM, provided by Certified Nurse Aide (CNA) #2, assisted by CNA #4, revealed CNA #2 removed the top sheet, and placed a towel over the resident's lap area. CNA #2 performed all of the incontinent care without closing the window blinds. CNA #2 pulled the privacy curtain between the bed and the door, and left the window blinds open. Interview with CNA #2 on 01/12/17 at 3:00 PM, confirmed the blinds were left open during incontinent care for Resident #13. Review of in-services provided by the facility dated 11/28/16 through 11/29/16, titled Privacy, revealed during resident care the room door should be closed, and the curtain should be pulled around the bed. The in-service did not address closing the window blinds. Review of the facility's Face Sheet revealed the facility admitted Resident #13 on 06/14/07. Resident #13's [DIAGNOSES REDACTED]. Review of Resident #13's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/14/16, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Resident #13 was able to understand others, and make herself understood to others. Resident #13 required extensive assistance with one to two person physical assist with bed mobility, transfers, toilet use, dressing, and bathing. Resident #13 was always incontinent of bowel and bladder.",2020-09-01
42,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-01-13,278,E,0,1,QXQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to accurately code the Minimum data Set (MDS) for two (2) of 23 MDS's reviewed. Resident #1 and Resident #2. Findings include: A review of the facility's policy titled Assessment Coordinator, dated (MONTH) 2001, revealed that each individual who completes a portion of the MDS assessment must certify the accuracy of that portion of the assessment. Resident #1 A review of the Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of (MONTH) 11, (YEAR), revealed under section H0100A, Resident #1 was coded as having an indwelling catheter, and Section H revealed Resident #1 as being occasionally incontinent of bladder. A review of the cumulative physician orders [REDACTED]. A review of the monthly Nursing Summary dated for (MONTH) 10, (YEAR) revealed Resident #1 was assessed, and required the use of an indwelling catheter related to a [DIAGNOSES REDACTED].#1. A staff interview on 01/13/2017 at 10:30 AM, with Registered Nurse (RN) #1, revealed it was confirmed the quarterly MDS with the ARD of 11/11/2016 was coded correctly under Section 0H0100A indicating an indwelling catheter, and coded incorrectly under Section 0H indicating the resident was occasionally incontinent of bladder. RN #1 confirmed she completed Section H for the quarterly MDS with the ARD of 11/11/2016, and electronically signed the MDS as complete on 11/23/2016 . During an interview on 1/12/2017 at 3:00 PM, with the MDS Coordinator/ Registered Nurse (RN) #2, it was confirmed Section H0100A was coded correctly, and section H was coded incorrectly. RN #2 stated the facility admitted Resident #1 with an indwelling catheter. A review of the Face Sheet revealed the facility admitted Resident #1 on 02/27/2014, with [DIAGNOSES REDACTED]. A review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/11/2016, revealed the Resident's Brief Interview for Mental Status (BIMS) score was 13, indicating intact cognition. Resident #2 Review of Resident #2's quarterly MDS with an ARD of 12/23/16, under Section H, H0400, revealed Resident #2 was coded a one (1) occasionally incontinent, instead of nine (9) not rated, because the resident had an Ostomy. This MDS under Section H, H0100 indicated Resident #2 had an Ostomy, documented by C. This Assessment revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of two (2) that indicated Resident #2 was severely cognitively impaired. In an interview with Registered Nurse (RN) #6 on 1/13/17 at 11:52 AM, it was revealed Resident #2 was admitted to the facility with a [MEDICAL CONDITION]. During an interview on 1/13/17 at 2:40 PM, RN #1 confirmed Resident #2 should have been coded a nine (9) instead of a one (1) because Resident #2 had a [MEDICAL CONDITION]. The Face Sheet indicated the facility admitted Resident #2 on 6/4/14, with the [DIAGNOSES REDACTED].",2020-09-01
43,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-01-13,279,D,0,1,QXQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to develop a Comprehensive Care Plan for a Ureostomy for Resident #11, and bowel and bladder incontinence for Resident #8, for two (2) of 21 Care Plans reviewed. Findings include: Review of the facility's policy titled, Care Plan-Comprehensive, dated (MONTH) 2001, revealed the facility would develop a Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs for each resident. The comprehensive care plan had been designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, reflect treatment goals and objectives in measurable outcomes, and identify the professional services that are responsible for each element of care. Resident #8 Review of Resident #8's Plan of Care revealed no Care Plan for bowel and bladder Incontinence was developed. An observation on 1/12/17 at 2:05 PM, revealed Certified Nursing Assistant (CNA) #1 and CNA #6 provided incontinent care for Resident #8 after an episode of incontinence. An interview with the Director of Nursing (DON) on 1/13/17 at 3:00 PM, revealed all residents should have a Care Plan reflective of identified needs. The DON confirmed Resident #8's Plan of Care did not address bowel and bladder incontinence. Review of the Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 10/31/16, under section H0300, revealed Resident #8 was frequently incontinent of bowel and bladder. This MDS revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated Resident #8 was cognitively intact. Review of the Face Sheet revealed the facility admitted Resident #8 on 9/14/15, with the [DIAGNOSES REDACTED]. Resident #11 Record review of Resident #11's Care Plan revealed a Focus initiated on 6/13/2016 for High Risk for Impaired Skin Integrity related to bowel incontinence, [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), Diabetes (DM), General Weakness, [MEDICAL CONDITION], Hypertension (HTN), [MEDICAL CONDITION] (HLP), and Presence of a [MEDICATION NAME]. The interventions included change the [MEDICATION NAME] bag and wafer every 5 (five) days, and as needed. There was not a care plan developed with a Focus related to the potential problems for a [MEDICATION NAME] with individualized care, goals, and persons responsible to provide the care/interventions. Review of Resident #11's MDS with an ARD of 12/12/2016 revealed in Section G for Functional Status, Resident #11 required extensive assistance of two staff members for toilet use. Section H for Urinary Continence revealed he had a urinary ostomy. Interview on 01/13/2017 at 2:20 PM, with Registered Nurse (RN) #2 revealed no care plan for the [MEDICATION NAME] had been developed, and the person that had done the original care plan no longer worked there. Review of the facility's Face Sheet revealed the facility admitted Resident #11 on 06/01/2016. His [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 12/12/2016 revealed Resident #11 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated he had no cognitive impairment.",2020-09-01
44,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-01-13,281,D,0,1,QXQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, review of the facility's CNA (Certified Nursing Assistant) Scope of Practice/Orientation, Perry Potter Nursing Skills and Procedures Eighth Edition, Mississippi Board of Nursing Rules and Regulations, and facility policy review, the facility failed to follow professional standards of care related to the failure to check Resident #18's Percutaneous Endoscopic Gastrostomy (PEG) tube placement prior to medication administration for one (1) of two (2) PEG tubes observed during med (medication) pass, and failed to ensure licensed nursing staff applied Resident #13's medicated cream after completion of incontinent care for one (1) of five (5) incontinent care observations. Findings include: A review of the Mississippi Board Of Nursing Rules and Regulations in Chapter 3 section 1.3, revealed: medication administration may only be delegated to another registered nurse or licensed practical nurse and not to an unlicensed person. This would include medicated ointments, lotions and protective barriers, regardless of skin integrity. A review of the Perry Potter Nursing Skills and Procedures, eighth Edition, under the topic Topical Skin applications, revealed: The skill of administering topical medications cannot be delegated to nursing assistive personnel. Review of the facility's policy titled, Administering Medications Through An Enteral Tube, dated (MONTH) (YEAR), revealed the purpose of this procedure is to provide guidelines for the safe administration of medications through an Enteral tube. This policy revealed to check placement of the Nasogastric, Esophagostomy, or Gastrostomy Tube, auscultate the abdomen (approximately three inches (3) below the sternum) while injecting ten (10) milliliters (ml) of air into the tube, and listen for the whooshing sound in the stomach then gently pull back and aspirate stomach contents. Review of the facilities document titled, CNA Scope of Practice/Orientation, dated 07/16/13, revealed listed under the column labeled DONT the following instructions: Do not apply any topical ointments or creams that are medicated whether prescription or over the counter. Resident #18 An observation during medication administration on 1/13/17 at 11:12 AM, revealed Licensed Practical Nurse (LPN) #5 prepared to administer [MEDICATION NAME] 20 milligrams (mgs) and [MEDICATION NAME] 10 mgs. via Resident #18's PEG tube. LPN #5 proceeded to check the PEG tube placement, and pushed 10 millimeters (ml)s of water instead of air into the PEG Tube, and auscultated (listened for the whoosh sound) with a stethoscope below the Xyphoid Process (lower part of the sternum). In an interview on 1/13/17 at 11:30 AM, LPN #5 confirmed she used water instead of air to check placement of Resident #18's PEG tube. LPN #5 stated, I was nervous. Record review of the Face Sheet revealed the facility admitted Resident #18 on 4/3/12 with the included [DIAGNOSES REDACTED]. Review of Resident #18's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of (MONTH) 17, (YEAR), revealed the Brief Interview for Mental Status (BIMS) score was not completed due the resident was not able to complete the interview. Resident #18's Cognitive Skills for Daily Decision Making was coded a three (3), which indicated severe impairment, and rarely or never made decisions. Resident #13 Observation on 01/12/17 at 11:00 AM, revealed Resident #13 was provided incontinent care by Certified Nurse Aides (CNAs) #2 and #4. CNA #2 applied a cream to the rash on Resident #13's buttocks and perineal area after completing the incontinent care. Observation at this time of a package of the cream revealed it was Z-Guard, and Zinc Oxide 17% (percent) was listed as an active ingredient. Interview with CNA #2 on 01/12/17 at 3:00 PM, revealed she confirmed she applied the Z-Guard cream to the resident following the incontinent care. She further stated, Z-Guard cream was given to the CNAs by the nurses for all incontinent care, and from what they told us it was not a medicine. Interview with CNA #4 on 01/13/17 at 10:00 AM, revealed they were using Z-Guard as a barrier cream after incontinent care. CNA #4 stated, they told us today we could not use it because it has medicine in it, and we were told to take it all off the floor. Interview with Registered Nurse (RN) #1 on 01/13/17 at 10:15 AM, revealed she stated, Z-Guard is our house stocked barrier cream. Review of facility's document titled, CNA Visual /Bedside Kardex Report, for Resident #13 revealed instructions to use Z-Guard Barrier Cream with incontinent care. Review of Resident #13's Care Plan revealed an intervention to apply Z-Guard cream with incontinent care. Review of the facility's Face Sheet revealed the facility admitted the resident on 06/14/07. Resident #13's [DIAGNOSES REDACTED]. Review of Resident #13's MDS with an ARD of 12/14/16, revealed a Brief Interview of Mental Status (BIMS) score 14, indicating the resident was cognitively intact. Further review of the MDS revealed Resident #13 required extensive assistance with one to two (1 to 2) person physical assist with bed mobility, transfers, toilet use, dressing, and bathing. Resident #13 was always incontinent of bowel and bladder.",2020-09-01
45,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-01-13,282,E,0,1,QXQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to follow Resident #8 and Resident #13's Care Plan for the risk of impaired skin integrity for one (2) of five (5) incontinent care observations, and Resident #18's Care Plan for risk of altered nutrition related to (r/t) a feeding tube, for three (3) of 21 care plans reviewed. Findings include: Review of the facility's policy titled, Care Plan-Comprehensive, dated (MONTH) 2001, revealed the facility would develop a Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs for each resident. The comprehensive care plan had been designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, reflect treatment goals and objectives in measurable outcomes, and identify the professional services that are responsible for each element of care. Resident #8 Review of Resident #8's Care Plan initiated on 8/16/16, revealed the Focus for high risk for impaired skin integrity with the included intervention for prompt pericare after each incontinent episode. Observation of Resident #8's incontinent care provided by Certified Nursing Assistant (CNA) #1 and CNA #6 on 1/12/17 at 2:05 PM, revealed CNA #1 wiped down the middle of the vagina with an area of the washcloth that was previously used to wipe with. CNA #1 also wiped the anal area and left buttock upwards five (5) times with the same area of the washcloth. An interview on 1/12/17 at 2:20 PM, revealed CNA #1 stated she was not aware she had used the contaminated area of the cloth more than once. CNA #1 said she wiped the buttocks and the anal area multiple times with the same area of the cloth. Review of the facility's Face Sheet revealed the facility admitted Resident #8 on 9/14/15 with the [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/16, revealed a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated Resident #8 was cognitively intact. Further review of the MDS revealed Resident #8 was able to make herself understood, and able to understand others. Resident #8 was independent, or required limited assistance with set up, or one person physical assist with bed mobility, transfers, dressing, toilet use, and bathing. Resident #8 was occasionally incontinent of bowels, and frequently incontinent of bladder. Resident #13 Review of resident #13's Care Plan initiated on 7/22/2014 for High Risk for Impaired Skin Integrity related to bowel and bladder incontinence listed the intervention for prompt pericare after each incontinent episode. An observation on 1/12/17 at 11 AM, revealed Certified Nursing Assistant (CNA) #2 and #4 provided Resident #13's incontinent care. CNA #2 cleaned each side, and the middle of the resident's labia, and the buttocks, but did not clean any other areas of the perineum, or the rectum. In an interview with CNA #2 on 01/12/17 at 3:00 PM, CNA #2 confirmed she cleaned only the labia in the perineal area. CNA #2 stated she had been checked off on incontinent care about four (4) months ago. CNA #2 stated the resident could get an infection of the bladder, or Urinary Tract Infection [MEDICAL CONDITION] if proper technique was not used. Interview on 01/13/17 at 10:15 AM, with Licensed Practical Nurse (LPN) #3, and Registered Nurse (RN) #1 revealed LPN #3 stated the care plans should be followed. RN #1 stated the CNAs are taught to look at, and follow care plans. Review of the facility's Face Sheet revealed the facility admitted Resident #13 on 06/14/07. Resident #13's [DIAGNOSES REDACTED]. Review of Resident #13's MDS with an ARD of 12/14/16, revealed a Brief Interview of Mental Status (BIMS) score 14, indicating the resident was cognitively intact. Further review of the MDS revealed Resident #13 required extensive assistance with one to two (1 to 2) person physical assist with bed mobility, transfers, toilet use, dressing, and bathing. Resident #13 was always incontinent of bowel and bladder. Resident #18 Review of Resident #18's Care Plan initiated on 3/27/14 for high risk for altered nutrition r/t a feeding tube revealed the included intervention to check placement by auscultation and aspiration before administration of medications. On 1/13/17 at 11:12 AM, an observation during the medication administration revealed Licensed Practical Nurse (LPN) #5 prepared to administer [MEDICATION NAME] 20 milligrams (mgs) and [MEDICATION NAME] 10 mgs. via Resident #18's PEG tube. LPN #5 checked the PEG tube placement, and pushed 10 millimeters (ml)s of water instead of air into the PEG Tube, and auscultated with a stethoscope below the Xyphoid Process (lower part of the sternum). An interview on 1/13/17 at 11:30 AM, revealed LPN #5 confirmed she used water instead of air to check placement of Resident #18's PEG tube. LPN #5 stated, I was nervous. Record review of the Face Sheet revealed the facility admitted Resident #18 on 4/3/12 with the [DIAGNOSES REDACTED]. Review of Resident #18's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of (MONTH) 17, (YEAR), revealed the Brief Interview for Mental Status (BIMS) score was not completed due to the resident was not able to complete the interview. Resident #18's Cognitive Skills for Daily Decision Making was coded a three (3), which indicated severe impairment, and rarely or never made decisions. Further reveiw of the MDS revealed Resient #18 had a feeding tube while a resident at the facility. Resident #18 received a proportion of her total calories of 51% (percent) or more through parentaral or tube feedings, and an average of 501 cc (cubic-centimeters) or more of fluid per day by IV (intravenous) or tube feeding. Resident #18 required extensive to total assistance with one to two (1 to 2) person physical assist with bed mobility, transfers, dressing, toilet use, and bathing.",2020-09-01
46,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-01-13,315,E,0,1,QXQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to provide incontinent care in a manner to prevent Urinary Tract Infections for two (2) of five (5) incontinent care observations, for Resident #8 and Resident #13. Findings include: Review of the facility's policy titled, Perineal Care, with a date of (MONTH) 2014, revealed the purposes of the procedure was to prevent infections. Instructions for care of the female resident were to separate the labia and wash area downward from front to back, continue to wash the perineum moving outward to and including thighs, wipe the rectal area thoroughly wiping from the base of the labia and extending over the buttocks. After wiping an area, fold the washcloth or use a new washcloth or pre-moistened wipe. A review of the facility's policy titled, Infection Control Policies/Practices, with a date of (MONTH) 2014 revealed all personnel will be informed of infection control policies and practices, and any changes thereof through orientation program and regularly scheduled in-service training programs. Resident #8 Observation of Resident #8's incontinent care provided by Certified Nursing Assistant (CNA) #1 and CNA #6 on 1/12/17 at 2:05 PM, revealed CNA #1 wiped down the middle of the vagina with an area of the washcloth that was previously used to wipe with. CNA #1 also wiped the anal area and left buttock upwards five (5) times with the same area of the washcloth. An interview on 1/12/17 at 2:20 PM, revealed CNA #1 stated she was not aware of she had used the contaminated area of the cloth more than once, and she confirmed she wiped the buttocks and the anal area multiple times with the same area of the cloth. Review of the facility's Face Sheet revealed the facility admitted Resident #8 on 9/14/15 with the [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/16, revealed a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated Resident #8 was cognitively intact. Further review of the MDS revealed Resident #8 was able to make herself understood, and able to understand others. Resident #8 was independent, or required limited assistance with set up, or one person physical assist with bed mobility, transfers, dressing, toilet use, and bathing. Resident #8 was occasionally incontinent of bowels, and frequently incontinent of bladder. Resident #13 An observation on 1/12/17 at 11 AM, revealed Certified Nursing Assistant (CNA) #2 and #4 provided Resident #13's incontinent care. CNA #2 cleaned each side, and the middle of the labia, and buttocks area only. CNA #2 did not clean any other areas such as the thighs, suprapubic area, groin area, perineum, or rectal area. On 11/12/16 at 3:00 PM, an interview with CNA #2 revealed she did the incorrect steps due to being nervous. CNA #2 confirmed Resident #13's labia was the only area she cleaned. CNA #2 further stated she had been checked off on incontinent care about four (4) months ago. CNA #2 confirmed the resident could get an infection of the bladder, or Urinary Tract Infection [MEDICAL CONDITION] if proper technique was not used. Review of the facility's document titled, Annual CNA Clinical Skills Checklist for the (Name of Facility), dated 7/13/16, revealed CNA #2's and an instructor's signature on the checklist which indicated CNA # 2 correctly performed perineal care. A review of the facility's document titled, Skills Check - Perineal Care - Female Resident with a date of 11/17/16, indicated CNA # 2 correctly performed pericare. Review of the facility's Face Sheet revealed the facility admitted the resident on 06/14/07. Resident #13's [DIAGNOSES REDACTED]. Review of Resident #13's MDS with an ARD of 12/14/16, revealed a Brief Interview of Mental Status (BIMS) score 14, indicating the resident was cognitively intact. Further review of the MDS revealed Resident #13 required extensive assistance with one to two (1 to 2) person physical assist with bed mobility, transfers, toilet use, dressing, and bathing. Resident #13 was always incontinent of bowel and bladder.",2020-09-01
47,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-01-13,322,D,0,1,QXQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to check the placement of Resident #18's Percutaneous Endoscopic Gastrostomy (PEG) tube by auscultation with air prior to medication administration. This was for one (1) of two (2) PEG tubes observed during the med (medication) pass. Findings include: Review of the facility's policy titled, Administering Medications Through An Enteral Tube, dated (MONTH) (YEAR), revealed the purpose of this procedure is to provide guidelines for the safe administration of medications through an Enteral tube. This policy revealed to check placement of the Nasogastric, Esophagostomy, or Gastrostomy Tube, auscultate the abdomen (approximately three inches (3) below the sternum) while injecting ten (10) milliliters (ml) of air into the tube, and listen for the whooshing sound in the stomach then gently pull back and aspirate stomach contents. During an observation of medication administration on 1/13/17 at 11:12 AM, Licensed Practical Nurse (LPN) #5 prepared to administer [MEDICATION NAME] 20 milligrams (mgs) and [MEDICATION NAME] 10 mg. via Resident #18's PEG tube. LPN #5 proceeded to check the PEG tube placement, and pushed 10 millimeters (ml)s of water instead of air into the PEG tube. LPN #5 checked the placement by auscultation with a stethoscope she placed below the Xyphoid Process (lower part of the sternum). An interview with LPN #5 on 1/13/17 at 11:30 AM, revealed LPN #5 stated, I was nervous, and she confirmed she used water instead of air to check placement of the PEG tube for Resident #18. Review of Resident #18's Order Summary Report physician's orders [REDACTED]. 2) [MEDICATION NAME] 20 mg. via [DEVICE] four times a day for muscle spasms. 3) [MEDICATION NAME] HCL Solution ([MEDICATION NAME]) 10 mg./10 ml (milliliter) give four times a day r/t (related to) Gastro-Esopheal Reflux Disease (GERD) without Esophagitis. Record review of the Face Sheet revealed the facility admitted Resident #18 on 4/3/12 with the included [DIAGNOSES REDACTED]. Review of Resident #18's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of (MONTH) 17, (YEAR), revealed the Brief Interview for Mental Status (BIMS) score was not completed due to the resident was not able to complete the interview. Resident #18's Cognitive Skills for Daily Decision Making was coded a three (3), which indicated severe impairment, and rarely or never made decisions. Further review of the MDS revealed Resident #18 had feeding tube while a resident at the facility. Resident #18 received a proportion of her total calories of 51% (percent) or more through parentaral or tube feedings, and an average of 501 cc (cubic-centimeters) or more of fluid per day by IV (intravenous) or tube feeding. Resident #18 required extensive to total assistance with one to two (1 to 2) person physical assist with bed mobility, transfers, dressing, toilet use, and bathing.",2020-09-01
48,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-01-13,441,F,0,1,QXQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, facility policy review, the facility failed to ensure infection control measures were maintained to prevent the possibility of the spread of infection/contamination during incontinent care for Resident #7 for one (1) of five (5) incontinent care observations, during [MEDICATION NAME] care for Resident #11 for one (1) of three (3) wound care observations, during medication pass for Resident #2 for one (1) of twenty-seven(27) medication administration opportunties observed, and one (1) of two (2) blood glucose fingerstick checks observed, for Resident #2. Findings include: Review of the facility's policy titled, Infection Control Policies/Practices, dated (MONTH) 2014 revealed the primary purpose of the facility's infection control policies and practices are to establish guidelines to follow in providing a safe, sanitary, and comfortable environment, and to aid in preventing the development and transmission of diseases and infections. Review of the facility's policy titled, Care of Facility Property, dated (MONTH) 2014 revealed all equipment used during the course of a shift must be cleaned, and where indicated, disinfected prior to returning to use. Resident #2 An observation of Resident #2's Blood Glucose Fingerstick Check on 1/12/17 at 4:12 PM, revealed Licensed Practical Nurse (LPN) #4 failed to wash her hands prior to the finger stick, and placed the glucometer on Resident #4's bed without a surface barrier. LPN #4 returned to the med cart, and placed the contaminated Glucometer on the medication cart without disinfecting the machine. LPN #4 cleaned the Glucometer with two (2) alcohol prep pads instead of a germicidal/disinfectant wipe. In an interview with LPN #4 on 1/12/17 at 4:25 PM, LPN #4 revealed she had some in-service on infection control practices completed when she was hired four (4) months ago. LPN #4 stated she sometimes cleaned the Glucometer with the Bleach wipes located in the bottom of the medication cart. LPN #4 stated she used hand sanitizer prior to the Glucose check. An observation during medication pass on 1/18/17 at 9:06 AM, revealed Registered Nurse (RN) #6 dropped Resident #2's Intravenous Piggy Back (IVPB) medication (an antibiotic) on the floor, picked it up, and placed it into the medication tray with other medications. RN #6 flushed Resident #2's Saline Lock (SL) with a pre-filled syringe of Normal Saline prior to connecting the IVPB med she previously dropped on the floor, then discarded it (pre-filled syringe of Normal Saline) into the trash container in the room instead of in a SHARPS container. The trash container had a clear trash liner. An interview with RN #6 on 1/13/17 at 10:30 AM, revealed when asked how should she clean off an IVPB med that has touched the floor? RN #6 replied you would clean it off with the (Name Brand) bleach wipes. RN #6 confirmed she dropped the IVPB onto the floor, and then proceeded to hang the medication on Resident #2 without cleaning it. Regarding RN #6 disposing the Normal Saline flush into the trash container, RN #6 stated, I just used it for flush, it's not contaminated with blood. When asked is it ok to dispose of the flush syringe in the regular trash, RN #6 stated the flush was used to flush the saline lock for Resident #2. Review of the facility's Face Sheet revealed the facility admitted Resident #2 on 6/4/16 with the [DIAGNOSES REDACTED]. Record review of Resident #2's quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 12/23/16 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of two (2) that indicated Resident #2 was severely cognitively impaired. Resident #11 An observation on 1/12/17 at 10:10 AM, revealed LPN #2 provided [MEDICATION NAME] care for Resident #11. LPN #2 did not place a barrier cover over Resident #11's overbed table. LPN #2 placed the following items onto the overbed table: 1 (one) container of [MEDICATION NAME] solution, 1 (one)package of gauze dressing, 7 (seven) plastic vials of normal saline solution, 1 (one) roll of paper tape, and vinyl gloves. LPN #2 removed a pair of bandage scissors from her pocket, and cut the [MEDICATION NAME] stoma bag opening, placed the scissors on the table without cleaning them, and then picked up the scissors and placed them back into her uniform pocket. After completing the [MEDICATION NAME] care, LPN #2 placed the above [MEDICATION NAME] care items onto the resident's dresser in his room. The roll of paper tape was left on the overbed table. LPN #2 did not disinfect the overbed table before she left the resident's room. Interview on 01/12/2017 at 4:45 PM, with LPN #2 revealed she did not clean the bandage scissors, and they should have been stored in a bag. LPN #2 stated, I know now not to put them in my pocket. LPN #2 confirmed she should have used a drape, and cleaned the overbed table with blue top wipes. LPN #2 stated she did not clean her scissors, and the overbed table because she was in a hurry. Review of LPN #2's Orientation In-Service Acknowledgement record dated 04/04/2016 revealed LPN #2's initials were documented for Prevention/Infection Control. Review of the facility's In-Service Training Attendance Record titled, Infection Control, review of policy, review of practices related to resident care, med pass, isolation, and handwashing, dated 11/28 to 11/29/16, revealed LPN #2's initials were documented on the Sign In Sheet. Review of the facility's Face Sheet revealed the facility admitted Resident #11 on 06/01/2016, and readmitted him on 09/07/2016. Resident #11's [DIAGNOSES REDACTED]. Review of Resident #11's Minimum Data Set with and Assessment Reference Date of 12/12/2016 revealed Resident #11 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated he had no cognitive impairment. Review of Section H for Urinary Continence revealed the resident had a urinary ostomy. Section I for Active [DIAGNOSES REDACTED]. Resident #7 An observation on 01/13/17 at 11:00 AM, revealed Certified Nursing Assistant (CNA) #1 performed incontinent care on Resident #7. After completing the care, CNA #1 did not remove the soiled gloves, and touched Resident #7's clean brief and incontinent pad that was placed under the resident. An interview on 01/13/17 at 11:20 AM, revealed CNA #1 stated, I forgot to take my gloves off before putting on the clean brief and pad. CNA #1 stated, That was an infection control break. An interview on 01/13/17 at 12:40 PM, with the Director of Nursing (DON) revealed the training with the CNAs covered infection control during peri-care. The DON stated the gloves should have been changed from soiled to clean areas. A review of CNA #1's Skills Check: Perineal care-Male Resident, dated 11/18/16, revealed steps to remove gloves after care and before repositioning resident, and a checkmark was placed beside this step marked as completed correctly. A review of the facility's Face Sheet revealed the facility admitted Resident #7 on 10/14/15. Resident #7's [DIAGNOSES REDACTED]. A review of Resident #7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/16 revealed Resident 7's Brief Interview for Mental Status (BIMS) score was conducted per staff interview, and was a three (3), which indicated severe cognitive impairment.",2020-09-01
49,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2019-03-08,640,D,0,1,M3XR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility statement review, and staff interview, the facility failed to submit the Minimum Data Set (MDS) assessment within seven (7) days after completion of Resident #67's MDS assessment. This concern was identified for one (1) of 31 MDS assessments reviewed. Findings include: Review of a typed statement on the facility's letterhead, dated 03/08/19 and signed by the Administrator, revealed: The Boyington Health and Rehabilitation utilizes the RAI (Resident Assessment Instrument) manual for MDS (Minimum Data Set) assessments and guidelines for completion of MDS. Record review revealed Resident #67 was admitted by the facility on 10/13/18, and was discharged on [DATE]. Resident #67 had a one (1) day stay at facility. Review of the Casper Report revealed the MDS, with the target date of 10/14/18, was not submitted and accepted until 1/31/19. An interview, on 03/08/19 at 9:12 AM, revealed RN #1 stated, I saw that it was late when I returned from maternity leave. RN #4 did the assessment while I was out and she closed it, but did not lock it. I saw it and transmitted it 120 days late. I use the RAI manual for coding the MDS. An Interview, on 03/08/19 at 9:06 AM, with the Director of Nursing (DON) revealed the MDS assessment was submitted late. The DON stated it was identified, corrected, and we put it on our Quality Assessment and Assurance Concern (QAPI). The DON stated Registered Nurse (RN) #4 was filling in for RN #1 due to our regular MDS Nurse was on maternity leave. The DON stated RN #4 did the assessment, but failed to lock it in, and when RN #1 returned to work she found the error and corrected it by submitting the assessment. We knew it was late, but we submitted it anyway. An interview, on 03/08/19 with 9:15 AM, revealed RN #4 stated, I was doing MDS while RN #1 was out on maternity leave and I didn't lock the assessment. I guess I just over looked it somehow.",2020-09-01
50,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2019-03-08,656,D,0,1,M3XR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, facility policy review, and staff interview, the facility failed to implement the comprehensive care plans related to Residents #2, #57, and #133's wound care, and for Resident #51's catheter care. This concern was identified for four (4) of 31 care plans reviewed. Findings include: Review of the facility's policy titled, Care Plans-Comprehensive, dated 11/2017, revealed that it is the policy of this facility that a Comprehensive Care Plan that includes measurable objectives and timetables to meet medical, nursing, mental and psychological needs is developed for each resident. The facility policy stated that each resident's Comprehensive Care Plan is designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, and reflect treatment goals and objectives in measurable goals. The facility policy stated that the Comprehensive Care Plan has been designed to prevent declines in the resident's functional status/ functional levels. The Comprehensive Care Plan has been designed to reflect treatment goals and objectives in measurable outcomes. The policy further stated care plans are revised as changes in the resident's condition dictate and reviews are made at least quarterly. Resident #2 A review of the Comprehensive Care Plan for Resident #2, revealed a Focus problem, initiated on 01/15/15, for Stage 4 pressure wounds to the right and left ischiums, and a Stage 4 pressure wound to the sacrum initiated on 09/10/2018. The Care Plan revealed the measurable goals stated there will have been noted improvement in size and depth of the pressure wounds to the right and left ischiums by next review with no further signs of skin integrity alterations, and no pain with wound treatment. The Target Date was 06/03/19. The Care Plan included an intervention, dated 03/05/2019, for nursing department to cleanse the wound to the left ischium, right ischium, and sacrum with Normal Saline (NS), pat dry, apply skin prep to peri-wound, Fill wound with alginate extra rope wound dressing, cover with four by four (4x4) gauze, and cover with super absorbent dry dressing daily and as needed (PRN). An observation, on 03/06/2019 at 8:46 AM, revealed Resident #2's wound care was provided by Registered Nurse (RN) #3. RN #3 performed the wound care on three (3) separate pressure wounds: A Stage 4 pressure wound to the left (L) Ischium, a Stage 4 pressure wound to the right (R) Ischium, and a Stage 4 pressure wound to the sacral area. RN #3 performed the wound care to both the Stage 4 pressure wound to the (L) Ischium and the Stage 4 pressure wound to the (R) Ischium, without incident. During the wound care on the Stage 4 pressure wound to the sacral area, RN #3 removed the soiled dressing from the wound, and then continued with the wound care by applying two (2) out of three (3) dressing ropes without washing her hands. After applying the second dressing rope, it was then that RN #3 removed her gloves, washed her hands, put on new gloves, and then continued to apply the third dressing rope into the wound. An interview with Registered Nurse (RN) #3, on 03/07/19 at 11:00 AM, revealed she did not wash her hands going from cleaning the sacral wound and discarding the soiled gauze, and applying the first two medicated rope dressings. An interview, on 03/07/2019 at 11:15 AM, with the Director of Nursing (DON), revealed Registered Nurse (RN) #3 should have washed her hands after she cleaned the sacral wound, and before she applied the medicated rope dressing. The DON also stated the staff was expected to follow the care plan. During an interview, on 03/07/2019 at 1:54 PM. with Licensed Practical Nurse (LPN) #1 / Care Plan Coordinator, it was revealed that it was the intent of developing the comprehensive care plan that the care plan was to be followed. LPN #1 stated that it was her expectation that the nurse would provide the wound care treatment, without risking the possible spread of infection. During an interview, on 03/07/2019 at 4:08 PM, with RN #1/ Care Plan Coordinator, it was revealed that it was her expectation that once the comprehensive care plan has been developed, that the care plan would be followed thereafter. RN #1 stated the discipline that the intervention task is assigned to, should perform the intervention. Review of Resident #2's Discharge Minimum Data Set (MDS), dated [DATE], revealed a Basic Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Further review of the MDS revealed Resident #2 was coded for the presence of two (2) Stage 3 pressure wounds. Review of Resident #2's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/18, revealed a Basic Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Further review of the MDS revealed Resident #2 was coded for two (2) Stage 4 pressure wounds. Review of the Face Sheet revealed Resident #2 was admitted by the facility on 03/05/2013, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #51 On 3/7/19 at 2:05 PM, an observation revealed Certified Nursing Assistant (C NA) #1 performed Resident #51's catheter care. CNA #1 failed to wash her hands prior to beginning the catheter care. CNA #1 applied her gloves, pulled some clean wipes from the wipe container and began the catheter care. CNA #1 wiped around the catheter near the resident's penis three times using one wipe, and rotated the wipe as she wiped. She then used another wipe to wipe in a downward motion on the resident's groin areas, using a clean wipe for each side. CNA #1 held the catheter tubing near the meatus, and wiped away from the meatus three times. She then repositioned Resident #51 onto his left side, and cleaned his buttocks, wiping the buttock areas in a circular, and back and forth motion, using the same wipe to clean the resident's entire buttocks area. On 03/07/19 at 4:26 PM, an interview with Registered Nurse (RN) #1 revealed, she would expect the staff to implement the comprehensive care plan. Review of the Physician Orders, with a start date of 12/21/18, revealed the order to change the Foley Catheter as needed for leakage or blockage, and check the leg anchor every shift and as needed. Foley Catheter care every shift. Foley Catheter size 16 French (FR) to bedside drainage, check for patency every shift and change as needed. Review of Resident #51's most recent comprehensive MDS, with an ARD of 12/19/18, revealed Resident #51 was coded for an indwelling urinary catheter/condom catheter, and not rated for urinary continence. Further review of the MDS revealed a BIMS score of 15, which indicated Resident #51 was cognitively intact. A review of the facility's Face Sheet revealed the facility admitted Resident #51 on 03/13/18 with a [DIAGNOSES REDACTED]. Resident #57 Review of Resident #57's Comprehensive Care Plan revealed Focus for Impaired Skin Integrity, dated 12/03/18, for a Stage 2 Pressure Wound to the sacrum, and 01/23/18 for a current visual Stage 4. The Goal stated the Pressure Ulcer will show signs of healing and remain free from infection. The initial date was 01/23/19, and the Target date was 04/23/19. The Interventions included wound care as ordered dated 06/05/18. Review of Resident #57's Treatment Administration Record (TAR), for (MONTH) 2019, revealed the following: Clean Sacrum with NS (Normal Saline), Pat dry apply Santyl in a thin layer, pack with gauze and cover with silicone dressing daily and PRN (as needed). Order Date 01/08/19. An observation on, 03/07/19 at 10:15 AM, revealed Registered Nurse (RN) #3/Wound Care Nurse performed wound care to Resident #57's sacrum. RN #3 placed a red bag on Resident #57's bed to the right of the resident's right leg. RN #3 removed the old dressing, and discarded the dressing in the red bag. RN #3 washed her hands and began to clean the wound. RN #3 cleaned the wound and patted it dry. RN #3 applied the Santyl to the wound bed with a Q-tip, and covered the wound with a dressing. RN #3 used the same gloves that she had on while cleaning the wound to apply the Santyl and the clean dressing to the wound. RN #3 failed to remove her gloves, wash her hands and re-glove after cleaning the wound, and before applying the Santyl and the clean dressing to the wound. An interview, on 03/07/19 at 10:48 AM, revealed RN #3 confirmed, she knew what she did when she did it. RN #3 stated she didn't change gloves and wash her hands after cleaning the wound, and before she applied the Santyl and the clean dressing. An Interview, on 03/08/19 at 8:37 AM, revealed Licensed Practical Nurse (LPN) #1/Care Plan Nurse stated, If Resident #57 had a care plan created for wound care then she would expect the care plan to be followed. Review of Resident #57's Significant Change MDS, with an ARD of 01/11/19, revealed a BIMS score of 10, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #57 was coded for an unstageable wound. Resident #133 Review of Resident #133's Care Plan revealed a Focus, dated 03/04/19, for impaired skin integrity due to a wound to the right foot related to amputation of the right great toe. The Goal stated the wound to the right great toe would show signs of healing by/through the review date. The Goal was initiated on 03/04/19, and the Target Date was 06/02/19. The Interventions included the physician's orders [REDACTED]. 1/2 strength wet to dry packing. Cover with 4x4s and wrap with Kerlix PRN (as needed) when wound vac is reapplied. Start Date 03/04/19. (2) Wound vac (negative pressure wound therapy) in place to wound to right great toe amputation site. Apply wound vac at amputation site at 125 mmHg (millimeters of Mercury) Change Q (every) Tuesday and Friday. Start Date 03/04/19. An observation, on 03/05/19, 4:40 PM, revealed Registered Nurse (RN) #3/Wound Care Nurse provided Resident #133's wound care to the right foot/great toe. RN #3 was assisted by Certified Nursing Assistant (CNA) #3. RN #3 set up the wound care supplies on the over bed table, and then she placed the red biohazard bag on Resident #3, which positioned the right toe wound between RN #3 and the red biohazard bag. After looking over the supplies RN #3 identified she forgot to get scissors from the wound care cart. RN #3 left the room, and returned with the scissors in her bare hands. RN #3 laid the scissors on the tray containing her clean dressings without cleaning the scissors. RN #3 removed the dirty dressing, and discarded it into the red biohazard bag. RN #3 washed her hands and gloved to begin cleaning the wound. RN #3 wiped the wound with normal saline soaked gauze, and discarded the gauze into the red bag. RN #3 got another piece of normal saline gauze, wiped the other side of the wound, and discarded the gauze into the red bag. RN #3 took another piece of the normal saline gauze, wiped the wound, and the normal saline dripped down the side of the foot. RN #3 took the same piece of gauze and reached down to catch the dripping saline and wiped back towards the cleaned wound going from an uncleaned area to a cleaned area, thus wiping dirty to clean. RN #3 did not reclean the wound before attempting to apply the wound vac to the wound. RN #3 washed her hands and gloved, and then picked up the foam that was to be packed into the wound and crossed the cleaned wound over to the red bag and held the foam above the red bag, with the dirty dressing and gauze in it, and began trimming the foam with the uncleaned scissors. RN #3 brought the foam from over the red bag back to the wound, and placed it on the wound. She then reached back over and got the second piece of foam and crossed the clean wound again going to the red bag. RN #3 began trimming the foam over the red bag, and then brought the foam back and placed it on wound. She picked up the end of the wound vac that was to be placed over the foam on the wound. RN #3 placed the wound vac tubing on Resident #133's gown. The end to the tubing was uncapped. RN #3 sealed the part of the wound vac with the dressings cut earlier. She then picked up the tubing from the gown and hooked it to the wound vac itself without cleaning the uncapped tube. Suction was obtained. RN #3 cleaned up her trash, washed her hands, and exited the room. An interview, on 03/05/19 at 5:10 PM, with RN #3/Wound Care Nurse revealed, I did wipe the wound from dirty to clean and I knew it when I did it. RN #3 stated, I didn't think about crossing over the wound to the red bag with the foam then bringing it back over and putting it in the wound. I can see where that would be a contamination issue. I cleaned the scissors before bringing them in the room, but I didn't reclean them after bringing them into the room in my hand. I didn't think about that being an issue but I can see where they could be considered dirty being toted in my bare hand. I held the foam above the red bag to trim it, and I wasn't thinking about it being a contamination issue since I didn't touch it. But with the dirty dressing being in the red bag I can see it being a issue. Record review of Resident #133's Physician order [REDACTED]. 1/2 strength wet to dry packing. Cover with 4x4s and wrap with Kerlix PRN (as needed) when wound vac is reapplied. Start Date 02/27/19. (2) Wound vac (negative pressure wound therapy) in place to wound to right great toe amputation site. Apply wound vac at amputation site at 125 mmHg (millimeters of Mercury) Change Q (every) Tuesday and Friday. Start Date 02/26/19. During an interview, on 03/08/19 at 8:37 AM, Licensed Practical Nurse (LPN) #1/Care Plan Nurse revealed she would expect a resident's care plan for wound care would be followed. Review of the Face Sheet revealed Resident #133 was admitted by the facility, on 02/12/19, with the included [DIAGNOSES REDACTED]. Review of Resident #133's Admission MDS, with an ARD of 02/19/19, revealed a BIMS score of 11, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #133 was coded for a Stage 2 wound.",2020-09-01
51,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2019-03-08,658,D,0,1,M3XR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to administer Resident #61's multidose inhaler in a manner to prevent thrush for one (1) of three (3) residents observed for multidose inhaler administration. Findings include: Review of the Mississippi Nursing Practice Law, with an effective date of (MONTH) 1, 2010, revealed on pages three and four (3 & 4) of 26: 73-15-5 Definitions. (2) The practice of nursing by a registered nurse means the performance for compensation of services which requires substantial knowledge of biological, physical, behavioral, psychological, and sociological sciences, and of nursing theory as the basis for assessment, diagnosis, planning intervention, and evaluation in the promotion, maintenance of health; management of individual's responses, to illness, injury or infirmity; the restoration of optimum function; or the achievement of a dignified death. Nursing practice includes, but is not limited to, administration, teaching, counseling, delegation, and supervision of nursing, and execution of the medical regimen, including the administration of medications, and treatments prescribed by any licensed or legally authorized physician, or dentist. (5) The practice of nursing by a licensed practical nurse means the performance for compensation of services requiring basic knowledge of the biological, physical, behavioral, psychological, and sociological sciences, and of nursing procedures which do not require the substantial skill, judgement, and knowledge required of a registered nurse. These services are performed under the direction of a registered nurse, or a licensed physician, or licensed dentist, and utilize standardized procedures in the observation, and care of the ill, injured, and infirm; in the maintenance of health; in action to safeguard life and health; and in the administration of medications, and treatments prescribed by any licensed physician, or licensed dentist authorized by state law to prescribe. Review of the Medication Guide (no date) for [MEDICATION NAME] revealed rinse mouth with water and spit the water out after each dose (2 puffs) of [MEDICATION NAME]. Do not swallow the water. This will help to lessen the chance of getting a fungus infection (thrush) in mouth and throat. On 03/06/19 at 9:00 AM, an observation during the medication pass, revealed Licensed Practical Nurse (LPN) #2 administered [MEDICATION NAME] 80-4.5 mcg two (2) puffs to Resident #61. LPN #2 gave Resident #61 water, and told him to swish the water in his mouth. Resident #61 swallowed the water. LPN #2 said great Job. LPN #2 did not educate the resident to spit the water out. Review of Resident #61's Physicians Orders, dated 02/04/19, revealed [MEDICATION NAME] Aerosol 80-4.5 mcg (micrograms)/ACT ([MEDICATION NAME]-[MEDICATION NAME]) two (2) puffs inhaled orally every 12 hours related to [MEDICAL CONDITION], Unspecified. Rinse mouth with water after use do not swallow. Review of Resident #61's Medication Administration Record, [REDACTED]. Rinse mouth with water after use do not swallow. During an interview, on 03/08/19 at 11:34 AM, LPN #2 confirmed she should have told the resident not to swallow the water. LPN #2 said the resident can get thrush by swallowing the water after inhaling steroids. During an interview, on 03/08/19 at 11:36 AM, the Director of Nursing (DON) confirmed the nurse should have asked the resident to spit the water out after inhaling steroids to prevent thrush. A review of Resident #61's Face Sheet revealed the facility admitted Resident #61, on 01/03/2019, with [DIAGNOSES REDACTED]. A review of Resident #61 Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/14/2019, revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.",2020-09-01
52,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2019-03-08,686,D,0,1,M3XR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, record review, and facility policy review, the facility failed to provide wound care in a manner to promote healing for three (3) of six (6) resident wound care observations: Resident #2, Resident #57, and Resident #133. Findings Include: A review of the facility's policy titled, Pressure Ulcer Treatment, dated (MONTH) (YEAR), revealed that it is the purpose of this facility's procedure to provide guidelines for the treatment of [REDACTED]. The Pressure Ulcer Treatment procedure outlined certain steps in the procedure as follows: Put on exam gloves, loosen tape and remove dressing, remove gloves, then wash hands, and now put on clean gloves. Observe the pressure ulcer, dress the pressure ulcer with the prescribed dressing, discard all disposable items into designated container, and remove gloves and discard into designated container. Wash hands. Resident #2 An observation, on 03/06/2019 at 8:46 AM, revealed Resident #2's wound care was provided by Registered Nurse (RN) #3. RN #3 performed the wound care on three (3) separate pressure wounds: A Stage 4 pressure wound to the left (L) Ischium, a Stage 4 pressure wound to the right (R) Ischium, and a Stage 4 pressure wound to the sacral area. RN # 3 performed the wound care to both of the Stage 4 pressure wounds to the (L) Ischium and (R) Ischium, without incident. During the wound care on the Stage 4 pressure wound to the sacral area, RN #3 discarded the soiled 4X4 gauze used for cleaning the wound, and then continued with the wound care by applying two (2) out of three (3) dressing ropes into the wound bed without changing her gloves and washing her hands. After applying the second dressing rope, it was then that RN #3 removed her gloves, washed her hands, put on new gloves, and then continued to apply the third dressing into the wound. During an interview, on 03/07/2019 at 11:00 AM, Registered Nurse (RN) #3 confirmed she did not wash her hands after she discarded the soiled gauze from cleaning the sacral wound, and before she applied the first two (2) medicated rope dressings. RN #3 stated she remembered washing her hands before she applied the third medicated rope dressing. RN #3 stated, I didn't realize I didn't wash my hands, because I usually wash my hands before and after each time I apply the rope dressing into the wound. RN #3 stated not washing your hands is an infection control concern. A review of Resident #2's Order Summary Report for Active Orders as of 03/08/2019, revealed an order, dated 03/05/19 and start date of 03/06/19, to cleanse wound to sacrum with normal saline, pat dry, apply skin prep to peri-wound. Fill wound with alginate extra rope wound dressing, cover with 4x4 gauze, and cover with super absorbent dry dressing daily and as needed (PRN) every day shift. Review of Resident # 2's Electronic Treatment Administration Record (ETAR), dated (MONTH) 03/01/2019-03/31/2019) 2019, revealed the following treatment been provided for the sacral wound: Cleanse wound to sacrum with Normal Saline (NS) and pat dry, apply skin prep to peri-wound, Fill wound with alginate extra rope wound dressing, cover with four by four (4x4) gauze, and cover with super absorbent dry dressing daily and as needed (PRN) every day shift. During an interview, on 03/07/2019 at 11:15 AM, the Director of Nursing (DON) revealed RN #3 should have washed her hands after she cleaned the sacral wound, and before she applied the medicated rope dressing. The DON stated, If your hands are not washed, that it is an infection control concern. An interview, on 03/07/2019 at 1:54 PM, with Licensed Practical Nurse (LPN) #1/Care Plan Coordinator, revealed it was her expectation that the nurse would provide the wound care treatment, without risking the possible spread of infection. An interview, on 03/07/2019 at 3:32 PM, with Registered Nurse (RN) #2/Infection Control Nurse, said during the wound care provided on Resident #2, RN #3 should have washed her hands after cleaning the wound, and prior to the packing of the wound with the rope dressing. Review of Resident #2's Discharge Minimum Data Set (MDS), dated [DATE], revealed a Basic Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Further review of the MDS revealed Resident #2 was coded for the presence of two (2) Stage 3 pressure wounds. Review of Resident #2's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/18, revealed a Basic Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Further review of the MDS revealed Resident #2 was coded for two (2) Stage 4 pressure wounds. Review of the Face Sheet revealed Resident #2 was admitted by the facility on 03/05/2013, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #57 An Observation, on 03/07/19 at 10:15 AM, revealed Registered Nurse (RN) #3/Wound Care Nurse, performed wound care to resident #57 sacrum with the assistance of Certified Nursing Assistant (CNA) #3. RN #3 placed a red bag on resident's bed to the right side of the resident's right leg. RN #3 removed the old dressing and discarded the dressing in the red bag. RN #3 washed her hands, gloved, and began to clean the wound. RN #3 cleaned the wound, and patted it dry. RN #3 applied Santyl to the wound bed with a Q-tip applicator, and covered the wound with a silicone dressing. RN #3 wore the same gloves that she had on while cleaning the wound to apply the Santyl and clean dressing to the wound. RN #3 failed to remove her gloves, wash her hands, and re-glove after cleaning the wound and before applying the Santyl and the clean dressing to the wound. During an interview, on 03/07/19 at 10:48 AM, RN #3/Wound Care Nurse, stated, I knew what I did when I did it. I didn't change gloves and wash my hands after cleaning the wound and before I applied the Santyl and the clean dressing. It could be an infection control issue. Review of Resident #57's Electronic Treatment Administration Record (ETAR), dated (MONTH) 2019, revealed the daily wound care treatment to the sacrum was provided daily as follows:. Clean sacrum with Normal Saline (N/S), Pat dry, and apply Santyl in a thin layer. Pack with gauze and cover with silicone dressing daily and PRN. An interview, on 03/07/19 at 3:22 PM, with RN #2/ Infection control nurse, revealed, RN #3 should have removed her gloves, washed hands and re-gloved before placing the Santyl and bandage on the clean wound. I see that as an infection control Issue. An interview, on 03/07/19 at 3:44 PM, with the Director of Nursing (DON) revealed, the nurse not changing her gloves and washing her hands after cleaning the wound and before applying Santyl and the dressing is an infection control issue. Review of Resident #57's Significant Change MDS, with an ARD of 01/11/19, revealed a BIMS score of 10, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #57 was coded for an unstageable wound. Resident #133 An observation, on 03/05/19, 4:40 PM, revealed Registered Nurse (RN) #3/Wound Care Nurse provided Resident #133's wound care to the right foot/great toe. RN #3 was assisted by Certified Nursing Assistant (CNA) #3. RN #3 set up the wound care supplies on the over bed table, and then she placed the red biohazard bag on Resident #3, which positioned the right toe wound between RN #3 and the red biohazard bag. After looking over the supplies RN #3 identified she forgot to get scissors from the wound care cart. RN #3 left the room, and returned with the scissors in her bare hands. RN #3 laid the scissors on the tray containing her clean dressings without cleaning the scissors. RN #3 removed the dirty dressing, and discarded it into the red biohazard bag. RN #3 washed her hands and gloved to begin cleaning the wound. RN #3 wiped the wound with normal saline soaked gauze, and discarded the gauze into the red bag. RN #3 got another piece of normal saline gauze, wiped the other side of the wound, and discarded the gauze into the red bag. RN #3 took another piece of the normal saline gauze, wiped the wound, and the normal saline dripped down the side of the foot. RN #3 took the same piece of gauze and reached down to catch the dripping saline and wiped back towards the cleaned wound going from an uncleaned area to a cleaned area, thus wiping dirty to clean. RN #3 did not reclean the wound before attempting to apply the wound vac to the wound. RN #3 washed her hands and gloved, and then picked up the foam that was to be packed into the wound and crossed the cleaned wound over to the red bag and held the foam above the red bag, with the dirty dressing and gauze in it, and began trimming the foam with the uncleaned scissors. RN #3 brought the foam from over the red bag back to the wound, and placed it on the wound. She then reached back over and got the second piece of foam and crossed the clean wound again going to the red bag. RN #3 began trimming the foam over the red bag, and then brought the foam back and placed it on wound. She picked up the end of the wound vac that was to be placed over the foam on the wound. RN #3 placed the wound vac tubing on Resident #133's gown. The end to the tubing was uncapped. RN #3 sealed the part of the wound vac with the dressings cut earlier. She then picked up the tubing from the gown and hooked it to the wound vac itself without cleaning the uncapped tube. Suction was obtained. RN #3 cleaned up her trash, washed her hands, and exited the room. An interview, on 03/05/19 at 5:10 PM, with RN #3/Wound Care Nurse revealed, I did wipe the wound from dirty to clean and I knew it when I did it. RN #3 stated, I didn't think about crossing over the wound to the red bag with the foam then bringing it back over and putting it in the wound. I can see where that would be a contamination issue. I cleaned the scissors before bringing them in the room, but I didn't reclean them after bringing them into the room in my hand. I didn't think about that being an issue but I can see where they could be considered dirty being toted in my bare hand. I held the foam above the red bag to trim it, and I wasn't thinking about it being a contamination issue since I didn't touch it. But with the dirty dressing being in the red bag I can see it being a issue. Record review of Resident #133's Physician order [REDACTED]. 1/2 strength wet to dry packing. Cover with 4x4s and wrap with Kerlix PRN (as needed) when wound vac is reapplied. Start Date 02/27/19. (2) Wound vac (negative pressure wound therapy) in place to wound to right great toe amputation site. Apply wound vac at amputation site at 125 mmHg (millimeters of Mercury) Change Q (every) Tuesday and Friday. Start Date 02/26/19. During an interview, on 03/07/19 3:08 PM, RN #2/Infection Control Nurse, revealed wiping the resident's wound from dirty to clean and not recleaning the wound before dressing it would be a infection control issue. RN #2 said RN #3 should not have crossed the leg with the foam to the red bag. RN #2 stated RN #3 shouldn't go across the wound with the wound vac foam because your crossing the clean wound with supplies coming from the over bed table. RN #2 said RN #3 was going back to the clean wound with something dirty after she held it over the red bag. RN #2 also stated the tubing should not have been laid on Resident #133's gown. It should have been on a clean surface or RN #3 should have cleaned it before connecting it to the other capped end of the tube. RN #2 also stated the scissors should have been recleaned before using them since she had transported them in her bare hand. An interview, on 03/07/19 at 3:49 PM, with the Director of Nursing (DON) revealed RN #3's failure not to reclean the scissors before cutting the clean dressing was an infection control issue. The DON stated RN #3 crossing the clean wound with the foam was an infection control issue also. The DON stated RN #3 holding the foam over the red bag to trim it, and then bringing it back to the wound and packing the wound with the foam was an infection control issue. The DON stated RN #3 laying the uncapped tube of the wound vac suction part placed on top of the wound on the resident's gown and not cleaning it before connecting it to the capped end of the actual wound vac was an infection control issue. The DON stated RN #3 should have cleaned her scissors after having them in her hand and before cutting a clean dressing. Review of the Face Sheet revealed Resident #133 was admitted by the facility, on 02/12/19, with the included [DIAGNOSES REDACTED]. Review of Resident #133's Admission MDS, with an ARD of 02/19/19, revealed a BIMS score of 11, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #133 was coded for a Stage 2 wound.",2020-09-01
53,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2019-03-08,690,D,0,1,M3XR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to provide Resident #51 and Resident #109's catheter care in a manner to prevent the possibility of a Urinary Tract Infection [MEDICAL CONDITION], for two (2) of five (5) resident catheter care observations. Findings include: A review of the facility's policy titled Catheter Care, Urinary dated (MONTH) (YEAR) revealed: Equipment and Supplies included pre-moistened wipes. Steps in the Procedure: 1. Wash hands. 17. Clean from the least contaminated to most contaminated area. Review of the facility's policy titled, Perineal Care, dated (MONTH) (YEAR), revealed: Equipment and Supplies included pre-moistened wipes. 18. For Male Resident- Steps in the Procedure - b. Wash perineal area starting with urethra and working outward. (2) Wash and rinse urethral area using a circular motion. f. Instruct, or assist resident to turn on his side. g. Using new washcloth, apply soap or skin cleansing agent or use pre-moistened wipe and wash. h. Using new washcloth, rinse the rectal area thoroughly to include the area under the scrotum, the anus, and the buttocks. If pre-moistened wipes are used, rinsing is not necessary. On 03/07/19 at 2:05 PM, an observation revealed Certified Nursing Assistant (CAN) #1 provided Resident #51's catheter care. CNA #1 entered Resident #51's room, applied her gloves, pulled some clean wipes from the wipe container, and begin the catheter care. CNA #1 did not wash her hands prior to donning the gloves and beginning the catheter care. CNA #1 wiped around the catheter near the resident's penis three times using one wipe, and rotated the wipe as she wiped. She then used another wipe to wipe in a downward motion of the resident's groin areas, using a clean wipe for each side. CNA #1 held the catheter tubing near the meatus, and wiped away from the meatus three times. She then repositioned Resident #51 onto his left side and cleaned his buttocks, wiping the buttocks areas in a circular and back and forth motion, using the same wipe to clean the resident's entire buttocks area. CNA #1 failed to wipe Resident #51's buttocks from front to back, or from least contaminated area to most contaminated area. An interview on 03/07/19 at 3:44 PM, with CNA #1 revealed she should have washed her hands before beginning the procedure. She also stated she should have wiped from front to back in an upward motion. An interview on 03/07/19 at 9:29 AM, with Registered Nurse (RN) #7 revealed Resident #51 was very independent, and does not like for the staff to assist him with anything although he needs it. RN #7 stated he does not think Resident #51 has had any Urinary Tract Infections (UTIs), but he does have spasms. He stated the resident has the catheter because he has some [DIAGNOSES REDACTED] from his [MEDICAL CONDITION]. An interview, on 03/07/19 at 3:49 PM, with the Director of Nursing (DON) revealed CNA #1 should have washed her hands so she does not carry anything in to the resident. The DON stated CNA #1 should have wiped in an upward position for infection control purposes. An interview, on 03/07/19 at 3:26 PM, with RN #2 revealed CNA #1 should have washed her hands, gathered her supplies, and placed her supplies on a barrier, and then proceed to perform the catheter care. RN #2 also stated CNA #1 should have used one wipe to wipe each time in an upward position. Review of the Physician Orders, with a start date of 12/21/18, revealed; change Foley Catheter as needed for leakage or blockage. Foley Catheter, check leg anchor every shift and as needed. Foley Catheter care every shift. Foley Catheter size 16 French (FR) to bedside drainage, check for patency every shift and change as needed. Review of Resident #51's most recent comprehensive MDS, with an ARD of 12/19/18, revealed Resident #51 was coded for an indwelling urinary catheter/condom catheter, and not rated for urinary continence. Further review of the MDS revealed a BIMS score of 15, which indicated Resident #51 was cognitively intact. A review of the facility's Face Sheet revealed the facility admitted Resident #51 on 03/13/18 with a [DIAGNOSES REDACTED]. Resident #109 An observation, on 03/07/19 at 8:45 AM, revealed Resident #109 was lying in bed with the head of bed elevated. Further observation revealed Resident #109's catheter bag was lying in the bed with the resident, and the urine was backing up into the tube into the bladder. An observation, on 03/07/19 at 9:00 AM, revealed Resident #109 was lying in the bed with the catheter bag lying in the bed with the resident, and the urine was backing up into the tube into the bladder. An observation, on 03/07/19 at 9:38 AM, with the Director of Nursing (DON) present, and another surveyor revealed Resident #109 was lying in the bed. The catheter bag was lying in the bed with Resident #109, and the urine was backing up in the tubing into the bladder. An interview, on 03/07/19 at 9:40 AM, with the Director of Nursing (DON) confirmed the catheter was lying in the bed with Resident #109. The DON also confirmed the urine was backing up in the tube into the bladder. The DON confirmed this resident has chronic Urinary Tract Infections. Review of Resident #109's Care Plan revealed a Focus for high risk for infection related to having an indwelling catheter due to Obstructive and Reflux [MEDICAL CONDITION] and Neuromuscular Dysfunction of the Bladder, and History of Urinary Tract Infections (UTIs). Review of the Interventions revealed no intervention for placement of the catheter bag/tubing below the bladder level to prevent backflow of urine and possible UTI. During an interview, on 03/07/19 10:40 AM, Certified Nursing Assistant (CNA) #2 revealed she was looking for a wheelchair because the resident was going out to a doctor's appointment. CNA #2 stated she forgot to move the catheter bag off the bed. CNA #2 said the resident could develop an infection by allowing the urine to back up in the catheter. A review of the Face Sheet revealed the facility admitted Resident #109, on 05/06/2016, with [DIAGNOSES REDACTED]. A review of Resident #109's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/15/2019, revealed Resident #109 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Further review of the MDS revealed Resident #109 was checked for the use of an indwelling catheter, external catheter, or ostomy. Resident #109's Urinary Continence was checked not rated due to a catheter, urinary ostomy, or no urine output during the seven (7) day observation period.",2020-09-01
54,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2019-03-08,761,D,0,1,M3XR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the disposal of expired medications, for two (2) of three (3) medication storage room observations. Findings Include: Record Review of the facility's policy titled, Storage of Medications revealed drugs and biologicals should be stored in a safe, secure and orderly manner. No discontinued, outdated, or deteriorated drugs or biologicals are available for use in this center. All such drugs are destroyed. An observation, on 03/06/19 at 11:49 AM, revealed expired medication in the 100 Hall medication storage room. One (1) bottle of Geri-Mox (antacid), expired on 01/2019, and two (2) bottles [MEDICATION NAME] ([MEDICATION NAME]) expired on 01/2019. During an interview, on 03/06/19 at 11:52 AM, Registered Nurse (RN)# 5 confirmed the medications in the medication storage room on the 100 Hall were expired. RN #5 said she had just checked all of the meds to make sure there were no expired medications. An observation, on 03/07/19 at 11:54 AM, revealed the medication room on the 300 Hall had three (3) aspirin bottles with an expiration date of 01/2019, and two (2) [MEDICATION NAME] bottles expired on 02/2019. During an interview, on 03/07/19 at 11:59 AM, RN #7 confirmed the medications in the medication storage room on the 300 Hall were expired. During an interview, on 03/08/19 at 12:03 PM, the Director of Nursing (DON) confirmed the meds were expired. The DON said the meds should be checked daily to make sure they are not expired.",2020-09-01
55,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2019-03-08,880,E,0,1,M3XR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, record review, and facility policy review, the facility failed to ensure measures to prevent the possibility of a Urinary Tract Infection [MEDICAL CONDITION] and/or cross contamination during catheter care for Residents #51, for one (1) of six (1 of 6) catheter care observations. The facility also failed to prevent the possible spread of infection and cross contamination during wound care by failure to wash hands during Residents #2, #57, and #133's wound care, for three of six (3 of 6) wound care observations. Findings Include: Review of facility's policy titled, Infection Control Monitoring, dated (MONTH) (YEAR), revealed it is the policy of the center to investigate the cause of infections (nosocomial, community and hospital acquired) and the manner of spread. The records will be maintained and infectious trends or any identified problems or potential problems will be reported to the Administrator, Director of Nurses and the Quality Assurance Committee. Follow up action will be taken as necessary. The objectives of the facilities Infection Control Policies and Practices are to: prevent, identify, report, and control infections and other communicable diseases. Designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Establish guidelines to follow in the implementation of isolation precautions. Maintain records of incidents and corrective actions related to infections. Establish guidelines to follow in implementing standard precautions/universal precautions of the handling of blood/ bodyguards and Antibiotic Stewardship Program. A review of the facility's policy titled, Hand Hygiene dated (MONTH) (YEAR), revealed that it is the policy of this facility handwashing/ hand hygiene shall be regarded by this center as a means of preventing the spread of infections. The policy stated that all personnel shall follow our established handwashing procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. The policy stated that associates must perform appropriate handwashing procedures under the following conditions: before handling clean or soiled dressings, gauze pads, etc., after handling used dressings, after handling items potentially contaminated items with blood, body fluids, excretions, or secretions, and after removing gloves. Review of the facility's policy titled, Catheter Care, Urinary, dated (MONTH) (YEAR), revealed the bag should be held below the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Resident #2 An observation, on 03/06/2019 at 8:46 AM, revealed Resident #2's wound care was provided by Registered Nurse (RN) #3. RN #3 performed the wound care on three (3) separate pressure wounds: a Stage 4 pressure wound to the left (L) Ischium, a Stage 4 pressure wound to the right (R) Ischium, and a Stage 4 pressure wound to the sacral area. RN #3 performed the wound care to both the Stage 4 pressure wounds to the (L) Ischium and the (R) Ischium without incident. During the wound care on the Stage 4 pressure wound to the sacral area, RN #3 discarded the soiled 4X4 gauze used for cleaning the wound, and then continued with the wound care by applying two (2) out of three (3) dressing ropes into the wound bed without washing her hands. After applying the second dressing rope, it was then that RN #3 removed her gloves, washed her hands, put on new gloves, and then continued to apply the third dressing into the wound. During an interview, on 03/07/2019 at 11:00 AM, Registered Nurse (RN) #3 confirmed she did not wash her hands after she discarded the soiled gauze from cleaning the sacral wound, and before she applied the first two (2) medicated rope dressings. RN #3 stated she remembered washing her hands before she applied the third medicated rope dressing. RN #3 stated, I didn't realize I didn't wash my hands, because I usually wash my hands before and after each time I apply the rope dressing into the wound. RN #3 stated that not washing your hands is an infection control concern. During an interview, on 03/07/2019 at 11:15 AM, with the Director of Nursing (DON), the DON revealed RN #3 should have washed her hands after she cleaned the sacral wound, and before she applied the medicated rope dressing. The DON stated, If your hands are not washed, that is an infection control concern. During an interview, on 03/07/2019 at 1:54 PM, with Licensed Practical Nurse (LPN) #1/Care Plan Coordinator, LPN #1 stated that it was her expectation that the nurse would provide the wound care treatment, without risking the possible spread of infection. An interview, on 03/07/2019 at 3:32 PM, with Registered Nurse (RN) #2/Infection Control Nurse, confirmed that during the wound care provided on Resident #2, that RN #3 should have washed her hands after cleaning the wound, and prior to the packing of the wound with rope dressing. Review of the Face Sheet revealed that Resident #2 was admitted by the facility on 03/05/2013, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's Discharge Minimum Data Set (MDS), dated [DATE], revealed a Basic Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Further review of the MDS revealed Resident #2 was coded for the presence of two (2) Stage 3 pressure wounds. Review of Resident #2's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/18, revealed a Basic Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Further review of the MDS revealed Resident #2 was coded for two (2) Stage 4 pressure wounds. Resident #57 An observation, on 03/07/19 at 10:15 AM, revealed Registered Nurse (RN) #3/Wound Care Nurse performed wound care to Resident #57's sacrum. Certified Nursing Assistant (CNA) #3 assisted RN #3 with the wound care. RN #3 placed a red bag on Resident #57's bed to the right side of Resident #57's right leg. RN #3 removed the old dressing, and discarded the dressing into the red bag. RN #3 washed her hands, gloved, and began to clean the wound. RN #3 cleaned and patted the wound dry. RN #3 applied Santyl to wound bed with a Q-tip applicator, and covered the wound with a silicone dressing. RN #3 wore the same gloves she had on while cleaning the wound to apply the Santyl and clean dressing to the wound. RN #3 failed to remove her gloves, wash her hands and re-glove after cleaning the wound, and before applying Santyl and the clean dressing to the wound. An interview, on 03/07/19 at 10:48 AM, revealed RN #3/ Wound Care Nurse stated, I knew what I did when I did it. I didn't change gloves and wash my hands after cleaning the wound and before I applied the Santyl and the clean dressing. It could be an infection control issue. An interview, on 03/07/19 at 3:22 PM, revealed RN #2/ Infection Control Nurse stated, RN #3 should have removed her gloves, washed hands and re-gloved before placing the Santyl and bandage on the clean wound. I see that as an infection control issue. An interview, on 03/07/19 at 3:44 PM, with the Director of Nursing (DON) revealed, the nurse not changing her gloves and washing her hands after cleaning the wound and before applying Santyl and the dressing is an infection control issue. Review of Resident #57's Significant Change MDS, with an ARD of 01/11/19, revealed a BIMS score of 10, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #57 was coded for an unstageable wound. Resident #133 An observation, on 03/05/19, 4:40 PM, revealed Registered Nurse (RN) #3/Wound Care Nurse provided Resident #133's wound care to the right foot/great toe. RN #3 was assisted by Certified Nursing Assistant (CNA) #3. RN #3 set up the wound care supplies on the over bed table, and then she placed the red biohazard bag on Resident #3, which positioned the right toe wound between RN #3 and the red biohazard bag. After looking over the supplies RN #3 identified she forgot to get scissors from the wound care cart. RN #3 left the room, and returned with the scissors in her bare hands. RN #3 laid the scissors on the tray containing her clean dressings without cleaning the scissors. RN #3 removed the dirty dressing, and discarded it into the red biohazard bag. RN #3 washed her hands and gloved to begin cleaning the wound. RN #3 wiped the wound with normal saline soaked gauze, and discarded the gauze into the red bag. RN #3 got another piece of normal saline gauze, wiped the other side of the wound, and discarded the gauze into the red bag. RN #3 took another piece of the normal saline gauze, wiped the wound, and the normal saline dripped down the side of the foot. RN #3 took the same piece of gauze and reached down to catch the dripping saline and wiped back towards the cleaned wound going from an uncleaned area to a cleaned area, thus wiping dirty to clean. RN #3 did not reclean the wound before attempting to apply the wound vac to the wound. RN #3 washed her hands and gloved, and then picked up the foam that was to be packed into the wound and crossed the cleaned wound over to the red bag and held the foam above the red bag, with the dirty dressing and gauze in it, and began trimming the foam with the uncleaned scissors. RN #3 brought the foam from over the red bag back to the wound, and placed it on the wound. She then reached back over and got the second piece of foam and crossed the clean wound again going to the red bag. RN #3 began trimming the foam over the red bag, and then brought the foam back and placed it on wound. She picked up the end of the wound vac that was to be placed over the foam on the wound. RN #3 placed the wound vac tubing on Resident #133's gown. The end to the tubing was uncapped. RN #3 sealed the part of the wound vac with the dressings cut earlier. She then picked up the tubing from the gown and hooked it to the wound vac itself without cleaning the uncapped tube. Suction was obtained. RN #3 cleaned up her trash, washed her hands, and exited the room. An interview, on 03/05/19 at 5:10 PM, with RN #3/Wound Care Nurse revealed, I did wipe the wound from dirty to clean and I knew it when I did it. RN #3 stated, I didn't think about crossing over the wound to the red bag with the foam then bringing it back over and putting it in the wound. I can see where that would be a contamination issue. I cleaned the scissors before bringing them in the room, but I didn't reclean them after bringing them into the room in my hand. I didn't think about that being an issue but I can see where they could be considered dirty being toted in my bare hand. I held the foam above the red bag to trim it, and I wasn't thinking about it being a contamination issue since I didn't touch it. But with the dirty dressing being in the red bag I can see it being a issue. During an interview, on 03/07/19 3:08 PM, RN #2/Infection Control Nurse, revealed wiping the resident's wound from dirty to clean and not recleaning the wound before dressing it would be a infection control issue. RN #2 said RN #3 should not have crossed the leg with the foam to the red bag. RN #2 stated RN #3 shouldn't go across the wound with the wound vac foam because your crossing the clean wound with supplies coming from the over bed table. RN #2 said RN #3 was going back to the clean wound with something dirty after she held it over the red bag. RN #2 also stated the tubing should not have been laid on Resident #133's gown. It should have been on a clean surface or RN #3 should have cleaned it before connecting it to the other capped end of the tube. RN #2 also stated the scissors should have been recleaned before using them since she had transported them in her bare hand. An interview, on 03/07/19 at 3:49 PM, with the Director of Nursing (DON) revealed RN #3's failure not to reclean the scissors before cutting the clean dressing was an infection control issue. The DON stated RN #3 crossing the clean wound with the foam was an infection control issue also. The DON stated RN #3 holding the foam over the red bag to trim it, and then bringing it back to the wound and packing the wound with the foam was an infection control issue. The DON stated RN #3 laying the uncapped tube of the wound vac suction part placed on top of the wound on the resident's gown and not cleaning it before connecting it to the capped end of the actual wound vac was an infection control issue. The DON stated RN #3 should have cleaned her scissors after having them in her hand and before cutting a clean dressing. Review of the Face Sheet revealed Resident #133 was admitted by the facility, on 02/12/19, with the included [DIAGNOSES REDACTED]. Review of Resident #133's Admission MDS, with an ARD of 02/19/19, revealed a BIMS score of 11, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #133 was coded for a Stage 2 wound. Resident #51 On 3/7/19 at 2:05 PM, an observation revealed Certified Nursing Assistant (CNA) #1 performed Resident #51's catheter care. CNA #1 entered Resident #51's room, applied her gloves, pulled some clean wipes from the container, and began the catheter care. CNA #1 did not wash her hands. CNA #1 wiped around the catheter near the resident's penis three times using one wipe and rotated the wipe as she wiped. She then used another wipe to wipe in a downward motion of the resident's groin areas, using a clean wipe for each side. CNA #1 held the catheter tubing near the meatus, and wiped away from the meatus three times. She then repositioned Resident #51 onto his left side, and cleaned his buttocks, wiping the buttocks areas in a circular and back and forth motion using the same wipe to clean the resident's entire buttocks area. On 03/07/19 at 3:44 PM, an interview with CNA #1 revealed she should have washed her hands before beginning the procedure, and she should have wiped from front to back in an upward motion to prevent the possibility of an infection. An interview, on 03/07/19 at 9:29 AM, revealed Registered Nurse (RN) #7 stated Resident #51 was very independent and did not like for the staff to assist him with anything although he needed it. RN #7 stated he does not think Resident #51 has had any Urinary Tract Infections (UTIs), but he does have spasms. He stated the resident has the catheter because he has some [DIAGNOSES REDACTED] from his [MEDICAL CONDITION]. On 03/07/19 at 3:49 PM, an interview with the Director of Nursing (DON) revealed CNA #1 should have washed her hands so she does not carry anything in to the resident. The DON stated CNA #1 should have wiped in an upward position for infection control purposes. On 03/07/19 at 3:26 PM, an interview with RN #2 revealed, CNA #1 should have washed her hands, gathered her supplies and placed her supplies on a barrier then proceeded to perform her catheter care. RN #2 also stated CNA #1 should have used one wipe to wipe each time in an upward position. Review of Resident #51's most recent comprehensive MDS, with an ARD of 12/19/18, revealed Resident #51 was coded for an indwelling urinary catheter/condom catheter, and not rated for urinary continence. Further review of the MDS revealed a BIMS score of 15, which indicated Resident #51 was cognitively intact. A review of the facility's Face Sheet revealed the facility admitted Resident #51 on 03/13/18 with a [DIAGNOSES REDACTED].",2020-09-01
56,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-05-18,280,E,1,0,UDH111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and facility policy review, the facility failed to develop/revise Care Plans for Pressure Ulcers for seven (7) of seven (7) residents reviewed for Pressure Ulcers; Residents #7, #8, #9, #10, #11, #12 and #13. The facility also failed to revise Resident #1's Care Plan for continued treatment of [REDACTED].#1, one (1) of 13 sampled resident care plans reviewed; which involved eight (8) of 13 residents. Findings include: Review of the facility policy entitled Care Plan-Comprehensive, dated 11/01, revealed, Policy Interpretation and Implementation 1. An Interdisciplinary Team, in coordination with the resident, his/her family or representative develops and maintains a Comprehensive Care Plan for each resident and 4. Care plans are revised as changes in the resident's condition dictate. Resident #1 Review of Resident #1's Care Plan revealed a Focus, dated 02/25/17, for rash & (and) itching. The approaches included the use of the medication [MEDICATION NAME] Cream (medication for Scabies) 5 % (per cent) Apply from neck down topically one (1) time only for itching initiated 04/04/17, revised 05/10/17, and resolved 05/10/17. Resident #1 continued to have itching at the sites of the scabies, and an order, dated 04/19/17, was added for [MEDICATION NAME] 0.1% Ointment due to itching. The Care Plan was never updated with a Focus of Scabies, nor was there a Focus of history of Scabies. The approach for the [MEDICATION NAME] Cream had not been resolved until 05/10/17, even though it was only to be administered once, and the date it was initiated was 04/04/17. A Focus area of Infection, dated 02/25/17, revealed an Intervention for [MEDICATION NAME] 0.3% ointment, Instill one (1) inch in left eye every eight (8) hours, initiated 03/06/17. Review of the cumulative order summary report for 05/17 revealed the medication order was no longer in effect, since it was not on the cumulative orders. This medication had not been discontinued from the Care Plan. Interview, on 05/10/17 at 3:25 PM, with the Registered Nurse (RN) Risk Manager/Infection Control Nurse revealed Resident #1 no longer had Scabies, but now he had an inflammation rash where the Scabies had been and this was not on the Care Plan. Interview, on 05/10/17 at 2:30 PM, with the Registered Nurse (RN) PPS (Preferred Payer Source) Co-coordinator confirmed the order for the [MEDICATION NAME] was not a current order and should have been removed from the Care Plan. She was unsure of the date the medication had been discontinued. Review of the Admission Record revealed the facility admitted Resident #1 on 02/25/17, with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/10/17, revealed the Resident scored 13 of 15 on the Brief Interview for Mental Status (BIMS) which indicated he was cognitively intact. Resident #7: Review of Resident #7's current Care Plan revealed the following: 1. A Focus for Resident #7 of High risk for infection R/T (related to) resident has indwelling catheter, Dx (diagnosis) [MEDICAL CONDITION] and GR IV (Grade 4)) to coccyx, Hx (history of) UTI's (Urinary tract infections) [MEDICAL CONDITION]. An Intervention was for Sacral wound: Cleanse with N/S (normal saline), pat dry, pat (pack) with Maxsorb AG (silver) and cover with foam dressing daily and prn (as needed). The Care Plan did not specify the cause or type of the sacrum/coccyx wound, which had been on the 05/12/17 wound report as a stage IV pressure ulcer on the sacrum. The Care Plan also did not include the current treatment, which was a wound vac (vacuum), which was ordered on [DATE]. 2. A Focus of Resident #7 of: impaired skin integrity revealed Interventions, initiated 3/3/17, which included Cleanse left lateral ankle with N/S, pat dry, apply maxsorb extra AG and cover with dry dressing every three (3) days and PRN. Another Intervention was for: Cleanse right lateral ankle N/S N/S (with normal saline), pat dry, apply Maxsorb extra AG, and cover with dry dressing every three (3) days and prn. Review of a hand written order, dated 05/04/17, revealed orders for Wound care to L (left) lateral ankle & (and) R (right) anterior foot, [MEDICATION NAME] q (every) 72 hrs. (hours) & prn, and neither of the current treatments were on the Care Plan. Review of the weekly wound report, dated 05/12/17 revealed the wounds were recorded on the pressure ulcer sheet as pressure ulcers and both were a stage III (3). The stages of the two (2) areas on the ankles were not included on the Care Plan, nor were they documented/identified as pressure ulcers in the Focus of the Care Plan. Review of the Weekly Wound Information Sheet(s) for Resident #7 revealed the following: 1. A Sacrum wound, which was identified as a pressure type wound was documented on 05/10/17. 2. A left ankle wound, which was identified as a pressure type wound was documented on 05/10/17. 3. A right ankle wound, which was identified as a pressure type wound was documented on 05/10/17. Interview, on 05/16/17 at 12:30 PM, with the MDS/CP LPN (Minimum Data Set/Care Plan Licensed Practical Nurse) confirmed neither pressure ulcers for the ankles on Resident #7 included the stage of the pressure ulcers. Interview, on 05/16/17 at 12:55 PM, with the MDS/CP LPN confirmed the treatment to the sacrum in the Care Plan for Resident #7 was not the current treatment documented in the Physician's Orders. She confirmed Care Plans should have been initiated/updated with the current treatments. The MDS/CP LPN also stated when a resident returned from the hospital, she tried to update the Care Plan within one (1) to two (2) weeks, but she had not updated this Resident's Care Plan. Review of the Admission Record revealed the facility readmitted Resident #7 on 12/22/16, with [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an Assessment Reference Date (ARD) of 03/18/17, revealed he scored 9 of 15 on the Brief Interview for Mental Status (BIMS), which indicated he had moderate cognitive impairment. Resident #8 Review of the Care Plan for Resident #8 revealed a Focus for Impaired skin integrity AEB (as evidenced by): Area to right side of head (resolved). The Unstageable pressure ulcer on the Resident's right heel was not included in the Focus of the Care Plan. The Interventions included the current pressure ulcer care correctly; but there was no mention of the type of wound or the stage of the wound for the treatment. Review of the Weekly Wound Information Sheet for Resident #8, dated 05/04/17, revealed the type of the wound on the right heel was a pressure ulcer. Interview, on 05/16/17 at 1:45 PM, with the MDS/CP LPN confirmed the Care Plan did not include the current pressure ulcer on Resident #8's right heel, nor did it include the type of ulcer or the stage of the ulcer. Review of the Admission Record revealed the facility readmitted Resident #8 on 03/01/17, with [DIAGNOSES REDACTED]. Review of the admission MDS, with an ARD of 03/07/17, revealed he scored 3 of 15 on the BIMS, which indicated he had severe cognitive impairment. Resident #9 Review of the Care Plan for Resident #9 revealed a Focus for Impaired skin integrity AEB area to right buttocks, right top of hand. Review of the Interventions included Cleanse right buttock with normal saline, pat dry, skin prep per wound, apply [MEDICATION NAME] every three (3) days and prn, which was initiated 5/2/17. Review of the weekly wound report revealed on the pressure ulcer page there was a stage II pressure ulcer documented as acquired in the facility as a stage II on 5/2/17 for Resident #9. Interview, on 05/17/17 at 10:20 AM, with the MDS/CP LPN confirmed the Care Plan did not include the type of wound (pressure ulcer) or the stage of the pressure ulcer for Resident #9 Review of the Admission Record revealed the facility readmitted Resident #9 on 07/03/10, with diagnoses, which included Dementia and Type 2 Diabetes. Review of the quarterly MDS, with an ARD of 04/19/17, revealed the Resident scored zero (0) of 15 on the BIMS, which indicated he had severe cognitive impairment. Resident #10: Review of Resident #10's Care Plan revealed a Focus of Impaired Skin Integrity as evidenced by Stage III pressure ulcer to sacrum. Interventions included Cleanse stage III pressure ulcer to sacrum w/NS (with normal saline), pat dry, apply [MEDICATION NAME] sheet, cover and secure every other day and prn The date of this pressure ulcer order was 12/08/16. Review of the cumulative Order Summary Report for 05/17, revealed Resident #10 had an order, dated 04/09/17 for Wound vac. (vacuum) to sacrum @ (at) 125 mmHg (millimeters of mercury) continuous. The Care Plan was not updated with this current pressure ulcer treatment. Interview, on 05/16/17 at 1:20 PM, with the MDS/CP LPN confirmed Resident #10's Care Plan did not include the current pressure ulcer treatment. The MDS/CP LPN also stated it was her responsibility to be sure the Care Plans were updated, and stated it was an oversight not to have updated the Care Plan. The MDS/CP LPN also stated she had been employed by the facility since 01/17. Review of the Admission Record revealed the facility readmitted Resident #10 on 03/18/17, with [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an ARD of 04/30/17, revealed the Resident scored 15 of 15 on the BIMS, which indicated he was cognitively intact. Resident #11 Review of Resident #11's Care Plan revealed a Focus of Impaired skin integrity as evidenced by open area to sacrum/left buttocks. The Interventions included treatments for left buttock wound, left horizontal gluteal crease, left stump and right buttocks #1 and #2. There was no identification of what type and/or stages of these wounds. Review of the weekly wound report revealed Resident #11 had stage II wounds to the sacrum, left ishium and right ishium on the sheet for pressure ulcers, and there were no wounds recorded on the sheet for Other Skin Integrity Report. Interview, on 05/16/17 at 1:40 PM, with the MDS/CP LPN confirmed the Care Plan did not include the stage of the pressure ulcers, or the identification of the wounds as pressure ulcers or other skin concerns for Resident #11. Review of the Admission Record revealed the facility admitted Resident #11 on 08/22/16, with [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an ARD of 02/23/1,7 revealed he scored 3 of 15 on the BIMS, which indicated he had severely impaired decision making abilities. Resident #12: Review of the Care Plan for Resident #12 revealed a Focus for Impaired skin integrity as evidenced by: stage IV pressure ulcer to left & (and) right buttocks (ishiums). DTI (deep tissue injury) (now stage II) pressure ulcer to right lateral foot and Right heel pressure ulcer & left ishium. There were no Intervention (s) for the right lateral foot, nor were there any current Physician Orders for treatment to the right lateral foot. There was no documented evidence of a wound to the right lateral foot from 03/03/17 to 05/10/17. The care plan was not revised to include the right lateral foot pressure ulcer was resolved. Review of the physicians orders dated 5/11/17, revealed treatment to the right and left ischium for Santyl, Collagen and Calcium Alginate and cover with dressing daily and prn (as needed). The care plan was not updated to include the right ischium treatment for [REDACTED]. Interview, on 05/17/17 at 10:40 AM, with the MDS/CP Licensed Practical Nurse (LPN) confirmed there was no documentation of a wound to the right lateral foot for Resident #12. The MDS/Care Plan LPN also stated she did not include the stage and cause of the wounds (pressure ulcer or non-pressure wound) in the Care Plan if the information was not included in the Physician's Order. She also stated she did review the weekly wound report, but had not been instructed to include the stage and cause of the wound in the Care Plan. Review of the Admission Record revealed the facility readmitted Resident #12 on 01/21/15, with [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an ARD of 03/14/17, for Resident #12 revealed he scored 15 of 15 on the Brief Interview for Mental Status BIMS, which indicated he was cognitively intact. Resident #13: Observation of Resident #13's wounds/dressings revealed a wound on the right shin, the left lateral leg at the ankle, left ishium and coccyx. Review of Resident #13's Care Plan revealed a Focus for 1/23/17 -actual open area to left lateral leg, wound to coccyc (coccyx); right shin date initiated 01/23/17. Review of the current wound treatments revealed there were also wounds on the right buttock and right posterior thigh, but although these areas were included in the Interventions (s), these wounds were not included in the focus. Review of Resident #13's documentation on the pressure ulcer report, dated 05/12/17, revealed the Resident had a wound on the posterior right thigh, coccyx and two (2) areas on the left lateral leg as well as an area on the right shin. The care plan did not include both areas on the left lateral lower leg. Interview, on 05/17/17 at 10:25 AM, with the MDS/CP LPN, confirmed the wounds were not identified on the Care Plan with the stage or type of ulcers (pressure) for Resident #13. Review of the Admission Record revealed the facility readmitted Resident #13 on 03/07/17, with [DIAGNOSES REDACTED]. Review of the admission MDS revealed the Resident scored 15 of 15 on the BIMS, which indicated he was cognitively intact.",2020-09-01
57,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-05-18,281,D,1,0,UDH111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, review of instructions for the Negative Pressure Wound Therapy (NPWT) and the Nurse Practice Act, the facility failed to obtain an order for [REDACTED]. Findings include: Resident #7 Review of the Pressure Settings instructions, provided by the facility for the NPWT, not dated, revealed the pressure can be adjusted in increments of 25 millimeters (mm) Hg ( mercury) from 25 to 200 mm Hg. The Default setting is 125 mm Hg. Review of the readmission orders [REDACTED]. The order did not include the negative pressure setting for the wound. In an interview, on 05/17/17 at 11:25 AM, the Medical Director confirmed all orders for NPWT should always contain the pressure to be used on the wound. Review of the Admission Record revealed the facility readmitted Resident #7 on 12/22/16, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/18/17, revealed he scored 9 of 15 on the Brief Interview for Mental Status (BIMS), which indicated he had moderate cognitive impairment. Unsampled Resident D Review of the Mississippi Nursing Practice Law, effective 07/01/10, revealed, Definitions, 2. Nursing practice includes, but is not limited to, administration, teaching, counseling, delegation and supervision of nursing, and execution of the medical regimen, including the administration of medications and treatments prescribed by any licensed or legally authorized physician or dentist. Review of the discontinued physician's orders [REDACTED]. Review of the cumulative Order Summary Report for Physician order [REDACTED]. Observation of Unsampled Resident D's room, on 05/10/17 at 11:30 AM, revealed isolation supplies were on the door of the Resident's room. Unsampled Resident D's roommate was Unsampled Resident H, who had no order for isolation. During an interview on 05/11/17 at 3:40 PM, the Interim Director of Nursing (DON) confirmed Unsampled Resident D had been placed in isolation due to ESBL in the urine, which was revealed in a laboratory result from 01/25/17, and the isolation was discontinued on 02/23/17. The DON was unable to determine why the isolation supplies remained on the door for facility staff to use since the isolation had been discontinued. The interim DON also stated the Infection Control Nurse should have caught that and discontinued the isolation. Review of the Admission Record revealed the facility admitted Unsampled Resident D on 02/05/15, with [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an ARD of 04/16/17, revealed the Resident scored 12 of 15 on the BIMS, which indicated she had moderately impaired cognitive abilities.",2020-09-01
58,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-05-18,441,E,1,0,UDH111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff interview and facility policy review, the facility failed to maintain and monitor infection tracking for three (3) of six (6) sampled residents with isolation procedures and two (2) of eight (8) Unsampled residents with isolation procedures, Residents #1, #7, and #11 and Unsampled Residents #B and #C; for five (5) of eight (8) residents. Findings include: Review of the facility policy entitled, Infection Control Policies/Practices, dated 08/14, revealed, Policy Interpretation and Implementation, 2. d. Maintain records of incidents and corrective actions related to infections. Resident #1: Review of the Care Plan for Resident #1 revealed [MEDICATION NAME] Cream for Scabies had been initiated/administered to the Resident on 04/04/17. Review of the Monthly Infection Control Report revealed there was no entry for Scabies for the month of (MONTH) (YEAR). There was one (1) entry for Resident #1, on 04/13/17, for Symptoms -itching with an order for [REDACTED]. There was no Site, Care Plan or Date Resolved documented on the Infection Control Report. There was no indication as to why itching would have been included on the log as an infection. Interview with the Infection Control Registered Nurse (RN), on 05/12/17 at 1:10 PM, revealed she was responsible for the Monthly Infection Control Report as well as having tracked and trended infections in the facility. The Infection Control RN stated the Scabies had not been recorded on the Infection Control Report for Resident #1 because an antibiotic was not given. She also stated in hind sight she should have included the Scabies on the Infection Control Report. Review of the Admission Record revealed the facility admitted Resident #1 on 02/25/17, with diagnoses, which included Cerebral Infarction and [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/10/17, revealed the Resident scored 13 of 15 on the Brief Interview for Mental Status (BIMS,) which indicated he was cognitively intact. Resident #7: Observation of Resident #7, on 05/11/17 at 2:35 PM, revealed there were isolation supplies on the door of his room. Review of Resident #7's clinical record revealed there had been no order for isolation written. There was an order for [REDACTED]. Interview, on 05/11/17 at 2:35 PM, with RN #1 revealed he thought Resident #7 had been in isolation due to ESBL (Extended-Spectrum B-Lactamases) in his urine, but he was unable to locate an order for [REDACTED].#1 also stated the isolation was implemented after an order was written for [MEDICATION NAME]. Review of the Admission Record revealed the facility readmitted Resident #7 on 12/22/16, with diagnoses, which included Type 2 Diabetes Mellitus and Morbid Obesity. Review of the quarterly MDS, with an ARD of 03/18/17, revealed he scored 9 of 15 on the BIMS which indicated he had moderate cognitive impairment. Resident #11 Observation on 05/10/17 at 11:30 AM, revealed there were isolation supplies on the door of Resident #11's room. Review of the cumulative Order Summary Report for Physician's Orders for 05/17, revealed an order dated 03/14/17, for Contact Isolation for MRSA (Methicillin-Resistant Staphylococcus Aureus). Further review of the Physician's Orders revealed Resident #11 did not have a current order for an antibiotic. Review of Resident 11's roommate's chart (Unsampled G) revealed there was no order for isolation. Interview, on 05/12/17 at 11:25 AM, with the interim Director of Nurses (DON) confirmed the antibiotics for Resident #11 were ordered on [DATE], for five (5) days, and the isolation was never discontinued, and she was unable to provide an explanation as to why the isolation was never discontinued. Review of the Admission Record revealed the facility admitted Resident #11 on 08/22/16, with diagnoses, which included Dementia and [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an ARD of 02/23/17, revealed he scored 3 of 15 on the BIMS, which indicated he had severely impaired decision making abilities. Unsampled Resident B Observation, on 05/10/17 at 11:30 AM, revealed there were isolation supplies on Unsampled Resident B's door. Review of Unsampled Resident B's cumulative Order Summary Report of Physician's Orders for 05/17, revealed an order, dated 03/17/17, for Contact Isolation for MRSA in L (left) hip wound. The only current antibiotic order for Unsampled Resident B was [MEDICATION NAME] for a sinus infection, which did not include an isolation order. Review of a handwritten order, dated 04/11/17, revealed an order to D/C (discontinue) all wound orders. Interview on 05/11/17 at 3:10 PM, with Licensed Practical Nurse (LPN) #1, revealed Unsampled Resident B had been on the antibiotic [MEDICATION NAME] for 14 days on the 03/17/17 order. LPN #1 also stated the isolation order was probably not discontinued when the wound orders were discontinued. LPN #1 stated the nurses work with the Infection Control RN to discontinue isolation when appropriate. Review of the Admission Record revealed the facility admitted Unsampled Resident B on 10/04/16, with diagnoses, which included Pressure Ulcer of Sacrum and Type two (2) Diabetes Mellitus. Review of the quarterly MDS, with an ARD of 03/30/17, revealed she scored 15 on 15 on the BIMS, which indicated she was cognitively intact. Unsampled Resident C Observation, on 05/10/17 at 11:30 AM, revealed Unsampled Resident C had isolation supplies on the door of the room. Review of Unsampled Resident C's cumulative Order Summary Report for 05/17, revealed an order, dated 03/17/17 for Contact Isolation for VRE ([MEDICATION NAME] Resistant [MEDICATION NAME]) in Wound. There was an order, dated 05/11/17, for the antibiotic [MEDICATION NAME] for Leukocytosis (elevated [NAME] Blood Cell level, which indicated a possible infection). Interview with LPN #1, on 05/11/17 at 3:30 PM, revealed Unsampled Resident C had been placed on antibiotics for 14 days on 03/17/17, due to a wound infection with an order for [REDACTED].#1 also stated the Resident had been started on an antibiotic on 05/11/17, due to a Urinary Tract Infection, but no order or need for isolation. LPN #1 stated she did not know why the isolation had not been discontinued after the antibiotic treatment to the wound was discontinued. Review of the Admission Record revealed the facility readmitted Unsampled Resident C on 08/06/16, with diagnoses, which included Chronic Obstructive Pulmonary Disease and Urinary Tract Infection. Review of the quarterly MDS, with an ARD of 02/04/17, revealed the Resident scored 15 of 15 on the BIMS which indicated he was cognitively intact.",2020-09-01
59,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-05-18,514,E,1,0,UDH111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review the facility failed to ensure accurate and completely documented medical records as evidenced by conflicting information about wounds and whether they were acquired or admitted , where they were located and types of wounds for five (5) of seven (7) residents reviewed with pressure sores; Residents #7, #10, #11, #12, and #13. Findings include: Resident #7: Review of the Weekly Wound Information Sheet, for Resident #7, revealed the following wound assessments: 1. Right Ankle: weekly documentation present with conflicting information: 03/7/17- Right Ankle Pressure Ulcer, acquired 11/2/16, originally unstageable with current stage III. 03/28/17-Documentation changed to Right lateral ankle pressure ulcer, originally unstageable with current stage II. 05/10/17-Documentation goes back to Right Ankle pressure ulcer, admitted on [DATE] as a current stage II with no original staging. 2. Left Ankle: weekly documentation present with conflicting information: 3/7/17-Left ankle Pressure Ulcer, acquired 11/14/16, originally unstageable with current stage III. 3/28/17-Changed to Left lateral ankle pressure ulcer, originally unstageable with current stage III. 5/10/17-Goes back to Left ankle pressure ulcer, now as admitted with on 5/4/17, no original stage recorded, current stage II. 3. Sacrum: weekly documentation present with conflicting information: 3/7/17-Sacrum, Pressure Ulcer, admitted as stage IV on 10/14/16, with current stage IV and original Stage IV. 5/10/17-Sacrum, Pressure Ulcer, changed to admitted with on 5/4/17 with current stage of III and original stage was not documented. Review of Resident #7's current care plan did not reveal the type of wounds or stages of the ankle wounds. Interview, on 05/16/17 at 12:30 PM, with the MDS/CP LPN (Minimum Data Set/Care Plan Licensed Practical Nurse) confirmed neither pressure ulcers for the ankles on Resident #7 included the stage of the pressure ulcers. Review of the Admission Record revealed the facility readmitted Resident #7 on 12/22/16, with [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an Assessment Reference Date (ARD) of 03/18/17, revealed he scored 9 of 15 on the Brief Interview for Mental Status (BIMS), which indicated he had moderate cognitive impairment. Resident #10: Review of the Weekly Wound Information Sheet, for Resident #10, revealed the following wound assessments: weekly documentation with conflicting information: 3/2/17-sacrum pressure ulcer, admitted [DATE] originally a stage III and currently a stage III. 5/2/17-sacrum pressure ulcer, acquired 6/6/14, originally a stage III with current stage III. 5/9/17-sacrum pressure ulcer, switched back to admitted on [DATE], originally and currently a stage III. 5/16/17-sacrum pressure ulcers switched to acquired on 3/18/17, original and current stage III. Review of the Admission Record revealed the facility admitted Resident #10 on 6/6/14, and readmitted Resident #10 on 03/18/17, with [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an ARD of 04/30/17, revealed the Resident scored 15 of 15 on the BIMS, which indicated he was cognitively intact. Resident #11: Review of the Weekly Wound Information Sheet, for Resident #11, revealed the following wound assessments: 1. Left Ischium: weekly documentation present with conflicting information: 3/3/17-Left Ischium pressure ulcer, admitted with on 2/6/17, originally and currently a stage II. 3/17/17-Changed to Left Buttock pressure ulcer, still admitted with on 2/6/17, originally and currently a stage II. 3/31/17-Changed back to Left Ischium pressure ulcer, still admitted on [DATE], originally and currently a stage II. 5/10/17-Left Ischium pressure ulcer, with an acquired date of 5/8/17, originally and currently a stage II. 2. Right Ischium: weekly documentation present with conflicting information: 3/3/17-Right Ischium pressure ulcer, admitted [DATE], originally and currently a stage II. 3/17/17-Right Ischium pressure ulcer changes to acquired on 2/6/17, originally and currently a stage II. 4/7/17-Right Ischium pressure ulcer changes back to admitted with on 2/6/17, original and current stage II. 5/17/17-Right Ischium pressure ulcer changes back to acquired on 5/8/17, stage II original and current. Review of the Admission Record revealed the facility admitted Resident #11 on 08/22/16, with [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an ARD of 02/23/17, revealed he scored 3 of 15 on the BIMS, which indicated he had severely impaired decision making abilities. Resident #12: Review of the Weekly Wound Information Sheet, for Resident #12, revealed the following wound assessments: 1. Right Heel: weekly documentation present with conflicting information: 4/14/17-Right Heel pressure ulcer, acquired 4/13/17, originally and currently stage II. 5/11/17-Right Heel pressure ulcer has an acquired date of 2/2/17, original and current stage II. 5/17/17 Right heel pressure ulcer also had the acquired date of 2/2/17. 2. Right Buttock: weekly documentation present with conflicting information: 3/3/17-Right buttock pressure ulcer, admitted [DATE], original and current stage IV. 4/28/17-Right buttock pressure ulcer changed to admitted with on 3/5/17 with original and current stage IV. 5/5/17-changes to Right Ischium pressure ulcer, present on admission on 3/5/13 with original and current stage IV. 5/11/17-Right Ischium (Buttock) pressure ulcer, present on admission on 3/5/13, original and current stage IV. 5/17/17-Right Ischium, present on admission 3/5/13 with original stage IV and current stage III. 3. Left Buttock-weekly documentation present with conflicting information: 3/3/17-Left Buttock pressure ulcer on admit 3/5/13, original and current Stage IV. On 4/21/17 the measurements were 8.0 centimeters (cm) long by (x) 6.2 cm wide by 1.0 depth, then on 4/28/17 the measurements were 3.8 cm x 2.0 cm x 1.0 cm. On 5/5/17 the measurements went back to 8.2 cm x 6.3 cm x 1.0. 5/5/17-changes to Left Ischium pressure ulcer, present on admit 3/5/13 with original stage IV and current stage III. 5/11/17-Left Ischium (Left Buttock) pressure ulcer, admitted [DATE] with original stage IV and current stage III. 5/17/17-Left Ischium pressure ulcer only, admitted [DATE] with original stage IV and current stage III. There was no documentation on the care plan to indicate type and stage of wounds. Interview, on 05/17/17 at 10:40 AM, with the MDS/CP Licensed Practical Nurse (LPN) stated she did review the weekly wound report, but had not been instructed to include the stage and cause of the wound in the Care Plan. Review of the Admission Record revealed the facility admitted Resident #12 on 3/5/13, and readmitted Resident #12 on 01/21/15, with [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an ARD of 03/14/17, for Resident #12 revealed he scored 15 of 15 on the Brief Interview for Mental Status BIMS, which indicated he was cognitively intact. Resident #13: Observation of Resident #13's wounds/dressings on 5/17/17 at 9:20 AM, revealed a wound on the right shin, the left lateral leg at the ankle, left ishium and coccyx. Review of the Weekly Wound Information Sheet, for Resident #13, revealed the following wound assessments: 1. Sacrum-Weekly documentation present with conflicting information: 5/5/17-Sacrum pressure ulcer, acquired 4/30/17, original and current stage III. 5/11/17-changed to Coccyx pressure ulcer with the same information. 2. Left Lateral Leg #1: Weekly documentation present with conflicting information: 5/5/17-Left Lateral Leg #1, acquired 4/30/17, pressure ulcer, original and current unstageable. 5/18/17-changed to Left lower leg #1 pressure ulcer with the same information. 3. Left Lateral Leg #2: Weekly documentation present with conflicting information: 5/5/17-Left Lateral Leg #2 pressure ulcer, acquired 4/30/17, unstageable originally and currently. 5/18/17-changed to Left lower leg #2 pressure ulcer, acquired on 5/11/17, original and currently unstageable. 4. Right Shin: Weekly documentation present with conflicting information: 5/11/17-Right shin pressure ulcer, acquired 5/6/17, original and currently unstageble 5/18/17-Right shin pressure ulcer, acquired 4/30/17 with the same information. 5. Right upper Leg: Weekly documentation present with conflicting information: 3/10/17-Right upper leg pressure ulcer, acquired 1/25/17, original and current stage II. 5/5/17-Right upper leg pressure ulcer changed to acquired on 5/5/17, original and current stage III. 6. Right Posterior Thigh: Weekly documentation present with conflicting information: 5/11/17-Right Posterior Thigh pressure ulcer, admitted with on 1/25/17, original stage not documented, current stage III. 5/18/17-Right Posterior Thigh pressure ulcer, changed to acquired on 2/20/17, original stage II and current stage II. Review of Resident #13's current care plan revealed the wounds were not identified as to the stage and type of the wounds present on Resident #13. Interview, on 05/17/17 at 10:25 AM, with the MDS/CP LPN, confirmed the wounds for Resident #13 were not identified on the Care Plan with the stage or type of ulcers (pressure). Review of the Admission Record revealed the facility admitted Resident #13 on 2/27/14 and readmitted Resident #13 on 03/07/17, with [DIAGNOSES REDACTED]. Review of the admission MDS revealed the Resident scored 15 of 15 on the BIMS, which indicated he was cognitively intact.",2020-09-01
60,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2019-08-29,656,G,1,0,QXL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and facility policy review, the facility failed to implement Resident #3's Care Plan for high risk for skin impairment. The facility failed to perform weekly body audits to monitor, assess and prevent the reoccurrence of a pressure ulcer. The facility identified Resident #3 at high risk for pressure ulcers on admission, 02/06/19, due the presence of a Stage 3 sacral pressure ulcer. As a result, Resident #3 suffered harm due to the development of a Stage 3 sacral pressure ulcer identified, on 05/09/19, which required hospitalization for wound infection and debridement of the wound. This concern was identified for one (1) of six (6) wound care plans reviewed. Findings Include: Record review of the facility's policy titled, Comprehensive Care Plan Policy, dated (MONTH) (YEAR), revealed a Comprehensive Care Plan that includes measurable objectives and timetables to meet resident's medical, nursing, mental and psychological needs shall be developed for each resident. An interdisciplinary team, in coordination with the resident, his/her family or representative, develops and maintains a Comprehensive Care Plan for each resident. The Comprehensive Care Plan has been designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, build on residents strength, reflect treatment goals and objectives in measurable outcomes, Identify the professional services that are responsible for each element of care, prevent declines in the resident 's functional status/functional levels, enhance the optimal functioning of the resident by focusing on a rehabilitative program, ensure care plan is individualized and person-centered and reflects the resident's goal for admission and desired outcomes, and discharge plans. Review of the facility's policy titled, Prevention of Pressure Ulcers, dated (MONTH) 2019, revealed the skin observation schedule would be completed as follows: C.N.[NAME] (Certified Nursing Assistants) will complete total body observations at minimum on bath days. Charge Nurse will complete weekly skin observations on each resident, Licensed Nurse Weekly Skin Observation Form. Any residents with wounds will be documented on the Weekly Wound Information Sheet. The Care Plan will be revised/updated. Record review of Resident #3's Comprehensive Care Plan revealed the Focus, no date, for high risk for impaired skin integrity related to (r/t) occasional Bowel Incontinence, Diabetes, [MEDICAL CONDITION] and Actual Sacral Wound acquired on 05/09/2019. Interventions included Skin Observations weekly, and the staff assigned was the nurse. Further review of the Care Plan revealed a Focus for high risk for altered behavioral patterns as evidenced by the resident was short tempered with staff, and had episodes of cursing, attempting to hit staff, hitting and pinching staff when she does not want them to provide care. Resident also declines weights and medications at times. During an interview, on 08/29/19 at 10:00 AM, Registered Nurse (RN) #1/Treatment Nurse revealed Resident #3 was admitted with a healing Stage 3 sacral pressure ulcer on 02/06/2019. RN #1 stated the wound was healed on 02/21/2019. RN #1 said a Certified Nursing Assistant told her to check Resident #3's buttocks on 05/09/2019. RN #1 said Resident #3 was noted with a 10 centimeter (cm) x 5 cm unstageable sacral wound with a small amount of serosanguineous drainage. RN #1 reported the wound bed was covered with slough, and progressively worsened. RN #1 said she had not seen Resident #3's buttocks since 02/22/2019 (the date the sacral pressure ulcer had healed at the time of admission). RN #1 said the nurses on the floor are responsible for doing the body audits every week. RN #1 confirmed Resident #3 was considered high risk for the wound to reopen on her sacrum because she was obese, Diabetic, Chronic Urinary Tract Infections (UTIs), and a History of Pressure Ulcers. Review of Resident #3's medical record revealed no Weekly Skin Observations Forms were located from 02/21/19 until 05/09/19. Review of Resident #3's (MONTH) 2019 Treatment Administration Record (TAR), revealed an order dated 05/09/19 to cleanse the wound to the sacrum with Normal Saline (N/S). Pat dry. Apply Santyl to wound. Apply [MEDICATION NAME] to periwound. Cover with dry dressing daily and as needed (PRN) for soiled/dislodged dressing every day shift. Review of the hospital Emergency Department (ED) notes revealed Resident #3's service time and date was 05/22/19 at 12:59 PM. History of Present Illness: She was sent in because of change in hydration and alertness. Decreased diet and is refusing to take medications, meals, and fluids. Level of consciousness was alert, awake, and aware. Calm and cooperative. [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary revealed Resident #3 was admitted to the hospital, on 05/22/19, and discharged on [DATE]. Resident #3 underwent an Excisional Debridement of a 15 cm X 15 cm sacral and bilateral gluteal stage IV (4) decubitus ulcer. Incision and drainage of a left medial abcess. The discharge [DIAGNOSES REDACTED].[MEDICAL CONDITION], unspecified organism. Initial blood culture was positive for Staphylococcus lugdunensis. Repeat blood cultures were negative. Acute Urinary Tract Infection: Urine cultures were positive for Kliebsiella pneumonia and [MEDICATION NAME] faecalis. Sacral Decubitus Ulcer. Acute [MEDICAL CONDITION]. An interview with the Director of Nursing (DON), on 08/09/2019 at 2:00 PM, revealed the facility failed to follow Resident #3's Care Plan for high risk for skin alterations. The DON revealed she was not the DON at that time, however she was able to confirm the facility had not done weekly body audits for Resident #3 since the sacral pressure ulcer healed on 02/21/19. The DON revealed, as the DON she was responsible to ensure the Care Plans were accurate and implemented, but due to her new position as DON, she had not accomplished reviewing the care plans for accuracy and implementation at this time. The DON said the floor nurses were scheduled to do body audits on different residents every shift. The DON also said Resident #3 was a high risk for pressure ulcers because she had just healed from a wound, was unable to turn herself and was incontinent. The Certified Nursing Assistants (CNAs) who were assigned to provide Resident #3's care and the Licensed Practical Nurse (LPN) who was responsible to perform Resident #3's weekly body audits from 02/21/19 to 05/09/19 were no longer employed at the facility. The SA made phone call attempts to interview these employees, but either the phone was no longer in use, or no answer, and/or no return calls. Review of Resident #3's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/12/19, revealed the resident was admitted with the presence of one (1) Stage 3 pressure ulcer, and was identified as high risk for pressure ulcers. Resident #3's Basic Interview for Mental Status (BIMS) score was 14, which indicated no cognitive impairment. Review of Resident #3's Functional Status revealed she required: Extensive assistance with two persons physical assist with bed mobility, transfers, and toilet use. Total dependence with one person's physical assist with locomotion on and off the unit. Supervision with set up help with eating. Extensive assistance with one person's physical assist with personal hygiene and bathing. Resident #3 was always incontinent of bowel and bladder. Resident #3 had Range of Motion (ROM) impairment to her upper and lower extremities on one side. An interview with Licensed Practical Nurse (LPN) #1/Care Plan Nurse, on 08/29/2019 at 1:00 PM, revealed the facility failed to implement Resident #3's Care Plan regarding the high risk for skin alterations due to the nurses failed to perform the weekly body audits to assess the resident for pressure ulcers. LPN #1 confirmed the weekly body audits were performed to assess for and prevent new pressure ulcers, and she would expect the nurses to follow the Care Plan. A review of the facility's Face Sheet revealed Resident #3 was admitted by the facility, on 02/06/19, with the included [DIAGNOSES REDACTED]. A review of Resident #3's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/15/2019, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated the resident was cognitively impaired. Resident #3's Skin Condition revealed the presence of an unstageable pressure ulcer. Further review of the MDS revealed Resident #3's Functional Status: Transfers and locomotion on and off the unit was coded an eight (8), which indicated the activity did not take place. Dressing, bathing and toilet use, Resident #3 was totally dependent, and required one person's physical assist. Eating required supervision and set up help. Personal hygiene required extensive assistance with one person's physical assist. Resident #3 was always incontinent of bowel and bladder. Resident #3. Resident #3 had Range of Motion (ROM) impairment to her upper and lower extremities on one side.",2020-09-01
61,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2019-08-29,686,G,1,0,QXL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and facility policy review, the facility failed to perform weekly body audits to monitor, assess and prevent the reoccurrence of a pressure ulcer. The facility identified Resident #3 at high risk for pressure ulcers on admission, 02/06/19, due the presence of a Stage 3 sacral pressure ulcer. As a result, Resident #3 suffered harm due to the facility's identification of an unstageable sacral pressure ulcer, on 05/09/19, which required hospitalization for wound infection and debridement of the wound. This concern was identified for one (1) of six (6) wound care plans reviewed. Findings Include: Review of the facility's policy titled, Prevention of Pressure Ulcers, dated (MONTH) 2019, revealed the skin observation schedule would be completed as follows: C.N.[NAME] (Certified Nursing Assistants) will complete total body observations at minimum on bath days. Charge Nurse will complete weekly skin observations on each resident, Licensed Nurse Weekly Skin Observation Form. Any residents with wounds will be documented on the Weekly Wound Information Sheet. The Care Plan will be revised/updated. Review of the hospital Emergency Department (ED) notes revealed Resident #3's service time and date was 05/22/19 at 12:59 PM. History of Present Illness: She was sent in because of change in hydration and alertness. Decreased diet and is refusing to take medications, meals, and fluids. Level of consciousness was alert, awake, and aware. Calm and cooperative. [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary revealed Resident #3 was admitted to the hospital, on 05/22/19, and discharged on [DATE]. Resident #3 underwent an Excisional Debridement of a 15 cm X 15 cm sacral and bilateral gluteal stage IV (4) decubitus ulcer. Incision and drainage of a left medial abcess. The discharge [DIAGNOSES REDACTED].[MEDICAL CONDITION], unspecified organism. Initial blood culture was positive for Staphylococcus lugdunensis. Repeat blood cultures were negative. Acute Urinary Tract Infection: Urine cultures were positive for Kliebsiella pneumonia and [MEDICATION NAME] faecalis. Sacral Decubitus Ulcer. Acute [MEDICAL CONDITION]. Resident #3 did not return to the facility at the time of discharge from the hospital. Resident #3 was transferred to another facility. Review of the facility's Progress Notes, dated 05/22/19 at 9:18 AM, revealed the Nurse Practitioner (NP) documented Resident #3 was sent to the hospital Emergency Department (ED) for evaluation. An interview with Registered Nurse (RN) #1/Treatment Nurse, on 08/29/2019 at 10:00 AM, revealed Resident #3 was admitted with a healing stage 3 sacral pressure ulcer on (MONTH) 6, 2019. RN #1 said the wound healed on (MONTH) 21, 2019. RN #1 then stated, a Certified Nursing Assistant reported to her that she needed to check Resident #3's buttocks on 05/09/2019. RN #1 reported she observed a 10 centimeter (cm) by 5 cm unstageable wound to Resident #3's sacral area with a small amount of serosanguineous drainage. RN #3 also stated the wound bed was covered with slough. RN #1 reported the wound got progressively worse. RN #1 revealed she had not seen Resident #3's buttocks since (MONTH) 22, 2019. RN #1 said the nurses on the floor are responsible for body audits every week. RN #1 stated Resident #3 was considered high risk for the wound to reopen on her sacrum because she was obese, Diabetic, Chronic UTI's (Urinary Tract Infections), and a history of pressure ulcers. Review of Resident #3's Progress Note, dated 02/21/19 at 5:29 PM, documented by RN #1, revealed the pressure ulcer to the sacrum was healed. Treatment orders were discontinued. Review of Resident #3's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/12/19, revealed the resident was admitted with the presence of one (1) Stage 3 pressure ulcer, and was identified as high risk for pressure ulcers. Resident #3's Basic Interview for Mental Status (BIMS) score was 14, which indicated no cognitive impairment. Review of Resident #3's Functional Status revealed she required: Extensive assistance with two persons physical assist with bed mobility, transfers, and toilet use. Total dependence with one person's physical assist with locomotion on and off the unit. Supervision with set up help with eating. Extensive assistance with one person's physical assist with personal hygiene and bathing. Resident #3 was always incontinent of bowel and bladder. Resident #3 had Range of Motion (ROM) impairment to her upper and lower extremities on one side. Review of The Pressure Ulcer Reports revealed the following: 05/10/19, an unstageable pressure ulcer to Resident #3's sacrum. The wound measured 10 cm x 5 cm. The Pressure Relief Device was to turn every (q) two (2) hours, and the Treatment Plan was Santyl. 05/17/19, 10 cm x 10 cm unstageable pressure ulcer to the sacral area. Acquired 05/09/19. Added a wedge for pressure relief. Santyl continued for Treatment Plan. 05/24/19, 9.8 cm x 9.8 cm unstageable sacral pressure ulcer. Worsened-yes. Air mattress added for pressure relief, and Santyl for Treatment Plan. Each report was signed by RN #1/Treatment Nurse. Review of the Weekly Wound Information forms revealed the following: On 05/10/19 at 8:53 AM, on 05/09/19 an unstageable pressure ulcer was acquired. The wound measured 10 cm x 5 cm with a small amount of serosanguineous drainage. No odor. Slough was present. The peri-wound area was red with excoriation. The Responsible Party (RP), who was identified as Self, was notified on 05/09/19. The date the MD (Medical Doctor) initially notified or date of most recent status update: 05/07/19. The Progress stated: Resident with new unstageable wound to sacrum. Resident is noncompliant with turning and tends to get irritated when aids/nurses try to turn her. On 05/24/19 at 2:35 PM, continued to identify the unstageable sacral pressure ulcer. Measurements: 9.8 cm x 9.4 cm. Moderate amount serosanguineous drainage. Foul odor when dressing removed. Necrotic tissue to the wound base. Redness to perimeter of the wound. No pain. Progress: Wound to sacrum is being treated with Santyl. 90 % eschar and 10 % granulation. Continue to treat with Santyl at this time. The MD was notified on 05/21/19 of the current wound status. The RP, Self, was notified on 05/22/19. Review of Resident #3's Treatment Administration Record (TAR) for (MONTH) 2019, revealed an order, dated 05/10/19, to cleanse the sacrum with NS (Normal Saline). Pat Dry. Apply Santyl to wound. Apply [MEDICATION NAME] to periwound. Cover with dry dressing daily and PRN (as needed) for dislodged/soiled dressing every day shift. The order was discontinued on 05/22/19, the date Resident #3 was transferred to the hospital. The TAR also documented an order for [REDACTED]. Turn q hours, initiated on 02/06/19, with staff initials documenting Resident #3 was turned q two (2) hours while in bed from May1st to (MONTH) 22nd, except for one time on the 1st shift on 05/12/19. During the interview with the Director of Nursing (DON) on 08/09/2019 at 2:00 PM, she confirmed the facility had not done the weekly body audits for Resident #3. The DON said the floor nurses are scheduled to do body audit on different residents every shift. The DON confirmed there were no body audits done after Resident #3's wound healed in February. The DON also said Resident #3 was identified as a high risk for pressure ulcers because she had just healed from a wound and was unable to turn herself and would refuse to eat or drink at times and allow staff to provide care. The Certified Nursing Assistants (CNAs) who were assigned to provide Resident #3's care, and the Licensed Practical Nurse (LPN) who was responsible to perform the weekly body audits were no longer employed at the facility. The SA made attempts to contact these former staff members by phone, however the SA was unsuccessful due to the numbers were disconnected or there was no answer, or return call for a message left. A review of the facility's Face Sheet revealed Resident #3 was admitted by the facility, on 02/06/19, with the included [DIAGNOSES REDACTED]. A review of Resident #3's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/15/2019, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated the resident was cognitively impaired. Resident #3's Skin Condition revealed the presence of an unstageable pressure ulcer. Further review of the MDS revealed Resident #3's Functional Status: Transfers and locomotion on and off the unit was coded an eight (8), which indicated the activity did not take place. Dressing, bathing and toilet use, Resident #3 was totally dependent, and required one person's physical assist. Eating required supervision and set up help. Personal hygiene required extensive assistance with one person's physical assist. Resident #3 was always incontinent of bowel and bladder. Resident #3. Resident #3 had Range of Motion (ROM) impairment to her upper and lower extremities on one side.",2020-09-01
62,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-11-16,280,D,0,1,212T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to revised the care plan related to incontinence for one (1) of 24 resident care plans reviewed, Resident #3. Findings included: A facility policy titled Care Plan-Comprehensive, dated (MONTH) (YEAR), revealed the care plans would be revised as changes were noted in the resident's condition. A review of Resident #3's current care plan revealed he did not have a care plan related to the resident's incontinence and peri-care. A care plan concern for Urinary Tract Infection was marked as resolved on 11/13/17, with an intervention to discontinue the Foley catheter. An observation 11/13/17 at 2:30 PM, revealed Resident #3 did not have a Foley catheter bag visible. In an interview, on 11/13/17 at 11:00 AM, Licensed Practical Nurse (LPN) #1 said Resident #3 was incontinent of bowel and bladder since the recent removal of a Foley catheter. In an interview, on 11/16/17 at 10:30 AM, Registered Nurse (RN) # 1, Care Plan Nurse, said she was responsible to edit the care plans for Resident #3. RN #1 said Resident #3 was incontinent now and confirmed it was not listed on the current care plan. RN #1 said she had not updated the care plan since 11/13/17, because she had not had time. A review of the facility's face sheet revealed the facility admitted Resident #3 on 05/06/16. Resident #3's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/21/17, revealed staff assessed Resident 3 with severe cognitive impairment.",2020-09-01
63,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-11-16,282,D,0,1,212T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to follow the care plan related to incontinent care for one (1) of 16 care plans reviewed for incontinent care, Resident #9. Findings included: A facility Care Plan-Comprehensive policy, dated (MONTH) (YEAR), revealed the care plan would include measurable objectives to meet the medical, nursing, mental and psychological needs for each resident. A review of Resident #3's current Comprehensive Care Plan revealed the resident was at risk for skin break down related to incontinence of bowel and bladder. An intervention for this problem was to provide prompt peri-care after each incontinent episode. In an observation, on 11/15/17 at 9:45 AM, Certified Nursing Assistant (CNA) #1 and CNA #2 performed peri-care on Resident #9. CNA #1 completed care over the front of the perineum. CNA #1 and CNA #2 did not clean Resident #9's buttocks or the sacrum. In an interview, on 11/15/17 at 9:45 AM, CNA #1 said she had completed care on Resident #9 and said the policy was to clean the buttocks or the sacrum if the resident had an incontinent bowel movement. CNA #1 said she had completed training that included a check off for perineum care. CNA #1 confirmed she cleaned only the front perineal area. In an interview, on 11/16/17 at 10:15 AM, Registered Nurse (RN) #2, Staff Development, said the training for incontinent care included complete care which included to wash the front of the perineum and the buttocks and sacrum after each incontinence episode regardless of bowel movement. During an interview, on 11/16/17 at 10:35 AM, Registered Nurse (RN) #1, Care Plan Nurse, confirmed Resident 9's care plan included incontinent care. RN #1 said the care plan meant to complete peri-care by their training, which included the front and back of the perineal area. A review of the facility's face sheet revealed the facility admitted Resident #9 on 04/21/13. Resident 9's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/17, revealed staff assessed Resident 9 with severely impaired cognition. A review of Section H0300, dated 08/12/17, revealed Resident #9 was always incontinent of bladder.",2020-09-01
64,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-11-16,315,D,0,1,212T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to provide incontinent care to include the front perineal area, buttock and rectal areas, per policy, for one (1) of six (6) incontinent care observations. Findings included: A facility policy titled, Perineal Care, dated (MONTH) 2014, revealed the perineal care steps for a female resident would include to wipe the rectal area thoroughly, including the labia and the buttocks using the same technique as the perineal area. During an observation, on 11/15/17 at 9:45 AM, Certified Nursing Assistant (CNA) #1 and CNA #2 performed peri-care on Resident #9. CNA #1 completed care over the front of the resident's perineum. CNA #1 and CNA #2 did not clean Resident #9's buttocks or the sacrum. When interviewed, on 11/15/17 at 9:45 AM, CNA #1 said she had completed care on Resident #9 and said she thought the policy was to clean the buttocks or the sacrum if the resident had an incontinent bowel movement. CNA #1 said she had completed training that included a check off for perineum care. CNA #1 confirmed she only washed the front perineal area for Resident #9. During an interview, on 11/16/17 at 10:15 AM, Registered Nurse (RN) #2, Staff Development Nurse, said the training for incontinent care included complete care which included washing the front of the perineum and the buttocks and sacrum after each incontinence episode regardless of a bowel movement. During an interview, on 11/16/17 at 11:00 AM, the Director of Nursing (DON) confirmed the policy was to complete the peri-care, the front and the back because of the risk for skin breakdown, infection, and the resident may be still wet. A review of the facility's face sheet revealed the facility admitted Resident #9 on 04/21/13. Resident 9's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/17, revealed staff assessed Resident #9 with severely impaired cognition.",2020-09-01
65,BOYINGTON HEALTH AND REHABILITATION,255092,1530 BROAD AVE,GULFPORT,MS,39501,2017-11-16,469,D,0,1,212T11,"Based on observation, resident interview, staff interview, record review, and facility policy review the facility failed to provide a pest free environment for two (2) out of nine (9) halls, and one (1) out of two (2) dining rooms. Findings include: A review of the facility policy, titled Housekeeping and Pest Control, dated (MONTH) 2001, revealed pest control services should be provided monthly and as necessary. An observation on 11/13/17, starting at 10:20 AM until 11:45 AM, during initial tour of 100 hall, revealed two (2) gnats flying around in room 113 [NAME] Residents in the room stated, They come and go, but we haven't complained. Also, during tour, a fly was observed flying around in room 114, landing on bedside table. Resident in room 114 was unable to interview. An observation on 11/14/17, at 12:20 PM, in the dining hall between 100 hall and 200 hall, revealed two (2) flies swarming around the table of Un-Sampled Resident [NAME] An observation on 11/14/17, at 12:20 PM, in the dining hall between 100 hall and 200 hall, revealed two (2) flies around a resident's food tray. Un-Sampled Resident B was observed swatting the flies with her hand several times. Un-Sampled Resident B stated she had seen several fruit flies flying in Dining hall 100 during the lunch meal. An observation on 11/15/17 at 12:00 PM, in room 221, revealed several gnats swarming around Resident #12's face and bed. An observation on 11/16/17 at 8:30 AM, revealed two (2) flies around the nursing desk on the 300 hall. During an interview, on 11/14/17 at 10:00 AM, during Group, three (3) of 10 residents complained of seeing bugs in rooms and showers. Resident Un-Sample D stated he sees fly's in the Dining Room and big roaches in the 100 hall shower room. Review of the most recent Minimum Data Set (MDS), revealed Un-Sample Resident D had a BIMS score of 15, indicating no cognitive impairment. Resident Un-Sample C reported seeing roaches in her room. Review of the most recent MDS, revealed Un-Sample Resident C had a BIMS score of 9, indicating the resident's mental status is moderately impaired. During an interview, on 11/15/17 at 12:00 PM, Resident #12, stated he had been having problems with the gnats and the spray wasn't working. Review of the most recent MDS, revealed a BIMS score of 15, indicating Resident #12 had no cognitive impairment. In an interview, on 11/15/17 at 12:30 PM, the Assistant Administrator (AA), stated the facility sprayed for the flies, but the residents would leave food and snacks out which led to the attraction of flies. In an interview, on 11/16/17 at 11:20 AM, the Assistant Administrator stated there has been an issue in the past with pest. The AA also revealed only one (1) grievance was filed, back in August, concerning the presence of pest in the facility. The AA reveled the facility had a pest control contract with (name of Vendor) and the company sprayed once a month. During an interview, on 11/16/17 at 12:15 PM, Housekeeping #1 stated he relied on staff or residents to inform him if they see any pest and then he sprays the area with an insect spray, (name of spray). Review of a (Pest Control Company) invoice revealed the last monthly service was dated 11/6/17.",2020-09-01
66,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2020-01-24,600,J,1,0,17111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, record review, and facility policy review, the facility failed to ensure a resident was free from verbal abuse for one (1) of seven (7) residents reviewed for abuse, Resident #1. On [DATE], Certified Nursing Assistant (CNA) #1 was witnessed by staff being verbally abusive to Resident #1 in the dining room. CNA #1 was heard calling Resident #1 a mother [***] , told him not to put his mother [***] ing hands on her or she would box him. The incident was reported by Licensed Practical Nurse (LPN) #1 to the on-call nurse, LPN #2, on the day of the incident. LPN #2 spoke with the Director of Nursing (DON), who then instructed LPN #2 to assign CNA #1 to a different area and not have contact with Resident #1. CNA #1 continued to work on [DATE], as well as provided care to Resident #7, who was Resident #1's roommate. CNA #1 was allowed to work at the facility from [DATE] until 12/23/2019, without being suspended. The facility failed to report the verbal abuse to the appropriate State Agencies timely, and failed to protect Resident #1 and all other residents. The facility's failure to protect Resident #1 from verbal abuse and allowing a staff member to work in the facility, without reporting an incident of witnessed verbal abuse, placed Resident #1 and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the verbal abuse occurred. The SA notified the facility of the IJ and SQC on 01/22/2020 at 4:20 PM, and the IJ template was provided to the Administrator. The facility provided a credible Removal Plan on 0[DATE]20, in which the facility alleged all corrective actions were completed as of 0[DATE]20 and the IJ was removed on 01/24/2020. The SA validated the Removal Plan and determined the IJ was removed on 01/24/2020, prior to exit. Therefore, the scope and severity for 43 CFR(s): 4[AGE].12(a)(1), F[AGE]0, Freedom from Abuse, Neglect, and Exploitation, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy, undated, revealed: The resident has the right to be free from abuse. The policy defined Verbal Abuse as the oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. A review of the facility's Resident Rights policy, dated November 28, 2016, revealed: The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Review of a facility reported incident, submitted to the SA on 01/06/2020, documented on [DATE], CNA #1 verbally abused Resident #1. The report included a typed investigation, on the facility's letterhead, dated 1[DATE] and signed by the Administrator. The investigation documented on [DATE], Licensed Practical Nurse (LPN) #1 reported to the on-call nurse (LPN #2), an incident involving a verbal altercation between Resident #1 and CNA #1, which occurred in the dining room. The report documented LPN #1 stated Resident #1 became upset with CNA #1 about his meal, stood up from his chair, and yelled, I am going to beat your mother [***] ing ass. LPN #1 reported CNA #1 responded, You're not going to put your mother[***] ing hands on me. The investigation documented LPN #2 notified the Director of Nursing (DON) and gave instructions for CNA #1 to be reassigned and have no contact with Resident #1 until further notice. The investigation documented on 12/23/2019, the DON interviewed the Dietary Manager (DM), who witnessed the exchange between Resident #1 and CNA #1 on [DATE]. The DM reported CNA #1 entered the kitchen and told him that he needed to talk with Resident #1 about his meal. The DM further reported he asked CNA#1 what was the issue with Resident #1's meal, and she stated, Something isn't right with it, just his usual bullshit. I ain't got time to deal with his[***]today. The DM reported Resident #1 approached CNA #1 and told her You need to shut your [***] ing mouth and get the [***] out of my face. I'll whoop your ass. The DM reported CNA #1 responded, Mother [***] put your hands on me and watch what happens. The DM reported he asked another CNA to get the nurse while he redirected Resident #1 and CNA #1. The investigation report documented actions taken by the facility included Resident #1 was visited by the Social Worker and Nurse Practitioner on 12/23/2019, in-services initiated to staff regarding abuse policy and prevention on 12/24/2019, and the Administrator reviewed CNA #1's personnel file and background. A review of a typed statement by the Dietary Manager, dated and signed 12/23/2019, documented that on [DATE] at approximately 7:55 AM, the DM witnessed the incident between CNA #1 and Resident #1. The DM revealed CNA #1 came to the kitchen door to tell the dietary staff of an issue regarding Resident #1's meal. The DM documented CNA #1 stated loudly (within the presence of residents and staff), Something isn't right with it, just his usual bullshit, I ain't got time to deal with his[***]today. The DM documented Resident #1 approached CNA #1, in his wheelchair, and told her to shut your [***] ing mouth and I'll whoop your ass. The DM further documented, CNA #1 had her hands in fists at her sides, and stated to Resident #1, Mother[***] , put your hands on me and watch what happens. The DM revealed he intervened by stepping between Resident #1 and CNA #1, and instructed Resident #1 to return to his table and for CNA #1 to leave the dining room immediately. The DM revealed he asked another CNA to get a nurse to the dining room immediately. The DM documented when LPN #1 entered the dining room, he informed her of the situation, how it started, and what was said by Resident #1 and CNA #1. During an interview, on 1/21/2020 at 10:30 AM, the Administrator stated what she understood was when the incident occurred on [DATE], LPN #2, the on-call nurse, called the Director of Nursing (DON) to report the incident. The Administrator revealed the DON was informed CNA #1 told Resident #1, You're not going to put your mother [***] ing hands on me. The Administrator stated at the time of the incident, they needed more information about what happened and didn't know all the details. She revealed she needed to get further clarification, before coming to a conclusion, regarding the incident. The Administrator stated she believed at the time of occurrence, they removed CNA #1 from Resident #1, placed her on another hall in the building, thus protecting Resident #1. During an interview, on 01/21/2020 at 12:15 PM, Resident #1 revealed on [DATE], he was sitting in the cafeteria waiting on his breakfast tray and having a conversation with another resident. Resident #1 stated CNA #1 was all up in his business, and he told her to get the hell out of his business. Resident #1 stated CNA #1 went in the kitchen door and he heard her call him a Mother [***] . Resident #1 stated the man in charge of the kitchen (Dietary Manager) was standing right beside CNA #1 when she said that to him. Resident #1 stated he and his mother were not a Mother [***] and nobody was going to call him by that name. Resident #1 stated he also heard CNA #1 call him a Son of a [***] . Resident #1 stated he never threatened to hit CNA #1, but was just upset when she called him those names. Resident #1 stated when he heard what CNA #1 had called him, it made him feel damn low down. On 01/21/2020 at 12:38 PM, during an interview, the DON stated she received a call from LPN #2, on [DATE], regarding an incident in the dining room between Resident #1 and CNA #1, where they had cussed at each other. The DON stated she informed LPN #2 to tell LPN #1 for CNA #1 not to have any further contact with Resident #1. The DON revealed that was the last thing she heard about the issue until she returned to the facility on [DATE]. The DON stated she didn't think much about it, because it wasn't unusual for Resident #1 to curse staff, but it was uncommon for staff to curse him back. The DON stated after reading the written statements, when she returned on 12/23/2019, she realized that she should have sent CNA #1 home on [DATE]. The DON stated she would consider the incident to be verbal abuse. During a telephone interview, on 01/21/2020 at 1:00 PM, LPN #2 confirmed she was the on-call nurse on [DATE]. LPN #2 stated LPN #1 called and told her Resident #1 was in the dining room threatening CNA #1. LPN #2 stated LPN #1 told her Resident #1 stood up from his wheelchair and stated he was going to whip CNA #1's mother [***] ing ass. LPN #2 revealed LPN #1 further stated CNA #1 told Resident #1 he was not going to lay a mother [***] ing hand on her. LPN #2 stated she instructed LPN #1 to get CNA #1 to swap out residents with another CNA, and CNA #1 was not to have any contact with Resident #1. LPN #2 stated she called the DON and told her exactly what LPN #1 told her regarding the incident. LPN #2 revealed the DON instructed her to tell LPN #1 to swap CNA #1 out with another CNA taking care of Resident #1 as well. LPN #2 stated that she felt like CNA #1 cursing Resident #1 was considered verbal abuse. LPN #2 revealed the facility's policy stated it's not acceptable for staff to curse a resident. LPN #2 stated she felt the right decision was made on [DATE] when they moved CNA #1 away from Resident #1 until a thorough investigation could be done. During an interview, on 01/21/2020 at 2:45 PM, the Dietary Manager (DM) confirmed he was working the day of the incident ([DATE]). The DM stated Resident #1 was sitting in his normal place, when CNA #1 came to the kitchen door and said y'all need to talk to Resident #1 about his breakfast. The DM stated he asked CNA #1 what was wrong with Resident #1's breakfast and she stated just Resident #1 and his bullshit. The DM revealed what CNA #1 said, was loud enough to be heard by Resident #1. The DM revealed he saw Resident #1 push back from the table and start rolling in his wheelchair towards the kitchen door where CNA #1 was standing. The DM stated when Resident #1 approached CNA #1, Resident #1 told CNA #1 she needed to shut her [***] ing mouth and didn't need to be talking about him or he was going to whip her [***] ing ass. The DM stated he saw CNA #1 ball her fists up, but kept them at her side. The DM stated CNA #1 told Resident #1, Look here you mother [***] ing son of a [***] , if you come towards me, I'll knock you the [***] out. The DM stated he intervened and separated Resident #1 and CNA #1. The DM revealed he instructed CNA #1 to leave the dining room immediately, but she refused. The DM stated when CNA #1 refused to leave the dining room, he instructed another CNA in the dining room, to go and get a nurse. The DM revealed he instructed Resident #1 to go back to his table. The DM stated LPN #1 came to the dining room, and he pulled her aside and told her about the incident between Resident #1 and CNA #1. During an interview, on 01/21/2020 at 3:11 PM, CNA #2 stated that she was in the dining room, passing out meal trays, on [DATE], when the incident happened between Resident #1 and CNA #1. CNA #2 stated Resident #1 opened his tray up and said, I don't want this[***] and slid the tray across the table. CNA #2 stated she heard CNA #1 tell someone in the kitchen that they needed to come and see what was wrong with Resident #1's tray. CNA #2 stated Resident #1 was sitting at the table and suddenly pushed back and rolled to the kitchen door where CNA #1 was standing. CNA #2 stated told CNA #1, I heard what you said twice, along with a bunch of cuss words. CNA #2 revealed Resident #1 stood up from his wheelchair and stood over her (taller than CNA #1) and told CNA #1 he would beat her ass. CNA #2 stated she ran over to Resident #1 and intervened by telling the resident no and tried to assist him back into his wheelchair. CNA #2 stated CNA #1 told Resident #1, If you put your hands on me today, I'm going to box your ass. CNA #2 stated the Dietary Manager came out of the kitchen and told Resident #1 to go back to his seat. CNA #2 confirmed the Dietary Manager told CNA #1 to leave the dining room. A review of a written statement given by CNA #2, undated and provided by the facility, CNA #2 documented on 12/21/19 she heard CNA #1 curse Resident #1. The statement documented CNA #1 told Resident #1, (Name of Resident #1) if you put your hands on me, I will box your mother [***] ing ass. During an interview via phone on 1/21/20 at 4:29 PM, LPN #1 stated that Resident #1 and CNA #1 were in the dining room and she was called to the dining room by another CNA, who stated Resident #1 was threatening CNA #1. LPN #1 stated when she arrived, the Dietary Manager was talking to Resident #1. LPN #1 stated she noticed Resident #1 and CNA #1 were upset. LPN #1 stated CNA #1 told her Resident #1 had threatened to hit her. LPN #1 stated she told CNA #1 to come out of the dining room and she sent another CNA to the dining room to take CNA #1's place. LPN #1 revealed CNA #1 told her that Resident #1 didn't like what he got on his tray, got upset and threatened to hit her. LPN #1 stated she called the on-call phone nurse, LPN #2, and told her about the incident in the dining room with Resident #1 and CNA #1. LPN #1 stated LPN #2 told her to get CNA #1 out of the dining room and that she would call either the Administrator or the Director of Nursing (DON). LPN #1 stated she couldn't remember who called her back, but she was told to make sure CNA #1 didn't have any contact with Resident #1. During an interview, on 01/21/2020 at 4:37 PM, CNA #1 stated the incident with Resident #1 occurred on a weekend (Saturday, [DATE]). CNA #1 stated Resident #1 was in the dining room at breakfast, and he started fussing and cursing. CNA #1 stated she told him if he didn't stop, he would have to leave the dining room. CNA #1 stated she went to the kitchen to see about oatmeal for another resident and told the Dietary Manager to come and talk to Resident #1 because he was fussing about his food. CNA #1 stated while her back was turned, Resident #1 came over in his wheelchair, stood up and stated, I'm fixing to beat this black [***] . CNA #1 stated she told Resident #1, Don't put your mother [***] ing hands on me. CNA #1 confirmed CNA #2 came over, got between them, and tried to get Resident #1 to sit down in his chair. CNA #1 stated the Dietary Manager told her to get out of the dining room and that she couldn't talk to a resident like that. CNA #1 stated she told the Dietary Manager that Resident #1 was about to hit her, and she felt threatened. CNA #1 stated the Dietary Manager told her twice to leave the dining room, but she refused because she hadn't done anything. CNA #1 stated she left the dining room and told LPN #1 what had happened. CNA #1 revealed LPN #1 told her she was going to have to call the on-call nurse (LPN #2). CNA #1 stated LPN #2 called back and instructed LPN #1 to have her stay away from Resident #1. CNA #1 stated she continued to work on the hall, on [DATE], where Resident #1 resided and cared for Resident #1's roommate (Resident #7), who was non-verbal. CNA #1 stated if Resident #1 was in the room, she would leave and return when he wasn't present in the room. CNA #1 stated on 1[DATE]19, LPN #2 called the facility and told her not to work the dining room since Resident #1 ate in there. CNA #1 stated she was called to the Administrator's office on 12/23/2019 to discuss what had occurred on [DATE] with Resident #1 and to write a statement. CNA #1 stated she told the Administrator that she did curse Resident #1, even if it costed her job. A review of the Activity of Daily Living (ADL) look back report for Resident #7, who was Resident #1's roommate, revealed, CNA #1 provided care for Resident #7 on 12/21/19 at 10:44 AM. Care was provided after the incident in the dining room with Resident #1. Review of the time sheet for CNA #1, revealed she clocked in for work at the facility on [DATE], 1[DATE]19, and 12/23/2019. A review of the facility's Job Description for a Certified Nursing Assistant (CNA), signed on 06/17/19 by CNA #1, revealed: Assist in maintaining a positive physical and psychosocial environment for the residents. Essential duties and responsibilities included to maintain positive relationships with the residents. Review of the personnel file for CNA #1 revealed, a copy of the facility's Freedom for Abuse, Neglect, and/or Exploitation Prevention Plan Education, dated 06/17/2019 and signed by CNA #1. There were no prior discipline records noted. Review of a Sign In Sheet for an in-service, on Abuse and Neglect Prevention, dated 10/03/ , revealed CNA #1 signed as being in attendance. During an interview, on 01/22/2020 at 10:54 AM, the Administrator stated she felt like CNA #1 verbally abused Resident #1. On 01/22/2020 at 12:31 PM, during an interview, the DON stated she felt that CNA #1 cursing Resident #1 was verbal abuse, and she should have sent CNA #1 home pending further investigation. The DON stated she did not protect Resident #1 or any of the other residents by not sending CNA #1 home. A review of a typed statement by the DON, dated 12/23/2019, documented during an interview with CNA #1, she stated she had cursed Resident #1. During an interview, on 01/22/2020 at 3:15 PM, CNA #3 stated she was in the dining room on [DATE]. CNA #3 stated she heard CNA #1 tell Resident #1 not to put his mother [***] ing hands on her. CNA #3 stated the Dietary Manager came out of the kitchen and told CNA #1 to leave the dining room because she didn't have any business talking to Resident #1 like that. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which indicated cognitively intact. The facility submitted a credible Removal Plan on 0[DATE]20, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. 1. Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. On [DATE]20 100% of facility residents were assessed by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The Facility Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. A meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The Administrator, SSD, DON and Assistant DON initiated in- service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. On 12/30/2019, The Attorney General Office online report was submitted by the Facility Administrator. 7. On 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. On 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. On 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed and the jeopardy abated as of 0[DATE]20. The SA validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ. 1. The State Agency (SA) validated through record review, Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. The SA validated through record review, that on 0[DATE]20, a 100% assessment of facility residents by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The SA validated through interview and record review, the Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. The SA validated through interview and record review, a meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The SA validated through interview and record review, the Administrator, SSD, DON and Assistant DON initiated in- service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. The SA validated through interviews and record review, a Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. The SA validated through record review, on 12/30/2019, the Attorney General Office online report was submitted by the Facility Administrator. 7. The SA validated through interview and record review, on 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. The SA validated through interview and record review, on 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. The SA validated through interviews and record review, on 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed as of 0[DATE]20, and the IJ removed as of 01/24/2020.",2020-09-01
67,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2020-01-24,607,J,1,0,17111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review and facility policy review, the facility failed to implement their Abuse policy for protection of residents from verbal abuse, failed to protect other residents, and failed to report the allegation of abuse in a timely manner, for one (1) of seven (7) residents, Resident #1. This was evidenced by the facility allowing Certified Nursing Assistant (CNA) #1 to return to work following an incident of witnessed verbal abuse toward Resident #1. The facility failed to report the allegation of abuse to the required state agencies within the two (2) hour timeframe, per policy, to ensure appropriate actions were taken. On [DATE], CNA #1 was witnessed being verbally abusive to Resident #1 in the dining room, by staff members. CNA #1 was overheard calling Resident #1 a mother [***] , told him not to put his mother [***] ing hands on her or she would box him. The incident was reported by Licensed Practical Nurse (LPN) #1 to the on-call nurse, LPN #2, on the same day of the incident. LPN #2 reported the incident to the Director of Nursing (DON), who then informed LPN #2 to assign CNA #1 to a different hall, and for CNA #1 not to have any contact with Resident #1. CNA #1 was allowed to continue working on [DATE], and provided care to Resident #1's roommate, Resident #7. CNA #1 continued to work at the facility from [DATE] until 12/23/2019, without being suspended. The facility failed to report the verbal abuse to the appropriate State Agencies in a timely manner and failed to protect Resident #1 and all other residents. The failure of the facility to protect residents from verbal abuse by allowing a staff member to remain working at the facility, and failure to report an incident of witnessed verbal abuse within to two (2) hours to the designated State Agencies, per facility policy, placed Resident #1 and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the verbal abuse occurred. The SA notified the facility of the IJ and SQC on 01/22/2020 at 4:20 PM, and the IJ template was provided to the Administrator. The facility provided a credible Removal Plan on 0[DATE]20, in which the facility alleged all corrective actions were completed as of 0[DATE]20 and the IJ was removed on 01/24/2020. The SA validated the Removal Plan and determined the IJ was removed on 01/24/2020, prior to exit. Therefore, the scope and severity for 43 CFR(s): 4[AGE].12(b)(1)-(3), F[AGE]7, Develop/Implement Abuse/Neglect Policies was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy, undated, revealed: The resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, serving the resident. The facility's goal is to protect the resident from abuse. The facility has developed and implemented written policies and procedures designed to prohibit and prevent mistreatment. The prohibition plan includes the following components: Screening prospective employees, staff training, abuse and neglect prevention, identification of events, patterns or trends that may constitute abuse, investigation of allegations, protecting of the resident during investigations, reporting and responding. The facility will report alleged violations, conduct investigations of alleged violations, report the results to proper authorities, and take necessary corrective actions. Review of a facility reported incident, submitted to the SA on 01/06/2020, documented on [DATE], CNA #1 verbally abused Resident #1. The report included a typed investigation, on the facility's letterhead, dated 1[DATE] and signed by the Administrator. The investigation documented on [DATE], Licensed Practical Nurse (LPN) #1 reported to the on-call nurse (LPN #2), an incident between Resident #1 and CNA #1, which occurred in the dining room. The report documented LPN #1 stated Resident #1 became upset with CNA #1 about his meal, stood up from his wheelchair, and yelled, I am going to beat your mother [***] ing ass. LPN #1 reported CNA #1 responded, You're not going to put your mother [***] ing hands on me. The investigation documented LPN #2 notified the Director of Nursing (DON) and was given instructions for CNA #1 to be reassigned to another hall, and to have no contact with Resident #1 until further notice. The investigation report documented the actions taken by the facility included a visit by the Social Worker and Nurse Practitioner with Resident #1 on 12/23/2019, in-services initiated with staff regarding abuse policy and prevention on 12/24/2019, and the Administrator reviewed CNA #1's personnel file and background. There was no documentation of CNA #1 being suspended or sent home on the day of the incident ([DATE]). During an interview, on 01/21/2020 at 10:30 AM, the Administrator stated if she had known the detailed statements regarding the incident on [DATE] between CNA #1 and Resident #1, she would have suspended CNA #1. The Administrator stated it is the facility's policy to protect residents immediately. Upon review of the facility's Abuse policy, the Administrator stated they didn't follow the policy for reporting abuse. Review of the facility's Job Description for the Nursing Home Administrator (NHA), revealed: The NHA is responsible for the overall operations, leadership, management and success of the facility. Essential duties and responsibilities included to implement and communicate policies and procedures and oversee facility investigations and [MEDICATION NAME]. During an interview, on 01/21/2020 at 12:15 PM, Resident #1 revealed on [DATE], he was having a conversation with another resident and CNA #1 was all up in his business. Resident #1 stated he told CNA #1 to get the hell out of his business. Resident #1 stated CNA #1 went over to the kitchen door, and he heard her call him a Mother [***] . Resident #1 stated the Dietary Manager was standing right beside CNA #1 when she said it. Resident #1 stated he nor his mother was a Mother [***] and nobody was going to call him by that name. Resident #1 stated CNA #1 also called him a Son of a [***] . Resident #1 revealed he never threatened to hit CNA #1, but was upset when she called him those names. During an interview, on 01/21/2020 at 12:38 PM, the Director of Nursing (DON) stated the facility did not follow the policy to protect Resident #1 when CNA #1 was not sent home for cursing Resident #1. During an interview, on 01/21/2020 at 4:37 PM, CNA #1 confirmed that on the day of incident, she told Resident #1, Don't put your mother [***] ing hands on me. CNA #1 stated she told the Administrator on 12/23/2019 that she had cursed Resident #1. CNA #1 stated that she stayed on the 100 Hall on 12/21/19 and took care of Resident #7 (Resident #1's roommate). CNA #1 stated she saw Resident #1 probably three (3) more times after the incident in the dining room. CNA #1 stated Resident #1 was in the room when she went in to do patient care with Resident #7, but she left and came back when Resident #1 was gone from the room. A review of the time sheet for CNA #1 revealed she worked in the facility 12/21/19, 12/22/19 and [DATE]. A review of the facility scheduling document dated 12/21/19 revealed CNA #1 was assigned to resident rooms on the 100 Hall, which included Resident #1's room. During an interview, on 01/21/20 at 2:30 PM, the Administrator stated that she did not call the allegation of verbal abuse into the State Survey Agency until [DATE], after she started the investigation. The Administrator stated she thought she had 24 hours to report since there was no known injury. She stated she did not know she had to report an alleged abuse within two (2) hours. The Administrator revealed she did not report the incident of abuse to any local Law Enforcement Authority. She stated she called the incident of abuse to the State Survey Agency on 12/23/2019, to the Attorney General's Office (AG) on 12/30/2019 and mailed the final investigation information to the AG's office and to the State Agency on 1[DATE]. The facility submitted an acceptable Removal Plan on 0[DATE]20, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. 1. Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. On [DATE]20, 100% of facility residents were assessed by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The Facility Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. A meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The Administrator, SSD, DON and Assistant DON initiated in-service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. On 12/30/2019, The Attorney General Office online report was submitted by the Facility Administrator. 7. On 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. On 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. On 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed and the jeopardy abated as of 0[DATE]20. The SA validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ. 1. The State Agency (SA) validated through record review, Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. The SA validated through record review, that on 0[DATE]20, a 100% assessment of facility residents by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The SA validated through interview and record review, the Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. The SA validated through interview and record review, a meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The SA validated through interview and record review, the Administrator, SSD, DON and Assistant DON initiated in- service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. The SA validated through interviews and record review, a Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. The SA validated through record review, on 12/30/2019, the Attorney General Office online report was submitted by the Facility Administrator. 7. The SA validated through interview and record review, on 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. The SA validated through interview and record review, on 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. The SA validated through interviews and record review, on 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed as of 0[DATE]20, and the IJ removed as of 01/24/2020.",2020-09-01
68,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2020-01-24,609,J,1,0,17111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review, and facility policy review, the facility failed to report an allegation of staff to resident abuse within the two (2) hour required timeframe, for one (1) of seven (7) residents reviewed, Resident #1. On [DATE], Certified Nursing Assistant (CNA) #1 was witnessed by staff being verbally abusive to Resident #1 in the dining room. CNA #1 was heard calling Resident #1 a mother [***] , told him not to put his mother [***] ing hands on her or she would box him. The incident was reported by Licensed Practical Nurse (LPN) #1 to the on-call nurse, LPN #2, on the day of the incident. LPN #2 spoke with the Director of Nursing (DON), who then instructed LPN #2 to assign CNA #1 to a different area and not have contact with Resident #1. CNA #1 continued to work on [DATE], as well as provided care to Resident #7, who was Resident #1's roommate. CNA #1 was allowed to work at the facility from [DATE] until 12/23/2019, without being suspended. The facility failed to report the witnessed incident of verbal abuse to the appropriate State Agencies in a timely manner and failed to protect Resident #1 and all other residents. The facility's failure to notify the appropriate state agencies in a timely manner of an incident of witnessed verbal abuse, to ensure proper measures had been addressed, and allowing the staff member to continue working at the facility, placed Resident #1 and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the verbal abuse occurred. The SA notified the facility of the IJ and SQC on 01/22/2020 at 4:20 PM, and the IJ template was provided to the Administrator. The facility provided a credible Removal Plan on 0[DATE]20, in which the facility alleged all corrective actions were completed as of 0[DATE]20 and the IJ was removed on 01/24/2020. The SA validated the Removal Plan and determined the IJ was removed on 01/24/2020, prior to exit. Therefore, the scope and severity for 43 CFR(s): 4[AGE].12(c)(1)(4), F[AGE]9, Reporting of Alleged Violations, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan - Reporting/Response policy, revised 08/23/2017, revealed: If a covered individual of the facility becomes aware of information that gives him/her the reasonable suspicion that a crime has occurred against a resident or individual receiving care from this facility, he/she must notify the Administrator of the facility, the State Survey Agency and Attorney General's Office, and local Law Enforcement Agency. Reports must be within two (2) hours (if the allegation involves abuse or there is serious bodily injury) after forming reasonable suspicion. A review of an on-line submission record, sent to the Medicaid Fraud Control Unit (MFCU), revealed the Administrator submitted the report, on 12/30/2019, regarding the alleged verbal abuse incident, which occurred on [DATE]. Review of a facility reported incident to the State Agency, submitted on 01/06/2020, revealed an incident of verbal abuse occurred at the facility on [DATE], between CNA #1 and Resident #1. A review of a typed document, undated and signed by the Administrator revealed, the incident of verbal abuse, which occurred on [DATE], was reported to the Mississippi State Department of Health ([CONDITION]DH) hotline on 12/23/2019. The final investigative report was mailed to [CONDITION]DH and the Attorney General's Office on 1[DATE]. The State Agency (SA) confirmed via phone interview with SA Triage office, the Administrator reported the verbal abuse incident, which occurred on [DATE], on 12/23/2019. During an interview, on 01/21/2019 at 2:30 PM, the Administrator stated she did not call the incident of verbal abuse (which occurred on [DATE]), into the State Survey Agency until 12/23/2019, after she started the investigation. The Administrator stated she thought she had 24 hours to report the incident, since there was no known injury. The Administrator revealed she did not know an incident of alleged abuse had to reported within two (2) hours. During an interview, on 01/22/2020 at 12:14 PM, the Administrator revealed she did not report the incident to any local Law Enforcement Authority. The Administrator stated that she called the incident of verbal abuse to the State Survey Agency on 12/23/2019, and to the Attorney General's (AG) Office on 12/30/2019. The Administrator stated she mailed the final investigation information to the AG's office and State Agency on 1[DATE]. A review of the facility's Job Description for the Nursing Home Administrator (NHA), dated 08/10/2017, revealed: The NHA will be responsible for the overall operations, leadership, management and success of the facility in accordance with resident/employee needs, government regulations, and company policy. Essential duties and responsibilities included, to oversee facility investigations and [MEDICATION NAME], and to carry out supervisory responsibilities in accordance with the organizations policies and applicable laws. The facility submitted a credible Removal Plan on 0[DATE]20, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. 1. Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. On [DATE]20 100% of facility residents were assessed by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The Facility Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. A meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The Administrator, SSD, DON and Assistant DON initiated in-service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. On 12/30/2019, The Attorney General Office online report was submitted by the Facility Administrator. 7. On 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. On 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. On 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed and the jeopardy abated as of 0[DATE]20. The SA validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ. 1. The State Agency (SA) validated through record review, Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. The SA validated through record review, that on 0[DATE]20, a 100% assessment of facility residents by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The SA validated through interview and record review, the Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. The SA validated through interview and record review, a meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The SA validated through interview and record review, the Administrator, SSD, DON and Assistant DON initiated in- service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. The SA validated through interviews and record review, a Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. The SA validated through record review, on 12/30/2019, the Attorney General Office online report was submitted by the Facility Administrator. 7. The SA validated through interview and record review, on 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. The SA validated through interview and record review, on 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. The SA validated through interviews and record review, on 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed as of 0[DATE]20, and the IJ removed as of 01/24/2020.",2020-09-01
69,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2020-01-24,610,J,1,0,17111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review, and facility policy review, the facility failed to prevent further potential abuse and mistreatment from occurring, after a witnessed incident of staff to resident abuse, for one (1) of seven (7) residents reviewed, Resident #1. On [DATE], Certified Nursing Assistant (CNA) #1 was witnessed by staff being verbally abusive to Resident #1 in the dining room. CNA #1 was heard calling Resident #1 a mother [***] , told him not to put his mother [***] ing hands on her or she would box him. The incident was reported by Licensed Practical Nurse (LPN) #1 to the on-call nurse, LPN #2, on the day of the incident. LPN #2 spoke with the Director of Nursing (DON), who then instructed LPN #2 to assign CNA #1 to a different area and not have contact with Resident #1. CNA #1 continued to work on [DATE], as well as provided care to Resident #7 (Resident #1's roommate). CNA #1 was allowed to work at the facility from [DATE] until 12/23/2019, without being suspended. The facility failed to report the verbal abuse to the appropriate State Agencies timely and failed to protect Resident #1 and all other residents. The facility's failure to thoroughly investigate a witnessed staff to resident incident of verbal abuse, and prevent further potential abuse by allowing the staff member to continue working at the facility, placed Resident #1 and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the verbal abuse occurred. The SA notified the facility of the IJ and SQC on 01/22/2020 at 4:20 PM, and the IJ template was provided to the Administrator. The facility provided a credible Removal Plan on 0[DATE]20, in which the facility alleged all corrective actions were completed as of 0[DATE]20 and the IJ was removed on 01/24/2020. The SA validated the Removal Plan and determined the IJ was removed on 01/24/2020, prior to exit. Therefore, the scope and severity for 43 CFR(s): 4[AGE].12(c)(2)-(4), F610, Investigate/Prevent/Correct Alleged Violation, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy, undated, revealed: The resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, serving the resident. The facility's goal is to protect the resident from abuse. The facility has developed and implemented written policies and procedures designed to prohibit and prevent mistreatment. The prohibition plan includes the following components: Abuse and neglect prevention, identification of events, patterns or trends that may constitute abuse, investigation of allegations, protecting of the resident during investigations, reporting and responding. The facility will report alleged violations, conduct investigations of alleged violations, report the results to proper authorities, and take necessary corrective actions. A review of the facility policy titled, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan - Protection policy, undated, revealed, residents will be protected during an investigation whether it is abuse, neglect, exploitation, or mistreatment. The Administrator or the person in charge shall separate the alleged victim and the accused person immediately and maintain that separation until investigations are completed. While the investigation is being conducted, the employee accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator. Review of a facility reported incident, submitted to the SA on 01/06/2020, documented on [DATE], CNA #1 verbally abused Resident #1. The report included a typed investigation, on the facility's letterhead, dated 1[DATE] and signed by the Administrator. The investigation documented on [DATE], Licensed Practical Nurse (LPN) #1 reported to the on-call nurse (LPN #2), an incident between Resident #1 and CNA #1, which occurred in the dining room. The report documented LPN #1 stated Resident #1 became upset with CNA #1 about his meal, stood up from his wheelchair, and yelled, I am going to beat your mother [***] ing ass. LPN #1 reported CNA #1 responded, You're not going to put your mother [***] ing hands on me. The investigation documented LPN #2 notified the Director of Nursing (DON) and was given instructions for CNA #1 to be reassigned to another hall, and to have no contact with Resident #1. The investigation report documented the actions taken by the facility included a visit by the Social Worker and Nurse Practitioner with Resident #1 on 12/23/2019, in-services with staff regarding abuse policy and prevention initiated on 12/24/2019, and the Administrator reviewed CNA #1's personnel file and background. There was no documentation of CNA #1 being suspended or sent home on the day of the incident ([DATE]). During an interview, on 01/21/2020 at 10:30 AM, the Administrator stated if she would have known the detailed statements, CNA #1 would have been suspended the day the incident occurred. The Administrator stated her understanding was that LPN #2 called the DON to report CNA #1 told Resident #1, You are not going to put your mother [***] ing hands on me. The Administrator stated at the time the DON was notified, they needed more information about what happened and didn't know all the details. The Administrator stated CNA #1 worked at the facility on [DATE], 1[DATE]19 and 12/23/2019, until she was called to the office, on 12/23/2019, to make a statement regarding the incident. The Administrator stated CNA #1 got mad and left during the interview. The Administrator stated the facility's policy revealed it is their responsibility to protect residents immediately. The Administrator stated she believed at the time of the incident ([DATE]), they removed CNA #1 away from the resident, and placed her on another hall in the building, thus protecting Resident #1. During an interview, on 01/21/2020 at 12:38 PM, the Director of Nursing (DON) stated she received a call from Licensed Practical Nurse (LPN) #2, on [DATE], regarding an incident in the dining room between Resident #1 and CNA #1, where they had cursed at each other. The DON stated she told LPN #2 to instruct LPN #1 not to allow CNA #1 to have any further contact with Resident #1. The DON stated that was the last thing she heard about the issue until she returned to the facility on [DATE]. The DON revealed she didn't think much about it, because it wasn't unusual for Resident #1 to curse staff, but it was uncommon for staff to curse back at the resident. The DON stated after she read the written statements, when she returned on 12/23/2019, she realized she should have sent CNA #1 home on [DATE]. During an interview, on 01/21/2020 at 4:37 PM, CNA #1 stated, on [DATE], she was assigned to two (2) rooms on the 100 Hall, which included Resident #1's room. CNA #1 stated she stayed on the 100 hall and took care of Resident #1's roommate (Resident #7). CNA #1 stated she saw Resident #1 about three (3) more times, after the incident in the dining room. CNA #1 stated if Resident #1 was in the room, when she went to do patient care with Resident #7, she would leave and come back. An observation of Resident #7, by the State Agency, revealed the resident was non-verbal. A review of the time sheet for CNA #1 revealed she worked at the facility on [DATE], 1[DATE]19 and 12/23/2019. A review of the facility's assignment sheet, dated [DATE], revealed CNA #1 was assigned to Resident #1's room and one other room on the 100 Hall. Review of the facility's Activities of Daily Living look back report for Resident #7 (roommate of Resident #1), dated [DATE], revealed CNA #1 provided care for Resident #7 at 10:44 AM, which was approximately two (2) hours after the incident with Resident #1 in the dining room. The facility submitted an acceptable Removal Plan on 0[DATE]20, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. 1. Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. On [DATE]20, 100% of facility residents were assessed by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The Facility Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. A meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The Administrator, SSD, DON and Assistant DON initiated in-service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. On 12/30/2019, The Attorney General Office online report was submitted by the Facility Administrator. 7. On 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. On 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. On 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed and the jeopardy abated as of 0[DATE]20. The SA validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ. 1. The State Agency (SA) validated through record review, Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. The SA validated through record review, that on 0[DATE]20, a 100% assessment of facility residents by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The SA validated through interview and record review, the Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. The SA validated through interview and record review, a meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The SA validated through interview and record review, the Administrator, SSD, DON and Assistant DON initiated in- service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. The SA validated through interviews and record review, a Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. The SA validated through record review, on 12/30/2019, the Attorney General Office online report was submitted by the Facility Administrator. 7. The SA validated through interview and record review, on 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. The SA validated through interview and record review, on 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. The SA validated through interviews and record review, on 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed as of 0[DATE]20, and the IJ removed as of 01/24/2020.",2020-09-01
70,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2020-02-19,689,D,1,0,O7TC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review, and facility policy review, the facility failed to provide adequate supervision to prevent a resident from leaving the facility unsupervised, for one (1) of four (4) residents reviewed for risk of wandering/elopement. A review of the facility's, Elopement/Unsafe Wandering policy, dated 02/07/2012, revealed, it is the policy of the facility to protect the resident from harm while providing care in a manner that helps promote quality of life in a safe environment. Visual supervision may be necessary in some instances. The nursing staff will complete and document the visual checks as needed. A review of the Brief Interview for Mental Status (BI[CONDITION]), dated 11/18/2019, revealed Resident #1 had a score of 13, which indicated cognitively intact. The facility admitted Resident #1 on 11/18/2019. Review of Resident #1's Wandering Evaluation, dated 11/18/2019, revealed he was assessed and determined to be at risk for wandering/elopement. A review of Resident #1's comprehensive care plan, revealed a focused problem, initiated on 01/02/2020, for elopement risk/wanderer related to being mobile without assistance. The goal revealed the resident's safety would be maintained through the next review date. Interventions included to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, etc., and intervene as appropriate. There were no interventions in place for visual checks until [DATE]20. Resident #1's care plan also revealed an intervention for a yellow arm band to remain in place at times indicating resident is at risk for wandering, initiated on 02/02/2020. A review of (Name of Hospital) Emergency Documentation, revealed, Resident #1 was seen at the facility on 02/02/2020 at 6:30 AM with the chief complaint of escaped from nursing home. The document revealed that Resident #1 was found down the road by the local ambulance service. The document revealed the ambulance service called the facility and inquired if Resident #1 was missing. The facility told the ambulance service that Resident #1 was not missing, but called back a few minutes later and told them that he was missing. The documentation revealed Resident #1 was discharged back to the facility on [DATE] at 7:28 AM with what appeared to be a baseline mental status, vital signs normal, and no evidence of trauma or acute abnormally. Review of a hand-written statement by Registered Nurse (RN) #1, dated 02/02/2020, revealed during the 6:00 AM medication pass, she discovered Resident #1 was not in his bed. RN #1 alerted the Certified Nursing Assistant (CNA) #1 that Resident #1 was not in his room. She stated they started a room to room search for Resident #1. She stated the nurse from another unit came onto RN #1's unit and asked if they had Resident #1 on their unit. RN #1 stated that they were looking for Resident #1 at that time. RN #1 stated that the nurse from the other unit stated that the local ambulance service had called saying they had Resident #1 at a gas station and the other nurse told them they did not have a resident by that name. RN #1 called the local ambulance service and was told that the local ambulance service was in route to the hospital with Resident #1 related to disorientation. She stated that the local emergency room (ER) called for information on Resident #1. RN #1 stated that she reported to the Director of Nursing (DON) that CNA #1 had noticed cold air coming through the window and that the plexiglass window had been mostly pushed out. A review of a hand-written document by Licensed Practical Nurse (LPN) #1, dated 02/02/2020 at 6:10 AM, revealed a lady from the local ambulance service had called and reported they had a gentleman (Resident #1) at the local convenience store wearing an arm band indicating he was from the facility. LPN #1 stated she did not think they had anyone with that name missing, but they would do a head count and would call them back. LPN #1 documented she went to the different units at the facility. LPN #1 revealed when she went into the Cove unit, with Resident #1's name and room number, in which they had found on the computer, the staff were told they needed to do a head count. LPN #1 revealed at that time, Resident #1 was noted to be missing. Review of a hand-written document by LPN #2, dated 02/02/2020, revealed Resident #1 returned from the hospital on [DATE] at 9:15 AM and she asked Resident #1 what happened. LPN #2 documented that Resident #1 answered by stating he went out to see his girl, she said she loved him. LPN #2 revealed Resident #1 told her he went out of the window, but he wouldn't do it again. LPN #2 documented she spoke with Resident #1's Resident Representative (RR), and she told LPN #2 that Resident #1 had done the same thing when he lived with her. LPN #2 documented the RR stated Resident #1 climbed out of the window to go see his girl. A review of a hand-written statement by CNA #1, dated 02/02/2020, revealed she saw Resident #1 at 4:20 AM and he was lying in his bed. CNA #1 documented that at around 5:45 AM, RN #1 asked her where was Resident #1, and they began to search for Resident #1. CNA #1 revealed a few minutes later, LPN #1 came and asked if they had a resident by the name of Resident #1. CNA #1 documented LPN #1 stated that Resident #1 was at the store. Review of a hand-written statement by CNA #2, dated 02/02/2020, revealed she did not see Resident #1 through the night of 02/02/2020. CNA #2 documented that around 5:45 AM, Resident #1 was reported missing. CNA #2 revealed she assisted with the search for Resident #1, and during the search, LPN #1 came to the floor and asked did they have a resident by the name of Resident #1. During an interview, on 0[DATE]20 at 12:20 PM, the facility's Administrator stated she received a call on 02/02/2020 at approximately 6:22 AM, from the Director of Nursing (DON) stating Resident #1 had left the facility through a window, and the local ambulance service had taken him to the emergency room at the local hospital, and Resident #1 appeared confused. The Administrator stated when she got to the facility around 7:30 AM, she went and inspected Resident #1's room. She stated that part of the window in Resident #1's room was plexiglass and appeared to have been pushed out. The Administrator revealed the blinds were pulled down over the window to hide the opened window. She stated Resident #1's bed was fixed to look like there was a person lying under the covers of the bed. The Administrator stated she spoke to Resident #1's niece, who was the Resident Representative (RR), and she said Resident #1 would go out her window all the time and go to the hospital to look for his girl, and that was why she had to put him in the nursing home. The Administrator stated when Resident #1 returned to the facility by the local ambulance service, he was not confused, but was his same old self. She stated Resident #1 has a [DIAGNOSES REDACTED]. The Administrator revealed since Resident #1 has been at the facility, they have learned to understand what he says. The Administrator stated that when Resident #1 returned to the facility, around 9:15 AM on 02/02/2020, she went and talked with Resident #1, and he told her that he was going to see his girl. The Administrator stated she asked Resident #1 if he went out the door and he said no She stated that she then asked him if he went out the window, and he said yes. An observation and interview, on 0[DATE]20 at 1:45 PM, revealed Resident #1 sitting on the bed, near the door, talking with his roommate. Resident #1's roommate bed was located in front of the window. The Administrator, who was present in the room, asked Resident #1 if he remembered getting out, and Resident #1 smiled and nodded his head to gesture yes. The Administrator asked Resident #1 if he went out the door when he left the facility, and he shook his head to indicate no. The Administrator then asked Resident #1 if he went out the window, and he smiled and nodded his head to gesture yes. Resident #1 pointed down at his yellow bracelet on his left wrist and smiled. The Administrator told him that he had to leave the bracelet on, and Resident #1 shook his head to indicate no. During an interview, on 0[DATE]20 at 3:50 PM, the Administrator revealed, she thought they had done everything in place they could do to keep Resident #1 in view, except to put him one on one at all times and that was not possible. She stated they had no idea Resident #1 would go through the window. The Administrator stated she had no reason to expect Resident #1 to leave the facility. She stated that when Resident #1's niece placed him at the facility, she did not tell them he had previously left her home through a window. The Administrator stated they found that out when she spoke to Resident #1's niece the day (02/02/2020) he went out of the window at the facility. On 0[DATE]20 at 9:23 AM, during an interview with CNA #1, she stated on the morning of 02/02/2020 at 4:20 AM, she entered Resident #1's room to take care of his roommate. She stated Resident #1 was pretty self-sufficient to toilet himself, so she just peeked in on him at times to make sure he was okay. CNA #1 stated she doesn't wake Resident #1 up, if he is asleep. CNA #1 stated RN #1 went into the room around 5:40 AM to give Resident #1 his medicine and he wasn't in the room. She stated RN #1 asked her where was Resident #1, and she told RN #1 that he was in his bed earlier. CNA #1 stated RN #1 told her that Resident #1 was missing. CNA #1 stated they began to look for Resident #1, when LPN #1 came in and asked if they had Resident #1 on the unit. CNA #1 stated LPN #1 said that the local ambulance service had called and asked if they had Resident #1 at the facility, and LPN #1 told them that she didn't think so, but would check. CNA #1 stated RN #1 called the local ambulance service and verified it was Resident #1. She stated they began to try and figure out how Resident #1 got out of the locked door unit, knowing that there was no way he could have gotten out, without someone opening the door. CNA #1 stated they went into Resident #1's room, and he had blankets and covers piled under the cover like he was in the bed. CNA #1 stated she went over to the window to check and see if Resident #1 had opened the window, because the window slid from left and right. CNA #1 stated she leaned against the left side of the window, which was plexiglass, and it was loose at the bottom, like it wasn't sealed or something. She stated she pushed on it just a little and it went open. CNA #1 stated Resident #1 had even pulled the blinds down over the window, so it looked closed. She stated that she would have never found the open area of the window, if she hadn't leaned on it.",2020-09-01
71,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2017-03-10,157,D,0,1,U1S311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to ensure the physician was notified of a resident's low blood glucose level per the facility's diabetic protocol regarding blood glucose parameters for reporting, and failed to ensure the physician was notified when routine insulin was withheld for one (1) of eight (8) insulin dependent residents reviewed. (Resident #10). Findings include: A review of the facility's policy titled, Physician Notification of Change of Condition or Status, dated (MONTH) 1, 2000, revealed it was the policy of the facility to provide a mechanism for informing the resident's physician of changes that affect the resident. The procedure included the attending physician would be notified when there was a significant change in the resident's physical, mental, or psychological status, or when there was a need to alter treatment significantly. A review of the facility's policy titled, Diabetic Therapeutic Protocol, dated 06/01/2000, revealed a [DIAGNOSES REDACTED] Protocol that if a resident was asymptomatic, alert, and the finger stick blood glucose was less than 50, staff was to give a form of carbohydrate that contained glucose, recheck the finger stick glucose in 15 minutes, and if it remained less than 50, and the resident remained asymptomatic, repeat the treatment then notify the physician. The physician was to be notified even if the resident improved. A review of Resident #10's (MONTH) (YEAR) physician's orders [REDACTED]. A review of Resident #10's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. A review of the Nurse's Notes for the month of (MONTH) (YEAR) confirmed the resident had an accucheck that read a low blood glucose level of 41 at 6:00 AM on 03/06/17. The note further indicated the resident was alert and responsive, was given a form of carbohydrate that contained glucose, and another accucheck was taken at 6:30 AM that read a blood glucose level of 48. Treatment was repeated, and the next blood glucose level was obtained at 6:50 AM, and read 82. There was no indication in the Nurse's Notes Resident #10's physician was notified at that time of the low blood glucose. Further review of the Nurse's Notes revealed no indication Resident #10's physician was notified of the insulin being held on 03/07/17. An interview on 03/08/17 at 8:20 AM, with the Resident #10's attending Physician revealed he had not been notified of Resident #10 having a hypoglycemic episode on 03/06/17. He thought that perhaps his Physician's Assistant (a Certified Family Nurse Practitioner) may have been notified. The physician stated he expected that he or his assistant would be notified. Resident #10's attending Physician stated he was not notified the insulin was held on 03/07/17. An interview on 03/08/17 at 2:30 PM, with Registered Nurse (RN) #5 revealed she had not notified Resident #10's Physician, or obtained a physician's orders [REDACTED].#10's insulin on 03/07/17. RN #5 stated she should have contacted the physician to obtain an order to hold the insulin, but failed to do so, however, she felt she made the correct decision to hold the insulin based on Resident #10's glucose level, and nursing judgment. RN #5 stated there were no documented parameters for Resident #10. RN #5 stated she left early on 03/07/17, and did not report to the nurse relieving her that she had withheld Resident #10's insulin that day. An interview on 03/09/17 at 10:20 AM, with the Director of Nursing (DON) revealed hypoglycemic episodes, and holding insulin should be reported to the physician or physician's assistant. The DON stated the nursing staff should be more diligent in reporting given the resident's recent readmission on 3/3/17, due to hospitalization for [DIAGNOSES REDACTED]. An interview on 03/09/17 at 11:15 AM, with the Director of Nursing (DON) and the Certified Family Nurse Practitioner (CFNP) revealed the CFNP was Resident #10's attending Physician's assistant. The CFNP stated he came to the facility to perform daily rounds on 03/06/17, during the morning shift. The CFNP stated he saw Resident #10 to follow up on her return from a recent hospitalization , and requested from the nurse to see her vitals. The CFNP stated he identified on the MAR indicated [REDACTED]. The CFNP stated he had not been informed of the episode prior to his review of the MAR. The CFNP stated he would expect to be notified of hypoglycemic episodes, and was easily accessible to staff as was the attending physician. The CFNP stated he had not been notified of the nurse holding the insulin on 03/07/17. A review of Resident #10's Face Sheet revealed Resident #10 was originally admitted by the facility on 06/18/10, and had current [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/17, revealed Resident #10 was assessed by staff for cognitive skills for daily decision making, and found to be moderately impaired, indicating decisions were poor, and cues/supervision were required.",2020-09-01
72,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2017-03-10,159,D,0,1,U1S311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Residents Trust Fund, Resident Council meeting interview, and staff interview, the facility failed to make resident funds readily accessible at all times for 73 of 73 residents participating in the trust fund account, and the facility failed to ensure the resident's account balances did not reach or exceed the applicable resource limit for three (3) of 73 resident accounts reviewed. This affected Unsampled Residents B, C, and D. Findings include: Review of the facility's policy titled, Resident Trust Fund Policy & Agreement, dated (MONTH) 17, 2007, revealed there was nothing addressed to make funds available at all times to residents who choose to participate in the trust fund. Further review of the policy revealed: The facility must notify each resident receiving medical treatment assistance under Title XIX (Medicaid) when the amount in the resident's account reaches $200.00 less than the SSI (Supplemental Security Income) limit of $2,000.00, and $500.00 less than the Medicaid resource limit of $4,000.00 to remain eligible for Medicaid long term care benefits. The notice must include the fact that if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the applicable resource limits, the resident may lose eligibility for Medicaid or SSI. The facility must notify the Medicaid regional office of any resident receiving medical assistance under Title XIX when the resident's account balance reaches or exceeds the applicable resource limit to remain eligible for the Medicaid program. During the Resident Group meeting held on [DATE] at 2 PM, six (6) residents voiced a complaint that they usually got their money by the 3rd of each month, and they had not received it as of today. One resident spoke up and said the business office lady said it would be there tomorrow. She was new and didn't know she was supposed to request the money. Review of the residents', who attended the Group Interview, most recent Basic Interview for Mental Status (BIMS) revealed scores of 11 to 15, which indicated mild cognitive impairment, to no cognitive impairment. An interview conducted with the Business Office Manager on [DATE] at 10:10 AM, revealed when she was asked about the residents' money being available, she stated she's only been working here since (MONTH) 24, (YEAR). She revealed she didn't know she had to request the money ahead of time. The Business Office Manager further stated she didn't know money had to be available for the residents at all times. Review of the facility's Trial Balance sheet for [DATE] revealed the facility managed 78 resident trust funds. Of the 78, five (5) were expired residents. Unsampled Resident B had a balance of $4346.09 which put him $346.09 above his resource amount. Unsampled Resident C had a current balance of $5555.55, which put him $ 1555.55 over the resource amount of $4000.00. Unsampled Resident D had a current balance of $4425.40, which was $425.40 over the resource amount of $4000.00. The Social Worker was interviewed on [DATE] at 11:05 AM. She revealed she had been working with the family of Unsampled Resident B. and a burial policy was being purchased. The Social Worker revealed she had done nothing with Unsampled Resident C, and she thought Unsampled Resident D had expired. Further investigation with the Business Office Manager on [DATE] at 4:30 PM, revealed Unsampled Resident D left the facility against medical advice (AMA), and did not receive his money at the time of discharge. Facility staff revealed the resident was a veteran who was homeless, and preferred living homeless. The Business Office Manager stated she was unaware as to why they didn't return his money.",2020-09-01
73,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2017-03-10,160,D,0,1,U1S311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident Trust Fund review, facility policy review, and staff interview, the facility failed to ensure all funds were disbursed 30 days after death for five (5) of 78 residents who participated in the resident trust fund. This affected Unsampled Residents E, F, G, H, and I. Findings include: Review of the facility's policy titled, Resident Trust Fund Policy & Agreement, dated (MONTH) 17, 2007, revealed: 5. Upon death of a resident who has a Resident Trust Fund on deposit with the facility, the facility must convey within 30 days the residents funds, and a final accounting of these funds, to the individual or probation jurisdiction administering the Resident's estate. Review of the Residents Trust Fund accounts revealed Unsampled Residents E, F, G, H, and I were expired. Review of the facility's Trial Balance sheet documented the following: Unsampled Resident [NAME] expired on [DATE], with a balance of $768.25 on [DATE]. Unsampled Resident F expired [DATE], with a balance of $2551.85 as of [DATE]. Unsampled Resident G expired [DATE], with a remaining balance as of $1938.92 on [DATE]. Unsampled Resident H expired on [DATE], with a balance of $66.81 as of [DATE]. Unsampled Resident I had a balance of $2181.64 as of [DATE], she expired on [DATE]. During an interview with the Business Office Manager on [DATE] at 10:10 AM, she revealed she's unsure why the money is there. She's working to find out where it needs to go.",2020-09-01
74,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2017-03-10,253,D,0,1,U1S311,"Based on observation, and staff interview, the facility failed to ensure a safe, and clean homelike environment for 20 of 102 resident rooms. Findings include: During the initial tour on 03/07/17, from 10:30 AM until 11:30 AM, the following environmental concerns were observed: A Hall: Room 108: The bed mattress was torn, and scuff marks were on the wall. Room 110 C: The wallpaper around the air conditioner had torn areas. Room 112 C: There was a hole in the bricks along the window. Room 123: Unable to see out of the windows on the left side due to a build up of dirt, the window sills were dirty, and the front of the air conditioner unit was off. Room 117: There was paint peeling, and scuff marks on the wall. D Hall [RM #]2 A: Knats were flying around the resident's head. [RM #]4 A: Scuff marks were on the wall behind the bed. [RM #]5 A: Scrape marks were on the wall behind the bed. Observations, and interviews during the initial tour, with Registered Nurse (RN) #6, on 3/7/17 from 11:00 AM to 12:20 PM, revealed the following environmental concerns identified on the Memory Care Unit: Room 411: There were two (2) bottles of mouthwash, and two (2) toothbrushes in a plastic cup on the back of toilet unlabeled. Interview with RN #6 at this time revealed she was unsure if it was OK. She also confirmed dementia residents could drink the mouthwash, and there was a risk of cross contamination due to the toothbrushes could get mixed up. Room 412: A empty intravenous piggy back (IVPB) medication bag was on the back of the toilet. The medication bag label revealed the IVPB was an antibiotic for (Name of Resident) in Room 412 [NAME] RN #6 stated at this time the IVPB bag should be in a biohazard container because it was an IV. Further observations revealed the bathroom shower curtain was ripped with only four (4) of the 13 curtain rings attached to the shower curtain. Room 413: There was two (2) lotions and body washes unlabeled. Room 414: There was two (2) bottles of shampoo, soap, body wash, and cleansing foam in the shower unlabeled. There was also a can of hair spray, and two (2) bottles of mouthwash unlabeled sitting on the back of the toilet. Room 415: Had empty body washes, two (2) full bottles of unlabeled body washes on the back of the toilet. The drain cover was upside down with four prongs exposed. RN #6 stated the resident in this room was dependent, and would use a chair or go to the hall shower. There was also a hole in the center of the shower. Room 416: Had two (2) unlabeled bottles of mouthwash, two (2) bottles of shampoo, two (2) bottles of lotion, and a disposable razor on the back of the sink. A light bulb was out over the sink, and there was no privacy curtain by the B bed. RN #6 revealed they didn't have two residents in here for a while, and the B bed was not occupied. Room 418: Had a torn shower curtain with four (4) of the 12 curtain rings attached to the shower curtain. The shower curtain was crooked and sagging. Room 419: Did not have a shower curtain, and a hat used to collect urine/stool specimens was on the floor. There were unlabeled bottles of shampoo and mouthwash on the back of toilet, as well as toothbrushes and toothpaste at the back of the sink. RN #6 stated it should be labeled, and in a cup. Room 421: Had a light bulb out. One of two (1 of 2) mouthwash bottles was unlabeled, and two (2) bath basins were unlabeled in the tub. There were four (4) of the pop up type air fresheners in the room. All four of the air fresheners were dried up, or partially dried up. RN #6 stated she thought the family members brought the air fresheners. Room 426: Had unpackaged, unlabeled toothswabs, toothbrushes in a kidney shaped basin. The shower only had four (4) of 11 curtain rings hanging. Room 424: Had two (2) unlabeled bottles of shampoo, two (2) unlabeled urine/stool hats in the shower. RN #6 stated she was unsure why because the resident was incontinent, and there was only one resident in this room. On 3/7/17 at 11:58 AM, an observation, and interview in Room 119 with Licensed Practical Nurse (LPN) #3, revealed a shower chair in the the resident's shower with a meal tray containing a plate of food. The tray had large unidentified food particles, and fruit flies circling and landing on the plate. The meal ticket on the plate was dated 03/05/17. LPN #3 stated at this time anyone who sees it is responsible to pick them up. ` During an interview on 03/07/17 at 12:01 PM, Housekeeping Staff #1 confirmed the findings, and said she did not see the plate in the shower. She said if she had seen it, she would have removed it from the room. On 03/08/17 at 8:45 AM, an environmental walk through was done with the Maintenance Director. He acknowledged the aforementioned issues with the environment. He further revealed he was in the process of hiring an additional maintenance worker. On 03/08/7 at 1:30 PM, an interview with the Director of Nursing (DON) revealed she was asked about the used IV bag and unlabeled items. She revealed the IV bag should have been disposed of in a red bag. The residents' personal items should have been labeled, put in a plastic bag in the drawer, or behind the sink.",2020-09-01
75,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2017-03-10,278,D,0,1,U1S311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, facility policy review, and review of the Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, revealed the facility failed to accurately code Resident #5's Minimum Data Set (MDS) related to Range of Motion (ROM) for one (1) of twenty four (24) MDS's reviewed. Findings include: A review of the facility's policy titled, Resident Assessment, dated (MONTH) 1, 2000, revealed the purpose of the resident assessment is to describe the resident's capability to perform daily life function, and to identify significant impairments in functional capacity. A review of the Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual dated (MONTH) (YEAR) in Section Z0400 revealed the person who completes any section or portion of the MDS is required to sign the statement indicating that it is accurate. A review of Resident #5's History and Physical dated 12/14/2016, revealed on the physical examination assessment relating to the extremities, Resident #5 had a bilateral [MEDICAL CONDITION]. A review of the cumulative Physician order [REDACTED]. A review of the Admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 02/02/2017, for Resident #5, revealed section GO400B for Functional Limitation in Range of Motion was coded a zero (0), thus indicating no bilateral lower extremity impairment. During an interview on 03/08/2017 at 3:45 PM, with the MDS Coordinator/Registered Nurse (RN) #2, it was confirmed the Admission MDS with the ARD of 02/02/2017 in Section GO400B for Resident #5 was not coded correctly. RN #2 stated the MDS for Range of Motion (ROM) of the lower extremities should be coded a two (2), thus indicating impairment on both sides. RN #2 confirmed she was the nurse who had completed section G of the MDS, and signed it as being accurate on 02/04/2017. RN #2 also stated the CMS's RAI 3.0 Version Manual, is the policy and guideline used for completing the MDS for the facility. An interview on 03/08/2017 at 3:55 PM, with the Director of Nursing (DON), revealed the Admission MDS with an ARD date of 02/02/2017 was coded incorrectly as relating to the lower extremity impairment. The DON confirmed Resident #5 was a bilateral below the knee [MEDICAL CONDITION]. The DON confirmed the CMS's RAI Version 3.0 Manual was the policy and guideline used by the facility for the MDS completion. A review of the facility's Face Sheet revealed the facility admitted Resident #5 on 01/26/2017, with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/02/2017, revealed the resident's Brief Interview for Mental Status (BIMS) score was fifteen (15) indicating no cognitive impairment.",2020-09-01
76,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2017-03-10,280,D,0,1,U1S311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to revise Resident #10's care plan upon return from the hospital to reflect the discontinuation of sliding scale insulin for one (1) of eight (8) insulin dependent resident care plans reviewed. Findings include: A review of the facility's policy titled, Goals and Objectives, related to the Comprehensive Care Plan, undated, revealed goals and objectives were to be revised when the resident had been readmitted to the facility from a hospital stay. A review of Resident #10's Comprehensive Care Plan revealed a revision date of 12/05/16, and included an intervention for administering sliding scale insulin initiated on 5/25/16. Resident #10 was readmitted by the facility on 3/6/17, from the hospital. A review of physician's orders [REDACTED]. An interview on 03/09/17 at 4:35 PM, with Registered Nurse (RN) #2/Minimum Data Set (MDS) Nurse, revealed the care plan should have been revised to remove the intervention for sliding scale insulin when the resident returned from the hospital without an order for [REDACTED]. An interview on 03/09/17 at 11:15 AM, with the Director of Nursing (DON) revealed she had written reconciled orders when Resident #10 returned from the hospital. She stated the care plan should have been updated upon return from the hospital to reflect the discontinuation of sliding scale insulin, but she overlooked it. A review of Resident #10's Face Sheet revealed Resident #10 was originally admitted by the facility on 06/18/10, and had current [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/17, revealed Resident #10 was assessed by staff for cognitive skills for daily decision making, and found to be moderately impaired, indicating decisions were poor, and cues/supervision were required.",2020-09-01
77,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2017-03-10,282,E,0,1,U1S311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to follow the plan of care related to diabetic care for Resident #10, for one of eight (1 of 8) insulin dependent resident care plans reviewed, and catheter care for Residents #6, #15, and #16, for three of six (3 of 6) residents with catheters care plans reviewed. Findings include: Review of facility's policy titled, Care Plan-Comprehensive, (no date), revealed it is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives and time tables to meet the resident's medical, nursing and psychological needs. The comprehensive care plan has been designed to: Incorporate identified focus areas; Incorporate risk factors associated with identified problems; Build on the residents strengths; Reflect treatment goals and objectives in measurable outcomes that incorporate the resident's personal cultural practices and wishes; Identify the professional services that are responsible for every element of care; Enhance the optimal functioning of the resident by focusing on rehabilitative programs and sources as needed. Resident #10 A review of Resident #10's Care Plan revealed a care plan to address Diabetes originated on 09/15/16, with a revision date of 12/05/2016. The care plan had an intervention to, Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of [DIAGNOSES REDACTED]: Sweating, Tremor, Increased heart rate ([MEDICAL CONDITION], Pallor, Nervousness, Confusion, Slurred Speech, Lack of Coordination, Staggering Gait initiated on 09/15/2015. Further reveiw of the Care Plan revealed an intervention initiated on 9/15/15, to administer [MEDICATION NAME] (Detemir) insulin as ordered. An observation, and interview 03/07/17 at 4:20 PM, revealed Resident #10 was lying in bed. Certified Nursing Assistant (CNA) #4 was present in the room. There were clear plastic bags filled with linens, sheets and bedspreads, on the floor next to Resident #10's bed. CNA #4 stated she had just changed Resident #10 because the resident was sweating profusely. At this time Resident #10 was observed to be sweating profusely, her eyes were casting far to the left, and she was non-responsive when spoken to. Resident #10's skin was cool and clammy, and she was taking shallow quick breaths. CNA #4 stated she entered the room, and found Resident #10 to be sweating profusely, the bed was soaked with sweat and possibly urine. CNA #4 stated she had informed Licensed Practical Nurse (LPN) #5. CNA #4 stated she requested LPN #5 to turn the air conditioning down in the room because the resident was sweating so much. CNA #4 stated LPN #5 came into the room and turned the air conditioning down. CNA #4 stated she did not think LPN #5 had assessed the resident when he came in the room, and further stated the resident was talking to her earlier when LPN #5 was in the room. The State Agency surveyor stepped out of the room, and asked LPN #5 to check on Resident #10. LPN #5 entered the room, and Resident #10 responded to him when he assessed her. LPN #5 stated she looked, and responded as she normally does, but the sweating was unusual. LPN #5 stated Resident #10 had recently returned from a hospitalization for a hypoglycemic episode, and he would check her blood sugar level now. An interview on 3/7/17 at 5:25 PM, revealed CNA #4 stated she had asked LPN #5 to come to Resident #10's room about 4 PM due to the resident was sweating, and he was there about five (5) minutes later. CNA #4 stated Resident #10 was able to talk, and was responsive at that time. CNA #4 stated LPN #5 turned the air conditioner down, but did not think he checked the resident. CNA #4 stated LPN #5 was on the med cart at the time, and was making his way to Resident #10's room. CNA #4 stated LPN #5 checked Resident #10's blood sugar, and it was low. An interview on 3/7/17 at 5:30 PM, with LPN #5 revealed Resident #10's blood sugar was low at 43. He treated it with two (2) cups of Koolaid, and Med Pass. He notified the doctor who gave an order to recheck the blood sugar in 15 minutes, and if it is not up to 60, give the [MEDICATION NAME] one milligram intramuscular (1 mg. IM). LPN #5 stated he rechecked the blood sugar, and it was still 43, and he administered the [MEDICATION NAME] as ordered. Review of Resident #10's (MONTH) (YEAR) Medication Administration Record (MAR), and Nurse's Notes dated 3/7/17 at 5:30 PM, revealed LPN #5 documented the administration of the [MEDICATION NAME] one (1) mg. IM on 3/7/17 at 5:30 PM. An interview with Licensed Practical Nurse (LPN) #5 on 03/08/17 at 2:50 PM, regarding the care plan, revealed he agreed he did not follow the care plan, and should have checked Resident #10's blood sugar due to the profuse sweating when CNA #4 first reported it to him. A review of Resident #10's Nurse's Notes for the month of (MONTH) (YEAR) revealed the resident had an accucheck that read a low blood glucose level of 41 at 6:00 AM on 03/06/17, and the resident was alert and responsive, was given a form of carbohydrate that contained glucose, and another accucheck was taken at 6:30 AM that read a blood glucose level of 48. Treatment was repeated, and the next blood glucose level was obtained at 6:50 AM, and read 82. There was no indication in the Nurse's Notes Resident #10's physician was notified at that time of the low blood glucose. A review of Resident #10's Medical Record revealed the following: The Medication Administration Record (MAR) for the Month of (MONTH) (YEAR), revealed Resident #10's Detemir ([MEDICATION NAME]) insulin had been held on 03/07/17 during the 7AM to 3 PM shift by RN #5. A review of the Nurse's Notes for Resident #10 revealed no note regarding holding the insulin during the day shift on 03/07/17. Resident #10's Detemir ([MEDICATION NAME]) insulin was not administered per the Care Plan. An interview with Registered Nurse (RN) #5 on 03/08/17 at 2:30 PM, revealed she had withheld the insulin for Resident #10 during the day shift on 03/07/17, did not notify the physician of holding the insulin, and had not done a nurse's note regarding withholding the insulin. RN #5 stated she recorded on the MAR she withheld insulin due to parameters. RN #5 stated she left early, and did not report to RN #6 who releived her (RN #5) when she left, the insulin was held, so RN #6 did not report the insulin was held to LPN #5 when he came on to work the 3 PM to 11 PM shift. RN #5 agreed she did not follow Resident #10's care plan related to reporting and documenting. An interview on 03/08/17 at 8:20 AM, with Resident #10's attending Physician revealed he had not been notified of Resident #10 having a hypoglycemic episode on 03/06/17, or the insulin was held on 03/07/17. The physician stated he expected that he or his assistant would be notified. An interview on 03/09/17 at 10:20 AM, with the Director of Nursing (DON) revealed hypoglycemic episodes, and holding insulin should be reported to the physician or physician's assistant. Further interview with the Director of Nursing (DON) on 03/09/17 at 11:15 AM, revealed she agreed the care plan had not been followed related to reporting and monitoring of Resident #10's diabetic symptoms, and to administer the insulin as ordered. An interview on 03/09/17 at 11:15 AM, with the Director of Nursing (DON) and the Certified Family Nurse Practitioner revealed the CFNP stated he came to the facility to perform daily rounds on 03/06/17, during the morning shift. The CFNP stated he identified on the MAR Resident #10 had a hypoglycemic episode on the morning of 03/06/17. The CFNP stated he had not been informed of the episode prior to his review of the MAR. The CFNP stated he would expect to be notified of hypoglycemic episodes, and was easily accessible to staff as was the attending physician. The CFNP stated he had not been notified of the nurse holding the insulin on 03/07/17. A review of Resident #10's Face Sheet revealed Resident #10 was originally admitted by the facility on 06/18/10, and had current [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/17, revealed Resident #10 was assessed by staff for cognitive skills for daily decision making, and found to be moderately impaired, indicating decisions were poor, and cues/supervision were required. Resident #16 Review of Resident #16's Care Plan with a revision date of 03/08/17, revealed the resident will remain free from catheter-related trauma through review date. An intervention added to the Care Plan on 03/07/17, listed: Ensure leg strap is in place to secure Foley tubing. An observation in the presence of Licensed Practical Nurse (LPN) #3/Care Plan and Minimum Data Set Nurse, on 03/08/16 at 11:45 AM, revealed Resident #16 was in his bed. Resident #16 had a Foley catheter in place without a leg strap to secure the Foley catheter tubing to his leg. During an interview on 03/07/17 at 11:45 AM , LPN #3/Care Plan and MDS Nurse confirmed the findings, and revealed that using a leg strap with a Foley Catheter is to prevent damage by preventing pulling and tugging on the tubing. LPN #3 stated nurses and Certified Nursing Assistants (CNAs) were responsible for checking and applying the leg straps while delivering care. During an interview on 03/10 17 at 9:30 AM, Registered Nurse (RN) #2/MDS and Care plan Nurse, revealed a care plan's purpose is to guide caregivers to care for a resident. RN #2 revealed a revision to the plan of care was made on 03/08/17, to include the application of the Foley catheter strap. She confirmed the prior care plan did not include instructions to secure a Foley catheter to a resident's leg using a strap. RN #2 said most of the time a care plan is not that specific, and a Nurse or CNA would rely on their training. RN #2 stated placing a Foley Catheter strap is just part of Foley Catheter Care, and if they did not use a strap, then they did not follow the Plan of Care. Review of the Face sheet revealed the facility admitted Resident #16 on 12/29/16, with [DIAGNOSES REDACTED]. Resident #6 Review of Resident #6's Care Plan revealed a problem to address a Foley catheter in place with interventions to ensure a leg strap was in place to secure the Foley tubing, and position the catheter bag and tubing below the level of the bladder. Observation on 03/08/17 at 3:25 PM, revealed Certified Nursing Assistant (CNA #1) performed incontinent care on Resident #6. Resident #6's Foley catheter bag was lying on the bed near the resident's feet. Further observation during the Foley catheter care revealed at 3:35 PM, Resident #6 was lying on her back without a device to secure the Foley catheter tubing, and the Foley catheter tubing was lying between Resident #6's legs. Interview on 03/10/17 at 10:15 AM, with Licensed Practical Nurse (LPN) #2 revealed if the care plan states to provide catheter care and a Foley catheter strap is not present, then the care plan is not being followed. Review of the Face Sheet revealed the facility admitted Resident #6 on 02/01/17, with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/08/17, revealed Resident #6 did not fully complete the Brief Interview for Mental Status (BIMS). Per staff interview, Resident #6 has moderately impaired cognitive skills. Resident #15 Review of Resident #15's Care Plan revealed a problem to address the Foley catheter related to Benign Neoplasm of the Prostate, and risk for infection initiated on 9/20/16. Interventions included to provide Foley catheter care every shift, and prn (as needed). An observation, and interview on 03/07/17 at 12:25 PM, revealed Licensed Practical Nurse (LPN) #1 pulled back the covers on Resident #15. LPN #1 confirmed there was not a catheter strap in place on Resident #15. LPN #1 revealed the catheter strap should have been in place. A review of the Face Sheet revealed the facility admitted Resident #15 on 09/20/16, with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/16/16, revealed Resident #15 scored 14 on the Brief Interview for Mental Status (BIMS), which indicated cognitively intact.",2020-09-01
78,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2017-03-10,309,D,0,1,U1S311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to monitor, and notify Resident #10's physician of low blood glucose levels to ensure appropriate treatment and management, for one of eight (1 of 8) insulin dependent Diabetic residents reviewed. Findings include: A review of the facility's policy titled, Diabetic Therapeutic Protocol, dated 06/01/2000, revealed the physician must approve the use of the Diabetic Therapeutic Protocol for each of his/her resident's use and write a corresponding order in the medical record. Nurses will be informed of this practice upon hire and regularly thereafter. [DIAGNOSES REDACTED] Protocol: If the resident is asymptomatic, alert, and the finger stick blood glucose is less than 50 (or as indicated by the physician): 1. Give a form of carbohydrate that contains glucose. Orange juice with 2 (two) teaspoons of sugar is acceptable. If the resident is unable to swallow due to other medical conditions, give [MEDICATION NAME] one milligram intramuscular ( 1 mg. IM) now. 2. Recheck the finger stick blood glucose in 15 minutes. 3. If the finger stick blood glucose remains less than 50, and the resident remains asymptomatic, repeat the treatment. 4. Notify the physician. The physician is notified even if the resident improves. 5. If the finger stick blood glucose returns to normal, have the resident eat a meal or snack containing a form of protein, (i.e. peanut butter or cheese sandwich, milk, cheese and crackers). An observation and interview on 03/07/17 at 4:20 PM, revealed when the State Agency (SA) surveyor entered Resident #10's room, Resident #10 was lying in the bed, and observed to be sweating profusely. Resident #10's eyes were casted to the left, she was not responsive when spoken to, her skin felt cool and clammy, and she was taking shallow, quick breaths. Certified Nursing Assistant (CNA #4) was in the room with the resident at this time. CNA #4 stated when she entered the room, she found Resident #10 sweating profusely, the bed soaked with sweat and possibly urine. There were clear plastic bags containing linen, sheets and bedspreads on the floor next to the bed. CNA #4 said she had informed Licensed Practical Nurse (LPN #5) about Resident #10's profuse sweating, and had requested LPN #5 to turn the air conditioning down in the room because the resident was sweating so much. CNA #4 stated LPN #5 came into the room about five (5) minutes later, and turned the air conditioning down. CNA #4 stated she did not think LPN #5 assessed the resident when he came in the room at that time. CNA #4 did report Resident #10 was talking to her earlier when LPN #5 was in the room. The SA surveyor stepped out of the room and saw LPN #5 at the med cart in the hallway. The SA surveyor asked LPN #5 to check on Resident #10. LPN #5 entered room, and Resident #10 responded to him when he assessed her. LPN #5 stated the resident looked, and responded as she normally does, but the sweating was unusual. LPN #5 stated Resident #10 had recently returned from a hospitalization for a hypoglycemic episode, and he would check her blood sugar level. An interview with CNA #4 on 03/07/17 at 5:25 PM, for clarity regarding the time, and what she reported to LPN #5 revealed she told him at around 4:00 PM the resident was sweating, and asked if he could turn on the air conditioning. CNA #4 stated LPN #5 entered the room about five minutes later, and turned down the air conditioner. CNA #4 stated the resident was responsive at that time, and LPN #5 was coming down the hallway, and was about to get to the room. An observation of Resident #10 at 5:28 PM on 03/07/17, revealed the resident was responsive, but her responses to questions were incoherent. The resident was unable to state her name. An interview with LPN #5 on 03/07/17 at 5:30 PM, revealed LPN #5 had taken the Resident #10's blood glucose level, and it was 43 mg/dl (milligrams/deciliter). LPN #5 stated he gave her two (2) cups of Koolaid, and Med Pass, and called the attending physician (Medical Director). He stated the physician told him to check the glucose level again in about 15 minutes, and if it was still below 60 he was to administer [MEDICATION NAME] one milligram intramuscular (1mg IM). LPN #5 was observed taking the glucose level at this time. The glucose level was still 43, and LPN #5 administered the [MEDICATION NAME] IM. LPN #5 stated Resident #10 is always confused due to dementia, cannot state her name, and mostly says yes to questions. An interview with LPN #5 on 03/08/17 at 2:50 PM, regarding the hypoglycemic episode, and monitoring Resident #10's blood sugar, revealed LPN #5 stated he should have checked Resident #10's blood sugar due to the profuse sweating when CNA #4 initially reported it to him. LPN #5 stated it was hot in the room when he was called in by the CNA, and he thought the resident was sweating from the heat. An interview on 03/07/17 at 5:35 PM, with the Attending Physician confirmed he had been notified of Resident #10's hypoglycemic episode on 03/07/17 at 4:25 PM, by LPN #5. He stated he was told the resident was sweating and clammy, didn't look well, had a glucose level of 43, and the nurse had given her two cups of koolaid and med pass. The physician stated he was told the resident was responsive. He stated he instructed the nurse to check the insulin level again in 15-20 minutes, and if it was still below 60, to administer 1mg [MEDICATION NAME] IM. The physician could not recall if the resident had frequent episodes of [DIAGNOSES REDACTED], he had not been informed of any episodes since her return from the hospital, but his assistant (the Nurse Practitioner) may have information that he did not. He stated he had a lot of residents, and it was difficult to remember details. When asked if a resident with diabetes was sweating profusely would he expect the nurse to take the blood sugar level, and he said yes, sweating is a symptom of [DIAGNOSES REDACTED]. A review of the Medication Administration Record [REDACTED]. IM on 3/7/17 at 5:30 PM. Further review of the MAR indicated [REDACTED]. An interview on 03/08/17 at 2:30 PM, with Registered Nurse (RN) #5 revealed she held the prescribed dose of insulin for Resident #10 on 03/07/17. She stated she had not obtained a physician's orders [REDACTED]. RN #5 stated there were no documented parameters for holding insulin for Resident #10, but she held it based on the resident's history, and nursing judgment. RN #5 stated she left early on 03/07/17, and did not report to the nurse (RN #6) relieving her that she had withheld insulin that day. A review of the physician's orders [REDACTED]. Review of Resident #10's Nurse's Notes revealed no documentation regarding the Detemir insulin was held on 3/7/17, or the resident's Physician was notified the insulin was held. A review of the facility's Weights and Vitals sheet for Blood Sugars revealed the following blood sugars documented for 3/7/17: 84mg/dl at 5:08 AM, 112mg/dl at 11:16 AM, and 43mg/dl at 5:05 PM. A review of Resident #10's Care Plan revealed Resident #10 had a Care Plan to address Diabetes originated on 09/15/16, with a revision date of 12/05/2016. There was no revision of the care plan when the resident returned from the hospital on [DATE]. The care plan had an intervention to, Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of [DIAGNOSES REDACTED]: Sweating, Tremor, Increased Heart Rate ([MEDICAL CONDITION], Pallor, Nervousness, Confusion, Slurred speech, Lack of Coordination, staggering Gait initiated on 09/15/2015. A review of Resident #10's (MONTH) (YEAR) physician's orders [REDACTED]. A review of the Nurse's Notes for the month of (MONTH) (YEAR), revealed Resident #10 had an accu-check that read a blood glucose level of 41mg/dl at 6:00 AM on 03/06/17. The note further indicated the resident was alert and responsive, was given a form of carbohydrate that contained glucose, and another accucheck was taken at 6:30 AM that read a blood glucose level of 48 mg/dl. Treatment was repeated, and the next blood glucose level was obtained at 6:50 AM, and read 82. There was no indication in the nurse's notes the physician was notified at that time. Further review of the Nurse's Notes revealed Resident #10 was readmitted by the facility on 03/03/17, post hospitalization . A review of the facility's Weights and Vitals sheet for Blood Sugars revealed the following blood sugars documented on 3/6/17: 41mg/dl at 5:35 AM, 238 mg/dl at 11:29 AM, 155 mg/dl at 5:01 PM, and 148 at 8:53 PM. An interview on 03/08/17 at 8:30 AM, with the Attending Physician revealed he had not been notified of Resident #10 having a hypoglycemic episode on 03/06/17. The Attending Physician stated that perhaps his Physician's Assistant (a Certified Family Nurse Practitioner) may have been notified. The physician stated he expected that he or his assistant would be notified of hypoglycemic episodes, or if insulin was held. The Attending Physician stated he was not notified Resident #10's insulin was held on 03/07/17, but agreed it should be with a blood glucose level of 112. He stated he would expect a nurse to take the glucose level on a resident with diabetes if the resident exhibited profuse sweating. An interview on 03/09/17 at 10:20 AM, with the Director of Nursing (DON) revealed it was expected hypoglycemic episodes, and holding insulin should be reported to the physician or physician's assistant. The DON stated the nursing staff should have been more diligent in reporting given the resident's recent hospitalization for [DIAGNOSES REDACTED], and the nursing staff had not done as good a job as they should. An interview on 03/09/17 at 11:15 AM, with the Director of Nursing (DON) and Certified Family Nurse Practitioner (CFNP) revealed that he is the Physician's Assistant for the Attending Physician. The CFNP stated on 3/7/17, during the morning shift, he came to the facility to perform daily rounds, and follow up with the Resident #10 since her recent release back to the facility from the hospital. He stated he requested to see Resident #10's vital signs, and identified on the MAR indicated [REDACTED]. The CFNP stated he was not notified prior to inquiring about the hypoglycemic episode. The CFNP stated he also reviewed meal intakes, and decreased the resident's insulin dosage based on the information gathered. The CFNP stated he would expect to be notified of hypoglycemic episodes, and was easily accessible to staff as was the attending physician. The CFNP stated that he had not been notified of the nurse holding insulin on 03/07/17. A review of Resident #10's Face Sheet revealed Resident #10 was originally admitted by the facility on 06/18/10, and had current [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/17, revealed Resident #10 was assessed by staff for cognitive skills for daily decision making, and found to be moderately impaired, indicating decisions were poor, and cues/supervision were required.",2020-09-01
79,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2017-03-10,315,E,0,1,U1S311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review, the facility failed to provide catheter care in a manner to prevent the potential for infection and injury, for three (3) of six (6) residents reviewed with catheters. (Residents #5, #15, and #16). Findings include: Review of facility's policy titled, Catheter Care, Urinary, dated 8/25/14, revealed the Foley Catheter should remain secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh). Use standard precautions when handling or manipulating the drainage system. Maintain a clean technique when handling or manipulating the catheter, tubing or drainage bag. The urinary drainage bag should be held or positioned lower than the bladder at all times. This prevents the urine in the tubing and drainage bag from flowing back into the urinary bladder. For the female, use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Resident #16 An observation, and interview on 03/08/16 at 11:45 AM , revealed the State Agency (SA) surveyor and Licensed Practical Nurse (LPN) #3 observed Resident #16 lying in his bed with a Foley catheter in place, and without a leg strap to secure the Foley catheter tubing to his leg. An interview at this time with LPN #3 confirmed the finding, and revealed the use of a leg strap with a Foley catheter is needed to prevent damage by preventing pulling and tugging on the tubing. LPN #3 stated nurses and Certified Nursing Assistants (CNAs) were responsible for checking, and applying the leg straps while delivering care. During an interview on 03/10 17 at 09:30 AM, Registered Nurse( RN) #2 revealed nurses or Certified Nursing Assistants (CNAs) should know from their training that securing a Foley catheter to a resident's leg with a leg strap is part of catheter care. Review of Resident #16's Care Plan revealed facility admitted Resident #16 on 12/29/16. Resident #16's [DIAGNOSES REDACTED]. Resident #6 Observation on 03/08/17 at 3:25 PM, revealed CNA #1, assisted by CNAs #2 and #3 provided Resident #6's incontinent care. The State Agency (SA) surveyor entered the resident's room as the incontinent care was in progress. CNA #1 pulled gloves from her uniform pockets, donned the gloves, and began to clean Resident #6's buttocks. Resident #6 was incontinent of a bowel movement. Resident #6's Foley catheter drainage bag was observed lying on the bed near the resident's feet. Observation on 03/08/17 at 3:35 PM, revealed CNA#1 provided Resident #6's Foley catheter care with assistance from CNA #2 and CNA #3. Resident #6 was lying on her back, and did not have a device to secure the Foley catheter tubing. The Foley catheter bag continued to lie on the bed between the resident's legs during the Foley catheter care. CNA #1 cleaned the peri area by wiping from the back to the front, instead of from the front to the back to prevent contamination. Upon completion of the Foley care, CNA #1 placed the Foley bag into a privacy bag hanging near the foot of the bed. The Foley catheter tubing was hanging unsecured over the resident's left thigh. An interview on 03/08/17 at 4:20 PM, with CNA #1 revealed she didn't know who placed the Foley bag on top of the bed. CNA #1 stated, It's not suppose to be there. CNA #1 revealed she knew it shouldn't have been there, but didn't say anything. CNA #1 further stated by placing the Foley bag on the bed, it could cause an infection. CNA #1 confirmed she removed the gloves from her uniform pocket while performing the incontinent care. CNA #1 stated, I've always done that. I didn't know. CNA #1 confirmed she wiped from back to front during Resident #6's Foley catheter care. Interview on 03/08/17 at 4:30 PM, with CNA #2 revealed she saw the Foley bag lying on the bed, but wasn't' sure who placed it there. CNA #2 stated, it could cause urine to go back inside the resident, and cause a UTI (Urinary Tract Infection). CNA #2 revealed gloves are not clean anymore when placed inside your pockets. CNA #2 confirmed she witnessed CNA #1 wiping Resident #6 from the back to the front during the Foley catheter care. A review of Resident #6's Care Plan revealed the Focus problem to address a Foley catheter in place. Interventions included to ensure a leg strap was in place to secure the Foley tubing, and position the catheter bag and tubing below the level of the bladder. Interview on 03/08/17 at 4:15 PM, with Registered Nurse (RN) #1 revealed the Foley catheter bag should be placed at the foot of the bed below the resident. RN #1 further revealed by placing the bag on the bed it could back up, and cause a bladder infection and pain. RN #1 was asked if staff should store gloves in their uniform pockets, and RN #1 stated, Not that I'm aware of. An interview on 03/09/17 at 9:00 AM, with the Director of Nursing (DON) revealed the Foley catheter bag should hang below the resident's waist on the bed. The DON stated urine can back up in the urethra if the Foley catheter bag was not placed correctly. Interview on 03/09/17 at 9:30 AM, with CNA #3 confirmed the Foley catheter bag was on top of the bed when care was being provided to Resident #6. CNA #3 reported CNA #1 placed the Foley catheter bag on top of the bed. CNA #3 stated, it could back up, and could come open, and contaminate the bed, with the Foley bag being on the bed. CNA #3 confirmed she saw CNA #1 pull gloves from her pocket, and that it could cause the spread of infection. Interview on 03/10/17 at 10:15 AM, with Licensed Practical Nurse (LPN) #2, revealed her understanding of catheter care included observing the presence of a catheter strap. LPN #2 stated the catheter strap was used to prevent injury. LPN #2 revealed the CNAs were suppose to let the nurses know if there was not a strap in place. The nurse replace the straps. The CNA should disconnect the catheter tubing from the strap for the purpose of cleaning. Review of the Face Sheet revealed the facility admitted Resident #6 on 02/01/17 with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/08/17, revealed Resident #6 did not fully complete the Brief Interview for Mental Status (BIMS). Per staff interview, Resident #6 had moderate impaired cognitive skills. Resident #15 Observation, and interview on 03/17/17 at 12:25 PM, revealed LPN #1 pulled back Resident #6's covers at which time LPN #1 and the State Agency (SA) surveyor observed Resident #6 had a Foley catheter in place. LPN #1 confirmed there was not a catheter strap in place, and a catheter strap should have been in place. LPN #1 further revealed the nurse that changes the catheter, and performs the body audits was responsible for checking the catheter straps. LPN #1 stated the resident could receive a tear to the urethra, and it could accidentally get pulled out if a strap was not attached. A review of the Face Sheet revealed the facility admitted Resident #15 on 09/20/16, with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/16/16, revealed Resident #15 scored 14 on the Brief Interview for Mental Status (BIMS), which indicated cognitively intact.",2020-09-01
80,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2017-03-10,356,D,0,1,U1S311,"Based on observation, review of the facility's Nursing Staff Directly Responsible for Resident Care posting, and staff interview, the facility failed to ensure the nursing staff posting was not completed prior to the beginning of each shift as evidenced of staffing numbers being recorded prior to the beginning of each shift for three of four (3 of 4) days of the survey. Findings include: On 03/07/17 at 11:00 AM, an observation revealed the Nursing Staff Directly Responsible for Resident Care was posted near the front lobby. There were two days posted, 03/06/17 and 03/07/17, and both contained the numbers filled in for all three shifts. On the 03/06/17 sheet the hour numbers were crossed out and corrected. On the sheet for 03/07/17, the first, second and third shift hours were already written in for the day. At 03/07/17 at 5:10 PM, an interview with the Director of Nursing revealed she was unaware the hours could not be posted prior to the shift. She further revealed she would make the corrections on the sheet after the shift started. Observations on 03/08/17, and 03/09/17, revealed the numbers were again posted on the staffing sheets incorrectly",2020-09-01
81,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2017-03-10,371,F,0,1,U1S311,"Based on observation, staff interview, record review, and facility policy review, the facility failed to prevent the potential for food contamination and/or foodborne illness as evidenced by failure to remove soiled gloves during the tray line food service, to ensure all dietary staff was knowledgeable of how to calibrate food temp thermometers to ensure accuracy of food temperatures, and document temperature readings of all foods served, for one (1) of one (1) tray line observations. This deficient practice had the potential to affect all residents who received meals from the kitchen. Findings include: A review of ServSafe guidelines dated 2008, provided by the facility titled, When and How to Wash Your Hands, revealed you should wash your hands after you touch anything that may contaminate your hands. Review of ServSafe guidelines dated 2008, provided by the facility titled, How to Calibrate a Thermometer, revealed thermometers should be calibrated regularly to make sure the readings were correct, and thermometers should be calibrated to 32 degrees Fahrenheit. An observation of the tray line temperature readings on 03/08/17 at 11:20 AM, and interview, revealed Dietary Staff (DS) #2 placed a digital thermometer in a cup of ice water with gloved hands. The thermometer reached the reading of 34 degrees Fahrenheit (F). DS #2 stated the reading was 34 degrees F, and proceeded to test the temperature of the first food item on the line. When asked what the thermometer reading should be calibrated to prior to taking food temperatures, DS #2 stated, Anywhere from 34 degrees to 40 degrees. When asked what the facility policy was regarding calibration temperatures, DS #2 stated he wasn't sure, but he was ServSafe Certified, and that was what he learned from ServSafe. DS #2 then presented his ServSafe Certification Badge. DS #2 stated the digital thermometer could not be calibrated. DS #4 intervened at this time, and stated I will go get a thermometer that can be calibrated to 32 degrees F. DS #2 stated the digital thermometer would not get to 32 degrees F because it was being placed in ice water, not ice. Dietary Staff #4 returned with another thermometer. The thermometer was calibrated, and read 32 degrees F when placed in the ice water. DS #2 proceeded to take the tray line food temperatures. DS #2 was touching the lids and utensils with gloved hands, and cleaning the thermometer between each food item with alcohol wipes. DS #2 skipped two food containers on the tray line while taking temperatures. When asked what the food items were, DS #2 stated those are the alternative meat and alternative vegetable. DS #2 stated they don't have to be temped. When asked if he normally took the temperature of alternative foods, DS #2 stated, No, only a few people eat the alternative. There's no need to temp those. There is no place to record the temperatures on the temperature log anyway. The State Agency (SA) surveyor requested DS #2 to check the alternate food items at this time. DS #2 temped the alternative vegetable squash at 180 degrees Fahrenheit, then he picked up two (2) country fried steak patties from the alternate meat container with his gloved hand, and stuck the thermometer into the patties stating he couldn't get a high enough reading without stacking the patties. After obtaining the temperature, DS #2 placed the patties back into the container on top of the other patties. DS #2 walked over to a side prep table, reached under the table to the bottom shelf, retrieved two pot holder gloves, placed them over his gloved hands, opened the oven, retrieved two pans of lasagna, and placed them on the tray line. DS #2 removed the tin foil covering the lasagna pans, removed the pot holder gloves, and proceeded to take the temperature of the lasagna without changing gloves, or washing hands. When asked about touching the meat with his gloved hands, DS #2 stated he should have removed his gloves, washed his hands, and put on new gloves prior to touching the meat, or thrown away the meat that he touched. When asked about retrieving gloves from under the prep table, removing the lasagna from the oven, and then proceeding to temp foods wearing the same gloves, DS #2 stated he should have removed the gloves, washed his hands, and donned new gloves prior to temping the lasagna. An interview at 11:30 AM, with the Dietary Manager and the Dietician, revealed it was expected the staff knew thermometers were to be calibrated to 32 degrees F, hands should be washed and gloves changed when contaminated, and all foods served should have temperatures taken and recorded. The Dietary Manager pulled the temperature log, and confirmed there was no alternative food temperatures recorded, and there was no place on the form to record them. The DM stated she had not noticed this before, and was not aware that alternative food temperatures were not being taken or recorded. The Dietician stated that the facility adheres to ServSafe guidelines, and there had been an inservice on handling food safely, and washing hands.",2020-09-01
82,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2017-03-10,372,E,0,1,U1S311,"Based on observation, and staff interview, the facility failed to ensure garbage and refuse was contained inside garbage dumpsters, and dumpsters were closed for one (1) of two (2) dumpsters observed. Findings include: An observation, and interviews during an environmental tour with the Dietary Manager on 03/07/17 at approximately 10:25 AM, revealed the following: There were two (2) dumpsters utilized by the facility located outside on a concrete surface approximately 50 yards from the South end of the facility, and directly connected to an approximately one half acre field with high grass, and a wooded area beyond the field. On approach to the dumpsters, Housekeeping Staff (HK) #2 was observed throwing garbage bags from a rolling cart into a dumpster, and walked back toward the facility with the empty cart leaving the side door of the dumpster open. The ground and field surrounding the dumpsters were littered with garbage and refuse, including two (2) fluorescent light banisters, a light switch, a wheelchair footrest, a clear garbage bag with an empty medication card (no name was on the card), Intravenous (IV) tubing, latex gloves, two (2) plastic cups, empty cigarette packages, empty Boost bottles, soda bottles, aluminum cans, an unopened pack of enzo barrier cream, one opened box of large latex gloves with one glove inside the box, 22 loose latex gloves, empty bottles of shampoo and body wash, and a fast food bag with chicken bones inside. An interview at this time with HK #2 revealed he had left the dumpster door open. He stated he had been employed for two (2) days, and had not been instructed to close the dumpster after disposing of garbage, and the dumpster door was open when he came out to throw away garbage. HK #2 stated he could see why the dumpster door should be closed to prevent animals from getting inside, and strewing the garbage all out and into the woods. He stated the smell from the garbage would attract animals from the woods. HK #2 stated he did notice all of the debris and garbage on the ground outside the dumpster, and had not picked it up. He stated a lot of it appeared to be things thrown out by the maintenance staff, and dietary staff, and he wasn't responsible for that because he worked for housekeeping. The Dietary Manager stated she had worked at the facility for a month, and had not been out to the dumpsters before. She stated the dietary staff did use the dumpsters, but she thought that most of the debris appeared to be trash from resident rooms. The DM stated she was unsure who was responsible for keeping the dumpster area clean. An interview on 03/09/17 at 8:00 AM, with the Administrator, revealed housekeeping was responsible for keeping the dumpsters and surrounding area clean. She stated the dumpsters were located near the woods, and there were homeless people living in the woods who would, dumpster dive, and pull things out of the dumpster. She did expect housekeeping to clean the area if they saw garbage strewn, and expected the dumpsters to be closed after staff disposed of garbage. An interview on 03/10/17 at 10:55 AM, with the Housekeeping Supervisor, confirmed the Housekeeping Department was responsible for disposing of garbage, and keeping the area surrounding dumpsters free of debris. The Housekeeping Supervisor stated he expected housekeeping staff to pick up garbage, and dispose of it if strewn on the ground around the dumpsters, and to close the dumpster after disposal of garbage.",2020-09-01
83,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2017-03-10,441,D,0,1,U1S311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure infection control measures for the potential spread of infection were followed as evidenced by staff using gloves stored in uniform pockets to provide resident care, staff failure to change gloves, failure to dispose of medical waste, disinfect resident care equipment after use, and placing a nebulizer treatment on the floor during resident care. These deficient practices effected three of nine (3 of 9) residents observed during the med pass, Resident #15, Unsampled Residents J and K; one (1) of six (6) residents observed for Foley catheter care, Resident #6, one (1) of 102 resident rooms observed during the initial tour. Findings include: Review of the facility's policy titled, Gloves, dated (MONTH) 1, 2000, revealed hands should be washed immediately after removing gloves. Review of the facility's policy titled, Handwashing, dated (MONTH) 1, 2000, revealed personnel wash their hands to prevent the spread of infection and disease to other residents. Review of the facility's policy titled, Cleaning/Disinfection of Resident Care Items and Equipment, dated (MONTH) 15, 2010, revealed non-critical items were those in contact with intact skin and could be decontaminated when they are used. Review of the facility's policy titled, Intravenous Fluids (IV), Administration of, revealed: Infection Control: 6. Dispose of disposable equipment appropriately, 7. Dispose of hazardous materials appropriately. Resident #15 An observation during med pass on 03/08/17 at 9:10 AM, revealed License Practical Nurse (LPN) #4 performed a nebulizer treatment for [REDACTED]. LPN #4 dropped the intact plastic three (3) milliliter vial on the floor, then picked the vial up off the floor to use for the nebulizer treatment. LPN #4 placed the nebulizer machine on the floor beside the bed, and attached the nebulizer mask and tubing to the machine. LPN #4 told the resident, I will set this down here because it makes so much noise. LPN #4 put the medication into the nebulizer vial while the machine and the tubing were still on the floor. LPN #4 then picked up the machine, and placed it on overbed table while it was running, but did not disinfect the machine, or place a barrier on the table. An interview on 03/08/17 at 9:15 AM, revealed LPN #4 confirmed he did set the nebulizer machine on the floor. LPN #4 said he usually set the machine on the bedside table, but it shook, and made noise, and would slide off. An interview on 03/10/17 at 9:10 AM, with the Director of Nursing (DON) revealed the nurse should have set the nebulizer machine on the bedside table. The DON said the concern was the spread of infection. The DON said the pharmacists randomly selected nurses to observe during medication pass every month, and the pharmacist only reports to her if he had any problems. A review of a facility's In-Service dated 06/01/16, revealed to place a barrier down when setting anything down in the room. Unsampled Resident J An observation during med pass on 03/08/17 at 9:20 AM, revealed Registered Nurse (RN) #3 donned gloves, and applied two skin patches, an [MEDICATION NAME] and a [MEDICATION NAME], to Unsampled Resident J's skin. RN #3 removed her gloves, but did not wash or sanitize her hands before she typed on the computer keyboard on top of the medication cart. RN #3 then removed the pulse oximeter from her scrub top pocket, and placed it on top of the medication cart without disinfecting the device. Unsampled Resident K An observation on 03/08/17 at 12:25 PM, during med pass, revealed RN #3 donned gloves she had placed in her scrub top pocket. RN #3 mixed the Vancomyacin IVPB (Intravenous Piggy Back) medication, disinfected the top of the PICC (Peripheral Inserted Central Catheter) line, flushed the PICC line with Normal Saline, connected the IVPB tubing to the PICC line, and started the infusion via a IV (Intravenous) pump. RN #3 wore the same gloves she removed from her uniform pocket during the entire IV med set up and administration observation. An interview on 03/08/17 at 12:40 PM, revealed RN #3 confirmed she had used her pockets to store gloves and the pulse oximeter, and she nromallty did use her pockets to store her gloves. RN #3 said the concern was the spread of infection. An interview on 03/10/17 at 9:10 AM, revealed the DON said the gloves and the pulse oximeter should not be stored in uniform pockets. A review of a Medication Administration Observation dated 03/01/17, revealed RN #3 was observed by the pharmacist during medication pass. A review of the facility's Education In-Service Record-Medication Pass, dated 08/25/16 and 08/26/17, revealed nurses should wash hands before and after direct resident care. A review of the facility's Face Sheet revealed the facility admitted Resident #15 on 09/20/16. Resident #15's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/16, revealed Resident 15's Brief Interview for Mental Status (BIMS) was 14, which indicated intact cognitive status. Resident #6 Observation on 03/08/17 at 3:25 PM, revealed Certified Nursing Assistant (CNA #1) provided incontinent care for Resident #6. CNA #1 pulled gloves from her uniform pockets, and donned the gloves. CNA #1 began, and completed Resident #6's incontinent care using the gloves from her uniform pocket. Interview on 03/08/17 at 4:20 PM, revealed CNA #1 confirmed she removed gloves from her uniform pocket while performing Resident #6's incontinent care. CNA #1 stated, I've always done that. I didn't know. Interview on 03/08/17 at 4:30 PM, with CNA #2, revealed gloves are not clean anymore when placed inside your pockets. Interview on 03/09/17 at 9:30 AM, revealed CNA #3 confirmed she witnessed CNA #1 pulling gloves from her pocket. CNA #3 stated using contaminated gloves could cause the spread of infection. Interview on 03/08/17 at 4:15 PM, revealed Registered Nurse (RN) #1 stated when asked if staff should store gloves in their uniform pockets, Not that I'm aware of. A review of the Face Sheet revealed the facility admitted Resident #6 on 02/01/17, with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/08/17, revealed Resident #6 did not fully complete the Brief Interview for Mental Status (BIMS). Per staff interview, Resident #6 had moderate impaired cognitive skills. One (1) of 102 Resident Rooms Observations, and interviews during the initial tour on the Memory Care Unit with Registered Nurse (RN) #6, on 3/7/17 from 11:00 AM to 12:20 PM, revealed in room [ROOM NUMBER] A, an empty intravenous piggy back (IVPB) medication bag was on the back of the toilet. The medication bag label revealed the IVPB was an antibiotic for (Name of Resident) in room [ROOM NUMBER] [NAME] RN #6 stated at this time the IVPB bag should be in a biohazard container because it was an IV. On 03/8/17 at 1:34 PM, an interview with the Director of Nursing (DON) revealed the IV bag would be hazardous waste, and should have had the label removed, put in a red bag, and disposed of as medical waste. It should not have been left in the resident's bathroom.",2020-09-01
84,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2017-03-10,502,D,0,1,U1S311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility policy review, the facility failed to obtain Resident #5's laboratory test in a timely manner for one (1) of fourteen (14) resident records reviewed for laboratory test orders. Findings include: A review of the facility's policy titled, Request for Diagnostic Services, dated (MONTH) 26, 2007, revealed it is the policy of the facility that all orders for diagnostics services for each resident will be carried out as instructed by the physician's orders [REDACTED]. A review of the cumulative Physician order [REDACTED]. Review of Resident #5's lab results revealed a weekly CBC was not located for Friday, 02/24/17. An interview on 03/08/2017 at 4:00 PM, with the Director of Nursing (DON) confirmed the physician's orders [REDACTED]. The DON stated she had called the laboratory, and they confirmed there was no record of any laboratory tests for Resident #5 on 02/24/2017. The DON stated she was the staff member that monitors the diagnostic testing ordered by the physicians. The DON stated she had notified the physician the morning of 3/8/2017, and made him aware of the missing CBC for 02/24/2017. A review of the Face Sheet revealed the facility admitted Resident #5 on 01/26/2017, with the included [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/02/2017, revealed the resident's Brief Interview for Mental Status (BIMS) score was fifteen (15), indicating intact cognition.",2020-09-01
85,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2019-05-15,550,D,0,1,0E0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and interviews, the facility failed to ensure the residents' dignity was not compromised for two (2) of 24 sampled residents, Residents #21 and #37. Specifically, staff posted signage visible to others regarding a resident's personal care (Resident #21), and the facility staff failed to provide privacy for one (1) resident (Resident #37), leaving the resident's skin and/or body exposed. Findings include: Review of an undated facility policy tilted, Dignity and Respect, revealed, It is the policy of this facility to treat each resident with respect and dignity and care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life. 1. The staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings .3. Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtains shields the residents from passer-by. People not involved in the care of the resident shall not be present without the resident's consent while they are being examined or treated. Staff members shall knock before entering the resident's room. 4. Privacy of a resident's body shall be maintained during toileting, bathing, and other activities of personal hygiene, except when staff assistance is needed for the resident's safety . Resident #21 Review of Resident #21's Minimum Data Set (MDS), Significant Change Assessment, dated 03/05/19, revealed the facility admitted the resident on 04/19/17. Both of Resident #21's legs were amputated above the knee, with the most recent amputation (right leg) occurring on 02/25/19. The resident also had [DIAGNOSES REDACTED]. According to the MDS assessment, the resident had impairment on both sides of his body; had an indwelling urinary catheter; was always incontinent of bowel; and required extensive assistance with bed mobility, transferring, dressing, personal hygiene, and bathing. Observation, on 05/14/19 at 10:07 AM, of Resident #21's room, revealed the resident was in the bed nearest the entry door from the hallway. The resident's eyes were closed, and he was covered with a bedspread. There was a sign posted on the wall over the resident's bed which read, Do not fasten brief. Keep brief loose under buttocks and peri area to prevent kinking of tubing. The sign was hand written on an 8 x 11 inch piece of paper. During an observation on 05/14/19 at 11:10 AM, of Resident #21's daily wound care, revealed the sign remained posted over the resident's bed. On 05/14/19 at 2:28 PM, observation of Resident #21's room, revealed the sign remained posted on the wall above his bed. Observation on 05/15/19 at 9:03 AM, of Resident #21's room, revealed the sign remained posted over the resident's bed. Interview on 05/15/19 at 09:10 AM, with Resident #21 revealed the sign had been on the wall over his bed for about two (2) months, since he returned from the hospital following the amputation of his right leg. Resident #21 stated he did not request placement of the sign, but staff let him know they were posting it on the wall. He could not remember which staff member talked to him about the sign. The resident said that due to the condition of his lower body, and the indwelling catheter tubing, he had discomfort at the genital area if the brief was fastened. Review of Resident #21's physician's orders did not reveal placement of the sign was ordered. The care plan for Resident #21 included interventions for monitoring the resident's catheter tubing for kinks, and for observing the resident for any pain or discomfort related to the catheter. Interview, on 05/15/19 11:55 AM, with Certified Nursing Assistant (CNA) #1, revealed she thought the wound care nurse suggested the resident's brief should remain loose due to the resident's physical status, the recent amputation, the ongoing care of the resident's pressure ulcers, and the overall status of the resident's skin. CNA #1 stated she did not think the sign should be posted over the resident's bed. Instead, she said the information about the resident's brief could be communicated to nurses and CNAs at the change of each shift. CNA #1 said the information on the sign should remain confidential and should not become common knowledge for everyone who might enter the resident's room. Observation, on 05/15/19 at 12:30 PM, revealed the sign had been removed from the resident's wall. Interview on 05/15/19 at 12:40 PM, with Licensed Practical Nurse (LPN) #1, revealed the sign had just been taken down. The LPN stated she thought it was inappropriate for the sign to be posted over Resident #21's bed. She said it would alert staff to keep the resident's brief open, but visitors were also able to see the sign. She said staff should communicate resident care needs at shift change. LPN #1 further stated the sign did not enhance the resident's dignity because while posted on the wall, it informed anyone who came into the room that the resident wore a diaper. LPN #1 said the entire message on the sign was not appropriate, but she did not know when the sign was posted over the resident's bed, or who posted it. During an interview on 05/15/19 at 01:45 PM, with the Director of Nursing (DON), the DON revealed the sign should not have been posted over Resident #21's bed, and confirmed it was a dignity issue. She said the sign would inform anyone who came into the resident's room, such as visitors or non-clinical employees like maintenance staff, about the resident's personal care. The DON said she did not know who posted the sign. She said staff had other methods for communicating a resident's care needs which included; the Care Tracker system used by CNAs for updating and documenting care; another option was to communicate information about resident care during the verbal report between nursing staff that should occur at every shift change. Interview on 05/16/19 at 10:12 AM, with the facility's Administrator, revealed Departmental Staff were supposed to conduct daily rounds in assigned areas of the building, including the residents' rooms or living spaces. She said if staff persons identified concerns, they could report them at the morning meeting, so the issue(s) could be addressed as soon as possible. She said the staff who made the morning rounds had not reported any concerns with signage in residents' rooms. Resident #37 Review of Resident #37's undated Face Sheet (a document that contains demographic and [DIAGNOSES REDACTED]. Resident #37's [DIAGNOSES REDACTED]. Review of an admission MDS assessment, with the assessment reference date of 5/07/19, indicated Resident #37 scored a 15 (of 15) on the Brief Interview for Mental Status, indicating the resident was cognitively intact. Further review of the MDS assessment indicated the resident required two (2) staff assist for bed mobility, extensive two (2) staff assistance for transfers, dressing, toilet use and bathing and extensive one (1) staff assistance for personal hygiene. Review of Resident #37's current care plan for activities of daily living revealed the resident required staff assistance for eating, personal hygiene, toilet use, dressing and urinary incontinence. During an observation on 5/12/19 at 2:28 PM, Resident #37 was up in a wheelchair, sitting in the dining room. Her hospital gown was open in the back and pushed to the left side revealing the resident's back, left hip, thigh and part of her torso area. Interview with the RN/TCU (Transitional Care Unit) Unit Manager on 5/12/19 at 2:43 PM, following the observation of Resident #37 in the dining area, indicated she thought she was the resident was covered. Observation on 5/13/19 at 12:06 PM, Resident #37 was up in a wheelchair and was being pushed down the hallway by the Respiratory Therapist. The resident's shirt was pulled up to her breast and was exposing her stomach area and her back. When asked, CNA #3 stated the resident's shirt should be pulled down.",2020-09-01
86,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2019-05-15,623,D,0,1,0E0S11,"Based on facility policy review, record reviews, and interviews, the facility failed to provide written notification to the Ombudsman regarding hospital transfers, for two (2) of six (6) residents who were reviewed for transfers, Resident #106 and Resident #46. Findings Include: Review of the facility's undated Documentation RE: Transfer/Discharge revealed, Policy Statement: It is the policy of this facility that when a resident is transferred or discharged his or her medical records be documented as to the reasons why such action was taken .Procedure 5. Facility will notify the local ombudsman of the discharge and reason for the discharge. Review of an undated, written statement provided, and signed by the Administrator, confirmed there are no discharge/transfer logs for (MONTH) and (MONTH) 2019. Resident #106 Review of the electronic health record for Resident #106 revealed in (MONTH) 2019, Resident #106 was discharged to the hospital for surgery. Further review of the record failed to produce any record of the Ombudsman being notified of the transfer of Resident #106 to the hospital. Resident #46 Review of the electronic health record for Resident #46 revealed in (MONTH) 2019, Resident #46 was discharged to the hospital due to an Acute Ischemic Stroke. Further review of the record failed to produce any record of the Ombudsman being notified of the transfer of Resident #46 to the hospital. An attempt was made to review the Ombudsman notification records for (MONTH) and (MONTH) of 2019, and the facility failed to produce the requested records by the survey exit. On 5/15/19 at 10:15 AM, an interview with the Business Office Manager (BOM) was conducted. The BOM stated someone else was responsible for notifying the Ombudsman in (MONTH) and (MONTH) 2019, and there were no records available for review to confirm the notifications were sent. On 5/15/19 at 10:20 AM, an interview with the RN Nurse Consultant (RNNC) was conducted. The RNNC confirmed there were no records available that documented the notification of the ombudsman of the two (2) hospital transfers/discharges.",2020-09-01
87,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2019-05-15,641,D,0,1,0E0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed accurately for two (2) Residents, Resident #112 and Resident #122, of 26 Residents reviewed for MDS accuracy. Specifically, the facility failed to accurately assess Resident #112's fall status and Resident #122's discharge status. Findings include: Review of an undated, written statement provided by the facility MDS Consultant documented, The Pillars of Biloxi does not have a policy for MDS coding, but it is expected that the RAI (Resident Assessment Instrument) manual is followed when coding resident MDS assessments. Resident #112 Review of Resident #112's admission MDS assessment, dated 4/26/19, revealed the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS documented the resident had not had any falls in the last month prior to admission. Review of an Admission History and Physical, dated 4/16/19, revealed .The patient fell and broke her right wrist on 4/2/19 . During an interview on 5/15/19 at 11:31 AM, the MDS consultant stated the MDS was not coded correctly for the fall prior to admission. She stated the resident had a fall with fracture on 4/02/19, before being admitted to the facility. Resident #122 A closed record review for Resident #122 revealed the information provided in the discharge MDS assessment documented the resident was discharged to an acute care hospital from the facility on 3/15/19. However, a review of the discharge note, dated 3/15/19, and found in the medical record, revealed the resident was discharged to his/her home. The noted stated, Resident left the facility at 1500 (3:00 PM) via private automobile with family members present. During an interview, conducted on 5/15/19 at 5:25 PM, with the MDS Care Plan Coordinator (CPC), the MDS CPC confirmed the MDS discharge information for Resident #122 was coded incorrectly. MDS CPC did not provide an explanation for incorrect information, in the resident's record, but confirmed Resident #122 was discharged from the facility to his/her home with family.",2020-09-01
88,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2019-05-15,644,D,0,1,0E0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, and staff interview, the facility failed to provide a Level II Pre-Admission Screening and Resident Review (PASRR) for one (1) of three (3) sampled residents, Resident #21, reviewed for PASRR screenings. Specifically, Resident #21 was diagnosed with [REDACTED]. Findings include: Review of the facility policy, titled Physician Certification for Nursing Facility and MI/MR Screening, revised 09/05/14, revealed the purpose of the screening was for the physician to certify that a resident was appropriate for admission to a long-term care Medicare/Medicaid facility. Additionally, the policy revealed Social Services (S.S.), the Admissions Coordinator, and Medical Records (MR) personnel (or MR designee) would be responsible for completing and submitting the PASRR screening documents to the State Agency. Review of the Admission Record in Resident #21's electronic clinical record, revealed an original admission date of [DATE], and a readmission date of [DATE]. The Pre-Admission Screening (PAS) Level I Application for Long Term Care was completed on 05/16/17. According to the responses entered on the PAS application, Part B-Criteria for referral for Level II screening, the resident did not meet the criteria for a Level II screen. At that time there was no [DIAGNOSES REDACTED]. Continued review Resident #21's Admission Record, revealed a [DIAGNOSES REDACTED]. Review of Resident #21's admission Minimum Data Set (MDS) Assessment, dated 04/21/17, revealed in Section I: Active Diagnoses: [REDACTED]. Review of Psychiatric Notes, dated 06/14/17, and 07/05/17, revealed the resident was assessed with [REDACTED]. The resident reported to the Psychotherapist that he believed staff were talking about killing him. Review of a MDS Significant Change Assessment, dated 03/05/19, revealed Paranoid [MEDICAL CONDITION] was listed among Resident #21's diagnoses. Review of Resident #21's current Physician Orders, dated 05/15/19, revealed the resident had orders for [MEDICATION NAME] 1.5 milligram (mg) one (1) time per day, and for [MEDICATION NAME] 1.75 mg at bedtime. [MEDICATION NAME] is an antipsychotic medication used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder. Review of Resident #21's Comprehensive Care Plan (CP), revealed the CP included the resident's [DIAGNOSES REDACTED]. In an interview, on 05/15/19 at 4:21 PM, with the Business Office Manager (BOM), she stated that she was responsible for completing the PASRR Level I screening for newly admitted residents. She said the PAS date of 05/16/17, was the date the application was submitted to the State Agency. The BOM said she usually asked the Minimum Data Set (MDS) Nurse to review newly admitted resident's medications and to let her know if the resident was taking [MEDICAL CONDITION] medications. She said she was required to answer a question on the form about the resident's use of [MEDICAL CONDITION]. The BOM said she typically did not ask a nurse or physician to review the resident's diagnoses, because when she transmitted the completed Pre-Admission Screening (PAS) Level I Application for Long Term Care, she also transmitted the resident's History and Physical, their Admission Face Sheet including diagnoses, and the physician's orders to the State Agency to review. She said the State Agency would review the information and would notify the facility if the resident needed a Level II screening. She said the State Agency would then send a representative to the facility to complete the Level II screening. The Business Office Manager stated in Resident #21's case, another PASRR application should have been submitted to the State Agency when the [DIAGNOSES REDACTED]. She said, as far was she knew, there was no system in place that would alert her that a resident received a new [DIAGNOSES REDACTED].",2020-09-01
89,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2019-05-15,645,D,0,1,0E0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record reviews, and interview, the facility failed to complete a Pre-Admission Screening (PAS) prior to the resident's admission to a long-term care facility, as required. The facility's failure affected one (1) of five (5) residents reviewed for Pre-Admission Screening applications for long term care, Resident #37. Findings include: Review of a facility policy, titled Physician Certification for Nursing Facility and MI/MR (Mental Illness/Mental [MEDICAL CONDITION]) Screening, dated 9/15/14, revealed, Policy: The Admission Coordinator or designee will obtain a current Medicare certification, Pre-Admission Evaluation PAE (TN) PAS (MS), and PASRR on all Medicare Part A admissions .The Pre-Admissions Evaluation PAE (TN), PAS (MS) and PASRR are to be completed for Medicare A admissions including: a. New/Initial Medicare A admissions. B. Facility long-term care residents with qualifying hospitalization converting to Medicare A admission into facility. Review of Resident #37's undated Face Sheet (a document that contains demographic and [DIAGNOSES REDACTED]. Resident #37's [DIAGNOSES REDACTED]. Further review of Resident #37's electronic record lacked evidence of a PAS being completed for the resident, prior to admission in the long term care facility, as required. On 5/13/19 at 2:44 PM, a copy of the Pre-Admission Screening (PAS) was provided by Medical Records Director with the PAS date of 5/13/19. During an interview on 5/13/19 at 2:55 PM, with the Business Office Manager (BOM), she stated she was responsible for the PAS on the residents. She indicated she had just completed the PAS on 5/13/19. The BOM confirmed this was the first PAS that had been completed for Resident #37.",2020-09-01
90,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2019-05-15,656,D,0,1,0E0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record reviews, and interviews, the facility failed to ensure comprehensive, resident-centered care plans were developed and/or implemented for three (3) of 48 sampled residents, Residents #37, #89, and #112. Findings include: A review of an undated facility policy titled, Care Plan - Comprehensive, revealed, it is the policy of this facility to develop comprehensive care plans for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. In addition, the policy stated, The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's assessment or within twenty-one (21) days after the resident's admission, whichever occurs first. Resident #37 Record review of the undated care plans for Resident #37, revealed no care plan for the pressure ulcer to the right ischium. There were no interventions or goals related to the care of the pressure ulcer. Review of Resident #37's undated Face Sheet (a document that contains demographic and [DIAGNOSES REDACTED]. Resident #37's [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 5/07/19, revealed Resident #37 scored a 15 on the Brief Interview for Mental Status, indicating the resident was cognitively intact. Further review of the MDS, indicated Resident #37 required limited two (2) staff assist for bed mobility; extensive two (2) staff assistance for transfers, dressing, toilet use and bathing; and extensive one (1) staff assistance for personal hygiene. The MDS documented Resident #37 had one (1) unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar (dead tissue). The MDS indicated the pressure ulcer was present upon admission. Review of the Pressure Ulcer Report, dated 5/10/19, indicated the pressure ulcer to the right ischium measured 3.5 cm (centimeters) by 4.6 cm and was a Stage 3. Observation on 5/14/19 at 10:43 AM, with the RN Wound Nurse, revealed the pressure ulcer was clean and measured 2.8 cm by 4.1 cm and was a Stage 3. During an interview on 5/14/19 at 4:08 PM, the RN Wound Nurse confirmed there was not a care plan for the pressure ulcer to the right ischium for Resident #37. During an interview on 5/15/19 at 4:10 PM, the MDS Consultant confirmed Resident #37 did not have a care plan for the pressure ulcer to the right ischium. Resident #89 A review of Resident #89's, Baseline Care Plan, dated 4/30/19, revealed the resident's care plan identified the following: [NAME] Resident #89's Baseline Care Plan stated, I am at risk for falls related to decreased mobility. The care plan gave instructions for facility staff to ensure the resident's call light was within reach and ensure the resident was wearing appropriate footwear. B. Resident #89's, Baseline Care Plan further indicated, I have an infection. The care plan gave instructions to facility staff to ensure the resident's medication was administered as ordered and observe the resident for worsening symptoms. Resident #89's clinical record did not contain a comprehensive care plan that addressed the residents history of falls or UTI, at the time of the review. The resident's record review was on 5/14/19, 26 days after Resident #89 was admitted to the facility. A review of Resident #89's admission assessment, dated 4/25/19, revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. The assessment indicated Resident #89 used a wheelchair for mobility and needed extensive assistance of two (2) persons and a Hoyer lift for transfers. The resident was also assessed to receive antibiotics for a UTI; as well as physical therapy, occupational therapy, and speech therapy services at the facility. During an interview with the Minimum Data Set (MDS) Care Plan Coordinator (CPC) on 5/14/19 at 5:47 PM, the MDS CPC confirmed Resident #89 only had a Baseline Care Plan at the time of the record review, and further confirmed he should have had a Comprehensive Care Plan completed and implemented. The MDS CPC did not provide an explanation for facility's failure to develop and implement a Comprehensive Care Plan for Resident #89. Resident #112 Review of Resident #112's medical records lacked documentation that a comprehensive care plan for falls had been developed and implemented. Review of Resident #112's undated Face Sheet found in the electronic medical record, revealed the resident was admitted to the facility on [DATE]. Review of Resident # 112 's list of Medical [DIAGNOSES REDACTED]. Review of Resident #112's admission MDS assessment, dated 4/26/19, and the resident's Care Area Assessment (CAA) for falls, dated 5/1/19, revealed the facility was to proceed in care planning Resident #112 for falls. Care Areas are triggered by MDS responses and indicate a need for additional assessment or action for the identified care concerns. During an interview on 5/14/19 at 5:40 PM, the MDS CPC stated the resident only had baseline admission care plan. She confirmed the comprehensive care plan should have been completed and should include falls. The resident had been in the facility for 25 days and had no comprehensive, resident-centered care plan with measurable goals to achieve and/or maintain the resident's highest level of well-being. During an interview on 5/16/19 at 11:00 AM, the MDS Consultant confirmed the comprehensive care plan should be completed and implemented no later than 21 days after a resident's admission.",2020-09-01
91,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2019-05-15,657,D,0,1,0E0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy reviews, record reviews, observations, and interviews the facility failed to ensure the care plan was updated to include all interventions to prevent falls and/or minimize injuries from falls for one (1) of 24 Residents, Resident #51, reviewed for safety, supervision and/or falls. Findings include: Review of an undated facility policy, titled Care Plans - Comprehensive, revealed, It is the policy of this facility to develop comprehensive care plans for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs .4. Care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly . Review of an undated At risk for falls care plan, revealed interventions of: Bolsters on bed; Encourage resident to wear appropriate footwear when ambulating or mobilizing in wheelchair; Fall risk eval on admit, quarterly and prn (as necessary); PT (Physical Therapy) evaluate and treat as ordered and prn; Review information on past fall to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes, tilt wheelchair to prevent forward leaning. The care plan lacked the interventions for a low bed and mats on the floor at her bedside, that were currently being implemented by facility staff. An observation of Resident #51 on 05/12/19 at 8:42 AM, revealed the resident laying in a low bed, with a mat on the floor, visiting with a family member. The family member stated she had asked the staff to place a mat on the floor because she did not want Resident #51 to be hurt from falling out of bed. Review of Resident #51's undated Face Sheet found in the electronic medical record, revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Assessment (MDS) with an assessment reference date of 03/28/19, revealed Resident #51 had long and short-term memory problems, and was moderately impaired with decision making. The resident required extensive assist of two (2) staff for bed mobility, transfer, toilet use, and required extensive one (1) staff assist for dressing, eating, and personal hygiene. The MDS also documented Resident #51 had a history of [REDACTED]. Review of the CAA (Care Area Assessment) dated 03/28/19, revealed Resident #51 had difficulty maintaining sitting balance and impaired balance during transitions. The CAA indicated the resident had a potential for falls. During an interview on 5/14/19 at 3:00 PM, the MDS Coordinator confirmed the interventions of the low bed and mat to floor should have been added to the fall care plan for Resident #51. During an interview on 05/15/19 at 1:45 PM, the DON confirmed the care pan had not been updated to include the interventions for a fall mat and the low bed. She confirmed the care plan was not accurate, and it should include all interventions to prevent falls or reduce injuries from falls.",2020-09-01
92,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2019-05-15,676,D,0,1,0E0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observation, and record review the facility failed to provide a means to communicate for one (1) of two (2) sampled residents reviewed for communication deficits. Specifically, Resident #41's primary language was not English. There was no interpreter in the facility who could translate, and the facility had not arranged for devices and/or services to communicate with the resident in a manner that the resident could understand. Findings Include: A communication policy was requested from the facility during the survey. The Registered Nurse Consultant (RNC) provided a written, signed statement, dated 5/15/19, that confirmed the facility does not have a policy related to interpreter phone usage. Review of Resident #41's quarterly Minimum Data Set (MDS), dated [DATE], revealed: Does the resident need or want an interpreter to communicate with a doctor or health care staff? Answer-No. There is no preferred language listed for Resident #41, but the resident speaks Vietnamese only. Review of the care plan with a revision date of 5/26/2017, read: Focus: I have a communication problem r/t (related to) speaks limited English/primary language Vietnamese. Goal: I will be able to make basic needs known through the review date revised on 03/27/2019. Intervention: COMMUNICATION: Resident prefers to communicate in Vietnamese. On 5/12/19 at 11:48 AM, an interview with Registered Nurse (RN) #4 was conducted. RN #4 stated Resident #41 speaks Vietnamese and does not speak English. RN #4 stated staff communicate with Resident #41 speaking in English and using hand gestures, and Resident #41 appeared to understand some English, but responds only in Vietnamese. RN #4 also stated no other type of communication (communication board, interrupter, language phone line) is used to communicate with Resident #41. RN #4 said there were no communication boards available in the facility for residents with communication concerns to use. On 5/12/19 at 2:45 PM, an interview with Life Connection Assistant (LCA) #2 was conducted. LCA #2 stated Resident #41 does participate in some activities such as ball toss, connect 4, and movies, but the visits are limited due to the language barrier. On 5/12/19 at 4:02 PM an interview with Licensed Practical Nurse (LPN) #2 was conducted. LPN #2 stated there is a communication barrier with Resident #41. The LPN states they use simple questions and the resident responses appear reliable and relevant to questioning. LPN #2 stated there is no communication board, language phone line, or interpreter available to communicate with Resident #41. On 5/14/19 at 3:06 PM, an interview with LCA #1 was conducted. LCA #1 stated he uses hand gestures to communicate with Resident #41. Resident #41 appears to understand some English but does not speak English. Resident #41's responses appear appropriate to questioning. LCA #1 stated he attempted to use his phone to translate at times. LCA #1 stated no staff speak Vietnamese and no language line is available for use. On 5/14/19 at 3:45 PM, an interview with the Social Service Director (SSD) was conducted. The SSD stated there are no staff who speak Vietnamese and Resident #41 has no family or friends involved in his care. The SSD stated Resident #41 can read written questions and respond appropriately. The SSD also stated there in no language phone line available for use. On 5/14/19 at 4:07 PM, an interview with the Minimum Data Set (MDS) Care Plan Coordinator (CPC) was conducted. The MDS CPC stated Resident #41 speaks very little English and there are no staff who speak Vietnamese. The MDS CPC stated there is a language phone line available for use in the facility. On 5/14/19 at 4:07 PM, an interview with the MDS Consultant (MDSC) was conducted. The MDSC stated there is a language phone line available for use in the facility. On 5/15/19 at 4:10 PM, an interview with the RNC was conducted. The RNC stated there is a language phone line available for use in the facility, but there is no formal training provided to staff for the use of the language/interpretive phone line. Observation on 5/12/19 at 12:15 PM, of Resident #41 in is room, revealed he was seated on the bed responding to RN #4's questioning. Resident #41 responded to questions by shaking his head.",2020-09-01
93,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2019-05-15,684,D,0,1,0E0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policies, and interview, the facility failed to ensure a resident with a [DIAGNOSES REDACTED].#102, in a sample of 24 residents. This had the potential to cause a delay and/or alteration in treatment for [REDACTED]. Findings include: Review of a facility policy, titled Weights; Obtaining and Documenting, dated 12/27/17, revealed .Timing of Weights: 1. Daily; Daily weights should be done if ordered by the physician . Record review of Resident #102's admission Minimum Data Set (MDS) assessment, dated 4/25/19, revealed the resident was readmitted to the facility on that date after an acute hospitalization . The MDS revealed in Section I the resident had [DIAGNOSES REDACTED]. An observation of Resident #102 on 5/13/19 at 9:38 AM, revealed the resident was lying in bed, in her room. Her hands and arms were observed to be [MEDICAL CONDITION] (swollen). During an interview on 5/13/19 at 9:41 AM, Registered Nurse (RN) #2 stated the resident had gone to the hospital recently, and had been [MEDICAL CONDITION] since she came back. Review of the Progress Notes, dated 5/02/19, revealed the Nurse Practitioner assessment, . Chief complaint [MEDICAL CONDITION], inadequate diuresis .resident with recent hospitalization .while admitted had [MEDICAL CONDITION] and put on #30 fluid at the time of discharge. I started her on [MEDICATION NAME] (a diuretic) 40 daily, increasing it to bid (twice a day), she has only lost #3 (pounds) . Plan: D/c (discontinue) [MEDICATION NAME] 40 bid, [MEDICATION NAME] (a diuretic) 1 mg(milligram) one po bid, daily weights . Review of the resident's physician's orders [REDACTED].Daily weight one time a day for fluid retention . Review of the resident's Daily Weight record revealed the resident's weight on 5/03/19 was 197 pounds. There was a lack of documentation of the resident's daily weights for 5/04/19, 5/05/19, and 5/06/19. Review of Resident #102's care plans, dated 8/17/18, revealed I am on diuretic therapy r/t (related to) [MEDICAL CONDITION] .Obtain weight as ordered .I have altered cardiovascular status r/t .HF (Heart Failure) .observe/document/report PRN (as needed) any s/sx (signs and symptoms) of [MEDICAL CONDITION]: [MEDICAL CONDITION] .weight gain . During an interview on 5/14/19 at 1:50 PM, Certified Nursing Assistant (CNA) #5 stated she was a restorative CNA and they were responsible for the daily weights. She stated she weighed the resident on 5/03/19, and at that time the resident was on weekly weights, she was not aware the resident had been put on daily weights until 5/07/19. During an interview on 5/14/19 at 4:00 PM, RN #1, stated she had worked on 5/04/19, 5/05/19 and 5/06/19. She stated she had notified the Director of Nursing (DON) on 5/06/19, that the weights had not been done. The DON had told her to notify the restorative CNA to do the daily weights.",2020-09-01
94,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2019-05-15,686,D,0,1,0E0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review, record reviews, and interviews the facility failed to provide the treatments as ordered for a pressure ulcer for one (1) of five (5) residents, Resident #104, reviewed for pressure ulcers, in a sample of 24 residents. Not providing treatment as ordered, had the potential for the pressure ulcer to deteriorate. Findings include: Review of a facility's policy titled Skin Care Process, dated 1/17/18, revealed, It is the policy of this facility to provide care and services with the goal of maintaining the resident's skin integrity and to provide care and services that meet professional standards to treat the loss of skin integrity should it occur .1. Provides treatment according to physician's orders [REDACTED]. Review of Resident #104's undated Face Sheet found in the electronic record, revealed the resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) with the assessment reference date of 4/30/19, revealed Resident #104 had a BIMS (Brief Interview for Mental Status) of 15, which indicated the resident was alert and oriented. The MDS indicated Resident #104 required extensive assist of two (2) staff for bed mobility, transfer, dressing toilet use and personal hygiene. The MDS documented Resident #104 did not have any pressure ulcers at the time of the assessment. Review of an undated care plan for pressure ulcers, revealed Resident #104 had a Stage 2 pressure ulcer to the left medial thigh. The interventions for the Stage 2 pressure ulcer were: Administer medications as ordered; Monitor/document for side effects and effectiveness; Administer treatments as ordered and monitor for effectiveness; Assess/record/observe wound healing; Measure length, width, and depth where possible; Assess and document status perimeter, wound bed and healing progress; Report improvements and declines to the MD (Medical Doctor). Observe nutritional status; Serve diet as ordered, monitor intake and record; Observe/document/report PRN (as necessary) any changes in skin status: appearance, color, wound healing, s/s (signs and symptoms) of infection, wound size (length x(times) width x depth), stage comfort; Treat pain as per orders prior to treatment/turning to ensure the resident's comfort; Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate. Review of the facility's Pressure Injury Log, dated 5/10/19, revealed Resident #104 had a facility acquired pressure ulcer measuring 1.7 by .06 centimeters (cm) which was fluid filled. The treatment order was [MEDICATION NAME] twice a day. Review of the 05/2019 Treatment Administration Record, specified wound care apply [MEDICATION NAME] and tented border gauze to Stage 2 pressure ulcer of L (left) medial thigh, 7-10 AM and 7-10 PM. Start date 5/03/19. Further review of the treatment record indicated the dressing was not completed at all on 5/04/19, the morning of 5/06/19, the afternoon of 5/08/19, and the morning 5/12/19. On 5/12/19 at 1:04 PM, the dressing to Resident #104's left thigh was observed with a date of 5/10/19, the initials on the dressing were smeared and unreadable. The resident stated she had gotten a blister from her compression stocking. Resident #104 stated the dressing had not been changed twice a day as ordered on [DATE] and 5/12/19. During an interview on 5/14/19 at 8:50 AM, Resident #104 stated the midnight nurse had changed the dressing. The resident said the dressing to her left thigh was to be changed twice a day, and that was not done on 5/13/19 as ordered. The date on the dressing was observed as 5/14/19. During a telephone interview on 5/15/19 at 11:AM, the RN Wound Nurse indicated she had changed the dressing on 5/14/19, and the daily dressing changes had not been getting done. The Wound Nurse said she changed the dressings weekly when she did wound measurements, and the floor nurses did the daily treatments. During an interview on 5/15/19 at 1:00 PM, the RN TCU (Transitional Care Unit) Unit Manager (UM) confirmed the dressings should have been done, and she would look into the matter. The TCU UM did not provide any additional information regarding why the dressing changes had not been done. At 1:22 PM, the TCU UM stated she had not been aware the dressings had not been done as ordered for Resident #104. The RN Wound Nurse completed a dressing change on 5/16/19 at 8:10 AM. The Resident #104 agreed to an observation of the dressing change. Appearance of the pressure ulcer revealed the fluid in the blister had been absorbed and the wound bed was dry. The RN Wound Nurse stated she was going to call the Nurse Practitioner because the wound had improved, and she now needed the dressing order discontinued to leave the wound open to air to heal.",2020-09-01
95,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2019-05-15,698,D,0,1,0E0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record reviews, and staff interviews, the facility failed to maintain ongoing communication and collaboration with the [MEDICAL TREATMENT] facility for one (1) of one (1) residents reviewed for [MEDICAL TREATMENT] services (Resident #106) in a sample of 24 residents. Findings Include: Review of the [MEDICAL TREATMENT]-[MEDICAL TREATMENT] policy, Nursing Services-21, dated (MONTH) 23, 2010 read: Policy Statement: Residents with end stage [MEDICAL CONDITION] undergoing [MEDICAL TREATMENT] will receive care and services to attain or maintain the highest practicable physical, mental, and psychosocial well- being. The care and services will meet current standards of care .This facility will co-ordinate care with the [MEDICAL TREATMENT] provider .Medical and administrative information necessary for [MEDICAL TREATMENT] related care of the resident will be shared and communicated between the facility and the [MEDICAL TREATMENT] provider. The Clinical Practice Guideline [MEDICAL TREATMENT]-[MEDICAL TREATMENT], dated (MONTH) 24, 2010 read: Nutrition/Hydration, 5. Weight should be obtained weekly or as ordered by the physician. Pre and post [MEDICAL TREATMENT] weights will be obtained from the [MEDICAL TREATMENT] provider and sent to the facility for inclusion in the medical record. Review of Resident #106's Admission Record, dated 1/22/19, revealed the resident was initially admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#106 revealed, [MEDICAL TREATMENT] M-W-F (named clinic) Biloxi, chair time 12 PM. Review of the electronic medical record for Resident #106, dated 3/18/19 through 5/20/19, revealed four (4) completed [MEDICAL TREATMENT] Transfer Forms dated 3/18/19, 5/06/19, 5/08/19, 5/13/19. Based on the physician order [REDACTED]. On 5/14/19 at 3:30 PM, an interview with Licensed Practical Nurse (LPN) #1 was conducted. LPN #1 stated the [MEDICAL TREATMENT] sheets are collected by Medical Records for placement into the resident's record. On 5/15/19 at 11:20 AM, an interview with Medical Records (MR) was conducted. The MR staff confirmed the only completed communication forms for Resident #106 are dated 3/18/19, 5/06/19, 5/08/19, and 5/13/19. The MR staff also stated the facility does not always get the communication sheets back from the resident. On 5/15/19 at 12:30 PM, an interview with the Director of Nursing (DON) was conducted. The DON stated she had no knowledge of why the documents for the [MEDICAL TREATMENT] visits were not in the medical record for Resident #106. The DON stated the [MEDICAL TREATMENT] center orders labs and reviews the results and then communicates the results to the facility. The DON also stated she was not aware of the missing communication sheets between the facility and the [MEDICAL TREATMENT] center for Resident #106 until she was asked about it.",2020-09-01
96,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2019-05-15,812,F,0,1,0E0S11,"Based on facility policy reviews, observations, and staff interviews the facility failed to store, prepare, and serve food under sanitary conditions for 117 of 121 residents who receive food from dietary services in the facility. Specifically, food was improperly stored in the walk-in freezer, and prepared without staff wearing appropriate hair covers in the facility's kitchen. The facility reported a census of 121 at the time of the survey, with four (4) residents received tube feedings. Findings Include: The Staff Attire policy, Dining Services Policy and Procedure Manual, HCSG Policy 024, dated 9/17, read Policy Statement: All employees wear approved attire for the performance of their duties .Procedures: 1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. The Food Storage: Cold Foods policy, Dining Services Policy and Procedure Manual, HCSG Policy 019, dated 9/17, read Policy Statement: All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated will be appropriately stored in accordance with guidelines of the FDA Food Code .Procedures .5. All foods will be stored wrapped or in covered containers, labeled dated, and arranged in a manner to prevent cross contamination. Observation on 5/12/19 at 9:01 AM, in the kitchen, revealed Dietary Aide (DA) #1 with facial hair on his chin approximately 0.25-0.50 inch in length. The DA was working in the food preparation area of the kitchen and plating fruit for lunch without wearing a facial hair cover. Observation on 5/12/19 at 9:20 AM, in the kitchen, revealed the Lead Supervisor (LS) who had a beard approximately 0.25-0.50 inch in length. The LS was working in the food preparation area of the kitchen not wearing a facial hair cover. Observation on 5/12/19 at 9:30 AM, in the kitchen, revealed the Dietary Manager (DM) who had a beard approximately 0.25-0.50 inch in length. The DM was also working in the food preparation area of the kitchen not wearing a facial hair cover. Observation on 5/12/19 at 9:20 AM, at the walk-in freezer, revealed an ice build-up that prevented the door from closing properly. The ice was approximately one (1) inch wide and three (3) inches in length. There was also ice and frost build-up on the left side of the door entering the freezer. The build-up was approximately two (2) inches thick and ran approximately 18-20 inches in length form the inside corner of the unit to approximately two-three inches into the doorway. The ice build-up was preventing the freezer door from completely closing. The freezer temperature was not affected. Additional observations in the freezer on 5/12/19 at 9:23 AM, revealed a 10 pound (lb.) box of sandwich steaks contaminated by the ice build-up located on the left side of the cooling unit that had dripped down onto the open box of meat. There was also an open box containing six 5.33-ounce frozen beef patty fritters which had freezer burn. The LS disposed of the boxes and contents at the time of the observation. On 5/12/19 at 1:40 PM, an interview with the DM was conducted. The DM confirmed he was not wearing a facial hair cover while in the food preparation area of the kitchen. The DM also confirmed LS and DA #1 were not wearing facial hair covers in the food preparation areas and should have been. The DM stated both staff members were educated on the wearing of facial hair restraints.",2020-09-01
97,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2019-05-15,924,E,0,1,0E0S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of the facility policy the facility failed to ensure all corridors had handrails firmly secured and affixed to the corridor walls. Observations conducted on 5/12/19, and 5/15/19, revealed 15 loose handrails in four (4) of four (4) corridors of the facility. Findings include: Review of the undated facility policy titled Monthly Handrail Inspection indicated the facility was responsible for ensuring handrails were inspected monthly. The policy stated, Check all hand rails in hallways. Make sure that hand rails are secure, painted, and in proper repair. Review of the facility's checklist titled, Monthly Hand Rail Inspection Checklist, dated 8/16/18 through 4/16/19, revealed inspections documented for the past nine (9) months identified no loose handrails in the facility. Random observations conducted during an initial tour of the facility on 5/12/19 at 8:45 AM, revealed loose handrails located in all four (4) corridors of the facility. During environmental observations, conducted with the Maintenance Director present, on 5/15/19 at 11:29 AM, 15 handrails were identified as loose or broken, or not securely affixed to the wall. The following handrails were identified and confirmed to be in disrepair by the Maintenance Director: 1. Loose handrail located in front foyer entrance on the left side. 2. Loose handrail located between room [ROOM NUMBER]/110. 3. Loose handrail located between room [ROOM NUMBER]/111. 4. Loose handrail located between room [ROOM NUMBER]/104. 5. Loose handrail located between room [ROOM NUMBER]/112. 6. Loose handrail located between room [ROOM NUMBER]/106. 7. Loose handrail located between room [ROOM NUMBER] and corridor doorway. 8. Loose handrail located next to room [ROOM NUMBER]. 9. Loose handrail located outside the main dining unit. 10. Loose handrail located outside room [ROOM NUMBER]. 11. Loose handrail located outside room [ROOM NUMBER]. 12. Loose handrail located outside room [ROOM NUMBER]. 13. Loose handrail located outside shower room on the 400 unit. 14. Loose handrail located outside room [ROOM NUMBER]. 15. Loose handrail located outside room [ROOM NUMBER]. An interview conducted with the Maintenance Director on 5/15/19 at 12:02 PM, revealed the Maintenance Director had not identified the loose handrails prior to the environmental tour and confirmed there were 15 handrails identified as loose or broken. The Maintenance Director had no explanation for why the handrails were not identified during the monthly handrail inspections during the last eight (8) months.",2020-09-01
98,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2019-06-12,755,D,1,0,WHQH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, policy review and staff and family interviews, the facility failed to obtain medications ordered for Resident #4 on admission. This was for one (1) of four (4) residents reviewed. Findings include: Review of the policy entitled, Ordering and Receiving Medications from Provider, dated 12/27/06, stated: Policy: Medications and related products are received from the provider pharmacy on a timely basis. Review of the Admission Record revealed the facility admitted Resident #4, on 05/15/19, with [DIAGNOSES REDACTED]. Review of the Admission/Five (5) day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/22/19, revealed Resident #4 scored 11 of 15 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. Review of the Medication Review Report for Resident #4, in (MONTH) 2019, revealed the following medications were ordered: 1 An order, dated 05/15/19, for [MEDICATION NAME] Patch weekly 10 MCG/HR (micrograms per hour) 1 (one) patch trans dermally in the morning every 7 (seven) days for pain. 2. An order, dated 05/15/19, for [MEDICATION NAME] 5 MG (Milligrams) by mouth one (1) time a day. 3. An order, dated 05/15/19, for [MEDICATION NAME] Solution Pen-Injector 100 Units/ML (Milliliter), Inject 35 units subcutaneously two (2) times a day. 4. An order, dated 05/15/19, for [MEDICATION NAME] tablet 10-325 MG give 1 (one) tablet by mouth every 8 (eight) hours as needed for pain for 5 (five days). 5. An order, dated 05/15/19, for [MEDICATION NAME] tablet 5 (five) M[NAME] Give 1 (one) tablet by mouth at bedtime. Review of the Pharmacy receipts and Medication Administration Sheets (MARs) for Resident #4 revealed the following: 1. The facility did not order the [MEDICATION NAME] Patches, but received a patch from the Responsible Person/Party (RP), and documented on the MAR it had been applied on 05/16/19. 2. The facility did not order the strength of the [MEDICATION NAME], but obtained the medication from the family, and documented on the MAR he received it 05/16/18. The strength was changed after this dose. 3. The facility did not receive the vial of [MEDICATION NAME] until 05/18/19, and the documentation on the MAR indicated it had been started on 05/17/19. The RP reported the facility had been using the Resident's Pen-Injector from home prior to receiving the vial. This was documented on the MAR beginning 05/15/19. 4. The facility received the [MEDICATION NAME] tablets on 05/17/19, and the first dose was administered on 05/18/19 per the Controlled Drug Record. The resident received Tylenol as needed, which was documented as effective. 5. The facility did not receive the [MEDICATION NAME] until 05/17/19, but the facility documented administration on 05/15/19. This was confirmed by the RP the resident's home medications were provided until the facility received the medication. An interview, on 06/12/19 at 11:10 AM, with the Director of Nursing (DON), revealed the medications were delivered from the out of town pharmacy, and the local back-up pharmacy never delivered any medications for Resident #4. Resident #4 had been admitted by the facility on 05/15/19 at 7:51 PM. An interview, on 06/12/19 at 11:20 AM, with Resident #4's RP, revealed when the resident was admitted , there were no medications ordered at that time, and she brought in the medications he had used at home when he arrived at the facility. She stated the facility used the home medications for several days before the ordered medications arrived.",2020-09-01
99,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2015-12-17,248,E,0,1,XQS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, record review and facility policy review, the facility failed to conduct resident activities as scheduled on the male locked unit for one (1) of two (2) locked dementia units. Findings included: A review of the facility Policy Statement revealed, Activity programs designed to meet the needs of each resident are available on a daily basis and Activities are scheduled 7 (seven) days a week and resident are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. A Review of the POS [REDACTED]. The facility had scheduled activity Whamo at 10:00 AM, Room Visit for 1:00 PM and Mourning Star Baptist Church at 2:00 PM for Wednesday, (MONTH) 16 . An observation on 12/15/15 from 8:30 AM until 10:30 AM of the male locked dementia unit revealed no activities were held. Observation during this time revealed the residents residing on the locked unit were seated in the day area with their heads down. The facility staff had a television tuned to cartoons. In an interview on 12/15/15 at 12:25 PM, Certified Nursing Assistant (CNA) #1 confirmed no activity had been held this morning and said, We used to have someone assigned to do activities but there has not been anyone lately. An observation on 12/15/15 at 2:30 PM revealed residents seated in the day area and a few residents walking in the hallway on the male locked unit. There was no activity (Bingo) held at this time as scheduled. In an interview on 12/15/15 at 2:50 PM Resident #9 said, We haven't played Bingo today; I enjoy it when we do play. An interview on 12/15/15 at 3:00 PM revealed CNA # 2 said the activities on the locked male unit were infrequent and no one was assigned to do activities on their unit. CNA # 2 said, It's like we have been forgotten. On 12/15/15 at 3:10 PM, an interview with the Activities Director revealed the activities department was short a staff member and due to the Christmas activities, the activities department had not been able to do the activities as scheduled on the calendar. Activity Director said occasionally a CNA would help but no certain CNA was assigned to assist. An observation on 12/16/15 at 10:25 AM revealed the residents on the male locked unit were not involved in any activities. The posted calendar revealed Whamo was scheduled for 10:00 AM on 12/16/15. In an interview on 12/16/15 at 12:40 PM, CNA #1 confirmed the activity scheduled for 10:00 AM (Whamo) had not been held on the male locked unit. An interview on 12/16/15 at 3:40 PM revealed Resident #24 said, If they played Bingo yesterday, I didn't get invited. An interview on 12/16/15 at 1:30 PM revealed Resident #24 said, There's not much to do back here; you know. I'd like to go to the casino sometimes. I don't get out much; Bingo sometimes but not much going on. I stay to myself but getting outside some would be nice. A review of the facility's face sheet revealed the facility admitted Resident #9 on 9/25/13. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/02/15 revealed Resident #9's Brief Interview for Mental Status (BIMS) score was 12 indicating Resident #24 had moderate cognitive impairment. A review of the facility's face sheet revealed the facility admitted Resident #24 on 11/10/14. Resident #24's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/16/15 revealed Resident #24's Brief Interview for Mental Status (BIMS) score was 13 indicating Resident #24 had no cognitive impairment.",2020-09-01
100,THE PILLARS OF BILOXI,255093,2279 ATKINSON ROAD,BILOXI,MS,39531,2015-12-17,252,D,0,1,XQS711,"Based on observation and staff interview, the facility failed to create a homelike atmosphere on the male locked unit for one (1) of five (5) halls observed. Findings included: Observation on 12/15/15 at 12:25 PM revealed the male locked dementia unit had blank walls on both hallways with no homelike decor on the unit. Observation on 12/16/15 at 3:40 PM revealed rooms 106, 107, 108, 110, 111, 113, 116, 117, 118, 119, 120, 122, 123 lacked evidence of residents' personal preferences and homelike decorations. Rooms 101 and 102 were occupied during the observation. An observation, during initial tour on 12/14/15 at 10:55 AM, revealed Rooms 101 and 102 shared bathroom had peeling non-slip strips and the wall was cracked and buckled at the door . Observation of shared bathroom for Rooms 111 and 112 revealed cracked and broken sheet rock wall near the door. An interview on 12/16/15 at 3:40 PM Account Manager and Housekeeping Supervisor confirmed the above observations. Housekeeping Supervisor said, I'm paying attention now; after comparing this (East male locked unit) with the women's locked unit, this place has no pictures or anything; nothing like the other units.",2020-09-01