rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2018-01-17,609,D,0,1,1JS611,"Based on record review and interview it was determined that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, an entity report of an abuse allegation was not submitted to the State Survey Agency until 48 hours after the incident occurred. Findings include: On 1/17/18 the facility abuse reports were reviewed. Review of the Abuse Report UT 287 of a resident to resident altercation revealed the date of the incident as 11/27/17 and the initial report was sent to the State Survey Agency on 11/29/17. On 1/17/18 at 11:36 AM an interview was conducted with the facility Social Worker (SW). The SW stated that she was responsible for sending in the entity report of an abuse allegation to the State Survey Agency. The SW stated that the initial report had to be reported in 24 hours if no serious bodily injury and within 2 hours if serious bodily injury. The SW confirmed that the report UT 287 was late and greater than 24 hours.",2020-09-01
2,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2018-01-17,676,E,0,1,1JS611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined the facility did not give the appropriate services to maintain or improve the resident's activities of daily living for 5 of 30 sample residents. Specifically, residents did not receive assistance with eating. Resident identifiers: 7, 11, 36, 54 and 56. Findings include: 1. Resident 36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/9/18, the noon meal service was observed on the Special Needs Unit (SNU). Resident 36 was served his meal at 12:07 PM. Resident 36 was not cued to eat until 12:17 PM at which time resident 36 consumed his first bite of food. Resident 36's medical record was reviewed on 1/16/18. On 11/14/17, the facility staff completed an annual Minimum Data Set (MDS) Assessment. The facility staff assessed resident 36 as needing extensive assistance with a one person physical assist when eating meals. The facility staff developed a nutritional care plan with documented goals of, no wt (weight) loss and Will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx (signs or symptoms) of malnutrition through review date. One of the interventions developed to achieve the goals included Provide assistance or cueing with meals as needed. 2. Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/10/18, the breakfast meal service was observed on the SNU. Resident 56 was served her meal at 8:03 AM. Resident 56 was not cued or assisted to eat until 8:21 AM at which time resident 56 consumed his first bite of food. Resident 56's medical record was reviewed on 1/11/18. On 11/30/17, the facility staff completed a quarterly MDS Assessment. The facility staff assessed resident 56 as needing extensive assistance with a one person physical assist when eating meals. The facility staff developed a nutritional care plan with documented goals of, Will have no significant weight change thru (sic) next review and Will tolerate diet texture w/o (without) signs of aspiration through next review. One of the interventions developed to achieve the goals included, Provide set-up, supervision, cues and assistance as needed with meals and snacks. 3. Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/9/18 at 11:58 AM, an observation was made of resident 11 in the dining room. Resident 11 was observed to be assisted with eating at 12:35 PM by the Restorative Nurses Aide (RNA). (Note: Resident 11 waited 37 minutes for assistance with eating.) On 1/10/18 at 8:02 AM, an observation was made of resident 11 in the dining room. Resident 11 was observed be served her breakfast meal at 8:02 AM. Resident 11 was assisted by the facility Registered Dietitian (RD) at 8:28 AM. (Note: Resident 11 waited 26 minutes for assistance with eating.) Resident 11's medical record was reviewed on 1/11/18. A quarterly MDS dated [DATE] revealed that resident 11 required supervision with oversight, encouragement, or cueing set up help only. A nutrition care plan dated 8/9/17 revealed a Focus of Has nutritional problems or potential nutritional problem r/t (related to) low BMI (Body Mass Index). Requires mech (mechanical) altered diet. Increased needs r/t repletion. 8/9/17 significant undesired wt (weight) loss. A goal developed was, Will maintain adequate nutritional status as evidenced by maintaining weight without further wt loss no s/sx of malnutrition through review date. An intervention developed was, Provide assistance or cueing with meals as needed. On 1/17/18 at 7:57 AM, an interview was conducted with Certified Nurse Assistant (CNA) 5. CNA 5 stated that resident 11 required assistance with eating. CNA 5 stated that resident 11 refuses at times but resident will respond to verbal cueing for eating. On 1/17/18 at 9:00 AM, an interview was conducted with the RD. The RD stated that resident 11 needed to be assisted with eating. The RD stated that resident 11 should not wait over 20 minutes for assistance with eating. 4. Resident 54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/9/18 at 11:58 AM, an observation was made of resident 54 in the dining room. Resident 54 was assisted with her lunch meal at 12:19 PM by Registered Nurse (RN) 3. RN 3 was observed to verbally cue resident 54 with eating. (Note: Resident 54 waited 21 minutes for assistance with eating.) On 1/10/18 at 8:06 AM, an observation was made of resident 54 in the dining room. Resident 54 was observed to take a bite out of a dry piece of toast. Resident 54 was observed to put her thumb into her cereal and licked it several times. Resident 54 was observed to have her breakfast plate placed about 6 inches in front of her. At 8:20 AM, an observation was made of a staff member placing a spoon in resident 54's cereal. Resident 54 was not observed to be assisted or cued for 14 minutes after her meal was delivered. An admission MDS dated [DATE] revealed that resident 54 required 1 person supervision, oversight, encouragement or cueing with eating. A care plan dated 11/22/17 and updated on 12/8/17 revealed, (Resident 54) is at risk for has (sic) nutritional problems r/t Dementia with behavioral disturbance. One of the goals developed was, Will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition through review date. An intervention developed was, Provide assistance or cueing with meals as needed. On 1/11/18 at 2:42 PM, an interview was conducted with CNA 8 and Licensed Practical Nurse (LPN) 3. CNA 8 and LPN 3 stated that resident 54 required verbal cueing with eating. CNA 8 and LPN 3 stated that resident 54 refused to be fed and then not eat if a bite was offered. CNA 8 and LPN 3 stated that resident 54 will eat when verbally cued or when silverware was placed into resident 54's hand. On 1/16/18 at 12:44 PM, an interview was conducted with the RD. The RD stated that resident 54 needed verbal cueing. The RD stated that residents needed to be cued or provided assistance when their meals were served. 5. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 1/9/18 the following observations were made during lunch service. a. 12:09 PM: Resident 7 was served her meal. A CNA was observed to cut resident 7's food for her and cue her to eat. b. 12:14 PM: Resident 7 was observed to have one bite of food and then look around the room. c. 12:28 PM - 12:32 PM: Resident 7 was observed to have eight more bites of food. Resident 7 was not observed to be cued to eat again during the meal. On 1/10/18 from 7:47 AM to 8:47 AM, during breakfast service, the following observations were made. a. Resident 7 was observed to be pushing her toast around on her plate with her fork. b. 8:27 AM: A CNA was observed to offer to cut resident 7's toast for her. Resident 7 refused. Resident 7 was observed to consume a bite of her eggs and drink her milk. Resident 7 was not observed to be cued to eat again during the meal. On 1/11/18 from 7:45 AM to 8:31 AM, during breakfast service, the following observations were made: a. 7:45 AM: Resident 7 was sitting in her wheelchair in the dining room. b. 8:12 AM: Resident 7 was served a plate of scrambled eggs, hash browns, toast, hot cereal and a strawberry mighty shake. c. 8:20 AM: Resident 7 was sitting at the table with her left arm propped up on the wheelchair arm. Resident 7's head was leaned up against her hand. Resident 7 had not received cueing or assistance with eating. d. 8:24 AM: Resident 7 was cued by a tablemate, followed by a CNA to eat her breakfast. The CNA handed a strawberry mighty shake to resident 7 to drink. On 1/17/18, a review of resident 7's medical record was completed. Resident 7's most recent weight on 12/21/17 was 99 pounds. Resident 7's BMI was 15.3. Resident 7's care plan for nutrition revealed that resident 7 had increased needs to support weight gain. Resident 7's interventions for weight gain included, to cue resident 7 and provide assistance as needed during meals. On 1/17/18 at 9:00 AM, CNA 2 was interviewed. CNA 2 stated that resident 7 needs continuous encouragement throughout meals to eat. CNA 2 stated that resident 7 usually ate more at breakfast. CNA 2 stated that when resident 7 did not eat much of her meal she would be offered an alternate, usually resident 7 was more accepting of desserts and sweets. On 1/17/18 at 9:05 AM, CNA 1 was interviewed. CNA 1 stated that most of the time resident 7 ate really well and other times she just needed encouragement.",2020-09-01
3,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2018-01-17,677,D,0,1,1JS611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility did not ensure that 1 of 30 sample residents who were unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, a resident's nails were not clipped. Resident identifier: 79. Findings include: Resident 79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/9/18 at 2:37 PM, resident 79's nails were observed to be an estimated 1/4 inch long, pointed, and unkempt. On 1/16/18 at 10:01 AM, resident 79's nails were observed to still be long and unkempt. On 1/16/18 at 10:35 AM, Certified Nurse Assistant (CNA) 1 stated that resident 79 nails were cut during his showers. CNA 1 stated that it would be documented on the shower logs. CNA 1 stated that sometimes resident 79 was combative with cares but that he should still get his nails cut as needed. Resident 79's shower skin assessments were reviewed and revealed the following information: a. On 1/2/18, resident 79's CNA documented that resident 79's nails were not clipped and did not need clipping. b. On 1/9/18, resident 79's CNA documented that resident 79's nails were not clipped and did not need clipping. c. On 1/12/18, resident 79's CNA documented that resident 79's refused his shower and that his nails were not clipped and did not need clipping. On 1/16/18 at 12:58 PM, the Director of Nursing (DON) was interviewed. The DON stated that residents who need their nails cut should have them cut has needed during showers. The DON stated that she had in-serviced CNA staff on nail care and on ensuring that shower sheets are filled out completely and properly. The DON stated that she would look at resident 79's nails. On 1/16/18 at 2:10 PM, the DON was re-interviewed. The DON stated that she asked the staff to cut resident 79's nails after she saw them. The DON stated that resident 79's nails should have been cut sooner.",2020-09-01
4,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2018-01-17,684,D,0,1,1JS611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, residents were observed to be coughing during meals and were not assessed for swallowing difficulties. In addition, a resident with a physicians order for thickened liquids was observed to receive regular liquids. Resident identifiers: 65 and 66. Findings include: 1. Resident 66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/11/18 at 12:28 PM, an observation was made of resident 66 in the Secure Needs Unit (SNU) dining room. Resident 66 was observed to be coughing. Resident 66 was observed to be served thin liquid beverages. Resident 66 was observed to cough when she drank the beverages. Resident 66's medical record was reviewed on 1/11/18. A nutrition care plan dated 9/6/17 and updated 1/5/18 revealed, (Resident 66) has nutritional problems or potential nutritional problems r/t (related to) edentulous, requires mechanically altered diet. One of the goals developed was, Tolerate diet texture. An intervention developed was, Monitor/document/report to MD (medical doctor) prn (as needed) for s/sx (signs and symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Resident 66's progress notes revealed the following entries: a. 1/2/18 at 1:57 PM, Res (resident) currently showing s/sx of influenza. MD notified. Obtain influenza A and B culture. b. 1/2/18 at 2:23 PM, .MD notified of lab results. No new orders at this time. c. 1/3/18 at 6:00 AM, Result received for flu swab on 1/2, negative for Influenza at this time. MD notified. [MEDICATION NAME] ordered for all. d. 1/5/18 at 2:27 PM, Registered Dietitian Note .Resident with flu s/s n (nausea)/v (vomiting), fever lab negative influenza. Meal intake poor (less than) 50% s/s flu effecting intake. FORTIFIED MECHANICAL SOFT texture, THIN LIQUIDS consistency, decaf coffee, may use sippy cups to drink liquids for resident comfort. e. 1/6/18 at 11:58 PM, Resident continues on [MEDICATION NAME]. no s/sx adverse effects. coughing continues. On 1/11/18 at approximately 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that there were no residents with symptoms of the flu in the SNU. The DON stated that she talked with the Speech Language Pathologist (SLP) and the SLP did not have concerns about residents coughing during the meal on 1/11/18. On 1/17/18 at 11:15 AM, an interview was conducted with the facility SLP. The SLP stated that on 1/11/18 the DON talked to her about resident 66 coughing during meals. The SLP stated that nursing staff informed her on 1/12/18 that resident 66 was coughing and liquid was slipping out of her lips. The SLP stated that she assessed resident 66 and determined resident 66 required nectar thickened liquids. The SLP stated that resident 66 refused, so a risk verses benefits form was signed by resident 66. The form titled Risks/Benefits Notification was signed on 1/12/18 by resident 66 after the observation of resident coughing with beverages in the dining room. 2. Resident 65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/10/18, the breakfast meal service was observed on the SNU. Resident 65 was served her breakfast at 8:00 AM. Resident 65 was served a mechanical soft diet with thin liquids. Resident 65 coughed through out the meal service including after drinking fluids and after bites of food. On 1/11/18, resident 65 was observed during the noon meal service on the SNU. Resident 65 coughed multiple times and stated to the SLP. Resident 65 stated the the SLP, I choked on something that I ate. The SLP removed resident 65's thin liquids and provided resident 65 with nectar thick liquids. Resident 65's medical record was reviewed on 1/11/18. On 12/1/17 a nutritional care plan was developed for resident 65. The facility staff documented a focus area of, .has nutritional problem or potential nutritional problem r/t (related to) Dementia with lewy bodies, [MEDICAL CONDITION], anxiety disorder, DM (diabetes mellitus) (type) II, Stage 3 [MEDICAL CONDITIONS](hypertension), [MEDICAL CONDITION], (and) mood disorder. The goal developed was, Will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition through review date. One of the interventions developed to achieve the goal was, Monitor/document/report to MD PRN for s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. An interview was conducted with Certified Nurse Assistant (CNA) 6 on 1/11/18 at approximately 8:15 AM. CNA 6 was asked if she reported that resident 65 was coughing throughout the meal service on 1/10/18. CNA 6 stated that she did not report that resident 65 was coughing. An interview was conducted with Licensed Practical Nurse (LPN) 3 on 1/11/8 at approximately 8:20 AM. LPN 3 was asked if she received a report of resident 65 coughing through out the meal service on 1/10/18. LPN 3 stated that she had not received a report of resident 65 coughing during the meal service. On 1/11/18, the SLP completed an swallowing evaluation on resident 65. The SLP document that resident 63 had dysphagia during the oral phase and dysphagia during the oropharyngeal phase. On 1/16/18 at 8:05 AM, resident 65 was observed during the breakfast meal service. Resident 65 was served a glass of milk and a glass of water that had not been thickened. An interview was conducted with CNA 3 on 1/16/18 at 8:10 AM related to resident 65's thin liquids. CNA 3 stated that resident 65 was not on thickened liquids. An interview was conducted with LPN 1 on 1/16/18 at 8:13 AM related to resident 65's thin liquids. LPN 1 stated that resident 65 was to be served nectar thickened liquids. An interview was conducted with CNA 4 on 1/16/18 at 8:15 AM. CNA 4 had a glass of water and a glass of milk in her right hand that was covered with a burgundy napkin. When questioned, CNA 4 stated that she had removed the thin liquids that she had served to resident 65. CNA 4 stated that she did not know that resident 65 was to receive nectar thickened liquids. An interview was conducted with the DON on 1/16/18 at 8:30 AM, The DON stated that staff assisting in the dining rooms were to report episodes of coughing during the meals to the charge nurse.",2020-09-01
5,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2018-01-17,689,D,0,1,1JS611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined for 2 of 30 sampled residents that the facility did not ensure that the resident's environment remains as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a fall from occurring and care planned interventions were not implemented. Additionally, another resident had sustained [MEDICAL CONDITION] smoking a cigarette. Resident identifiers 64 and 66. Findings include: 1. Resident 64 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 1/09/18 at 2:15 PM, an observation was made of the resident's room. A fall mat was observed next to bed and the bed was in the lowest position. Resident 64 was observed laying on her left lateral side facing the wall. On 1/10/18 at 11:25 AM, an observation was made of resident 64's room. Resident 64 was not located in her room and this surveyor was unable to locate resident 64 anywhere on the locked unit. On 1/10/18 at 11:30 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 64 propelled herself around the unit in her wheelchair. RN 1 stated she might have gone to an appointment. When asked who would inform him of her departure from the unit, RN 1 stated transportation would let him know. An observation was then made of RN 1 and Certified Nurse Assistant (CNA) 5 conducting a room to room search of the locked unit to locate resident 64. An observation was then made of RN 1 calling the transportation staff to inquire about resident 64's location. Activities Staff (AS) 1 located resident 64 in room [ROOM NUMBER] on the floor. Resident 64 was observed to be located in front of her wheelchair on the floor laying on her left side with her left cheek resting on the ground. RN 1 was observed to assess resident 64 by performing range of motion (ROM) flexion/extension exercise of resident 64's right lower extremity from the knee joint down. Resident 64 was observed to be non-verbal at this time and eyes were open. An observation was made of RN 1 and CNA 3 assisting resident 64 into a sitting position and then transferring resident 64 into a wheelchair. RN 1 was then observed to assess ROM flexion/extension of bilateral lower and upper extremities, pupil response testing, and then squeeze resident 64's hips. An observation was made of resident 64's posture in the chair as forward leaning and resident 64 was unable to hold herself up independently. RN 1 was observed to hold resident 64 in place in wheelchair during the transfer back to her room. Resident 64's wheelchair was observed not to have a pressure alarm on it. Resident 64 was transferred back to bed with a 2 person assist by RN 1 and CNA 3 by a pivot transfer method. Resident 64 was observed to be unable to bear weight on her left lower extremity and the knee was bent with the leg drawn upward. CNA 3 stated that resident 64 can normally stand with assistance for incontinence brief changes and that her current inability to stand was a change from her baseline. Resident 64's footwear was observed to be socks with no shoes, no slip socks not worn. RN 1 noted to exit the room leaving CNA 3 alone to provide cares. On 1/10/18 at 11:47 AM, an observation was made of the Medical Doctor (MD) assessing resident 64 while lying in bed on the left lateral side. The MD stated that when resident 64 was in pain she was able to vocalize it by crying out, and that resident 64 had a history of [REDACTED]. The MD assessed resident 64 and stated, The resident is guarding her left side and grimaced in pain when left hip was touched and I don't like that she is this quiet. CNA 3 and the MD exited resident 64's room. Resident 64's bed was elevated to hip level with the left side against the wall. No staff were present in the room for approximately 2-3 minutes. On 1/10/18 at 11:55 AM, an observation was made of CNA 3 positioning resident 64 in bed to provide incontinence care. While positioning resident 64 on her back the resident was observed to yell owe multiple times. Resident 64 was observed to resist laying fully supine but attempted to reposition multiple times to the left lateral side. An observation was made of CNA 3 rolling resident 64 to her right lateral side. Resident 64 was agitated and repeatedly stated owe during the position change. Upon completion of the incontinence care CNA 3 was observed to clip the call light to resident 64's sheets next to her head. CNA 3 stated that resident 64 was unable to use the call light to call for help. The bed was placed in the lowest position and the floor mat was observed next to the bed. RN 1 returned to resident 64's room and stated that the MD had ordered an X-ray of resident 64's left hip and left lower extremity. On 1/10/18 resident 64's medical records was reviewed. Review of the incident reports for falls revealed the following: a. On 11/22/17, resident 64 was found on the floor in another resident's room. A small abrasion was noted to the resident's nose. Assessment indicated that resident 64 had a [MEDICAL CONDITION] and it contributed to the fall from her wheelchair. Resident 64 continued to have two more [MEDICAL CONDITION] and Emergency Medical Services (EMS) was called to transport the resident to the hospital. b. On 12/21/17, resident 64 sustained an unwitnessed fall from her wheelchair when the chair became lodged in the door frame to the bathroom. Immediate actions taken was to assess for injuries and neurological checks were started. c. On 1/7/18, resident 64 sustained an unwitnessed fall from her wheelchair and was found on the floor in her room. Immediate actions taken was to assess for injuries and neurological checks were started. Review of the care plan revealed a focus area of at risk for falls related to weakness, cognitive impairment, MS, [MEDICAL CONDITION] disorder. The following interventions was noted on the care plan: a. On 7/23/17 an intervention of Be sure the call light is within reach, family request to keep call light out of reach-Resident does not remember to use call light d/t (due to) impaired cognition-Staff to anticipate resident needs was initiated. b. On 11/22/17 status [REDACTED]. c. On 12/15/17 an intervention of Uses chair/bed electronic alarm. Ensure the device is in place as needed was initiated. d. On 12/21/17 status [REDACTED]. e. On 1/10/18 status [REDACTED]. Review of progress notes revealed a therapy note on 1/10/18 stating, This therapist assessed wheelchair cushion for positioning and comfort identification of need for additional pressure relief to coccyx area and potential need for increased anterior support for proper pelvic positioning, Vicair vector cushion modified with removal of air cells from posterior chambers and added air cells to anterior chambers for increased pressure offloading of coccyx and increased support under distal thighs for pelvic stability. No other documentation could be found to indicate that the wheelchair cushion had been assessed prior to this date. On 1/14/18 the following progress note was added, Late Entry: Note Text: Upon review of re-admission note on 1/5/18, this nurse contacted (name of spouse) regarding his statement that he has found (resident 64) with the call light around her neck. (spouse): I walked into (resident 64's) room on 12/30/17 and she was laying in bed and had her call light wrapped around her neck. I took it off her and I went and told the nurse. The nurse came in and looked at (resident 64) and she was fine. I know she grabs at everything so I don't want her to accidentally hurt herself. I am not concerned that she is trying to harm herself. Notified MD, DON (Director of Nursing), Administrator, SW (Social Work). Advised (spouse's name) that call light will be removed from her immediate reach. Removed call light near resident bed. Resident does not use call light due to cognition. Staff will continue to anticipate needs and monitor frequently. Intervention: SW evaluated resident. Call light was removed from resident immediate reach. Staff was educated regarding reporting incidences in a timely matter. Review of the X-ray report for the left tibia/fibula and left femur on 1/10/18 revealed an impression of no bony abnormalities noted. On 1/11/18 at 7:55 AM an observation was made of resident 64 up in the wheelchair propelling herself down hallway, tab alarm present. Resident 64 was observed to be wearing the same socks as yesterday s/p fall, not no slip socks and no shoes was present. On 1/11/18 at at 8:50 AM an interview was conducted with the DON. The DON stated that resident 64 was currently not wearing non skid socks. This surveyor informed the DON that the resident had the same socks on as yesterday status [REDACTED]. On 1/11/18 at 2:25 PM a repeat interview was conducted with the DON. The DON stated that resident 64 did not have her chair alarm present during the fall on 1/10/18 and that it was removed because the resident likes to lift herself up purposely to hear the alarm sound. The DON was aware that the intervention was still care planned. No further information was provided. On 1/16/18 at 8:22 AM an interview was conducted with the DON. The DON stated that the resident's care plan still states chair alarm as they are effective and needed with her [MEDICAL CONDITION] disorder to alert staff. The DON further stated that she is in the process of working with staff to improve their assessment skills and she in-serviced staff over the weekend on pressure alarm placement and utilizing the Kardex to check the plan of care for residents. 2. Resident 66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/10/18 at 3:25 PM, an observation was made of resident 66. Resident 66 was observed to reside in the Secured Unit (SNU). Resident 66 was observed to be walking through the hall with black sweat pants. Resident 66's sweat pants hand small holes on the right thigh and knee area. Resident 66's medical record was reviewed on 1/11/18. A care plan dated 6/14/17 and updated on 12/19/17 revealed, (Resident 66) has potential for injury r/t(related to) Smoking, history of non-compliance with smoking policy. The goals developed were, Will have no injuries related to smoking and Will be compliant with smoking protocols and individual smoking plan until next review. Interventions developed on 6/14/17 were, Observe smoking while in designated area and supervision while smoking. Resident 66's progress notes revealed the following entries: a. 6/9/17 at 8:07 PM, Weekly note/skin check: Resident is alert and oriented x 2-3 (person, place and time). Able to verbalize needs and concerns to staff.Burns noted on R (right) finger from smoking. b. 6/13/17 at 8:22 PM, .Burns noted on R finger from smoking. c. 7/12/17 at 2:38 PM, Saw resident walking down the hall towards outside. I gave another resident a pain pill. I went outside to see if she was really outside. I caught the resident outside picking up cigarette butts by the cigarette holder. I told the resident she cannot go outside without a staff member. I asked her what she was doing and she replied looking for a cigarette to smoke. I educated her on scheduled smoke breaks and that she cannot be outside at this time since it is not a smoke break. I returned the resident to her room to try to get more sleep. d. 7/16/17 at 11:56 PM, This evening around 2345 (11:45 PM) a staff member observed the resident outside with a lighter. The nurse and aide approached the resident and asked her about the lighter and the resident denied having one in her room or outside. Resident will continue to be monitored when she goes outside, DON (Director of Nursing) will be notified also. e. 7/19/17 1:51 PM, Skin/Wound Note Note Text: 1. R 3rd finger superior, burn: 0.7cm (centimeter) L (length) x 1.3cmW (width) x 0cmD (diameter). 2. R 3rd finger distal, burn: 0.4cmL x 0.4cmW x 0cmD. 4. R 4th finger, burn: 0.4cmL x 0.4cmW x 0cmD.Resident educated on dressing care. f. 7/19/17 at 11:27 PM, Tonight another resident told me that they saw (resident 66) with a lighter and that's why she has been trying to get butts out of the holder. When I asked (resident 66) if she had a lighter she told me she did not. I asked her if I could look around her room and she said I could. After looking around residents room I found a pink lighter. Resident said it was '(name removed)'. I explained to her that she is not allowed to have lighters in her room. I told her I would hold on to in the nurses cart with her name on it. Resident understands she is not allowed to have lighters in her room and knows that the nurse has her lighter. g. 7/21/17 at 1:07 PM, IDT reviewed an incident that occurred on 7/19. Resident noted to [MEDICAL CONDITION] her right 3rd AND 4TH FINGERS. Resident stated that while she is smoking the cherry falls off [MEDICAL CONDITION] finger. However resident is on supervised smoking and this has not been witnessed. Resident has been witnessed collecting cigarette butts and a lighter was found in her room. It appears resident has been smoking the cigarette butts while unattended.a friend was notified as well as NP (Nurse Practitioner). Resident educated on the risk of smoking the butts and the risk of burning herself, she allowed staff to search her room where the lighter was found and she agreed to keep it at the nurses station.[MEDICAL CONDITION] treated per MD orders. h. 7/24/17 at 4:00 AM, Nurse found resident outside in employee parking smoking a cigarette. When asked what resident was doing she stated she was smoking. Nurse asked where resident got the cigarette and resident said she had it in her purse. Nurse and CNA asked resident to give the remaining cigarettes to the nurse and resident stated she didn't have any more. Resident showed nurse and CNA that her purse was empty of cigarettes. i. 8/2/17 at 6:14 PM, R 3rd finger distal, burn: 1.3cmL x 0.8cmW x 0.1cmD. Wound bed red moist granulation. Peri-wound macerated from bandage being wet, no drainage noted. No odor present. Resident denies pain r/t wound. Dressing applied per order. Resident educated on dressing care. j. 8/3/17 at 6:02 PM, SS (Social Services) contacted Weber County Ombudsman regarding resident and smoking policy. Ombudsman stated that he spoke with resident and resident expressed understanding of smoking policy and smoking safely. No other concerns noted at this time. k. 8/8/17 at 11:15 PM, Reddened area to left knee. No blistering noted and resident denies any pain or discomfort to area. Educated resident on not getting hot beverages. Instead I gave her the tea packets from the med room. No signs or symptoms of infection. Earlier the aids informed me that she was outside smoking at 1630 (4:30 PM) before scheduled smoke break and unsupervised. When the aid asked where she got the cigarette from she replied 'a stranger'. Educated the resident on the smoking policy. Will continue to monitor her. l. 8/17/17 at 1:35 PM, Res was noted to be outside digging through the cigarette butt container and getting the cigarette butts out and eating them. Staff educated resident on smoking policy and not eating butts. Res communicated understanding. Res placed remaining butts that were in her hand back into the container. Res was also found to have a lighter this AM, res re-directed and gave the lighter to the staff. m. 12/6/17 at 6:35 PM, Blisters found on resident's left knee smaller than the size of a dime all together. There is a hole in her sweats from a cigarette burn. Res was wearing apron while smoking during shift. Blisters are still closed and res states no pain. n. 12/7/17 at 9:05 AM, IDT Late Entry: Note Text: Resident reviewed in IDT following incident in which resident was noted to have blisters on her leg with burn marks through her pants. Staff educated that resident must be supervised at all times during smoke breaks and that staff must ensure proper placement of smoking apron to prevent injury. Resident 66's smoking evaluation revealed the following: a. 6/14/17, Resident attends supervised smoking sessions. She is unsafe to smoke independently. b. 8/7/17, Resident has cigarette holder that employee puts cigarette in the holder for resident. Employee is lighting cigarette for resident. Resident correctly and safely used cigarette holder. c. 8/31/17, Resident has been on a floor where she could smoke when ever she wanted unsupervised but recently has moved to the lock down memory unit-resident falls asleep while smoking and drops cigarette ashes on her clothes can not unsupervised - discussed with resident the safety issues and the need to be supervised while smoking and the smoke times the floor goes out. On 1/6/18 at 12:10 PM, an interview was conducted with the DON. The DON stated that the unit manager that looked into the burn incident on 12/6/17. The DON stated that the unit manager did not work at the facility. The DON stated that she did not know how resident 66 [MEDICAL CONDITION] she was supervised during smoking. On 1/11/18 at 2:19 PM, a follow up interview was conducted with the DON. The DON stated that she thought resident 66's smoking apron moved to the side and was burned by the ash. The DON stated that staff were to watch her and make sure the cigarette did not burn down to resident 66's fingers. The DON further stated that resident 66 was supplied with an extender for her cigarette. The DON further stated that all residents on the D hall were supervised during smoking. The DON stated that staff monitored the blisters to see what happened and CNA's should have watched her closer when smoking to prevent the apron from sliding. The DON stated that resident 66 resided on the C hall and was found smoking unsupervised. The DON stated that resident 66 was moved to the D hall for increased supervision. On 1/11/18 at 3:12 PM, a follow up interview was conducted with the DON. The DON stated that there were no investigation into [MEDICAL CONDITION] 66 sustained on 6/9/17, 7/19/17, 8/2/17 and 12/6/17.",2020-09-01
6,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2018-01-17,692,D,0,1,1JS611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible. Specifically, there were 2 resident's that lost weight and nutritional interventions developed were not implemented. Resident identifiers: 11 and 66. Findings include: 1. Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/9/18 at 12:45 PM, resident 11 was observed in the Secured Unit (SNU) dining room. Resident 11 was observed to ask the Restorative Nurses Aide (RNA) to take her back to her room. Resident 11 was observed to eat 1 bite of food from her plate. RNA confirmed resident 11 ate 1 bite of food. On 1/10/18 at 8:02 AM, resident 11 was observed in the SNU dining room. Resident 11 was observed to drink coffee with milk. Resident 11 was observed to not be served nutritional supplement drink. Resident 11 did not eat more than 25 percent of her meal. On 1/17/18 at 7:57 AM, an observation was made of resident 11 in the SNU dining room. Resident 11 was observed to pour milk into her coffee. Resident 11 was not observed to be provided a nutritional supplement drink. On 1/17/18 at 8:00 AM, an interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated that nutritional supplement drinks were served with resident's meal and not when coffee was served. Resident 11's medical record was reviewed on 1/11/18. Resident 11's weights documented in the electronic medical record were: (Note: All weights were in pounds.) a. 7/5/17 97.25 b. 8/2/17 95.25 c. 9/5/17 90.25 d. 10/5/17 90.75 e. 11/8/17 90.5 f. 12/8/17 90.5 e. 12/29/17 89.0 g. 1/5/18 89.5 h. 1/12/18 86.0 Resident 11's nutrition progress notes revealed the following: a. 10/20/17 at 4:15 PM, Registered Dietitian Note: Resident back to 90.75#, same as 10/5 wt (weight). Interventions are in place; intake remains low. Will check with nursing intake of coffee with health shake. b. 12/21/17 at 11:26, Registered Dietitian Note: wt 12/21 88.8 loss 2.6% x 1 wk (week), 11/24 91 loss 2.4% x 1 month. Non significant wt loss x 1 month. Wt loss undesired d/t BMI (body mass index) 14.3 underweight.Diet: FORTIFIED PUREED texture, THIN LIQUIDS consistency, EXTRA SAUCES TO MEATS & MASHED POTATOES; to 4 oz health shake mixed with 4 oz milk heated in mug TID (three times a day) with meals. c. 1/10/18 at 11:00 AM, Registered Dietitian Note: resident requests coffee Q (every) meal consumes health shake best if mixed with coffee vs (verses) milk clarify order. Coffee mixed with 1/2&1/2 TID snack remains appropriate. d. 1/11/18 at 11:27 AM, Registered Dietitian Note Note. : wt 1/10 86.2 1/5 89.5 12/8 90.5 loss 3.7% x 1 wt, 4.8% x 1 month non significant wt loss. Wt loss undesired BMI 14.4 underweight. Resident with difficulty swallowing observation snack coughing/choking on liquids. Discussion with ST (Speech Therapist) resident refusing GI consult to r/o (rule out) restriction per ST recommendations. Multiple interventions in place to meet needs. Diet: FORTIFIED PUREED texture, THIN LIQUIDS consistency, EXTRA SAUCES TO MEATS & MASHED POTATOES; 4 oz heated health shake mixed with coffee in mug TID (three times a day) with meals. Snacks TID snack coffee mixed with 1/2&1/2.Resident has been accepting coffee with health shake d/t (due to) wt loss, increased calorie of health shake change snacks to coffee mixed with health shake. change med pass to TID. Resident declines table change to restorative will allow staff to feed at times. Weekly weights in place. RD (Registered Dietitian) to follow PRN (as needed). On 1/17/18 at 9:00 AM, an interview was conducted with the facility RD. The RD stated that resident 11 had weight loss. The RD stated that resident 11 had gastrointestinal issues but the family and resident 11 refused to consult with a specialist. The RD stated that resident 11 should have a nutritional supplement in her coffee three times a day. The RD stated she did not know why resident 11 was not provided the nutritional supplement. 2. Resident 66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/10/18 at 8:32 AM, an observation was made of a meal that had not been eaten in the dining room. There was a meal ticket with the tray that revealed it was resident 66's breakfast meal. The breakfast meal had not been touched. On 1/10/18 at 9:43 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 66 was at an appointment. RN stated that he was not sure if resident 66 ate but that he thought she had a yogurt prior to leaving for the appointment. A review of resident 66's weights were as following in the electronic medical record: (Note: All weights were in pounds.) a. 1/12/18 140.0 b. 1/5/18 140.4 c. 12/8/17 149.0 d. 11/8/17 156.0 e. 10/2/17 162.75 f. 9/14/17 159.75 g. 8/2/17 164.25 h. 7/5/17 163.75 Resident 66's nutritional care plan dated 9/6/17 revealed a focus of (Resident 66) has nutritional problems or potential nutritional problems r/t (related to) edentulous requires mechanically alter diet, likes to drink coffee, history skipping meals due to sleeping during the day. Nonsignificant weight loss x 3 months (and) 6 months, HTN, [MEDICAL CONDITION]. Resident desires wt loss to 135 (pounds). 1/5/18 significant wt loss. A few of the goals revealed, Will maintain adequate nutritional status as evidenced by no significant wt change no s/sx (signs or symptoms) of malnutrition through review date and resident to achieve wt loss at non significant rate to 135 (pounds). One intervention developed was, Provide, serve diet as ordered, Monitor intake and record q (every) meal. (Note: Resident 66 was not observed to eat her breakfast meal on 1/10/18 and resident had documented weight loss.) On 1/17/18 at 9:50 AM, an interview was conducted with the Dietary Manager (DM) and Cook 1. DM stated that if a resident had an appointment during a meal the nurse will notify dietary to provide a meal early or provide a sack meal. Cook 1 stated that she had not provided an early meal or sack meal for resident 11.",2020-09-01
7,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2018-01-17,697,D,0,1,1JS611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined for 1 of 30 sampled resident that the facility did not ensure that pain management was provided to residents who require such services. Specifically, a resident sustained [REDACTED]. Resident identifier 64. Findings include: Resident 64 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 1/10/18 at 11:30 AM, resident 64 was found on the floor in an unoccupied room. Resident 64 was observed to be located in front of her wheelchair on the floor laying on her left side with her left cheek resting on the ground. Registered Nurse (RN) 1 was observed to assess resident 64 by performing range of motion (ROM) flexion/extension exercise of resident 64's right lower extremity from the knee joint down. Resident 64 was observed to be non-verbal at this time and eyes were open. An observation was made of RN 1 and Certified Nurse Assistant (CNA) 3 assisting resident 64 into a sitting position and then transfer her into the wheelchair. RN 1 was then observed to assess ROM flexion/extension of bilateral lower and upper extremities, pupil response testing, and then squeeze resident 64's hips. An observation was made of resident 64's posture in the chair as forward leaning and resident 64 was unable to hold herself up independently. RN 1 was observed to hold resident 64 in place in wheelchair during the transfer back to her room. Resident 64 was transferred back to bed with a 2 person assist by RN 1 and CNA 3 by a pivot transfer method. Resident 64 was observed to be unable to bear weight on her left lower extremity and the knee was bent with the leg drawn upward. CNA 3 stated that resident 64 could normally stand with assistance for incontinence brief changes and that her current inability to stand was a change from her baseline. RN 1 noted to exit the room leaving CNA 3 alone to provide cares. On 1/10/18 at 11:47 AM, an observation was made of the Medical Doctor (MD) assessing resident 64 while lying in bed on the left lateral side. The MD stated that when resident 64 was in pain she was able to vocalize it by crying out, and that resident 64 had a history of [REDACTED]. The MD assessed resident 64 and stated, The resident is guarding her left side and grimaced in pain when her left hip was touched and I don't like that she is this quiet. At this time CNA 3 and the MD exited resident 64's room. On 1/10/18 at 11:55 AM, an observation was made of CNA 3 positioning resident 64 in bed to provide incontinence care. While positioning resident 64 on her back the resident was observed to yell owe multiple times. Resident 64 was observed to resist laying fully supine but attempted to reposition multiple times to the left lateral side. An observation was made of CNA 3 rolling resident 64 to her right lateral side while grabbing resident 64 on the left hip and left femur for positioning. Resident 64 was agitated and repeatedly stated owe during the position change. On 1/10/18 resident 64's medical records was reviewed. Review of the physician orders [REDACTED]. a. [MEDICATION NAME] Tablet 325 milligrams (mg), give 2 tablets via [DEVICE] (gastrostomy tube) every 4 hours as needed for mild pain. b. [MEDICATION NAME] Solution 250 mg/5 milliliter (ml), give 18 ml via [DEVICE] two times a day for pain. c. [MEDICATION NAME] Tablet 7.5-325 mg, give 1 tablet via [DEVICE] every 6 hours as needed for breakthrough pain. d. Monitor Level of pain every shift. Review of Medication Administration Record [REDACTED]. At 3:20 PM [MEDICATION NAME] 7.5-325 mg was administered with a numeric pain level of 5 documented. Review of care plan for pain revealed a focus of has chronic pain related to MS, pain to left knee, swelling, vascular malformation, pressure ulcer, depression, (and) decreased mobility. Interventions included the following: a. Administer [MEDICATION NAME] medication as per orders, give 1/2 hour before treatment or care. b. Monitor/record/report to Nurse any signs or symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing); Body (tense, rigid, rocking, curled up, thrashing). c. Pain assessment every shift. d. Report to Nurse any change in usual activity attendance patterns or refusal to attend activities relate to signs or symptoms or complaints of pain or discomfort. Review of nursing progress notes revealed the following: a. On 1/10/18 at 1:22 PM, Resident is Anxious/Agitation. Resident is Restless. and PAIN: Yes unable to assess Pnl (pain level) 5 - 1/10/18 at 17:46 (5:46 PM) Pain scale: PAINAD (Pain Assessment in Advanced Dementia) unable to assess pain medication, repositioning, dim lights. b. On 1/11/18 at 5:47 PM, LATE ENTRY 1/10/18 at 1500 (3:00 PM): resident appeared to be very restless. Resident repeatedly was calling out. Res (resident) kept grabbing at the side of her bed and appeared to be fidgeting. Res kept repeating the same phrase over and over. Res was unable to console or distract. Facial grimacing was noted. Res body appeared very tense and rigid. One of resident's hands were clenched. Out of baseline for resident. c. On 1/10/18 at 6:35 PM, Activities reported resident had fallen on the floor in room [ROOM NUMBER] on D hall. Upon assessment, res was found lying on L (left) side face to the floor. Res confused, not oriented to person, place, time, and situation. ROM (range of motion) WNL (within normal limits) to BUE (bilateral upper extremities) and BLE (bilateral lower extremities). Facial grimacing noted. Res appeared very restless and tense. Review of the neurological assessment on 1/10/18 revealed check marks in the column of response to pain starting at 11:45 AM and continued until 2:30 PM. On 1/10/18 at 3:10 PM an interview was conducted with RN 1. RN 1 stated that the check marks through the pain column on the neurological assessment indicated that the resident has pain and one of the PAINAD scale identifiers. RN 1 stated that the PAINAD score is used to assess pain in non-verbal residents such as resident 64. RN 1 stated resident 64 currently has a PAINAD score of 5 with the following identifiers: facial grimacing, tense, difficult to console, and occasional moan. It should be noted that resident 64 received her first dose of PRN (as needed) pain medication [MEDICATION NAME] after the surveyor inquired about pain assessments for non-verbal residents. On 1/11/18 at 1:55 PM a repeat interview was conducted with RN 1. RN 1 stated that no CNA reported that resident 64 was complaining of pain on 1/10/18 after her fall and during incontinence care. RN 1 further stated that with resident 64 he would be careful with weight bearing, ROM, and movement of the affected extremity until confirmation of no injury was obtained from the X-ray. On 1/11/18 at 2:25 PM an interview was conducted with the Director of Nursing (DON). The DON stated that her expectation of staff after a resident has sustained a fall was to do a head to toe assessment and to start neurological assessments per protocol. The DON further stated that resident 64 had arthritis in her left knee that caused her chronic pain. On 1/16/18 at 8:32 AM a repeat interview was conducted with the DON. The DON stated that her expectation of staff was to assess the resident every time complaints of pain were expressed, especially since resident 64 was non-verbal and could be communicating other needs this way. The DON stated that the staff were expected to assess a resident for pain post fall and that the CNA's should be communicating the complaints of pain to the RN so the RN can assess the resident.",2020-09-01
8,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2018-01-17,744,D,0,1,1JS611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined for 1 of 30 sampled residents that the facility did not provide the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for a resident diagnosed with [REDACTED]. Resident identifier 68. Findings include: Resident 68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/09/18 at 10:43 AM an observation was made of Certified Nursing Assistant (CNA) 3 providing incontinence care to resident 68. An observation was made of resident 68 hitting and biting CNA 3 during the incontinence care and nearly striking CNA 3's face. CNA 3 was observed to continue with the care until finished. Resident 68 was observed to be agitated and combative the entire time. An immediate interview was conducted with CNA 3. CNA 3 stated, The resident gets agitated a lot. CNA 3 stated that the nurse usually gave resident 68 medication to calm her down, and further stated that nothing else calms resident 68 down. On 1/9/18, resident 68's electronic medical records was reviewed. Review of resident 68's orders revealed the following: a. [MEDICATION NAME] ([MEDICATION NAME]) tablet 0.5 milligram (mg) by mouth two times a day. b. Non-Pharmalogical interventions done: 1. Redirection, 2. Speak to/Approach in a calm manner, 3. Reposition, 4. Offer snacks/fluid/milk, 5. Assess for pain, 6. Provide a quiet environment, 7. Encourage to express feelings, 8. Take to activities, 9. Provide reassurance ([MEDICATION NAME]) every shift. Review of the progress note on 6/25/17 revealed, Resident was kicking and grabbing at staff to get their attention. Staff attempted redirection, giving snacks, and giving her an activity, resident continued to come to staff and kick and grab. Review of care plan revealed the following focus areas and interventions: a. Has impaired cognitive function/dementia with an intervention of refer to MY WAY plan of care located in resident's room. b. Has Altered behavior pattern and ineffective individual coping as evidenced by (AEB) easily startled by sounds or touch within environment, agitation, anxiety, tearful, combativeness related to Dementia Alzheimer's late stage. Interventions include; allow rest/nap between meals as desired by resident to reduce combative and anxious behavior, Ensure resident can see you before you touch or move her, provide a quiet environment as much as possible, explain cares prior to starting cares in unhurried manner, may need to go for a walk in wheelchair when anxious to calm down, prefer her door closed when resting in bed, monitor/record/report to Medical Doctor labile mood or agitation, and See MY WAY form to implement individualized request from resident daily which includes sleep cycle, Activities of Daily Living (ADL's) and dining preference. Review of resident 68's MY WAY plan revealed the following preferences: a. Bathing every other day and shower with a wash rag. Order: Head (face), Chest, Arms, Back, Groin, Legs, Feet b. Toileting preference is to give me privacy c. Dining/Eating preference are: I feed myself with both hands and I drink liquids throughout the day d. Dressing preference are sleep in pajamas or night gown, I stand and sit while I dress, and I don't wear a bra. e. Schedule is to sleep at 7:00 PM f. Assistive devices are a wheel chair g. Hobbies are I would rather do individual activities. Review of Interdisciplinary Team (IDT) notes revealed no documentation to show behaviors of hitting, pinching and biting were discussed. On 1/16/18 at 2:40 PM, an interview was conducted with CNA 7. CNA 7 stated that the resident was feisty and hits and pinches when transfers or incontinence care are being provided. CNA 7 stated that she usually stops the activity that is upsetting the resident and comes back later to finish with the care. On 1/16/18 at 2:45 PM, a repeat interview was conducted with CNA 3. CNA 3 stated that the resident gets agitated and hits, slaps, pinches and bites. CNA 3 stated that the behaviors were towards staff and other residents. CNA 3 stated that the interventions to calm her down were to lay her back down in bed and the nurse will give her medication. CNA 3 again stated that no other interventions calm resident 68 down. On 1/16/18 at 2:55 PM an interview was conducted with CNA 4. CNA 4 stated that resident 68 hits staff and other residents and that I thinks she (resident 68) likes to hit people. CNA 4 stated that the interventions to calm the resident down were back massages, hand massages and laying her down in bed. 01/17/18 at 7:42 AM interview was conducted with the Corporate Resource Nurse (CRN) 1. CRN 1 stated that the MY WAY plan was something that the previous corporation implemented and was not currently an intervention. CRN 1 stated that the MY WAY plan was essentially a preference care sheet based on an interview conducted with the family upon admission. On 1/17/18 at 8:00 AM a repeat interview was conducted with CRN 1. CRN 1 stated that dementia training was provided annually and upon hire through a computer based training and was scheduled for 1/25/18. CRN 1 further stated that the facility also utilized the MY WAY plan with those staff members who were aware of it and that the plan has additional training with it, but knows that the new Director of Nursing (DON) had not provided the training because she was unaware of the plan. CRN 1 was informed of the observation between resident 68 and CNA 3. CRN 1 stated that she would immediately provide education to CNA 3.",2020-09-01
9,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2018-01-17,760,D,0,1,1JS611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that residents were not free of significant medication errors for 2 of 30 sample residents. Specifically, a licensed nurse administered prescribed medications to the wrong residents twice. Resident identifiers: 65 and 73. Findings include: 1. Resident 65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 65's medical record was reviewed on 1/11/18. Upon admission to the facility, orders were to administer the following medications to resident 65: a. [MEDICATION NAME] 100 mg (milligrams) daily; b. [MEDICATION NAME] 40 mg daily; c. [MEDICATION NAME] 60 mg daily; d. Vitamin D3 units daily; e. [MEDICATION NAME] 0.25 mg twice a day; and f. Potassium Chloride 30 meq (milliequivalents) twice a day; On 12/6/17 at 11:58 AM, Registered Nurse (RN) 2 documented in a progress note, Nurse came on shift with two new residents. One resident came to the nurses station and asked for her medications. Nurse asked for her name and resident did not reply. CNA (Certified Nurse Assistant) stated her name and nurse as resident 'are you _____?' resident replied yes. Res (Resident) was given wrong morning medications. Nurse assessed resident and her vitals are BP (blood pressure) 118/70 HR (heart rate) 71 Temp (temperature) 98.1 RR (respiration rate) 20. MD (Medical Doctor) assess Resident stated that resident was acting normal and that he had no issues or concerns. Approx. (approximately) 45 minutes after taking medications resident threw up. (Note: Resident 63 was given resident 73's ordered medications.) 2. Resident 73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 73's medical record was reviewed on 1/11/18. Upon admission to the facility, orders were to administer the following medications to resident 73: a. Donepezil 10 mg daily; b. [MEDICATION NAME] 125 mcg (micrograms) daily; c. [MEDICATION NAME] 28 mg daily; d. Potassium Chloride 20 meq daily; and e. Apixaban 5 mg twice a day; On 12/6/17 at 12:01 AM, RN 2 documented in a progress note, Nurse came on shift with two new residents. Other Res (resident) was identified by CNA to nurse. Nurse asked for this residents name and resident did not reply. Nurse asked resident 'are you ______?' resident replied yes. Nurse checked for name band and none noted. Res was given wrong morning medications. Nurse assessed resident and her vitals are BP 129/76 HR 88 Temp 98.1 RR 16. MD Resident stated that resident was acting normal and that he had no issues or concerns. (Note: Resident 73 was given resident 65's ordered medications.) An interview was conducted with the Director of Nursing (DON) related to the medication errors. The DON stated that RN 2 worked once a week and was not familiar with resident 65 and 73. The DON stated that an investigation into the medication errors were conducted. The DON stated that RN 2 was educated related to to the 10 rights of medication administration.",2020-09-01
10,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2018-01-17,801,D,0,1,1JS611,"Based on interview and record review it was determined that the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not a employee a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Findings include: On 1/9/18 at 8:14 AM, an interview was conducted with the facility DM. The DM stated that the RD billed the facility for 59 hours during the month of (MONTH) (YEAR). The DM stated that the RD was not full time. On 1/17/18 at 10:30 AM, the Administrator provided an e-mail dated 10/9/17 from the facility RD. The e-mail revealed that the DM qualified . to take the 90 hour nutrition training for pathway III for CDM (Certified Dietary Manager). On 1/17/18 at 10:30 AM, an interview was conducted with the Administrator. The Administrator stated that the DM was not currently enrolled in a dietary course to obtain the qualifications. The Administrator stated that he thought the requirements were not in effect until 11/28/18.",2020-09-01
11,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2018-01-17,802,E,0,1,1JS611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility did not employ sufficient staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and [DIAGNOSES REDACTED]. Specifically, meals were observed to be served late in the secured unit. Resident identifiers: 66 and 73. Findings include: 1. The following Meal Service Times were posted in the dining room: A & D Halls Breakfast 7:45 AM Lunch 12:00 PM Dinner 5:45 PM 2. On 1/10/18 at 8:00 AM, an observation was made in the secured/D hall dining room. Resident 73 was observed to be drinking other residents beverages at her table prior to her meal being served. Resident 73 was served at 8:02 AM. Resident 73 was observed to not take other residents beverages after the breakfast meal was served. (Note: The breakfast meal was served 15 minutes after the posted meal time.) 3. On 1/16/18 at 8:05 AM, observations were made in the secured/D hall dining room. A resident was yelling out, resident 73 was observed to stand up and walk around the dining room. Resident 73 was observed to not sit to eat until 8:21 AM when her breakfast meal was served. Resident 66 was observed to lean to the side in her booth. Resident 66 was observed to be moving sideways multiple times until her food was served. Another resident was observed yelling out until his food was served. (Note: The first tray was served 31 minutes after the posted meal time.) 4. On 1/17/18 at 10:49 AM, an interview was conducted with the Dietary Manager (DM) and Cook 1. The DM stated that she did not know why the breakfast meals were served late. Cook 1 stated that the food left the kitchen at 7:40 AM. Cook 1 stated that the C hall was served before the D hall on 1/16/18. 5. On 1/17/18 at 9:00 AM, an interview was conducted with the Registered Dietitian (RD). The RD stated that she noticed that the breakfast meal was served late on 1/16/18. The RD stated that she did not know why the meal was late. The RD further stated it was important for residents in the secured unit to have meals on time.",2020-09-01
12,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2018-01-17,812,E,0,1,1JS611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, taco seasoning and dried herbs were open to the air; the oven doors were soiled with a white substance; the ice machine drain was not 2 inches above the floor drain; the ice cream refrigerator was soiled; and the dish machine chemicals had a small opening in the tube from the dish machine. Findings include: 1. On 1/9/18 at 8:14 AM, an initial tour was conducted of the facility kitchen. The following observations were made: a. There was taco seasoning, ground [MEDICATION NAME], and whole tarragon leaves open to air. b. The oven doors were soiled with a white substance. c. The ice machine had a drain that was not 2 inches above the floor drain. d. The ice cream refrigerator was soiled on the outside. e. The dish machine chemicals labeled Ultra San had a small opening that the tube from the dish machine was in. On 1/16/18 at 12:44 PM, an interview was conducted with the Registered Dietitian (RD). The RD confirmed the above observations. 2. On 1/17/18 at 10:49 AM, a follow up interview observation was made of the facility kitchen. a. The ice cream refrigerator was soiled. b. The oven doors were soiled with a white substance. c. The side of the stove was soiled with white substance. An interview was immediately conducted with the Dietary Manager (DM). The DM stated that the white substance on the oven doors was between the glass. The DM confirmed that the ice cream refrigerator was soiled. The DM stated she did not know why the Ultra San did not have the small opening covered.",2020-09-01
13,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2018-01-17,880,E,0,1,1JS611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determine for 5 of 30 sampled residents that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a resident was observed to handle the beverage carafes in the dining room and drink from other resident's glasses, a resident was observed to wipe her nose on the dining room table cloths, a residents tube feeding tubing connector was contaminated and reconnected to the resident without being changed, and multiple residents were observed to have a productive cough during dining in the dining room. Resident identifiers: 11, 54, 64, 68, and 73. Findings include: 1. Resident 68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/9/18 at 12:07 PM and at 12:25 PM, an observation was made of resident 68 wiping her nose on the dining room table cloth during the lunch meal. No observation was made of the dining room table linens being changed. Resident 68 was also observed to have a wet productive cough during the lunch meal. On 1/09/18 at 10:43 AM, resident 68 was heard moaning and coughing from hallway. On 1/10/18 at 8:22 AM, an observation was made of resident 68 wiping her nose on the dining room table cloth during the breakfast meal. No observation was made of the dining room table linens being changed. Resident 68 was also observed to have a wet productive cough during the breakfast meal. On 1/9/18, resident 68's electronic medical records was reviewed. Review of the nursing progress notes on 1/2/18 stated, Note Text: Res (Resident) started on [MEDICATION NAME] 75 mg (milligrams) BID (twice a day) x (times) 5 days per MD (Medical Doctor) request for [MEDICATION NAME]. Review of the labs revealed no documentation to indicate that resident 68 was tested for influenza. Review of the temperature summary record revealed the following: a. On 1/3/18 at 10:47 AM, resident 68 had a temperature of 99.1 F (degrees Fahrenheit) b. On 1/7/18 at 10:58 AM, resident 68 had a temperature of 97.7 F c. On 1/11/18 at 1:59 PM, resident 68 had a temperature of 97.7 F Review of the physician orders [REDACTED]. On 1/16/18 10:02 AM, an interview was conducted with the facility Administrator. The Administrator stated that he had his staff change out the table linens as needed and that there was no set schedule. No additional information was provided when he was informed that resident 73 was touching all the beverage carafes during dining. 2. Resident 64 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 1/09/18 at 2:12 PM, an observation was made of resident 64 lying in bed on the left lateral side with the head of the bed elevated 30 degrees. Resident 64's tube feed was running at 145 milliliters per hour (ml/hr.), and was dated 1/8/17 at 2000 (8:00 PM). The tube feed tubing was observed to be disconnected from resident 64 and on the bed sheets behind the resident spilling the formula behind her. On 1/09/18 at 2:52 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the tube feed was not connected when she went into the residents room at 2:24 PM. LPN 1 stated that it was underneath the resident and she moved it while the linens were being changed. On 1/09/18 at 3:28 PM, observed resident 64 to be in bed with the tube feed hooked back up to resident 64's gastrostomy tube. The tubing was observed to be dated 1/8/17 at 2000 (8:00 PM). On 1/16/18 at 12:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the tube feeding bag and tubing was to be changed every 24 hours and as needed if the connector tip was contaminated. The DON further stated that the staff should have changed the bag and tubing after the connector was found unhooked and underneath the resident. 3. Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/10/18 at 8:08 AM, an observation was made of resident 11 coughing in the dining room. At 8:19 AM, an observation was made of resident 11 coughing. Resident 11 was observed to continue to cough throughout the dining observation. On 1/10/18 at 11:02 AM, an observation was made of resident 11 coughing through the lunch meal. Resident 11 was not observed to cover her mouth. Resident 11 stated to staff that she did not feel good. On 1/16/18 at 8:05 AM, an observation was made of resident 11. Resident 11 was coughing throughout the breakfast meal. Resident 11 was not observed to cover her mouth when coughing. Resident 11's medical record was reviewed on 1/11/18. Resident 11's temperature documented in the medical record were: (Note: All temperatures were in degrees Fahrenheit.) a. 1/10/18 99.9 b. 1/9/18 97.9 c. 1/7/18 97.0 d. 1/6/18 98.8 e. 1/5/18 100.0 Resident 11's progress notes revealed the following: a. On 1/3/18 at 6:00 AM, Result received from flu swab on 1/2/18, positive for Influenza [NAME] MD notified of result. [MEDICATION NAME] ordered. b. On 1/6/18 at 11:54 PM, Resident continues [MEDICATION NAME] tx (treatment). poor appetite this shift. supplements offered and refused. c. On 1/6/18 at 6:44 PM, Resident continues on [MEDICATION NAME] tol (tolerated) well no issue or side effects, will continue to monitor for s/s (signs and symptoms) of further flu VS (Vital Signs) WNL (Within Normal Limits). (Note: Resident had a documented temperature on 98.8.) d. On 1/8/18 at 3:11 PM, FLU: Res has finished her [MEDICATION NAME] regimen, no signs of adverse effects noted. Res is still having a lot of lethargy, WCTM (Will Continue To Monitor). On 1/11/18 at 12:04 PM, an interview was conducted with the DON. The DON stated the nurse obtained resident 11's vital signs and listened to her lungs. The DON stated that resident 11 was fine. The DON stated that a fever was 100.3 degrees Fahrenheit but if a resident had a temperature of 99.9 then staff should intervene. 4. Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 1/10/18 at 12:36 PM, an observation was made of resident 54 in the dining room. Resident 54 was observed to be coughing during the dining meal. Resident 54 was not observed to cover her mouth when coughing. Resident 54 was observed to cough on other residents meals. On 1/16/18 at 8:20 AM, an observation was made of resident 54 in the dining room. Resident 54 was observed to cough during the meal. Resident 54 was not observed to cover her mouth when coughing. Resident 54 was observed to cough on other residents meals. Resident 54's medical record was reviewed on 1/11/18. Resident 54's progress note dated 1/2/18 revealed, Res started on [MEDICATION NAME] 75 mg BID x 5 days per MD request for [MEDICATION NAME]. 5. On 1/10/18 at 9:08 AM, an observation was made of resident 73 in the secured unit dining room. Resident 73 was observed to touch and pick up carafes with milk and juice. Resident 73 was observed to touch the carafes and replacing the carafes into a container with ice. On 1/10/18 at 9:18 AM, an interview was conducted with Dietary Aide 1. DA 1 stated that the beverages in the carafes were used for 3 days and then discarded. DA 1 stated that the carafes were not washed after each meal.",2020-09-01
14,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2019-02-21,684,D,0,1,R8D511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 of 41 sample residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, one resident who had a tube feeding was not positioned appropriately to receive the feeding per the plan of care and one resident who had pressure ulcers did not have her heels floated per the plan of care. Resident identifiers: 9 and 57. Findings include: 1. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 10:01 AM, an observation was made of resident 9 as she was lying in bed. Resident 9's bed was observed to be at approximately a 20 degree angle. Resident 9 was observed to have slid down in bed, lying flat with her chin resting on her chest. Resident 9's tube feeding was observed to be running. The care plan dated 2/4/19 for resident 9 revealed that resident 9 had a care area of (Resident 9) requires tube feeding r/t (related to) coma. The goal for resident 9 included Will remain free of side effects or complications related to tube feeding through review date. Feeding tube insertions site will be free of s/sx (signs and symptoms) of infection through the review date. Will maintain adequate nutritional and hydration status aeb (as evidenced by) weight stable, no s/sx of malnutrition or dehydration through review date. The interventions for resident 9 included HOB (head of bed) elevated 45 degrees during and thirty minutes after tube feed Elevate HOB at least 30-45 degrees at all times during feeding On 2/21/19 at 8:32 AM, an observation was made of resident 9 as she was lying in bed. Resident 9 was observed to be lying flat. Resident 9's tube feeding was observed to be running. On 2/21/19 at 8:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that she was unaware of any special positioning needs for resident 9. On 2/21/19 at 8:44 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that resident 9 should be positioned at 45 degrees, she cannot be flat, she could aspirate. RN 5 stated that the Licensed Practical Nurse (LPN) was just in the room and had just completed the dressing change for resident 9 and should have repositioned her back to 45 degrees. On 2/21/19 at 8:51 AM, an interview was conducted with the facility Director of Nursing (DON) and the facility Corporate Resource Nurse (CRN). The facility DON stated that resident 9 should be at least 30 degrees, not flat. The CRN stated that she will do education right now. 2. Resident 57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/20/19 at 8:41 AM, an observation was made of resident 57's wound care to the pressure ulcer on the top of resident 57's right foot. A foam pad was observed to be under resident 57's knees and calves. An observation was made of resident 57's bilateral heels to be resting on the mattress. physician's orders [REDACTED]. A care plan dated 12/24/18 revealed that resident 57 had a care area of (Resident 57) had pressure ulcer or potential for pressure ulcer development r/t unstageable pressure ulcer right heel and right dorsum foot, impaired mobility, incontinence, hx (history) [MEDICAL CONDITION] [MEDICAL CONDITION]. The goal for resident 57 included Pressure ulcer will show signs of healing and remain free from infection by/through review date. The interventions for resident 57 included Administer treatments as ordered and monitor for effectiveness Float heels. Follow facility policies/protocols for the prevention/treatment of [REDACTED].>On 2/20/19 at 8:41 AM, an interview was conducted with RN 3. RN 3 stated that obviously we have to talk with the CNAs again as the foam was not placed where it needed to be and you saw her heels on the mattress. RN 3 stated that resident 57 was very compromised and that her heels needed to be floated to prevent the unstageable pressure ulcer that had recently healed, from opening up again.",2020-09-01
15,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2019-02-21,688,D,0,1,R8D511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, 1 of 41 sample residents did not receive appropriate range of motion services and experienced a decline in range of motion. Resident identifier: 17. Findings include: Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 9:45 AM, an observation was made of resident 17. Resident 17 was observed laying in a tilt and space wheelchair, and had contractures to the left upper area of his body. On 2/20/19, resident 17's care plans were reviewed. Resident 17's care plan related to his physical mobility, dated 9/25/17 and revised 1/5/18, documented the following information: a. Focus: (Resident 17) has limited physical mobility r/t (related to) Contracture to L wrist (left), hand, shoulder, hips, knees, and right ankle . b. Goal: Will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date . c. Interventions: MOBILITY: Is totally dependent on staff for locomotion . MOBILITY: Uses Tilt & (and) Space w/c (wheelchair) for locomotion . Monitor/document/report to MD (Medical Director) PRN (as needed) s/sx (signs or symptoms) of immobility: contracture forming or worsening, thrombus formation, skin-breakdown, fall related injury . Provide gentle range of motion as tolerated with daily care . On 2/21/19 at 8:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she was not sure what the restorative therapy staff did for resident 17's contractures. On 2/21/19 at 8:09 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she did not know what kind of range of motion services resident 17 received. On 2/21/19 at 8:54 AM, a follow up interview was conducted with RN 1. RN 1 stated she spoke with the Director of Nursing (DON), and resident 17 received gentle range of motion with cares as tolerated in accordance with his care plan. RN 1 further stated she did not know where the range of motion sessions were documented. On 2/21/19 at 9:17 AM, an interview was conducted with the Restorative Aide (RA). The RA stated resident 17 was not participating in the restorative program at present, and she did know when resident 17 last received restorative program services. The RA further stated she did not know where the range of motion sessions were documented. In addition, the RA stated that the therapy staff typically reviewed residents and referred them to the restorative program. On 2/21/19 at 9:21 AM, an interview was conducted with RN 2. RN 2 stated she performed active and passive range of motion exercises with resident 17, but he was not participating in the restorative program. RN 2 further stated there was no documentation of the exercises performed with resident 17. On 2/21/19 at 9:54 AM, an interview was conducted with the Occupational Therapist (OT). The OT stated a contracture screen was performed for resident 17 the week prior and it was noted that he had less range of motion in his wrist. The OT further stated therapy services were determined based on screenings that were conducted a couple times per year, and residents were discharged from therapy services to the restorative program. In addition, the OT stated she did not know when resident 17 had last received therapy services. On 2/21/19 at 10:02 AM, an interview was conducted with the MDS (Minimum Data Set) Coordinator. The MDS Coordinator stated she also coordinated the restorative program, and all restorative sessions were documented in the electronic medical record as Restorative Nursing notes. The MDS Coordinator further stated she did not know when resident 17 last participated in the restorative program. On 2/21/19, resident 17's Restorative Nursing notes were reviewed. The notes documented the following information: 9/26/17 . Reviewed in RNA (restorative nursing assistance) Meeting: D/C (discharge) RNA PROM (passive range of motion) program. Nursing to provide PROM through pain-free available range w/ (with) cares. (Note: This note was the sole Restorative Nursing note documented in resident 17's medical record.) On 2/21/19 at 10:02 AM, an interview was conducted with the Director of Therapy Rehabilitation (DOR). The DOR stated contracture and range of motion screenings were conducted on a quarterly basis, and resident 17 was receiving therapy services at present related to a little bit of change in his right wrist. The DOR further stated the therapy department trained restorative nursing aides to address residents' specific needs. On 2/21/19 at 10:40 AM, a follow up interview was conducted with the DOR. The DOR stated resident 17 received physical therapy services in (MONTH) (YEAR), and there was no decline in resident 17's range of motion noted at that time. The DOR further stated resident 17 was not referred to the restorative program following physical therapy services, but staff were trained on the floor in accordance with resident 17's needs. On 2/21/19 at 11:51 AM, an interview was conducted with the DON. The DON stated resident 17 did not receive restorative program services, but staff were trained on the floor to perform exercises with him as part of daily cares. The DON further stated any range of motion services were not documented aside from resident 17's care plan and associated kardex.",2020-09-01
16,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2019-02-21,710,E,0,1,R8D511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 1 of 41 sample residents, that the facility did not ensure that each resident's medical care was supervised by a physician. Specifically, a resident's Primary Care Physician (PCP) did not respond to a [MEDICAL CONDITION] meeting recommendation for approximately two and a half months. Findings include: Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/21/19, a review of resident 21's medical record was completed. Resident 1's [MEDICAL CONDITION] Quarterly Review dated 8/13/18 revealed that resident 21 was on 12.5 milligrams (mg) [MEDICATION NAME] twice daily (BID) and that the committee recommended to discontinue the [MEDICATION NAME]. Resident 21's PCP signed the review in agreement on 10/23/18. On 11/13/18, a facility nurse signed and 'noted' the physician's agreement. (Note: The PCP did not respond to the [MEDICAL CONDITION] Committee's recommendation from 8/13/18 through 10/23/18. After the PCP agreed to the recommendation it was 3 weeks before the facility noted the agreement and discontinued resident 21's [MEDICATION NAME].) A review of resident 21's progress notes revealed the following information. a. On 8/15/18 at 11:41 AM, Resident reviewed in [MEDICAL CONDITION] meeting. Resident currently taking Duloxetine 30 mg Q (every) AM, tracking negative statements, 4 noted. Also taking [MEDICATION NAME] 12.5 mg BID, tracking hallucinations, 7 noted. Recommended to d/c (discontinue) [MEDICATION NAME]. Re-eval (evaluate) in 90 days. MD (Medical Director) agrees with recommendation at this time. Notified daughter of change. b. On 11/14/18 at 3:11 PM, clarification: reviewed in [MEDICAL CONDITION] meeting 8/13/18, just received response to recommendation on 11/12/18. c. On 11/13/18 at 3:11 PM, N.O. (new order) d/c (discontinue) [MEDICATION NAME] (QUEtiapine [MEDICATION NAME]) Give 12.5 mg by mouth two times a day for mood disorder DISCONTINUE Date/Reason: 11/13/2018 15:10 (3:10 PM) reviewed in [MEDICAL CONDITION] meeting 8/13/18: d/c [MEDICATION NAME]. d. On 11/13/18 at 3:11 PM, Resident reviewed in [MEDICAL CONDITION] meeting 8/13/18: taking [MEDICATION NAME] 12.5 mg BID for mood disorder, tracking hallucinations, 5 during the day/2 at night. Taking Duloxetine 30 mg Q AM (every morning) for depression tracking tearfulness, 4 during the day/0 at night. Recommended Actions: d/c [MEDICATION NAME]. MD agreed and signed off to discontinue [MEDICATION NAME]. On 2/21/19 at 8:24 AM, the Director of Nursing (DON) was interviewed. The DON stated that the MD was at all [MEDICAL CONDITION] meetings, however resident 21's PCP was not the MD. The DON stated that the recommendations were sent to resident 21's PCP, however he did not respond for over 2 months. The DON stated that she was not the DON at that time, however she would have expected the former DON to have followed up on the recommendation with resident 21's PCP.",2020-09-01
17,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2019-02-21,761,E,0,1,R8D511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, opened multi-dose vials of insulin were not labeled with open dates and opened multi-dose vials of insulin were expired and still available for use. Additionally, an insulin pen with instructions to keep refrigerated was found on a medication cart. Findings include: On 2/20/19 at 7:30 AM, an observation was made of a medication cart on the A hall. Observations were made of the following insulin medications: [REDACTED] a. [MEDICATION NAME] 100 unit/ml (milliliter) vial opened with an expiration date of 2/16/18. b. [MEDICATION NAME] R 100 unit/ml vial opened with no open date. c. Humulog 100 unit/ml vial opened with no open date. On 2/20/19 at 7:35 AM, an interview was conducted with Registered Nurse (RN) 3 on the A hall. RN 3 confirmed the above insulin medication were opened and expired or had no open date on the vials. RN 3 stated insulin was to be discarded 28 days after it was opened. RN 3 stated the night shift audited the cart for expired medications. RN 3 stated she would discard then above mentioned insulin vials. On 2/20/19 at 7:45 AM, an observation was made of a medication cart on the C hall. Observations were made of the following insulin medications: [REDACTED] a. [MEDICATION NAME] 100 unit/ml (3 ml) insulin pen, unopened and not refrigerated. Instructions were attached to the pen to keep refrigerated. b. [MEDICATION NAME] 100 unit/ml vial opened and dated 1/15/19. c. [MEDICATION NAME] R 100 unit/ml vial, opened, with no open date. d. [MEDICATION NAME] 100 unit/ml vial, opened and dated 1/12/19. On 2/20/19 at 7:50 AM, an interview was conducted with RN 4 on the C hall. RN 4 stated the Unit Manager audited the medications carts. RN 4 stated, a company audited the medication carts as well. RN 4 confirmed the insulin pen should have been refrigerated until it was opened. RN 4 confirmed the above mentioned insulin vials were expired or opened with no opened date recorded. RN 4 stated she would discard the above mentioned insulin medications. On 2/20/19 at 10:00 AM, The Director of Nursing (DON) was interviewed. The DON stated expired medications were to be discarded. The DON stated a consultant pharmacist and a floor nurse audited the medications carts weekly, as well as the Unit Managers.",2020-09-01
18,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2019-02-21,810,E,0,1,R8D511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide special eating equipment and utensils for residents who need them. Specifically, 1 of 41 sample residents did not receive a weighted spoon in accordance with physician's orders [REDACTED]. Findings include: Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 12:15 PM, an observation was made of resident 28 during lunch service. Resident 28 was observed to scoop ground meat onto her fork and attempted to bring the fork to her mouth. Resident 28 was observed to visibly shake and struggled to guide the fork to her mouth, and the ground meat fell off of her fork and onto her lap. Resident 28 was then observed to use her hands to eat the remainder of the meal. (Note: Resident 28's silverware was not weighted.) On 2/20/19 at 12:16 PM, a follow up observation was made of resident 28 during lunch service. Resident 28 was observed to cut a piece of pie into smaller pieces using a spoon. Resident 28 was then observed to eat each bite of pie and a bowl of diced fruit with her hands. (Note: Resident 28's silverware was not weighted.) On 2/20/19, resident 28's physician orders [REDACTED]. a. Order: FORTIFIED diet, MECHANICAL SOFT - Chopped texture, HONEY THICK consistency b. Directions: scoop plate, SIPPY CUP, POSITION FULLY UP RIGHT, x (extra) -SAUCE/GRAVY TO MEAT WHEN APPLICABLE. Finger food as able. AM (morning) snack coffee & (and) health shake. WEIGHTED SPOON. Health shake TID (three times per day) with meals. Cheeseburger w/ (with) fries Q (every) L (lunch) & D (dinner) non ground hamburge (sic) On 2/20/19, resident 28's Registered Dietitian notes were reviewed. The notes documented the following information: a. 10/4/18; Diet: FORTIFIED MECHANICAL SOFT - Chopped texture, HONEY THICK consistency, scoop plate, SIPPY CUP, POSITION FULLY UPRIGHT . WEIGHTED SPOON . b. 3/15/18; Diet: FORTIFIED MECHANICAL SOFT, HONEY THICK consistency, PLATE GUARD, SIPPY CUP, POSITION FULLY UPRIGHT . WEIGHTED SPOON . c. 3/1/18; Diet: FORTIFIED MECHANICAL SOFT, HONEY THICK consistency, PLATE GUARD, SIPPY CUP, POSITION FULLY UPRIGHT . WEIGHTED SPOON . On 2/21/19 at 8:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated residents who had [MEDICAL CONDITIONS], or experienced a stroke were examples of those who may have required weighted silverware. CNA 1 further stated she had no idea if resident 28 required weighted silverware and would have notified the nurse, speech therapist, restorative aide, and dietitian if she noticed resident 28 struggling to eat her meal. On 2/21/19 at 10:12 AM, an interview was conducted with the Registered Dietitian (RD). The RD stated weighted silverware was typically prescribed for residents whose hands shake. The RD further stated resident 28 should have received a weighted spoon with her meals, and confirmed that the physician order [REDACTED]. On 2/21/19 at 11:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 28 should have received weighted silverware and it was missed by the staff.",2020-09-01
19,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2019-02-21,812,E,0,1,R8D511,"Based on observation, record review, and interview, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service and safety. Specifically, food items were covered in frost, food items were not labeled and dated properly, food items were beyond the use by date, and steam table trays were unsanitary. Findings include: On 2/19/19 at 8:20 AM, the following observations were made during initial tour of the facility kitchen. a. In the walk-in refrigerator, i. A squeeze bottle of what appeared to be ranch lacked a date, food label and had residue around the bottle opening. Dietary Staff Member (DSM) 1 was interviewed. DSM 1 disposed of the ranch. ii. A 5 pound container of cottage cheese was open and lacking an open date. iii. A 5 pound container of sour cream was open and lacking an open dated. DSM 1 stated that both the sour cream and cottage cheese should have an open dated. DSM 1 stated that he was uncertain how long they could be kept once open but would say 30 days and could find out. iv. A carton of liquid eggs was open without an open dated. DSM 1 stated that the eggs are usually used within the day they are opened and he was surprised to see an opened container in the refrigerator. b. In the walk-in freezer, i. A box of lo mein was being stored on the floor. ii. Hot dogs stored in a zip-top bag had considerable frost. c. In the pan storage and dry food storage areas, there was considerable dirt and debris on the floors. d. In the reach in freezer, i. Deli chicken stored in a zip-top bag had considerable frost. ii. Black beans stored in a zip-top bag had considerable frost. iii. Red beans stored in a zip-top bag had considerable frost. On 2/19/19 at 11:50 AM, during lunch service an observation was made of the steam trays. The steam table had four tray wells. The first tray well did not contain water, food splatter and residue was observed on the interior sides and bottom of the tray. DSM 2 was observed to place the plate bases in this steam tray. The other three steam trays contained water, there was visible residue on the interior sides of the steam trays, the water appeared unclean, and there was a coating on the bottom of the steam trays. At the end of the meals service, DSM 2 was observed to empty the steam trays, but was not observed to clean or sanitize the trays. On 2/21/19 at 9:35 AM, the above concerns were addressed with the Dietary Manager (DM). The DM stated that she was new to the building and they have been working on cleaning and improving the kitchen. The DM stated that she was still learning the guidelines for how long to keep some food items, but would keep food items for three days after being opened unless she heard otherwise. The DM stated that the steam tables should be cleaned every night, or after meal service if there was a spill. The DM observed the steam tables and stated that it appeared this had not been getting done. This surveyor observed that they steam trays appeared to be in the same condition as observed on 2/19/19.",2020-09-01
20,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2019-02-21,880,E,1,1,R8D511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, it was determined that the facility failed to establish and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff did not place signage outside a resident's room identifying the need for transmission-based precautions, two resident rooms had signage that had fallen off the wall. Multiple rooms of residents with respiratory illness with resistant bacteria, had PPE (personal protective equipment) at the resident door, had garbage cans that were spilling over with PPE in the resident room and/or garbage cans that were within three feet of the resident when doffing PPE in resident rooms. Additionally, cross contamination was observed in the dining room. Resident identifiers: 9, 10, 15, 57 and 58. Findings include: 1. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/20/19 at 9:25 AM, an observation was made of resident 9's pressure ulcer dressing change. When the dressing change was completed, an observation was made of facility staff and this surveyor, taking off PPE and placing it in the resident's regular garbage receptacle near the door. The garbage receptacle was observed to have multiple items of PPE and spilling over the top, thus allowing gloves and masks to fall to the floor. 2. Resident 10 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 11:10 AM, an interview was conducted with resident 10's daughter. An observation was made of resident 10's daughter in his room without the use of PPE. Resident 10's daughter was sitting at his side while in his recliner. Resident 10's daughter was observed to be touching resident 10, the arm of the recliner, the top of the overbed table and other surfaces in resident 10's room. Additionally, an observation was made of the sign that had hung on the wall near resident 10's room, the sign had fallen down to the floor and was stuck in the moulding along the wall, thus allowing anyone to enter resident 10's room without any knowledge to see the nurse prior to entering the room. On 2/19/19 at 11:20 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 10's daughter was in school to become an Occupational Therapist, had done her homework on the CRAB infection, and that the risk of her getting sick was really very low. LPN 1 stated that resident 10's daughter understood the risks and and that was why she was in the room without PPE. LPN 1 stated that resident 10's daughter, does it all the time, it's her choice. On 2/19/19 at 12:27 PM, an observation was made of resident 10 while in the therapy room. Resident 10 was observed to have to PPE covering his mouth. On 2/20/19 at 11:50 AM, an observation was made of resident 10's daughter in his room without the use of PPE. Resident 10's daughter was observed to be providing cares to resident 10. Resident 10's daughter was observed to be touching resident 10, the surfaces of resident 10's bed, bed sheets, wheelchair and other surfaces in resident 10's room. On 2/20/19 at 12:22 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that they had educated resident 10's daughter multiple times regarding the use of PPE and the importance of using it. The facility DON stated that a sign had been placed on all isolation rooms and did not know it had fallen off the wall. The facility DON stated that resident 10 was ok to go to therapy without PPE if his stoma was covered. The facility DON stated that she did not know if the CRAB infection were to be spread if resident 10 coughed or sneezed during therapy. The facility DON stated that resident 10's CRAB infection was colonized and that they had obtained three cultures, two being negative for CRAB and one being positive for CRAB. The facility DON stated that they were trying to get three consecutive cultures being negative for the CRAB before taking resident 10 off isolation precautions. Documentation was requested from the facility DON showing that resident 10's CRAB infection was colonized. (NOTE: No documentation could be located in the medical record to show that resident 10's CRAB infection was colonized. No additional documentation was provided by the facility DON to show that resident 10's CRAB infection was colonized.) 3. Resident 15 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 1:21 PM, an observation was made of resident 15's wife in his room without the use of any PPE. Additionally, there was no sign on resident 15's door or wall near his door to alert visitor's to see the nurse prior to entering resident 15's room. On 2/20/19 at 11:11 AM, an observation was made of resident 15's wife again in his room without the use of any PPE. On 2/20/19 at 12:22 PM, an interview was conducted with the facility DON. The facility DON stated that they had educated resident 15's wife multiple times regarding the use of PPE while in the facility. The facility DON stated that a sign had been placed on all isolation rooms and did not know where the sign that was on resident 15's wall had gone. 4. Resident 57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/20/19 at 8:41 AM, an observation was made of resident 57's pressure ulcer wound treatment. An observation was made of facility staff and this surveyor, taking off PPE and placing it in the resident's regular garbage receptacle near resident 57's bed within 3 feet of resident 57's personal space. 5. Resident 58 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 2:38 PM, an interview was conducted with resident 58. On 2/19/19 at 2:38 PM, an observation was made of resident 58 sitting in her chair next to her table. An observation was made of resident 58's regular garbage receptacle sitting right next to resident 58. This surveyor had to take off PPE, bend over to throw the PPE in the trash receptacle next to resident 58. On 2/20/19 at 12:22 AM, an interview was conducted with the facility DON. The facility DON stated that no red biohazard bags were needed per the CDC (Center for Disease Control) guidelines unless there was blood or other resident fluid that was able to be wrung out. Then biohazard bags were necessary for those bodily fluids. The facility DON stated that the garbage was to be taken out each time that PPE was placed in the garbage by facility staff. The facility DON stated that they could get other garbage receptacles in the rooms near the doorways to throw the PPE away. The Guidance for the Selection and Use of PPE in Healthcare Settings by the CDC, revealed that the PPE as defined by the Occupational Safety and Health (OSHA) Administration is specialized clothing or equipment worn by an employee for protection against infectious materials. The Guidance additionally revealed that the PPE should be removed at doorway before leaving patient room or in anteroom. 6. On 2/19/19, the following observations were made during lunch service in the dining room located within the C hallway. a. At 12:15 PM, the Concierge was observed to assist with delivering meal trays to residents throughout the dining room. b. At 12:19 PM, the Concierge was observed to cut up food for a resident using the resident's silverware. c. At 12:25 PM, the Concierge was observed to hold another resident's straw and guide the straw to the resident's mouth. (Note: No observations were made of the Concierge washing or sanitizing her hands between assisting residents.) On 2/21/19 at 8:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated during meal service, hands should have been washed and sanitized after delivering each tray, between feeding residents, and after touching anything. On 2/21/19 at 11:01 AM, an interview was conducted with the Concierge. The Concierge stated staff members carried small containers of hand sanitizer in their pockets. The Concierge further stated staff were expected to to sanitize their hands after passing each tray and wash their hands after passing three trays. In addition, the Concierge stated hands should have been sanitized after cutting up food for a resident. On 2/21/19 11:12 AM, an interview was conducted with the Director of Nursing (DON). The DON stated during meal service, staff should have been washing their hands after touching a resident and in between providing care for residents.",2020-09-01
21,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2017-05-03,225,D,1,0,74IB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility did not thoroughly investigate or report an allegation of abuse or neglect for 2 of 11 sample residents. Resident identifiers: 8 and 11. Findings include: On 5/3/17 at 12:45 PM, an interview was conducted with resident 8 regarding the care she received at the facility. When asked whether she felt she was treated with respect and dignity, resident 8 stated that there was one Certified Nursing Assistant (CNA) who was rude. When asked to explain, resident 8 stated that CNA 2 had lied to her when she requested a snack, stating there weren't any available. Resident 8 also stated that CNA 2 had humiliated other staff members in front of her. Resident 8 also stated that CNA 2 had yelled at her when she asked for help, saying she did not have time to help the resident. Resident 8 stated that she refused to have CNA 2 assist her with any more cares. On 5/3/17 at 1:00 PM, CNA's 2 employee record was reviewed. CNA 2's employee record revealed a Corrective Action Plan (CAP) for the CNA dated 11/23/16. The CAP revealed that CNA 2 had been given a written warning regarding her work performance. The following items were listed as the performance issues that warranted the written warning: .10/1/16: Reported that aid refused to do showers because it is 'not her job'. Or that staff member states resident is refusing showers when the resident is stating that they really want one. 10/1/16: Ignoring specific resident rooms call light. 10/1/116 (sic): Transferring residents via hoyer lift without mandated second staff member present. 10/1/16: Leaving resident dirty linens in their rooms or left on the resident to sleep in. 10/1/16: Speaking Spanish in front of the residents with other staff in the resident rooms. 10/17/16: Not washing hands before and after resident cares. Not washing hands before serving food in the dining room. 10/17/16: Bringing a dead bird into the facility, into the resident dining area, pretending like she was going to throw it at staff, and not washing hands afterwards, prior to patient cares. 11/1/16: Washing a residents hair, although resident stated she did not want to have her hair washed because they had recently had the beautician set their hair. 11/15/16: Multiple wholes (sic) in charting. 11/16/16: Making resident feel ashamed for spilling fluid on pants. Resident was drying pants with the fan and stated that they felt belittled . On 5/3/17 at 1:10 PM, the facility abuse investigations from 9/1/16 through 5/3/17 were reviewed. No allegations of abuse and subsequent investigations regarding CNA 2 were located. No allegations of abuse were reported to the state survey and certification agency regarding CNA 2. On 5/3/17, the facility's Abuse Investigations Policy and Procedure was reviewed. The Policy revealed the following: . 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 2. The individual conducting the investigation will, as (sic) a minimum: . b. Interview the person(s) reporting the incident; c. Interview any witnesses to the incident; . h. Interview other residents with whom the individual provides care or services and/or interacts; .9. The results of the investigation will be recorded on approved documentation forms. 10. The investigator will give a copy of the completed documentation to the Administrator within 5 working days of the reported incident. . 12. The Administrator will provide a written report of the results of all alleged abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, and others as may be required by state or local laws, within five (5) working days of the reported incident. On 5/3/17 at 1:45 PM, the Administrator (ADM) and Administrator in Training (AIT) were interviewed regarding CNA 2. The ADM and AIT stated that CNA 2 had worked in all areas of the facility, and that multiple staff members had requested not to work with CNA 2. The ADM and AIT stated that they had received complaints by another resident, resident 11, regarding CNA 2 and provided two grievance forms. The grievance forms were subsequently reviewed. On 9/26/16 resident 11 filed a grievance with facility staff regarding CNA 2. Resident 11 reported she was frustrated because staff was abrupt when answering call light and did not attend to concerns in a timely manner. Resident 11 filed a second grievance on 12/8/16 stating that she was concerned with (CNA 2's) bedside manner, response time to call lights, her attitude and approach when performing cares. The ADM and AIT stated that they had not reported the incidents listed in CNA 2's employee file or the grievance forms because no specific residents were mentioned. The ADM and AIT confirmed that they did not conduct an abuse investigation for the allegations made by resident 11 or the allegations made by other staff about CNA 2's treatment of [REDACTED].",2020-09-01
22,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2017-05-03,333,D,1,0,74IB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined that the facility did not ensure that residents were free of significant medication errors for 1 of 11 sample residents. Specifically, an antibiotic ordered to treat a urinary tract infection was not administered as ordered. Resident identifier: 9. Findings include: Resident 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/3/17 at 10:49 AM, an interview was conducted with resident 9. Resident 9 stated that she had a urinary tract infection with [MEDICAL CONDITION] resistant staphylococcus aureaus and had been treated with an antibiotic. Resident 9's medical record was reviewed on 5/3/17. Review of the physician's orders [REDACTED]. The licensed nursing staff documented that resident 9 was to be on contact isolation precautions related to [MEDICAL CONDITION] resistant staphylococcus aureaus. On 4/28/17 an order was received to discontinue the Bactrim DS and start resident 9 on [MEDICATION NAME] 100 mg (milligrams) 1 tablet by mouth twice a day for 5 days. Review of the Nurse's Notes revealed the following nursing entries: a. 4/21/17 from 6:00 AM to 6:00 PM: N (nausea) V (vomiting) noted. new order for [MEDICATION NAME] on contact precautions r/t (related to)[MEDICAL CONDITION] ([MEDICAL CONDITION] resistant staphylococcus aureaus) in urine UTI (urinary tract infection). b. 4/21/17 from 6:00 PM to 6:00 AM: .continues on abx (antibiotic). C/O (complained of) nauseated (sic) (with) abx given [MEDICATION NAME] for nausea (with) effective results. c. 4/22/17 from 6:00 PM to 6:00 AM: .She continues on ABX for UTI, tolerating treatment well, she has reported some nausea that is relieved with PRN (as needed) [MEDICATION NAME], no other adverse effects observed/reported. d. 4/23/17 at 10:30: .Pt. (patient) continues on abx for UTI . e 4/23/17 from 6:00 PM to 6:00 AM: .continues on abx (with) no adverse effects, she is tolerating well . f. 4/24/17 from 6:00 PM to 6:00 AM: .Cont (continues) of (sic) abx for UTI. Reports med gives her upset stomach but is relieved (with) PRN [MEDICATION NAME]. g. 4/25/17 from 6:00 AM to 6:00 PM: .taking ABX to treat uti, tolerating well w (with)/no AE (adverse effects) noted. h. 4/26/17 from 6:00 AM to 6:00 PM: .Antibiotic therapy continues (without) any issues or stated side effects. i. 4/26/17 from 6:00 PM to 6:00 AM: .Continues on abx for uti. Res (resident) reports abx upsets her stomach that is relieved (with) PRN [MEDICATION NAME]. j. 4/27/17 from 6:00 PM to 6:00 AM: .Continues on abx for UTI. Res c/o abx giving her upset (sic) stomach that is relieved (with) PRN [MEDICATION NAME]. k. 4/28/17 from 6:00 PM to 6:00 AM: .Restarted on [MEDICATION NAME] and [MEDICATION NAME] for UTI. Res (Resident) has had no adverse reactions to new Rx (prescription). l. 4/28/17 from 6:00 AM to 6:00 PM: .symptomatic for UTI symptoms burning, frequency, cramping.pt. states she is frustrated she is still sick with uti. m. 4/29/17 from 6:00 M to 6:00 AM: .She continues on ABX for UTI. She is tolerating treatment well. No adverse effects observed/reported. Precautions are in place. n. 4/30/17 at 10:30 AM: .On Abx for UTI. o. 4/30/17 from 6:00 PM to 6:00 AM: .continues on abx for uti (with) no adverse side effects . p. 5/1/17 from 6:00 PM to 6:00 AM: .Cont (continues) on abx for uti tolerating well, no adverse effects noted. q. 5/2/7 from 6:00 PM to 6:00 AM: .she continues on abx (with) no signs or reports of adverse effects, she is tolerating well . Review of the (MONTH) and (MONTH) (YEAR) Medication Administration Records revealed that resident 9 received only 5 doses of [MEDICATION NAME] 100 mg tablets instead of the 10 doses as ordered. On 5/3/17 at 10:45 AM, and interview was conducted with Unit Manager (UM) 1. UM 1 confirmed that resident 9 did not receive the full antibiotic treatment as ordered by the physician.",2020-09-01
23,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2017-05-03,353,E,1,0,74IB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility did not employee a sufficient number of staff to provide the cares to the resident as care planned. Specifically, 3 out of 11 residents stated that there was not enough staff, 1 resident did receive timely assistance with her activities of daily living, 2 staff members stated that there was not enough staff to complete their tasks as assigned, and the Resident Council complained of call lights not being answered timely in January, February, (MONTH) and April. Resident identifiers: 1, 7 and 10. Findings include: 1. On 5/3/17 at 8:29 AM, resident 1 was interviewed. Resident 1 stated that his call light had not been answered for an hour at times. 2. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's medical record was reviewed on 5/3/17. Resident 7's nurses notes documented that resident 7 was incontinent of bladder and continent of bowel. A quarterly Minimum Data Set (MDS) assessment dated [DATE] for resident 7 was reviewed. Staff documented on the MDS that resident 7 was always incontinent of bladder, but always continent of bowel. On 5/3/17 at 11:10 AM, an interview was conducted with resident 7 regarding the cares she received at the facility. Resident 7 stated that there were not enough staff at the facility. Resident 7 stated that she was incontinent and that after she soiled her brief, she would press her call light to alert the staff that she required assistance with a brief change. Resident 7 stated that after she pressed her call light, she would have to wait at least an hour for staff to assist her because staff are more interested in gossiping than they are in helping me. 3. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 10's medical record was reviewed on 5/3/17. A quarterly MDS assessment dated [DATE] for resident 10 was reviewed. Staff documented on the MDS that resident 10 was always incontinent of both bowel and bladder. Resident 10's care plan and nurses notes documented that resident 10 was incontinent at times, and required the use of briefs. Resident 10's Activities of Daily Living (ADL) flow sheet indicated that resident 10 required extensive assistance with bed mobility, toileting and grooming. On 5/3/17 at approximately 8:27 AM, an observation was made of resident 10. Resident 10 was laying in her bed with her eyes closed, and her head tilted to the right. Resident 10 had a full cup of orange juice on her bedside table. There was an odor of urine in the hallway outside of resident 10's room. On 5/3/17 at approximately 10:14 AM, an observation was again made of resident 10. Resident 10 appeared to be in the same position as observed earlier, with her head tilted to the right, and a full cup of orange juice on her bedside table. There was an odor of urine in the hallway outside of resident 10's room. On 5/3/17 at 11:00 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that she was assigned to provide cares for resident 10 that day CNA 1 also stated that she had arrived at work at 6:00 AM, and had changed resident 10's brief shortly after she arrived, at approximately 6:45 AM. CNA 1 stated that resident 10 had refused to get out of bed after that, and that the CNA had offered a snack and checked resident 10's brief at approximately 10:45 AM. The CNA confirmed that it had been approximately 4 hours since she had checked on resident 10 to determine if she required incontinence cares. Immediately following the interview with CNA 1, the CNA was observed to enter resident 10's room to provide incontinence care. There was a strong odor of stool in the hallway outside of resident 10's room. 4. Review of the Resident Council Meetings from (MONTH) through (MONTH) (YEAR) were reviewed. The Resident Council complained of the following: a. 1/11/17: Call lights being slow to be answered at times. Resident state early afternoon and also after 10 PM. The facility staff documented, staff inserviced on call light response time being no longer than 2 minutes. Note: An in-service memorandum, dated 1/18/17, from the facility Staff Development Coordinator to the Nursing Staff was attached to the Resident Council complaint which documented, .Call lights must be answered within 2 minutes of when they are pushed. Call lights must be within reach at all times when a resident is in their rooms (sic). All nursing staff are responsible for answering call lights. b. 2/13/17: Call light (sic) are slow to be answer (sic) mostly weekends and after dinner. c. 3/14/17: Call lights are slow to be answers (sic) mostly weekend and after dinner. SDC (Staff Development Coordinator) is reminding staff to answer call light ASAP (as soon as possible. The facility staff documented, Systems in play, call lights improving will continue to monitor. Note: An in-service memorandum, dated 3/14/17, from the facility Staff Development Coordinator to the Nursing Staff was attached to the Resident Council complaint which documented, .Call lights must be answered within 2 minutes of when they are pushed. Call lights must be within reach at all times when a resident is in their rooms (sic). All nursing staff are responsible for answering call lights. If multiple call lights are going off but you do not have enough time to help someone, please answer the call light, let the resident know a time frame in which you will be able to assist them, ie: 'you are next in line to get ready for bed' or 'I should be done in the dining room in about 10-15 min (minutes).' THEN: Follow through with what you say. If you are forgetful, keep a piece of paper or notepad in your pocket and write things on it that you must remember. There are times when it is very busy and it can be overwhelming to get to all of the call lights. Keeping good communication with the residents will make them more understanding and patient as things are getting completed. d. 4/5/17: Call light (sic) are often slow to be answered mostly after dinner. Residents state this is better. Note: An in-service memorandum, dated 4/3/17, from the facility Staff Development Coordinator to the Nursing Staff was attached to the Resident Council complaint which documented, .Call lights must be within reach of the resident's reach at ALL times when they are in their rooms. There is NO exception. Call lights must be answered within 2 minutes of when they are pushed. Call lights must be within reach at all times when a resident is in their rooms. All nursing staff are responsible for answering call lights. Call lights must be answered within 2 minutes of when they are pushed. Call lights must be within reach at all times when a resident is in their rooms (sic). All nursing staff are responsible for answering call lights.",2020-09-01
24,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2017-05-03,467,E,1,0,74IB11,"> Based on observation, it was determined the facility did not provide adequate ventilation to control odors. Specifically, there was pervasive odors throughout the facility. Resident identifier: 10. Findings include: 1. On 5/3/17 at 8:10 AM, there was a pervasive fecal odor throughout the Monarch hallway. The fecal odor maintained until a staff member sprayed an air freshener throughout the hallway. 2. On 5/3/17 at approximately 8:30 AM, an observation was made of room 10 on the 300 hall. There was an odor of urine in the hallway outside of the room, as well as inside the room. 3. On 5/3/17 at approximately 8:30 AM, an observation was made of room 19 on the 300 hall. There was an odor of urine in the hallway outside of the room, as well as inside the room. 4. On 5/3/17 at approximately 8:27 AM, an observation was made of resident 10. Resident 10 was laying in her bed with her eyes closed. There was an odor of urine in the hallway outside of resident 10's room. 5. On 5/3/17 at approximately 10:14 AM, an observation was again made of resident 10. Resident 10 appeared to be in the same position as observed earlier. There was an odor of urine in the hallway outside of resident 10's room. 6. On 5/3/17 at approximately 8:35 AM, an observation was made of the 400 hall. Upon entering the hall, a strong odor of both urine and fecal matter was present. The odor was observed throughout the hall. 7. On 5/3/17 at 8:36 AM, a facility staff member was observed to spray air freshner throughout the 400 hall.",2020-09-01
25,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2016-08-18,241,E,0,1,AV3G11,"Based on observation, the facility did not promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 6 of 32 sample residents. Specifically, residents in the Special Needs Unit waited for their meals to be served for up to 40 minutes. Resident identifiers: 42, 71, 84, 91, 94 and 179. Findings include: On 8/15/16, the lunch meal was observed in the Special Needs Unit. At 11:50 AM, the dining observation began. Residents 42, 71, 84, 94 and 179 were seated at their assigned tables. The first tray was not delivered until 12:22 PM, which left the residents waiting for their lunch meal for 32 minutes before being served. On 8/16/16, the lunch meal was observed in the Special Needs Unit. At 11:55 AM, the dining observation began. Residents 71 and 91 were seated at their assigned table. The following was observed: a. At 12:13 PM, resident 71's meal was delivered. However, the cutlery was not delivered until 12:25 PM. Resident 71 waited a total of 30 minutes before she was able to eat her meal. b. At 12:17 PM, resident 91's meal was delivered. Resident 91 waited 22 minutes before being served her meal. On 8/17/16, the breakfast meal was observed in the Special Needs Unit. At 8:09 AM, the dining observation began. Residents 84 and 91 were seated at their assigned table. The following was observed: a. At 8:13 AM, resident 91 was served a glass of milk and juice. At 8:17 AM, resident 91 leaned forward and attempted to lick the juice out of the glass. At 8:23 AM, resident 91 leaned forward again to attempt to lick the juice out of the glass. At 8:24 AM, resident 91's breakfast meal was served. At 8:27 AM, Certified Nurse Assistant (CNA) 1 assisted resident 91 to eat her breakfast. Resident 91 waited 27 minutes before she was able to eat her meal. b. At 8:37 AM, resident 84's breakfast meal was delivered. Resident 84 waited 28 minutes for his meal to be delivered. On 8/17/16, the noon meal was observed in the Special Needs Unit. At 11:47 AM, the dining observation began. Resident's 71, 84 and 91 were seated at their assigned table. The following was observed: a. At 11:50 AM, resident 91 was served a glass of chocolate milk. At 11:52 AM, resident 91 leaned forward and attempted to sip the chocolate milk without lifting the glass up. At 11:54 AM, resident 91 again leaned forward and attempted to sip the chocolate milk without lifting the glass up. At 12:28 PM, resident 91's lunch was delivered. Resident 91 waited 38 minutes for her lunch to be delivered. b. At 12:28 PM, resident 71 was served her lunch meal. However, cutlery was not delivered to resident 71 until 12:34 PM. Resident 71 waited 38 minutes for her lunch to be delivered. c. At 12:35 PM, resident 84 was served his lunch meal. Resident 84 waited 45 minutes for his lunch to be delivered.",2020-09-01
26,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2016-08-18,282,E,0,1,AV3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility did not provided services in accordance with each resident's written plan of care for 4 of 32 sample residents. Specifically, the facility staff did not assess the resident's food preferences. Resident identifiers: 71, 84, 91, and 179. Findings include: 1. Resident 91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 91's medical record was reviewed on 8/17/16. Review of the care plans developed for resident 91 revealed a Nutritional risk m/b (manifested by) needs assist w (with)/meals/eating, cognitive and physical decline, mood & (and) behavior, restless, significant st (short term (memory) loss in six months r/t (related to) MS [MEDICAL CONDITIONS](gastro-esphageal reflux disease), gingivitis, risk caries & periodontal disease that was developed on 11/18/15. The Goals that were developed included, Will have no significant weight change through 10/25/16. The interventions developed to achieve the goal included, Honor my food likes and dislikes. There was no documentation in the medical record which indicated that resident 91's food preferences were assessed. On 8/16/16 at approximately 2:00 PM, an interview was conducted with the Dietary Manager (DM) 1. The DM 1 stated that resident 91's likes and dislikes had been assessed and would provide a copy of the likes and dislikes to the survey staff. (Note: A copy of resident 91's likes and dislikes were not provided to the survey staff on 8/16/16.) On 8/16/16, the DM 1 completed a Food Preferences Interview with resident 91's husband and consultation with the nursing staff. 2. Resident 179 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 179's medical record was reviewed on 8/16/16 On 8/16/16, resident 179's nutrition care plan was reviewed. Resident 179's nutrition care plan included to honor food and fluid likes and dislikes. Resident 179's likes and dislikes could not be located in resident 179's chart. On 8/17/16 at 2:05 PM, an interview was conducted with the DM 1. The DM 1 confirmed that resident 179's food preferences was not completed until 8/16/16. 3. Resident 71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 71's medical record was reviewed on 8/16/16. On 8/16/16, resident 71's nutrition care plan was reviewed. Resident 71's nutrition care plan included to honor food and fluid likes and dislikes. Resident 71's likes and dislikes could not be located in resident 71's chart. On 8/17/16 at 2:05 PM, an interview was conducted with the DM 1. The DM 1 confirmed that resident 179's food preferences was not completed until 8/16/16. 4. Resident 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 84's medical record was reviewed on 8/16/16. On 8/16/16, resident 84's nutrition care plan was reviewed. Resident 84's nutrition care plan included to honor food and fluid likes and dislikes. Resident 84's likes and dislikes could not be located in resident 84's chart. On 8/17/16 at 2:05 PM, an interview was conducted with the DM 1. DM 1 confirmed that resident 179's food preferences was not completed until 8/16/16.",2020-09-01
27,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2016-08-18,309,D,0,1,AV3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, it was determined for 1 of 32 sample residents that the facility did not provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility staff were not coordinating care with a contracted hospice company. Resident identifiers: 94. Findings include: Resident 94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/16/16 at 1:00 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated there was a sticker in the front of the resident's medical record identifying if the resident was on hospice. RN 1 was not able to identify how the hospice agency communicates with the facility regarding resident 94's care. RN 1 stated that the hospice notes could be located under the hospice tab in the medical record. (Note: Resident 94's hospice tab in the medical record was one sheet of paper containing patient care notes dated 8/5/16, 8/9/16, and 8/12/16 written by the licensed facility staff.) On 8/16/16 at 1:25 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the hospice agency faxes documentation related to resident 94's care to the facility. The DON stated that the recent faxes for resident 94 may not have been filed as yet. On 8/16/16 at approximately 2:30 PM, the health information employee provided hard copies of resident 94's hospice notes. The health information employee stated the medical record for resident 94 now contained the hospice documentation that had not been filed. Upon review of Resident 94's medical record, the hospice physician certified hospice services beginning 7/20/16. The hospice initial plan of care was dated 7/20/16. However, the notes were not accessible for facility staff to review and plan care. 8/16/16 at 2:53 PM, surveyor requested the DON locate the hospice notes for Resident 94 beginning 7/28/16 to current that were not in the medical record. On 8/17/16 at 9:15 AM, the DON provided additional notes for 7/28/16, 8/2/16, 8/5/16, 8/9/16, and 8/12/16.",2020-09-01
28,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2016-08-18,329,D,0,1,AV3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 1 of 32 sample residents, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used without adequate indication for its use. Specifically, an antipsychotic medication was administered on an as needed basis for pacing up and down the hallway. Resident identifier: 91. Findings include: Resident 91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 91's medical record was reviewed on 8/17/16. On 6/18/16, an order was received to administer [MEDICATION NAME] 5 mg (milligrams) as needed daily. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The agitation was documented as Cont (continuous) Pacing. On two separate occasions, the licensed nurse administered the [MEDICATION NAME] along with two 5-325 mg [MEDICATION NAME] tablets and [MEDICATION NAME] 2 mg. Review of the (MONTH) (YEAR) MARs revealed that the [MEDICATION NAME] was administered twice for being restless and with agitation. The agitation was documented as Cont Pacing. The [MEDICATION NAME] was administered with two 5-325 mg [MEDICATION NAME] tablets and [MEDICATION NAME] 2 mg on one occasion. On 8/17/16 at 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 91 went to a Neurologist appointment on 6/18/16 and returned with a new order to administer the [MEDICATION NAME] as needed. The DON stated that resident 91 had not had an increase in her behaviors. The DON was unable to state why the [MEDICATION NAME] was administered for continuous pacing.",2020-09-01
29,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2016-08-18,333,D,0,1,AV3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility did not ensure that residents were free of significant medication errors for 2 of 32 sampled residents. Specifically, resident's did not receive insulin as ordered by the physician. Resident identifiers: 152 and 191. Findings include: 1. Resident 152 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 152's medical record was reviewed on 8/17/16. A physician's orders [REDACTED]. If blood sugar less than 80 notify the Medical Doctor (MD), If blood sugar 80 to 140, give no insulin; If blood sugar 141 to 180, give 3 Units; If blood sugar 181 to 220, give 4 Units; If blood sugar 221 to 260, give 6 Units; If blood sugar 261 to 300, give 8 Units; If blood sugar 301 to 340, give 10 Units; If blood sugar 341 to 380, give 12 Units; If blood sugar 381 to 420, give 14 Units; If blood sugar greater than 420 notify the MD. A review of resident 152's (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) Medication Administration Record [REDACTED] a. On 6/11/16 at 7:00 AM, a blood sugar of 197 was documented. Resident 152 received 3 Units of insulin instead of the 4 Units per the sliding scale. b. On 6/12/16 at 7:00 AM, a blood sugar of 143 was documented. Resident 152 received no insulin instead of the 3 Units per the sliding scale. c. On 6/15/16 at 11:30 AM, a blood sugar of 143 was documented. Resident 152 received no insulin instead of the 3 Units per the sliding scale. d. On 6/24/16 at 9:00 PM, a blood sugar of 179 was documented. Resident 152 received 4 Units of insulin instead of the 3 Units per the sliding scale. e. On 7/3/16 at 7:00 AM, a blood sugar of 141 was documented. Resident 152 received 1 Unit of insulin instead of the 3 Units per the sliding scale. f. On 8/3/16 at 4:30 PM, a blood sugar of 143 was documented. Resident 152 received no insulin instead of the 3 Units per the sliding scale. 2. Resident 191 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 191's medical record was reviewed on 8/16/16. A physician's orders [REDACTED]. If blood sugar less than 80 refer to PRN (as needed) protocol and notify MD; If blood sugar 80 to 120, give 0 Units; If blood sugar 121 to 150, give 1 Units; If blood sugar 151 to 200, give 3 Units; If blood sugar 201 to 250, give 5 Units; If blood sugar 251 to 300, give 7 Units; If blood sugar 301 to 350, give 9 Units; If blood sugar 351 to 400, give 11 Units; If blood sugar 401 to 450, give 14 Units; If blood sugar greater than 450 notify the MD. A review of resident 191's (MONTH) (YEAR) MAR indicated [REDACTED]. Resident 191 received 0 Units of insulin instead of the 1 Units per the sliding scale. A physician's orders [REDACTED]. A review of resident 191's (MONTH) (YEAR) MAR indicated [REDACTED]. On 8/17/16 at 9:50 AM, an interview was conducted with the Director of Nursing (DON). No additional documentation was provide. On 8/17/16 at 11:55 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated when a line was drawn on the MAR indicated [REDACTED]. On 8/17/16 at 12:05 PM, an interview was conducted with LPN 2. LPN 2 stated that the line drawn on the MAR means that no insulin was required per the sliding scale ordered by the physician. On 8/17/16 at 12:10 PM, an interview was conducted with LPN 3. LPN 3 stated that the line drawn on the MAR indicated [REDACTED].",2020-09-01
30,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2016-08-18,362,E,0,1,AV3G11,"Based on observation it was determined the facility did not employ sufficient support personnel competent to carry out the functions of the dietary service. Specifically, observations were made of meals delivered late in the Special Needs Unit dining room. Findings include: The following meal times were posted in the dining rooms: Breakfast 8:00 AM Lunch 12:00 PM Dinner 5:00 PM The following meals were observed to be served late in the Special Needs Unit dining room: a. On 8/15/16 the first lunch tray was served at 12:22 PM. b. On 8/17/16 the first breakfast tray was served at 8:14 AM. c. On 8/17/16 the first lunch tray was served as 12:20 PM. d. On 8/18/16 the first breakfast tray was served at 8:12 AM.",2020-09-01
31,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2016-08-18,364,D,0,1,AV3G11,"Based on observation and interview, the facility did not provide food that was palatable, attractive and at the proper temperature. Specifically, a resident voiced a concern with the food quality of the pureed meals and a test tray revealed that the pureed food served was not palatable. Additionally, food was not served according to the menu. Resident identifiers: 50, 71, 108, and 179. Findings include: 1. On 8/16/16 at 12:08 PM, resident 71's lunch tray was observed. Resident 71's tray appeared to contain approximately 1 cup scoop of a thick white substance covered in gravy, approximately 1/4 cup of a thin white substance, and 1/4 cup of a pureed green vegetable. The two smaller portions did not hold their shape and spread into each other. On 8/16/16 at 12:10 PM, an interview was conducted with resident 179. Resident 179 had finished less than half of her pureed lunch and was eating gelatin. Resident 179 stated that the food had no flavor, she could not eat it and the bread was just sopping wet. Resident 179 further stated that she didn't think a dog would eat it. 2. During breakfast service on 8/17/16, the pureed meal consisted of pureed oatmeal, pureed eggs, and pureed sausage with gravy over a slurried (milk soaked) biscuit. Resident 50 received a pureed tray, and there was no gravy observed on resident 50's biscuit. Resident 108 received a pureed tray, and there was no gravy observed on resident 108's biscuit. On 8/17/16 at 8:22 AM, a tray was prepared for resident 71. A certified nurses assistant checked resident 71's meal card and asked dietary staff member (DSM) 1 if it was supposed to have gravy. DSM 1 stated that it should get gravy but she was waiting on a spoodle. DSM 1 had asked another staff member for a spoodle, and held resident 71's tray until she got a spoodle for gravy. On 8/17/16 at 8:27 AM, an interview was conducted with DSM 1. DSM 1 stated that some of the previously delivered puree trays were sent out without gravy because she did not have a spoodle to serve the gravy. DSM 1 stated that gravy would need to be sent to those residents who had not received it. 3. On 8/17/16 lunch service was observed for c hall and the special needs unit. For residents with a regular diet order, between 2 and 5 meatballs were observed to be served on the trays. The menu revealed that residents with a regular diet order should have received a 4 oz serving of meatballs. On 8/17/16 at 2:06 PM, an interview was conducted with dietary manager (DM) 2. DM 2 stated that the meatballs were 1 oz each and a 4 oz serving would have contained 4 meatballs. On 8/17/16 at 12:12 PM, a fortified puree tray was observed. The fortified plate was squirted with butter. The butter pooled in spots within the spaghetti and green beans. On 8/17/16 at 12:30 PM, a pureed test tray was received. The following observations were made of each food item on the test tray: a. Pureed garlic bread: lukewarm slurried bread soaked in milk, no flavor or seasoning, parts of the bread were still dry and did not easily break apart. b. Pureed green beans: a small green dollop, encompassed by the spaghetti sauce; smooth texture, no flavor or seasoning. c. Pureed spaghetti noodles with pureed meatballs and spaghetti sauce: marinara sauce was flavorful, however did not mix well with the salty instant mashed potatoes used for spaghetti noodles. On 8/17/16 at 2:06 PM, an interview was conducted with DM 2. DM 2 stated that the staff had attempted to prepare pureed spaghetti for lunch but the consistency was not right so mashed potatoes were served instead. DM 2 stated that they had a new product coming in to replace the slurried bread products.",2020-09-01
32,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2016-08-18,371,E,0,1,AV3G11,"Based on observation, it was determined the facility did not store, serve, distribute and serve food under sanitary conditions. Specifically, kitchen floors were not cleaned sufficiently, dish storage racks were not clean, there were unlabeled food items and observations of cross contamination. Findings include: 1. On 8/15/16 at 8:02 AM, the following observations were made during a tour of the kitchen: a. Three puree food molds in the storage area were observed to have food residue on the edges. b. Storage racks in the pan and equipment area had a greasy residue on them. c. Floors in the storage rooms contained dirt and debris along the edges of the walls. On 8/17/16 at 2:06 PM, an interview was conducted with dietary manager (DM) 1 and DM 2. No further information was provided. 2. On 8/15/16 at approximately 8:15 AM, the following observations were made in the residents' snacks refrigerator on the special needs unit: a. An opened mighty shake carton was lacking an open date. b. A Gatorade drink was lacking a resident label. 3. On 8/17/16, during breakfast service the following observations of cross contamination were made: a. 8:03 AM, Dietary Staff Member (DSM) 3's bare hand made contact with the inside of a bowl while serving oatmeal. b. 8:08 AM, DSM 3's bare hand made contact with the inside of a bowl while serving cream of wheat. On 8/17/16, during lunch service the following observations of cross contamination were made: a. 12:00 PM, DSM 2's bare hand made contact with spaghetti noodles hanging over a resident's bowl while serving. b. 12:04 PM, a certified nursing assistant picked up a salad bowl with their thumb over the top of the salad bowl and proceeded to place the bowl on a residents tray. c. 12:12 PM, three plates were observed to have spaghetti noodles hanging over the edge of the plates touching the serving tray and diet card slips. On one plate, the noodles were observed to touch the DSM 2's hand as the plate was moved onto the serving tray.",2020-09-01
33,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2016-08-18,428,D,0,1,AV3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the pharmacist did not identify medication irregularities for 1 of 32 sample residents. Specifically, a resident received an as needed antipsychotic without adequate indication for its use. Resident identifier: 91. Findings include: Resident 91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 91's medical record was reviewed on 8/17/16. On 6/18/16 an order was received to administer Zyprexa 5 mg (milligrams) as needed daily. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The agitation was documented as Cont (continuous) Pacing. On two separate occasions, the licensed nurse administered the Zyprexa along with two 5-325 mg Norco tablets and Valium 2 mg. Review of the (MONTH) (YEAR) MARs revealed that the Zyprexa was administered twice for being restless and with agitation. The agitation was documented as Cont Pacing. The Zyprexa was administered with two 5-325 mg Norco tablets and Valium 2 mg on one occasion. On 7/28/16, the contracted pharmacist documented that resident 91 had no medication irregularities. The pharmacist did not identify that resident 91 had not been on antipsychotics in the past and that there was no documentation that indicated that resident 91 had an increase in her behaviors to justify the use of the Zyprexa as needed. On 8/17/16 at 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 91 went to a Neurologist appointment on 6/18/16 and returned with a new order to administer the Zyprexa as needed. The DON stated that resident 91 had not had an increase in her behaviors. The DON was unable to state why the Zyprexa was administered for continuous pacing.",2020-09-01
34,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2016-08-18,514,D,0,1,AV3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility did not maintain complete and accurate medical records for 1 of 31 sampled residents. Specifically,one resident's Medication Administration Record [REDACTED]. Findings include: 1. Resident 191 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 191's medical record was reviewed on 8/16/16. A physician's orders [REDACTED]. A review of resident 191's (MONTH) (YEAR) MAR indicated [REDACTED] a. On 8/2/16 at 5:30 PM, no documentation was present for the administration of the [MEDICATION NAME]. b. On 8/2/16 at 3:30 PM, no documentation was present for the administration of the [MEDICATION NAME]. c. On 8/2/16 at 5:00 PM, no documentation was present for the administration of the carvedilol. d. On 8/2/16 at 5:00 PM, no documentation was present for the administration of the [MEDICATION NAME] sulfate. (Note: Resident 191 was admitted to the facility on [DATE] at 1:39 PM.) A physician's orders [REDACTED]. A review of resident 191's (MONTH) (YEAR) MAR indicated [REDACTED] a. On 8/12/16 at 11:30 AM and 4:30 PM, no documentation was present for the administration of the insulin. b. On 8/13/16 at 11:30 AM and 4:30 PM, no documentation was present for the administration of the insulin. c. On 8/16/16 at 11:30 AM and 4:30 PM, no documentation was present for the administration of the insulin. On 8/17/16 at 9:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she had interviewed the nursing staff and the nursing staff confirmed that they had administered the medications as prescribed to resident 191. On 8/17/16, late entry documentation notes were provided by the DON to justify that the medications in question were administered by the nursing staff as prescribed by the physician.",2020-09-01
35,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2018-09-05,609,E,1,0,UVZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials in accordance with state law through established procedures. Specifically, there were resident to resident altercations that were not reported to the State Agency. Resident identifiers: 4, 5, and 8. Findings include: 1. Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 8's medical record was reviewed on 9/5/18. Resident 8's progress notes were reviewed and revealed the following entries: a. On 5/24/18 at 7:20 PM, Pt (patient) was being yelled at by a resident that he stole her money. Resident had a hold of pts sweat pants at the waist and would not let go. Nurse and aid (sic) saw what was happening and helped the 2 get separated. The resident then kicked the pt and the pt then punched the resident in the shoulder. Staff asked the pt to move away from the situation. Pt moved away from situation. No further incidents. b. On 6/20/18 at 5:20 PM, The CNA (Certified Nursing Assistant) walked into the resident room to let him know it was time to head down for dinner when she found him and another resident kissing and the other resident's sweatshirt was off and starting to take off the undergarments but was stopped by CN[NAME] Both of the residents were spoken to and told they were not to be going into the room together. Residents were removed from the room and sent to the dining room and put on 15 min (minute) checks. Family, MD (Medical Doctor), and DON (Director Nursing) notified. c. On 7/1/18 at 8:30 PM, Resident was found by nursing staff, in his room, in bed with a female peer, undressed from the waist down. Residents were separated by nursing staff, with female being assisted out of the bed and guided to her room by nursing staff. Resident redirected and reminded by nursing staff that he needed to stay out in public areas with female peers. Nursing staff will continue to monitor resident behaviors. Notifications: Resident's son (name removed), DON, MD (name removed.). d. On 7/9/18 at 10:00 PM, Aides were helping another male resident (2) with changing clothes in the resident's (2) room, when this resident (1) came into the room and hit resident (2) on right forehead. Resident (1) stated that he didn't know why he did .he knew it was wrong .but he thought resident (2) was being mean to aides at the time. Resident's were separated by nursing staff, Resident (1) was redirected from the room and reminded that he should not hit people, including other resident's or staff. Notifications: DON, NP (name removed), Residents son. e. On 7/19/18 at 10:31 AM, This report is for resident C. Resident B ambulated into resident A's room, this upset resident A and Resident A tried to push resident B out of the room which evidently pushed resident B to the floor. Resident C stepped into room from hall to get between these resident A and B and resident C punched this resident A in the face. When nurse entered room resident A was standing with aide assisting to calm him, resident B was on the floor on his right side. Resident B stated he is ok. Assisted resident B out of room to a safe location. Resident A has redness noted to R (right) cheekbone and R lower eye, which is starting to bruise slightly. Offered ice pack to resident for face. Will continue to monitor all of these resident closely for next 72 hours. Family, MD and social services aware. f. On 7/26/18 at 9:35 PM, 1930 (7:30 PM) This nurse heard someone yell 'knock it off.' I turned and looked down the hall toward the dining room and this Resident and the resident from room [ROOM NUMBER]-D were hitting each other's heads with their fists closed. This nurse ran down the hall yelling for them to stop which they did. When asked what happened this resident stated 'She is crazy!' When this nurse educated both resident that they are not to be hitting anyone this resident stated 'I know. I am sorry. It is just that when someone hits me its my instinct to hit back.' The resident from room [ROOM NUMBER]-D mumbled something under her breath and walked away. No injuries noted on either Resident. No further issues noted. g. On 7/29/18 at 6:17 PM, This nurse heard CNA yell and when I looked down the hall the Resident from room [ROOM NUMBER] fell to the ground. CNA reported that this (sic) she was grabbing at this Resident's hands. He got mad and shoved her and she fell . This nurse educated resident that he absolutely can not shove or hit other resident. He stated 'she started it and I just reacted.' No injuries noted to either party. Staff has monitored both residents closely and intervened as needed. h. On 8/15/18 at 2:03 PM, Res (resident) 2 was sitting in (sic) Res 1's (this resident) on the recliner. Res 1 was sitting on his bed. The door to the hallway was open. Nurse heard yelling coming from room. Nurse went in to find both residents standing on their feet arguing. Nurse took Res 2 away from Res 1, to Res 2 room. Res 1 states 'she hit me in the arm and I hit her back. I didn't do it hard, I didn't want to hurt her, but I want to protect myself' Nurse assessed Res 1, no injuries to arm, and no injuries to left hand that punched the other resident. Res denied any pain. i. On 8/16/18 at 12:43 PM, PT to discharge to (another facility) at approximately 1300 (1:00 PM). Review of a facility log titled, State of Utah Abuse Reporting Log revealed there were no reported incidents from 4/23/18 until 8/11/18. The resident to resident altercations in the above nursing progress notes for resident 8 were not on the log. (Note: Review of the State Agency's records revealed that none of the above incidences had been reported to the State Agency.) 2. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 9/5/18. Resident 4's incident reports were reviewed and revealed the following entries: a. On 6/28/18 at 7:30 PM, Resident (Res 1) was sleeping in bed when another resident (Res 2) entered into Res 1 room. Res 1 got out of bed and started shouting at Res 2 which made Res 2 shout back. Staff quickly went into room. Staff witnessed Res 1 punched Res 2 in the chest which made him step back to hit the wall. Res 2 skimmed Res 1 on the arm, no redness or bruising noted to arms. Staff separated resident's immediately taking Res 2 out of Res 1 room. BP (blood pressure) 140/90 HR (heart rate) 84 RR (respiratory rate) 18. Stated no pain at this time. Stated another 'man came into his room and he can't hear so he punched him' Stated 'no new pain and that the man did not hit him.' b. On 7/13/18 at 5:14 PM, Another resident wandered into residents room. Resident does not like this, became very upset, grabbed other resident by the left arm and started punching him in the back. Residents were separated. No injuries noted. c. On 7/19/18 at 9:40 AM, This report is for resident [NAME] Resident B ambulated into residents A's room, this upset resident A and resident A tried to push the resident B out of the room, which evidently pushed resident B to the floor. Resident C stepped into the room from hall to get between theses residents A and B and resident C punched this resident A in the face when nurse entered room resident A was standing with aide assisting to calm him, resident B was on the floor on his right side. Resident B stated he is ok. Assisted resident B out of room to a safe location. Resident A has redness noted to R cheekbone and R lower eye, which is starting to bruise slightly. Offered ice pack to resident for face. Will continue to monitor all of these residents closely for next 72 hours. Family, MD (medical doctor) and social services aware. d. On 7/29/18 at 12:30 PM, This nurse walked into room # 5 to complete treatment on this resident. I found this resident #2-D laying across his bed and he was naked from the waist down, sitting on top of her, bending down to kiss her. This nurse yelled for him to stop and told him to get off of her. He refused. I yelled for help and 2 CNA came in. This nurse informed him that he needed to get off of her, that she was not able to give consent due to her dementia and he stated 'Yes she can.' This nurse then told him again to get off of her, that he did not have the right to do this and he stated 'yes, I do.' This nurse and one CNA assisted him off of her while the other CNA got this (sic) her off the bed. Resident #2-d's brief was still in place and pants were still on. Shirt was still in place. She did not seem in any distress and made no complaints. CNAs assisted her back to her room and into bed to rest. Call light is within reach. This nurse educated Resident that this behavior is unacceptable. Resident was angry and yelled for this nurse to 'get out'. When this nurse told him he was not allowed to do this he stated 'yes I can.' e. On 8/16/18 at 10:28 PM, RN (Registered Nurse) was walking out of another residents (sic) room and CNAs were walking out of shower room when resident pushed another resident out of his room and knocked the resident onto the floor. Other resident was helped up and assisted by the CNAs to the nurse station. Resident was talked to about asking for help when someone goes into his room. He stated he got slapped by the resident and was upset. RN reminded to call for help to prevent any further incidents from happening. Review of a facility log titled, State of Utah Abuse Reporting Log revealed there were no reported incidents from 4/23/18 until 8/11/18. The resident to resident altercations in the above incident reports for resident 4 were not on the log. (Note: Review of the State Agency's records revealed that none of the above incidences had been reported to the State Agency.) 3. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's medical record was reviewed on 9/5/18. Incident reports for resident 5 were reviewed and revealed the following: a. On 4/23/18, Aids (sic) found resident laying in bed under the covers with another resident. Resident had all her clothes on. Pt (patient) has no signs of distress. Other resident had pants and underwear off. (Note: This report was on the facility's abuse reporting log, but had not been reported to the State Agency.) On 9/5/18 at 2:29 PM, an interview with the Resident Advocate (RA). The RA stated that she was filling in for the Social Worker who was on maternity leave. The RA stated that she started as the RA on 7/17/18. The RA stated that she had not developed interventions after resident to resident altercations. The RA stated that after altercations between residents the management team had a meeting to discuss what happened, as well as new interventions to prevent another incident. The RA stated that when there was a concern regarding resident to resident altercation, she reported the altercation to Adult Protective Services (APS) which was the State Agency. The RA stated that she was not aware that the State Agency was different from APS. The RA then confirmed that she had not made a separate phone call to the State Agency to report the incidences because she had misunderstood.",2020-09-01
36,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2018-09-05,660,D,1,0,UVZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined that the facility did not develop and implement an effective discharge planning process that focused on the resident's discharge goals, and the preparation of residents to be active partners and effectively transition to post-discharge care. Specifically, facility staff did not appropriately fill out paperwork for the New Choice Waver for a resident to discharge home. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/5/18 at approximately 12:30 PM, an interview was conducted with resident 1. Resident 1 stated that her plan since admission was for her to discharge home with family and a personal aide. Resident 1 stated that she needed the New Choice Waver completed for her to discharge home with an aide. Resident 1 stated that the Resident Advocate (RA) did not fill out the New Choice Waver (NCW) paperwork correctly. Resident 1 stated that she was delayed in discharge for 30 days because the paperwork was filled out incorrectly. Resident 1's medical record was reviewed on 9/5/18. A care plan dated 5/9/18 revealed, (Resident 1) wishes to return home. The goal revealed, Will verbalize/communicate and understanding of the discharge plan and describe the desired outcome by the review date. The intervention revealed, Establish a pre-discharge plan with the resident, family/caregiver and evaluate progress and revise plan. Social service progress notes revealed the following entries: a. On 6/5/18 at 10:05 AM, Resident is A (alert) & (and) O (oriented) (times) 3. She is able to voice her needs and concerns to staff. Resident has high anxiety and depression. b. On 8/6/18 at 5:06 PM, Resident was notified she would be moving from A-13 to C-18. Resident was very upset and started yelling at me. She stated she didn't want to have a room mate. Resident spoke with (Administrator). Trying to help he (sic) find a new place where she can have her own room. Resident said she was not going to wait and is calling home health and other facilities. c. On 8/28/18 at 12:07 PM, Resident come (sic) into RA's office and began to complain about how RA messed up her new choice waver and (Discharge Nurse) couldn't find the papers. She said that's why she didn't make the dead line. RA called NCW on speaker phone. RA asked why her NCW was postponed tell (sic) Oct (October) (YEAR). The NCW said that everything was turned in before the dead line but all the people involved was (sic) not able to asses (sic) her in time for September. She stated RA don't (sic) lesson (sic) to her complaints and that RA could care less. RA tried to explain. Resident began yelling 'Your (sic) the reason am (sic) still her (sic). Your (sic) messed it all up. And im (sic) calling everyone and get you fired.' And left office. d. On 8/28/18 at 12:20 PM, Resident come (sic) in and demanded RA to say she messed up her paperwork, also to say she was sorry. RA refused and recommended she talk to (discharge nurse) or (Director of Nursing (DON)) about her issues. On 9/5/18 at 2:04 PM, an interview was conducted with the R[NAME] The RA stated that she was filling in as the RA since the employee went on maternity leave. The RA stated that the NCW program allowed for residents to go into an assisted living. The RA stated that residents were able to discharge home with NCW. The RA stated that resident 1 and her husband filled out the paper work for NCW but they were not sure where she wanted to discharge. The RA stated that the home health agency involved did not fill out their portion of the NCW for resident 1 to discharge home. The RA stated resident 1 was unable to discharge home with NCW because the paperwork had to wait until (MONTH) 1st because of billing with medicaid. The RA stated that she had not followed up with NCW to see if the home health agency had submitted their information for her to discharge on (MONTH) 1st. The RA stated that resident 1 was upset about everything. The RA stated that she only know how to fill out paper work and send the NCW in. On 9/5/18 at 2:16 PM, an interview was conducted with the Discharge Nurse (DN). The DN stated that he was one of the discharge planners at the facility. The DN stated that he had been the discharge planner since (MONTH) (YEAR). The DN stated that resident 1 wanted to go home on the NCW, so she could get an aide for more assistance when she discharged home. The DN stated that staff should have started the NCW sooner but it fell through the cracks. The DN stated when he was reviewing resident 1's medical record he noticed she required a hoyer lift for transfers and he knew that resident 1 would not have been approved to discharge to an Assisted Living Facility (ALF). The DN stated that he had physical therapy re-evaluate the need for a mechanical lift for resident 1. The DN stated that resident 1 planned to discharge home but her husband stated to the DN that he was unable to care for resident 1 without help at night. The DN stated that he did not document the conversation. The DN stated that therapy did not have enough time to evaluate resident 1's transfer status because they were busy with other residents. The DN stated that he could have submitted the NCW form and received the initial approval sooner so she could have discharged on (MONTH) 1st. The DN stated that he could have called and got NCW approval sooner because she had a personal lift at home, so resident 1 did not need a physical therapy evaluation.",2020-09-01
37,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2019-10-03,584,E,1,0,CR9Z11,"> Based on observation and interview it was determined that the facility did not provide a comfortable and homelike environment. Specifically, residents were residing in their rooms during construction. Additionally, the hallways had unidentified splatter on the walls, residents fans were soiled, lifts were soiled and a wheelchair in the hallway was soiled. Resident Identifiers: 9 and 10. Findings include: On 10/2/19 at 12:15 PM, an observation was made of the B hall. The following observations were made: 1. There was a dried fluid splatter on the wall outside room B-15. 2. There was a substance on the outside of the food cart in the B hall. 3. There was a lift soiled with debris and black substance on the bottom part of the hoyer with a red substance on 1 leg of the lift. 4. There was a black plastic set of drawers outside room B-13 with a cup mark and a clear dried substance on the top. 5. There was a fan in room B12 that was soiled with dust and a red substance. 6. The light switch by the nurses' station on the B hall had a dried red substance that was dripping down the wall. 7. There was a fan in room B6 that had dust and debris on it. 8. There was a picture in the hallway that had a dried substance on the glass. On 10/2/19 at 2:23 PM, an observation was made of a sit to stand lift in the B hall. The sit to stand lift was observed to be soiled with dust and debris. On 10/3/19 at 9:00 AM, an observation was made of the C hall. There was a splattered dry fluid on the hallway walls in the C hall outside room C16 and C6. There was a wheelchair in the hallway with a brown substance on the cushion and a white substance on the wheels. On 10/3/19 at 9:00 AM, an observation was made of room C11 and C13. The rooms were observed to have a temporary plastic construction wall. The construction workers were observed to remove the walls while the residents were in his bed. On 10/3/19 at 9:05 AM, an observation was made of the C hallway. A large hole was observed in the ceiling. The hallway walls were also observed to have unidentified splatter marks and dried fluid drips in multiple places. On 10/3/19 at 11:39 AM, an observation was made of a maintenance man in room C13 installing a new heating unit. Tools were observed to be on the floor in room C13 and it was very noisy, the resident was observed lying in bed with eyes closed. On 10/3/19 at 12:59 PM, an observation was made of room C15. Room C15 was observed to have a temporary wall up and one resident was still residing in the room. On 10/3/19 at 9:25 AM, an interview was conducted with Construction Worker (CW) 1. CW 1 stated the temporary walls were 9 foot by 12 foot. CW 1 stated that the temporary walls were in resident rooms until the outside wall was done. CW 1 was observed to be completing drywall work with no window in the wall. On 10/3/19 at 9:30 AM, an interview was conducted with the Project Manager (PM). The PM stated that the facility was replacing all of the outside walls in the resident rooms with foam insulated walls. The PM stated the facility was also replacing the windows with double pane windows, and installing new heating and cooling units in resident rooms for better energy maintenance. The PM stated that during construction in double occupancy resident rooms, the facility temporarily moved the resident by the window to another room, the resident in the bed closest to the door remained in the room during construction. The PM stated that they placed a temporary plastic wall up in the resident room, in between the resident and the outside wall for 2-3 days while they replaced the wall and window. The PM stated that they had been working in the facility since (MONTH) to replace all the outside walls, stated they expected to be done some time in November. On 10/3/19 at 11:34 AM, an interview was conducted with Certified Nursing Assistance (CNA) 1. CNA 1 stated that the facility staff only moved residents out of the double occupancy rooms. CNA 1 stated that the facility temporarily moved the resident that was closest to the window for about 2 days. CNA 1 stated that he did not know why the facility did not move both residents out of the room while they were doing construction. On 10/3/19 at 11:35 AM, an interview was conducted with Housekeeper 1. Housekeeper 1 stated that the facility did not move both residents out of double occupancy rooms during construction because the temporary plastic wall did not infringe on the space of the resident by the door. Housekeeper 1 stated that it was easier if the facility only had to move one resident out of the room. Housekeeper 1 stated that she wiped the walls in the hallway when it needed it. Housekeeper 1 stated that the dried fluid substance on the wall in the hallway was from the hand sanitizers. Housekeeper 1 stated that the pictures in the hall were wiped down weekly. Housekeeper 1 stated she did not know why there was a dried substance on the glass of the picture frame. On 10/3/19 at 11:39 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she was told by the facility management that the staff was to only move the resident that was closest to the window, and leave the other resident in the room with the temporary plastic wall. RN 1 stated that she had never seen the facility move both residents out of the room when construction was done on the room. On 10/3/19 at 12:59 PM, an interview was conducted with resident 9. Resident 9 stated that the facility moved his roommate out of the room during construction but not him. Resident 9 stated that the facility did not offer to let him move out of the room during construction. Resident 9 stated that it was a little cold in his room since the wall was torn out and the temporary wall did not have any insulation. On 10/3/19 at 12:59 PM, an interview was conducted with resident 10. Resident 10 stated that the facility did not offer to let him move rooms during construction, but that the facility put a temporary wall up.",2020-09-01
38,HERITAGE PARK HEALTHCARE AND REHABILITATION,465003,2700 WEST 5600 SOUTH,ROY,UT,84067,2019-10-03,686,D,1,0,CR9Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined, for 1 of 10 sample residents, that the facility did not ensure that each resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. In addition, a resident that developed a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, facility staff did not document a resident's pressure ulcers upon admission. After identifying a resident's pressure ulcers treatments were not completed according to physician's orders [REDACTED]. Findings include: Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/2/19 at 2:42 PM, an interview and observation was conducted of resident 3. Resident 3 stated that she had wounds on her back and hips. Resident 3 stated that she had wounds Off and On at various times. Resident 3 stated that she had wounds of her feet. Resident 3's feet were observed to be wrapped with soft booties on both feet and a cushion in her wheelchair. On 10/3/19 at 12:30 PM, an observation was made of resident 3's feet with Registered Nurse (RN) 3. RN 3 was observed to remove a dressing from resident 3's right toe area. RN 3 stated that there was no bandage on the lateral foot. RN 3 stated that the wound must have been healed. RN 3 stated that the wound on resident 3's toes was probably sort of a pressure sore, I would think. Resident 3's left heel was observed to be boggy with a red area approximately 1 by 2 cm that was non-blanchable. Resident 3's feet were observed to be very dry. Resident 3 refused to have her other pressure ulcers observed. Resident 3's medical record was reviewed on 10/2/19. An admission assessment dated [DATE] at 10:22 PM revealed in the skin section, Open sore to left upper buttocks 4 x 4. Fragile skin. Bruise on abdomen. Both heels soft. Resident 3's care plan were requested from the facility on 10/17/19. The care plans that were created on 9/3/19 and revised on 10/15/19 revealed, (Resident 3) has potential/actual impairment to skin integrity r/t (related to) [MEDICAL CONDITIONS] (End Stage [MEDICAL CONDITION]) w/ (with) [MEDICAL TREATMENT],[MEDICAL CONDITION](hypertension), [MEDICAL CONDITION], incontinence, DM (diabetes mellitus), impaired mobility. Pressure injury stage 4 to left & right buttock. Pressure injury unstageable to left heel. The goal developed was, Will have no complications r/t trach, permacath site, pressure injury stage 4 to left and right buttock - pressure injury unstageable to left heel through review date. An intervention developed on 9/3/19 was, Encourage good nutrition and hydration in order to promote healthier skin and needs pressure relieving cushion to protect the skin while up in chair. Additional interventions were developed on 9/18/19, Needs pressure relieving/reducing mattress to protect the skin while in bed. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow facility protocols for treatment of [REDACTED]. Use lotion on dry skin. Additional interventions created on 10/7/19 with a date initiated as 9/4/19 were, Needs pressure relieving cushion to protect the skin while up in chair. Float heels while in bed. Encourage to wear Pressure relieving boots. A Skin/wound note from the Wound Nurse (WN) 9/4/19 at 1:55 PM revealed, Left buttock, pressure injury sage 4 (on admit) 2.2 cm (centimeters) L (length) x 2.0 cm W (width) x 0.7 cm D (diameter). Wound status: not healed. hyper gran (granulation): no tunneling/undermining: no. drainage: moderate serous. odor: mild. pain: 0. granulation: 50-75%. slough: 1-49%. periwound color: normal for patient. periwound texture: scar tissue. periwound moisture: maceration.Resident is new admit to facility. Resident stated that she has had this wound for over 4 years and has previously been hospitalized for [REDACTED]. Resident 2's (MONTH) 2019 Treatment Administration Record (TAR) revealed an order dated 9/5/19 for left buttock dressing to be changed on Monday, Wednesday and Friday. The first treatment was completed on 9/6/19 and there was no nurses initials on the treatment for [REDACTED]. An admission Minimum Data Set ((MDS) dated [DATE] revealed that resident 3 had 1 stage 4 unhealed pressure ulcer and was at risk for developing pressure ulcers. The MDS further revealed that resident 3 was receiving pressure ulcer care and ointments/medications other than to the feet. An admission Braden scale was completed on 10/2/19. Resident 3 had a score of 14.0 which was considered at moderate risk for skin breakdown. (Note: The first braden score was documented on 10/2/19.) A nursing note dated 9/10/19 reveled, .she had her dressings done to her buttocks area and foot, no new issues. A skin evaluation on 9/10/19 revealed, Wound to left posterior thigh dressed as ordered. No [MEDICAL CONDITION] noted. Right port per [MEDICAL TREATMENT]. Resident has redness/small wound to bridge of nose, soft pad in place this shift. Good skin turgor noted. A Skin/Wound Note dated 9/13/19 at 2:55 PM, 1. Left buttock, Pressure injury stage 4 (on admit): 5.0cmL x 7.0cmW x 0.3cmD. wound status: not healed. 2. Right buttock, pressure injury stage 4 (on admit) previously healed: 10.2cmL x 8.0cmW x 0.1cmD. Wound status: not healed.Notes: previously healed stage 4. 3. Right lateral Ankle/Foot, Arterial Ulcer (on admit): 1.7cmL x 1.5cmW x 0.1cmD. wound status: not healed.Note: area is very scarred and the skin is tight and shiny. 4. Right Medial Ankle/Foot, Arterial Ulcer (on admit): 9.0cmL x 11.0cmW x 0.1 cmD. not healed.Notes area is very scarred and the skin is tight and skiny. 5. Right Lateral 3rd toe, arterial ulcer (on admit): 1.0 cmL x 0.7cmW x 0.4cmD. Wound status: not healed.Notes: previous amputation to 4th & 5th toe. A Skin/Wound Note dated 9/16/19 at 1:38 PM revealed, Clarification of Note 9/13/19: . (Note: The note was the same as the note on 9/13/19.) An order progress note dated 9/16/19 at 4:23 PM, N.O (new order) Left buttock and R buttock: remove dressing, cleanse with NS (Normal Saline), apply skin prep to periwound, apply hydrogel to wound bed, cover with bordered gauze or bordered foam. Every day shift Mon (Monday), Wed (Wednesday), Fri (Friday). Start Date: 9/18/2019. An order progress note dated 9/17/19 at 2:26 PM, N.O. Right lateral 3rd Toe: remove dressing, cleanse with NS or soap and water, apply skin prep to periwound, apply hydrogel to wound base, cover with bordered gauze. every shift every Tue (Tuesday), Thu (Thursday), Sat (Saturday). Start Date: 9/19/19. Resident 29's (MONTH) 2019 TAR was reviewed and the first treatment documented was on 9/19/19. An order progress note dated 9/17/19 at 2:28 PM, N.O. Right Lateral Foot: remove dressing, cleanse with NS or soap and water, apply skin prep to periwound, apply hydrogel to wound bed, cover with bordered gauze or bordered foam. every day shift Tue, Thu, Sat Start Date: 9/19/19. Resident 29's (MONTH) 2019 TAR was reviewed and the first treatment documented was on 9/19/19. A Skin/Wound Note dated 9/17/19 at 2:29 PM, 1. Left Buttock, Pressure Injury Stage 4 (on admit) previously healed stage 4 pressure injury, open on admit: 4.8cmL x 7.0cmW x no measurable depth. Wound status: not healed.2. Right buttock, Pressure Injury Stage 4 (on admit) previously healed stage 4 pressure injury, not open on admit: 13.0cmL x 8.0cmW x 0.1 cmD. Wound status: not healed.3. Right Lateral Ankle/Foot, Arterial Ulcer (on admit) previously healed, not open on admit: 1.5cmL x 1.0cmW x 0.1cmD. wound status: not healed.4. Right Medial Ankle/Foot, Arterial Ulcer (on admit) previously healed, not open on admit: 0.0cmL x 0.0cmW x 0.0cmD. Wound status: Resolved. Epithelized skin is very thin. 5. Right Lateral 3rd Toe, Arterial Ulcer (on admit): 0.7cmL x 0.5cmW x 0.2cmD. wound status: not healed. Resident 2's (MONTH) 2019 Treatment Administration Record (TAR) revealed an order dated 9/16/19 for left buttock and right buttock to remove dressing, cleanse with NS, apply skin prep to periwound, apply hydrogel to wound bed, cover with bordered gauze or foam every Monday, Wednesday and Friday. The first documented treatment was on 9/18/19. A skin evaluation dated 9/17/19 revealed, Wound to left posterior thigh dressed as ordered. No [MEDICAL CONDITION] noted. right port per [MEDICAL TREATMENT]. Resident has redness/small wound to bridge of nose, soft pad in place this shift. Good skin turgor noted. A Skin evaluation dated 9/24/19 revealed, Wound to left posterior thigh dressed as ordered. No [MEDICAL CONDITION] noted. Right port per [MEDICAL TREATMENT]. Resident has redness/small wound to bridge of nose, soft pad in place this shift. Good skin turgor noted. A skin evaluation dated 10/1/19 revealed, Wound to left posterior thigh dressed as ordered. No [MEDICAL CONDITION] noted. right port per [MEDICAL TREATMENT]. Resident has redness/small wound to bridge of nose, soft pad in place this shift. Good skin turgor noted. A local wound care company's notes revealed measurements for resident 3's wounds dated 10/1/19. The following measurements were documented: (Note: All measurements were in cm.) 1. Left buttock stage 4 pressure injury. The measurements were 8.5x8.5x0.2. 2. Right lateral 3rd toe was an abrasion. The measurements were 0.6x0.5x0.1. 3. Right buttock stage 4 pressure injury. The measurements were 4.5x15x4 On 10/3/19 at 12:08 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that she completed resident 3's skin assessment upon admission. RN 2 stated that resident 3 had a Big pressure ulcer on her buttock. RN 2 stated that she did not remember seeing wounds on resident 3's feet or on the right buttock. On 10/3/19 at 12:22 PM, an interview was conducted with the Director of Nursing (DON). The DON stated wound rounds were done every Tuesday. The DON stated that she needed to review resident 3's medical record regarding wound development. On 10/3/19 at approximately 1:00 PM, an interview was conducted with the Wound Nurse (WN). The WN stated that she assessed resident 3's wound the day of admission or the next day. The WN stated that resident 3 was admitted with a left ischium buttock wound, right lateral/medial and a 3rd toe wound. The WN stated that resident 3 had history of chronic wounds. The WN stated that resident had flap surgery in the past on the buttocks. The WN stated that on 9/4/19 she did not do a full body skin check and only looked at the wound on resident 3's buttock. The WN stated that she found resident 3's right foot wrapped on 9/13/19. The WN stated that she was not sure who put a wrap on resident 3's foot. The WN stated that she thought the wound looked vascular. The WN stated that she did not see resident 3's wounds on 9/24/19 with the a local wound company because resident 3 was in [MEDICAL TREATMENT]. The WN stated that resident 3 did not have shoes. The WN stated that on 10/1/19 resident 3 had booties on her feet. The WN stated that the wound Nurse Practitioner (NP) and her told the Certified Nursing Assistant's (CNA) that resident 3 needed to have booties on at all times. The WN stated that she was off for 2 weeks and did not look at resident 3's wounds for 2 weeks. The WN stated that she saw resident 3's wounds on 9/13/19, 9/17/19 and 10/1/19. The WN stated that she did not know why the wound dressing was not initialed by a nurse on 9/11/91. The WN stated that if the initials were not signed then the treatment was not completed. The WN confirmed that resident 3's wounds did not look New when she saw them for the first time on 9/13/19. The WN stated that the wounds had healing tissue which could have been developed after and admission and were healing or prior to admission. The WN stated that she completed a wound dressing change when she measured the wounds on 9/13/19 and 9/17/19 when she measured the wounds. The WN stated that she did not document what treatments were administered to resident 3's wounds. The WN stated that on 10/1/19 she discussed with CNA's the importance of the off loading boots to her feet. The WN stated that resident 3 did not have anything ordered for her dry skin to prevent further breakdown on her feet. The WN stated that she was not sure if CNAs were putting lotion on resident 3's feet. The WN stated that a communication order was put into the electronic medical record and nurses were to make sure the order was completed. The WN stated that resident 3 did not have a communication order in her medical record. On 10/3/19 at approximately 3:00 PM, an interview was conducted with the DON and the Cooperate Resource Nurse (CRN). The DON and CRN stated that resident 3 had a history of [REDACTED]. The DON stated that she contacted the nurse regarding the treatment not initialed on 9/11/19. The DON stated that the nurse tried to do the treatment but the resident refused. The DON stated that the nurse told her that she passed on the information for the next nurse. The DON stated that the nurse stated she was not sure if resident 3's treatment was completed.",2020-09-01
39,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2018-04-30,578,D,0,1,C87F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined, for 1 of 43 sample residents, that the facility did not include provisions to inform and provide written information concerning the right to accept or refuse medical or surgical treatment and at the residents option formulate an advance directions. Resident identifier: 264. Findings include: 1. Resident 264 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 264's medical record was reviewed on 4/24/18. Review of resident 264's physician orders [REDACTED]. On the facility's documenting system, a header displayed a resident's code status so it could be quickly identified. On 4/24/18 at 9:31 AM it was noted that resident 264 did not have a code status listed in the header. The hard chart was searched and the POLST form within was blank. The advanced directives or POLST form could not be found when searched for in the facility's documenting system. In that documenting system, there was a form titled Advanced Directives which was signed by the resident and a facility representative on 4/5/18. This form stated that a facility representative was made aware by the resident or resident representative that advance directives exist, but a copy was not provided to the facility. It did not indicate what the resident's wishes for advanced directives were. The form stated The Resident acknowledges that it is the Resident's responsibility to provide (facility's name) with copies of the Resident's advance directives for incorporation into the Resident's medical record. The form also stated (Facility's name) shall act in accordance with the residents advance directives if the advance directives were executed in accordance with applicable State law. On 4/24/18 at 9:45 AM an interview was conducted with resident 264. Resident 264 stated she did have an advanced directive, but it was at a different facility. Resident 264 stated she didn't remember ever filling out a POLST while at the facility. On 4/25/18 at 10:46 AM when the POLST form was requested, it was provided. It had been completed on 4/24/18. The Director of Nursing affirmed the form was completed the previous day.",2020-09-01
40,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2018-04-30,580,E,1,1,C87F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined, for 4 of 43 sample residents, that the facility did not immediately inform the resident representative when there was a need to alter the resident's treatment and commence a new form of treatment. Specifically, one resident's physician was not notified of a change in condition, and three resident's physician's were not notified of medications that had not been administered nor of multiple medications that had not been given timely. Resident identifiers 4, 37, 163 and 170. Findings include: 1. Resident 170 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 170's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/12/18 New order by MD (Medical Doctor) for the patient: DC [MEDICATION NAME] Inhaler; amt (amount): 2 inhalations; Special Instructions: Dx (diagnoses) [MEDICAL CONDITIONS] Four Times A Day New order: Re-start on 1/16/2018 [MEDICATION NAME] inhaler; amt: 1 inhalations; Four Times A Day Increase monitoring for any respiratory issues. Notified (sic) to MD for any acute respiratory problem. Asses (sic) the patient every shift for respiratory problem. b. 1/28/18 at 21:30 (9:30 PM), (Recorded as Late Entry on 1/29/18 at 23:59 (11:14 PM), CNA (Certified Nursing Assistant) came to tell LN (Licensed Nurse) to come check on pt (patient) out of concern. LN went to observe pt. Called pt name and gently shook her shoulder, pt easily roused and responded. Ask how she was feeling and if she was in any pain, stated that she was just tired. Denies pain/discomfort at this time. Pt in no apparent distress. Pt was laying flat, LN raised HOB (head of bed) to semi fowlers. VS (vital signs) checked (Temperature) 98.2, (Pulse) 112, (Respirations) 14, (Blood Pressure) 96/62, (Oxygen Saturations) 92% 5L (liters) via NC (nasal cannula). Blood sugar 350. Lung sounds CTA (clear to auscultation) bilaterally. Respirations even and unlabored. Encouraged fluids. Pt checked and changed, barrier cream applied with brief change. Will notify MD. Nursing will continue to monitor. (NOTE: The nursing progress note did not explain what the concern was with resident 170 Additionally, the note was added to the medical record as a late entry after resident 170 had passed away.) c. 1/29/18 at 00:01 (12:01 AM), Went to check on pt, pt sleeping and easily roused. Responsive and able to respond appropriately to questions. Pt in no apparent distress and denies pain and/or SOB (shortness of breath). Respirations even and unlabored at 14, [MEDICAL CONDITION] (continuous positive air pressure) in place per orders while pt asleep. Nursing will continue to monitor. d. 1/29/18 at 3:02 AM, Checked on pt, still sleeping and easily roused. [MEDICAL CONDITION] in place and functioning. Woke her up and had her drink some water, responded and drank without any coughing or choking noted. CNA doing regular rounding and brief checks Q (every) 2 hours alternating with LN Q 2 hrs (hours). e. 1/29/18 at 5:00 AM, Pt check shows pt still sleeping in no apparent distress and easily woken. Cap (capillary) refill f. 1/29/18 at 5:30 AM, CNA was in room checking pt brief, LN joined to observe pt before the end of shift. Pt respirations even and unlabored. Pt in no apparent distress, skin pink warm and dry. [MEDICAL CONDITION] in place, pt responded to name and gentle shoulder shake. Denies pain, discomfort, or SOB. HOB elevated and RR 14. Encouraged pt to drink fluids throughout the day. Will report to oncoming nurse to monitor pt and encourage fluids throughout the day. g. 1/29/18 at 8:10 AM, Patient was find (sic) with respiratory distress, unresponsive with minimal arouse (sic), vitals was taking (sic) manually with no reading, patient with pulse 60 per min, respiration 24, laborated (sic) with O2 (oxygen) reading (saturations) 66 5 (66% on 5 liters of oxygen) in [MEDICAL CONDITION], interventions, change to face mask with 6 L oxygen, pull the head back to facilitated (sic) breading (sic) new O2 (saturation) 88%. Blood sugar check, blood sugar: 366 mg (milligrams)/dl (deciliter). Patient was able to open her eyes and was asked if she wanna (sic) go to ER (emergency room ), she state (sic) 'yes', 911 was called and MD notified. The vital sign report for resident 170 revealed that resident 170's vital signs were monitored and recorded as the following: a. 1/26/18 at 8:34 AM, Blood Pressure (BP) - 145/76, Pulse (P) - 78, Respirations (R) - 16, Temperature (T) - 97.8. O2 Saturation - 95% (NOTE: the report did not reveal if the oxygen saturation was with oxygen or on room air.) b. 1/27/18 at 9:57 AM, BP - 153/73, P - 83, R - 16, T - not taken, O2 Saturation - 90% (NOTE: the report did not reveal if the oxygen saturation was with oxygen or on room air.) c. 1/27/18 at 17:25 (5:25 PM), BP - 98/61, P - 68, R - 16, T - 97.9, O2 Saturation - 95% (NOTE: the report did not reveal if the oxygen saturation was with oxygen or on room air. Additionally, no documentation could be located in the medical record that resident 170's physician had been notified of the decrease in resident 170's BP and P, nor was there continued monitoring of the BP and P after they had decreased.) d. 1/28/18 at 9:03 AM, BP - not taken, P - not taken, R - 20, T - 97.8, O2 Saturation - 94% e. 1/29/18 at 10:07 AM, T - 97.9. (NOTE: It was unknown how this temperature was taken and documented as resident 170 had already been sent to the hospital in a nearly unresponsive state. Additionally, no vital signs could be located in the medical record consistent with the vital signs that were written in the late note on 1/29/18 at 11:14 PM.) No documentation could be located in the medical record to show resident 170's physician had been notified about the change in condition nor what the change in condition was. 2. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 37's medical record was reviewed. physician's orders [REDACTED]. a. 10/18/17, [MEDICATION NAME]/[MEDICATION NAME] 2.5/0.05 Nebulizer every 8 hours. b. 12/1/16, [MEDICATION NAME] 20 mg (milligrams)/ml (milliliter) subcutaneous at Bedtime. c. 12/27/18 through 2/8/18, [MEDICATION NAME] 1 mg to 3.5 mg daily (QD). d. 7/17/18, [MEDICATION NAME] 70 mg weekly. e. 9/26/18, [MEDICATION NAME] 40 mg QD. f. 1/6/18, [MEDICATION NAME] 100 mg three times daily (TID). g. 1/2/18, [MEDICATION NAME] 2.5 mg QD. h. 10/9/17, [MEDICATION NAME] 20 mg QD. i. 1/11/18, Potassium Chloride 20 mEq twice daily (BID). j. 5/11/18, [MEDICATION NAME] 40 mg QD. k. 5/1/17, Sprionolactone 25 mg QD. l. 5/11/17, [MEDICATION NAME] 50 mcg QD. m. 12/12/18, [MEDICATION NAME] 200 mg at bedtime. n. 1/16/18 through 1/22/18, [MEDICATION NAME] 1 gram; intravenous (IV) once a day for UTI (Urinary Tract Infection). The Medication Administration Record [REDACTED] a. On 1/8/18 and 1/14/18 [MEDICATION NAME] 20 mg injection was not administered due to Drug/Item unavailable. b. On 1/16/18, [MEDICATION NAME] 1 gram IV was not administered to resident 37 due to waiting on med (medication) from pharmacy. c. On 3/10/18 [MEDICATION NAME] 100 mg was administered at 16:19 (4:19 PM), 2 hours and 19 minutes after it was due, due to Drug/Item unavailable. d. On 4/22/18 [MEDICATION NAME] 100 mg was Not Administered due to condition. e. On 4/22/18 [MEDICATION NAME] 3 mg was Not Administered, On Hold, Pt (patient) is very sleepy. According to the MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) resident 37 had multiple medications administered late including [MEDICATION NAME]/[MEDICATION NAME] TID, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 3 mg QD, [MEDICATION NAME] 70 mg weekly, [MEDICATION NAME] 40 mg QD, [MEDICATION NAME] 100 mg TID, [MEDICATION NAME] 2.5 mg QD, [MEDICATION NAME] 20 mg QD, Potassium Chloride 20 mEq BID, [MEDICATION NAME] 40 mg QD, [MEDICATION NAME] 25 mg QD, [MEDICATION NAME] 50 mcg QD and [MEDICATION NAME] 200 mg at bedtime No documentation could be located in resident 37's medical record to show that resident 37's physician had been notified of the medications that had not been administered nor of the late administration of resident 37's medications. 3. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 4's medical record was reviewed. physician's orders [REDACTED]. a. 4/17/17, [MEDICATION NAME] 325 mg 2 tablets TID. b. 8/15/18, [MEDICATION NAME] 10 mg QD. c. 4/18/17, Aspirin 81 mg QD. d. 8/15/17, [MEDICATION NAME] 5 mg at bedtime. e. 4/17/17, [MEDICATION NAME] 100 mg BID. f. 8/15/17, [MEDICATION NAME] 40 mg at bedtime. g. 1/30/17, [MEDICATION NAME] 10 mg QD. h. 4/17/18, [MEDICATION NAME] 10 mg QHS (bedtime) hold for systolic (blood pressure (BP)) i. 8/15/17, [MEDICATION NAME] 0.5 mg BID. j. 9/30/17, [MEDICATION NAME] 5 mg every six hours; at 2:00 AM, 8:00 AM, 2:00 PM and 8:00 PM, Hold if asleep. The MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) for resident 4 revealed the following: a. [MEDICATION NAME] 0.5 mg administered on 1/27/18 at 10:00 PM, 2/22/18 at 12:00 PM, 3/12/18 at 11:00 PM and 3/27/18 at 10:00 PM. Administration of the [MEDICATION NAME] 0.5 mg were administered two to four hours after they were due. b. [MEDICATION NAME] 0.5 mg was not administered on 2/28/18. c. [MEDICATION NAME] 5 mg administered on 3/24/18 at 10:00 PM, 4/7/18 at 12:00 AM, 4/10/18 at 9:30 AM and 4/23/18 at 4:45 AM. 3 administrations of the [MEDICATION NAME] 5 mg were administered 1 1/2 hours to 2 hours and 45 minutes after they were due. The administration of the [MEDICATION NAME] 5 mg at 12:00 AM was administered 2 hours before it was due. d. [MEDICATION NAME] 20 mg was administered on 1/11/18 with a BP of 108/70, 1/18/18 with a BP 112/57, 1/19/18 with a BP 132/56, 2/24/18 with a BP 109/56, 3/22/18 with a BP 120/51, 3/25/18 with a BP 112/58 d. [MEDICATION NAME] 5 mg was not administered on 1/12/18 at 2:00 PM, 1/14/18 at 8:00 PM, 1/16/18 at 2:00 PM, 2/22/18 at 8:00 AM, 2/22/18 at 2:00 PM, 3/8/18 at 8:00 AM, 4/10/18 at 2:00 PM. According to the MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), resident 4 had multiple medications administered late including [MEDICATION NAME] 325 mg TID, [MEDICATION NAME] 10 mg, Aspirin 81 mg daily, [MEDICATION NAME] 5 mg at bedtime, [MEDICATION NAME] 100 mg twice daily, [MEDICATION NAME] 40 mg at bedtime, [MEDICATION NAME] 10 mg daily, [MEDICATION NAME] 20 mg at bedtime, [MEDICATION NAME] 0.5 mg twice daily and [MEDICATION NAME] 5 mg every 6 hours No documentation could be located in resident 4's medical record to show that resident 4's physician had been notified of the medications that had not been administered nor of the late administration of resident 4's medications. 4. Resident 163 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 163's medical record was reviewed. physician's orders [REDACTED]. a. 10/30/17 through 11/9/[MEDICATION NAME] mg twice daily at 8:00 AM and 8:00 PM for UTI. b. 12/20/17 through 12/24/17 [MEDICATION NAME] 1.25 grams IV daily at 5:00 PM [MEDICAL CONDITION] Bacteremia. c. 10/13/17 Eliquis 5 mg twice a day at 8:00 AM and 8:00 PM for A-fib ([MEDICAL CONDITION]). The MAR for (MONTH) (YEAR) and (MONTH) (YEAR) revealed the following: a.[MEDICATION NAME] mg administered on 11/2/17 at 10:24 AM, 11/3/17 at 9:27 AM and 11/7/17 at 10:20 PM. Administration of [MEDICATION NAME] mg was 1 hour and 27 minutes to 2 hours and 24 minutes after they were due. b. [MEDICATION NAME] 1.25 grams IV administered on 12/20/17 at 7:23 PM. Administration of the [MEDICATION NAME] 1.25 grams was 2 hours and 23 minutes after it was due. c. Eliquis 5 mg not administered on 11/24/17 at 8:00 AM because med not avaialble(sic) notifeid (sic) pharmacy. No documentation could be located in resident 163's medical record to show that resident 163's physician had been notified of the late administration of resident 163's medications. On 4/30/18 at 10:30 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that the physician should have been notified of the medications that had not been administered and and the late medications. On 4/30/18 at 4:30 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated I understand and see why there is a concern with this resident because of the lack of interventions. The facility DON acknowledged that there were no interventions of calling resident 170's physician, monitoring for the change in condition and no vital sign monitoring. Cross Refer to F-684, F-757 and F- 760",2020-09-01
41,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2018-04-30,636,E,1,1,C87F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, it was determined that for 4 of 43 sample residents, that the facility did not conduct initially and periodically a comprehensive Minimum Data Set (MDS) Assessments within the timeframes prescribed. Specifically, multiple MDS Assessments were documented as accepted with warnings for being submitted late. Residents identifiers: 22, 37, 38, and 45. Findings include: 1. Resident 22 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 22's medical record was reviewed. According to the medical record, the MDS Assessments that had been completed on an annual and quarterly basis, revealed that multiple MDS Assessments had been submitted with a warning indicator by their dates. Two MDS assessment records dated 2/6/18 and 9/3/17 were pulled for review. The MDS record dated 9/3/17 revealed the code: 3749A-warning and the message: Assessment Completed late. On 4/30/18 at 3:48 PM, an interview was conducted by the facility MDS Coordinator. The facility MDS Coordinator stated that the MDS Assessment had a target date of 9/3/17 and was due to be submitted to the Center for Medicare and Medicaid Services (CMS) on 9/16/17. The facility MDS Coordinator stated that the MDS Assessment was submitted late on 10/2/17. 2. Resident 45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 45's medical record was reviewed. According to the medical record, the MDS assessments that had been completed on an annual and quarterly basis, revealed that multiple MDS Assessments had been submitted with a warning indicator by their dates. Two MDS Assessment records dated 12/17/17 and 3/17/18 were pulled for review. The MDS record dated 12/17/17 revealed the code: 3749A-warning and the message: Assessment Completed late. The MDS assessment dated [DATE] revealed the code: 3749A-warning and the message: Assessment Completed late. On 4/30/18 at 3:48 PM, an interview was conducted by the facility MDS Coordinator. The facility MDS Coordinator stated that the MDS Assessment that had a target date of 12/17/17 and was due to be submitted to the Center for Medicare and Medicaid Services (CMS) on 12/30/17. The facility MDS Coordinator stated that the MDS Assessment was submitted late on 1/2/18. The MDS Coordinator stated that the MDS assessment dated [DATE] was due to be submitted to CMS on 3/30/18. The facility MDS Coordinator stated that the MDS Assessment was submitted late on 4/3/18. 3. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 37's medical record was reviewed. According to the medical record, the MDS Assessments that had been completed on an annual and quarterly basis, revealed that multiple MDS Assessments had been submitted with a warningindicator by their dates. Two MDS Assessment records dated 4/26/17 and 3/10/18 were pulled for review. The MDS assessment dated [DATE] revealed the code: 3749A-warning and the message: Assessment Completed late. The MDS assessment dated [DATE] revealed the code: 3749A-warning and the message: Assessment Completed late. On 4/30/18 at 3:48 PM, an interview was conducted by the facility MDS Coordinator. The facility MDS Coordinator stated that the MDS assessment dated [DATE] had a target date of 5/10/17 but was submitted late on 5/17/17. The facility MDS Coordinator stated that the MDS assessment dated [DATE] had a target date of 3/24/18 but was submitted late on 3/26/18. 4. Resident 38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 38's medical record was reviewed. According to the medical record, the MDS Assessments that had been completed on an annual and quarterly basis, revealed that multiple MDS Assessments had been submitted with a warningindicator by their dates. Two MDS Assessment records dated 9/8/17 and 3/11/18 were pulled for review. The MDS assessment dated [DATE] revealed the code: 3749A-warning and the message: Assessment Completed late. The MDS assessment dated [DATE] revealed the code: 3749A-warning and the message: Assessment Completed late. On 4/30/18 at 3:48 PM, an interview was conducted by the facility MDS Coordinator. The facility MDS Coordinator stated that the MDS assessment dated [DATE] had a target date of 9/22/17 but was submitted late on 10/9/17. The facility MDS Coordinator stated that the MDS assessment dated [DATE] had a target date of 3/25/18 but was submitted late on 3/27/18. On 4/30/18 at 3:48 PM, an interview was conducted with the facility MDS Coordinator. The facility MDS Coordinator stated that the warning indicator for the MDS assessments could be for a misspelled name or for a change for resident. The facility MDS Coordinator stated that the reason for the warning could be a validation report and could apply to residents transfers, acceptances, rejections, admissions, discharges, etc. The facility MDS Coordinator stated that she was busy, overwhelmed and that she submitted multiple MDS Assessments as well as care plans later than normal. The facility MDS Coordinator stated that each MDS Assessment would last 3-4 hours and that with a building the size of the facility, it was impossible for her to complete the MDS Assessments on time. The facility MDS Coordinator stated that she would have one facility member to help her for a few hours per week, but that lately that person had been pulled to do other things in the facility so she was working on the MDS Assessments herself.",2020-09-01
42,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2018-04-30,656,E,0,1,C87F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 2 of 43 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that included measurable objectives and timeframe's to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically resident's MDS and careplan contained conflicting information. Resident identifiers 7 and 18. Findings include: 1. Resident 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/18, Resident 18's medical record was reviewed. Resident 18's MDS section G0110 1B revealed that resident 18 required a 2+ person extensive assistance for transfers. Resident 18's care plan revealed that resident 18 required 1-2 extensive assistance for ADL's. 2. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/18, Resident 18's medical record was reviewed. Resident 7's MDS section G0110 1B revealed that resident 7 required a 2+ person extensive assistance for transfers. Resident 7's care plan revealed that resident 7 required extensive/max/total dependence of 1-2 persons. Cross Refer F-689",2020-09-01
43,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2018-04-30,657,D,0,1,C87F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined, for 1 of 43 sample residents, that the facility did not review and revise the comprehensive care plan. Specifically, one resident's care plan was not revised to reflect that a resident who had a tibia/fibula fracture, was placed as a non weight bearing status. Resident identifier: 37. Findings include: Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 at 4:30 PM, an interview was conducted with resident 37. Resident 37 stated that she had had a fall from an inappropriate transfer which resulted in a right tibia/fibula fracture. On 4/26/18 resident 37's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/26/18 at 22:49 (10:49 PM), X-ray results received per fax. Poss. (possible) Fx. (fracture) at RLE (right lower extremity). (Physician 1) called T.O. (telephone order) send res to E.R. (emergency room ) of choice for F/U. Daughter called, no answer, message left. Res is alert and oriented x 2. Res informed of report and trans (transport) to hospital. Res cant (sic) remember which hosp (hospital) she goes to. Res (resident) reports little pain at this time. PRN pain medication given r/t transport and repositioning. Daughter just returned call and stated (Name of Hospital) is fine. b. 1/27/18 at 00:15 (12:15 AM), 2330 (11:30 PM) (Name of Ambulance) here to trans res to (Name of Hospital) for X-rays to Rt lower leg. All HS (hour of sleep) and prn pain medication provided prior to trans. c. 1/27/18 at 3:14 AM, 0300 (3:00 AM) Res returned from hospital per (Name of Ambulance). Fx confirmed at RLE. F/U appt (appointment) to be made with (Physician 2) MD. Phone (phone withdrawn) ASAP (as soon as possible). Paperwork from Hospital states this Fx is non-operative. Res is to be non-wt (weight) bearing and leg should be protected during transfers. Res is alert and oriented. Res does not want a PRN pain pill. She states she just wants to go to sleep. ABX infusing at this time. Flushed without difficulty . The Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 37 required an extensive 2 person assistance with transfers. The ADL Care Plan dated 7/11/16 for resident 37, revealed the following: ADL Functional/Rehabilitation Potential Impaired mobility, generalized weakness and chronic pain with ROM impairments to BLE (bilateral lower extremities). Requires extensive assistance x 1-2+ staff for transfers, bed mobility. The Goal on the ADL Care Plan revealed that (Resident 37) will receive the assistance she needs to complete all ADL's and preferred routines Q (every) shift and as needed or requested. The Approaches included, Provide extensive assist x 1-2 for bed mobility, transfers, toileting, dressing, bathing and locomotion on/off unit (NOTE: The MDS Assessment and the care plan documented a discrepancy between a two person extensive assistance by facility staff and 1-2+ person extensive assistance by facility staff.) No documentation could be located in the medical record to show that facility staff revised the comprehensive care plan so that facility staff would know that resident 37 was a non weight bearing status. On 4/26/18 at 3:50 PM, an interview was conducted with the facility MDS Coordinator. The facility MDS Coordinator stated she was the only person to do the MDS Assessment for the entire facility and that she was overwhelmed. The MDS Coordinator stated that she was having a hard time completing the MDS Assessment and then updating the care plans to reflect the resident current status. The MDS Coordinator stated that the care plan should have been updated to reflect resident 37's non weight bearing status.",2020-09-01
44,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2018-04-30,684,D,1,1,C87F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review it was determined, for 2 of 43 sample residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, one resident's leg was not monitored after a fall and increase in pain and one hospice resident did not receive his medications and had to be sent back to the hospital. The deficient practice identified for the change in condition was found to have occurred at a harm level. Resident identifiers: 37 and 171. Findings include: 1. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 at 4:30 PM, an interview was conducted with resident 37. Resident 37 stated that she had had a fall from an inappropriate transfer which resulted in a right tibia/fibula fracture. On 4/26/18 resident 37's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/24/18 at 15:04 (3:04 PM), CNA (Certified Nursing Assistant) notified nurse for assistance with resident on floor. CNA states that during transfer when patient was on the bed that she was not quite far enough on the bed when slide board was removed and pt (patient) slid from bed to floor and landed on her buttocks and did not hit her head. Vitals taken and within normal limits. Pt assess (sic) before transfer and pt is able to bend knees and toes have good ROM (range of motion) with a minor increase in pain. Pt is also able to move bottom half of legs with some difficulty but normal ROM for patient. Pt transferred back into bed and skin check done with a little patch of [DIAGNOSES REDACTED] to knee and no other injuries noted. ROM continues to be normal for patient when assessed in bed. Patient continues to c/o (complain of) minor increase pain to right lower leg, [MEDICATION NAME] 5-325 mg (milligrams) administered and tolerated well. MD notified of fall and [DIAGNOSES REDACTED] to knee and increase in pain. No new orders at this time. ADON (Assistant Director of Nursing) notified. Resident is comfortable in bed at this time and will continue to monitor. b. 1/24/18 at 17:56 (5:56 PM), (Recorded as Late Entry on 1/26/18 at 23:59 (11:59 PM), Continue to check on patient often, Pt states pain medications are helpful for right leg pain. No changes to ROM or pain noted at this time. Pt appears comfortable in bed at this time and eating dinner. Will continue to monitor. c. 1/25/18 at 5:50 AM, Alert and oriented x (times) 3. Res reports ongoing UTI (urinary tract infection) symptoms. F/U (follow up) UA (urinalysis) at lab at this time. Midline remains in place at RUE (right upper extremity) flush without difficulty. One person ext. (extensive) ass (assistance) with brief changes. No s/s (signs/symptoms) injuries r/t (related to) recent fall. No increased pain r/t fall. VS (vital signs) = WNL (within normal limits). No changes noted. d. 1/25/18 at 1800 (6:00 PM), Resident is resting in bed and denies pain r/t the witness (sic) fall on 01/24/18, no skin issue noted or reported during this shift, IV (intravenous) Tigecycline administered per ordered (sic), the IV line is in place and with IV dressing intact on right arm, flushed with NS (normal saline) without problems, VS taken with (temperature) 97.3, (pulse) 67, (respirations) 16, (blood pressure) 111/66 and O2 (oxygen) sats (saturations) 92%, fluids applied and encouraged. e. 1/26/18 at 5:38 AM, IV ABX (antibiotic) infusion and flushes without difficulty. Afebrile, alert and oriented x 2 this shift. C/O pain at Rt (right) leg r/t recent fall. Reports about a 5/10 because they just changed me. No falls on this shift. No OOB (out of bed) on this shift. All PO (by mouth) meds as ordered and prn (as needed) pain medications provided and effective for pain res (sic). Res checked frequently throughout shift. Resting quietly most of Noc (night). WCTM (Will continue to monitor). f. 1/26/18 at 18:51 (6:51 PM), Resident c/o'd (complained of) increasing pain to right knee during giving nursing care, the right knee is bigger than left. It (sic) reported to (Physician 1). New order from (Physician 1) to X-ray to right knee and hip. X-ray was called in. Resident continues on IV ABX to treat UTI, no s/s of ASE (adverse side effects) noted, VS taken with (sic) T (temperature) 97.6, P (pulse) 63, R (respirations) 16, BP (blood pressure) 105/59 and O2 sats 91% on O2 3L (liters) via NC (nasal cannula). IV line is in place and with IV dressing intact to right arm, and flushed with NS without problems. g. 1/26/18 at 19:15 (7:15 PM), Received report from day nurse. Portable x-ray in rout (sic) for x-ray of Rt. hip and LOE (lower extremity). Res (Resident) is alert and oriented x 2. Res reports no pain at this time unless moved. Res informed of coming procedure. h. 1/26/18 at 22:49 (10:49 PM), X-ray results received per fax. Poss. (possible) Fx. (fracture) at RLE (right lower extremity) . No documentation could be located in the medical record to show that resident 37's right lower leg had been continuously monitored for changes after the fall on 1/24/18 after resident 37 had an increase in pain. Additionally, the facility staff did not order an X-Ray for resident 37's right lower extremity until 1/26/17, two days after the fall on 1/24/18, even though resident 37 had reported to facility staff that she had an increase in pain. 3. Resident 171 was admitted to the facility on [DATE] on hospice care with [DIAGNOSES REDACTED]. On 4/26/18 resident 171's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/24/18 at 15:55 (3:55 PM), Patient (pt) admitted to (Name of Facility) for hospice and comfort care. Discharge dx (diagnoses): hepatocellular [MEDICAL CONDITION]. Depression and/or anxiety features due to general medical condition; [MEDICAL CONDITION]. Past medical hx (history): DM; [MEDICAL CONDITION]; GERD; dementia. Hx of Hep ([MEDICAL CONDITION]) C; chronic back pain; hepatic [MEDICAL CONDITION] in (MONTH) (YEAR); portal vein [MEDICAL CONDITION]; DM II; [MEDICAL CONDITION]; perpheral [MEDICAL CONDITION]; DGD (unknown); resltless (sic) leg syndrome; hearing loss; abdominal aortic aneurysm; [MEDICAL CONDITION]; claudication; kidney stones; hx of UTIs (urinary tract infections). Patient is under (Name of Hospice) care/MD (Medical Doctor: (Name of MD). b. 1/24/18 at 18:55 (6:55 PM), Pt is alert and oriented to self only. Pt arrived to facility via (Name of Transportation). Pt admitted with liver failure and [MEDICAL CONDITION]. Pat being admitted to hospice upon arrival .Pt c/o (complains of) some belly pain r/t [MEDICAL CONDITION] .Pt has a history of aggressive behaviors while at home but have diminished since starting [MEDICATION NAME]. c. 1/24/18 at 19:09 (7:09 PM), Recorded as late entry on 1/25/18 at 7:13 PM, Discussed with Hospice nurse medications that they were D/C (discontinued). Informed hospice nurse that we had no medications for this res (resident) and we were waiting for hospice to supply. RN a/t (sic)be surprised at this and stated she would make a phone call re (regarding) med (medication) delivery. d. 1/25/18 at 6:13 AM, No medications have been delivered for this res. (Name of Hospice) to supply medications. e. 1/25/18 at 16:15 (4:15 PM), Resident is alert and orient (oriented) to self, is confusion (sic) and wandering to hallway, resident's room and outside of building, no c/o pain, no s/s of SOB, skin is W/D/I (warm, dry and intact), VS taken with T 98.0, P 83, R 18, BP 105/59, O2 Sats 94% on RA (room air), ate 100% of breakfast, good eating and drinking. LN was unable to administered (sic) medications for resident d/t (due to) resident's hospice pharmacy did not delivery (sic) his medications. LN called the hospice at 07:30 AM and had not received his medications. Resident was transferred to ER of (Name of Hospital) fur further evaluation r/t high elopement risk. Resident's spouse, (Name of Hospital) were notified, and the spouse came and got all resident's belongings. A discharge and Transfer - Physician Discharge Summary revealed the following: discharge date - 1/25/18 Discharge Time - 1615 (4:15 PM) Significant Changes in Condition - Increased confusion, elopement risk Final Diagnoses/Condition Upon Discharge - Stable, discharged to (Name of Hospital) for eval (evaluation) and treatment. Review of physician's orders [REDACTED]. a. [MEDICATION NAME] 300 mg (milligrams) TID (three times daily) for [MEDICAL CONDITION] b. [MEDICATION NAME] 10 gm (grams)/15 ml (milliliters); 45 ml (30 grams total) TID for [MEDICAL CONDITION] c. [MEDICATION NAME] 1000 mg QD (every day) at dinner time for DM d. [MEDICATION NAME] 40 mg QD before breakfast e. [MEDICATION NAME] 25 mg QHS (bedtime) for [MEDICAL CONDITION] m/b (manifested by) episodes of uncontrollable anger f. [MEDICATION NAME] 25 mg QD for ascites g. [MEDICATION NAME] 550 mg BID for hepatic [MEDICAL CONDITION] h. [MEDICATION NAME] 10 mg rectally QD prn (as needed) i. Fleet Enema 19.7 gm/118 ml rectally QD prn j. Milk of Magnesia 400 mg/5 ml, administer 30 ml (2400 mg total) QD prn k. Tylenol 325 mg 2 tabs (650 mg total) Q 4 hrs prn for general pain The Medication Administration Record [REDACTED]. On 4/25/18 at 1:11 PM, an interview was conducted with the (Name of Hospice) receptionist. The (Name of Hospice) receptionist stated that resident 171 had been admitted under their care for hospice services and that resident 171 had been sent back to the ER because his medications had not been delivered. The (Name of Hospice) receptionist stated that she was unaware of the circumstances and would call me back. The (Name of Hospice) receptionist stated that they would have supplied an [NAME] (emergency) kit for resident 171 which contained [MEDICATION NAME] and [MEDICATION NAME]. On 4/25/18 at 1:55 PM, an interview was conducted with the facility DON and the facility Corporate Nurse (CN). The facility DON and the facility CN stated that they should have followed up on the medications and that going to a different pharmacy to get resident 171's medications would have been a good idea. The facility DON stated that they had actually paid for medications before for a resident when medications had not come in but did not think of that. On 4/25/18 at 2:38 PM, an interview was conducted with the Hospice RN (HRN). The HRN stated that they had no notification that the medications had not been delivered to the facility until the morning of 7/25/18. The HRN stated that they felt terrible. The HRN stated that they had either had a software failure or the nurse had not hit the send button when the medications were ordered and that their pharmacy never got the order for the medications. Cross Refer to F-689 and F-849",2020-09-01
45,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2018-04-30,689,G,1,1,C87F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and medical record review, it was determined for 3 of 43 sample residents, that the facility did not ensure that the resident environment remains as free of accident hazards as is possible. Specifically, one resident was transferred via use of a sliding board by a CNA (Certified Nursing Assistant) who had received no training for the transfer. In addition, observations were made of a laundry chute that was unlocked and unattended, two chemicals were found in an unlocked and unattended housekeeping closet and multiple oxygen tanks were found to be stored near an exit doorway as well as empty and full oxygen tanks being stored in the same closet. Resident identifiers: 7, 56 and 37. Findings include: HARM 1. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 at 4:30 PM, an interview was conducted with resident 37. Resident 37 stated that she had had a fall from an inappropriate transfer which resulted in a right tibia/fibula fracture. On 4/26/18 resident 37's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/24/18 at 15:04 (3:04 PM), CNA (Certified Nursing Assistant) notified nurse for assistance with resident on floor. CNA states that during transfer when patient was on the bed that she was not quite far enough on the bed when slide board was removed and pt (patient) slid from bed to floor and landed on her buttocks and did not hit her head. Vitals taken and within normal limits. Pt assess (sic) before transfer and pt is able to bend knees and toes have good ROM (range of motion) with a minor increase in pain. Pt is also able to move bottom half of legs with some difficulty but normal ROM for patient. Pt transferred back into bed and skin check done with a little patch of [DIAGNOSES REDACTED] to knee and no other injuries noted. ROM continues to be normal for patient when assessed in bed. Patient continues to c/o (complain of) minor increase pain to right lower leg, [MEDICATION NAME] 5-325 mg (milligrams) administered and tolerated well. MD notified of fall and [DIAGNOSES REDACTED] to knee and increase in pain. No new orders at this time. ADON (Assistant Director of Nursing) notified. Resident is comfortable in bed at this time and will continue to monitor. b. 1/24/18 at 17:56 (5:56 PM), (Recorded as Late Entry on 1/26/18 at 23:59 (11:59 PM), Continue to check on patient often, Pt states pain medications are helpful for right leg pain. No changes to ROM or pain noted at this time. Pt appears comfortable in bed at this time and eating dinner. Will continue to monitor. c. 1/25/18 at 5:50 AM, Alert and oriented x (times) 3. Res reports ongoing UTI (urinary tract infection) symptoms. F/U (follow up) UA (urinalysis) at lab at this time. Midline remains in place at RUE (right upper extremity) flush without difficulty. One person ext. (extensive) ass (assistance) with brief changes. No s/s (signs/symptoms) injuries r/t (related to) recent fall. No increased pain r/t fall. VS (vital signs) = WNL (within normal limits). No changes noted. d. 1/25/18 at 1800 (6:00 PM), Resident is resting in bed and denies pain r/t the witness (sic) fall on 01/24/18, no skin issue noted or reported during this shift, IV (intravenous) Tigecycline administered per ordered (sic), the IV line is in place and with IV dressing intact on right arm, flushed with NS (normal saline) without problems, VS taken with (temperature) 97.3, (pulse) 67, (respirations) 16, (blood pressure) 111/66 and O2 (oxygen) sats (saturations) 92%, fluids applied and encouraged. e. 1/26/18 at 5:38 AM, IV ABX (antibiotic) infusion and flushes without difficulty. Afebrile, alert and oriented x 2 this shift. C/O pain at Rt (right) leg r/t recent fall. Reports about a 5/10 because they just changed me. No falls on this shift. No OOB (out of bed) on this shift. All PO (by mouth) meds as ordered and prn (as needed) pain medications provided and effective for pain res (sic). Res checked frequently throughout shift. Resting quietly most of Noc (night). WCTM (Will continue to monitor). f. 1/26/18 at 18:51 (6:51 PM), Resident c/o'd (complained of) increasing pain to right knee during giving nursing care, the right knee is bigger than left. It (sic) reported to (Physician 1). New order from (Physician 1) to X-ray to right knee and hip. X-ray was called in. Resident continues on IV ABX to treat UTI, no s/s of ASE (adverse side effects) noted, VS taken with (sic) T (temperature) 97.6, P (pulse) 63, R (respirations) 16, BP (blood pressure) 105/59 and O2 sats 91% on O2 3L (liters) via NC (nasal cannula). IV line is in place and with IV dressing intact to right arm, and flushed with NS without problems. g. 1/26/18 at 19:15 (7:15 PM), Received report from day nurse. Portable x-ray in rout (sic) for x-ray of Rt. hip and LOE (lower extremity). Res (Resident) is alert and oriented x 2. Res reports no pain at this time unless moved. Res informed of coming procedure. h. 1/26/18 at 22:49 (10:49 PM), X-ray results received per fax. Poss. (possible) Fx. (fracture) at RLE (right lower extremity). (Physician 1) called T.O. (telephone order) send res to E.R. (emergency room ) of choice for F/U. Daughter called, no answer, message left. Res is alert and oriented x 2. Res informed of report and trans (transport) to hospital. Res cant (sic) remember which hosp she goes to. Res reports little pain at this time. PRN pain medication given r/t transport and repositioning. Daughter just returned call and stated (Name of Hospital) is fine. i. 1/27/18 at 00:15 (12:15 AM), 2330 (11:30 PM) (Name of Ambulance) here to trans res to (Name of Hospital) for X-rays to Rt lower leg. All HS (hour of sleep) and prn pain medication provided prior to trans. j. 1/27/18 at 3:14 AM, 0300 (3:00 AM) Res returned from hospital per (Name of Ambulance). Fx confirmed at RLE. F/U appt (appointment) to be made with (Physician 2) MD. Phone (phone withdrawn) ASAP (as soon as possible). Paperwork from Hospital states this Fx is non-operative. Res is to be non-wt (weight) bearing and leg should be protected during transfers. Res is alert and oriented. Res does not want a PRN pain pill. She states she just wants to go to sleep. ABX infusing at this time. Flushed without difficulty . An X-Ray report dated 1/26/18 at 19:27 (7:27 PM) revealed that Bones: Two views were obtained with limited positioning. There is a nearly [MEDICATION NAME] oriented [MEDICAL CONDITION] right tibial metaphysis without any obvious displacement on this AP (anterior-posterior) radiograph. There is also a [MEDICATION NAME] oriented adjacent acute [MEDICAL CONDITION] right fibula but this appears to be associated with an area of old healed fracture as well. There is an old healed [MEDICAL CONDITION] fibular diaphysis .Impression: Acute nondisplaced fractures of the proximal right tibia and fibula although radiographic evaluation is limited . A facility Event Report dated 1/24/18 at 14:44 (2:44 PM) revealed that the investigation of the fall was completed on 1/25/18 and closed on 1/31/18. The Event Report revealed the following: Fall Summary: Intercepted fall (resident eased to the floor). Location of Fall: Resident Room. Shift when Occurred: Day. Activity during or just prior to fall: Transfer assisted by staff. Was fall witnessed: Yes By Whom: (CNA 1). Does resident exhibit or complain of pain related to the fall? If so, describe location. Yes, location right lower leg. On a scale of 0-10, how does resident rate intensity of pain if able or indicate based on observation. 5-6: Moderate Pain Note any injury to the head, extremities, or trunk. No injury noted. Does the resident exhibit or complain of the following: Weakness. Range of Motion: ROM X 4 without pain/limitations. Positioning of extremities: Rotation/Deformity/Shortening of Right Lower Extremity. Level of Consciousness: Alert wakefulness - Perceives the environment clearly and responds appropriately to stimuli . Speech: Clear - Distinct, intelligible words . Last toileted: 1400 (2:00 PM). Resident continence status at time of fall: Wet . Did resident complain of, experience or be observed with any of the following prior to/at time of fall: Lost strength/appeared to get weak . Were restraints/devices in use at the time of the fall: Yes - slide board . IDT Notes: Resident status prior to event (assessment): During transfer using sliding board, patient slid on the floor. No injury noted at that time. Risk Factors: MS ([MEDICAL CONDITION]); [MEDICAL CONDITIONS]; [MEDICAL CONDITION]; history of venous [MEDICAL CONDITION] and embollsm (sic); TIA ([MEDICAL CONDITION]); CKD ([MEDICAL CONDITION]); urine retention; [MEDICAL CONDITIONS]; OSA ([MEDICAL CONDITION]); [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION];[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease); hx (history) of recurrent UTIs (urinary tract infections). Use of sliding board per order. Preventive measures prior to even: sliding board use as per order. Care plan risk factors and interventions: The following areas reviewed: progress notes; orders; care plans . Resident/Staff Education: Root Cause: CNA removed sliding board thinking patient is sitting at the edge of the bed New Interventions Implemented: RP (unknown) MD informed; ROM and skin check assessment; CNA to have 1:1 with PT (physical therapy)/OT (occupational therapy) to review transfers using sliding beard (sic), care plan update. The Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 37 required an extensive 2 person assistance with transfers. The ADL Care Plan dated 7/11/16 for resident 37, revealed the following: ADL Functional/Rehabilitation Potential Impaired mobility, generalized weakness and chronic pain with ROM impairments to BLE (bilateral lower extremities). Requires extensive assistance x 1-2+ staff for transfers, bed mobility. The Goal on the ADL Care Plan revealed that (Resident 37) will receive the assistance she needs to complete all ADL's and preferred routines Q (every) shift and as needed or requested. The Approaches included, Provide extensive assist x 1-2 for bed mobility, transfers, toileting, dressing, bathing and locomotion on/off unit (NOTE: The MDS Assessment and the care plan documented a discrepancy between a two person extensive assistance by facility staff and 1-2+ person extensive assistance by facility staff.) A New Employee Orientation Checklist dated 1/15/18 for CNA 1 revealed that CNA 1 had been oriented regarding using gait belts for transferring residents safely and the proper way to use mechanical lifts such as a hoyer lift and sit to stand lift. No documentation could be located in the employee file to show that CNA 1 had been trained to safely use a sliding board for transfers. On 4/26/18, a written statement by CNA 1 was provided by the facility DON. The written statement revealed, Nurse needed (Resident 37) into bed, I was notified she was a 1 person transfer on board. We fixed her shirt for a transfer into bed, she wanted to rest. I fixed her wheelchair to (sic) close to her bed and place (sic) transfer board under her leg and on her bed. Transferred (sic) with barrer (sic) weight 100 %. She tried to help me tranfer (sic) her but got to (sic) weak, she was already on the board between her wheelchair and bed, we tried (sic) to transfer again from same position but slid forward onto my weight and slid off board. Called for help while she was barring her weight on me and no one came. No one came to help, after the fall, she slowly slid on to floor. The Inservice Training/Seminar Report regarding Slide Board Transfer Review that accompanied CNA 1's written statement was dated 1/28/18, four days after resident 37's fall from the sliding board transfer. On 4/26/18, a form that was not dated was provided by the TD for safety measures for resident 37 revealed the following: a. Precautions: falls, skin integrity b. Assistive Devices: FWW (Front Wheeled Walker), slide board, power w/c (wheelchair). c. Transfers: Ext (extensive) A (assistance) x 1 person using FWW or slide board. d. Comments: Sometimes (Resident 37) is having a weaker day than normal. She will let you know when she wants to use the slide board, instead of the FWW. On 4/26/18 at 1:00 PM, an interview was conducted with the TD. The TD stated that the undated form was some training that was provided to CNA 1 after resident 37's fall. No documentation could be located in the medical record to show that CNA 1 had been trained regarding safe practices when using a sliding board for transfers. On 4/26/18 at 1:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she heard a loud thud the day of resident 37's fall and that CNA 1 started yelling. LPN 1 stated that she went right into the room and assessed resident 37 for injuries. LPN 1 stated that the sliding board had not been placed correctly onto the bed and subsequently had become loose from the bed. LPN 1 stated that resident 37 was not on the bed far enough and started to fall and that CNA 1 lowered her to the floor. LPN 1 stated that her assessment for injuries consisted of placing her hand on resident 37's hip and then bending her right leg up and down at the knee, to see if she could feel any popping out of the hip. LPN 1 stated that she was able to know if there was a problem with her hip if there was popping out. LPN 1 stated that resident 37 was picked up off of the floor to a standing position and assisted back to bed. LPN 1 stated that the CNAs were aware of the transfer needs by resident 37 because they were in a binder at the nursing station. (NOTE: The transfer needs available in the binder were the current needs for resident 37.) LPN 1 stated that the previous paperwork for resident 37's needs had been shredded. On 4/26/18 at 2:00 PM, an interview was conducted with the Therapy Director (TD). The TD stated that therapy would change out the paperwork in the CNA binders at the nursing stations and that the paperwork was there to inform the CNA staff of the transfer needs for the residents. The TD stated that he no longer had a copy of the assistance that was required for resident 37 prior to resident 37's fall on 1/24/18. The TD provided physical therapy notes dated 12/20/18 which revealed a short term goal for resident 37 that Pt will perform sliding board transfer bed w/c (wheelchair) safely w (with)/CNAs and therapy. The target date for the goal was 1/16/18. The TD stated that there had not been any training provided to the CNA staff regarding sliding board transfers but that a lot of the CNAs in the facility have been here for [AGE] years and know how to do sliding board transfers. On 4/26/18 at 2:35 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 confirmed that there was paperwork that detailed the resident's needs for transfers and that the had been kept in a binder at each nursing station. RN 1 stated that all the paperwork was updated as the resident's needs changed and confirmed that the previous paperwork for resident 37's transfer needs in (MONTH) (YEAR) had been shredded. RN 1 stated that because the needs of the residents change so often, that the old paperwork was no longer needed. On 4/26/18 at 3:50 PM, an interview was conducted with the facility MDS Coordinator. The facility MDS Coordinator stated that she obtained her information from documentation from the CNA staff as well as the nursing staff to complete the MDS section G for Functional Status. The facility MDS Coordinator stated that the slide board transfer training had not been provided to the CNA staff and that the CNA staff should never have been attempting to transfer resident 37 with the slide board. The facility MDS Coordinator stated that the slide board transfer training had only been provided to the RNA (Restorative Nursing Assistant) staff. The facility MDS Coordinator confirmed that the staff member that had attempted to transfer resident 37 just prior to the fall on 1/24/18 was a CNA and that she should never have attempted the transfer with resident 37. On 4/26/18 at 4:45 PM, an interview was conducted with Resident 37. Resident 37 stated that she remembered the fall on 1/24/18. Resident 37 stated that the sliding board had not been properly placed on the bed and that when it became loose, CNA 1 pulled the sliding board out from the bed and she fell on her knee. Resident 37 stated that she had been unable to stand on her leg when the nursing staff helped her off the floor because she had severe pain in her right leg after the fall. Potential for Harm 2. Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 resident 56's medical record was reviewed. A History and Physical (H&P) dated 12/13/18 at 1:04 PM revealed that resident 56 was admitted with altered mental status and hepatic [MEDICAL CONDITION] which was treated with [MEDICATION NAME]. Nursing progress notes revealed the following episodes of confusion and altered mental status: a) 12/19/17 at 12:47 AM, resident had critically high serum ammonia level of 140. b) 12/20/17 at 9:17 AM, staff reported that res (resident) refused breakfast this am, nurse went in to check Res and he reports that he didn't refuse breakfast .when nurse returned to the room .res yelled what after she called his name, he states that nurse was bothering him .nurse tried to recheck his BP (blood pressure) after first check was 85/50 .and he refused and started saying to 'go away.' c) 12/20/17 at 10:15 AM, (resident 56) is more confused and lethargic today d) 12/20/17 at 10:23 AM, (resident 56) couldn't recall talking to MD before nurse returned to the room. e) 12/24/17 at 1:07 PM, Resident was found standing next to the toilet .staring at the wall. facial twitching noted. Resident responded inappropriately to every other question with WHAT DO YOU WANT?! slight bilateral tremors noted BUE (bilateral upper extremities) .Nurse assisted resident to his bed requiring 1 person extensive assist f) 12/24/17 at 6:27 PM, Resident was found urinating on heating vents .when asked what he was doing residents only response was WHAT! Nurse attempted to move patient away from the area, resident began swinging his arms .Nurse assisted resident back to bed .requiring 1 person extensive assist .Due to residents cognition needs were anticipated, attempted to change his soiled clothes the resident swung his arm hitting CNA on her ribs .Resident alert and oriented to self. when asked why he hit the CNA his only response was WHAT! pupils were dilated, exhibited facial ticks, BUE involuntary tremors, Unable to follow simple commands . g) 12/28/17 at 10:14 AM, (resident) requires supervision for transfers, bed mobility, toileting and meals. h) 1/1/18 at 11:01 PM, Resident is acting exceedingly confused tonight .(resident) was repeatedly trying to get out one of the rear doors, entering the wrong door codes several times in a row, and unable to enter the appropriate code even when another resident related the proper code to him. Resident was unable to verbalize why he wanted to go outside .Resident was repeating back bits and pieces of Nurse's speech. Displayed short bursts of angry behavior, followed by laughter .Also noted rocks and mud in water, in a cup in his bathroom. Asked resident why he had that, and he stated that it was so that he could 'check up on the staff.' i) 1/1/18 at 11:14 PM, Ammonia drawn with some difficulty. Nurse and CNA escorted Lab Tech to Resident's room, given the concern about violent behavior. Resident began yelling at lab tech, but then agreed to allow draw if brought a cup of juice. Nurse quickly obtained orange juice per his request, and resident agreed to allow draw. Juice was handed to CNA Resident stated The juice is TOO CLOSE!!! and CNA held the juice farther back. Then he stated, I can't see it now! and orange juice was brought closer. At which point, (resident) grabbed juice from CNA's hand, nearly spilling it, before quickly drinking it down. CNA instructed to perform frequent checks on Residents. Nurse plans to do so as well. j) 1/2/18 at 8:50 AM, (resident) responds to questions with what .visible tremors in right hand noted. Res does not answers (sic) to questions appropriately, hen (sic) .he move his hand toward nurse as he attempted to hit her . k) 1/2/18 at 1:27 PM, Res continues to have generized (sic) tremors, not following commands, responds to voice but only answers what to questions. Res was found standing in front of the sink, holding on to top of mirror. two person extensive assist needed to get him back to his bed, when nurse attempted to give his med, he continued to move his head from left to right and then lay back down . l) 1/3/18 at 1:01 AM, Resident continues to display confused behavior .confused about time .Resident ambulated down the hall and defecated on the carpet .Now grunting and grimacing as if he is in pain, but states he does not want any medications. This is unusual behavior for this resident .CNA and Nurse making frequent and regular checks upon resident. m) 1/3/18 at 9:36 AM, Res is alert and awake to name only. when ask (sic) about situation, place or time, res stays quiet and keeps eating .visible tremors noted to bil (bilateral) hands, unsteady gait when ambulating .res has been seen getting out of bed on his own at time, staff immediately in room to help d/t fall risk. Res required two person extensive assist for transfers . n) 1/6/18 at 12:20 AM, monitoring continues r/t recent episodes of tremors/lethargy/change in mental status . o) 2/1/18 at 2:40 AM, (resident) stated he had fallen in his room .(he) stated he was getting up from chair and went down onto his bottom. asked how he went down, pt stated that his feet went out from under him and he landed on his bottom . p) 2/1/18 at 9:55 AM, (resident) appears lethargic, oriented to name only, will answer silvers when asked for the year .visible hand tremors noted .res requires supervision for transfers, bed mobility and toileting .mental status has changed from baseline . q) 2/2/18 an IDT note investigating the fall on 2/1 at 2:40 AM revealed (the resident) states his legs were weak and did not realize it until he stood up frequent visual check by LNs and CNAs due to patient intermittent confusion . r) 2/3/18 at 3:07 AM, entered room to find pt standing at door to BR (bathroom or bedroom) in a puddle of urine, noted confusion w/ pt, pt is responsive verbal/tactile stimuli, doesn't answer questions . s) 2/3/18 at 6:28 AM, (resident) continued to not answer questions . t) 2/3/18 at 6:46 PM, .patient was sitting on toilet he has eyes closed, he will answer questions when shaken but gets irritated when you shake him to answer questions . u) 2/26/18 at 9:46 AM, pt with twitching movement to bil (bilateral) hands and legs, responds to voice but unable to follow commands properly v) 2/26/18 at 6:08 PM, (resident) requires extensive assist from staff for ADL's . w) 2/27/18 at 8:34 AM, (resident) reports that yesterday 'I was out of it' x) 3/14/18 at 10:15 AM, pt appears oriented with slow mentation . y) 3/14/18 at 7:00 PM, this nurse noted that pt appeared to (sic) drowsy/sedated z) 3/14/18 at 8:56 PM, pt appears to continue w/ drowsiness/sedated behavior .told pt we were concerned and that he appeared to be behaving differently . aa) 3/18/18 at 10:31 AM, pt with slight tremors, standing in front of toilet, does note (sic) follow commands, just states to leave him alone . bb) 3/19/18 at 1:02 AM, Resident .with variable sense of time, but confusion and forgetfulness . cc) 3/23/18 at 5:22 AM, res on floor .when asked what happened, res replied what. When asked res's (sic) name, res replied what. res continued to reply what to all questions asked dd) 3/23/18 at 5:56 AM, Resident continues to appear to be drowsy/lethargic, wont grasp hands when prompted or push w/ feet when prompted . ee) 3/23/18 at 8:00 AM, Resident remained lethargic in bed .resident is incontinent of bladder, currently wearing brief Resident is unable to respond to simple questions. His only response to any question is 'What' . ff) 3/23/18 at 12:00 PM, Resident is still lethargic and unable to appropriately respond to simple questions. resident remains incontinent of bladder .needs are anticipated by staff due to cognition . gg) 3/23/18 at 7:01 PM, (resident) .does not elaborate .nor does he make eye contact Resident is exhausted and has stayed in bed the whole shift .Resident requires 1 person extensive assist with transfers, toileting, bed mobility and hygiene. hh) 3/23/18 at 10:08 PM, res appears to continue w/ drowsiness. res has been up and ambulating w/ assist to BR and back to bed. res is .providing some verbal response to questions like 'what', 'yeah' . ii) 3/30/18 at 8:16 PM, resident does not remember and is unaware of his lethargic state .Resident stated he needed to go out to buy a phone, make a stop to (Grocery Store) to buy some snacks. Resident was gone for 5 hours. leaving at 1130 and returning at 5:15 PM. Resident left again around 5:45 stated he was going to (Name of Restaurant) to get a malt shake and he has not returned . 3/30/18 at 9:13 PM, res returned to facility at approx (approximately) 2030 (8:30 PM) w/ groceries in hand . jj) 3/29/18 at 3:31 PM, Resident is lethargic and unable to follow simple instructions, When asked how he feels resident will only reply 'WHAT?!' Resident unable to swallow pills and refused to eat due to his condition. Involuntary bilateral tremors noted to BUE, Resident is B&B incontinent . kk) 4/7/18 at 12:38 PM, Pt had good sleep from 1100 am till now . ll) 4/7/18 at 4:56 PM, Pt slept most afternoon (sic) . mm) 4/7/18 at 6:00 PM, Pt was very lethargic .aid (sic) down in roommate's bed around 1700 PM. 3 staff tried to persuade Pt to go back to his own bed. Pt agreed to go back to his own bed, sat up, but could not stand up by self, refused to be touched, then refused to go back to his own bed. Pt sat in bed with eyes closed, high fall risk. Nearly half an hours (sic), staffs (sic) held Pt's arms, Pt stepped to his bed nn) 4/8/18 at 11:13 AM, Resident .had episode of lethargic (sic) and hospice came in and assessed resident. oo) 4/13/18 at 8:52 AM, pt is laying perpendicular to the bed, attempting to stand it (sic) up on his own, answers 'what' to every question, visible tremors, unable to take meds at this time d/t risk of aspiration. pt was assisted up and lay in bed properly . pp) 4/13/18 at 1:00 PM, .pt continues be (sic) lethargic, tremors, unsteady gait when ambulates. pt required two person assist to go back to bed after attempting to get up to go to the bathroom . qq) 4/19/18 at 2:28 PM, Pt has been lethargic today Pt urinated on the floor and attempted to redirect patient .Hospice states he has been having more episodes similar to this lately . rr) 4/20/18 at 8:46 AM, pt resting in bed .unable to follow commands .does not answer questions accordingly meds were held this am ss) 4/23/18 at 10:59 AM, He was comatose last Thursday and Friday . tt) 4/24/18 at 8:54 AM, Res. noted to have ST (slight tremor) to posterior left hand .Res. reports he obtained it when he passed out. Res. dose (sic) not recall when he 'passed out.' . A review of resident 56's Medication Administration Record [REDACTED]. The resident did not take medications on the following dates: a) 2/3 Not administered: due to condition. Comment: not able to wake up enough to swallow meds. b) 3/23 Not administered: due to condition. Comment: Resident lethargic unable to take meds. Notified hospice., c) 3/24 Not administered: Refused. Comment: Pt very sleepy. Hospice notified., d) 3/29 Not Administered: Due to condition. Comment: Lethargic and unable to swallow., e) 4/1 Not Administered: Due to condition. f) 4/13 Not administered: Other. Comment: Pt unable to swallow. g) 4/19, Not administered: Due to condition. Comment: resident is very drowsy; meds held. h) 4/20 Not administered: Other. Comment: clinical decision. On 4/25/18, a log of when resident 56 left the facility was obtained. The following entries were identified on the log: a) Sign out: 12/14/17 at 11:00 AM. Return: 2:20 PM b) Sign out: 12/18/17 at 2:27 PM. No return time recorded c) Sign out: 12/18/17 at 2:45 PM. Return: 4:10 PM d) Sign out: 12/30/17 at 10:35 AM. Return: 1:00 PM e) Sign out: 12/31/17 at 11:55 AM. Return: 2:15 PM f) Sign out: 1/5/18 at 12:55 PM. Return: 7:50 PM g) Sign out: 1/6/18 at 12:30 PM. Return: 4:15 PM h) Sign out: 1/8/18 at 4:10 PM. Return: 7:30 PM i) Sign out: 1/10/18 at 11:15 AM. No return time recorded j) Sign out: 1/10/18 at 1:45 PM. Return: 7:40 PM k) Sign out: 1/11/18 at 11:10 AM. Return: 6:40 PM l) Sign out: 1/12/18 at 1:15 PM. Return: 3:30 PM m) Sign out: 1/14/18 at 12:15 PM. Return: 5:55 PM n) Sign out: 1/16/18 at 12:50 PM. No return time recorded o) Sign out: 1/18/18 at 7:50 PM. No return time recorded p) Sign out: 1/19/18 at 3:20 PM. No return time recorded q) Sign out: 1/24/18 at 5:00 PM. No return time recorded r) Sign out: 1/28/18 at 12:30 PM. Return: 2:15 PM s) Sign out: 1/31/18 with no sign out or return time recorded t) Sign out: 2/11/18 at 6:15 PM. Return: 8:50 PM u) Sign out: 2/13/18 at 2:45 PM. Return: 8:20 PM v) Sign out: 3/1/18 with no sign out or return time recorded w) Sign out: 3/30/18 with no sign out or return time recorded x) Sign out: 3/30/18 with no sign out or return time recorded y) Sign out: 4/3/18 at 9:00 AM. No return time recorded z) Sign out: 4/5/18 at 11:45 AM. No return time recorded aa) Sign out: 4/5/18 at 7:40 PM. No return time recorded bb) Sign out: 4/9/18 at 9:30 AM. No return time recorded cc) Sign out: 4/11/18 at 1:40 PM. Return: 2:14 PM dd) Sign out: 4/16/18 with no sign out or return time recorded ee) Sign out: 4/22/18 at 2:30 PM. No return time recorded ff) Sign out: 4/23/18 at 2:00 PM. No return time recorded While reviewing the progress notes, it was revealed that the resident had left the facility without documenting when he left or returned on the sign out log. The following occurrences were identified in the progress notes: a) 3/21/18 at 7:25 PM, Resident left LOA (leave of absence) this morning stated he was going to (Church Property). last Pain medication was given around 8 am. resident left facility at 1045. Resident returned at 1530, stated he had a lot of fun. resident laughed and joked and stated he was in a lot of pain 10/10. administered prn pain medication granting positive results to the resident . b) 3/27/18 at 6:00 PM, pt arrived to facility after being gone a couple hours. pt stated to nurse that he fell when he was in a department store. described i",2020-09-01
46,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2018-04-30,725,E,1,1,C87F11,"> Based on observation, interview and record review it was determined, for 7 of 43 sample residents, that the facility did not provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psycohosical well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diganosis of the facility's resident population in accordance with the facility assessment. Specifically, residents complained to the surveyors and in resident council meetings about the staffing level, and waiting time required for the call lights to be answered. Resident identifiers: 1, 2, 22, 30, 39, 60 and 62. Findings include: 1. On 4/23/18 at 11:49 AM, an interview was conducted with resident 22. Resident 22 stated that she felt that the facility did not have enough staff. Resident 22 stated that after she would use her call light, she would wait for half an hour or longer for someone to respond. Resident 22 stated that the staffing was worse in afternoon hours and on weekends. 2. On 4/23/18 at 4:10 PM, an interview was conducted with resident 2. Resident 2 stated that the facility did not have enough staff available. Resident 2 stated that the facility had no consistency with staffing and that some days the facility would have multiple agency staff who would not know the residents or what to do with them. Resident 2 stated that he would wait for an hour or longer at times for someone to help him out of the bed and to his wheelchair. Resident 2 stated that the administration was aware of this problem because residents would mention the staffing issue during resident council meetings. Resident 2 stated that often the staff would walk into a room, would turn the call light off and inform the resident that they would be back in few minutes, then never return. Resident 2 stated that the call light would have to be reactivated. 3. On 4/26/18 at 6:10 PM, an interview was conducted with resident 39. Resident 39 was observed to be sitting on her bed with the call light on the floor. Resident 39 stated that the facility should have more staff available. Resident 39 stated that most of the time the staff would respond to her call light in 10-15 minutes. Resident 39 stated that sometimes the staff would walk into her room, turn the call light off and would say that they would come back. Resident 39 stated that the staff would never return until approximately 45 minutes later or not come back at all. 4. On 4/26/18 at 6:20 PM, an interview was conducted with resident 60. Resident 60 stated that the facility needed more staff. Resident 60 stated that he would wait for long periods of time for the call light to be answered, some days 30 minutes or more. Resident 60 stated that most of the staff were good and wanted to help, but they would be just very busy all the time. 5. On 4/26/18 at 6:25 PM, an interview was conducted with resident 62. Resident 62 stated that the facility did not have enough staff available and that people in the building would wait for long periods of time for someone to respond to their call lights. 6. On 4/26/18 at 6:32 PM, an interview was conducted with resident 1. Resident 1 stated that the facility and residents could benefit from more staff. Resident 1 stated that he waited for his call light to be answered for up to an hour. Resident 1 stated that the staff would sometimes come into the room only to turn the light off, tell them that they would be back in few minutes and that they would never come back until the call light was reactivated or would came back few hours later. Resident 1 stated that the facility would have agency staff coming to help very often and he did not like that because the majority of the agency staff would not know the residents or how to perform certain tasks. Resident 1 stated that it was hard on the residents but also the facility staff who would need to train the agency staff and to be pulled away from their regular duties. 7. On 4/26/18 at 6:40 PM, an interview was conducted with resident 30. Resident 30 stated that the facility had a problem with the staffing and that she would wait for long periods of time for someone to answer her call light when she would need help. On 4/30/18 at 6:00 PM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that if someone would call in sick or have an emergency, then they would be short staffed. RN 5 stated that the facility would use agency staff to fill openings in the schedule and that she (RN 5) would spend half of her shift training them what to do so she would not be able to finish her own tasks. RN 5 stated that they would always benefit from few extra people. On 4/30/18 at 3:18 PM, an interview was conducted with RN 7. RN 7 stated that she had recently hired on full time with the facility, but that she had worked as an agency nurse in the facility prior to her full time job. RN 7 stated that when she worked as an agency nurse, she had maybe 20 minutes of training before she was working the floor, and that training consisted of computer program training only. RN 7 stated that she had not had any training except for the computer program. On 4/30/18 at 2:30 PM, and interview was conducted with the facility Director of Nursing (DON). The facility DON stated that they had enough staff available. The DON stated that their staffing schedule was created based on the census. The DON stated that they would have agency staff from time to time, but that they tried to have less and less of them. The DON stated that it was hard to keep good employees, that they would pay their staff really well, and that people would go to work somewhere else or would quit their jobs for different reasons. The DON stated that they were always hiring. On 4/26/18 at 2:03 PM, an interview was conducted with resident council attendants. The residents complained that call lights go unanswered. One resident stated my legs have gone numb on the toilet while waiting for someone to come. Another stated I timed them and it once took them an hour and thirty five minutes to attend to me Another stated We try to use the call lights, but they're much more responsive to yelling. We feel bad about it but you got to holler when you got to holler.",2020-09-01
47,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2018-04-30,726,E,1,1,C87F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, it was determined for 11 of 43 sample residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility must ensure that licensed nurses have the specific competencies and skill set necessary to care for residents' needs as identified through resident assessments, and described in the plan of care. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs. Specifically, one resident was transferred via a sliding board resulting in a tibial/fibula fracture without the CNA (Certified Nursing Assistant) staff being trained for sliding board transfers, one resident who twisted her ankle and sustained a tibial/fibula fracture was not reported to licensed nursing staff and one resident's change in condition did not get reported to oncoming nursing staff. Additionally, multiple residents medications were either not administered or administered late due to facility staff having to help and train agency staff and residents complained about the issues in resident council meetings. Resident identifiers: 1, 2, 4, 18, 22, 30, 37, 39, 60, 62 and 170. Findings include: 1. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 4:30 PM, an interview was conducted with resident 37. Resident 37 stated that she had had a fall from an inappropriate transfer which resulted in a right tibia/fibula fracture. On [DATE] resident 37's medical record was reviewed. Nursing progress notes revealed the following entries: a. [DATE] at 15:04 (3:04 PM), CNA (Certified Nursing Assistant) notified nurse for assistance with resident on floor. CNA states that during transfer when patient was on the bed that she was not quite far enough on the bed when slide board was removed and pt (patient) slid from bed to floor and landed on her buttocks and did not hit her head. Vitals taken and within normal limits. Pt assess (sic) before transfer and pt is able to bend knees and toes have good ROM (range of motion) with a minor increase in pain. Pt is also able to move bottom half of legs with some difficulty but normal ROM for patient. Pt transferred back into bed and skin check done with a little patch of [DIAGNOSES REDACTED] to knee and no other injuries noted. ROM continues to be normal for patient when assessed in bed. Patient continues to c/o (complain of) minor increase pain to right lower leg, [MEDICATION NAME] ,[DATE] mg (milligrams) administered and tolerated well. MD notified of fall and [DIAGNOSES REDACTED] to knee and increase in pain. No new orders at this time. ADON (Assistant Director of Nursing) notified. Resident is comfortable in bed at this time and will continue to monitor. b. [DATE] at 17:56 (5:56 PM), (Recorded as Late Entry on [DATE] at 23:59 (11:59 PM), Continue to check on patient often, Pt states pain medications are helpful for right leg pain. No changes to ROM or pain noted at this time. Pt appears comfortable in bed at this time and eating dinner. Will continue to monitor. c. [DATE] at 5:50 AM, No increased pain r/t fall. VS (vital signs) = WNL (within normal limits). No changes noted. d. [DATE] at 1800 (6:00 PM), Resident is resting in bed and denies pain r/t the witness (sic) fall on [DATE], no skin issue noted or reported during this shift, IV (intravenous) Tigecycline administered per ordered (sic), the IV line is in place and with IV dressing intact on right arm, flushed with NS (normal saline) without problems, VS taken with (temperature) 97.3, (pulse) 67, (respirations) 16, (blood pressure) ,[DATE] and O2 (oxygen) sats (saturations) 92%, fluids applied and encouraged. e. [DATE] at 5:38 AM, C/O (complains of) pain at Rt (right) leg r/t recent fall. Reports about a ,[DATE] because they just changed me. No falls on this shift. No OOB (out of bed) on this shift. All PO (by mouth) meds as ordered and prn (as needed) pain medications provided and effective for pain res (sic). Res checked frequently throughout shift. Resting quietly most of Noc (night). WCTM (Will continue to monitor). f. [DATE] at 18:51 (6:51 PM), Resident c/o'd (complained of) increasing pain to right knee during giving nursing care, the right knee is bigger than left. It (sic) reported to (Physician 1). New order from (Physician 1) to X-ray to right knee and hip. X-ray was called in. Resident continues on IV ABX to treat UTI, no s/s of ASE (adverse side effects) noted, VS taken with (sic) T (temperature) 97.6, P (pulse) 63, R (respirations) 16, BP (blood pressure) ,[DATE] and O2 sats 91% on O2 3L (liters) via NC (nasal cannula). IV line is in place and with IV dressing intact to right arm, and flushed with NS without problems. An X-Ray report dated [DATE] at 19:27 (7:27 PM) revealed that Bones: Two views were obtained with limited positioning. There is a nearly [MEDICATION NAME] oriented [MEDICAL CONDITION] right tibial metaphysis without any obvious displacement on this AP (anterior-posterior) radiograph. There is also a [MEDICATION NAME] oriented adjacent acute [MEDICAL CONDITION] right fibula but this appears to be associated with an area of old healed fracture as well. There is an old healed [MEDICAL CONDITION] fibular diaphysis .Impression: Acute nondisplaced fractures of the proximal right tibia and fibula although radiographic evaluation is limited . A New Employee Orientation Checklist dated [DATE] for CNA 1 revealed that CNA 1 had been oriented regarding using gait belts for transferring residents safely and the proper way to use mechanical lifts such as a hoyer lift and sit to stand lift. On [DATE], a written statement by CNA 1 was provided by the facility DON. The written statement revealed, Nurse needed (Resident 37) into bed, I was notified she was a 1 person transfer on board. We fixed her shirt for a transfer into bed, she wanted to rest. I fixed her wheelchair to (sic) close to her bed and place (sic) transfer board under her leg and on her bed. Transferred (sic) with barrer (sic) weight 100 %. She tried to help me tranfer (sic) her but got to (sic) weak, she was already on the board between her wheelchair and bed, we tried (sic) to transfer again from same position but slid forward onto my weight and slid off board. Called for help while she was barring her weight on me and no one came. No one came to help, after the fall, she slowly slid on to floor. The Inservice Training/Seminar Report regarding Slide Board Transfer Review that accompanied CNA 1's written statement was dated [DATE]. On [DATE] at 1:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she heard a loud thud the day of resident 37's fall and that CNA 1 started yelling. LPN 1 stated that she went right into the room and assessed resident 37 for injuries. LPN 1 stated that the sliding board had not been placed correctly onto the bed and subsequently had become loose from the bed. LPN 1 stated that resident 37 was not on the bed far enough and started to fall and that CNA 1 lowered her to the floor. LPN 1 stated that her assessment for injuries consisted of placing her hand on resident 37's hip and then bending her right leg up and down at the knee, to see if she could feel any popping out of the hip. LPN 1 stated that she was able to know if there was a problem with her hip if there was popping out. LPN 1 stated that resident 37 was picked up off of the floor to a standing position and assisted back to bed. LPN 1 stated that the CNAs were aware of the transfer needs by resident 37 because they were in a binder at the nursing station. (NOTE: The transfer needs available in the binder were the current needs for resident 37.) LPN 1 stated that the previous paperwork for resident 37's needs had been shredded. On [DATE] at 3:50 PM, an interview was conducted with the facility MDS Coordinator. The facility MDS Coordinator stated that the slide board transfer training had not been provided to the CNA staff and that the CNA staff should never have been attempting to transfer resident 37 with the slide board. The facility MDS Coordinator stated that the slide board transfer training had only been provided to the RNA (Restorative Nursing Assistant) staff. The facility MDS Coordinator confirmed that the staff member that had attempted to transfer resident 37 just prior to the fall on [DATE] was a CNA, had never been trained for the sliding board transfer and that she should never have attempted the transfer with resident 37. In addition to resident 37's fall, resident 37 had multiple medications that had been administered late and included the following: According to the MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) resident 37 had multiple medications administered late including [MEDICATION NAME]/[MEDICATION NAME] TID, [MEDICATION NAME] 20 mg at bedtime, [MEDICATION NAME] 3 mg QD, [MEDICATION NAME] 70 mg weekly, [MEDICATION NAME] 40 mg QD, [MEDICATION NAME] 100 mg TID, [MEDICATION NAME] 2.5 mg QD, [MEDICATION NAME] 20 mg QD, Potassium Chloride 20 mEq BID, [MEDICATION NAME] 40 mg QD, Sprionolactone 25 mg QD, [MEDICATION NAME] 50 mcg QD and [MEDICATION NAME] 200 mg at bedtime. 2. Resident 170 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 170's medical record was reviewed. Nursing progress notes revealed the following entries: a. [DATE] New order by MD (Medical Doctor) for the patient: DC [MEDICATION NAME] Inhaler; amt (amount): 2 inhalations; Special Instructions: Dx (diagnoses) [MEDICAL CONDITIONS] Four Times A Day New order: Re-start on [DATE] [MEDICATION NAME] inhaler; amt: 1 inhalations; Four Times A Day Increase monitoring for any respiratory issues. Notified (sic) to MD for any acute respiratory problem. Asses (sic) the patient every shift for respiratory problem. b. [DATE] at 21:30 (9:30 PM), (Recorded as Late Entry on [DATE] at 23:59 (11:14 PM), CNA (Certified Nursing Assistant) came to tell LN (Licensed Nurse) to come check on pt (patient) out of concern. LN went to observe pt. Called pt name and gently shook her shoulder, pt easily roused and responded. Ask how she was feeling and if she was in any pain, stated that she was just tired. Denies pain/discomfort at this time. Pt in no apparent distress. Pt was laying flat, LN raised HOB (head of bed) to semi fowlers. VS (vital signs) checked (Temperature) 98.2, (Pulse) 112, (Respirations) 14, (Blood Pressure) ,[DATE], (Oxygen Saturations) 92% 5L (liters) via NC (nasal cannula). Blood sugar 350. Lung sounds CTA (clear to auscultation) bilaterally. Respirations even and unlabored. Encouraged fluids. Pt checked and changed, barrier cream applied with brief change. Will notify MD. Nursing will continue to monitor. (NOTE: The nursing progress note did not explain what the concern was with resident 170 Additionally, the note was added to the medical record as a late entry after resident 170 had passed away.) c. [DATE] at 00:01 (12:01 AM), Went to check on pt, pt sleeping and easily roused. Responsive and able to respond appropriately to questions. Pt in no apparent distress and denies pain and/or SOB (shortness of breath). Respirations even and unlabored at 14, [MEDICAL CONDITION] (continuous positive air pressure) in place per orders while pt asleep. Nursing will continue to monitor. d. [DATE] at 3:02 AM, Checked on pt, still sleeping and easily roused. [MEDICAL CONDITION] in place and functioning. Woke her up and had her drink some water, responded and drank without any coughing or choking noted. CNA doing regular rounding and brief checks Q (every) 2 hours alternating with LN Q 2 hrs (hours). e. [DATE] at 5:00 AM, Pt check shows pt still sleeping in no apparent distress and easily woken. Cap (capillary) refill f. [DATE] at 5:30 AM, CNA was in room checking pt brief, LN joined to observe pt before the end of shift. Pt respirations even and unlabored. Pt in no apparent distress, skin pink warm and dry. [MEDICAL CONDITION] in place, pt responded to name and gentle shoulder shake. Denies pain, discomfort, or SOB. HOB elevated and RR 14. Encouraged pt to drink fluids throughout the day. Will report to oncoming nurse to monitor pt and encourage fluids throughout the day. g. [DATE] at 8:10 AM, Patient was find (sic) with respiratory distress, unresponsive with minimal arouse (sic), vitals was taking (sic) manually with no reading, patient with pulse 60 per min, respiration 24, laborated (sic) with O2 (oxygen) reading (saturations) 66 5 (66% on 5 liters of oxygen) in [MEDICAL CONDITION], interventions, change to face mask with 6 L oxygen, pull the head back to facilitated (sic) breading (sic) new O2 (saturation) 88%. Blood sugar check, blood sugar: 366 mg (milligrams)/dl (deciliter). Patient was able to open her eyes and was asked if she wanna (sic) go to ER (emergency room ), she state (sic) 'yes', 911 was called and MD notified. h. [DATE] at 11:09 AM, Nurse contact (sic) (Name of Hospital) to follow up condition for the patient. LN was informed patient being admitted to ICU (Intensive Care Unit), it was no (sic) provided diagnostic or reason why patient was admitted to the hospital. They state it is HIPPA (sic) (Health Information Portability and Accountability Act - HIPAA) code. The vital sign report for resident 170 revealed that resident 170's vital signs were monitored and recorded as the following: a. [DATE] at 8:34 AM, Blood Pressure (BP) - ,[DATE], Pulse (P) - 78, Respirations (R) - 16, Temperature (T) - 97.8. O2 Saturation - 95% (NOTE: the report did not reveal if the oxygen saturation was with oxygen or on room air.) b. [DATE] at 9:57 AM, BP - ,[DATE], P - 83, R - 16, T - not taken, O2 Saturation - 90% (NOTE: the report did not reveal if the oxygen saturation was with oxygen or on room air.) c. [DATE] at 17:25 (5:25 PM), BP - ,[DATE], P - 68, R - 16, T - 97.9, O2 Saturation - 95% (NOTE: the report did not reveal if the oxygen saturation was with oxygen or on room air. Additionally, no documentation could be located in the medical record that resident 170's physician had been notified of the decrease in resident 170's BP and P, nor was there continued monitoring of the BP and P after they had decreased.) d. [DATE] at 9:03 AM, BP - not taken, P - not taken, R - 20, T - 97.8, O2 Saturation - 94% physician's orders [REDACTED]. Notified (sic) to MD for any acute respiratory problem. Asses (sic) the patient every shift for respiratory problem had not been included in the order. No documentation could be located in the medical record to show that the nurse called resident 170's physician about the change in condition nor what the change in condition was. On [DATE] at 1:53 PM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated that he was on duty when resident 170 had gone into [MEDICAL CONDITION] and that he was in the room and yelling for help. RN 4 stated that the facility PDON had responded and came into the room. RN 4 stated that he had told the PDON to call 911 and she did. RN 4 did not recall that anyone else was in the room nor that the crash cart had been requested. RN 4 stated that he had been told in report from the night shift nurse that resident 170 was sleepy. On [DATE] at 4:30 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that she had been called overhead by the facility Past Director of Nursing (PDON). The facility PDON the morning of [DATE] and was told by the PDON to get the crash cart because resident 170 was in [MEDICAL CONDITION]. The facility DON stated that they did not do CPR (Cardiopulmonary Resuscitation) because resident 170 was a DNR. The facility DON stated that she did not document her involvement in the incident because resident 170 went to the hospital. The facility DON stated that she did not know why there were not more vital sign documentation in the medical record after resident 170 had a change of condition, nor why resident 170's physician had not been notified by the facility nursing staff. The facility DON stated that she felt as though it was a documentation error. The facility DON further stated I understand and see why there is a concern with this resident because of the lack of interventions. The facility DON acknowledged that there were no interventions of calling resident 170's physician, monitoring for the change in condition and no vital sign monitoring. 3. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 4's medical record was reviewed. physician's orders [REDACTED]. According to the MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), resident 4 had multiple medications administered late including [MEDICATION NAME] 325 mg 2 tablets TID, [MEDICATION NAME] 10 mg QD, Aspirin 81 mg QD, [MEDICATION NAME] 5 mg at bedtime, [MEDICATION NAME] 100 mg BID, [MEDICATION NAME] 40 mg at bedtime, [MEDICATION NAME] 10 mg QD, [MEDICATION NAME] 10 mg QHS, [MEDICATION NAME] 0.5 mg BID and [MEDICATION NAME] 5 mg every six hours. 4. On [DATE] at 4:10 PM, an interview was conducted with resident 2. Resident 2 stated that the facility did not have enough staff available. Resident 2 stated that the facility had no consistency with staffing and that some days the facility would have multiple agency staff who would not know the residents or what to do with them. Resident 2 stated that he would wait for an hour or longer at times for someone to help him out of the bed and to his wheelchair. Resident 2 stated that the administration was aware of this problem because residents would mention the staffing issue during resident council meetings. Resident 2 stated that often the staff would walk into a room, would turn the call light off and inform the resident that they would be back in few minutes, then never return. Resident 2 stated that the call light would have to be reactivated. 5. On [DATE] at 6:32 PM, an interview was conducted with resident 1. Resident 1 stated that the facility and residents could benefit from more staff. Resident 1 stated that he waited for his call light to be answered for up to an hour. Resident 1 stated that the staff would sometimes come into the room only to turn the light off, tell them that they would be back in few minutes and that they would never come back until the call light was reactivated or would came back few hours later. Resident 1 stated that the facility would have agency staff coming to help very often and he did not like that because the majority of the agency staff would not know the residents or how to perform certain tasks. Resident 1 stated that it was hard on the residents but also the facility staff who would need to train the agency staff and to be pulled away from their regular duties. On [DATE] at 6:00 PM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that if someone would call in sick or have an emergency, then they would be short staffed. RN 5 stated that the facility would use agency staff to fill openings in the schedule and that she (RN 5) would spend half of her shift training them what to do so she would not be able to finish her own tasks. RN 5 stated that they would always benefit from few extra people. On [DATE] at 3:18 PM, an interview was conducted with RN 7. RN 7 stated that she had recently hired on full time with the facility, but that she had worked as an agency nurse in the facility prior to her full time job. RN 7 stated that when she worked as an agency nurse, she had maybe 20 minutes of training before she was working the floor, and that training consisted of computer program training only. RN 7 stated that she had not had any training except for the computer program. On [DATE] at 2:30 PM, and interview was conducted with the facility Director of Nursing (DON). The facility DON stated that they had enough staff available. The DON stated that their staffing schedule was created based on the census. The DON stated that they would have agency staff from time to time, but that they tried to have less and less of them. The DON stated that it was hard to keep good employees, that they would pay their staff really well, and that people would go to work somewhere else or would quit their jobs for different reasons. The DON stated that they were always hiring. Cross Refer to F-684, F-689, F-757 and F-760 6. On [DATE] at 2:03 PM, an interview was conducted with resident council attendants. One resident mentioned We will be woken up at midnight or 1:00 AM for medications that were due at 8:00 PM. They other residents agreed. The residents stated that medications are sometimes 5 hours late. The residents stated medications that were supposed to be given before breakfast were given at lunch. All residents agreed with above statements.",2020-09-01
48,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2018-04-30,755,E,0,1,C87F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 6 of 43 sample residents, that the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. Specifically medications were not available from the pharmacy for administration. Resident identifiers: 22, 37, 56, 63, 163 and 165. Findings include: 1. Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 resident 56's Medication Administration Record [REDACTED] For (MONTH) (YEAR), resident 56 had the following physician orders: a) [MEDICATION NAME], 1/4/18-1/28/18, 5 mg(milligrams)/mL (milliliter), amount to administer: 0.25 mL; oral, every 6 hours The order was changed to the following: [MEDICATION NAME], 1/28/18-1/30/18, 10 mg/5L, amount to administer 1 mL=2 mg; oral, every 8 hours. The medication was not available on the following dates: a) 1/4/18 at 6:00 PM Not administered: Drug/item unavailable. Comment: Notified hospice. b) 1/5/18 at 12:00 AM Not administered: Other. Comment: med not available; will f/u w/ hospice. c) 1/5/18 at 6:00 AM Not administered: other. Comment: med not available; will f/u w/ hospice. d) 1/5/18 at 12:00 PM Not administered: Drug/Item unavailable. Comment: Notified hospice, administered prn pain medication. e) 1/29/18 at 8:00 AM Not administered: Other. Comment: Hospice to deliver. f) 1/30 at 12:00 AM Not administered: drug/item unavailable. Comment: day nurse reported contacting hospice. Resident also reported contacting them. Not sent to facility. On 1/30/18 at 3:00 AM, a nursing progress note revealed, Resident activated call light and asked after the status of his Methadose (sic). Nurse reported that he has been having conversations with hospice .and that he is trying to get the situation resolved ASAP (as soon as possible). Resident stated that he will be making another (following on the night of 29 Jan) angry phone call in the morning if it does not arrive. Resident in the mean time requested/received/accepted PRN (as needed) [MEDICATION NAME] and [MEDICATION NAME] and stated he was going to try to get some sleep . For (MONTH) (YEAR), resident 56 had the following physician orders: a) [MEDICATION NAME], 1/30/18-2/20/18, 10 mg/mL, amount to administer: 0.2 mL (2 mg); oral, every 8 hours. The order was changed to the following: [MEDICATION NAME], 2/20/18-3/8/18, 10 mg/mL, amount to administer 0.3 mL ( 3 mg); oral, every 8 hours) b) [MEDICATION NAME] 10 gram/15 mL, amount to administer 30 mL; oral, every 6 hours c) [MEDICATION NAME], 200 mg (milligrams); oral, once a day The medications were not available on the following occurrences: a) 2/12/18 [MEDICATION NAME] Not administered Drug/item unavailable. Comment: pharmacy called, will deliver today. b) 2/19/18 [MEDICATION NAME] at 12:00 AM Not administered: Comment: Notified[NAME]with Bristol Hospice. c) 2/19/18 [MEDICATION NAME] at 8:00 AM Not administered: Drug/Item unavailable hospice called and notified. d) 2/20/18 [MEDICATION NAME] at 8:00 AM Not administered: Drug/Item unavailable. Comment: awaiting pharmacy, notified hospice. e) 2/20/18 [MEDICATION NAME] at 4:00 PM Drug/Item unavailable. Comment: awaiting pharmacy, notified hospice nurse. On 4/30/18 an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that some of the occurrences shouldn't have happened because the facility did have the medication available. The DON stated that they likely happened due to new nurses or agency nurses who were unfamiliar with the system and building. 2. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 37's medical record was reviewed. physician's orders [REDACTED]. a. 1/16/18 through 1/22/18, [MEDICATION NAME] 1 gram; intravenous (IV) once a day for UTI (Urinary Tract Infection). b. 12/1/16, [MEDICATION NAME] 20 mg (milligrams)/ml (milliliter) subcutaneous at Bedtime. c. 1/6/18, [MEDICATION NAME] 100 mg Three Times a Day (TID) for [MEDICAL CONDITION]. The Medication Administration Record [REDACTED] a. On 1/16/18, [MEDICATION NAME] 1 gram IV was not administered to resident 37 due to waiting on med (medication) from pharmacy. b. On 1/8/18 and 1/14/18, [MEDICATION NAME] 20 mg injection was not administered due to Drug/Item unavailable. c. On 3/10/18, [MEDICATION NAME] 100 mg was administered at 16:19 (4:19 PM), 2 hours and 19 minutes after it was due, due to Drug/Item unavailable. 3. Resident 163 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 163's medical record was reviewed. physician's orders [REDACTED]. a. 10/13/17, Eliquis 5 mg twice a day at 8:00 AM and 8:00 PM for A-fib ([MEDICAL CONDITION]). The MAR for (MONTH) (YEAR) and (MONTH) (YEAR) revealed the following: c. Eliquis 5 mg not administered on 11/24/17 at 8:00 AM because med not avaialble(sic) notifeid (sic) pharmacy. 4. Resident 63 was admitted to the facility on [DATE] on hospice care with [DIAGNOSES REDACTED]. On 4/26/18 resident 63's medical record was reviewed. Review of physician's orders [REDACTED]. a. [MEDICATION NAME] 300 mg (milligrams) TID (three times daily) for [MEDICAL CONDITION] b. [MEDICATION NAME] 10 gm (grams)/15 ml (milliliters); 45 ml (30 grams total) TID for [MEDICAL CONDITION] c. [MEDICATION NAME] 1000 mg QD (every day) at dinner time for DM d. [MEDICATION NAME] 40 mg QD before breakfast e. [MEDICATION NAME] 25 mg QHS (bedtime) for [MEDICAL CONDITION] m/b (manifested by) episodes of uncontrollable anger f. [MEDICATION NAME] 25 mg QD for ascites g. [MEDICATION NAME] 550 mg BID for hepatic [MEDICAL CONDITION] h. [MEDICATION NAME] 10 mg rectally QD prn (as needed) i. Fleet Enema 19.7 gm/118 ml rectally QD prn j. Milk of Magnesia 400 mg/5 ml, administer 30 ml (2400 mg total) QD prn k. Tylenol 325 mg 2 tabs (650 mg total) Q 4 hrs prn for general pain The Medication Administration Record [REDACTED]. On 4/25/18 at 1:55 PM, an interview was conducted with the facility DON (Director of Nursing) and the facility Corporate Nurse (CN). The facility DON and the facility CN stated that they should have followed up on the medications and that going to a different pharmacy to get resident 63's medications would have been a good idea. The facility DON stated that they had actually paid for medications before for a resident when medications had not come in but did not think of that. The facility DON stated that medications should always be available to the residents. On 4/25/18 at 2:38 PM, an interview was conducted with the Hospice RN (HRN). The HRN stated that they had no notification that the medications had not been delivered to the facility until the morning of 7/25/18. The HRN stated that they felt terrible. The HRN stated that they had either had a software failure or the nurse had not hit the send button when the medications were ordered and that their pharmacy never got the order for the medications. 5. Resident 165 was admitted to the facility on [DATE] at 17:40 (5:40 PM) on hospice care with [DIAGNOSES REDACTED]. On 4/26/18 resident 165's medical record was reviewed. Nursing progress notes revealed that resident 165's medications were unable to be administered as they had not been delivered from the hospice company. Physician orders [REDACTED]. a. [MEDICATION NAME] 5 mg QD at 8:00 AM b. Bumetadine 1 mg 3 tablets (3 mg total) BID c. [MEDICATION NAME]-Salmeterol 250-50 mcg (micrograms) 1 puff inhalation BID d. [MEDICATION NAME]-[MEDICATION NAME] Nebulizer 0.02% BID e. [MEDICATION NAME] 25 mg QD at 8:00 AM f. Potassium Chloride 20 mEq (milliequivalant) QD at 8:00 AM The MAR for resident 165 for (MONTH) (YEAR) revealed the following: a. 11/11/17 at 8:00 AM - [MEDICATION NAME] 5 mg Not Administered: Drug unavailable, Hospice notified. b. 11/11/17 at 8:56 AM - Bumetadine 1 mg 3 tablets Not Administered: Drug unavailable, Hospice notified. c. 11/10/17 at 8:00 PM - [MEDICATION NAME]-Salmeterol 250/50 mcg Not Administered: Drug Unavailable. d. 11/11/17 at 8:00 AM - [MEDICATION NAME]-Salmeterol 250/50 mcg Not Administered: Drug unavailable, Hospice notified. e. 11/10/17 at 8:00 PM - [MEDICATION NAME]-[MEDICATION NAME] Nebulizer 0.02% Not Administered: Drug Unavailable. f. 11/11/17 at 8:00 AM - [MEDICATION NAME]-[MEDICATION NAME] Nebulizer 0.02% Not Administered: Drug unavailable, Hospice notified. g. 11/11/17 at 8:00 AM - [MEDICATION NAME] 25 mg Not Administered: Drug unavailable, Hospice notified. h. 11/11/17 at 8:00 AM - Potassium Chloride 20 mEq Not Administered: Drug unavailable, Hospice notified. On 4/25/18 at 1:15 PM, an interview was conducted with the facility DON. The facility DON stated that resident 165 did not miss very many medications. The facility DON stated that the medications should have been here and accessible for the resident. 6. Resident 22 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 22's medical record was reviewed. physician's orders [REDACTED]. a. [MEDICATION NAME] 0.5 mg at bedtime (HS). The Medication Administration Record [REDACTED] a. 4/6/18, [MEDICATION NAME] 0.5 mg was not administered due to not being available. Cross Refer F-757, F-760 and F-849",2020-09-01
49,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2018-04-30,757,E,1,1,C87F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined that for 5 of 43 sample residents, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, multiple residents had multiple medications administered late as well as medications that were not available for administration. Resident identifiers: 4, 25, 37, 45 and 59. Findings include: 1. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 37's medical record was reviewed. physician's orders [REDACTED]. a. 10/18/17, [MEDICATION NAME]/[MEDICATION NAME] 2.5/0.05 Nebulizer every 8 hours. b. 12/1/16, [MEDICATION NAME] 20 mg (milligrams)/ml (milliliter) subcutaneous at Bedtime. c. 12/27/18 through 2/8/18, [MEDICATION NAME] 1 mg to 3.5 mg daily (QD). d. 7/17/18, [MEDICATION NAME] 70 mg weekly. e. 9/26/18, [MEDICATION NAME] 40 mg QD. f. 1/6/18, [MEDICATION NAME] 100 mg three times daily (TID). g. 1/2/18, [MEDICATION NAME] 2.5 mg QD. h. 10/9/17, [MEDICATION NAME] 20 mg QD. i. 1/11/18, Potassium Chloride 20 mEq twice daily (BID). j. 5/11/18, [MEDICATION NAME] 40 mg QD. k. 5/1/17, Sprionolactone 25 mg QD. l. 5/11/17, [MEDICATION NAME] 50 mcg QD. m. 12/12/18, [MEDICATION NAME] 200 mg at bedtime. The Medication Administration Record [REDACTED] a. On 1/8/18 and 1/14/18 [MEDICATION NAME] 20 mg injection was not administered due to Drug/Item unavailable. According to the MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) resident 37 had multiple medications administered late including the following dates: a. [MEDICATION NAME]/[MEDICATION NAME] TID, 2.5/0.05 every 8 hours 1/1/18, 1/2/18, 1/4/18, 1/5/18 x 2, 1/6/18 x 2, 1/7/18, 1/9/18 x 3, 1/10/18, 1/11/18 x 2, 1/12/18 x 2, 1/13/18 x 3, 1/14/18, 1/15/18, 1/16/18, 1/17/18 x 2, 1/20/18, 1/21/18, 1/22/18, 1/23/18, 1/24/18 x 2, 1/25/18, 1/27/18, 1/28/18, 1/29/18, 1/30/18, 1/31/18, 2/2/18, 2/5/18, 2/6/18, 2/7/18, 2/8/18, 2/9/18 and 2/10/18. b. [MEDICATION NAME] 20 mg at bedtime, 1/8/18, 1/11/18, 1/12/18, 1/13/18, 1/14/18, 1/18/18, 1/26/18, 2/1/18, 2/6/18, 2/7/18, 2/8/18, 2/9/18, 2/10/18, 3/8/18, 3/9/18, 3/14/18, 3/23/18, 3/28/18, 3/31/18, 4/13/18, 4/16/18 and 4/20/18. c. [MEDICATION NAME] 3 mg QD, 1/13/18, 1/17/18, 1/20/18, 1/21/18, 1/22/18, 1/23/18, 1/24/18, 1/25/18, 1/27/18, 1/29/18, 1/31/18, 2/5/18, 2/6/18, 2/19/18, 3/9/18, 3/30/18, 4/4/18 and 4/17/18. d. [MEDICATION NAME] 70 mg weekly, 1/30/18, 2/6/18, 3/6/18, 3/20/18 and 4/3/18. e. [MEDICATION NAME] 40 mg QD, 1/4/18, 1/5/18, 1/6/18, 1/7/18, 1/9/18, 1/11/18, 1/12/18, 1/13/18, 1/17/18, 1/20/18, 1/21/18, 1/22/18, 1/23/18, 1/24/18, 1/25/18, 1/27/18, 1/28/18, 1/29/18, 2/7/18, 2/8/18, 2/10/18, 2/11/18, 2/12/18, 2/13/18, 2/16/18, 2/17/18, 2/18/18, 2/21/18, 2/22/18, 2/23/18, 2/24/18, 2/25/18, 2/26/18, 2/27/18, 2/28/18, 3/1/18, 3/2/18, 3/3/18, 3/4/18, 3/8/18, 3/9/18, 3/10/18, 3/12/18, 3/15/18, 3/22/18, 3/23/18, 3/24/18, 3/27/18, 3/29/18 and 3/31/18. f. [MEDICATION NAME] 100 mg TID, 1/7/18, 1/8/18, 1/9/18 x 2, 1/10/18, 1/11/18 x 3, 1/12/18 x 2, 1/13/18 x 3, 1/14/18, 1/16/18, 1/17/18, 1/18/18, 1/20/18, 1/21/18, 1/22/18 x2, 1/23/18 x 2, 1/24/18 x 2, 1/25/18, 1/26/18, 1/27/18 x 2, 1/28/18, 1/29/18 x 2, 1/30/18, 1/31/18 x 2, 2/1/18, 2/2/18, 2/6/18, 2/7/18, 2/8/18, 2/9/18, 2/10/18, 2/11/18, 2/12/18, 2/13/18, 2/16/18, 2/17/18, 2/18/18, 2/21/18, 2/22/18, 2/23/18, 2/24/18, 2/25/18, 2/26/18, 2/27/18, 2/28/18, 3/2/18, 3/3/18, 3/4/18, 3/8/18, 3/9/18, 3/10/18, 3/12/18, 3/14/18, 3/15/18, 3/20/18, 3/22/18, 3/23/18, 3/24/18, 3/26/18, 3/27/18, 3/28/18, 3/29/18, 3/31/18, 4/1/18, 4/3/18, 4/4/18, 4/5/18, 4/7/18, 4/9/18, 4/12/18, 4/13/18, 4/16/18, 4/19/18, 4/20/18, 4/21/18, 4/23/18 and 4/24/18. g. [MEDICATION NAME] 2.5 mg QD, 1/4/18, 1/5/18, 1/6/18, 1/9/18, 1/11/18, 1/12/18, 1/17/18, 1/20/18, 1/21/18, 1/22/18, 1/23/18, 1/24/18, 1/25/18, 1/26/18, 1/27/18, 1/29/18, 4/20/18, 4/23/18 and 4/24/18. h. [MEDICATION NAME] 20 mg QD, 1/4/18, 1/5/18, 1/6/18, 1/7/18, 1/9/18, 1/11/18, 1/12/18, 1/13/18, 1/17/18, 1/20/18, 1/21/18, 1/22/18, 1/23/18, 1/24/18, 1/25/18, 1/27/18, 1/29/18, 1/31/18, 2/2/18, 2/7/18, 2/8/18, 2/10/18, 2/12/18, 2/13/18, 2/16/18, 2/17/18, 2/18/18, 2/21/18, 2/22/18, 2/23/18, 2/24/18, 2/25/18, 2/26/18, 2/27/18, 2/28/18, 4/1/18, 4/3/18, 4/4/18, 4/5/18, 4/7/18, 4/20/18, 4/23/18 and 4/24/18. i. Potassium Chloride 20 mEq BID, 1/4/18, 1/5/18, 1/6/18, 1/7/18, 1/9/18, 1/11/18, 1/12/18, 1/13/18 x 2, 1/17/18, 1/20/18, 1/21/18, 1/22/18, 1/23/18, 1/24/18, 1/25/18, 1/27/18, 1/29/18, 1/31/18, 2/6/18, 2/7/18, 2/8/18, 2/10/18, 2/11/18, 2/12/18, 2/13/18, 2/16/18, 2/17/18, 2/18/18, 2/19/18, 2/21/18, 2/22/18, 2/23/18, 2/24/18, 2/25/18, 2/26/18, 2/27/18, 2/28/18, 3/1/18, 3/2/18, 3/3/18, 3/4/18, 3/8/18, 3/9/18, 3/10/18, 3/12/18, 3/15/18, 3/20/18, 3/22/18, 3/23/18, 3/24/18, 3/26/18, 3/27/18, 3/28/18, 3/29/18, 3/30/18, 3/31/18, 4/1/18, 4/3/18, 4/4/18, 4/5/18, 4/7/18, 4/9/18, 4/12/18, 4/13/18, 4/17/18, 4/19/18, 4/20/18, 4/21/18, 4/23/18 and 4/24/18. j. [MEDICATION NAME] 40 mg QD, 1/4/18, 1/5/18, 1/6/18, 1/11/18, 1/12/18, 1/17/18, 1/18/18, 1/19/18, 1/20/18, 1/21/18, 1/22/18, 1/23/18, 1/24/18, 1/25/18, 1/26/18, 1/27/18, 1/29/18, 1/31/18, 2/2/18, 2/3/18, 2/4/18, 2/5/18, 2/7/18, 2/8/18, 2/9/18, 2/10/18, 3/2/18, 3/3/18, 3/4/18, 3/8/18, 3/9/18, 3/10/18, 3/12/18, 3/15/18, 3/20/18, 3/22/18, 3/23/18, 3/24/18, 3/27/18, 3/29/18, 3/31/18, 4/1/18, 4/3/18, 4/4/18, 4/5/18, 4/7/18, 4/20/18, 4/23/18 and 4/24/18. k. Sprionolactone 25 mg QD, 1/4/18, 1/5/18, 1/6/18, 1/7/18, 1/9/18, 1/11/18, 1/12/18, 1/13/18, 1/17/18, 1/20/18, 1/21/18, 1/22/18, 1/23/18, 1/24/18, 1/25/18, 1/27/18 and 1/29/18. l. [MEDICATION NAME] 50 mcg QD, 1/4/18, 1/5/18, 1/6/18, 1/11/18, 1/12/18, 1/17/18, 1/18/18, 1/19/18, 1/20/18, 1/21/18, 1/22/18, 1/23/18, 1/24/18, 1/25/18, 1/26/18, 1/27/18, 1/29/18, 1/31/18, 2/2/18, 2/3/18, 2/4/18, 2/5/18, 2/7/18, 2/8/18, 2/9/18, 2/10/18, 2/13/18, 2/16/18, 2/17/18, 2/18/18, 2/21/18, 2/22/18, 2/23/18, 2/24/18, 2/25/18, 2/26/18, 2/27/18, 2/28/18, 3/2/18, 3/3/18, 3/4/18, 3/8/18, 3/9/18, 3/10/18, 3/12/18, 3/15/18, 3/20/18, 3/22/18, 3/23/18, 3/24/18, 3/27/18, 3/29/18, 3/31/18, 4/1/18, 4/3/18, 4/4/18, 4/5/18, 4/7/18, 4/20/18, 4/23/18 and 4/24/18. m. [MEDICATION NAME] 200 mg at bedtime, 1/8/18, 1/11/18, 1/12/18, 1/13/18, 1/14/18, 1/18/18, 1/26/18, 1/27/18, 2/5/18, 2/6/18, 2/19/18, 2/22/18, 3/1/18, 3/2/18, 3/3/18, 3/4/18, 3/8/18, 3/9/18, 3/10/18, 3/12/18, 3/15/18, 3/20/18, 3/22/18, 3/23/18, 3/24/18, 3/27/18, 4/13/18, 4/16/18 and 4/22/18. 2. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 4's medical record was reviewed. physician's orders [REDACTED]. a. 4/17/17, [MEDICATION NAME] 325 mg 2 tablets TID. b. 8/15/18, [MEDICATION NAME] 10 mg QD. c. 4/18/17, Aspirin 81 mg QD. d. 8/15/17, [MEDICATION NAME] 5 mg at bedtime. e. 4/17/17, [MEDICATION NAME] 100 mg BID. f. 8/15/17, [MEDICATION NAME] 40 mg at bedtime. g. 1/30/17, [MEDICATION NAME] 10 mg QD. h. 4/17/18, [MEDICATION NAME] 10 mg QHS (bedtime) hold for systolic (blood pressure (BP)) i. 8/15/17, [MEDICATION NAME] 0.5 mg BID. j. 9/30/17, [MEDICATION NAME] 5 mg every six hours; at 2:00 AM, 8:00 AM, 2:00 PM and 8:00 PM, Hold if asleep. The MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) for resident 4 revealed the following: a. [MEDICATION NAME] 0.5 mg administered on 1/27/18 at 10:00 PM, 2/22/18 at 12:00 PM, 3/12/18 at 11:00 PM and 3/27/18 at 10:00 PM. Administration of the [MEDICATION NAME] 0.5 mg were administered two to four hours after they were due. b. [MEDICATION NAME] 0.5 mg was not administered on 2/28/18. c. [MEDICATION NAME] 5 mg administered on 3/24/18 at 10:00 PM, 4/7/18 at 12:00 AM, 4/10/18 at 9:30 AM and 4/23/18 at 4:45 AM. Three administrations of the [MEDICATION NAME] 5 mg were administered 1 1/2 hours to 2 hours and 45 minutes after they were due. The administration of the [MEDICATION NAME] 5 mg at 12:00 AM was administered 2 hours before it was due. d. [MEDICATION NAME] 20 mg was administered on 1/11/18 with a BP of 108/70, 1/18/18 with a BP 112/57, 1/19/18 with a BP 132/56, 2/24/18 with a BP 109/56, 3/22/18 with a BP 120/51, 3/25/18 with a BP 112/58 d. [MEDICATION NAME] 5 mg was not administered on 1/12/18 at 2:00 PM, 1/14/18 at 8:00 PM, 1/16/18 at 2:00 PM, 2/22/18 at 8:00 AM, 2/22/18 at 2:00 PM, 3/8/18 at 8:00 AM, 4/10/18 at 2:00 PM. According to the MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), resident 4 had multiple medications administered late including the following dates: a. [MEDICATION NAME] 325 mg TID, 1/5/18, 1/6/18, 1/7/18, 1/8/18, 1/10/18, 1/11/18, 1/12/18, 1/13/18, 1/14/18 x2, 1/16/18, 1/17/18, 1/20/18 x 2, 1/23/18, 1/26/18, 1/27/18 x 2, 1/28/18, 2/2/18 x 2, 2/3/18, 2/4/18, 2/5/18, 2/6/18 x 2, 2/7/18 x 2, 2/9/18, 2/12/18, 2/17/18, 2/19/18, 2/22/18, 2/25/18, 2/26/18, 2/28/18, 3/4/18, 3/5/18 x 2, 3/6/18, 3/8/18, 3/9/18, 3/11/18, 3/12/18 x 2, 3/14/18, 3/17/18, 3/18/18, 3/19/18, 3/24/18, 3/25/18, 3/26/18, 3/27/18, 4/1/18, 4/3/18, 4/4/18 x 2, 4/6/18, 4/9/18 x 2, 4/10/18, 4/11/18 x 3, 4/12/18, 4/13/18 x 2, 4/18/18, 4/20/18, 4/23/18 and 4/24/18. b. [MEDICATION NAME] 10 mg daily, 1/3/18, 1/5/18, 1/6/18, 1/7/18, 1/9/18, 1/10/18, 1/11/18, 1/12/18, 1/13/18, 1/14/18, 1/16/18, 1/26/18, 1/27/18, 1/30/18, 2/1/18, 2/2/18, 2/3/18, 2/4/18, 2/5/18, 2/6/18, 2/7/18, 2/11/18, 2/18/18, 2/25/18, 2/26/18, 3/4/18, 3/5/18, 3/6/18, 3/8/18, 3/12/18, 3/17/18, 3/18/18, 3/20/18, 3/28/18, 4/2/18, 4/3/18, 4/4/18, 4/6/18, 4/9/18, 4/10/18, 4/11/18, 4/13/18, 4/16/18, 4/18/18, 4/23/18 and 4/24/18. c. Aspirin 81 mg daily, 1/5/18, 1/6/18, 1/11/18, 1/12/18, 1/13/18, 1/16/18, 1/17/18, 1/20/18, 1/26/18, 1/27/18, 1/30/18, 2/2/18, 2/3/18, 2/4/18, 2/5/18, 2/6/18, 2/7/18, 2/25/18, 2/26/18, 3/4/18, 3/5/18, 3/8/18, 3/12/18, 3/17/18, 3/18/18, 4/3/18, 4/4/18, 4/6/18, 4/9/18, 4/10/18, 4/11/18, 4/13/18, 4/16/18, 4/18/18, 4/23/18 and 4/24/18. d. [MEDICATION NAME] 5 mg at bedtime, 1/7/18, 1/8/18, 1/14/18, 1/20/18, 1/27/18, 1/29/18, 3/5/18, 3/9/18, 3/11/18, 3/12/18, 3/19/18, 3/24/18, 3/27/18, 4/1/18, 4/6/18 and 4/11/18. e. [MEDICATION NAME] 100 mg twice daily, 1/5/18, 1/6/18, 1/7/18, 1/8/18, 1/11/18, 1/12/18, 1/13/18, 1/14/18, 1/16/18, 1/17/18, 1/20/18, 1/26/18, 1/27/18 x 2, 1/29/18, 1/30/18, 2/2/18, 2/3/18, 2/4/18, 2/5/18, 2/6/18, 2/7/18, 2/25/18, 2/26/18, 3/6/18, 3/14/18, 3/25/18, 3/26/18, 3/4/18, 3/5/18 x 2, 3/8/18, 3/9/18, 3/11/18, 3/12/18 x 2, 3/17/18, 3/18/18, 3/19/18, 3/24/18, 3/27/18, 4/1/18, 4/3/18, 4/4/18, 4/6/18 x 2, 4/9/18, 4/10/18, 4/11/18 x 2, 4/13/18, 4/16/18, 4/18/18, 4/20/18, 4/23/18 and 4/24/18. f. [MEDICATION NAME] 40 mg at bedtime, 1/7/18, 1/8/18, 1/14/18, 1/20/18, 1/27/18, 1/29/18, 3/5/18, 3/9/18, 3/11/18, 3/12/18, 3/19/18, 3/24/18, 3/27/18, 4/1/18, 4/6/18, 4/11/18 and 4/20/18. g. [MEDICATION NAME] 10 mg daily, 1/5/18, 1/6/18, 1/11/18, 1/12/18, 1/13/18, 1/16/18, 1/17/18, 1/20/18, 1/26/18, 1/27/18, 1/30/18, 2/2/18, 2/3/18, 2/4/18, 2/5/18, 2/6/18, 2/7/18, 2/25/18, 2/26/18, 3/4/18, 3/5/18, 3/8/18, 3/12/18, 3/17/18, 3/18/18, 4/3/18, 4/4/18, 4/6/18, 4/9/18, 4/10/18, 4/11/18, 4/13/18, 4/16/18, 4/18/18, 4/23/18 and 4/24/18. h. [MEDICATION NAME] 20 mg at bedtime, 1/7/18, 1/8/18, 1/14/18, 1/15/18, 1/27/18, 1/29/18, 3/5/18, 3/9/18, 3/11/18, 3/12/18, 3/19/18, 3/24/18, 4/1/18, 4/6/18 and 4/20/18. i. [MEDICATION NAME] 0.5 mg twice daily, 1/5/18, 1/6/18, 1/7/18, 1/8/18, 1/11/18, 1/12/18, 1/13/18, 1/14/18, 1/16/18, 1/17/18, 1/20/18, 1/26/18, 1/27/18 x 2, 1/29/18, 1/30/18, 2/2/18, 2/3/18, 2/4/18, 2/5/18, 2/6/18, 2/7/18, 2/25/18, 2/26/18, 3/4/18, 3/5/18 x 2, 3/9/18, 3/11/18, 3/12/18 x 2, 3/17/18, 3/18/18, 3/19/18, 3/24/18, 3/27/18, 4/1/18, 4/3/18, 4/4/18, 4/6/18 x 2, 4/9/18, 4/10/18, 4/11/18 x 2, 4/13/18, 4/16/18, 4/18/18, 4/20/18 and 4/23/18. j. [MEDICATION NAME] 5 mg every 6 hours, 1/5/18 x 2, 1/6/18, 1/7/18, 1/8/18, 1/9/18, 1/10/18, 1/11/18, 1/12/18, 1/13/18, 1/14/18, 1/15/18, 1/17/18, 1/20/18, 1/22/18, 1/23/18 x 2, 1/24/18, 1/25/18, 1/26/18, 1/27/18 x 2, 1/29/18 x 2, 1/30/18 x 2, 2/2/18, 2/3/18, 2/4/18, 2/5/18 x 2, 2/6/18 x 2, 2/7/18, 2/11/18, 2/14/18, 2/15/18, 2/18/18, 2/20/18, 2/23/18, 2/25/18 x 2, 2/26/18, 2/17/18 x 2, 3/3/18, 3/4/18 x 2, 3/5/18 x 3, 3/6/18, 3/8/18, 3/9/18, 3/10/18, 3/11/18, 3/12/18 x 3, 3/15/18, 3/17/18 x 2, 3/18/18 x 2, 3/19/18 x 2, 3/23/18 x 2, 3/24/18, 3/27/18, 3/30/18, 4/1/18 x 2, 4/2/18, 4/3/18, 4/4/18 x 2, 4/6/18 x 2, 4/9/18, 4/10/18, 4/11/18 x 2, 4/13/18 x 2, 4/14/18, 4/15/18, 4/16/18 x 2, 4/18/18, 4/20/18, 4/21/18, 4/22/18, 4/23/18 x 2 and 4/24/18. On 4/24/18 at 1:20 PM, an interview was conducted with the facility DON (Director of Nursing). The facility DON stated that at times the internet will go down and is the reason that the MAR's show that medications were administered on time but charted late. The facility DON stated that when the internet goes down, they have a backup computer that will print off a MAR for the night and that is how the nursing staff know what medications are due and will administer the medications on time. The facility DON stated that the paper MAR's were then shredded. The facility DON stated that they thought the medication administration had improved, obviously we need to do some training with the nursing staff. On 4/24/18 at 2:30 PM, an interview was conducted with RN 7. RN 7 stated that if the internet goes down, there was a computer on the West side of the facility that they could go to and print off a list of medications that were due. RN 7 stated that the list included all residents of the hall and included all medications as well as all treatments. RN 7 stated that they had to go through the report by hand to see which medications were due so that the medications could be administered. RN 7 stated that the internet did not go down too often. On 4/24/18 at 2:40 PM, an interview was conducted with RN 8. RN 8 stated that if the internet went down, she would then look at the desktop and write down every medication that was due. RN 8 stated that she could then pass the medications. RN 8 stated that the internet did not go down often. On 4/24/18 at 3:00 PM, an interview was conducted with the medical records director (MRD). The MRD stated that the server had to be replaced about a month ago. The MRD stated that she shredded the MAR's from administration if the internet was down because she had been taught to do so. The MRD stated that she could start saving them now if we wanted. On 4/26/18 at 10:10 AM, interview with the facility contracted pharmacist. The facility contracted pharmacist stated that he had noticed the many documentation's of the late charting but medications given on time and had talked with previous DON about this. The facility contracted pharmacist stated that he had not been made aware that it was a wifi/IT issue and that the facility nursing staff were not able to always follow med (medication) pass on the computers nor did he know that the facility nursing staff had to pull a hallway report with all medications and treatments and go through each page to see what medication was currently due and then double documenting on medications as charting had to be done later. On 4/30/18 at 3:25 PM, an interview was conducted with RN 9. RN 9 stated that it is a pain to look through the printed material to figure out what medications are due and when. RN 9 stated that if you hadn't looked at the amount of insulin after a blood sugar taken, you're screwed. RN 9 stated that medications were hard to get administered on time because of the hotspots in the building that were not available. RN 9 stated that they had to reset the system 3 times today. RN 9 further stated that she had not reported the issue to administrative staff, what's the point? They know it's happening. Cross Refer F-760 3. Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 25's medical record was reviewed. physician's orders [REDACTED]. a. 11/25/17, [MEDICATION NAME] 2000 units to be given QD. b. 12/5/17, [MEDICATION NAME] 0.5 mg BID. c. 2/23/18, [MEDICATION NAME] 0.5 mg BID. d. 12/29/18, [MEDICATION NAME] 15 mg at QHS. e. 11/25/18, [MEDICATION NAME] Inhaler QD. f. 2/23/18, [MEDICATION NAME] inhaler BID. According to the MAR for (MONTH) (YEAR) and (MONTH) (YEAR), resident 25 had multiple medications administered late including the following dates: a. [MEDICATION NAME] 0.5 mg on 3/1/18, 3/2/18, 3/3/18, 3/5/18, 3/6/18, 3/7/18, 3/8/18, 3/9/18, 3/12/18, 3/14/18, 3/16/18, 3/17/18, 3/18/18, 3/19/18, 3/22/18, 3/27/18, 3/29/18, 4/4/18, 4/12/18, 4/17/18, 4/20/18, 4/23/18 and 4/24/18. b. [MEDICATION NAME] 0.5 mg on 3/6/18, 3/19/18, 3/27/18, 4/4/18, 4/12/18, 4/17/18, 4/20/18, 4/23/18, and 4/24/18. c. [MEDICATION NAME] Inhaler on 3/6/18, 3/19/18, 3/27/18, 4/4/18, 4/12/18, 4/20/18, and 4/23/18. 4. Resident 45 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18, resident 45's medical record was reviewed. physician's orders [REDACTED]. a. Humalog sliding scale insulin before meals and at HS. b. [MEDICATION NAME] 50 units BID. c. [MEDICATION NAME] 20 mg QD. d. [MEDICATION NAME] 40 mg QD. e. [MEDICATION NAME] 50 mg BID. According to the MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), resident 45 had multiple medications administered late including the following dates: a. Humalog sliding scale insulin on 1/2/18, 1/3/18, 1/4/18, 1/8/18, 1/9/18, 1/10/18, 1/11/18, 1/12/18, 1/13/18, 1/14/18, 1/15/18, 1/16/18, 1/18/18, 1/19/18, 1/20/18, 1/21/18, 1/25/18, 1/26/18, 1/27/18, 1/28/18, 1/29/18, 2/2/18, 2/5/18, 2/6/18, 2/7/18, 2/9/18, 2/10/18, 2/12/18, 2/16/18, 2/17/18, 2/21/18, 2/22/18, 2/23/18, 2/25/18, 2/26/18, 2/27/18, 2/28/18, 3/5/18, 3/9/18, 3/10/18, 3/12/18, 3/17/18, 3/18/18, 3/19/18, 3/20/18, 3/21/18, 3/22/18, 3/23/18, 3/25/18, 3/26/18, 3/29/18, 3/30/18, 3/31/18, 4/1/18, 4/3/18, 4/6/18, 4/9/18, 4/10/18, 4/12/18, 4/19/18, and 4/20/18. b. [MEDICATION NAME] Insulin on 1/2/18, 1/4/18, 1/8/18, 1/9/18, 1/10/18, 1/11/18, 1/13/18, 1/14/18, 1/15/18, 1/16/18, 1/18/18, 1/19/18, 1/20/18, 1/21/18, 1/25/18, 1/26/18, 1/28/18, 1/29/18, 2/2/18, 2/5/18, 2/7/18, 2/9/18, 2/18/18, 2/21/18, 2/22/18, 2/23/18, 2/25/18, 2/28/18, 3/4/18, 3/5/18, 3/9/18, 3/12/18, 3/17/18, 3/18/18, 3/19/18, 3/21/18, 3/22/18, 3/23/18, 3/25/18, 3/26/18, 3/29/18, 3/30/18, 3/31/18, 4/1/18, 4/6/18, 4/9/18, 4/10/18, 4/12/1/18, and 4/20/18. c. [MEDICATION NAME] 20 mg on 1/3/18, 1/7/18, 1/8/18, 1/9/18, 1/10/18, 1/14/18, 1/16/18, 1/17/18, 1/20/18,2/7/18, 2/11/18, 2/21/18, 2/25/18, 2/26/18, 3/5/18, and 4/9/18. d. [MEDICATION NAME] 40 mg on 1/16/18, 1/17/18, 1/20/18, 2/7/18, 2/25/18, 2/26/18, 3/5/18, 4/9/18, and 4/13/18. e. [MEDICATION NAME] 50 mg on 1/7/18, 1/8/18, 1/9/18, 1/17/18, 1/15/18, 1/16/18, 1/17/18, 1/20/18, 1/21/18, 1/26/18, 1/29/18, 1/30/18, 2/1/18, 2/7/18, 2/25/18, 2/26/18, 3/5/18, 3/9/18, 3/12/18, 3/19/18, 3/22/18, 3/25/18, 3/26/18, 4/1/18, and 4/9/18. 5. Resident 59 resident was originally admitted on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. substance dependence. On 4/30/18 resident 59's medical record was reviewed. physician's orders [REDACTED]. a. [MEDICATION NAME] 55 units QHS. b. [MEDICATION NAME] Insulin 15 units TID. c. [MEDICATION NAME] 2 grams/100 ml (milliliters) Q 8 hours. d. [MEDICATION NAME] 40 QD. e. [MEDICATION NAME] 20-25 mg QD. f. Carvedilol 6.25 mg BID. g. [MEDICATION NAME] 500 mg BID. h. [MEDICATION NAME] 20 mg QD. i. [MEDICATION NAME] 40 mg QD. According to the MAR for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), resident 59 had multiple medications administered late including the following dates: a. [MEDICATION NAME] 55 units on 1/29/18, 1/30/18,1/3/18, 2/9/18,2/11/18, 2/14/18 and 4/17/18. b. [MEDICATION NAME] Insulin 15 units on 1/29/18, 2/1/18, 2/2/18, 2/5/18, 2/8/18, 2/9/18, 2/15/18, 2/16/18, 2/20/18, 2/22/18. c. [MEDICATION NAME] 2 gm/100 ml on 2/1/18 X 2, 2/2/18, 2/5/18, 2/8/18, 2/9/18 x 2, 2/10/18, 2/11/18, 2/12/18, 2/15/18, 2/16/18, 2/17/18, 2/18/18, 2/19/18 x 2, 2/21/18 x 2, 2/22/18 x 2, and 2/23/18. d. [MEDICATION NAME] 40 mg on 1/30/18, 1/31/18,2/1/18, 2/2/18, 2/5/18, 2/7/18, 2/8/18, 2/9/18, 2/10/18, 2/12/18, 2/13/18, 2/15/18, 2/16/18, 2/17/18, 2/19/18, 2/22/18, 2/23/18, 4/15/18, 4/20/18, and 4/24/18. e. [MEDICATION NAME] 20-25 mg on 2/1/18, 2/2/18, 2/4/18, 2/5/18, 2/7/18, 2/8/18, 2/9/18, 2/12/18, 2/13/18, 2/15/18, 2/16/18, 2/17/18, 2/19/18, 2/22/18, and 2/23/18. f. Carvedilol 6.25 mg on 4/13/18, 4/19/18, 4/20/18, and 4/24/18. g. [MEDICATION NAME] 500 mg on 4/15/18, 4/17/18, 4/20/18, and 4/24/18. h. [MEDICATION NAME] 20 mg on 4/13/18, 4/15/18, 4/20/18, and 4/24/18. i. [MEDICATION NAME] 40 mg on 4/13/18, 4/15/18, 4/20/18, and 4/24/18. On 4/24/18 at 2:00 PM, an interview was conducted with the facility Director of Nursing (DON) and the facility administrator. The facility DON stated that the problem with the late medications was that the internet keeps going down, then the facility nursing staff are still giving the medications on time but documenting late that they were administered. The facility Administrator confirmed this and stated that they had notified their corporate IT person in California. The facility Administrator and DON stated they would tell the staff to reset the system and wait for it to come on line again. The facility DON stated that they were unable to get help with the internet system and was frustrated as well with the problems that were occurring because of it. On 4/24/18 at 2:30 PM, an interview was conducted with Registered Nurse (RN) 7. RN 7 stated that if the internet goes down, there was a computer that they could go to and print off a list of medications and treatments and the times that they were due. RN 7 stated that the list was not for just one resident but that it was for the entire unit. RN 7 stated that they had to go through the entire report to see what medications and treatments were due and that it would delay the administration of the medications to the residents on the hall. RN 7 stated that it was rare that the internet would go down. On 4/24/18 at 2:40 PM, an interview was conducted with RN 8. RN 8 stated that if the internet goes down, then she would look at the desktop and write down the medications that were due and then administer the medications. RN 8 stated that the internet did not go down often. On 4/26/18 at 10:10 AM, an interview was conducted with the facility pharmacist. The facility pharmacist stated that he has had the internet go down about three times in the last year. The facility pharmacist stated that usually the facility would shut it down and restart the internet and he could continue on. The facility pharmacist stated that there was one time when he had to work from his home office to look at resident medical records because the internet was having problems.",2020-09-01
50,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2018-04-30,760,E,1,1,C87F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined that the facility did not ensure that 17 of 43 sample residents were free of significant medication errors. Specifically, multiple residents had medications that were not administered, received the wrong medication, were administered late or medications were not available. One resident received a double dose of [MEDICATION NAME]. Resident identifiers: 3, 4, 18, 20, 25, 30, 37, 45, 56, 59, 63, 163, 165, 166, 168, 169 and 263. Findings include: 1. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 37's medical record was reviewed. physician's orders [REDACTED]. a. 1/16/18 through 1/22/18, [MEDICATION NAME] 1 gram; intravenous (IV) once a day for UTI. b. 12/1/16, [MEDICATION NAME] 20 mg (milligrams)/ml (milliliter) subcutaneous at Bedtime. c. 1/6/18, [MEDICATION NAME] 100 mg Three Times a Day (TID) for [MEDICAL CONDITION]. d. 3/5/18, [MEDICATION NAME] 3 mg on Sunday, Tuesday, Thursday, Saturday. The Medication Administration Record [REDACTED] a. On 1/16/18, [MEDICATION NAME] 1 gram IV was not administered to resident 37 due to waiting on med (medication) from pharmacy. b. On 1/8/18 and 1/14/18, [MEDICATION NAME] 20 mg injection was not administered due to Drug/Item unavailable. c. On 3/10/18, [MEDICATION NAME] 100 mg was administered at 16:19 (4:19 PM), 2 hours and 19 minutes after it was due, due to Drug/Item unavailable. d. On 4/22/18, [MEDICATION NAME] 100 mg was Not Administered due to condition. e. On 4/22/18, [MEDICATION NAME] 3 mg was Not Administered, On Hold, Pt (patient) is very sleepy. 2. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 4's medical record was reviewed. physician's orders [REDACTED]. a. 8/15/17, [MEDICATION NAME] 0.5 mg twice daily (BID). b. 9/30/17, [MEDICATION NAME] 5 mg every six hours; at 2:00 AM, 8:00 AM, 2:00 PM and 8:00 PM, Hold if asleep. c. 8/15/17, [MEDICATION NAME] 20 mg QHS (bedtime) hold for systolic (blood pressure (BP)) The MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed the following: a. [MEDICATION NAME] 0.5 mg administered on 1/27/18 at 10:00 PM, 2/22/18 at 12:00 PM, 3/12/18 at 11:00 PM and 3/27/18 at 10:00 PM. Administration of the [MEDICATION NAME] 0.5 mg were administered two to four hours after they were due. b. [MEDICATION NAME] 0.5 mg was not administered on 2/28/18. c. [MEDICATION NAME] 5 mg administered on 3/24/18 at 10:00 PM, 4/7/18 at 12:00 AM, 4/10/18 at 9:30 AM and 4/23/18 at 4:45 AM. Three administrations of the [MEDICATION NAME] 5 mg were administered 1 1/2 hours to 2 hours and 45 minutes after they were due. The administration of the [MEDICATION NAME] 5 mg at 12:00 AM was administered 2 hours before it was due. d. [MEDICATION NAME] 5 mg was not administered on 1/12/18 at 2:00 PM, 1/14/18 at 8:00 PM, 1/16/18 at 2:00 PM, 2/22/18 at 8:00 AM, 2/22/18 at 2:00 PM, 3/8/18 at 8:00 AM, 4/10/18 at 2:00 PM. d. [MEDICATION NAME] 20 mg was administered on 1/11/18 with a BP of 108/70, 1/18/18 with a BP 112/57, 1/19/18 with a BP 132/56, 2/24/18 with a BP 109/56, 3/22/18 with a BP 120/51, 3/25/18 with a BP 112/58. 3. Resident 163 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 163's medical record was reviewed. physician's orders [REDACTED]. a. 10/30/17 through 11/9/17,[MEDICATION NAME] mg twice daily at 8:00 AM and 8:00 PM for UTI. b. 12/20/17 through 12/24/17, [MEDICATION NAME] 1.25 grams IV daily at 5:00 PM [MEDICAL CONDITION] Bacteremia. c. 10/13/17, Eliquis 5 mg twice a day at 8:00 AM and 8:00 PM for A-fib ([MEDICAL CONDITION]). The MAR for (MONTH) (YEAR) and (MONTH) (YEAR) revealed the following: a.[MEDICATION NAME] mg administered on 11/2/17 at 10:24 AM, 11/3/17 at 9:27 AM and 11/7/17 at 10:20 PM. Administration of [MEDICATION NAME] mg was 1 hour and 27 minutes to 2 hours and 24 minutes after they were due. b. [MEDICATION NAME] 1.25 grams IV administered on 12/20/17 at 7:23 PM. Administration of the [MEDICATION NAME] 1.25 grams was 2 hours and 23 minutes after it was due. c. Eliquis 5 mg not administered on 11/24/17 at 8:00 AM because med not avaialble(sic) notifeid (sic) pharmacy. 4. Resident 169 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 169's medical record was reviewed. A Medication Error report form dated 4/12/18, revealed that resident 169 had a [MEDICATION NAME] 7.5/325 mg tablet administered rather than the [MEDICATION NAME] 7.5/325 mg tablet as ordered by her physician. 5. Resident 168 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 168's medical record was reviewed. A Medication Error report form dated 2/14/18 revealed that resident 168 was to receive [MEDICATION NAME] 7.5 mg daily at bedtime. The physician's orders [REDACTED]. 6. Resident 166 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 166's medical record was reviewed. A Medication Error report form dated 12/7/17 revealed that resident 166 had to receive D ([MEDICATION NAME]) 5W at 75 ml/hr, [MEDICATION NAME] as needed and blood sugar checks every 30 minutes due to a second administration of resident 166's [MEDICATION NAME] 30 units after the nurse misread the MAR. A Medication Error report form dated 2/23/18 revealed that resident 166 was to receive Losartan 50 mg daily. The physician's orders [REDACTED]. 7. Resident 20 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 20's medical record was reviewed. A Medication Error report form dated 2/14/18 revealed that resident 20 had not received his [MEDICATION NAME] Patch on 12/11/18. 8. Resident 165 was admitted to the facility on [DATE] at 17:40 (5:40 PM) on hospice care with [DIAGNOSES REDACTED]. On 4/26/18 resident 165's medical record was reviewed. A Medication Error report form dated 12/17/18 revealed that resident 165 had [MEDICATION NAME] administered rather than the [MEDICATION NAME] for his pain on 12/16/18. 9. Resident 63 was admitted to the facility on [DATE] on hospice care with [DIAGNOSES REDACTED]. On 4/26/18 resident 63's medical record was reviewed. Review of physician's orders [REDACTED]. a. [MEDICATION NAME] 300 mg (milligrams) TID (three times daily) for [MEDICAL CONDITION] b. [MEDICATION NAME] 10 gm (grams)/15 ml (milliliters); 45 ml (30 grams total) TID for [MEDICAL CONDITION] c. [MEDICATION NAME] 1000 mg QD (every day) at dinner time for DM d. [MEDICATION NAME] 40 mg QD before breakfast e. [MEDICATION NAME] 25 mg QHS (bedtime) for [MEDICAL CONDITION] m/b (manifested by) episodes of uncontrollable anger f. [MEDICATION NAME] 25 mg QD for ascites g. [MEDICATION NAME] 550 mg BID for hepatic [MEDICAL CONDITION] h. [MEDICATION NAME] 10 mg rectally QD prn (as needed) i. Fleet Enema 19.7 gm/118 ml rectally QD prn j. Milk of Magnesia 400 mg/5 ml, administer 30 ml (2400 mg total) QD prn k. Tylenol 325 mg 2 tabs (650 mg total) Q 4 hrs prn for general pain The Medication Administration Record [REDACTED]. On 4/25/18 at 1:55 PM, an interview was conducted with the facility DON and the facility Corporate Nurse (CN). The facility DON and the facility CN stated that they should have followed up on the medications and that going to a different pharmacy to get resident 63's medications would have been a good idea. The facility DON stated that they had actually paid for medications before for a resident when medications had not come in but did not think of that. 10. Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 25's medical record was reviewed. physician's orders [REDACTED]. a. 12/5/17, [MEDICATION NAME] 0.5 mg BID. b. 2/23/18, [MEDICATION NAME] 0.5 mg BID. The MAR for (MONTH) (YEAR) and (MONTH) (YEAR) for resident 25 revealed the following: a. [MEDICATION NAME] 0.5 mg was administered late on 3/1/18, 3/2/18, 3/3/18, 3/5/18, 3/6/18, 3/7/18, 3/8/18, 3/9/18, 3/12/18, 3/14/18, 3/16/18, 3/17/18, 3/18/18, 3/19/18, 3/22/18, 3/27/18, 3/29/18, 4/4/18, 4/12/18, 4/17/18, 4/20/18, 4/23/18 and 4/24/18. b. [MEDICATION NAME] 0.5 mg, was administered late on 3/6/18, 3/19/18, 3/27/18, 4/4/18, 4/12/18, 4/17/18, 4/20/18, 4/23/18, and 4/24/18. 11. Resident 45 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18, resident 45's medical record was reviewed. physician's orders [REDACTED]. a. Humalog sliding scale insulin before meals and at HS. b. [MEDICATION NAME] 50 units BID. The MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) for resident 45 revealed the following: a. Humalog sliding scale insulin was administered late on 1/2/18, 1/3/18, 1/4/18, 1/8/18, 1/9/18, 1/10/18, 1/11/18, 1/12/18, 1/13/18, 1/14/18, 1/15/18, 1/16/18, 1/18/18, 1/19/18, 1/20/18, 1/21/18, 1/25/18, 1/26/18, 1/27/18, 1/28/18, 1/29/18, 2/2/18, 2/5/18, 2/6/18, 2/7/18, 2/9/18, 2/10/18, 2/12/18, 2/16/18, 2/17/18, 2/21/18, 2/22/18, 2/23/18, 2/25/18, 2/26/18, 2/27/18, 2/28/18, 3/5/18, 3/9/18, 3/10/18, 3/12/18, 3/17/18, 3/18/18, 3/19/18, 3/20/18, 3/21/18, 3/22/18, 3/23/18, 3/25/18, 3/26/18, 3/29/18, 3/30/18, 3/31/18, 4/1/18, 4/3/18, 4/6/18, 4/9/18, 4/10/18, 4/12/18, 4/19/18, and 4/20/18. b. [MEDICATION NAME] Insulin was administered late on 1/2/18, 1/4/18, 1/8/18, 1/9/18, 1/10/18, 1/11/18, 1/13/18, 1/14/18, 1/15/18, 1/16/18, 1/18/18, 1/19/18, 1/20/18, 1/21/18, 1/25/18, 1/26/18, 1/28/18, 1/29/18, 2/2/18, 2/5/18, 2/7/18, 2/9/18, 2/18/18, 2/21/18, 2/22/18, 2/23/18, 2/25/18, 2/28/18, 3/4/18, 3/5/18, 3/9/18, 3/12/18, 3/17/18, 3/18/18, 3/19/18, 3/21/18, 3/22/18, 3/23/18, 3/25/18, 3/26/18, 3/29/18, 3/30/18, 3/31/18, 4/1/18, 4/6/18, 4/9/18, 4/10/18, 4/12/1/18, and 4/20/18. 12. Resident 59 resident was originally admitted on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. substance dependence. On 4/30/18 resident 59's medical record was reviewed. physician's orders [REDACTED]. a. [MEDICATION NAME] 55 units QHS. b. [MEDICATION NAME] Insulin 15 units TID. c. [MEDICATION NAME] 2 grams/100 ml Q 8 hours. The MAR for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) for resident 59 revealed the following: a. [MEDICATION NAME] was administered late on 1/29/18, 1/30/18,1/3/18, 2/9/18,2/11/18, 2/14/18 and 4/17/18. b. [MEDICATION NAME] Insulin was administered late on 1/29/18, 2/1/18, 2/2/18, 2/5/18, 2/8/18, 2/9/18, 2/15/18, 2/16/18, 2/20/18, 2/22/18. c. [MEDICATION NAME] was administered late on 2/1/18 X 2, 2/2/18, 2/5/18, 2/8/18, 2/9/18 x 2, 2/10/18, 2/11/18, 2/12/18, 2/15/18, 2/16/18, 2/17/18, 2/18/18, 2/19/18 x 2, 2/21/18 x 2, 2/22/18 x 2, and 2/23/18. 13. Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/18 resident 30's medical record was reviewed. physician's orders [REDACTED]. a. [MEDICATION NAME] 30 mg TID. Hold for SBP b. Carvedilol 25 mg BID. Hold for SBP c. [MEDICATION NAME] 10 mg QD. Hold for SBP A Medication Error report form for revealed that resident 30 had 52 medication administration error's for (MONTH) (YEAR). A Medication Error report form revealed that resident 30 had 151 medication administration error's for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR). Each of the medication administration error's was due to administration of the [MEDICATION NAME], Carvedilol, or [MEDICATION NAME] outside of the parameters set by the physician. The MAR for February, (MONTH) and (MONTH) (YEAR) revealed the following errors: [MEDICATION NAME]: a) 2/1/2018 at 8:00 AM diastolic blood pressure (BP) was measured at 70 b) 2/2/2018 at 8:00 AM diastolic BP was measured at 77 c) 2/6/2018 at 8:00 AM diastolic BP was measured at 68 d) 2/8/2018 at 8:00 AM diastolic BP was measured at 78 e) 2/11/2018 at 8:00 AM diastolic BP was measured at 79 f) 2/16/2018 at 8:00 AM diastolic BP was measured at 78 g) 2/17/2018 at 8:00 AM diastolic BP was measured at 78 h) 2/20/2018 at 8:00 AM diastolic BP was measured at 77 i) 2/21/18 at 8:00 AM BP was measured at 133 systolic and 78 diastolic j) 2/22/2018 at 8:00 AM diastolic BP was measured at 74 k) 2/23/2018 at 8:00 AM diastolic BP was measured at 65 l) 2/24/2018 at 8:00 AM diastolic BP was measured at 72 m) 3/11/2018 at 8:00 AM diastolic BP was measured at 74 n) 3/14/2018 at 8:00 AM diastolic BP was measured at 69 o) 3/15/2018 at 8:00 AM diastolic BP was measured at 73 p) 3/17/2018 at 8:00 AM diastolic BP was measured at 72 q) 3/20/2018 at 8:00 AM diastolic BP was measured at 78 r) 3/24/2018 at 8:00 AM BP was measured at 127 systolic and 60 diastolic s) 3/29/2018 at 8:00 AM diastolic BP was measured at 63 t) 3/30/2018 at 8:00 AM BP was measured at 113 systolic and 56 diastolic u) 3/31/2018 at 8:00 AM diastolic BP was measured at 68 v) On 4/5/18 at 8:00 AM, diastolic BP was measured at 75 w) On 4/6/18 at 8:00 AM, diastolic BP was measured at 75 x) On 4/7/18 at 8:00 AM, BP was measured at 127 systolic and 60 diastolic y) On 4/12/18 at 8:00 AM, diastolic BP was measured at 65 z) On 4/13/18 at 8:00 AM, diastolic BP was measured at 72 aa) On 4/14/18 at 8:00 AM, diastolic BP was measured at 72 bb) On 4/17/18 at 8:00 AM, diastolic BP was measured at 70 cc) On 4/19/18 at 8:00 AM, diastolic BP was measured at 68 dd) On 4/20/18 at 8:00 AM, diastolic BP was measured at 70 ee) On 4/20/18 at 8:00 AM, diastolic BP was measured at 71 ff) On 4/24/18 at 8:00 AM, diastolic BP was measured at 70 Carvedilol: a) 2/1/2018 at 8:00 AM diastolic BP was measured at 70 b) 2/2/2018 at 8:00 AM diastolic BP was measured at 77 c) 2/2/2018 at 8:00 PM BP was measured at 135 systolic and 74 diastolic d) 2/6/2018 at 8:00 AM diastolic BP was measured at 68 e) 2/8/2018 at 8:00 AM diastolic BP was measured at 78 f) 2/9/2018 at 8:00 PM diastolic BP was measured at 78 g) 2/11/2018 at 8:00 AM diastolic BP was measured at 79 h) 2/11/2018 at 8:00 PM diastolic BP was measured at 79 i) 2/16/2018 at 8:00 AM diastolic BP was measured at 78 j) 2/17/2018 at 8:00 AM diastolic BP was measured at 78 k) 2/20/2018 at 8:00 AM diastolic BP was measured at 77 l) 2/21/18 at 8:00 AM BP was measured at 133 systolic and 78 diastolic m) 2/21/2018 at 8:00 PM diastolic BP was measured at 78 n) 2/22/2018 at 8:00 AM diastolic BP was measured at 74 o) 2/22/2018 at 8:00 PM diastolic BP was measured at 78 p) 2/23/2018 at 8:00 AM diastolic BP was measured at 65 q) 2/24/2018 at 8:00 AM diastolic BP was measured at 72 r) 2/24/2018 at 8:00 PM diastolic BP was measured at 78 s) 3/1/2018 at 8:00 PM BP was measured at 122 systolic and 68 diastolic t) 3/2/2018 at 8:00 PM BP was measured at 128 systolic and 76 diastolic u) 3/7/2018 at 8:00 PM BP was measured at 138 systolic and 78 diastolic v) 3/8/2018 at 8:00 PM diastolic BP was measured at 72 w) 3/9/2018 at 8:00 AM diastolic BP was measured at 72 x) 3/10/2018 at 8:00 PM diastolic BP was measured at 74 y) 3/11/2018 at 8:00 AM diastolic BP was measured at 74 z) 3/12/2018 at 8:00 PM BP was measured at 128 systolic and 68 diastolic aa) 3/14/2018 at 8:00 AM diastolic BP was measured at 69 bb) 3/14/2018 at 8:00 PM diastolic BP was measured at 69 cc) 3/15/2018 at 8:00 AM diastolic BP was measured at 73 dd) 3/15/2018 at 8:00 PM diastolic BP was measured at 76 ee) 3/17/2018 at 8:00 AM diastolic BP was measured at 72 ff) 3/20/2018 at 8:00 AM diastolic BP was measured at 78 gg) 3/20/2018 at 8:00 PM diastolic BP was measured at 72 hh) 3/24/2018 at 8:00 AM BP was measured at 127 systolic and 60 diastolic ii) 3/26/2018 at 8:00 PM diastolic BP was measured at 75 jj) 3/28/2018 at 8:00 PM diastolic BP was measured at 78 kk) 3/29/2018 at 8:00 AM diastolic BP was measured at 63 ll) 3/29/2018 at 8:00 PM BP was measured at 136 systolic and 74 diastolic mm) 3/30/2018 at 8:00 AM BP was measured at 113 systolic and 56 diastolic nn) 3/31/2018 at 8:00 AM diastolic BP was measured at 68 oo) On 4/5/18 at 8:00 AM diastolic BP was measured at 75 pp) On 4/5/18 at 8:00 PM diastolic BP was measured at 78 qq) On 4/6/18 at 8:00 AM diastolic BP was measured at 75 rr) On 4/7/18 at 8:00 AM BP was measured at 127 systolic and 60 diastolic ss) On 4/12/18 at 8:00 AM diastolic BP was measured at 65 tt) On 4/13/18 at 8:00 AM diastolic BP was measured at 72 uu) On 4/14/18 at 8:00 AM diastolic BP was measured at 72 vv) On 4/17/18 at 8:00 AM diastolic BP was measured at 70 ww) On 4/19/18 at 8:00 AM diastolic BP was measured at 68 xx) On 4/20/18 at 8:00 AM diastolic BP was measured at 70 yy) On 4/21/18 at 8:00 AM diastolic BP was measured at 71 zz) On 4/24/18 at 8:00 AM diastolic BP was measured at 70 aaa) On 4/7/18 at 8:00 PM diastolic BP was measured at 79 bbb) On 4/8/18 at 8:00 PM systolic BP was measured at 136 ccc) On 4/12/18 at 8:00 PM diastolic BP was measured at 78 ddd) On 4/14/18 at 8:00 PM diastolic BP was measured at 78 [MEDICATION NAME]: a) 2/1/2018 at 8:00 AM diastolic BP was measured at 70 b) 2/2/2018 at 8:00 AM diastolic BP was measured at 77 c) 2/2/2018 at 8:00 PM BP was measured at 135 systolic and 74 diastolic d) 2/3/2018 at 3:00 PM diastolic was measured at 77 e) 2/6/2018 at 8:00 AM diastolic BP was measured at 68 f) 2/8/2018 at 8:00 AM diastolic BP was measured at 78 g) 2/9/2018 at 9:00 PM diastolic BP was measured at 78 h) 2/11/2018 at 8:00 AM diastolic BP was measured at 79 i) 2/11/2018 at 8:00 PM diastolic BP was measured at 79 j) 2/16/2018 at 8:00 AM diastolic BP was measured at 78 k) 2/16/2018 at 9:00 PM diastolic BP was measured at 78 l) 2/17/2018 at 8:00 AM diastolic BP was measured at 78 m) 2/17/2018 at 3:00 PM diastolic BP was measured at 78 n) 2/20/2018 at 8:00 AM diastolic BP was measured at 77 o) 2/21/2018 at 8:00 AM BP was measured at 133 systolic and 78 diastolic p) 2/21/2018 at 3:00 PM diastolic BP was measured at 78 q) 2/21/2018 at 9:00 PM diastolic BP was measured at 78 r) 2/22/2018 at 8:00 AM diastolic BP was measured at 74 s) 2/22/2018 at 3:00 PM diastolic BP was measured at 76 t) 2/22/2018 at 9:00 PM diastolic BP was measured at 78 u) 2/23/2018 at 8:00 AM diastolic BP was measured at 65 v) 2/23/2018 at 3:00 PM diastolic BP was measured at 72 w) 2/24/2018 at 8:00 AM diastolic BP was measured at 72 x) 2/24/2018 at 9:00 PM diastolic BP was measured at 78 y) 2/28/2018 at 3:00 PM BP was measured at 130 systolic and 70 diastolic z) 3/1/2018 at 9:00 PM BP was measured at 122 systolic and 68 diastolic aa) 3/2/2018 at 9:00 PM BP was measured at 128 systolic and 76 diastolic bb) 3/7/2018 at 9:00 PM BP was measured at 138 systolic and 78 diastolic cc) 3/10/2018 at 9:00 PM diastolic BP was measured at 74 dd) 3/11/2018 at 8:00 AM diastolic BP was measured at 74 ee) 3/12/2018 at 9:00 PM BP was measured at 138 systolic and 72 diastolic ff) 3/14/2018 at 8:00 AM diastolic BP was measured at 69 gg) 3/14/2018 at 9:00 PM diastolic BP was measured at 69 hh) 3/15/2018 at 8:00 AM diastolic BP was measured at 73 ii) 3/15/2018 at 8:00 PM diastolic BP was measured at 76 jj) 3/17/2018 at 8:00 AM diastolic BP was measured at 72 kk) 3/20/2018 at 8:00 AM diastolic BP was measured at 78 ll) 3/20/2018 at 8:00 PM diastolic BP was measured at 72 mm) 3/24/2018 at 8:00 AM BP was measured at 127 systolic and 60 diastolic nn) 3/26/2018 at 8:00 PM diastolic BP was measured at 75 oo) 3/28/2018 at 8:00 PM diastolic BP was measured at 78 pp) 3/29/2018 at 8:00 AM diastolic BP was measured at 63 qq) 3/29/2018 at 8:00 PM BP was measured at 136 systolic and 74 diastolic rr) 3/30/2018 at 8:00 AM BP was measured at 113 systolic and 56 diastolic ss) 3/31/2018 at 8:00 AM diastolic BP was measured at 68 tt) On 4/5/18 at 8:00 AM diastolic BP was measured at 75 uu) On 4/5/18 at 9:00 PM diastolic BP was measured at 78 vv) On 4/6/18 at 8:00 AM diastolic BP was measured at 65 ww) On 4/7/18 at 8:00 AM BP was measured at 127 systolic and 60 diastolic xx) On 4/7/18 at 9:00 PM diastolic BP was measured at 79 yy) On 4/8/18 at 9:00 PM systolic BP was measured at 136 zz) On 4/11/18 at 3:00 PM diastolic BP was measured at 69 aaa) On 4/12/18 at 8:00 AM diastolic BP was measured at 65 bbb) On 4/12/18 at 9:00 PM diastolic BP was measured at 78 ccc) On 4/13/18 at 8:00 AM diastolic BP was measured at 65 ddd) On 4/14/18 at 8:00 AM diastolic BP was measured at 72 eee) On 4/14/18 at 9:00 PM diastolic BP was measured at 78 fff) On 4/17/18 at 3:00 PM diastolic BP was measured at 70 ggg) On 4/19/18 at 8:00 AM diastolic BP was measured at 68 hhh) On 4/20/18 at 8:00 AM diastolic BP was measured at 70 iii) On 4/21/18 at 8:00 AM diastolic BP was measured at 71 jjj) On 4/22/18 at 3:00 PM diastolic BP was measured at 79 kkk) On 4/25/18 at 3:00 PM BP was measured at 137 systolic and 86 diastolic On 4/30/18 an interview was conducted with the facility DON. The facility DON stated that she was aware that the resident had many medication errors in January. When the errors in February, March, and (MONTH) were revealed, the DON acknowledged that they should not have happened. In addition, resident 30 had physician's orders [REDACTED]. a) [MEDICATION NAME], 10 milligrams (mg), 1 time per day b) Carvedilol, 25 mg, 2 times per day. (Note: This order was changed on 4/6/18 to 25 mg once in the morning and 37.5 mg once an evening.) c) [MEDICATION NAME], 30 mg, 3 times per day d) [MEDICATION NAME], 100 unit/mL, 8 units, at bedtime e) [MEDICATION NAME], 5 mg, once a day f) [MEDICATION NAME] 100 unit/mL, administer per sliding scale, before meals g) [MEDICATION NAME], 40 mg, once a day Resident 30's MAR indicated [REDACTED] a) [MEDICATION NAME], had no blood pressure measurement or administration information on 2/27/18. was administered late on 1/5/18, 1/13/18, 1/14/18, 1/18/18, 1/19/18, 1/21/18, 1/26/18, 1/29/18, 2/1/18, 2/3/18, 2/6/18, 2/8/18, 2/10/18, 2/11/18, 2/14/18, 2/16/18, 2/17/18, 2/20/18, 2/21/18, 2/24/18, 3/1/18, 3/4/18, 3/7/18, 3/11/18, 3/13/18, 3/26/18, 3/27/18, 3/29/18, 4/7/18, 4/9/18, 4/14/18, 4/20/18 b) Carvedilol, had no blood pressure measurement or administration information on 3/11/18 at 8:00 PM or 3/27/18 at 8:00 PM. The carvedilol was administered late on 1/1/18, 1/5/18, 1/6/18, 1/7/18, 1/8/18, 1/9/18, 1/11/18, 1/12/18, 1/13/18, 1/14/18, 1/18/18, 1/19/18, 1/21/18, 1/26/18, 1/27/18, 2/1/18, 2/2/18, 2/3/18, 2/5/18, 2/6/18, 2/8/18, 2/10/18, 2/11/18 at 8:00 AM and 8:00 PM, 2/12/18 at 8:00 AM and 8:00 PM, 2/13/18 at 8:00 AM and 8:00 PM, 2/14/18, 2/16/18, 2/17/18, 2/18/18, 2/20/18, 2/21/18, 2/22/18, 2/24/18, 2/25/18, 2/28/18, 3/4/18 at 8:00 AM and 8:00 PM, 3/5/18, 3/6/18, 3/7/18 at 8:00 AM and 8:00 PM, 3/8/18, 3/9/18, 3/10/18, 3/11/18, 3/13/18 at 8:00 AM and 8:00 PM, 3/14/18, 3/15/18, 3/17/18, 3/18/18, 3/19/18, 3/23/18, 3/25/18, 3/26/18 at 8:00 AM and 8:00 PM, 3/17/18, 3/29/18, 4/1/18, 4/6/18, 4/7/18, 4/9/18, 4/12/18, 4/14/18, 4/20/18, 4/21/18 c) [MEDICATION NAME], was administered late on 1/4/18, 1/5/18, 1/7/18, 1/8/18, 1/9/18, 1/10/18, 1/13/18, 1/14/18 at 8:00 AM and 9:00 PM, 1/15/18, 1/17/18, 1/18/18, 1/19/18, 1/21/18, 1/22/18, 1/24/18 at 3:00 PM and 9:00 PM, 1/25/18, 1/26/18 8:00 AM and 9:00 PM, 1/27/18, 1/29/18 8:00 AM and 3:00 PM, 1/31/18, 2/1/18 at 8:00 AM and 3:00 PM, 2/3/18 at 8:00 AM and 3:00 PM, 2/4/18, 2/5/18 at 3:00 PM and 9:00 PM, 2/6/18, 2/8/18, 2/9/18, 2/10/18 at 8:00 AM and 3:00 PM, 2/11/18 at 8:00 AM and 9:00 PM, 2/14/18, 2/15/18, 2/16/18 at 8:00 AM and 9:00 PM, 2/17/18, 2/18/18 3:00 PM and 9:00 PM, 2/20/18, 2/21/18, 2/22/18 at 3:00 PM and 9:00 PM, 2/23/18, 2/24/18, 2/27/18 3:00 PM and 9:00 PM, 2/28/18, 3/1/18, 3/3/18, 3/4/18 at 8:00 AM, 3:00 PM and 9:00 PM, 3/5/18 at 3:00 PM and 9:00 PM, 3/6/18, 3/7/18, 3/9/18, 3/11/18 at 8:00 AM and 3:00 PM, 3/12/18, 3/13/18 at 8:00 AM and 9:00 PM, 3/15/18, 3/16/18, 3/17/18, 3/18/18, 3/19/18, 3/23/18, 3/24/18, 3/26/18 at 8:00 AM and 9:00 PM, 3/27/18 at 8:00 AM, 3:00 PM and 9:00 PM, 3/29/18, 3/31/18, 4/4/18, 4/6/18 3:00 PM and 9:00 PM, 4/7/18, 4/9/18, 4/12/18 3:00 PM and 9:00 PM, 4/13/18, 4/14/18 8:00 AM, 4/18/18, 4/20/18 d) [MEDICATION NAME], had no blood sugar measurement or administration information on 3/8/18, 3/11/18, 3/26/18, 3/27/18. The [MEDICATION NAME] was administered late on 1/2/18, 1/4/18, 1/8/18, 1/9/18, 1/10/18, 1/11/18, 1/14/18, 1/15/18, 1/16/18, 1/17/18, 1/19/18, 1/20/18, 1/25/18, 1/26/18, 1/27/18, 2/2/18, 2/5/18, 2/6/18, 2/9/18, 2/11/18, 2/12/18, 2/13/18, 2/17/18, 2/18/18, 2/19/18, 2/22/18, 2/25/18, 2/27/18, 2/28/18, 3/4/18, 3/5/18, 3/6/18, 3/9/18, 3/10/18, 3/13/18, 3/14/18, 3/17/18, 3/18/18, 3/19/18, 3/21/18, 3/23/18, 3/25/18, 4/4/18, 4/6/18, 4/9/18, 4/12/18, 4/16/18, 4/18/18, 4/19/18, 4/21/18, 4/24/18, e) [MEDICATION NAME], was administered late on 1/2/18, and 1/31/18, 2/10/18, 2/12/18, 2/13/18, 3/5/18, 3/19/18, 3/25/18, 4/2/18, 4/3/18, 4/8/18, 4/10/18, 4/11/18, 4/17/18, 4/18/18, f) [MEDICATION NAME] Insulin, had no blood sugar or administration information on 2/12/18 at 8:00 am, 2/27/18 at 12:00 PM, 3/5/18 at 8:00 AM and 12:00 PM. The [MEDICATION NAME] Insulin was administered late on 2/1/18, 2/3/18 at 8:00 AM and 5:00 PM, 2/5/18 at 12:00 PM and 5:00 PM, 2/6/18, 2/7/18, 2/8/18, 2/9/18 2/10/18, 2/12/18, 2/17/18, 2/18/18, 2/21/18, 2/25/18, 2/27/18, 2/28/18, 3/4/18, 3/5/18, 3/7/18, 3/9/18, 3/10/18, 3/11/18 at 12:00 PM and 5:00 PM, 3/12/18, 3/15/18, 3/17/18, 3/18/18 at 12:00 PM and 5:00 PM, 3/24/18, 3/25/18, 3/26/18, 3/30/18, 4/2/18, 4/5/18 at 8:00 AM and 12:00 PM, 4/6/18, 4/7/18, 4/9/18, 4/10/18 8:00 AM and 5:00 PM, 4/11/18 8:00 AM and 5:00 PM, 4/13/18, 4/15/18, 4/16/18 at 8:00 AM and 5:00 PM, 4/17/18, 4/18/18, g) [MEDICATION NAME], was administered late on 1/4/18, 1/5/18, 1/6/18, 1/7/18, 1/11/18, 1/12/18, 1/13/18, 1/15/18, 1/18/18, 1/19/18, 1/20/18, 1/22/19, 1/23/18, 1/24/18, 1/26/18, 1/28/18, 2/1/18, 2/3/18, 2/4/18, 2/5/18, 2/6/18, 2/7/18, 2/8/18, 2/10/18, 2/11/18, 2/12/18, 2/13/18, 2/14/18, 2/16/18, 2/17/18, 2/19/18, 2/20/18, 2/21/18, 2/24/18, 2/26/18, 3/2/18, 3/3/18, 3/4/18, 3/5/18, 3/6/18, 3/7/18, 3/8/18, 3/11/18 at 8:00 AM and 12:00 PM, 3/13/18, 3/22/18, 3/26/18, 3/27/18, 3/29/18, 4/2/18, 4/4/18, 4/7/18, 4/11/18, 4/13/18, 4/14/18, 4/20/18 14. Resident 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 18 had physician orders [REDACTED]. a) [MEDICATION NAME], 100 mcg/hr, once a day every 3 days b) [MEDICATION NAME], 15 mg, four times a day Resident 18's MAR indicated [REDACTED]",2020-09-01
51,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2018-04-30,761,D,0,1,C87F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions. Specifically, multi dose vials of [MEDICATION NAME] were found in two medication rooms without open dates. Findings include: On 4/23/18 at 7:19 AM, an observation was made of the medication room on the Ensign Hall. One multi dose vial of [MEDICATION NAME] was noted to be without an open date. On 4/23/18 at 7:19 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 confirmed that there was no open date and did not know how long the [MEDICATION NAME] had been opened. RN 5 stated that the [MEDICATION NAME] should have had an open date. On 4/23/18 at 7:30 AM, an observation was made of the Cedar Cove Medication Room. One multi dose vial of [MEDICATION NAME] was noted to be without an open date. On 4/23/18 at 7:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 confirmed that there was no open date and did not know how long the vial had been opened. LPN 1 stated that there should have been an open date. A review of the Centers for Disease Control (CDC) Website under Info for providers: FAQ's (Frequently Asked Questions) regarding safe practices for medication injections revealed the following: 1. What is a multi-dose vial? A multi-dose vial is a vial of liquid medication intended for the [MEDICATION NAME] administration (injection or infusion) that contains more than one dose of medication. Multi-dose vials are labeled as such by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria. The preservative has no effect [MEDICAL CONDITION] and does not protect against contamination when healthcare personnel fail to follow safe injection practices. 2. Can multi-dose vials be used for more than one patient? Multi-dose vials should be dedicated to a single patient whenever possible. If multi-dose vials must be used for more than one patient, they should not be kept or accessed in the immediate patient treatment area. 3. When should multi-dose vials be discarded? Medication vials should always be discarded whenever sterility is compromised or questionable. In addition, the United States Pharmacopoeia (USP) General Chapter 797 (16 ) recommends the following for multi-dose vials of sterile pharmaceuticals: a. If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. b. If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer's expiration date. The manufacturer's expiration date refers to the date after which an unopened multi-dose vial should not be used. For information on storage and handling of vaccines please refer to the CDC Vaccine Storage and Handling Toolkit .",2020-09-01
52,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2018-04-30,842,D,0,1,C87F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 43 sample residents, that the facility did not maintain medical records on each resident that were accurately documented. Specifically, a resident on hospice did not have visits from hospice staff available in the medical record. Resident identifier: 56. Findings include: 1. Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 resident 56's medical record was reviewed. It was noted that the last hospice visit documented in the medical record was from 3/20/18. In the resident's progress notes the hospice RN had charted on 3/28, 4/10, 4/23, 4/26 and 4/30. On 4/26/18 at 9:40 AM an interview was conducted with the RN Case Manager of the hospice company. The RN Case Manager stated that she had notes with her from about 4/12/18 to current that needed to be given to the facility. On 4/30/18 at 2:50 PM an interview was conducted with the Medical Records Director (MRD). The MRD stated that the hospice staff was supposed to send over copies of their charting. The MRD stated that the facility would like to receive hospice notes within a week. Requested the MRD to search resident 56's record for notes beyond 3/20/18 from the hospice staff. The MRD was unable to find further documentation. The MRD acknowledged there was an incomplete medical record.",2020-09-01
53,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2018-04-30,849,D,0,1,C87F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined for 2 of 43 sample residents that the facility did not ensure that ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services. Specifically, two resident who were admitted to the facility on hospice, did not receive medications timely. Resident identifiers: 63 and 165. Findings include: 1. Resident 63 was admitted to the facility on [DATE] on hospice care with [DIAGNOSES REDACTED]. On 4/26/18 resident 63's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/24/18 at 15:55 (3:55 PM), Patient (pt) admitted to (Name of Facility) for hospice and comfort care. Discharge dx (diagnoses): hepatocellular [MEDICAL CONDITION]. Depression and/or anxiety features due to general medical condition; [MEDICAL CONDITION]. Past medical hx (history): DM; [MEDICAL CONDITION]; GERD; dementia. Hx of Hep ([MEDICAL CONDITION]) C; chronic back pain; hepatic [MEDICAL CONDITION] in (MONTH) (YEAR); portal vein [MEDICAL CONDITION]; DM II; [MEDICAL CONDITION]; [MEDICAL CONDITION]; DGD (diabetes and glandular disease); restless leg syndrome; hearing loss; abdominal aortic aneurysm; [MEDICAL CONDITION]; claudication; kidney stones; hx of UTIs (urinary tract infections). Patient is under (Name of Hospice) care/MD (Medical Doctor: (Name of MD). b. 1/24/18 at 18:55 (6:55 PM), Pt is alert and oriented to self only. Pt arrived to facility via (Name of Transportation). Pt admitted with liver failure and [MEDICAL CONDITION]. Pt being admitted to hospice upon arrival .Pt c/o (complains of) some belly pain r/t [MEDICAL CONDITION] .Pt has a history of aggressive behaviors while at home but have diminished since starting [MEDICATION NAME]. c. 1/24/18 at 19:09 (7:09 PM), Recorded as late entry on 1/25/18 at 7:13 PM, Discussed with Hospice nurse medications that they were D/C (discontinued). Informed hospice nurse that we had no medications for this res (resident) and we were waiting for hospice to supply. RN a/t (sic) be surprised at this and stated she would make a phone call re (regarding) med (medication) delivery. d. 1/25/18 at 6:13 AM, No medications have been delivered for this res. (Name of Hospice) to supply medications. e. 1/25/18 at 16:15 (4:15 PM), Resident is alert and orient (oriented) to self, is confusion (sic) and wandering to hallway, resident's room and outside of building, no c/o pain, no s/s of SOB, skin is W/D/I (warm, dry and intact), VS taken with T 98.0, P 83, R 18, BP 105/59, O2 Sats 94% on RA (room air), ate 100% of breakfast, good eating and drinking. LN was unable to administered (sic) medications for resident d/t (due to) resident's hospice pharmacy did not delivery (sic) his medications. LN called the hospice at 07:30 AM and had not received his medications. Resident was transferred to ER of (Name of Hospital) fur further evaluation r/t high elopement risk. Resident's spouse, (Name of Hospital) were notified, and the spouse came and got all resident's belongings. A discharge and Transfer - Physician Discharge Summary revealed the following: discharge date - 1/25/18 Discharge Time - 1615 (4:15 PM) Significant Changes in Condition - Increased confusion, elopement risk Final Diagnoses/Condition Upon Discharge - Stable, discharged to (Name of Hospital) for eval (evaluation) and treatment. physician's orders [REDACTED]. a. [MEDICATION NAME] 300 mg (milligrams) TID (three times daily) for [MEDICAL CONDITION] b. [MEDICATION NAME] 10 gm (grams)/15 ml (milliliters); 45 ml (30 grams total) TID for [MEDICAL CONDITION] c. [MEDICATION NAME] 1000 mg QD (every day) at dinner time for DM d. [MEDICATION NAME] 40 mg QD before breakfast e. [MEDICATION NAME] 25 mg QHS (bedtime) for [MEDICAL CONDITION] m/b (manifested by) episodes of uncontrollable anger f. [MEDICATION NAME] 25 mg QD for ascites g. [MEDICATION NAME] 550 mg BID (twice daily) for hepatic [MEDICAL CONDITION] h. [MEDICATION NAME] 10 mg rectally QD prn (as needed) i. Fleet Enema 19.7 gm/118 ml rectally QD prn j. Milk of Magnesia 400 mg/5 ml, administer 30 ml (2400 mg total) QD prn k. Tylenol 325 mg 2 tabs (650 mg total) Q 4 hrs prn for general pain The Medication Administration Record [REDACTED]. On 4/25/18 at 1:11 PM, an interview was conducted with the (Name of Hospice) receptionist. The (Name of Hospice) receptionist stated that resident 63 had been admitted under their care for hospice services and that resident 63 had been sent back to the ER because his medications had not been delivered. The (Name of Hospice) receptionist stated that she was unaware of the circumstances and would call me back. The (Name of Hospice) receptionist stated that they would have supplied an [NAME] (emergency) kit for resident 63 which contained [MEDICATION NAME] and [MEDICATION NAME]. On 4/25/18 at 1:55 PM, an interview was conducted with the facility DON (Director of Nursing) and the facility Corporate Nurse (CN). The facility DON and the facility CN stated that they should have followed up on the medications and that going to a different pharmacy to get resident 63's medications would have been a good idea. The facility DON stated that they had actually paid for medications before for a resident when medications had not come in but did not think of that. The facility DON stated that the hospice company was suppose to send all of resident 63's medications. On 4/25/18 at 2:38 PM, an interview was conducted with the Hospice RN (HRN). The HRN stated that they had no notification that the medications had not been delivered to the facility until the morning of 7/25/18. The HRN stated that they felt terrible. The HRN stated that they had either had a software failure or the nurse had not hit the send button when the medications were ordered and that their pharmacy never got the order for the medications. 2. Resident 165 was admitted to the facility on [DATE] at 17:40 (5:40 PM) on hospice care with [DIAGNOSES REDACTED]. On 4/26/18 resident 165's medical record was reviewed. Nursing progress notes revealed that resident 165's medications were unable to be administered as they had not been delivered from the hospice company. Physician orders [REDACTED]. a. [MEDICATION NAME] 5 mg QD at 8:00 AM b. Bumetadine 1 mg 3 tablets (3 mg total) BID c. [MEDICATION NAME]-Salmeterol 250-50 mcg (micrograms) 1 puff inhalation BID d. [MEDICATION NAME]-[MEDICATION NAME] Nebulizer 0.02% BID e. [MEDICATION NAME] 25 mg QD at 8:00 AM f. Potassium Chloride 20 mEq (milliequivalant) QD at 8:00 AM The MAR for resident 165 for (MONTH) (YEAR) revealed the following: a. 11/11/17 at 8:00 AM - [MEDICATION NAME] 5 mg Not Administered: Drug unavailable, Hospice notified. b. 11/11/17 at 8:56 AM - Bumetadine 1 mg 3 tablets Not Administered: Drug unavailable, Hospice notified. c. 11/10/17 at 8:00 PM - [MEDICATION NAME]-Salmeterol 250/50 mcg Not Administered: Drug Unavailable. d. 11/11/17 at 8:00 AM - [MEDICATION NAME]-Salmeterol 250/50 mcg Not Administered: Drug unavailable, Hospice notified. e. 11/10/17 at 8:00 PM - [MEDICATION NAME]-[MEDICATION NAME] Nebulizer 0.02% Not Administered: Drug Unavailable. f. 11/11/17 at 8:00 AM - [MEDICATION NAME]-[MEDICATION NAME] Nebulizer 0.02% Not Administered: Drug unavailable, Hospice notified. g. 11/11/17 at 8:00 AM - [MEDICATION NAME] 25 mg Not Administered: Drug unavailable, Hospice notified. h. 11/11/17 at 8:00 AM - Potassium Chloride 20 mEq Not Administered: Drug unavailable, Hospice notified. On 4/25/18 at 1:55 PM, an interview was conducted with the facility DON. The facility DON stated that resident 165 did not miss very many medications. The facility DON stated that resident 165 should have had his medications available to him. Crosss Refer to F-684",2020-09-01
54,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2019-05-23,580,D,0,1,PDL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status, or a need to alter treatment significantly. Specifically, a resident would refuse scheduled doses of insulin and the physician was not consistently notified of those refusals. Resident identifier: 49. Findings include: Resident 49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/22/19, resident 49's medical record was reviewed. Resident 49's physician's orders [REDACTED]. a. Start Date 11/1/18, 0600 (6:00 AM) [MEDICATION NAME] Solution 100 UNIT/ML (units per milliliter) (Insulin Detemir) Inject 50 unit subcutaneously one time a day for DM (diabetes mellitus) b. Start Date 11/1/18 1815 (6:15 PM) [MEDICATION NAME] Solution 100 UNIT/ML (Insulin Detemir) Inject 45 units subcutaneously one time a day for DM Resident 49's Medical Administration Record (MAR) was reviewed for (MONTH) and (MONTH) of 2019. The MAR indicated [REDACTED]. Resident 49 had refused the scheduled dose of insulin on the following dates: a. 4/2/19 at 6:15 PM; b. 4/26/19 at 6:00 AM and 6:15 PM; c. 4/27/19 at 6:00 AM and 6:15 PM; d. 4/30/19 at 6:00 AM and 6:15 PM; e. 5/1/19 at 6:15 PM; f. 5/2/19 at 6:00 AM; g. 5/12/19 6:00 AM. The nursing progress notes for resident 49 were reviewed. They revealed that for the above dates, there was no documentation that the doctor or nurse practitioner had been notified of the refusals. On 5/23/19 at 9:50 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that if a scheduled medication was held, the doctor should be notified. LPN 3 stated that the refusal and notifying the doctor should be documented in the progress notes. On 5/23/19 at 12:53 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident refused a scheduled medication, the doctor should be notified. The DON stated that the refusal and physician contact should be documented in the resident's progress notes.",2020-09-01
55,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2019-05-23,622,D,1,1,PDL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure that the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving provider. Specifically, the resident's physician did not document the reason for discharge in the medical record. In addition, the receiving provider did not receive contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, Advance Directive information, all special instructions or precautions for ongoing care, as appropriate, comprehensive care plan goals, and all other necessary information to ensure a safe and effective transition of care. Resident identifiers: 124. Findings include: Resident 124 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 124's medical record was reviewed on 5/21/19. an order for [REDACTED]. (Note: The temporary guardianship was to expire on 3/15/19.) A physician's orders [REDACTED]. A Social Service Note dated 2/24/19 at 12:04 AM, documented (Resident 124) is a [AGE] year old male with 'hx (history) alcohol and drug abuse' admitted [DATE] from (Hospital name) where he was taken 'after being found pulseless in asystole.' Hospital discharge notes indicate that (Resident 124) 'has been hospitalized since 12/21 with severe Korsakoff' and 'has very poor/no insight and is unable to care for himself long term.' Office of Public Guardianship appointed guardianship to act on resident's behalf. LCSW (Licensed Clinical Social Worker) met with (Resident 124) for welcome, information gathering, and review of resident rights and facility grievance policy. (Resident 124) was alert and oriented x (times) 3. His mood and affect seemed appropriate, short term memory and insight limited. He did not report (nor did he appear to be attending to) any internal stimuli. Current plan for discharge is unclear per resident's report. He indicates he 'has a job' and is ambivalent about 'staying in Utah or going back to California.' Social worker will address discharge planning during first IDT (interdisciplinary team) meeting. A Care Conference dated 2/28/19, documented . Resident states his ultimate goal is to d/c (discharge) to friend's home in Ogden. Guardian stated guardianship will expire d/t (due to ) not meeting criteria. A Social Service Note dated 3/5/19 at 3:16 PM, documented Spoke with (Deputy Guardian name) who needed M[NAME]A (Montreal Cognitive Assessment), BIMS (Brief Interview for Mental Status), and letter from DON (Director of Nursing) re: (regarding) capacity. Sent requested documentation and asked that (Deputy Guardian name) send a copy of court order if changes to guardianship order. A Social Service Note dated 3/12/19 at 11:31 AM, documented Spoke with guardian, (Deputy Guardian name). She said we are ok to discharge tomorrow 3/13/19. Called bishop who will try to be here for discharge in the morning at 10-11 am but will call to let us know if he can make it. A Discharge Summary note dated 3/13/19 at 11:09 AM, documented: Reason for DC (discharge) (Met Goals, Change of Condition, etc.): Patient met goals discharge date : 3/13/19 Discharge Time: 1100 (11:00 AM) Discharge Location: Ogden with Friend (name of friend) Transported by: (name of friend) (friend) Home Health/hospice agency (specify agency if applicable): N/a (not applicable) Order Summary sent & (and) signed with resident/responsible party: Yes Medications sent with resident/responsible party: All medications including narcotics signed by resident. Resident left with all personal belongings: Yes Resident verbalized understanding of discharge education: Yes Follow with PCP (primary care physician) scheduled? (if no, educate resident to schedule): Resident knows to schedule an appointment A physician's orders [REDACTED]. On 5/21/19 at 12:56 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 124 wanted to go home. RN 1 stated that resident 124 was in a lot of pain and had spoken to the Nurse Practitioner (NP) regarding his pain. RN 1 stated that when the NP suggested that resident 124 go to a pain clinic resident 124 refused. RN 1 stated that resident 124 would request to go to the emergency room but did not have a reason to go to the emergency room . RN 1 stated that she had heard from other staff that resident 124 did not qualify to be at the facility. RN 1 stated that she was the nurse that completed the discharge for resident 124 and she was under the impression that it was a last minute discharge. RN 1 stated that she did not get a physician's orders [REDACTED]. RN 1 further stated that she printed out resident 124's Order Summary Report so he was able to self administer his medications after discharge. On 5/21/19 at 1:39 PM, an interview was conducted with the LCSW. The LCSW stated that resident 124's plan since admission was to discharge home with the bishop. The LCSW stated that when a resident was admitted to the facility she would complete a discharge assessment and planning, discuss barriers, and anticipation of needs. The LCSW stated that resident 124 was not sure where he was going to go when discharged but she had been speaking with resident 124's bishop about discharge. The LCSW stated that resident 124 did not have a lot of options for discharge. The LCSW stated that when a resident has limited options she will complete applications for housing with the resident. The LCSW stated that she was not sure if resident 124 would have qualified for an Assisted Living Facility so she did not submit the New Choice Waiver application for resident 124. The LCSW stated that the Physician would always get involved with a resident discharge. The LCSW stated that she had a discharge packet that she would complete for the nursing staff that will include physician's orders [REDACTED]. The LCSW stated that she was not sure that the Physician completed an order for [REDACTED]. The LCSW stated that she was still trying to learn her job. On 5/21/19 at 3:04 PM, an interview was conducted with the Minimum Data Set (MDS) coordinator. The MDS coordinator stated that resident 124's cognition had a significant improvement from the day of hospital discharge until a few days after admission. The MDS coordinator stated that she thought resident 124 would qualify for long term care after reviewing the hospital records. The MDS coordinator stated that resident 124 was so impaired, she thought he would be long term. The MDS coordinator stated that a M[NAME]A was completed on resident 124 at the facility and resident 124 scored 26 out of 30 which was showing normal ranges. The MDS coordinator stated that resident 124's Korsakoff's was related to alcohol and he recovered quite fast. The MDS coordinator stated that on going dementia was anticipated with resident 124's condition. The MDS coordinator stated that resident 124 was very high level functioning, required very little therapy, and Speech said there was nothing they could do with him. The MDS coordinator stated that with resident 124's high level functioning he was not meeting Long Term Care criteria. The MDS coordinator stated that resident 124 did not want to be at the facility and he did not qualify to be at the facility. The MDS coordinator stated that there was not much the facility could do for resident 124 and he was homeless prior to his most recent hospital stay. The MDS coordinator stated that the staff were trying to figure out a safe plan for discharge. The MDS coordinator stated that a friend of resident 124's agreed he could come home with him. The MDS coordinator further stated that the weekend prior to discharge resident 124 tried to leave the facility and stated that he wanted to leave. The MDS coordinator stated that the staff on Monday set up the discharge for resident 124. The MDS coordinator further stated that unfortunately, there was no other discharge documentation that could be provided. The MDS coordinator stated that sometimes there were extra documents, but in this case there was not. On 5/22/19 at 11:13 AM, an interview was conducted with the DON. The DON stated that the LCSW would bring her a list of residents who will be discharging and the MDS coordinator will issue the resident Notice of Medicare Non-Coverage forms. The DON stated that the staff will usually notify the Physician, obtain discharge orders, and the Physician will agree if the discharge was safe from a medical standpoint. The DON stated that after the morning standup meetings the staff will review residents that were going to be discharged . The DON stated that every member of each discipline team would need to agree that the discharge was safe. The DON stated that resident 124 was not reviewed in the morning standup meeting because because it was implemented after resident 124 discharged from the facility. The DON stated that resident 124's cognition was much greater than what the hospital paperwork lead her to think. The DON stated that therapy gave the okay to discharge and she knew that resident 124 was okay medically. Additional documentation provided by the LCSW on 5/22/19, included email correspondence between the LCSW and OPG Deputy Guardian. On 3/12/19 at 9:33 AM, LCSW documented . Does this mean that we are okay to discharge (Resident 124) (even if court order is not finalized)? . On 3/12/19 at 10:33 AM, Deputy Guardian documented . You can discharge tomorrow. That's when the guardianship expires. (Note: an order for [REDACTED]. The temporary guardianship was to expire on 3/15/19.)",2020-09-01
56,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2019-05-23,641,D,0,1,PDL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 28 sampled residents, that the facility assessment did not accurately reflect the resident's status. Specifically, a resident who did not have a urinary catheter was coded as having one. Resident identifier: 52. Findings include: Resident 52 was admitted to the facility on [DATE] and readmitted after a hospital stay on 3/15/19 with [DIAGNOSES REDACTED]. On 5/20/19 at 11:00 AM, an interview was conducted with resident 52. Resident 52 stated that he has never had an indwelling urinary catheter. Resident 52 indicated that he had two urinals at his bed side and one of the urinals was observed to be half full of urine. Resident 52's medical record was reviewed on 5/22/19. A Medicare 30 Day scheduled Minimum Data Set (MDS) assessment dated [DATE], documented that resident 52 had an indwelling catheter. On 5/22/19 at 12:26 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she has worked at the facility for approximately three and a half months. RN 1 stated that during the time she has worked at the facility resident 52 has not had an indwelling urinary catheter. On 5/22/19 at 12:30 PM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that on 4/9/19, resident 52 was coded as having an indwelling urinary catheter according to the Certified Nursing Assistant task charting for resident 52. The MDS coordinator stated that if resident 52 had the indwelling urinary catheter for one day it would be coded on the MDS. No records were located in resident 52's medical record indicating that resident 52 had an indwelling urinary catheter.",2020-09-01
57,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2019-05-23,661,D,1,1,PDL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility that anticipates discharge did not have a discharge summary that included a recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent laboratory, radiology, and consultation results. Specifically, a resident did not have a complete discharge summary that included a post discharge plan of care. Resident identifiers: 124. Findings include: Resident 124 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 124's medical record was reviewed on 5/21/19. A Discharge Summary note dated 3/13/19 at 11:09 AM, documented: Reason for DC (discharge) (Met Goals, Change of Condition, etc.): Patient met goals discharge date : 3/13/19 Discharge Time: 1100 (11:00 AM) Discharge Location: Ogden with Friend (name of friend) Transported by: (name of friend) (friend) Home Health/hospice agency (specify agency if applicable): N/a (not applicable) Order Summary sent & (and) signed with resident/responsible party: Yes Medications sent with resident/responsible party: All medications including narcotics signed by resident. Resident left with all personal belongings: Yes Resident verbalized understanding of discharge education: Yes Follow with PCP (primary care physician) scheduled? (if no, educate resident to schedule): Resident knows to schedule an appointment A Transfer/Discharge Report dated 3/13/19, documented the following information: a. Resident Information: Resident Name, Unit, Room/Bed, admitted , Resident number, Sex, Birthdate, Age, Marital Status, Religion, Primary Language, Medicaid number, and Social Security number. b. Other Information: allergies [REDACTED]. c. Primary Contact: Name and Relationship. d. Primary Physician: Physician e. Diagnoses: [REDACTED]. f. Last Vital Signs: Blood pressure dated 2/24/19, Pulse dated 2/28/19, Temperature dated 2/18/19, and Respirations dated 2/28/19. (Note: The Transfer/Discharge Report did not include a recapitulation of resident 124's stay at the facility, a final summary of the resident's status, and discharge plan of care. A discharge summary must include an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another.) On 5/21/19 at 12:56 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 124 wanted to go home. RN 1 stated that resident 124 was in a lot of pain and had spoken to the Nurse Practitioner (NP) regarding his pain. RN 1 stated that when the NP suggested that resident 124 go to a pain clinic resident 124 refused. RN 1 stated that resident 124 would request to go to the emergency room but did not have a reason to go to the emergency room . RN 1 stated that she had heard from other staff that resident 124 did not qualify to be at the facility. RN 1 stated that she was the nurse that completed the discharge for resident 124 and she was under the impression that it was a last minute discharge. RN 1 stated that she did not get a physician's orders [REDACTED]. RN 1 further stated that she printed out resident 124's Order Summary Report so he was able to self administer his medications after discharge. On 5/21/19 at 1:39 PM, an interview was conducted with the Licensed Clinical Social Worker (LCSW). The LCSW stated that she had a discharge packet that she would complete for the nursing staff that would include physician's orders [REDACTED]. The LCSW stated that she was not sure that the Physician completed an order for [REDACTED]. The LCSW stated that she was still trying to learn her job. On 5/21/19 at 3:04 PM, an interview was conducted with the Minimum Data Set (MDS) coordinator. The MDS coordinator stated that unfortunately, there was no other discharge documentation that could be provided. The MDS coordinator stated that sometimes there were extra documents, but in this case there was not. The MDS coordinator stated that resident 124 did not have a complete discharge summary and a physician's orders [REDACTED]. On 5/22/19 at 11:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the LCSW would bring her a list of residents who will be discharging and the MDS coordinator will issue the resident Notice of Medicare Non-Coverage forms. The DON stated that the staff will usually notify the Physician, obtain discharge orders, and the Physician will agree if the discharge was safe from a medical standpoint. The DON stated that after the morning standup meetings the staff will review the residents that were going to be discharged . The DON stated that every member of each discipline team would need to agree that the discharge was safe. The DON stated that resident 124 was not reviewed in the morning standup meeting because it was implemented after resident 124 discharged from the facility.",2020-09-01
58,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2019-05-23,677,D,0,1,PDL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 28 sampled residents, that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, 2 residents complained of not receiving showers and the facility's documentation was unable to prove that they had been provided. Resident identifiers: 48 and 52. Findings include: 1. Resident 48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/20/19 at 1:30 PM, an interview was conducted with resident 48. Resident 48 stated she was not provided showers on a consistent basis. Resident 48 stated that on the 8th of (MONTH) she had received a shower, and was not showered again until (MONTH) 17th. Resident 48 stated prior to (MONTH) 8th she believed she had gone three and a half weeks without a shower. Resident 48 stated she had to beg for showers. On 5/21/19, resident 48's medical record was reviewed. Resident 48 had a Quarterly Minimum Data Set (MDS) assessment completed on 4/21/19. Under section G0120 titled Bathing resident 48 was coded as needing physical help in part of the bathing activity. For the amount of support provided resident 48 was coded as needing two person physical assist. Resident 48 also had a Quarterly MDS assessment completed on 1/19/19. Under section G0120, resident 48 was coded as requiring total dependence for bathing. Resident 48's care plan was reviewed and under a section titled focus the following was revealed: .The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) disease process, impaired balance, limited mobility, limited ROM (range of motion) chronic pain to lower lumbar. (At) risk for altered ADL's r/t: decline in functional ADL activity such as bed mobility .transfer .walking .dressing .toileting .and personal hygiene and bathing. The facility's record of when resident 48 received a shower or bath was requested. There was a document titled Follow up question report. This was a task which the Certified Nursing Assistants (CNA)'s filled out. The facility also provided papers which were titled shower sheets. The follow up question report and shower sheets revealed that resident 48 had received showers on the following dates: a. 2/18/19 b. 2/22/19 c. 3/5/19 (this was an 11 day gap from 2/22/19) d. 3/3/19, The shower sheets revealed resident 48 had refused a shower e. 3/30/19 (This was a 23 day gap from 3/7/19) f. 4/12/19 (This was a 13 day gap from 3/30/19) g. 4/24/19 (This was a 12 day gap from 4/12/19) h. 4/27/19 i. 5/15/19 (This was an 18 day gap from 4/27/19) j. 5/17/19 k. 5/19/19 l. 5/20/19 On 5/22/19 at 8:45 AM, an interview was conducted with CNA 6. CNA 6 stated that the CNA's know how much assistance a resident required based off of verbal reporting and the kardex. CNA 6 stated the kardex was the document which the CNA's would reference to know how to care for the residents. Resident 48's kardex was requested from the facility. Under a section titled Bathing it stated Resident prefers Tues (Tuesday), Thurs (Thursday), Sat (Saturday) PM (in the afternoon) after Dinner and PRN (as needed). On 5/22/19 at 10:10 AM, an interview was conducted with CNA 7. CNA 7 stated she had worked at the facility for one year and knew resident 48. CNA 7 stated that resident 48 required total assistance for bathing. CNA 7 stated resident 7 required a hoyer to transfer her. On 5/23/19 at 11:59 PM, an interview was conducted with CNA 5. CNA 5 stated that resident 48 required extensive assistance with showers and was totally dependent. CNA 5 stated she had worked at the facility for 2 years and worked in the section where resident 48's room was located 2 to 3 times a week. CNA 5 stated that she could recall one occasion where resident 48 had refused a shower. On 5/23/19 at 12:53 PM an interview was conducted with the Director of Nursing (DON). The DON stated that a shower sheet should be completed whether a shower was completed or refused. The DON acknowledged the gaps in resident 48's bathing and did not provide further information. 2. Resident 52 was admitted to the facility on [DATE] and readmitted after a hospital stay on 3/15/19 with [DIAGNOSES REDACTED]. On 5/20/19 at 11:00 AM, an interview was conducted with resident 52. Resident 52 stated that his scheduled shower days were Tuesdays, Thursdays, and Saturdays. Resident 52 stated that the facility does not have enough staffing to get his showers done. Resident 52's medical record was reviewed on 5/22/19. A Medicare 30 Day scheduled MDS assessment dated [DATE], documented that resident 52 required 2 person extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. A Skilled Nursing assessment dated [DATE], documented that resident 52 does not weight bear and requires assistance with bed mobility, transfers, and toilet use. In addition, resident 52 requires two person with total dependence of mechanical lift for transferring, one person with total assistance for toileting, one person with extensive assistance for bed mobility and upper body dressing, one person with total assistance for lower body dressing and footwear. A review of the CNA task charting for bathing and the Shower Sheets for resident 52 documented the following entries: (Note: It was documented that resident 52 prefers Tuesdays, Thursdays, and Saturdays for showers.) a. On Tuesday 3/5/19, received a shower. (Note: resident 52 did not receive a shower on Thursday 3/7/19.) b. On Saturday 3/9/19, received a shower. c. On Tuesday 3/12/19, received a shower. (Note: resident 52 did not receive a shower on Thursday 3/14/19 or Saturday 3/16/19.) d. On Tuesday 3/19/19, received a shower. (Note: resident 52 did not receive a shower on Thursday 3/21/19.) e. On Sunday 3/24/19, received a shower. (Note: resident 52 did not receive a shower on Tuesday 3/26/19, Thursday 3/28/19, Saturday 3/30/19, or Tuesday 4/2/19.) f. On Thursday 4/4/19, refused shower. (Note: resident 52 did not receive a shower on Saturday 4/6/19.) g. On Tuesday 4/9/19, received a shower. h. On Thursday 4/11/19, refused shower. (Note: resident 52 did not receive a shower on Saturday 4/13/19, Tuesday 4/16/19, Thursday 4/18/19, and Saturday 4/20/19.) i. On Tuesday 4/23/19, received a shower. j. On Thursday 4/25/19, received a shower. (Note: resident 52 did not receive a shower on Saturday 4/27/19.) k. On Tuesday 4/30/19, received a shower. l. On Thursday 5/2/19, refused shower. (Note: resident 52 did not receive a shower on Saturday 5/4/19.) m. On Tuesday 5/7/19, received a shower. n. On Thursday 5/9/19, received a shower. (Note: resident 52 did not receive a shower on Saturday 5/11/19.) o. On Tuesday 5/14/19, received a shower. p. On Thursday 5/16/19, refused shower. q. On Saturday 5/18/19, received a shower. r. On Tuesday 5/21/19, received a shower. On 5/22/19 at 1:14 PM, an interview was conducted with CNA 1. CNA 1 stated that she showers resident 52 on Saturdays. CNA 1 stated that she usually does not work on Tuesdays or Thursdays. CNA 1 stated that shower sheets were completed for each resident after their shower. CNA 1 stated that she was bad at completing the shower sheet forms. CNA 1 stated that showers should be charted in the CNA task section of the resident medical record. CNA 1 further stated that resident 52's charting for bathing should be correct. On 5/23/19 at 7:54 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 52 was scheduled to shower three times a week. CNA 2 stated that resident 2 was his own worst enemy because the CNAs will approach resident 52 about getting a shower and resident 52 will ask to be showered in the afternoon even though he was scheduled for the morning. CNA 2 stated that the afternoon CNAs were unable to get to resident 52 because they have scheduled showers they need to complete. CNA 2 stated that resident showers should be charted in the CNA task section of the resident medical record and a shower sheet should be completed with each shower. CNA 2 further stated that there was a shower CNA approximately four or five months and that was very helpful with getting resident showers completed timely and honoring request. On 5/23/19 at 9:00 AM, an interview was conducted with the DON. The DON stated that resident showers were assigned by rooms. The DON stated that Mondays, Wednesdays, and Fridays showers were assigned to the even number rooms and Tuesdays, Thursdays, and Saturdays showers were assigned to the odd number rooms. The DON stated that they will honor resident request if they have a preference or want to change their shower days. The DON stated that the shower days will be put in the CNA task charting in the resident medical record so the CNAs know which days to shower the resident. The DON stated that the CNAs need to complete a shower sheet for the resident even for a shower refusal. The DON stated that if a resident was scheduled for a morning shower and request to be rescheduled that day to an evening shower the CNAs were expected to give report to the CNA on the next shift and the shower should be completed. The DON stated that if the resident would like the evening shower all the time, the change needs to be made for the resident. The DON stated that the CNA task charting for bathing triggered the CNA staff to chart showers on an as needed basis everyday. The DON stated that it was recently changed in the CNA task charting to trigger on the resident's specific shower days. The DON stated that the CNAs should never chart the task as not applicable. The DON further stated that in the past they have used a shower CNA and was going to start using a shower CNA again in (MONTH) because there were issues with resident showers not being completed and incorporating the shower CNA was helpful.",2020-09-01
59,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2019-05-23,684,D,0,1,PDL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, physician ordered physical therapy was not provided to a resident. Resident identifier: 43. Findings include: Resident 43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/20/19 at 10:53 AM, an interview was conducted with resident 43. Resident 43 stated that he had been on physical and occupational therapy a while ago, but not in the recent months. Resident 43 stated they've given up on me. On 5/21/19 resident 43's medical record was reviewed. A Physician's progress note dated 5/9/19 at 4:38 PM, revealed, PT (physical therapy) evaluation and Rx (prescription) for L (left) shoulder rotator cuff strain. A copy of resident 43's physical therapy notes were requested. The last therapy notes were completed in (MONTH) 2019. Resident 43's physician's orders [REDACTED]. On 5/22/19 at 12:15 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she had not had experience putting in a physical therapy order. RN 1 stated she would assume she would inform the therapists or go to the Director of Nursing (DON) to find out what to do. On 5/22/19 at approximately 1:00 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that if a resident appeared to need therapy, she would talk to therapy. LPN 2 stated if a physician ordered therapy, then she would put the order in and go inform therapy of the order. On 5/23/19 at 9:50 AM, an interview was conducted with LPN 3. (Note: LPN 3 was the nurse who put in the physician's orders [REDACTED]. LPN 3 stated that if she were to receive a physician's orders [REDACTED]. LPN 3 stated she knew resident 43 had physical therapy recently because she had put the order in. On 5/23/19 at 12:08 PM, an interview was conducted with the Therapy Director (TD). The TD stated he had not received the 5/9/19 order for resident 43 to receive therapy. The TD stated that to order physical therapy, the nurses would come and inform the therapy department or the nurses would go talk with the DON or Assistant Director of Nursing. The TD stated nursing should not be putting in physician orders [REDACTED]. On 5/23/19 at 12:53 PM, an interview was conducted with the DON. The DON stated that a lot of the therapy referrals went through her. The DON stated nurses could go directly to the therapy department. The DON stated nurses could put in an order. The DON stated the therapy department was part of the interdisciplinary meetings and referrals often happened then.",2020-09-01
60,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2019-05-23,689,E,0,1,PDL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 4 of 28 sample residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, one resident was not on supervised smoking, had repeated falls outside while smoking, and did not have documentation that neurological checks were performed after the resident had a fall and hit his head. The same resident had repeated interventions. Another resident's fall was not assessed nor were appropriate interventions put in place. Another resident had an incident with her power wheelchair and an assessment for her safely utilizing the powerchair was not completed until a month later. Another resident had multiple falls with no new interventions. Resident identifiers: 3, 13, 32, and 43. Findings include: 1. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/21/19, resident 3's medical record was reviewed. Resident 3's progress notes revealed the following: a. On 1/1/19 at 10:54 AM, resident 3 was on 72 Hour Event Charting for an unwitnessed fall. The actual event was not documented in the progress notes. The note on 1/1/19, appeared to be the only note charted for that particular fall. b. On 1/2/19 at 1:59 PM, a Fall note was completed which stated Resident found sitting on floor in front of chair. States that he got dizzy and fell . Resident tried getting up without walker. Assessment complete .Freq (frequent) visual checks performed. Resident reminded to use walker when getting up or call for assistance . c. On 1/4/19 at 2:57 PM, an IDT (interdisciplinary team) Event Review was completed. It stated it was for an unwitnessed fall on 12/31/18. It stated: .Resident went outside to smoke .Resident was found outside on ramp, Resident was feeling tired earlier in the day, nurse encouraged resident to stay inside and rest but insisted on going outside. Refused to have nurse or staff present with him. Staff found resident outside on the ramp. Resident stated to nurse that he felt weak and lost his balance and fell when he was walking back inside from smoking and fell on the ramp .Root cause: likely r/t (related to) ambulating with walker outside when not feeling well. New interventions implemented MD (Medical Doctor) and caregiver notified. New orders for STAT (immediately) UA (urinalysis), CBC (complete blood count), and BMP (basic metabolic panel). Lad (sic) results came back MD reviewed and no new orders noted. Neuro checks were started. Education to resident to ask for assistance when feeling tired. PT (physical therapy) post fall assessment. Will continue to monitor and notify MD of any adverse changes. d. On 1/4/19 at 7:30 PM, an IDT Event Review was completed. It stated it was for an unwitnessed fall on 1/2/19. It stated: Residnet (sic) was found on the floor in his room next to chair. Residnet (sic) stated 'I was trying to get up but I got dizzy and passed out. I am okay though.' Neuros started. Full assessment complete .Resident reminded to use walker when getting up or to call for help. Freq visual checks in place .Root cause: resident fell when getting up from chair. New interventions implemented: MD was notified no new orders. PT post fall assessment, neuro checks. On further investigation resident stated he got up without his walker and fell . PT and nursing to continue to educate resident to use walker when ambulating or even just standing up to reposition. Resident stated understanding. Continued education to ask for assistance and use call light when needing assistance. Sign placed in room to remind resident to ambulate with walker e. On 1/19/19 at 10:33 AM, an Event/Alert Charting note was initiated. It stated resident was found outside at side door had fallen and hit head on falling. Small hematoma noted on back of head. grips equal and strong, eyes equal and reactive. Interventions: Reminded to ask for assistance when needed. when (sic) over call light instructions. Resident reaction to interventions: I just want a cigarette . f. On 1/21/19 at 2:32 PM, an IDT event review of fall on 1/19/19 was completed and stated the following: Resident was found outside at the side of the door, he had fallen and hit head on railing. Small hematoma noted on back of head Preventive measures prior to event: frequent monitoring and observation by direct care staff, nursing assessment, call light within reach. Root cause: likely r/t losing balance outside and falling. New interventions implemented: MD and caregiver notified, Neuro checks started, PT post fall, Have resident on assisted smoking due to recent falls outside. Encourage resident to use walker when ambulating. Notify MD of any adverse changes. Continue to monitor hematoma to head . g. On 2/7/19 at 5:26 PM, a nurses note stated the following Pt (patient) was found smoking in his bedroom, sitting in recliner. Reminded pt of smoking policy. 1 extra cigarette removed. Pt denies having a lighter. Will continue to monitor. h. On 3/8/19 at 6:30 PM, an Event/Alert Charting was initiated. It stated: Reported from previous nurse, that around 18:15 (6:15 PM) patient was found on his knees on the floor, next to his chair in room [ROOM NUMBER], patient was alert, responsive to verbal and physical stimuli, cooperative, able to ambulated (sic) with walker, skin intact, no redness, swollen (sic) noted, no pain reported .No c/o (complaints of) pain at this time, when asked patient what happened stated I was sliding off from chair . i. On 4/11/19 at 5:30 AM, a nurses note stated At 5:45 AM patient lying on the floor, looking up, alert, able to follow commands, oriented by name person and place, stated wanted to put the shoes (sic), lost balance and fell , assessment done, small abrasion on nose and forehead, no bleeding, no swollen, no pain reported, vital signs were taken .after 10 minutes went outside to smoke, instruction about safety and fall precaution given, patient v/u (unknown acronym) and will use call light for assistance, Neurocheck started . On 5/22/19 at 1:08 PM, an observation was conducted of resident 3's room. The sign which was to be implemented as an intervention for the fall on 1/2/19 was not observed. Resident 3's neuro reports were reviewed. The facility had documentation of neuro checks in their medical charting system for the following dates: 12/31/18, 1/2/19, 3/8/19 and 4/11/19. Neuro checks for the date of 1/19/19 in which the resident fell outside, hit his head on a railing and obtained a small hematoma was not located. There was file under the date of 1/19/19, however they were a copy of the neuro check for the fall on 3/8/19. A copy of the neuro checks done on 1/19/19 was requested from the facility and was not provided. Resident 3's smoking safety evaluations were reviewed. Resident 3 had a quarterly Smoking Safety Evaluation completed on 2/3/19 which revealed the following: a. Resident demonstrates impaired orientation in one or more of the following areas: Person, Place, Time . b. Resident has a [DIAGNOSES REDACTED]. c. Resident demonstrates one of more of the following cognitive impairments: Poor safety awareness, impaired short-term memory, impulsiveness . d. Resident has a history of unsafe smoking practices . e. Resident demonstrates non-compliance with smoking policy (i.e. smoking in designated areas only, appropriate disposal of cigarettes, etc.) . f. Resident has condition or [DIAGNOSES REDACTED]. At the bottom of the smoking safety evaluation, a section titled Scoring had the following marked for resident 3. 4-6 points (each of the above statements was a point). Resident is unable to smoke independently. Resident requires supervision while smoking. Care Plan required. Review for need of behavioral program. Completion of Risk vs. (versus) Benefits needed. Provide and document education for identified safety needs. Resident 3 had an assessment for his fall risk completed on 2/3/19. This was a quarterly assessment titled Morse Fall Scale. The assessment revealed that resident 3 was identified as a high fall risk. Under section C or Ambulatory Aid resident 3 was identified as one who uses crutches, cane or walker. Under section F titled Mental Status resident 3 was identified as one who overestimates or forgets limits. On 5/22/19 at 11:42 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she worked in the hall which resident 3 resided once a week. RN 2 stated that if a resident fell , neuro checks would be initiated. RN 2 stated nurses could assess what's going on and let people know what an intervention could be but ultimately interventions came from management. RN 2 stated that the root cause would be identified by the Director of Nursing (DON) and other management members. RN 2 stated that the root cause and intervention comes from our documentation. RN 2 stated that interventions to prevent further falls were communicated down to the nursing staff by the DON or Assistant Director of Nursing (ADON). RN 2 stated that resident 3 hadn't had any falls that she was aware of. RN 2 stated that if a resident was an assisted smoker, they could only go out of the building when accompanied by assistance. RN 2 stated the door to the smoking area was locked. On 5/22/19 at 11:58 AM, an interview was conducted with Certified Nursing Assistant (CNA) 8. CNA 8 stated that when a resident fell and it was unwitnessed, neurocheck would be initiated. CNA 8 stated interventions were relayed by the nurses. CNA 8 stated he was not aware of any falls resident 3 had had. On 5/22/19 at approximately 1:00 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that when a resident had a fall, the interventions were determined by management. LPN 2 stated that management would come by and notify staff verbally. LPN 2 stated that the intervention was then passed on from shift to shift. LPN 2 stated that the interventions was passed on from nurse to the CN[NAME] On 5/22/19 at 3:16 PM, an observation was made of resident 3. Resident 3 was observed to go towards the back door. This particular door was the designated door which lead out to the smoking area for residents. It had an alarm and required a code to exit. Resident 3 was observed to approach the door, put in the code, unlock the door, and exit the building. Resident 3 was not utilizing any assistive device to walk such as a walker. Resident 3 was observed to make his way to the smoking area. On 5/23/19 at 8:45 AM, an interview was conducted with CNA 6. CNA 6 stated that neuro checks were initiated after a fall when the nurse said to do them. CNA 6 stated future falls were prevented by interventions from the nurse. CNA 6 stated each shift was responsible for rounding with the other CNA's and nurse to be aware of who was on fall precautions. CNA 6 stated that a system called a kardex was available to provide information on each resident. CNA 6 stated the kardex was the CNA's reference guide. CNA 6 stated she didn't often work with resident 3 but knew he was one that needs to be watched. On 5/23/19 at 9:47 AM, an interview was conducted with resident 3. Resident 3 stated he could not have cigarettes or a lighter in his room any longer. Resident 3 stated that all he had to do was request cigarettes and a lighter from the nurse and he will be provided with them. Resident 3 stated that he knew the code to the back door and often let himself out. Resident 3 stated there had been times he had been out there alone. On 5/23/19 at 9:50 AM, an interview was conducted with LPN 3. LPN 3 stated that the nurse who was working at the time of the fall decided the intervention and informed the rest of the staff. LPN 3 stated she was not concerned about any resident's ability to retain education as an intervention on that hall. LPN 3 stated she did not think resident 3 had any falls. LPN 3 was observed to enter the medical charting system and stated it appeared resident 3 had a fall on 4/11/19. LPN 3 stated interventions for that fall were teaching and educating the resident and frequent monitoring. LPN 3 stated frequent monitoring meant that the CNA's were going in a lot, about every hour to two hours. LPN 3 stated resident 3 had poor mental status and confusion. LPN 3 stated resident 3 required a lot of reminders and reassurance. LPN 3 stated that when resident 3 was in a confused state, he was checked on frequently. LPN 3 stated resident 3 was an independent smoker. LPN 3 stated that if a resident was on supervised smoking, it would be in their orders. LPN 3 stated that staff are aware of when resident 3 goes out so we watch and make sure that he comes back. On 5/23/19 at 10:10 AM, an interview was conducted with CNA 7. CNA 7 stated that interventions would be in the computer somewhere. CNA 7 stated she was not aware of any falls resident 3 had had. On 5/23/19 at 11:59 AM, an interview was conducted with CNA 5. CNA 5 stated that neurochecks were initiated after a resident fell . CNA 5 stated that nurses were over interventions. CNA 5 stated that interventions were then passed on from shift to shift in report. When asked if resident 3 had had any falls CNA 5 stated not that I know of and that he didn't require any interventions. On 5/23/19 at 12:53 PM an interview was conducted with the DON. The DON stated that management would develop interventions after a fall. The DON stated that interventions were communicated to staff directly by her or in notes. The DON stated that interventions were documented in the 72 hour event charting which would notify each shift of the new intervention. The DON stated that fall interventions would also be put on the CNA's kardex. The DON stated interventions were decided at the IDT meetings. The DON stated resident 3 had been assessed as safe to be outside but he could not have his own cigarettes or lighter in his room. The DON stated resident 3 was safe to go outside by himself. The DON stated she was unable to recall any falls resident 3 had had. The DON stated that resident 3 did have confusion and would forget things. When concern was expressed over the interventions implemented for resident 3, the DON responded resident 3 was a hard one. The DON stated that resident 3 had ups and down and would get stronger and weaker and go on and off assisted smoking. The DON stated resident 3 would be assessed again. The DON acknowledged the lack of neuro check for 1/19/19 and the lack of a sign in resident 3's room as per the intervention for the 1/2/19 fall. On 5/23/19 a copy of resident 3's kardex was requested from the facility. There was no indication on the kardex that resident 3 required assisted or supervised smoking. 2. Resident 43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/21/19 resident 43's medical record was reviewed. Resident 43's nursing progress notes were reviewed and revealed the following: a. On 3/13/2019 at 5:10 PM, the following was revealed: Fall Note, Note Text: Resident shoes stuck to the trim in the entering the bath room and lost his balance and the CNA lowered the resident to the floor. Noted injuries: abrasions to the knees bilaterally, covered the abrasion c (with) skin prep (sic) and bordered gauze, administered Tylenol for pain. VITALS:BP (blood pressure) 103/61 HR (heart rate) 112, TEMP (temperature) 97.5, RR (respiratory rate) 20, o2 (oxygen) 96, room air, neuro checks started, WCTM (will continue to monitor). b. On 3/13/19 at 9:56 PM, a note titled 72 hour event charting was filled out. It stated interventions: Fall and safety precautions maintained, assessment, vital signs, use the call light for help. c. On 3/14/19 at 5:37 PM, a 72 hour event charting note stated interventions: reminders to use call light for assistance, good foot wear, surroundings uncluttered. d. On 3/14/19 at 10:00 PM, a 72 hour event charting note stated interventions: fall precautions maintained, using call light for assistance, uncluttered surroundings. e. On 3/15/19 at 12:17 PM, a 72 hour event charting note stated interventions: reminders to use call light, for assistance, good footware (sic), uncluttered surroundings. (Note: at the time of the fall, resident 43 was wearing shoes, was receiving assistance, and it was not clear if cluttered surroundings had contributed.) There was no follow up interdisciplinary team note in the progress notes. A request was made from the facility for the incident investigation into this fall and none was provided. On 5/22/19 at 11:42 AM an interview was conducted with RN 2. RN 2 stated that resident 43 had a fall a couple of months ago. RN 2 stated that resident 43 was being assisted by a CNA and was bringing his walker into the restroom. RN 2 stated that walker hit the metal piece and he fell . RN 2 could not recall who was assisting resident 43. On 5/22/19 at 11:58 AM, an interview was conducted with CNA 8. CNA 8 stated that he was not aware of any falls that resident 43 had had. On 5/22/19 at 12:15 PM, an interview was conducted with RN 1. RN 1 stated that when a fall occurred, 72 hour fall charting was initiated, as well as the event charting, assessment and risk management. RN 1 stated that risk management was the incident report. On 5/23/19 at 8:45 AM an interview was conducted with CNA 6. CNA 6 stated that resident 43 had a fall recently. CNA 6 did not know whether resident 43 was on any fall precautions. CNA 6 stated that she was aware it had been a witnessed fall and that resident 43 had gotten afriad but did not know any more details. On 5/23/19 at 9:50 AM, an interview was conducted with LPN 3. LPN 3 stated resident 43 had not had a fall that she could recall. On 5/23/19 at 10:10 AM, an interview was conducted with CNA 7. CNA 7 stated resident 43 hadn't had any falls that she was aware of. On 5/23/19 at 11:59 PM, an interview was conducted with CNA 5. CNA 5 stated she took care of the section in which resident 43 resided 2 to 3 times a week. CNA 5 stated resident 43 had not had any falls she was aware of. On 5/23/19 at 12:53 PM, an interview was conducted with the DON. The DON stated that when a fall occurred, the nurses should initiate a risk management report and event charting. The DON stated that a fall committee and an IDT meeting would then discuss the event and decide on an intervention. The DON stated that the whole process was revamped 2 weeks ago. The DON stated she noticed that an incident report had not been completed for resident 43's fall on 3/13/19. The DON stated that she agreed that the intervention did not match the possible root cause of the fall. 3. Resident 32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/21/19 resident 32's medical record was reviewed. Resident 32's progress notes revealed the following: a. 11/3/18 at 11:40 PM, a Fall note stated: Resident was coming (sic) back in to the facility from smoking, they (sic) were some visitors, resident drives a power chair, she did not put attention that she was driving too close to them, resident run over visit left foot (this is what visito (sic) stated), this nurse gave resident teaching, to be careful, to take her distance, to slow down, resident understand what she did wrong, after resident was assisted to bed, breathing treatment administered, and also got O2 (oxygen) at 3L (liters) per NC (nasal cannula) to maintain saturations above 90% at time of incident O2 78% with treatment O2 up to 94%. b. 11/7/18 at 5:53 PM, a nurses note stated: PT found on floor in a sitting position with wheelchair directly behind her back. Pt states she was trying to turn her TV and slid from her chair. Pt had a pillow behind her back at time of fall to (sic). Neuro checks started . c. 11/9/18 at 10:44 AM an interdisciplinary team note stated: Review of (fall) on 11/9/18 .interventions: frequent staff monitoring, proper positioning when in w/c (wheelchair), motorized w/c returned to res (resident) . d. 12/16/18 at 1:55 PM, an incident note stated: Res was found outside on the ground next to her electric w/c by guest coming in facility. Res was going outside to smoke and she said her w/c kept turning in circles and she couldn't make it stop and the wheel hit the curb and she fell out. Nurse assessed and she was found to have a (sic) open wound to LLE (left lower extremity) and c/o pain to arm. Res stated she didn't hit her head. Wound to LLE was bandaged d/t (due to) bleeding. e. 12/18/19 at 10:14 AM, a Social Services Note stated: Met with resident to discuss recent fall outside and smoking safety. Resident agreed to let LCSW (Licensed Clinical Social Worker) take cigarettes and put at the nurses station. Resident will get cigarette from nurse station when she goes to smoke and will exit through the back door to smoke at the smoking shack to avoid ice patches in the parking lot. Resident verbally agreed that is she is seen smoking anywhere other than the designated smoking area, she will be put on assisted smoking program and will lose access to her wheelchair because of the safety hazard posed by wheeling through the parking lot in snow/ice conditions. f. 12/18/19 at 1:03 PM, IDT Event Review stated: IDT review of unwitnessed fall on 12/16/18 .patient was found on the ground next to her electric W/C by a guest that was coming into the facility. Patient was going outside to smoke and she states that her W/C kept turning in circles and she could not make it stop and the wheel hit the curb and patient states she fell out. Nurse assessed the patient and found to have open wound to LLE and c/o pain to arm. Patient states she did not hit her head, patient was transferred to (nearby hospital) for there eval Root Cause: likely r/t hitting curb in wheelchair causing her to fall out of chair New Interventions implemented: Resident returned from ER (emergency room ) stiches (sic) placed to LLE .Resident will now keep cigarettes at nurses station, Resident agrees that she will smoke at the designated smoking area and is aware that if she is seen smoking up front she will be put on assisted smoking. g. 1/12/19 at 3:34 AM, 72 Hour charting was initiated and stated: SOB (shortness of breath) with exertion .resident lethargic, mumbling, don't know where she was, saturations where (sic) about 77 (percent) RA (room air) O2 at 3L per nc was started saturation when (sic) to 97% resident needs O2 at 3L per nc at all times, except when to smoke, prior incident resident was outside smoking h. 1/13/19 at 3:24 AM, a 72 hour charting note stated: Resident goes to smoke under supervision, she was upset, angry, it was explained to her that it was for her safety, if she feels dizzy or SOB there is some body next o her to help immediately (sic), resident finally accepted to be under supervision, when (sic) to smoke, resident uses O2 at 3L per NC at all times except when to smoke .saturations before smoking 98% after smoking this Hs (at bed time) 82 RA . i. 1/14/19 at 5:38 AM, a 72 hour Event charting note stated: Resident AA & O (alert and oriented) monitoring saturations before and after smoking, continues using nebulizers, [MEDICATION NAME], O2 at 3L sats RA after smoking 76% with O2 3L sats 96% j. 1/14/19 at 10:00 AM, an IDT Event Review note stated: .came back from smoking. Resident stated to nurse I don't know what happened, i remember I was smoking after that I don't remember .Resident was lethargic and mumbling, saturations where (sic) about 77% on room air. 3 litters (sic) of oxygen place on Resident per orders nasal cannula and saturations went up to 97% and Resident became more alert and oriented .Root Cause: [MEDICAL CONDITION]ly r/t Pt refuses to wear O2 at times with chronic underlying respiratory conditions, goes outside to smoke frequently. New interventions implemented: MD notified, nursing placed oxygen back on and educated resident to stay inside and keep oxygen on. Education on smoking cessation. Nursing to continue to monitor and notify MD of any adverse changes . k. 5/8/19 at 2:18 PM, a nurses note stated: Resident was outside smoking when an aide called for help, LN (Licensed Nurse) went outside and resident was on the ground laying in the smokers shacks in front of her electric W/C. Resident SATS were in the 80's with bluish gray lips. l. 5/9/19 at 10:18 AM, an IDT Event Review note stated: Event description:[NAME] was smoking outside, her w/c frame bent causing her to fall out onto the patio in the prone position; unwitnessed fall, found by CN[NAME] On assessment, superficial abrasions noted to BLE (bilateral lower extremities) . Risk factors: Unsupervised smoker, electric w/c, [MEDICAL CONDITION]-left side .Root Cause: bent w/c frame causing her to fall out of w/c. New interventions: PT evaluation to get w/c fixed; PT post fall assessment, neurological checks per protocol, use of manual wheelchair until electric w/c if (sic) fixed, monitoring abrasion-keep open to air .supervised smoking program . Resident 32 had a quarterly fall assessment completed on 3/6/19. It was titled the Morse fall scale. The assessment revealed to the question Has the resident ever fallen before? the answer recorded was No. The result of the assessment was that resident 32 was a moderate fall risk. (Note: resident 32 had had 3 falls from (MONTH) (YEAR) to 3/6/19.) A wheelchair safety evaluation was completed on 1/18/19. The previous power chair assessment had been completed on 11/7/18. There was not a wheelchair safety evaluation completed at the time of the fall on 12/16/18 in which the resident stated she kept turning in circles and she couldn't make it (the wheelchair) stop hit the curb, and .fell out. On 5/22/19 at 11:42 AM, an interview was conducted with RN 2. RN 2 stated that she was not aware of incidences with resident 32 recently. On 5/22/19 at 11:58 AM, an interview was conducted with CNA 8. CNA 8 stated resident 32 has had a couple of falls and fallen while smoking. On 5/23/19 at 8:45 AM, an interview was conducted with CNA 6. CNA 6 stated resident 32 was a fall risk and was very anxious. When asked if resident 6 had any falls or required interventions, CNA 6 stated, there should be a note if she's had a fall or interventions. CNA 6 stated that a system called a kardex was available to provide information on each resident. CNA 6 stated the kardex was the CNA's reference guide. On 5/23/19 at 9:50 AM, an interview was conducted with LPN 3. LPN 3 stated she was aware resident 32 had had incidences but was unable to provide details. LPN 3 was observed to access the facility's medical charting system. LPN 3 stated that resident 32's last incident had occurred on 4/18/19. LPN 3 stated resident 32's oxygen was low. LPN 3 stated that's why we supervise (her) now. LPN 3 stated it took a lot of reminding and teaching with her. LPN 3 stated resident 32 was on supervised smoking. LPN 3 stated that if a resident was on supervised smoking, it would be in their orders. On 5/23/19 at 10:10 AM, an interview was conducted with CNA 7. CNA 7 stated that resident 32 had been leaning over while she was smoking outside. CNA 7 stated that the intervention for that fall was to put her in a manual wheelchair and have her be on supervised smoking. On 5/23/19 at 11:59 AM, an interview was conducted with CNA 5. CNA 5 stated that resident 32 had falls. CNA 5 stated that resident 32 had fallen outside while on a smoke break. CNA 5 stated that the intervention was to take away resident 32's cigarettes at night. CNA 5 stated that resident 32 was an independent smoker who could take herself outside. A copy of resident 32's kardex was requested from the facility. It revealed under the safety section that resident 32 could smoke supervised. Resident 32's order history was requested from (MONTH) (YEAR) to the time of the survey. There was no order indicating that resident 32 had ever been on a supervised or assisted smoking program. On 5/23/19 at 12:08 PM an interview was conducted with the Therapy Director (TD). The TD stated that resident 32 had multiple events with her powerchair. The TD stated that when we do the tests (wheelchair driving tests) she passes with flying colors. The TD stated that resident 32 was only allowed to go to the smoking area and then back in. The TD stated she has fallen out of her chair and hit her leg. The TD agreed that resident 32's ability to safely drive the power wheelchair should have been assessed at that time. The TD stated that the medical company who maintains resident 32's power chair had come out and fixed it before. The TD stated that he did not recall having resident 32's powerchair fixed or looked at in May. On 5/23/19 at 12:53 PM an interview was conducted with the DON. The DON stated if a resident had an incident involving their wheelchair, then they would be referred to physical therapy for a driving test. The DON stated therapy attended the IDT meetings and referrals often happened then. The DON acknowledged that resident 32's wheelchair driving safety should have been assessed after the incident 12/16/18. 4. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/20/19 at 7:40 AM, an observation was made of resident 13 in his room. Resident 13 had debris scattered around his bed. Resident 13 was interviewed. Resident 13 stated that he used to walk but now he rides in a wheelchair. On 5/23/19 a review of resident 13's electronic medical record was completed. A review of fall incident reports revealed the following falls: a. 11/4/18 at 2:01 AM b. 12/7/18 at 8:34 PM c. 1/6/19 at 1:02 PM d. 1/9/19 at 5:50 AM e. 2/17/19 at 2:00 PM Resident 13's falls care plan included the following interventions that were initiated on 11/18/18: a. Add signage to room reminding resident to use urinal at bed side when needed to urinate/and reminder to use call light when needing assistance . b. After each meals have resident be offered toileting, if he wants to be placed to bed or in recliner, or go read newspaper in activities . c. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . d. Educate staff not to leave resident on toilet unattended . e. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility . f. Ensure that the resident is wearing appropriate footwear and/or non-skid socks when ambulating or mobilizing in w/c . g. Resident is to be a 2 person extensive assist with all transfers. Standing recliner in room & sit-to-stand Hoyer from bed & manual wheelchair . h. Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family/caregivers/IDT as to cause (TRUNCATED)",2020-09-01
61,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2019-05-23,690,D,0,1,PDL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, a resident with a suprapubic catheter developed two urinary tract infections. Resident identifier: 25. Findings include: Resident 25 was admitted to the facility on [DATE] and was readmitted on [DATE] and 5/17/19 with [DIAGNOSES REDACTED]. On 5/20/19, an observation was made of resident 25 resting in her room. Resident 25 had contact precautions on the door to her room. Resident 25 stated that she was very sick and [MEDICAL CONDITION]. On 5/23/19, a review was conducted of resident 25's medical record. A physician's orders [REDACTED]. for suprapubic catheter. The order had a hold date from 3/1/19 to 3/4/19, when resident 25 was hospitalized , and a discontinue date of 3/4/19. A physician's orders [REDACTED]. The order was discontinued on 3/4/19. On 12/16/18, resident 25's care plan for recurrent urinary tract infections (UTIs) was updated. The care plan included the following intervention: Suprapubic catheter care Q shift & (and) PRN. Monitor insertion site & provide tx (treatment) to site as directed. Refer to TAR (Treatment Administration Record) for current tx orders & special instructions for daily care of SP (suprapubic) catheter to bladder. A review of resident 25's TAR revealed no orders for catheter cares between 3/4/19 and 5/22/19. A pharmacy review note dated 3/5/19 at 7:49 PM, revealed . Res (resident) readmitted p (with) urosepsis and pneumonia. A review of nursing notes revealed the following: a. On 4/1/19 at 4:50 PM, Resident c/o (complained of) 'urinating through her urethra'. Refused to allow assessment both yesterday and then today, until this afternoon. DON (Director of Nursing) came to room and assisted LN (licensed nurse) in convincing Resident to cooperate with assessment of catheter, replacement and UA (urine analysis), CBC (complete blood count), CMP (complete metabolic panel), which have been ordered. Resident cooperated with sterile placement of new (silicone) catheter, 18Fr/30ml (French, milliliters). It is hoped that the larger lumen will be assistive, and that the larger balloon will also help to prevent infection. UA specimen obtained from new catheter, and sent to lab via facility phlebotomist. Urine cloudy. b. On 4/3/19 at 6:58 PM, Received UA C&S (culture and sensitivity) results Resident is positive for Proteus Vulgaris. Notified NP (nurse practitioner) and receive new orders: [MEDICATION NAME] 500 mg (milligrams) PO (by mouth) BID (twice daily) x (times) 7 days. c. On 4/6/19 at 7:06 PM, [MEDICATION NAME]-UTI Assessment/Observation: decreased burning, increased awareness, pt (patient) reports that she feels better . d. On 4/10/19 at 6:09 AM,Cipro for UTI Interventions: [MEDICATION NAME] for UTI secondary to indwelling catheter Resident Reaction to Interventions: patient tolerating abx (antibiotic), no signs of rxn (reaction) . e. On 4/14/19 at 8:24 PM:, Resident completed PO ABX without Sx (symptoms) of allergic or other adverse effects. Provided patient teaching on the importance of good hydration in good GU ([MEDICAL CONDITION]) health. Particularly, given that she has a suprapubic catheter in. Urine slightly dark colored, but clear/non-sedimented (sic) at present. f. On 4/30/19 at 5:51 AM, Difficult to give pt meds (medications) this morning. Pt was very lethargic. g. On 4/30/19 at 1:13 PM, Resident acting more confused this morning. Held [MEDICATION NAME] D/T (due to) confusion and lethargy. Resident has been perking up, but still displaying some confusion and forgetfulness. She is afebrile. Informed (provider). UA specimen obtained . h. On 5/5/19 at 1:10 AM, The order you have entered [MEDICATION NAME] Inj (injectable) 40 MG/ML (milliliter) Inject 60 mg intramuscularly two times a day for UTI . i. On 5/5/19 at 11:52 PM, Pt continues on new order for [MEDICATION NAME] Inj 40 MG/ML Inject 60 mg intramuscularly for UTI. No adverse reactions noted. Pt has been lethargic this shift. Able to wake up when name called. Meds given in applesauce. Foley running well down to drain. C/o pain and given oxy 5mg with relief. Will continue to monitor. j. On 5/6/19 at 6:37 PM, Resident coop (cooperative) with IM (intramuscular) ABX. No Sx of allergic or other adverse reaction, thus far. She shows notable improvement from prior week, when UA/C&S was obtained. Encouraging hydration . k. On 5/7/19 at 2:18 AM, Pt continues to receive abx for recent UTI. Pt has been lethargic and moody towards staff. Pt has been yelling rather than using call light. Pt has been demanding CNA's (certified nursing assistants) change her when she is dry. Pt has been changed per request and given pain meds for 5/10 pain with relief. No adverse reactions noted to IM injections. Fluids encouraged. l. On 5/11/19 at 11:52 AM, The order you have entered [MEDICATION NAME] Tablet 500 MG ([MEDICATION NAME]) Give 500 mg by mouth one time a day for Indicated for Pneumonia for 10 Days. m. On 5/11/19 at 5:49 PM, X-ray technician arrived to perform x-rays on residents chest. Resident was not responding appropriately to verbal stimuli. Resident would stare off for a while and not speak.no hand grasp noted. when her name was called resident would look at the person that is speaking to her and she would turn away. Resident was pale. SpO2 (oxygen saturation) 91% at 3 liters of oxygen. Temp (temperature) 98.8, pulse 91, BP (blood Pressure) 150/85, respiration 18. Notified NP (resident's provider), received orders to send resident out for further evaluation. Called (local hospital) ED (emergency department) . n. On 5/17/19 at 5:30 PM, Received Nurse to nurse report from Nurse . RN (Registered Nurse) at (local) Hospital. Resident was admitted to hospital with [MEDICAL CONDITION], and pneumonia. Resident has a central line.currently on [MEDICATION NAME] PO to end in 8 days. Suprapubic catheter in place. dressing is clean dry and intact. o. On 5/17/19 at 7:30 PM, Resident arrived at facility at 1750 (5:50 PM) via medical transport on a stretcher. Resident was diagnosed with [REDACTED]. Resident is Alert and oriented x 2 confused with situation and time. Resident was also exhibiting hallucinations evidenced by resident stating the Ceiling is melting. Resident was agitated by transportation and the move. Resident is currently in contact isolation [MEDICAL CONDITIONS]. Resident has c/o generalized pain administered prn pain medication granting somewhat positive results to resident. lungs diminished at base of lungs no labored breathing nor SOB (shortness of breath) noted. Resident is currently on continuous oxygen 4 liters via NC (nasal cannula). Suprapubic catheter is intact and draining into down drain bag, Catheter size 18fr 30cc. clear yellow urine noted. dressing on suprapubic stoma site is clean dry and intact. 2 person extensive assist with bed mobility, hygiene and toileting. Residents has large bruises noted on BUE (bilateral upper extremities) from previous blood draws. resident has a lumen central venous catheter in place on right chest . p. On 5/17/19 at 11:37 PM, Staff was notified of pts isolation and placed pt in a private room with PPE (personal protective equipment) set up outside the door. Pt was very upset about the change, pt is very confused, possibly due to her UTI. Pt called the cops and stated 'they have just left me.' RN was standing in the room while she called and she could not explain why she was calling them. Police called the main desk, RN explained pts medical condition and assured them that she is rcvng (receiving) all cares. Social Worker called. Social Worker and RN visited with pt to calm her down. q. On 5/18/19 at 6:40 PM, Primary Diagnosis: [REDACTED]. r. On 5/20/19 at 8:46 PM, Notable improvement in the clarity of her speech and expressed thoughts, as well as eye contact during discussions. No difficulty accepting medications or cares (Note: No nursing notes or treatment notes stated that nurses had observed the suprapubic catheter site, cleaned it, or redressed it between 3/4/19 and 5/22/19. The catheter was changed one time on 4/1/19.) A review of laboratory results for resident 25 revealed the following: a. On 4/1/19, Urine culture (UCX) results revealed an infection caused by proteus vulgaris b. On 5/3/19, UCX results revealed that resident 25 had an infection caused by four bacterium: [NAME]ella morganii, Pseudomonas aeruginosa, Staphylococcus aureus, and [MEDICATION NAME] faecalis. On 5/23/19 at 9:05 AM, an interview was conducted with RN 3. RN 3 stated that resident 25 had experienced some confusion with her urinary tract infections. RN 3 stated that the protocol had been to clean the suprapubic catheter site with normal saline and cover with a drain sponge. RN 3 stated that the nurse should clean the site every shift and document the cleaning. RN 3 stated that orders for catheter cleaning should be in the TAR. RN 3 was unable to locate physician's orders [REDACTED]. On 5/23/19 at 9:27 AM, an interview was conducted with the DON. The DON stated that resident 25 also had a [DIAGNOSES REDACTED]. The DON stated that resident 25 was lethargic and very sick. The DON stated that staff had been putting a silver alginate over the stoma site a few months back to control bacterium. The DON stated that CNAs were performing catheter cares. The DON stated that resident 25 had been referred to an infectious disease doctor. On 5/23/19 at 9:47 AM, an interview was conducted with CNA 4. CNA 4 stated that catheter cares for CNAs meant that they wiped the catheter and resident's perineal area. CNA 4 stated that she also cleaned the tubing down to the drain bag. CNA 4 stated that if there was a dressing on the suprapubic catheter stoma site, the CNA would contact the nurse for cares. CNA 4 stated that she did not apply dressings to stoma sites. On 5/23/19 at 9:50 AM, a follow-up interview was conducted with RN 3. RN 3 stated that if there was not an order to perform catheter cares on the TAR, any nursing cares would have been documented in a progress note. RN 3 stated that the wound nurse was also responsible for cares, and would document in a nursing note if cares had been performed. RN 3 stated that CNAs would not perform the dressing change for resident 25's suprapubic catheter. On 5/23/19 10:05 AM, a follow-up interview was conducted with the DON. The DON stated that there was documentation stating that one nurse had changed resident 25's suprapubic catheter one time between 3/4/19 and 5/1/19. The DON stated that there was no documentation that any of the nurses cleaned and dressed resident 25's suprapubic catheter site between 3/4/19 and 5/22/19. The DON submitted Suprapubic Catheter Care instructions as part of the facility's Nursing Services Policy and Procedure Manual. Cares for suprapubic catheters included the following: a.Observe the resident for signs and symptoms of urinary tract infection and [MEDICAL CONDITION]. Report findings to your supervisor . b. Wash around the catheter site with soap and water. (Note: If the resident has a drainage sponge around the stoma site, remove the drainage sponge before washing with soap and water.) Wash the outer part of the catheter tube with soap and water. c.Inspect the stoma site and skin around the stoma for any redness or skin breakdown. d.Documentation: The following information should be recorded in the resident's medical record: .all assessment data obtained during the procedure. How the resident tolerated the procedure. If the resident refused the procedure, the reason(s) why and the intervention taken. Results of skin assessment around the stoma site",2020-09-01
62,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2019-05-23,757,D,0,1,PDL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 28 sampled residents, the facility did not ensure that resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, the facility did not administer blood pressure medications as ordered by the resident's physician. Resident identifiers: 16 and 39. Findings include: 1. Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/23/19, a medical record review was conducted for resident 16. A physician's orders [REDACTED]. A review of resident 16's Medication Administration Record [REDACTED] a. On 4/14/19, for the PM dose, BP 99/62 b. On 4/18/19, for the PM dose, BP 90/51 c. On 4/19/19, for the PM dose, BP 97/62 On 5/22/19 at 12:29 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that the MAR indicated [REDACTED]. RN 2 was able to identify that resident 16's blood pressure medication was ordered to be held if the SBP was below 110. RN 2 stated that she would have contacted the physician when the blood pressure was out of parameters and would not administer the medication. RN 2 identified that the medication should have been held for resident 16. On 5/22/19 at 12:55 PM, an interview was conducted with the Director of Nursing (DON). The DON identified that the medication for resident 16 was given outside of the physician's orders [REDACTED]. 2. Resident 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/23/19, a record review was completed for resident 39. Resident 39's physician's orders [REDACTED]. a. On 3/6/19, [MEDICATION NAME] HCL ([MEDICATION NAME]) tablet, 60 mg, give 60 mg by mouth three times a day for HTN, Hold for SBP b. On 3/15/19, [MEDICATION NAME] HCL tablet, 60 mg, give 60 mg by mouth three times a day [MEDICAL CONDITION] for SBP c. On 3/21/19, [MEDICATION NAME] HCL tablet 2.5 mg, give one tablet by mouth two times a day for [MEDICAL CONDITION]. Hold if SBP > (greater than) 150. Resident 39's (MONTH) 2019 MAR indicated [REDACTED] a. On 3/6/19 at 8:00 PM, for a BP of 103/77 b. On 3/7/19 at 8:00 PM, for a BP of 107/70 c. On 3/11/19 at 8:00 PM, for a BP of 103/68 d. On 3/16/19 at 8:00 AM, for a BP of 109/73 e. On 3/16/19 at 2:00 PM, for a BP of 109/73 f. On 3/16/19 at 8:00 PM, for a BP of 99/66 g. On 3/18/19 at 8:00 PM, for a BP of 105/70 h. On 3/19/19 at 8:00 AM, for a BP of 105/70 i. On 3/19/19 at 2:00 PM, for a BP of 105/70 Resident 39's (MONTH) 2019 MAR indicated [REDACTED]. On 5/22/19 at 12:29 PM, an interview was conducted with RN 2. RN 2 stated that the physician's orders [REDACTED]. RN 2 stated that the parameters were displayed before the nurse obtained the medication. RN 2 stated that the nurse was responsible to determine if the resident should receive a particular medication based on the parameters. RN 2 stated that the medications should have been held for resident 39 and the physician should have been contacted. On 5/22/19 at 12:39 PM, an interview was conducted with RN 1. RN 1 stated that none of the providers had authorized nurses to give medications outside the ordered parameters. RN 1 stated that a nurse should have charted if the physician was contacted and an order was received to give the medication outside of the parameters established in the order. RN 1 stated that the blood pressure medication for resident 39 should have been held based on the ordered parameters. On 5/22/19 at 12:45 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the nurses were responsible to watch for the parameters of medication orders. LPN 1 stated that it was the nurse's responsibility to determine if a medication should be administered based on the order. LPN 1 stated that an order to hold blood pressure medication with an SBP under 110 was standard protocol. LPN 1 stated that if he had questions about the validity of a blood pressure reading, he would obtain the BP himself. LPN 1 stated that he carried a manual blood pressure cuff to obtain a more accurate reading. On 5/22/19 at 12:55 PM, an interview was conducted with the DON. The DON identified that the medications for resident 39 were administered outside of the physician's orders [REDACTED].",2020-09-01
63,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2019-05-23,761,D,0,1,PDL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, a multi-dose vial of insulin was expired and available for use and administered to the resident. In addition, a resident was observed to have 2 medication cups on the bedside table with pills in the cups. Resident identifiers: 25 and 27. Findings include: 1. On [DATE] at 8:49 AM, an interview was conducted with resident 27. Resident 27 was observed to have two medication cups on his bed side table with pills in the cups. Resident 27 stated that the nursing staff always leave his medications on the bedside table. Resident 27 stated that he does not like the staff standing over him while he takes his medications. On [DATE] at 8:03 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that if a resident had medications left at the bed side it should be on the resident's care plan. LPN 2 stated that there were not any residents on her hall that self administer medications or that can have there medications at the bedside. LPN 2 stated that resident 27 was very particular about his medications and he was aware of what medications he takes. On [DATE] at 8:49 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident request to self administer medications they should have an assessment and a physician's orders [REDACTED]. The DON stated that the staff should notify the Physician regarding the resident request and what medications the resident will be self administering. The DON stated that she would prefer that the nursing staff not leave any medications at the residents bed side. (Note: A physician's orders [REDACTED].) 2. On [DATE] at 7:38 AM, the medication cart on the Ensign Peak Hall was inspected. There was a multi-dose vial of [MEDICATION NAME]100 units/milliliter with an open date of [DATE]. The medication was available for use. (Note: The [MEDICATION NAME] was to be discarded on [DATE].) An immediate interview was conducted with LPN 1. LPN 1 stated that once a multi-dose vial was opened it would be discarded in approximately 4 weeks. LPN 1 stated that the expired [MEDICATION NAME]was administered to resident 25 during the morning medication administration prior to this surveyor identifying that it was expired. On [DATE] at 11:16 AM, an interview was conducted with the DON. The DON stated that multi-dose vials should be discarded after 28 days of opening. The DON stated that she would go around every morning and talk with the nurses and remind them to check there medication carts for expired medication.",2020-09-01
64,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2019-05-23,773,D,0,1,PDL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined for 1 of 28 sampled residents that the facility did not provide or obtain laboratory (lab) services when ordered by the physician. Specifically, results of a basic metabolic panel (BMP) blood test were not reported to the physician. Resident identifier: 16. Findings include: Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/23/19, a medical record review was conducted for resident 16. A review of a nursing note dated 2/16/19 at 2:04 PM, revealed, Labs: BMP collected and MD (Medical Doctor) reviewed all lab values, New Orders; repeat BMP X (times) 1 week. Results for a BMP obtained on 2/20/19 were faxed to the facility on [DATE] at 7:35 AM. On 5/23/19 at 7:15 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that nurses signed lab reports when they received them and then nurses contacted the physician. RN 3 stated that the faxed test results were received this morning, and were not received previously. RN 3 stated that he signed the order today. On 5/23/19 at 10:15 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that there was no record that nursing staff had received the results or contacted the physician about the results from the lab test on 2/20/19.",2020-09-01
65,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2019-05-23,775,D,0,1,PDL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that for 1 of 28 sampled residents that the facility did not file, in the resident's clinical record, laboratory (lab) reports that were dated and contained the name and address of the testing laboratory. Specifically, one resident did not have laboratory reports filed in their medical record. Resident identifier: 16. Findings include: Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/23/19, a medical record review was conducted for resident 16. A review of nursing notes revealed the following: a. On 2/11/19 at 3:47 AM, Residents BMP (basic metabolic panel) Labs were not collected on 2/10/19. Notified Md (Medical Doctor) (resident's physician), received new orders to Re-check labs 2/11/19 BMP b. On 2/16/19 at 2:04 PM, Labs: BMP collected and MD reviewed all lab values, New Orders; repeat BMP X (times) 1 week. A review of scanned laboratory results revealed that no laboratory reports dated after 1/14/19 were located in resident 16's medical record. On 5/23/19 at 8:30 AM, an interview was conducted with a Medical Records (MR) staff member. The MR staff member stated that all laboratory reports that had been received by the facility before the current week had been scanned into the electronic medical record. On 5/23/19 at 7:15 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that laboratory results were faxed from the testing laboratory and then acknowledged by the nurse. RN 3 stated that after the nurse received the results, the physician was contacted, and then the lab result was scanned into the resident's electronic medical record. RN 3 stated that he did not receive resident 16's BMP results dated 2/20/19 prior to today. On 5/23/19 at 10:20 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that there was no evidence that the lab results for the two BMP obtained on 2/20/19, were received by the facility prior to this morning.",2020-09-01
66,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2016-11-30,157,D,0,1,16UX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined the facility did not immediately consult with the resident's physician for 1 of 34 sample residents. Specifically, the facility nursing staff did not notify the Medical Doctor (MD) of an abnormal blood sugar per the physician's orders [REDACTED]. Findings include: Resident 24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 24's medical record was reviewed on 11/30/16. A physician's orders [REDACTED]. If blood sugar is greater than 414, give 22 units. If blood sugar is greater than 414, call MD . A review of resident 24's (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Record [REDACTED] a. 10/26/16 at 8:00 PM, a blood sugar of 460 was documented. The nursing staff documented that 22 Units of Humalog was administered. b. 11/17/16 at 8:00 PM, a blood sugar of 438 was documented. The nursing staff documented that 22 Units of Humalog was administered. No documentation could be located indicating that the MD had been notified. On 11/20/16 at 1:58 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the nurse did not contact the MD per physician's orders [REDACTED].>",2020-09-01
67,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2016-11-30,371,E,0,1,16UX11,"Based on observation and interview, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service and safety. Specifically, concerns were identified related to cross contamination during food preparation, expired food items, and dating, labeling, and covering food items. Findings include: On 11/28/16 at 7:45 AM, the following observations were made during an initial tour of the main kitchen: a. Cracked and peeled caulking along the left-hand side of the dishmachine between the wall and the stainless steel counter. b. A dented can of Ensure within the dry storage area. c. A large container of brown sugar was open to the air within the dry storage area. d. A plastic container of strawberries was visibly moldy within the walk-in refrigerator. e. An opened container of ranch dressing was dated 2/15.17, indicating a two-year expiry period within the walk-in refrigerator. f. A container of salsa was undated within the walk-in refrigerator. g. Two containers of lemon juice were dated BEST BEFORE (YEAR) NOVEMBER 14 within the walk-in refrigerator. h. One container of lemon juice was dated BEST BEFORE (YEAR) NOVEMBER 15 within the walk-in refrigerator. i. Five containers of pesto appeared to have visible, white mold growth within the walk-in refrigerator. j. A plastic bag of grapes, with an individual package of Oreo cookies inside the bag, was labeled with an indecipherable date and resident identifier within the walk-in refrigerator. k. A reusable ice pack was stored among food items within the standing refrigerator. l. A plastic bag of chicken fingers was undated within the standing refrigerator. m. A plastic package of raw chicken breasts was stored on the top shelf, above berries and pre-cooked fish products, within the standing refrigerator. On 11/28/16 at 8:35 AM, an observation was made of the cook during breakfast preparation. The cook was observed to crack three eggs into a frying pan, wipe her hands on her apron, and then proceeded to prepare residents' meal trays without changing her gloves. On 11/28/16 at 8:10 AM, the following observations were made of the refrigerator located within the independent dining room: a. A tomato with visible mold was in the door of the refrigerator. b. A plastic bag of individual pizzas was undated within the freezer. On 12/29/16 at 7:30 AM, the following additional observations were made of food storage areas within the main kitchen: a. A plastic bag of sausage links was undated within the walk-in refrigerator. b. The plastic container of strawberries with visible mold, as previously noted, remained within the walk-in refrigerator. c. A plastic package of raw chicken breasts was undated within the walk-in freezer. d. The plastic bag of chicken fingers, as previously noted, was open to the air and remained undated within the standing refrigerator. e. A box of cookie dough was open to air within the standing refrigerator. On 11/29/16 at 2:51 PM, an interview was conducted with Dietary Staff Member (DSM) 1. DSM 1 stated all food items should have been labeled, dated, and covered. DSM 1 further stated all expired or visibly moldy foods should have been thrown away. In addition, DSM 1 stated that gloves should have been changed after cracking eggs in order to prevent cross contamination. DSM 1 further stated that the dietary staff was responsible for cleaning and maintaining the refrigerator located within the independent dining room. On 11/30/16 at 7:45 AM, an interview was conducted with DSM 2. DSM 2 stated all food items should have been labeled, dated, and covered. DSM 2 further stated all expired or visibly moldy foods should have been thrown away, and raw meat should have been stored on the bottom shelf of the refrigerator. In addition, DSM 2 stated that gloves should have been changed immediately after cracking eggs. DSM 2 further stated that the dietary staff was responsible for cleaning and maintaining the refrigerator located within the independent dining room. On 11/30/16 at 10:04 AM, an interview was conducted with the Dietary Manager (DM). The DM stated all food items should have been labeled, dated, and covered, and an expiry date range of two years was not acceptable. The DM further stated that expired or visibly moldy foods and dented cans should have been thrown away, and raw meat should not have been stored on top of anything. In addition, the DM stated that the dietary staff was responsible for auditing food storage areas after each shift, and cleaning and maintaining the refrigerator located within the independent dining room on a daily basis. The DM further stated that gloves should have been changed immediately after cracking eggs, and confirmed the risk of bacterial growth within cracked and peeled caulking around the high-moisture dishmachine area.",2020-09-01
68,MT OLYMPUS REHABILITATION CENTER,465006,2200 EAST 3300 SOUTH,SALT LAKE CITY,UT,84109,2016-11-30,502,D,0,1,16UX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 1 of 34 sample residents, that the facility did not provide or obtain laboratory (lab) services timely to meet the needs of the residents. Specifically, labs were not obtained as ordered by the physician. Resident identifiers: 24. Findings include: Resident 24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 24's medical record was reviewed on 11/30/16. A physician's orders [REDACTED]. A review of the laboratory values revealed that a CBC and CMP for resident 24 was completed on 10/10/16. The Medical Doctor documented to increase resident 24's [MEDICATION NAME] to 80 milligrams for five days and check a BMP (basic metabolic panel) on Sunday (10/16/16). No documentation could be located in resident 24's medical record indicating that the BMP blood draw was completed on 10/16/16. On 11/30/16 at 1:58 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the BMP blood draw for resident 24 was missed.",2020-09-01
69,HARRISON POINTE HEALTHCARE AND REHABILITATION,465009,3430 HARRISON BOULEVARD,OGDEN,UT,84403,2017-06-22,248,E,0,1,WP7B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility did not provide activities, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choices of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 5 of 25 sample residents. Specifically, residents complained that activities did not meet their needs and there were no activities on the weekends to meet their needs. Resident identifiers: 29, 38, 53, 55 and 56. Findings include: 1. The facility activities calendar for (MONTH) (YEAR) was reviewed and revealed the following scheduled activities for 6/19/17 through 6/22/17. a. 6/18/17:10:30 AM LDS Services 2:00 PM Therapy Animals b. 6/19/17: 10:30 AM Exercise 12:00 AM, Reminiscing 3:00 PM Prize Bingo c. 6/20/17: 10:00 AM Horse Races 12:00 AM Trivia 2:00 PM Resident Council 7:00 PM Baptist Bible Study d. 6/21/17: Use Your Noodle Day!!! 10:00 AM Movie Channel 3 Ocean's Eleven 10:30 AM LDS Services 12:00 PM Sensory Hand Washing 3:00 PM Reading outdoors e. 6/22/17: 9:30 AM Exercise Group 10:00 AM Catholic Service 10:30 AM Music & Motion with Marsha 12:00 PM Time Slips 2:00 PM Van Outing f. 6/23/17: 10:30 AM Yardzee 12:00 PM Current Events 4:00 PM Violin Students 4:00 PM LDS Missionaries 7:00 PM Bingo g. 6/24/17: 10:30 Baptist Service 12:00 PM Music Reminiscing 2:00 Root Beer Float Social (Note: There are 2 scheduled evening activities on Tuesday nights at 7:00 PM and Friday nights at 7:00 PM. Tuesday nights were scheduled for a religious event. The scheduled activities on Sundays were LDS services and Therapy Animals.) On 6/19/17 at 12:00 PM, an observation was made of the Reminiscing activity. The activity was completed by 12:22 PM. On 6/20/17 at 11:00 AM, an observation was made of a music activity that was not scheduled. The facility staff were observed to do a signing activity with the residents in the main dining room. The activity was completed within 10 minutes. 2. Resident 29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/20/17 at 9:30 AM, an interview was conducted with resident 29. Resident 29 stated that there were not enough staff and that the facility did not offer enough activities. On 6/21/17 at 10:33 AM, a follow up interview was conducted with resident 29. Resident 29 stated that the activities were not very good since the Activities Director (AD) also became the Dietary Manager (DM). Resident 29 stated that the activities were kind of a joke. Resident 29 stated that the bingo on Friday nights was not good and the prize was a small piece of candy. Resident 29 stated that there were no weekend activities and it was boring. Resident 29 was observed to be given a pool styrofoam noodle and instructed that he could hit staff below the waste with the noodle. Resident 29 took the pool noodle and rolled his eyes. Resident 29 stated, These are childish games and I don't like them. Resident 29 stated that resident council did not have regular meetings and that there was not a resident council meeting in April. Resident 29's medical record was reviewed on 6/21/17. A significant change Minimum Data Set ((MDS) dated [DATE] revealed that it was Very Important to read books, newspapers, listen to music and getting outside. The MDS revealed that being around pets, keeping up with the news and doing things with groups were Not very important. The MDS revealed that religious activities were Not important at all. A care plan dated 12/17/15 and revised on 9/5/16 revealed a Focus of I, (Resident 29) exhibit independence in leisure activities manifested by my ability to structure my own time; my ability to choose group activities of interest; I have independent hobbies/interests; I need reminders; I prefer independent leisure; I have little interest/pleasure in doing things. One of the goals developed was, I will attend at least: 1 social activity per week to increase in sense of community as evidenced by building meaningful relationships with peers during activities; 1 emotional activity per week for increase in interest/pleasure in doing things as evidenced by participating in activities of interest; 90 days. Some of the interventions developed were, Invite and involve me in my activities of importance/interest including: Pet visits/therapy, music, TV/Movies, helping others, crafts, outside, socials, Catholic services, trip and Monitor for satisfaction with my leisure choices. An activity note dated 6/19/17 revealed, Continue care plan. An activity assessment dated [DATE] revealed (Resident 29) exhibits independence in leisure activities manifested by ability to structure own time; ability to choose group activities of interest; has independent hobbies/interests; needs reminders; prefers independent leisure; has little interest/pleasure in doing things. The assessment further revealed, (Resident 29) is maintaining highest level of independence possible as evidenced by making choices about and participating in activities of importance/interest daily. It was documented, (Resident 29) attends bingo per week for increase in sense of community; poem building and service projects for increase in interest/pleasure in doing things. Upon quarterly review (resident 29) is currently following plan of care. No changes at this time. 3. Resident 38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/19/17 at 12:26 PM, an interview was conducted with resident 38. Resident 38 stated that she was not aware of any evening activities. Resident 38's medical record was reviewed on 6/21/17. An annual MDS dated [DATE] revealed that pets and being outside were very important to resident 38. The MDS further revealed that having books, newspapers and magazines to read, listening to music, group activities, keeping up with the news and religious services were not important at all for resident 38. A care plan dated 12/4/15 and updated on 12/17/16 revealed a Focus of I (resident 38) exhibit alteration in my thought process manifested by my: cognitive impairment; I need prompts/cues to choose activities; I have problems with coping; [MEDICAL CONDITION], anxiety; I need help structuring my own time; I need one step directions; I need reminders and/or assistance to/from activities. One of the goals developed was, I will attend at least; 1 cognitive activity per week for retention of cognitive abilities as evidenced by memory recall during activities; 2 social activities per week for increase in sense of community as evidenced by participating in group activities of interest; 1 emotional activity per week for increase in interest/pleasure in doing things as evidenced by participating in activities of interest; 1 spiritual activity per week for increase in coping skills as evidenced by attending spiritual activities (times) 90 days. Some of the developed interventions were, Invite and involve me in my activities of importance/interest including: LDS services, music, socials, pet therapy/visits, outside, Bingo, helping others, reading, gardening, games, cards, flowers, trips, exercise. (Note: The MDS revealed that religious services were not important at all but the care plan revealed that they were going to invite and involve her in LDS services.) An activity note dated 6/19/17 revealed, Continue care plan. An activity note dated 12/17/16 revealed, . Social and Emotional Barriers to leisure: Problems with coping. Leisure Skills: Has sufficient leisure skills and interests. Has appropriate materials and resources to participate in leisure.Resident is able to identify and participate in activities of importance.Alteration in Thought Process care plan will focus on involving resident in activities of importance, pain management, and retention of cognitive abilities. A quarterly Activities Evaluation dated 3/28/17 and was locked by staff on 6/15/17 reveled, Upon quarterly review (resident 38) is currently following plan of care with assistance from staff. No changes at this time. 4. Resident 55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/19/17 at 1:19 PM, an interview was conducted with resident 55. Resident 55 stated that she was not aware of activities in the evening and on the weekends. Resident 55's medical record was reviewed on 6/21/17. An annual MDS dated [DATE] revealed that it was very important for resident 55 to interact with pets and go outside. The MDS further revealed religious services were somewhat important to her. The MDS revealed that keeping up with the news, listening to music, and reading books, magazines and news papers were Not very important. A care plan dated 6/19/17 revealed, (Resident 55) exhibits independence in leisure activities manifested by the ability to structure own time; ability to choose group activities of interest; has independent hobbies/interest; Poor health/pain limits activity involvement; needs assistance to/from activities; often fatigued from treatments; has little interest/pleasure in doing things. One of the goals developed was, Will attend at least: 1 social activity per week for increase in sense of community as evidenced by participating in group activities of interest (times) 90 days. Some of the interventions developed were, Invite and involve me in my activities of importance/interest including: music, pet visits, games, outdoors, socials, Bingo, shopping, Fishing, cooking. An Activity - Admission Evaluation dated 4/26/17 revealed, Resident is independent in choosing activities and leisure items of interest. An activities note dated 6/19/17 revealed, .Resident is able to identify and participate in activities of importance. impaired mobility, pain, and fatigue are potential barriers to leisure participation.Independent Leisure Focus care plan will focus on involving resident in activities of importance, increase in self esteem, pain management, and supporting self-directed leisure choices. 5. Resident 53 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. On 6/19/17 at 2:34 PM, an interview was conducted with resident 53. Resident 53 stated she feels like there are not enough activities provided for residents at the facility. Resident 53 medical record was reviewed on 6/21/17. An admission MDS dated [DATE] revealed that books, newspapers, magazines to read, listen to music, be around pets, go outside, and religious practices were very important to resident 53. Resident 53 felt that keeping up with news and doing activities with groups of people were somewhat important. A care plan dated 4/6/17 had a Focus of, (Resident 53) exhibits independence in leisure activities manifested by the ability to structure own time; ability to choose group activities of interest; has independent hobbies/interest; has a disinterest in group activities; prefers to spend time with family/friends; Poor health/pain limits activity involvement; needs assistance to/from activities; often fatigued from treatments; has difficulties managing mood at times. A goal developed was, Will accept at least 1:1 visit per week for encouragement and socialization (for) 90 days. Some interventions developed were, Invite and involve me in my activities of importance. interest including: puzzles, TV/movies, music, news, pet visits, LDS services, bingo, knitting/crochet, reading, outdoors and Supply me with independent leisure activities. An Activity - Admission Evaluation dated 3/24/17 revealed resident 53's Assessed needs were, Encourage resident to attend activities in facility. An activity note dated 4/6/17, Resident is able to identify and participate in activities of importance. Impaired mobility, mood, pain, and fatigue are potential barriers to leisure participation. The Care Plan Focus revealed, Independent Leisure Focus care plan will focus on involving resident in activities of importance, increase in self esteem, pain management, and supporting self-directed leisure choices. 6. Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/19/17 at 3:00 PM, an interview was conducted with resident 56. Resident 56 stated there were no activities on the weekends and that he was really board. Resident 56's medical record was reviewed on 6/21/17. An admission MDS dated [DATE] revealed that listening to music, pets, keeping up with the news, going outside and religious services were Very Important to resident 56. Resident 56 felt that being in activities with groups of people were Somewhat Important. An Activity - Admission Evaluation dated 2/5/17 revealed, Resident is independent in choosing activities and leisure items of interest. Would like reminders of current activities. An activities note dated 2/23/17 revealed, .Analysis of Findings: Resident is able to identify and participate in activities of importance. Impaired mobility, mood, pain, and fatigue are potential barriers to leisure participation. Care Plan Focus: Independent Leisure Focus care plan will focus on involving resident in activities of importance, increase in self esteem, pain management, and supporting self directed leisure choices. 7. The Resident Council Minutes were reviewed and revealed the following: a. 2/28/17, Activities: Announced of new Activities Director to start by the end of next week. More church services. Meeting other people. b. 3/21/17, Activities: Announced that (Name of staff member) will be taking activities. c. 5/5/17, Activities: Announced that (Name of staff member) will start back being the TRT (Therapeutic Recreational Therapist) in activities. d. 5/23/17, No concerns On 6/22/17 at 11:45 AM, an interview was conducted with the facility Activities Director (AD). The AD stated that the weekend activities were relaxing. The AD stated that the church volunteers passed out games and puzzles on Sunday for residents. The AD stated that she recently was changed back to the AD and was also the facility Dietary Manager. The AD stated that residents were assessed upon admission and quarterly for activities. The AD stated that residents had not had any complaints about the activities. The AD stated that the last AD did not have a resident council meeting in (MONTH) so there were 2 meetings in May.",2020-09-01
70,HARRISON POINTE HEALTHCARE AND REHABILITATION,465009,3430 HARRISON BOULEVARD,OGDEN,UT,84403,2017-06-22,253,E,0,1,WP7B11,"Based on observation and interview it was determined that the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, there was a brown substance on a hand rail in a resident bathroom, there were bugs observed in the facility, there was a liquid on the floor in a bathroom and residents complained the facility was not clean. Resident identifiers: 93 and 94. Findings include: 1. On 6/19/17 at 8:18 AM, an interview was conducted with resident 94. Resident 94 stated that her bathroom was not cleaned regularly. Resident 94 stated that there had been a brown substance on the hand rail in her bathroom for at least 2 days. Resident 94 stated she can only imagine what it was. Resident 94 stated that her bathroom always smelled. An observation was immediately conducted of resident 94's bathroom. There was a brown substance on the hand rail and the bathroom had a strong odor. At 3:30 PM, an observation was made of resident 94's bathroom. There was still a brown substance on the hand rail and the bathroom had a strong odor. 2. On 6/19/17 at 10:23 AM, an observation was made of the bathroom in room 17. There was a liquid substance on the floor and there was a strong urine odor. 3. On 6/20/17 at approximately 12:30 PM, an observation was made of three box elder bugs crawling on the inside window of the Northeast exit door. 4. On 6/20/17 at 2:37 PM, an interview was conducted with resident 93. Resident 93 stated that he had just killed a big black spider in his bathroom. An observation was immediately conducted on resident 93's bathroom. There was a black object that was crumpled in the corner of the bathroom which appeared to resemble a spider. On 6/22/17 at approximately 12:30 PM, an interview was conducted with the House Keeper (HK). The HK stated that she was hired a week ago. The HK stated that the day shift cleaned the front half of the facility resident room and the night house keeper cleaned the back half. The HK stated that bathrooms should be cleaned daily. The HK stated that she observed bugs by the doors to the outside. The HK stated that she would report any bugs to her supervisor.",2020-09-01
71,HARRISON POINTE HEALTHCARE AND REHABILITATION,465009,3430 HARRISON BOULEVARD,OGDEN,UT,84403,2017-06-22,323,G,0,1,WP7B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that for 1 of 25 sample residents, the facility did not ensure that each resident was safe from accident hazards. Specifically, a resident sustained [REDACTED]. The findings were cited at a harm level due to the resident not having adequate supervision to prevent falls. Resident identifier: 35. Findings include: Resident 35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/22/17 at approximately 9:10 AM, an observation was made of resident 35 laying in bed. The bed was not in the low position. Certified Nurse Assistant (CNA) 1 who was in the room confirmed that bed was not in lowest position. CNA 1 lowered the resident's bed approximately 12 - 18 inches to the lowest possible position. CNA 1 stated that staff will lower resident's bed but resident had access to bed control and would often return the bed to a normal height. Resident 35's medical record was reviewed on 6/22/17. Review of the admission MDS (Minimum Data Set) Assessment, dated 2/13/17, revealed that the facility staff assessed resident 35 as requiring limited assistance with a one person physical assist for transfers, ambulating, toileting, and bed mobility. The facility staff also identified that resident 35 had sustained falls in the last 2-6 months prior to admission. A Care Area Assessment (CAA) triggered for falls. The facility staff documented that the care area would be addressed in a care plan. Review of resident 35's care plan revealed an Activities of Daily Living (ADL) Self Care Performance Deficit care plan that was initiated on 2/7/17. The goal developed was Will safely perform Bed mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene) (sic) with modified independence) through the review date. The interventions developed to achieve the goal included: Occupational (OT), Physical (PT), Speech-Language Therapy (ST) evaluation and treatment to establish functional maintenance program per physician orders, Requires extensive assist x 2 (two person assistance) for adls, .Encourage to use bell to call for assistance. 1. On 2/5/17 at 3:45 PM, an incident report documented, CNA found resident sitting in a corner of her room, crying stating that she slipped and hit her head and shoulder on her closet door. unsure of what she was doing. On 2/5/17 an actual fall care plan was developed. The goal developed was Will resume usual activities without further incident through the review date. The intervention developed was to replace the quad can with a walker. 2. On 2/21/17 at 9:00 AM, an incident report documented, Pt (patient) was getting up from chair at the dinning (sic) table. Pt's leg hit the sit (sic) of the chair, hitting the chair out from under pt and causing pt to lose her balance. Pt fell to the right side. S/S (signs and symptoms) of increased pain to right shoulder noted at time of fall. Skin remains intact. Pt states right shoulder does hurt more after the fall. Staff there with pt at the time of fall. Additionally, the facility staff documented, Her pants were too tight and she could not bend and stand up correctly. (Note: Resident 35 required limited assistance with a one person physical assist with dressing.) The investigation into the incident was completed. The facility staff documented, She was walking with clothes on that impaired balance and fell . The interventions that were in place prior to the fall included: Call light within reach, frequently used item within reach, clear pathways, ensure non slip footwear, use of walker. (Note: The actual fall and ADL care plan did not include interventions for frequently used items within reach, clear pathways or ensure non slip footwear.) The new intervention documented on the incident report was Family to remove clothes and replace with clothes that is appropriate. The actual falls care plan was updated to include the new intervention of proper fitting clothes and provide pants that are not tight and inhibit function. 3. On 2/23/17 at 3:02 PM, an incident report documented, Floor (sic) by PT and CNA face down on the floor next to her bed, yelling and crying. Noted to be bleeding from her nose. Stated that she was trying to get up, rolled out of bed. The investigation into the incident was completed. The facility staff documented, She was attempting to self transfer and toilet self when she lost balance and fell from bed. The new intervention to be implemented was medications review/labs (laboratory). On 2/23/17 at 3:11 PM, the facility Licensed Vocational Nurse/Licensed Practical Nurse (LVN/LPN) Supervisor documented in a progress note, Found by PT and CNA after hearing a loud bang, found resident face down on the floor crying and screaming, noted that she was bleeding from both nares are (sic) swollen and tender with some discoloration. Has full ROM (range of motion) of all extremities, neuro (neurological) checks WNL (within normal limits) also VS (vital signs). Ice applied to nose scant bloody drainage, in bed with HOB (head of bed) up. Stated that she was trying to get up rolled out of bed falling onto the floor. Bed was in low position, call bell was clipped to her blankets with in easy reach. Daughter called message left to call facility. MD (Medical Director) and ADON (Assistant Director of Nursing) aware. On 2/23/17 at 6:00 PM, the facility LVN/LPN Supervisor documented in a progress note, NP (Nurse Practitioner) (name redacted) went into eval (evaluate) residents (sic) face/nose after fall, found her to be unresponsive this nurse also no reaction to sternal rubs, both pupils sluggish, drooling on right side, after approx. (approximately) 10 minutes became more alert, cognitively slow in response, after 30 minutes much brighter. NP requests eval (evaluation) at ER (emergency room ), daughter aware to meet her at the ER at (name of local hospital) EMS (Emergency Medical Services) called transported to (name of local hospital), report called to ER. Review of the hospital records indicated that resident 35 had a seizure with a low phenobarbital and valproic acid levels. The actual falls care plan was updated to include the new intervention of medication/labs. 4. On 2/28/17 at 3:45 PM, an incident report documented, Pt. found on floor of room, sitting in front of wc (wheelchair) facing the window. Pt had been in the DR (dining room) and pt took self in wc from the DR to pt's room. Brief wet with urine at time of fall. Pt reports pain to shoulder and lower back. No new skin concerns noted at time of fall. The investigation into the incident was completed. The facility staff documented, She attempted to self transfer and lost her balance. The new intervention to be implemented was to review the wheelchair for safety. The actual falls care plan was updated to include the new intervention of eval (evaluate) w/c (wheelchair) for safety. 5. On 3/15/17 at 8:15 AM, an incident report documented, CNA found resident on floor, calling out. This nurse found resident laying on left side on the floor leaning against the door jam. States that she did not hit her head then recounted this stating that she did. stated (sic) that she got up to go to the bathroom without help. The investigation into the incident was completed. The facility staff documented, Pt is alert with confusions (sic) she is able to make her need known. She despite repeated education about call light use and waiting for assistance she continues to not use call light or ask for assistance. She attempted to take herself to the bathroom and lost her balance and fell . The new intervention to be implemented was medication review and lab ordered. The actual falls care plan was updated to include the new intervention of seizure med (medication) review/labs re-education. 6. On 3/20/17 at 1:00 PM, an incident report documented, Pt found on floor laying face down along side the (sic) bed. Pt snoring at the time pt was found. Easily awaken. No noted injury. Call light within reach of pt, not activated. The investigation into the incident was completed. The facility staff documented, Pt is alert with confusions (sic) she is able to make her need known. She despite repeated education about call light use and waiting for assistance she continues to not use call light or ask for assistance. Pt was found laying on the floor with pillows under head, awoke easily and voiced no new complaints. The new intervention to be implemented was Encourage pt to have bed in lower position. 7. On 4/7/17 at 10:49 PM, an incident report documented, Found PT (patient) sitting on floor. Assessed cognitive function and assessed body. No abnormal findings. She was sat into bed. Neuro checks per facility protocol. MD notified. PT (patient) states she was trying to get into bed and she slid to the floor. The investigation into the incident was completed. The facility staff documented, Pt was found sitting on the floor voiced no new complaints at this time stated she tried to transfer self back to bed from w/c. The new intervention to be implement was Pt will be moved to room closer to nurse station as well as to bed which will make pt more visible to staff. On 4/7/17 at 10:52 AM, License Practical Nurse (LPN) 1 documented in a progress note, PT was found in her room. She stated that she had slid down her bed to the floor while trying to get into bed. Full assessment conducted yielding no notable concerns. PT placed into bed. Neuro checks per facility protocol. MD notified. On 4/8/17 at 10:23 PM, LPN 2 documented in a progress note, Patient returned from ED (emergency department). Patient has soft cast splint in place. Splint is to be kept on until follow up ortho (orthopedic) appointment in 1-2 days. Patient is to use w/c or crutches for mobility. On 4/10/17 at 11:18 AM, the ADON (Assistant Director of Nursing) documented in a progress note, IDT (Interdisciplinary Team) review of fall from 4/7/2017. At time of falls Had (sic) no skid socks on, no shoes, denied pain at time of fall, post fall pain 3/10 call light not activated. intervention to help prevent falls was to move closer to rear nursing station in a bed and re educated (sic) to call lights, items in reach and frequently used items, bed in lower position. Pt started to have swelling noted to left ankle and pain, x-ray was obtained and noted to have fx (fracture) to left ankle. family (sic) was notified upon x ray results She was sent to ER (emergency room ) for eval and treatment Review of hospital emergency room records, dated 4/8/17 at 7:01 PM, documented that upon x-ray of left ankle resident 35 sustained a distal fibular fracture with adjacent soft tissue swelling. A review of resident 35's ADL charting dated 4/1/17 through 4/16/2017 revealed that staff was not providing a two person transfer assistance during this time frame as documented in resident's care plan. Resident 35's actual falls care plan was not updated to include additional interventions. On 6/21/17 at approximately 1:10 PM, an interview was conducted with LPN 1. LPN 1 stated that on 4/7/17 he observed resident 35 sitting on the floor of her room with her back to the bed and legs extended outward. LPN 1 stated that he assessed the resident for pain, neurological status and muscular problems. LPN 1 stated that resident began to cry and when questioned as to why she was crying, resident stated she that she was scared because she had fallen. LPN 1 stated that the resident continued to deny pain. On 6/21/17 at approximately 1:40 PM, CNA 1 was interviewed. CNA 1 stated that resident 35 was provided with a low bed, call light in reach, bedside table and frequently used items in reach. CNA 1 stated that fall happened after breakfast and that resident's demeanor after the fall was the same as before the fall. CNA 1 stated resident did complain of pain in her leg and that the pain was reported to the nurse. (Note: This was resident 35's seventh fall in two months. The facility staff did not increase resident 35's supervision to prevent accidents from occurring.) 8. On 5/5/17 at 6:15 PM, the ADON documented in a progress note, resident has an assisted fall while being transferred from w/c to bed, was on bed and slide (sic) off, bed in lower position and lost her footing. No injury noted , (sic) no bruising, daughter called and left message fall (sic) at 6:12 pm, non slide socks on, walker in front of resident. Did not hit head per c.n.a On 5/5/17 at 8:46 PM, the ADON documented in a progress note, Resident had a fall while being transferred into bed was sitting on bed and slipped off, staff assisted , (sic) did not hit her head, walker was in front of her and c.n.a. turned to push w/c. Daughter called message left. No injury. Did not hit head. Will have two people assist when resident is sleepy. (Note: Resident 35's initial ADL's care plan indicated that two people were to transfer resident 35.) The actual falls care plan was updated to include lips (unknown) assessment-requires 2 person assist r/t (related to) cast/behaviors. (Note: The initial ADL's care plan indicated that resident 35 was to have a two person assistance with transfers.) 9. On 5/9/17 at 8:20 PM, a licensed nurse documented in a progress note, At about 2020 (8:20 PM) the nurse heard patient yelling for help to find patient on the ground with back against the bed. Bed was at it (sic) lowest position. Patient stated that she was trying to get herself in bed. Patient stated she took of (sic) her shoes and lowered the bed to the ground and tried to get in. No injuries were noted. Patient states her knee hurt but was able to do full ROM (range of motion) without pain. Call light was in reach. DON, family and MD were notified. On 5/10/17 at 5:21 PM, the DON documented in a progress note, IDT (interdisciplinary team) review of fall on 5/5/17 (and) 5/9/17.Pt was assisted to the floor as she began slipping and aide lowered her to floor voiced no new complaints at this time stated she tried to transfer self back to bed from w/c.New intervention: lips (unknown) assessments. The actual falls care plan was updated to include call light education and return demonstration. On 5/11/17 at 4:24 PM, the DON documented in a progress note, Spoke with (resident 35's daughter) that I think that this is behavior related as she had pants folded on bed, w/c cushion on bed and she was sitting on the floor but insisted she fell from bed. Pt reports that she activated call light but it was not in on. Call light was changed to bulb call light. Pt will not tell this nurse any further details of incident. CNA reported she attempted to go in to do vitals on pt and she refused to have vitals taken at that time. Daughter reports that she had conversation with pt earlier today, states she thinks mom may be in bad (sic) mood r/t her inability to visit r/t vital illness. States her mother is manipulative and act (sic) to get attention. 10. On 5/11/17 at 4:30 PM, the ADON documented in a progress note, Resident was on floor sitting next to bed, w/c was slightly away from bed with wheels locked and pressure reduction cushion set on bed, her pants and shirt were nicely folded. It appears that resident set herself on floor. No injuries noted she was crying and saying that she had her light on, call light not on , (sic) no socks on feet. unsure how resident could have slid out of bed with clothes folded on bed where she would have had to slide out. She stated that she slide (sic) out of bed. It appears to be possible behaviors , (sic) when speaking to daughter by DON she said she had not been up here due to being not there and that her mom had called her today and that she also though (sic) behaviors. No injuries , (sic) no pain more anxiety. On 5/12/17 at 7:02 PM, the DON documented in a progress note, IDT review of fall on 5/11/17.Pt was found sitting on floor. She would not state what occurred however pt bed was found with clothes neatly folded laying on bed, w/c cushion sitting on end of bed, bed was in low position.New intervention: new bubble call light placed in room. The actual falls care plan was updated to include bubble call light. 11. On 5/21/17 at 9:17 PM, a licensed nurse documented in a progress note, At about 1845 (6:45 PM) Nurse was called to patients room to find patient on the ground in front of her dresser. Patient was on her but (sic) facing the door with non-slip socks on. Patient has a small scratch on the right side of her nose that may or may not be r/t fall. Patient has two bumps on the back of her head. No other injuries were noted. Patient neuro assessment was started and VS (vital signs) have remained normal. Family, DON and NP were noted. On 5/22/17 at 4:17 PM, the DON documented in a progress note, IDT review of fall on 5/21/17.Pt was found sitting on floor. She would not state what occurred however pt bed was found with clothes neatly folded laying on bed, w/c cushion sitting on end of bed, bed was in low position.New intervention: Eval (evaluate) w/c for anti-tips. The actual falls care plan was updated to include eval for anti-tips on w/c (pt r/t weigh (sic) tips w/c despite anti-tips bars as she will lean to side. Given reacher. 12. On 6/3/17 at 11:12 AM, the LVN/LPN Supervisor documented in a progress note, Heard resident calling out found resident sitting on floor at edge of bed with w/c tipped, stated that she was trying to look in her hamper 'scootted (sic) to close to the edge' assessed for injury none noted, assisted back into w/c . On 6/5/17 at 12:28 PM, the DON documented in a progress note, Pt was found sitting on floor. Yelling out for help.New intervention: Room moved . The actual falls care plan was updated to include room moved. 13. On 6/4/17 at 10:59 AM, the LVN/LPN Supervisor documented in a progress note, Early this am (morning) was yelling in her room that she wanted to get UP NOW!, explained that she needed to wait a few minutes as her CNA was finishing with someone else. 'I don't care tell her to get her butt in HERE NOW! again reassured that she would be in, several minutes while this nurse was in the room the CNA came and got her up, she then attempted to get something from the vending machine, was mad that she could not. She then went down into the dining room and started crying because another resident in her 'Spot' and that no (sic) cares that she had to wait this am (morning). after breakfast went into her room, walked into bathroom without assist then fell on to right side with her face turned to the floor, noted to have a discoloration on forehead and small reddened area on her right side, had full ROM WNL assisted up into w/c X 4 (four) persons as she will NOT hold her own wt (weight). VS and Neuro checks good, assisted into bed with call bell and bed controls in reach. Shortly after CNA found resident laying sideways in her bed attempting to get up again, stated that she wanted to get up, asked why she did not call 'I don't need help' assisted into w/c. at nurses desk now. Daughter called about fall no answer message left to call facility, DON and PA (Physician's Assistant) aware of fall. On 6/5/17 at 12:34 PM, the DON documented in a progress note, IDT review of fall on 6/4/17.Pt was found laying on floor. Yelling out for help. Earlier in the day she told 'CNA' let (sic) see what happens when I fall as a response to aide helping get roommate dressed before her.New intervention: Dipstick ua (urinalysis) . The actual falls care plan was updated to include ua dipstick. On 6/5/17 at 10:49 AM, the DON documented in a progress note, Ua negative. On 6/6/17 at 4:17 PM, the ADON documented in a progress note, .has had some increased behavior and will tell staff that she is going to fall if she is not treated like their mother. She has some confusion will yell out at times and just scream, not r/t pain. She rated her pain 5/10 sometimes, has some SOB (shortness of breath) with activity, laying flat and rest ,is (sic) on oxygen when in bed. she did have a fall with fx (fracture). She remains a fall risk to (sic) despite intervention. Is ext (extensive) two person to stand transfers and toilet, ext for all adl functional cares, she could assist with dressing and washing face but needed assist and cues to assist.She could recall two word with cue sock, bed , (sic) blue knew yr (year) new month not day.She has confusion and other times she can answer questions from the past , (sic) knows staff names at times.has weakness in bialt (sic) (bilateral) legs and UE (upper extremities. 14. On 6/8/17 at 9:16 PM, a licensed nurse documented in a progress note, I was called into the patients bathroom by another nurse. Pt was lying on her R (right) side on the floor of the bathroom. there were no visible injuries, and no new c/o (complaints of) pain. at the time. pt's call light was on, aid/staff members were attempting to answer the patients call light, when the patient became anxious and tried to stand on her own. pt has been educated numerous times by staff and family to wait for help with cares. pt verbalizes understanding but continues to be noncompliant. pt was assisted back into her w/c, assessed further for any injuries, pt was cleaned up, and helped into bed for the evening. (Note: This was resident 35's fourteenth fall since her date of admission.) On 6/9/17 at 6:50 PM, the DON documented in a progress note, IDT review of fall on 6/8/17.Pt was found sitting on floor in bathroom. Yelling out for help. She had attempted to assist herself off of toilet.New intervention: Toilet Riser don't leave unattended in bathroom . The actual falls care plan was updated to include dont (sic) leave unattended in bathroom and toilet riser. On 6/22/17 at approximately 9:00 AM, an interview with the DON was conducted. The DON stated that the facility provided staffing according to the resident acuity and that acuity was based on resident behaviors and amount of assistance need for ADL's. The DON further stated that it was difficult to determine how much assistance resident 35 would need on a daily basis because her behavior and needs differed from day to day. The DON did acknowledge that the facility was not capable of providing resident 35 with 1 on 1 supervision. The DON stated that the facility had attempted several other interventions such as moving resident 35 closer to the nurses station but resident 35 and resident 35's daughter complained which led facility to moving resident 35 back to her original room. The DON stated that one of the earliest interventions put in place by the facility was a quick response time to the call light and resident reassurance that help would be available quickly but that resident 35 would still attempt unassisted self transfers. The DON also stated that the facility attempted to provide a wedge cushion and anti-tip bars on wheelchair but resident would often remove the cushion and anti-tip bars did not prevent her from sliding forward in her wheelchair.",2020-09-01
72,HARRISON POINTE HEALTHCARE AND REHABILITATION,465009,3430 HARRISON BOULEVARD,OGDEN,UT,84403,2017-06-22,353,E,0,1,WP7B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility did not have sufficient nursing staff, for 6 of 25 sample residents, with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. Specifically, residents and family complained there were not enough staff and resident council minutes revealed call lights were not answered timely. Resident identifiers: 23, 43, 53, 55, 80 and 92. Findings include: 1. On 6/19/17 at 1:45 PM, an interview was conducted with resident 43's family member. Resident 43's family member stated that Certified Nursing Assistant's (CNA's) will leave resident 43 in bed because there were not enough staff to watch her. Resident 43's family member stated that she was in the facility on 6/18/17 visiting and as she was assisting resident 43 back to her room, a CNA asked her if she wanted resident 43 back in bed. Resident 43's family member stated that the CNA told her that there were not enough staff to monitor resident 43 when she was out of bed. 2. On 6/19/17 at 1:30 PM, an interview was conducted with resident 23. Resident 23 stated that her call lights was not answered for over an hour on a regular basis. 3. On 6/19/17 at 1:26 PM, an interview was conducted with resident 92. Resident 92 stated that he had waited 3 hours to get a cup of coffee. Resident 92 stated there were not enough staff. 4. On 6/19/17 at 2:51 PM, an interview was conducted with resident 80. Resident 80 stated that he waited 30 minutes to an hour for his call light to be answered. 5. On 6/19/17 at 2:39 PM, an interview was conducted with resident 53. Resident 53 stated that there were not enough staff and she waited for an average of 20 minutes to have her call light answered. Resident 53 stated her husband, who resided in the facility, had to help her get on/off the bed pan on many occasions. 6. On 6/19/17 at 1:26 PM, an interview was conducted with resident 55. Resident 55 stated that she had to wait approximately 20 minutes to have her call light answered. 7. Resident council minutes were reviewed and revealed the following: a. 2/28/17, Nursing: Call lights being answered in a timely manner. b. 3/21/17, Nursing: Call lights are taken (sic) long to answer. c. 5/5/17, Nursing: Call lights need to be answered in a timely manner. d. 5/23/17, Nursing: No concerns. (Cross Refer to F323)",2020-09-01
73,HARRISON POINTE HEALTHCARE AND REHABILITATION,465009,3430 HARRISON BOULEVARD,OGDEN,UT,84403,2017-06-22,371,F,0,1,WP7B11,"Based on observation, interview and record review it was determined that the facility did not store prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dish machine temperatures and sanitizer were not at the levels required to sanitize, there were soiled area and there was shelving with paint chipping that were not sanitizable. Findings include: 1. On 6/19/17 at 8:18 AM, an initial tour of the kitchen was conducted. The following observations were made: a. There were white shelves that had food stored on them. The paint was chipped on some areas of the shelves. The shelves were soiled. b. There were 2 oven mitts with brown and black substances on them. c. There was a metal cover on the floor near the tray line that had 2 handles. The metal cover was soiled with debris in the handle area. 2. On 6/22/17 at 9:05 AM, a follow up observation was made of the facility kitchen. The following observations were made: a. The items listed above remained soiled. b. There were loose tiles on the wall by the door. c. There was a hole in the wall between the freezer and refrigerator that was covered with tape. d. There there was a large crack in the wall behind the dish machine. e. The hood vents were soiled with a brown and black substance. 3. On 6/22/17 at 9:18 AM, an observation was made of the facility dish machine. The following cycles were observed: (Note: All temperatures were in degrees Fahrenheit.) a. The wash cycle was 115 and the rinse was 120. Cook 1 was observed to document the wash temperature of 115 and the rinse temperature of 120 with the sanitizer solution of 100 on the Dish Machine Temperature Log form. An interview was immediately conducted with Cook 1. Cook 1 stated that the sanitizer was not tested because the temperatures were fine so the staff documented 100 because that's what we do. b. The wash cycle was 115 and the rinse was 122. c. The wash cycle was 115 and the rinse was 121 and the sanitizer was 50 parts per million (PPM). The dishes that were washed with the low temperatures were observed to be replaced and a cutting board was used. A form titled, Dish Machine Temperature Log dated (MONTH) (YEAR) revealed that on 6/2/17 for the dinner meal the wash temperature was 105. On 6/8/17 for dinner the temperature was 110 for the wash. A sign by the Dish Machine Temperature Log revealed, Make sure that the dishwasher is hitting temps (temperature) of 120-140 before putting dishes through. This may require you to run the dishwasher a few times prior to use. Dietary Aide (DA) 1 stated that the dish machine needed to be over 120 for the wash and rinse cycles and the sanitizer was to be over 100 and was checked with every meal. 4. On 6/22/17 at 9:35 AM, an observation was made of DA 1. DA 1 was observed to take the cutting board that had not been sanitized according to manufacture instructions to cut chicken. DA 1 was observed to pick up a sanitizer strip package with gloved hands while cutting chicken. DA 1 was observed to go back to cutting the meat with the same gloved hands that had touched the sanitizer strips container with. DA 1 stated that she washed her hands anytime there was a change in what she was doing. DA 1 stated that she would also wash her hands anytime that she left the kitchen and returned. On 6/22/17 at approximately 10:00 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that the shelving was not sanitizable. The DM stated that the dish machine temperatures were low and did not know why there were other documented days of low temperatures. The DM stated that dishes should not be used if the dish machine did not reach the temperature of 120 for wash and rinse with sanitizer of 100.",2020-09-01
74,HARRISON POINTE HEALTHCARE AND REHABILITATION,465009,3430 HARRISON BOULEVARD,OGDEN,UT,84403,2019-11-06,580,D,0,1,F3KR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 21 sampled residents, that the facility staff did not immediately consult with the resident's physician when there was a significant change in the residents status. Specifically, a resident had elevated blood glucose levels with a physician's orders [REDACTED]. There was no documentation the the physician was notified. Resident identifier: 20. Findings include: Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 20's medical record was reviewed on 11/5/19. A physician's orders [REDACTED].= 2 (Units); 200-249 = 4; 250-299 = 6; 300-349= 8; 350-399 = 10; [PHONE NUMBER]=12 notify MD (Medical Doctor) if > (greater than) 400, subcutaneously before meals and at bedtime for [MEDICAL CONDITION]. Resident 20's Medication Administration Record (MAR) for (MONTH) 2019 revealed the following blood glucose (BG) levels on 9/27/19. A BG of 468 at 11:30 AM, a BG of 429 at 3:30 PM, and a BG of 434 at 8:00 PM. There was no documentation that the physician was notified. Resident 20's MAR for (MONTH) 2019 revealed on 10/2/19 at 3:30 PM, a BG of 405. There was no documentation that the physician was notified. A physician's orders [REDACTED].= 3; 200 - 249 = 5; 250 - 299 = 7; 300 - 349 = 9; 350 - 399 = 11; 400 - 9999 = 13 notify MD if >400, subcutaneously four times a day for [MEDICAL CONDITION]. Resident 20's MAR for (MONTH) 2019 revealed the following BG levels. On 10/3/19 a BG of 442, on 10/4/19 a BG of 459, on 10/5/19 a BG of 420, on 10/8/19 a BG of 407, on 10/12/19 a BG of 425, and on 10/15/19 a BG of 415. There was no documentation that the physician was notified. On 11/5/19 at 3:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated when a resident blood glucose was over 400, the nurse documented the blood glucose, administered the insulin according to physician orders, and notified the physician. The DON stated there was a box for the nurses to check documenting that the physician was notified. The DON reviewed the MAR and there were no areas to document that the physician was contacted. On 11/5/19 at 3:33 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that there was no documentation that the physician had been notified when the blood glucose was greater than 400.",2020-09-01
75,HARRISON POINTE HEALTHCARE AND REHABILITATION,465009,3430 HARRISON BOULEVARD,OGDEN,UT,84403,2019-11-06,756,E,0,1,F3KR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 3 of 21 sampled residents, that the facility did not ensure that the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist. Specifically, residents did not have monthly pharmacy reviews completed by the pharmacist. Resident identifiers: 4, 20, and 23. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 11/5/19. The drug regimen reviews for resident 4 were reviewed. Resident 4 was not listed on the form provided by the pharmacist that revealed there were no irregularities for (MONTH) 2019. There was no form with recommendations for resident 4 for (MONTH) 2019. 2. Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 20's medical record was reviewed on 11/5/19. The drug regimen reviews for resident 20 were reviewed. Resident 20 was not listed on the form provided by the pharmacist that revealed there were no irregularities for (MONTH) and (MONTH) 2019. There was no form with recommendations for resident 20 for (MONTH) and (MONTH) 2019. 3. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The drug regimen review for resident 23 were reviewed. Resident 23 was not listed on the form provided by the pharmacist that revealed there were no irregularities for (MONTH) and (MONTH) 2019. There was no form with recommendations for resident 20 for (MONTH) and (MONTH) 2019. On 11/6/19 at approximately 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the resident's were reviewed monthly by the pharmacist. The DON stated that she did not have the recommendation forms for resident 4, 20, and 23.",2020-09-01
76,HARRISON POINTE HEALTHCARE AND REHABILITATION,465009,3430 HARRISON BOULEVARD,OGDEN,UT,84403,2019-11-06,760,D,0,1,F3KR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 21 sampled residents, that the facility did not ensure the residents were free of significant medication errors. Specifically, the facility did not administer [MEDICATION NAME] as ordered by the physician and the [MEDICATION NAME] order was not discontinued timely. Resident identifier: 2. Findings include: Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 11/5/19. 1. The Discharge Instructions/Order from the local hospital dated 7/19/19, documented that resident 2 had [DIAGNOSES REDACTED]. Resident 2 had a long term current use of anticoagulants related to [DIAGNOSES REDACTED] complicated by multiple [MEDICAL CONDITION] and ischemic [MEDICAL CONDITION]. Goal international normalized ratio (INR) was to be between 2 to 3. The hospital recommended continuing the [MEDICATION NAME] at 10 milligrams (mg) daily supplemented by [MEDICATION NAME] until INR in goal range. A review of the facility Order Summary Report documented the following physician's orders [REDACTED]. Continue until INR greater than (>) 2.0. A review of the PT ([MEDICATION NAME] time)/INR Dipstick Test documented that resident 2 had an INR of 2.7 on 7/22/19. Current Meds (Medications): [MEDICATION NAME] 7.5 mg and [MEDICATION NAME] discontinue when > 2.0. The Nurse Practitioner (NP) noted no change and check INR in one week on 7/29/19. A review of the PT/INR Dipstick Test documented that resident 2 had an INR of 3.6 on 7/29/19. Current Meds: [MEDICATION NAME] 7.5 mg daily and [MEDICATION NAME] discontinue when > 2.0. The NP noted to hold times 1 dose and check INR tomorrow on 7/30/19. A review of the PT/INR Dipstick Test documented that resident 2 had an INR of 2.7 on 7/30/19. Current Meds: [MEDICATION NAME] 7.5 mg held on 7/29/19. [MEDICATION NAME] 120 mg/0.8 ml continue until INR > 2.0. The NP noted to discontinue the [MEDICATION NAME] and check INR in 3 days. A review of the (MONTH) 2019 Medication Administration Record (MAR) documented that the [MEDICATION NAME] was discontinued on 7/30/19 at 5:48 PM. (Note: Resident 2 had an INR of 2.7 on 7/22/19. Resident 2 received 16 additional doses of [MEDICATION NAME].) 2. A review of the facility Order Summary Report documented the following physician's orders [REDACTED]. A review of the PT/INR Dipstick Test documented that resident 2 had an INR of 3.6 on 7/29/19. Current Meds: [MEDICATION NAME] 7.5 mg daily and [MEDICATION NAME] discontinue when > 2.0. The NP noted to hold times 1 dose and check INR tomorrow on 7/30/19. A review of the (MONTH) 2019 MAR documented that [MEDICATION NAME] 7.5 mg was administered on 7/29/19. The [MEDICATION NAME] dose should have been held. A review of the Patient [MEDICATION NAME] Log documented that resident 2 had an INR of 3.2 on 8/2/19. [MEDICATION NAME] Dose 7.5 mg. New Orders 7.5 mg on Saturday, Sunday, Tuesday, Thursday and 7 mg on Monday, Wednesday, and Friday. Next Test Date 8/5/19. A review of the PT/INR Dipstick Test documented that resident 2 had an INR of 2.4 on 8/5/19. Current Meds: [MEDICATION NAME] 7.5 mg on Saturday, Sunday, Tuesday, Thursday and 7 mg on Monday, Wednesday, and Friday. The NP noted no change and check INR in 1 week on 8/12/19. A review of the (MONTH) 2019 MAR documented that [MEDICATION NAME] 7.5 mg was administered on Monday 8/5/19. Resident 2 should have received 7 mg of [MEDICATION NAME]. A review of the PT/INR Dipstick Test documented that resident 2 had an INR of 2.6 on 9/5/19. Current Meds: [MEDICATION NAME] 9 mg. The Physician's Assistant was notified. No change and check INR in 1 week on 9/12/19. A review of the (MONTH) 2019 MAR documented that resident 2 had not received any [MEDICATION NAME] on 9/5/19, 9/6/19, 9/7/19, 9/8/19, 9/9/19, 9/10/19. and 9/11/19. A Nursing Progress Note dated 9/12/19, documented It was discovered that resident has not had [MEDICATION NAME] for the past week. INR today was taken and was 1.1. MD (Medical Director) was notified. Order to resume dose of 9 mg. Will continue to monitor patient. On 11/6/19 at 10:04 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident INR checks were documented on the Patient [MEDICATION NAME] log. LPN 1 stated that when an INR was due she would complete an INR worksheet. LPN 1 stated that the NP or MD would review the resident medical record and would make recommendations on the [MEDICATION NAME] dose and when to check the next INR. LPN 1 stated that after the INR worksheet was reviewed by the NP or MD the results and recommendations were recorded on the Patient [MEDICATION NAME] Log. LPN 1 further stated that the nursing staff would input the orders onto the resident MAR and the Director of Nursing (DON) would double check the orders for accuracy. LPN 1 stated that the facility had an INR machine and the nursing staff were able to complete the INR checks in the facility. LPN 1 stated that resident 2's surgeon or MD would have been contacted when resident 2 was therapeutic with the INR checks. LPN 1 stated that resident 2's surgeon or MD would have been contacted to have the [MEDICATION NAME] discontinued. LPN 1 further stated that she would contact the surgeon or MD if a resident was unable to tolerate the medication injections. LPN 1 stated that she would not discontinue a medication without contacting the MD. LPN 1 stated that if the MD was contacted she would document the contact either in a progress note or on the resident MAR. On 11/6/19 at 12:38 PM, an interview was conducted with the DON. The DON stated that the nursing staff were expected to verify initial orders from the hospital. The DON stated that the NP or the MD visit notes should reflect that the resident medications were reviewed. The DON stated that any orders the NP or MD put in place would supercede the hospital orders. The DON stated that the medication error for resident 2 was identified and was included in the facility Quality Assurance program on 9/13/19. The DON stated that herself or the nurse manager would track the [MEDICATION NAME] orders and the next INR check dates. The DON stated she would give the nursing staff a list for the day of the INR checks that were due. The DON stated that the INR worksheet would be completed by the nursing staff and reviewed by the clinician. The DON stated that the nursing staff would input new orders onto the resident MAR. The DON further stated that on the following morning she would verify the orders in the medical record and would document the orders on the tracking log.",2020-09-01
77,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2017-03-16,252,D,0,1,Q9V711,"Based on observation, interview and record review it was determined that the facility did not ensure that, 4 of 34 sampled residents had a clean, comfortable home-like environment, including supports for daily living safely. Specifically, there were soiled wheelchairs and residents stated their wheelchairs had not been cleaned. Resident identifiers: 5, 13, 14, and 20. Findings include: On 3/13/17 at 3:00 PM, an observation was made of resident 20's electric wheelchair. The wheelchair had debris and dust by the motor and on the area over the wheels. There was also debris on the foot rests. Resident 20 stated that her wheelchair was cleaned yearly but would like to have it cleaned more often. On 3/13/17 at 3:10 PM, an observation was made of resident 14's wheelchair. Resident 14's wheelchair had debris on the foot rests and was soiled on the seat. A follow up observation was conducted on 3/16/17 and resident 14's wheelchair had debris and was soiled on the foot rest and seat. On 3/14/17 at 8:49 AM, an observation was made of resident 5's wheelchair. Resident 5's wheelchair had dust and debris on the bottom area around the motor and on the plastic wheel covers. Resident 5 stated that she had to wipe her own wheelchair to clean it. Resident 5 stated that she would like the facility staff to clean her wheelchair. A follow up observation was conducted on 3/16/17 and resident 5's wheelchair was soiled on the footrest and on the wheel covers. On 3/16/17 at 12:29 PM, an observation was made of resident 13's electric wheelchair. Resident 13's wheelchair had food and debris on her foot rests and stated that she would like to have it cleaned. A follow up observation was conducted on 3/16/17 and resident 13's wheelchair was soiled on the foot rest and on the wheel covers. On 3/16/17 at 12:45 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that wheelchairs were cleaned at night by the staff. On 3/16/17 at 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that wheelchairs were cleaned during the night shift. The DON stated that there was a form that was signed by the staff that cleaned the wheelchair. The DON stated she had no additional information regarding the soiled wheelchair. A form titled, Wheelchair Cleaning Log revealed that the wheelchairs were signed as cleaned on 3/7/17 and 3/14/17.",2020-09-01
78,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2017-03-16,325,D,0,1,Q9V711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility did not assist 1 of 34 sample residents, with maintaining acceptable parameters of nutritional status, such as usual body weight or desirable body weight and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preference indicated otherwise. Specifically, a resident had lost a significant amount of body weight and had a low [MEDICATION NAME] level without documented interventions. Resident identifiers: 5. Findings include: Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's medical record was reviewed on 3/15/17. The following weights were documented in resident 5's electronic medical record: (Note: All weights were in pounds.) a. 3/6/17, 170 b. 2/27/17, 165.4 c. 2/20/17, 169.4 d. 2/13/17, 167.0 e. 1/9/17, 170 f. 1/2/17, 169.5 g. 12/29/16, 170.5 h. 12/19/16, 172.4 i. 12/6/16, 176 j. 11/30/16, 181 k. 11/23/16, 180 l. 11/17/16, 182 Resident 5 experienced a 5.1 % (percent) weight loss from 11/17/16 to 12/19/16. In addition, resident 5 experienced an 8.2 % weight loss from 11/17/16 to 2/13/17. (Note: The Minimum Data Set revealed that over 5% weight loss in 1 month and greater than 7.5 % in 3 months was considered a significant weight loss.) Resident 5's physician's orders [REDACTED]. Resident 5's laboratory values dated 1/19/17 were reviewed and revealed a low [MEDICATION NAME] level on 1/19/17 of 3.2 gm/dL (grams per deciliter) with a reference (normal) range of 3.4-5.0 gm/dL. Resident 5's total protein was low at 6.0 gm/dL with a reference range of 6.4-8.2 gm/dL. A Mini (miniature) Nutritional assessment dated [DATE] revealed that resident was at risk for malnutrition. The form revealed that resident 5's weight decreased 12 pounds in 3 months which was documented as not significant. It was documented that there was no weight since 1/9/17. There was no other information regarding resident 5's weight loss or low [MEDICATION NAME] level. A care plan was developed on 11/9/16 and updated on 12/31/16, 1/12/17 and 2/28/17. The problem was, I (resident 5) have nutritional status r/t (related to): Obesity with BMI (Body Mass Index) 38.(Resident 5) asks for traye (sic) not to be sent (at) times. The goals developed were, My weight will remain stable plus or minus 5% in 30 days through next review, My nutritional needs will be met through po (oral) intake through next review, My food preferences will be honored through next review. The approaches were, Offer and provide alternates for meals less than 50% eaten,. Weights per order. Notify physician of significant changes, .(Resident 5) has food in fridge (refrigerator). Brings from home (and) buys from store. On 3/16/17 at 10:30 AM, an interview was conducted with resident 5. Resident 5 stated that she had a [MEDICAL CONDITION] about [AGE] years ago and needed to eat small portions multiple times a day. Resident 5 stated that she had her own foods because she did not like the food offered by the facility. Resident 5 stated that when she was admitted in (MONTH) (YEAR) the Dietary Manager (DM) discussed her food preferences and resident 5 asked for small portions with snacks. Resident 5 stated that she had not received small portions with snacks as requested. Resident 5 stated that no dietary staff had discussed her weight loss or low [MEDICATION NAME] level with her. Resident 5 stated that she did not plan to loose weight as fast as she did. On 3/16/17 at 10:20 AM, an interview was conducted with the DM. The DM stated that resident 5 was at risk for malnutrition but did not know why the Registered Dietitian (RD) did not address the significant weight loss or low [MEDICATION NAME] level. The DM stated that resident 5 ate at the senior center for lunch most days and had her own foods in her room. The DM stated that she did not calculate that resident 5 had a significant weight loss for 1 and 3 months. The DM stated there was no documentation that resident 5 had been assessed by the RD. The DM stated that resident 5 should have been assessed and reviewed by the RD for her significant weight loss and low laboratory values.",2020-09-01
79,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2019-05-01,755,E,1,0,OCVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined, for 5 of 5 sample residents, that the facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail and enable an accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Specifically, nursing staff had telephone orders signed by the physician that were available to fill in for scheduled 2 medications. In addition, residents narcotic record log did not match the Medication Administration Records (MAR) for narcotic administration. Resident identifiers: 1, 2, 3, 4 and 5. Findings include: 1. On 4/30/19 at 1:00 PM, an observation was made with Registered Nurse (RN) 1 of her medication cart narcotic drawer. There were 5 telephone orders that were signed by the MD with his Drug Enforcement Administration (DEA) number written on them. The telephone orders did not have a date, resident name, medication or dosing instructions. The telephone orders were stamped with V.O.R.B. (verbal order read back). 2. Resident 2 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 5/1/19. Resident 2's physicians orders revealed the following: a. On 3/7/19, [MEDICATION NAME] immediate 5mg (milligrams) tablet (1) tab (tablet) po (oral) Q (every) 4h (hours) prn (as needed) pain (times) 30. The telephone order had Licensed Practical Nurse (LPN) 1's signature. There was a stamp V.O.R.B. with the Medical Director's (MD) signature and the MD's DEA number. b. On 3/18/19, [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tab. Give 1 tab po Q4 hours prn pain. The telephone order had to dispense 60 tablets with no refills. The telephone order had a nurses signature with V.O.R.B stamped above it and the physicians signature with the DEA number. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] immediate 5 mg every 4 hours as needed revealed that the medication was documented as signed out on the narcotic record log, but the medication was not documented on the MAR as being administered on the following dates; 3/6/19 at 12:30 AM, 3/7/19 at 8:00 PM, 3/8/19 at 5:00 AM and 3/12/19 at 6:30 AM. It should be noted that 4 doses were signed out on the narcotic record log and were not signed out as administered on the MAR. The (MONTH) 2019 MAR revealed on 3/9/19 at 1:25 AM that [MEDICATION NAME] was administered but the narcotic record log did not have the medication signed out. In addition, the MAR revealed that [MEDICATION NAME] 5 mg was administered on 3/27 at 4:27 PM and 3/31/19 at 5:59 PM. There was no corresponding narcotic record log available for the 2 doses. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] table 5-325 mg every 4 hours as need revealed that the medication was documented as signed out on the narcotic record log, but the medication was not documented on the MAR as being administered on the following dates; 3/14/19 at 10:30 PM, 3/15/19 at 2:30 AM, 3/20/19 at 6:00 AM, 3/20/19 at 9:00 AM, 3/22/19 at 6:00 AM, 3/23/19 at 11:00 PM, 3/25/19 at 6:00 AM, 3/26/19 at 3:00 PM, 3/26/19 at 7:00 PM, 3/27/19 at 4:50 PM, 3/28/19 at 3:00 AM, 3/31/19 at 6:00 PM, 3/31/19 at 10:00 PM, 4/3/19 at 5:00 AM, 4/4/19 at 2:40 AM, 4/4/19 at 9:30 PM, 4/5/19 at 5:00 PM, and 4/5/19 at 7:30 AM. It should be noted that 17 doses were signed out on the narcotic record log and were not signed out as administered on the MAR. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] tablet 5-325 mg every 4 hours as needed revealed the following: a. On 3/30/19, the MAR revealed that the [MEDICATION NAME] was administered three times that day at 1:59 AM, at 1:38 PM and at 6:37 PM. The narcotic record revealed [MEDICATION NAME] was pulled medication supply and administered at 12:30 AM, no time was documented, at 1:30 PM and at 6:30 PM. b. On 4/5/19, the MAR revealed that the [MEDICATION NAME] was signed as administered three times that day at 8:40 AM, at 1:55 PM, and at 7:44 PM. The narcotic record revealed [MEDICATION NAME] was pulled at 5:00 AM, at 7:30 AM, at 1:40 PM and at 7:45 PM. On 5/1/19 at 3:15 PM, an interview was conducted with LPN 1. LPN 1 stated that the Medical Director (MD) provided signed telephone order with his DEA number that were not filled in with the resident name, medication or dosing instructions. LPN 1 stated that the telephone order dated 3/7/19 for [MEDICATION NAME] had been signed by the MD prior to 3/7/19. LPN 1 stated that she filled in the order section on 3/7/19 and sent the telephone order to the pharmacy. LPN 1 stated that she called the MD to obtain a verbal order for the medication. 3. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 5/1/19. Resident 4's telephone orders revealed the following: a. On 1/25/19 at 4:35 PM, a verbal order for [MEDICATION NAME]-[MEDICATION NAME] Tablet 10-325 MG give 1 tablet by mouth every 4 hours as needed for pain related to Generalized abdominal pain. The physician signed the order on 1/30/19 at 5:06 PM. There was no script in the medical record. The order was discontinued on 3/4/19. b. On 2/15/19, [MEDICATION NAME] 10/325 1 tab po Q4H PRN. The order was to dispense 120 with no refills. The MD signed with the DEA number on the telephone order. There was no nurses signature. V.O.R.B was stamped on the telephone order. c. On 3/22/19, [MEDICATION NAME] tablet 10-325 M[NAME] Give 1 tablet Q 4 hours prn, NTE (not to exceed) 300 mg in 24 hr. Give 1 tablet po q 4 hours. NTE 3000mg in 24 hours. The order was to dispense 120 tablets with 3 refills. The telephone order had the MD signature and his DEA number. RN 1's signature with V.O.R.B was on the telephone order. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 10/325 mg revealed that the medication was documented as signed out on the narcotic log, but the medication was not documented on the MAR as being administered on the following dates; 2/23/19 at 7:25 AM, 3/9/19 at 10:30 AM, 4/7/19 at 12:00 PM, 4/11/19 at 9:00 PM, 4/12/19 at 9:00 PM, 4/14/19 at 1:20 PM, 4/15/19 at 9:55 PM, 4/18/19 at 9:00 PM, 4/26/19 at 6:45 PM and 4/28/19 at 9:00 PM. It should be noted that 10 doses were documented as administered in the narcotic log but not documented as administered in the MAR. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 10/325 mg revealed the following: a. On 2/4/19 at 12:10 PM, the MAR revealed that [MEDICATION NAME]-[MEDICATION NAME] 10-325 was administered and there was no record of the medication being administered according to the narcotic record log. b. On 2/22/19 at 11:33 AM, the MAR revealed that [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg was administered and there was no record of the medication being administered according to the narcotic record log. c. On 3/21/19 at 6:00 AM, the MAR revealed that the nurse did not sign in the MAR that the [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg was administered. The narcotic record log revealed that on 3/20/19 at 5:30 AM and 3/20/19 at 6:00 AM the medication was administered. d. 3/29/19 at 6:00 AM, the MAR revealed that the nurse did not sign that the [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg as being administered. The narcotic record log revealed that on 3/29/19 at 6:00 AM the [MEDICATION NAME] was administered. On 5/1/19 at 3:00 PM, an interview was conducted with LPN 2. LPN 2 stated that the MD provided the nurses signed telephone orders that did not have the residents name, medication or dispensing instruction. LPN 2 stated that she called the MD prior to filling in name, medication and dispensing instruction on the telephone orders. LPN 2 stated that she did not sign the telephone orders. LPN 2 confirmed that she wrote the telephone order on 2/15/19 for the [MEDICATION NAME] 10/325. LPN 2 stated that on 2/15/19 she used a telephone order that the MD had signed and not filled in. 4. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/1/19 resident 5's medical records were reviewed. Review of resident 5's physician orders [REDACTED]. a. On 10/3/18, a telephone order for [MEDICATION NAME] Extended Release (ER) 10 milligrams by mouth two times a day was written. The amount of medication ordered dispensed was 60 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. b. On 10/14/18, a telephone order for [MEDICATION NAME] (HCL) with Tylenol (APAP) 10/325 mg tablet, take 1 tablet by mouth every 6 hours as needed for pain was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. c. On 10/25/18, an order for [REDACTED]. The amount of medication ordered dispensed was 60 tablets. d. On 11/11/18, a telephone order for [MEDICATION NAME] Reformulated 10 mg tablet ER 1 tablet by mouth two times a day for pain was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. e. On 12/3/18, a telephone order for [MEDICATION NAME] HCL ER 10 mg 1 tablet by mouth two times a day was written. The amount of medication ordered dispensed was 60 tablets. The order did not contain a nurses signature, but was stamped V.O.R.B. f. On 1/29/19, a telephone order for [MEDICATION NAME] 10/325 mg 1 tablet by mouth every 6 hours as needed was written. The amount of medication ordered dispensed was 120 tablets. The order did not contain a nurses signature, but was stamped V.O.R.B. g. On 3/7/19, a telephone order for [MEDICATION NAME] Reformulated 10 mg tablet ER 1 tablet by mouth two times a day for pain was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. h. On 4/17/19, a telephone order for [MEDICATION NAME] Reformulated 10 mg tablet ER 1 tablet by mouth two times a day for pain was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by Registered Nurse (RN) 1. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] HCL APAP 10/325 mg every 6 hours as needed revealed that the medication was documented signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates; 8/29/18 at 9:00 PM, 9/7/18 at 1:00 AM, 9/12/18 at 4:00 AM, 9/13/18 at 2:00 AM, 10/3/18 at 2:00 AM, 10/12/18 at 1:00 AM, 11/13/18 (day not documented clearly but located between 11/9/18 and 11/22/18) at 1:00 AM, 11/26/18 at 9:50 AM, 11/28/18 at 10:00 AM, 11/29/18 at 4:00 PM, 12/1/18 at 10:10 AM, 12/2/18 at 10:30 AM, 12/18/18 at 5:00 AM, 12/29/18 at 11:59 PM, 1/22/19 at 7:00 AM, 2/1/19 at 5:00 AM, 2/15/19 at 3:00 AM, 2/15/19 at 11:30 PM, 2/17/19 at 1:20 AM, 3/16/19 at 6:00 AM, 3/21/19 at 11:00 PM, 3/31/19 at 3:00 PM, 4/12/19 at 6:20 AM, 4/20/19 at 12:45 AM, 4/25/19 at 1:00 AM, 4/25/19 at 11:30 PM, and 4/30/19 at 11:00 PM. It should be noted that 27 doses were documented as administered in the narcotic record log but not documented as administered in the MAR. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Reformulated 10 mg tablet ER by mouth twice daily revealed the following: a. On 11/8/18 at 10:00 AM, the medication was documented as refused and wasted. The narcotic log contained only one nurse signature for the wasted medication. b. The medication was documented as signed out on the narcotic record log on 2/2/19 at 9:30 PM and then again at 9:45 PM. The two scheduled doses were removed from the narcotic count for the one scheduled administration time. c. The medication was documented as signed out in the narcotic log on 2/9/19 at 11:30 PM twice. The two scheduled doses were removed from the narcotic count for the one scheduled administration time. d. On 4/13/19 at 19-23 (7:00 PM to 11:00 PM), there was a code documented which was to HOLD the medication and see progress notes. Review of the progress notes revealed no documentation for this medication. The medication was documented as signed out in the narcotic log and was deducted from the medication count. On 5/1/19 at 12:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 5 often refused her pain medications. The DON stated that if the resident refused the medication that the nursing staff should be documenting that in a progress note. The DON further stated that if the medication was pulled prior to the resident refusing then the nursing staff should be wasting the medication. The DON stated that the narcotic log should have two licensed nursing staff signatures when a narcotic was wasted. The DON stated that the documentation in the Narcotic Record log and the MAR should match. On 5/1/19 at 3:40 PM, an interview was conducted with LPN 3. LPN 3 stated that the pharmacy delivered two times a day except for Sunday afternoon. LPN 3 stated that narcotics were delivered in a different colored bag. LPN 3 stated that if a resident ran out of a narcotic pain medication that the nursing staff could write the prescription with the signed script provided by the MD. LPN 3 stated that nursing staff then call the MD to inform him of the new order. LPN 3 stated that she did not document that she called and notified the MD of the narcotic order that was written. LPN 3 stated that the nursing staff filled out paperwork because they were agents' of the MD. LPN 3 stated that an agent meant that they could write prescriptions on behalf of the MD. LPN 3 stated that as an agent the staff could only write for a refill of an existing order or a verbal order to write a new prescription. LPN 3 stated that the MD had provided the facility nursing staff with pre-signed blank telephone orders, and that she had used these to write prescriptions for narcotic pain medications in the past. LPN 3 stated that she was not aware any exclusions for being an agent and writing medication orders. LPN 3 again stated that she could write a prescription for narcotic pain medications. LPN 3 stated she could write for Scheduled II narcotics. LPN 3 stated that [MEDICATION NAME] was a Scheduled II and that Oxy was a Scheduled III and she could write a prescription for both of them. LPN 3 stated that she had written prescriptions for [MEDICATION NAME] and [MEDICATION NAME] as an agent for the MD. LPN 3 stated she had never written a prescription for [MEDICATION NAME] or [MEDICATION NAME]. LPN 3 stated that she had reconciled the narcotic log in the past. LPN 3 stated she looked at the narcotic sheets for anything strange. LPN 3 stated she looked at the dosage and checked if there were any missing doses. LPN 3 stated she would look at nursing notes or the MAR to see why a medication was not administered. LPN 3 stated I look for anything that is out of the norm. LPN 3 stated that whoever reconciled the narcotic log would sign in the DON spot located at the bottom of the sheet. LPN 3 stated that the narcotic logs were reviewed monthly at the end of the month for any discrepancies. LPN 3 stated that she had never reconciled the narcotic record log together with the MAR. On 5/1/19 at 4:01 PM, a follow-up interview was conducted with the DON. The DON stated that when she reconciled the narcotic logs she looked for the correct count and that the dose documented as given matched up. That the count is accurate. The DON stated that she did not compare the narcotic record log to the MAR. The DON stated they were not capturing or identifying discrepancies between the MAR and narcotic record log. The DON was asked how she identified or monitored to ensure that nursing staff were not diverting narcotics. The DON stated she made sure all the medication cards match, but not from MAR to narcotic sheet. 5. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was admitted to hospice on 1/3/19 for end of life cares, and passed away on 1/12/19. On 4/30/19 at 12:12 PM, an interview was conducted with LPN 1. LPN 1 stated that when a resident was on hospice, all of the resident's medications were provided by the hospice company. LPN 1 stated that the facility created a narcotic record log to track all hospice provided narcotics. On 4/30/19 resident 1's medical records were reviewed. Review of resident 1's physician orders [REDACTED]. a. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml (milliliters) 1ml by mouth every hour as needed for pain/shortness of breath. b. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml 0.25ml by mouth every hour as needed for pain/shortness of breath. c. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml 0.5ml by mouth every hour as needed for pain/shortness of breath. d. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml 0.75ml by mouth every hour as needed for pain/shortness of breath. e. On 1/8/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 20mg/ml 0.5ml by mouth every six hours for pain/terminal restlessness. f. On 1/3/19 an order was entered into the electronic medication order system for [MEDICATION NAME] Concentrate 2mg/ml give 0.5ml by mouth every two hours as needed for anxiety/restlessness. g. On 1/3/19 an order was entered into the electronic medication order system for [MEDICATION NAME] Concentrate 2mg/ml give 0.75ml by mouth every two hours as needed for anxiety/restlessness. h. On 1/8/19 an order was entered into the electronic medication order system for [MEDICATION NAME] Concentrate 2mg/ml 0.5ml by mouth every six hours for terminal restlessness. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 100mg/5ml revealed that the medication was documented as signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates: 1/6/19 at 2:00 PM, 1/8/19 at 10:00 AM, 1/10/19 at 8:00 PM, 1/10/19 at 10:00 PM, 1/11/19 at 2:00 AM, and 1/11/19 at 4:00 AM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 100mg/5ml revealed on 1/8/19 at 6:00 PM the medication was documented on the MAR as administered but was not documented as signed out on the narcotic log. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Concentrate 2mg/ml revealed that the medication was documented as signed out of the narcotic record log, but the medication was not documented on the MAR as being administered on the following dates: 1/3/19 at 7:30 PM and 1/11/19 at 4:00 AM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Concentrate 2mg/ml revealed on 1/12/19 at 6:00 AM the medication was documented on the MAR as administered but was not documented as signed out on the narcotic log. It should be noted that during resident 1's nine day stay at the facility: a. Six doses of [MEDICATION NAME] were signed out in the narcotic log but were not documented as administered on the MAR. b. One dose of [MEDICATION NAME] was documented as administered in the MAR but not signed out of the narcotic log. c. Two doses of [MEDICATION NAME] Concentrate were signed out in the narcotic log but were not documented as administered on the MAR. d. One dose of [MEDICATION NAME] Concentrate was documented as administered in the MAR but not signed out on the narcotic record log. 6. Resident 3 was admitted to the facility 9/29/17, discharged on [DATE] for pacemaker replacement and returned on 1/12/19, with [DIAGNOSES REDACTED]. On 4/30/19 resident 3's medical record was reviewed. Resident 3's active physician's orders [REDACTED].> a. On 7/27/18, an order was entered into the electronic medication order system for [MEDICATION NAME] Tablet 7.5-325 mg, give 1 tablet by mouth every 6 hours for pain. This order was discontinued 2/1/19. b. On 2/1/19, an order was entered into the electronic medication order system for [MEDICATION NAME] Tablet 10-325 mg, give 1 tablet by mouth every 6 hours for pain. c. On 1/3/18, an order was entered into the electronic medication order system for [MEDICATION NAME] HCL Tablet 50 mg, give 1 tablet by mouth every 4 hours as needed for pain. Resident 5's signed physician orders [REDACTED]. a. On 9/8/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by RN 1 and contained a V.O.R.B. (verbal order read back) stamp. b. On 9/23/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by RN 1 and contained a V.O.R.B. stamp. c. On 10/7/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 180 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. d. On 11/8/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 4 and contained a V.O.R.B. stamp. e. On 11/24/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. f. On 1/7/19, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by RN 2 and contained a V.O.R.B. stamp. g. On 12/22/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by RN 1 and contained a V.O.R.B. stamp. h. On 12/31/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by RN 1 and contained a V.O.R.B. stamp. i. On 1/25/19, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 5 and contained a V.O.R.B. stamp. j. On 2/1/19, a telephone order for [MEDICATION NAME] Tablet 10-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. k. On 2/28/19, a telephone order for [MEDICATION NAME] Tablet 10-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. l. On 4/1/19, a telephone order for [MEDICATION NAME] Tablet 10-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. m. On 9/29/18, a telephone order for [MEDICATION NAME] HCL Tablet 50 mg by mouth every 4 hours as needed was written. The amount of medication ordered dispensed was 90 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. n. On 11/23/18, a telephone order for [MEDICATION NAME] HCL Tablet 50 mg by mouth every 4 hours as needed was written. The amount of medication ordered dispensed was 180 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. o. On 1/25/19, a telephone order for [MEDICATION NAME] HCL Tablet 50 mg by mouth every 4 hours as needed was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. p. On 4/27/19, a telephone order for [MEDICATION NAME] HCL Tablet 50 mg by mouth every 4 hours as needed was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by LPN 5 and contained a V.O.R.B. stamp. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Tablet 7.5-325 mg every 6 hours revealed that on 1/6/19 at 6:00 AM, the medication was documented as administered on the MAR but was not documented as signed out on the narcotic record log. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Tablet 10-325 mg every 6 hours revealed that the medication was documented as administered on the MAR but was not documented as signed out on the narcotic record log for the following dates: 2/26/19 at 6:00 PM, 3/6/19 at 12:00 PM, and 3/10/19 at 6:00 PM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Tablet 10-325 mg every 6 hours revealed that the medication was documented as signed out of the narcotic log, but was then documented on the MAR as not being administered on the following dates: 3/21/19 at 6:00 AM and 3/29/18 at 6:00 AM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] HCL Tablet 50 mg every 4 hours as needed revealed that the medication was documented signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates: 9/6/18 at 8:30 PM, 10/4/18 at 9:00 AM, 10/10/18 at 8:00 PM, 10/11/18 at 8:00 PM, 10/16/18 at 8:00 PM, 10/23/18 at 8:00 PM, 10/25/18 at 3:00 AM, 10/25/18 at 9:00 PM, 10/28/18 at 9:30 AM, 11/5/18 at 10:50 AM, 11/7/18 at 8:00 PM, 11/8/18 at 9:00 PM, 11/9/18 at 9:00 PM, 11/14/18 at 8:00 PM, 11/15/18 at 3:00 PM, 11/15/18 at 9:00 PM, 11/19/18 at 3:00 PM, 11/20/18 at 9:00 PM, 11/21/18 at 9:00 PM, 11/28/18 at 9:00 PM, 11/30/18 at 4:00 PM, 12/4/18 at 9:00 PM, 12/5/18 at 9:00 PM, 12/7/18 at 9:00 PM, 12/12/18 at 9:00 PM, 12/13/18 at 9:00 PM, 12/18/18 at 9:20 PM, 12/19/18 at 3:00 AM, 12/19/18 at 8:00 PM, 12/29/18 at 9:50 AM, 1/13/19 at 4:35 PM, 1/15/19 at 9:00 PM, 1/16/19 at 9:00 PM, 1/17/19 at 10:00 PM, 1/23/19 at 9:00 PM, 1/24/19 at 2:30 PM, 1/29/19 at 9:00 PM, 1/30/19 at 8:30 PM, 2/4/19 at 8:55 PM, 2/5/19 at 9:00 PM, 2/7/19 at 10:15 AM, 2/9/19 at 1:45 PM, 2/10/19 at 10:00 AM, 2/12/19 at 8:30 PM, 2/19/19 at 9:00 PM, 2/20/19 at 8:00 PM, 2/21/19 at 10:00 AM, 2/21/19 at 2:00 PM, 2/21/19 at 9:00 PM, 3/1/19 at 1:45 PM, 3/5/19 at 3:15 PM, 3/20/19 at 2:30 PM, 3/21/19 at 9:00 PM, 3/26/19 at 4:00 PM, 3/28/19 at 7:45 PM, 4/2/19 at 10:30 AM, 4/2/19 at 8:30 PM, 4/10/19 at 9:00 PM, 4/11/19 at 9:00 PM, 4/15/19 at 9:15 PM, 4/17/18 at 9:00 PM, 4/18/19 at 9:00 PM, 4/23/19 at 8:00 PM, and 4/29/19 at 8:15 PM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] HCL Tablet 50 mg every 4 hours as needed revealed the medication was documented as administered on the MAR but was not documented as signed out on the narcotic record log for the following dates: 12/20/18 at 8:30 PM, 12/25/18 at 2:04 AM, 12/30/18 at 9:50 AM, and 2/8/19 at 1:46 PM. It should be noted that from (MONTH) (YEAR) through (MONTH) 2019, resident 3 had: a. One dose of [MEDICATION NAME] 7.5-325 mg was documented as administered on the MAR but was not documented as signed out on the narcotic log. b. Three doses of [MEDICATION NAME] 10-325 mg were documented as administered on the MAR but were not documented as signed out on the narcotic log. c. Two doses of [MEDICATION NAME] 10-325 mg were documented as signed out of the narcotic log, but were then documented on the MAR as not being administered. d. Fifty-two doses of [MEDICATION NAME] were documented as administered in the narcotic log but not documented as administered on the MAR. e. Four doses of [MEDICATION NAME] were documented as administered on the MAR but were not documented as administered in the narcotic log. On 4/30/19 at 12:12 PM, an interview was conducted with LPN 1. LPN 1 stated that if a resident asked for narcotic pain medication, the nurse signed the narcotic record log and document on the MAR that the medication was administered. LPN 1 stated that if the resident did not have an order for [REDACTED]. LPN 1 stated that the facility MD had all of the nurses listed as agents which meant that the nurses were able to write scripts for the facility MD. LPN 1 stated that the MD kept a stack of blank signed scripts at the facility, and that those were kept in the medication cart's narcotic drawers to be filled out as needed. LPN 1 stated that after she filled out the script she would then fax it to the pharmacy. LPN 1 stated that the pharmacy only delivered medications once or twice a day, so after faxing the script LPN 1 would then call the pharmacy for the combination code to the lock, to access the emergency kit in order to administer the narcotic to the resident as quickly as possible. LPN 1 stated that that the pharmacy would only give the combination code to the nurse after receiving the fax with the signed script. LPN 1 reported that narcotic medications in the nurses carts were counted at the beginning and end of each shift with the on-coming and off-going nurses to ensure all narcotics were correctly signed out of the Narcotic Log. On 4/30/19 at 1:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facilities process to obtain narcotics was to have the MD write a script and send it to the pharmacy for narcotics. The DON stated that if there were no refills for the narcotic medications then the MD would have to fill out another script and fax it to the pharmacy. On 4/30/19 at 3:29 PM, a follow up interview was conducted with the DON. The DON stated that the process for administering narcotics to a resident was that a resident needed to request a prn medication and then the nurse was to check the MAR for the order and the time it was last administered. The DON stated that the nurse was to sign on the MAR and the narcotic record log when a narcotic was administered. The DON stated that the narcotic record and the MAR were to match. The DON stated that the facility did not have a reconciliation process for narcotics. The DON stated that the nurses completed a count at every shift change. The DON stated that the Count was when both nurses compared the narcotic record sheet and the actual number of pills in the narcotic drawer. The DON stated that there was no process for reconciling the narcotics, the narcotic record log and the MAR. The DON stated that the MD had given approval for all the nurses to be Agents. The DON stated that an agent was able to fill in a signed script for narcotics with the MD's verbal permission. The DON stated that nurses were able to fill in the presigned scripts for scheduled 2 medications. The DON provided a copy of the agent contract. A form titled Designating Agent of Practitioner For Communicating Controlled Substance Pres",2020-09-01
80,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2019-05-01,842,E,1,0,OCVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined, for 5 of 5 sample residents, that the facility did not maintain accurate documentation of medical records for each resident. Specifically, residents Medication Administration Records (MARs) and narcotic record logs did not match. Resident identifiers: 1, 2, 3, 4 and 5. Findings include: 1. Resident 2 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 5/1/19. Resident 2's physicians orders revealed the following: a. On 3/7/19, [MEDICATION NAME] immediate 5mg (milligrams) tablet (1) tab (tablet) po (oral) Q (every) 4h (hours) prn (as needed) pain (times) 30. The telephone order had Licensed Practical Nurse (LPN) 1's signature. There was a stamp V.O.R.B. (verbal order read back) with the physicians signature and Drug Enforcement Administration (DEA) number. b. On 3/18/19, [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tab. Give 1 tab po Q4 hours prn pain. The order had to dispense 60 tablets with no refills. The telephone order had a nurses signature with V.O.R.B stamped above it and the physicians signature with the DEA number. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] immediate 5mg every 4 hours as needed revealed that the medication was documented as signed out on the narcotic record log, but the medication was not documented on the MAR as being administered on the following dates; 3/6/19 at 12:30 AM, 3/7/19 at 8:00 PM, 3/8/19 at 5:00 AM and 3/12/19 at 6:30 AM. It should be noted that 4 doses were signed out on the narcotic record and were not signed out as administered on the MAR. The (MONTH) 2019 MAR revealed 3/9/19 at 1:25 AM that [MEDICATION NAME] was administered but the narcotic record sheet did not have the medication signed out. In addition, the MAR revealed that [MEDICATION NAME] 5 mg was administered on 3/27 at 4:27 PM and 3/31/19 at 5:59 PM. There was no corresponding narcotic record log in the medical record for the 2 doses. Review of the Narcotic Record Log entries with the corresponding MAR for [MEDICATION NAME] table 5-325 mg every 4 hours as need revealed that the medication was documented as signed out on the narcotic record log, but the medication was not documented on the MAR as being administered on the following dates; 3/14/19 at 10:30 PM, 3/15/19 at 2:30 AM, 3/20/19 at 6:00 AM, 3/20/19 at 9:00 AM, 3/22/19 at 6:00 AM, 3/23/19 at 11:00 PM, 3/25/19 at 6:00 AM, 3/26/19 at 3:00 PM, 3/26/19 at 7:00 PM, 3/27/19 at 4:50 PM, 3/28/19 at 3:00 AM, 3/31/19 at 6:00 PM, 3/31/19 at 10:00 PM, 4/3/19 at 5:00 AM, 4/4/19 at 2:40 AM, 4/4/19 at 9:30 PM, 4/5/19 at 5:00 PM, and 4/5/19 at 7:30 AM. It should be noted that 17 doses were signed out on the narcotic record and were not signed out as administered on the MAR. Review of the Narcotic Record Log entries with the corresponding MAR for [MEDICATION NAME] tablet 5-325 mg every 4 hours as needed revealed the following: a. On 3/30/19, the MAR revealed that the [MEDICATION NAME] was administered three times at 1:59 AM, at 1:38 PM and at 6:37 PM. The narcotic record revealed [MEDICATION NAME] was pulled and administered at 12:30 AM, no time, at 1:30 PM and at 6:30 PM. b. On 4/5/19, the MAR revealed that the [MEDICATION NAME] was signed as administered three times at 8:40 AM, at 1:55 PM, 7:44 PM. The narcotic record revealed [MEDICATION NAME] was pulled at 5:00 AM, at 7:30 AM, at 1:40 PM and at 7:45 PM. 2. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 5/1/19. Resident 4's telephone orders revealed the following: a. On 1/25/19 at 4:35 PM, a verbal order for [MEDICATION NAME]-[MEDICATION NAME] Tablet 10-325 MG give 1 tablet by mouth every 4 hours as needed for pain related to Generalized abdominal pain. The physician signed the order on 1/30/19 at 5:06 PM. There was no script in the medical record. The order was discontinued on 3/4/19. b. On 2/15/19, [MEDICATION NAME] 10/325 1 tab po Q4H PRN. The order was to dispense 120 with no refills. The MD signed with the DEA number on the telephone order. There was no nurses signature. There was a stamp of V.O.R.B. c. On 3/22/19, [MEDICATION NAME] tablet 10-325 M[NAME] Give 1 tablet Q 4 hours prn, NTE (not to exceed) 300 mg in 24 hr. Give 1 tablet po q 4 hours. NTE 3000mg in 24 hours. The order was to dispense 120 tablets with 3 refills. The MD signed with the DEA number on the telephone order. RN 1's signature with V.O.R.B was on the telephone order. Review of the Narcotic Record Log entries with the corresponding Medication Administration Record (MAR) for [MEDICATION NAME] 10/325 mg revealed that the medication was documented signed out on the narcotic log, but the medication was not documented on the MAR as being administered on the following dates; 2/23/19 at 7:25 AM, 3/9/19 at 10:30 AM, 4/7/19 at 12:00 PM, 4/11/19 at 9:00 PM, 4/12/19 at 9:00 PM, 4/14/19 at 1:20 PM, 4/15/19 at 9:55 PM, 4/18/19 at 9:00 PM, 4/26/19 at 6:45 PM and 4/28/19 at 9:00 PM. It should be noted that 10 doses were documented as administered in the narcotic log but not documented as administered in the MAR. Review of the Narcotic Record Log entries with the corresponding MAR for [MEDICATION NAME] 10/325 mg revealed the following: a. On 2/4/19 at 12:10 PM, the MAR revealed that [MEDICATION NAME]-[MEDICATION NAME] 10-325 was administered and there was no record of the medication being administered on the narcotic record. b. On 2/22/19 at 11:33 AM, the MAR revealed that [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg was administered and there was no record of the medication being administered on the narcotic record. c. On 3/21/19 at 6:00 AM, the MAR revealed that the nurse did not sign in the MAR that the [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg was administered. The narcotic record revealed that on 3/20/19 at 5:30 AM and 3/2019 at 6:00 AM the medication was administered. d. 3/29/19 at 6:00 AM, the MAR revealed that the nurse did not sign that the [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg was administered. The narcotic record revealed that on 3/29/19 at 6:00 AM the [MEDICATION NAME] was administered. 3. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/1/19 resident 5's medical records were reviewed. Review of resident 5's physician orders [REDACTED]. a. On 10/3/18, a telephone order for [MEDICATION NAME] Extended Release (ER) 10 milligrams by mouth two times a day was written. The amount of medication ordered dispensed was 60 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. ( b. On 10/14/18, a telephone order for [MEDICATION NAME] (HCL) with Tylenol (APAP) 10/325 mg tablet, take 1 tablet by mouth every 6 hours as needed for pain was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. c. On 10/25/18, a order for [MEDICATION NAME] HCL ER tablet, ER 12 hour Abuse-Deterrent 10 mg, 1 tablet by mouth two times a day for moderate to severe pain was written. The amount of medication ordered dispensed was 60 tablets. d. On 11/11/18, a telephone order for [MEDICATION NAME] Reformulated 10 mg tablet ER 1 tablet by mouth two times a day for pain was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. e. On 12/3/18, a telephone order for [MEDICATION NAME] HCL ER 10 mg 1 tablet by mouth two times a day was written. The amount of medication ordered dispensed was 60 tablets. The order did not contain a nurses signature, but was stamped V.O.R.B. f. On 1/29/19, a telephone order for [MEDICATION NAME] 10/325 mg 1 tablet by mouth every 6 hours as needed was written. The amount of medication ordered dispensed was 120 tablets. The order did not contain a nurses signature, but was stamped V.O.R.B. g. On 3/7/19, a telephone order for [MEDICATION NAME] Reformulated 10 mg tablet ER 1 tablet by mouth two times a day for pain was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. h. On 4/17/19, a telephone order for [MEDICATION NAME] Reformulated 10 mg tablet ER 1 tablet by mouth two times a day for pain was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by Registered Nurse (RN) 1. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] HCL APAP 10/325 mg every 6 hours as needed revealed that the medication was documented signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates; 8/29/18 at 9:00 PM, 9/7/18 at 1:00 AM, 9/12/18 at 4:00 AM, 9/13/18 at 2:00 AM, 10/3/18 at 2:00 AM, 10/12/18 at 1:00 AM, 11/13/18 (day not documented clearly but located between 11/9/18 and 11/22/18) at 1:00 AM, 11/26/18 at 9:50 AM, 11/28/18 at 10:00 AM, 11/29/18 at 4:00 PM, 12/1/18 at 10:10 AM, 12/2/18 at 10:30 AM, 12/18/18 at 5:00 AM, 12/29/18 at 11:59 PM, 1/22/19 at 7:00 AM, 2/1/19 at 5:00 AM, 2/15/19 at 3:00 AM, 2/15/19 at 11:30 PM, 2/17/19 at 1:20 AM, 3/16/19 at 6:00 AM, 3/21/19 at 11:00 PM, 3/31/19 at 3:00 PM, 4/12/19 at 6:20 AM, 4/20/19 at 12:45 Am, 4/25/19 at 1:00 AM, 4/25/19 at 11:30 PM, and 4/30/19 at 11:00 PM. It should be noted that 27 doses were documented as administered in the narcotic log but not documented as administered in the MAR. Review of the Narcotic Record Log entries with the corresponding MAR for [MEDICATION NAME] Reformulated 10 mg tablet ER by mouth twice daily revealed the following: a. On 11/8/18 at 10:00 AM the medication was documented as refused and wasted. The narcotic log contained only one nurse signature for the wasted medication. b. The medication was documented as administered on the MAR but was not documented signed out on the narcotic log for the following dates; 11/26/18 at 7:00 AM to 11:00 AM (07-11), 11/28/18 at 07-11, 12/1/18 at 07-11, and 12/2/18 at 07-11. c. The medication was documented as administered on the MAR but was crossed out on the narcotic log for 1/24/19 at 9:30 AM. The medication was not documented as refused, was not documented as wasted, and was not deducted from the count. d. The medication was documented as administered on the MAR but was not documented as signed out on the narcotic log for 1/30/19 at 7:00 PM to 11:00 PM (19-23). e. The medication was documented as signed out in the narcotic log on 2/2/19 at 9:30 PM and then again at 9:45 PM. The two scheduled doses were removed from the narcotic count for the one scheduled administration time. f. The medication was documented as signed out in the narcotic log on 2/8/19 at 1:00 AM the medication was scheduled for administration between 7:00 AM and 11:00 AM. The second daily dose was documented as administered in the narcotic log at 11:00 AM. g. The medication was documented as signed out in the narcotic log on 2/9/19 at 11:30 PM twice. The two scheduled doses were removed from the narcotic count for the one scheduled administration time. h. On 4/13/19 at 19-23 the medication documented a code of HOLD see progress notes. Review of the progress notes revealed no documentation for this medication. The medication was documented as signed out in the narcotic log and was deducted from the medication count. On 5/1/19 at 12:30 PM an interview was conducted with the Director of Nursing (DON). The DON stated that the documentation in the narcotic record log and the MAR should match. The DON stated she did not know why the resident 5's MAR and narcotic record log did not match. 4. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was admitted to hospice on 1/3/19 for end of life cares, and passed away on 1/12/19. On 4/30/19 at 12:12 PM, an interview was conducted with LPN 1. LPN 1 stated that when a resident was on hospice, all of the resident's medications were provided by the hospice company. LPN 1 stated that the facility would create Narcotic Record sheets to track all hospice provided narcotics. On 4/30/19 resident 1's medical records were reviewed. Review of resident 1's physician orders [REDACTED]. a. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml (milliliters) 1ml by mouth every hour as needed for pain/shortness of breath. b. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml 0.25ml by mouth every hour as needed for pain/shortness of breath. c. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml 0.5ml by mouth every hour as needed for pain/shortness of breath. d. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml 0.75ml by mouth every hour as needed for pain/shortness of breath. e. On 1/8/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 20mg/ml 0.5ml by mouth every six hours for pain/terminal restlessness. f. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] Concentrate 2mg/ml give 0.5ml by mouth every two hours as needed for anxiety/restlessness. g. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] Concentrate 2mg/ml give 0.75ml by mouth every two hours as needed for anxiety/restlessness. h. On 1/8/19, an order was entered into the electronic medication order system for [MEDICATION NAME] Concentrate 2mg/ml 0.5ml by mouth every six hours for terminal restlessness. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 100mg/5ml revealed that the medication was documented signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates: 1/6/19 at 2:00 PM, 1/8/19 at 10:00 AM, 1/10/19 at 8:00 PM, 1/10/19 at 10:00 PM, 1/11/19 at 2:00 AM, and 1/11/19 at 4:00 AM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 100mg/5ml revealed on 1/8/19 at 6:00 PM the medication was documented on the MAR as administered but was not documented as signed out on the narcotic log. Review of the narcotic record log entries with the corresponding Medication Administration Record (MAR) for [MEDICATION NAME] Concentrate 2mg/ml revealed that the medication was documented as signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates: 1/3/19 at 7:30 PM and 1/11/19 at 4:00 AM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Concentrate 2mg/ml revealed on 1/12/19 at 6:00 AM the medication was documented on the MAR as administered but was not documented as signed out on the narcotic log. It should be noted that during resident 1's nine day stay at the facility: a. Six doses of [MEDICATION NAME] were signed out in the narcotic log but were not documented as administered in the MAR. b. One dose of [MEDICATION NAME] was documented as administered in the MAR but not signed out of the narcotic log. c. Two doses of [MEDICATION NAME] Concentrate were signed out in the narcotic log but were not documented as administered in the MAR. d. One dose of [MEDICATION NAME] Concentrate was documented as administered in the MAR but not signed out of the narcotic log. 5. Resident 3 was admitted to the facility 9/29/17, he left on 1/11/19 for pacemaker replacement and returned on 1/12/19, with [DIAGNOSES REDACTED]. On 4/30/19 resident 3's medical records were reviewed which revealed the following orders: a. On 7/27/18, an order was entered into the electronic medication order system for [MEDICATION NAME] Tablet 7.5-325 mg, give 1 tablet by mouth every 6 hours for pain. This order was discontinued 2/1/19. b. On 2/1/19, an order was entered into the electronic medication order system for [MEDICATION NAME] Tablet 10-325 mg, give 1 tablet by mouth every 6 hours for pain. c. On 1/3/18, an order was entered into the electronic medication order system for [MEDICATION NAME] HCL Tablet 50 mg, give 1 tablet by mouth every 4 hours as needed for pain. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Tablet 7.5-325 mg every 6 hours revealed that on 1/6/19 at 6:00 AM, the medication was documented as administered on the MAR but was not documented as signed out on the narcotic log. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Tablet 10-325 mg every 6 hours revealed that the medication was documented as administered on the MAR but was not documented signed out on the narcotic log for the following dates: 2/26/19 at 6:00 PM, 3/6/19 at 12:00 PM, and 3/10/19 at 6:00 PM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Tablet 10-325 mg every 6 hours revealed that the medication was documented as signed out of the narcotic log, but was then documented on the MAR as not being administered on the following dates: 3/21/19 at 6:00 AM and 3/29/18 at 6:00 AM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] HCL Tablet 50 mg every 4 hours as needed revealed that the medication was documented as signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates: 9/6/18 at 8:30 PM, 10/4/18 at 9:00 AM, 10/10/18 at 8:00 PM, 10/11/18 at 8:00 PM, 10/16/18 at 8:00 PM, 10/23/18 at 8:00 PM, 10/25/18 at 3:00 AM, 10/25/18 at 9:00 PM, 10/28/18 at 9:30 AM, 11/5/18 at 10:50 AM, 11/7/18 at 8:00 PM, 11/8/18 at 9:00 PM, 11/9/18 at 9:00 PM, 11/14/18 at 8:00 PM, 11/15/18 at 3:00 PM, 11/15/18 at 9:00 PM, 11/19/18 at 3:00 PM, 11/20/18 at 9:00 PM, 11/21/18 at 9:00 PM, 11/28/18 at 9:00 PM, 11/30/18 at 4:00 PM, 12/4/18 at 9:00 PM, 12/5/18 at 9:00 PM, 12/7/18 at 9:00 PM, 12/12/18 at 9:00 PM, 12/13/18 at 9:00 PM, 12/18/18 at 9:20 PM, 12/19/18 at 3:00 AM, 12/19/18 at 8:00 PM, 12/29/18 at 9:50 AM, 1/13/19 at 4:35 PM, 1/15/19 at 9:00 PM, 1/16/19 at 9:00 PM, 1/17/19 at 10:00 PM, 1/23/19 at 9:00 PM, 1/24/19 at 2:30 PM, 1/29/19 at 9:00 PM, 1/30/19 at 8:30 PM, 2/4/19 at 8:55 PM, 2/5/19 at 9:00 PM, 2/7/19 at 10:15 AM, 2/9/19 at 1:45 PM, 2/10/19 at 10:00 AM, 2/12/19 at 8:30 PM, 2/19/19 at 9:00 PM, 2/20/19 at 8:00 PM, 2/21/19 at 10:00 AM, 2/21/19 at 2:00 PM, 2/21/19 at 9:00 PM, 3/1/19 at 1:45 PM, 3/5/19 at 3:15 PM, 3/20/19 at 2:30 PM, 3/21/19 at 9:00 PM, 3/26/19 at 4:00 PM, 3/28/19 at 7:45 PM, 4/2/19 at 10:30 AM, 4/2/19 at 8:30 PM, 4/10/19 at 9:00 PM, 4/11/19 at 9:00 PM, 4/15/19 at 9:15 PM, 4/17/18 at 9:00 PM, 4/18/19 at 9:00 PM, 4/23/19 at 8:00 PM, and 4/29/19 at 8:15 PM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] HCL Tablet 50 mg every 4 hours as needed revealed the medication was documented as administered on the MAR but was not documented signed out on the narcotic log for the following dates: 12/20/18 at 8:30 PM, 12/25/18 at 2:04 AM, 12/30/18 at 9:50 AM, and 2/8/19 at 1:46 PM. It should be noted that from (MONTH) (YEAR) through (MONTH) 2019, resident 3 had: a. One dose of [MEDICATION NAME] 7.5-325 mg was documented as administered on the MAR but was not documented signed out on the narcotic log. b. Three doses of [MEDICATION NAME] 10-325 mg were documented as administered on the MAR but were not documented signed out on the narcotic log. c. Two doses of [MEDICATION NAME] 10-325 mg were documented signed out of the narcotic log, but were then documented on the MAR as not being administered. d. Fifty-two doses of [MEDICATION NAME] were documented as administered in the narcotic log but not documented as administered in the MAR. e. Four doses of [MEDICATION NAME] were documented as administered in the MAR but were not documented as administered in the narcotic log. On 4/30/19 at 12:12 PM, an interview was conducted with LPN 1. LPN 1 stated that if a resident asked for narcotic pain medication, the nurse should sign the narcotic out in the Narcotic Log book and document in the MAR that the medication was administered. LPN 1 reported that narcotic medications in the nurses carts were counted at the beginning and end of each shift with the on-coming and off-going nurses to ensure all narcotics were correctly signed out of the Narcotic Log. On 5/1/19 at 3:40 PM an interview was conducted with LPN 3. LPN 3 stated that she had reconciled the narcotic record log in the past. LPN 3 stated she looked at the narcotic sheets for anything strange. LPN 3 stated she looked at the dosage and checked if there were any missing doses. LPN 3 stated I look for anything that is out of the norm. LPN 3 stated that whoever reconciled the narcotic log would sign in the DON spot located at the bottom of the sheet. LPN 3 stated that the narcotic logs were reviewed monthly at the end of the month for any discrepancies. LPN 3 stated that she had never reconciled the narcotic log sheet together with the MAR. On 4/30/19 at 3:29 PM, a interview was conducted with the DON. The DON stated that the process for administering narcotics to a resident was that a resident needed to request a prn medication and then the nurse was to check the MAR for the order and last time it was administered. The DON stated that the nurse was to sign on the MAR and the narcotic record log when a narcotic was administered. The DON stated that the narcotic record and the MAR were to match. The DON stated that there was no process for reconciling the narcotic record sheet and the MAR. The DON stated she did not have additional information regarding the MAR and narcotic record log not matching.",2020-09-01
81,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,580,D,0,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined the facility did not immediately consult with the resident's physician for 1 of 31 sample residents. Specifically, the facility nursing staff did not notify the physician of abnormal blood glucose results. Resident Identifier: 93. Findings include: Resident 93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 93's medical record was reviewed on 6/20/18. Resident 93's (MONTH) (YEAR) Medication Administration Record [REDACTED] a. On 06/13/18 at 4:01 PM, low blood sugar of 37 mg/dL (milligrams per deciliter) b. On 06/14/18 at 6:21 PM, low blood sugar of 45 mg/dL c. On 06/16/18 at 8:10 AM, high blood sugar of 578 mg/dL On 6/20/18 at 10:55 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 reported that resident 93's blood sugars are not controlled. LPN 1 stated that she reported the blood sugar on 6/19/18 of 344 to the physician. On 6/20/18 at 11:12 AM, an interview was conducted with LPN 2. LPN 2 reported that if a resident had a blood glucose level under 60 mg/dL or over 400 mg/dL, she would notify the physician. LPN 2 stated if there was an order to notify the physician with a different parameter for blood glucose, she would follow the order. On 6/20/18 at 3:20 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that a resident's physician should be notified if a resident's blood glucose level was less than 60 or over 400. The DON did not provide additional information that the physician was contacted regarding the abnormal blood glucose levels on 6/13/18, 6/14/18 and 6/16/18.",2020-09-01
82,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,584,E,0,1,EUNP11,"Based on observation and interview, it was determined for 8 of 31 sampled residents, that the facility did not ensure each resident's environment was safe, clean and comfortable. Specifically, a resident had a dusty fan that was blowing on him, the floors had debris and sticky substances on them. In addition, there were linens on the floor, there were rusted soap dishes in showers, a toilet with a brown substance on the rim and bathroom fans were not functioning. Resident identifiers: 2, 4, 13, 14, 28, 32, 39 and 93. Findings include: 1. The following observations were made of resident 2's room and bathroom: a. On 6/18/18 at 10:33 AM, resident 2 was observed laying in bed with a floor fan next to his bed. The fan was observed to have dust on the blades and front cover. The fan was on and blowing toward resident 2. In addition, resident 2's shower was observed to have a rusted soap dish in it. b. On 6/19/18 at 11:38 AM, resident 2 was observed laying in bed with a floor fan next to his bed. The fan was observed to have dust on the blades and front cover. The fan was on and blowing toward resident 2. c. On 6/21/18 at 8:53 AM, an observation was made with Housekeeper (HK) 1. HK 1 stated that the fan was soiled. 2. The following observation was made of resident 4's room: a. On 6/19/18 at 11:18 AM, resident 4's room was observed to have debris on the floor. 3. The following observations were made of resident 13's room and bathroom: a. On 6/18/18 at 11:03 AM, there was a dried dark substance on the floor in the room and bathroom. There was food debris observed next to the bed with ants on it. b. On 6/19/18 at 10:41 AM, there was a sticky, dark substance on the floor. c. On 6/21/18 at 8:48 AM, an observation was made with HK 1 of the dried dark substance on the floor in the room and bathroom, a spider web on the west window, dead bugs on the window sill, and dirty blinds. HK 1 stated the room needed to be cleaned. 4. The following observations were made of resident 14's room and bathroom: a. On 6/18/18 at 1:25 PM, the floor had a sticky blackened areas that had smeared. b. On 6/19/18 at 11:08 AM, there was debris and sticky areas on the floor in the room. There was a dark substance that had splashed on floor to the left of the toilet. 5. The following observations were made of resident 28's room and bathroom: a. On 6/18/18 at 10:36 AM, there were two pink basins without labels in the bathroom. There were 2 residents residing in the room. One basin was on the toilet tank and one was on the floor beneath the sink. The bathroom fan was observed to not be functioning. b. On 6/19/18 at 9:48 AM, the bathroom fan was not functioning, the two pink buckets were observed on the handrail in the bathroom. The floor in residents room was sticky. c. On 6/21/18 at 9:05 AM, an observation was made with Certified Nursing Assistant (CNA) 1 and Licensed Practical Nurse (LPN) 3. CNA 1 and LPN 3 confirmed there was food on floor. CNA 1 stated, They'll (housekeeping) clean it later. d. On 6/21/18 at 8:43 AM, an interview was conducted with the Administrator. The Administrator stated he would check if the fan was functioning. The Administrator returned and stated that the fan was now working. 6. The following observations were made of resident 32's room and bathroom: a. On 6/18/18 at 12:13 PM, there were dried flowers petals and paper at the foot of the bed, directly below the television. There was additional white paper underneath the bed. b. On 6/18/18 at 12:27 PM, resident 32 stated that her room was cleaned daily, but had not been deep cleaned since she was admitted to the facility. There was a dirty towel lying on the floor in front of the toilet. c. On 6/19/18 at 2:26 PM, Observed dirty towel on bathroom floor, debris on floor of bathroom and under bed. 7. The following observations were made of resident 39's room and bathroom: a. On 6/18/18 at 1:48 PM, the bathroom fan was not functioning. There was dried dark brown substance on the toilet set and toilet. b. On 6/19/18 at 10:27 AM, the bathroom fan not functioning. There were two pink basins in bathroom, one on the floor and one on the handrail. The dried dark brown substance was on the toilet rim and flecks were on the toilet seat. c. On 6/21/18 at 8:43 AM, an observation was made with the Maintenance Director. The Maintenance Director stated that he checked fan and discovered a broken belt on the roof. The Maintenance Director stated that the belt was essential for all the bathroom fans on the east end of the east hall. 8. The following observations were made of resident 93's bathroom: a. On 6/19/18 at 11:38 AM, there was a rusted and soiled soap holder in the shower. On 6/20/18 at 12:39 PM, an interview was conducted with HK 1. HK 1 stated that rooms were cleaned daily. HK 1 stated that housekeeping dusted, moved furniture, swept and mopped each room daily. HK 1 stated that housekeeping also cleaned the bathroom, toilets, walls, refilled soap and paper towels. HK 1 stated that housekeeping was responsible to clean the bathroom vents. HK 1 stated that housekeeping worked from 7:00 AM to 4:00 PM daily. HK 1 stated that after 4:00 PM, the CNAs were responsible to wipe up spills and bathrooms. HK 1 stated that during the day, If there is a problem, they (staff) come get me. HK 1 stated that nurses inform housekeeping in the morning for overnight broken glass or other issues. On 6/21/18 at 7:52 AM, an interview was conducted with LPN 3. LPN 3 reported that they use a daily communication tool for any housekeeping issues. On 6/21/18 at 7:57 AM, an interview was conducted with the Social Services Worker (SSW). The SSW reported that there have been no complaints about cleanliness. On 6/21/18 at 8:07 AM, an interview was conducted with the Administrator and Maintenance Director. The Maintenance Director stated that he did not have a specific maintenance walk-through program. The Maintenance Director stated that during the walk-though, I look at the lights. The Maintenance Director stated that for non-working bathroom fans, staff tell him in morning meeting. The Maintenance Director stated that the bathroom fans were being replaced. The Maintenance Director further stated, We've been working on them for a while. We still have more to do. The Maintenance Director reported that there was a central fan on the roof that controls the fans in the back hallway that should be on all the time. The Administrator reported that there have been no complaints about housekeeping this year. On 6/21/18 at 9:15 AM, an interview was conducted with CNA 2. CNA 2 stated that she checked rooms for spills on the floor and garbage. CNA 2 stated that if something was on the floor for a while and housekeeping did not clean it, she would take care of it myself. On 6/21/18 at 9:17 AM, an interview was conducted with LPN 2. LPN 2 stated if she saw food on a resident's floor she would call housekeeping or clean it myself.",2020-09-01
83,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,656,D,0,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined for 1 of 31 sample residents that the facility did not develop a person-centered comprehensive care plan to meet the resident's medical, physical, mental or psychosocial needs. Specifically, a bladder incontinence care plan did not address how often incontinence care was to be provided. Resident identifiers: 9. Findings include: Resident 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's medical record was reviewed on 6/19/18. An annual Minimum Data Set (MDS) Assessment was completed by facility staff on 4/17/17. The facility staff assessed resident 9 as being always incontinence of urine. The facility staff documented that resident 9 was not on a toilet program (scheduled toileting or prompted toileting) at the time of admission /readmission or when urinary incontinence was identified. A quarterly MDS assessment was completed by facility staff on 3/28/18. The facility staff assessed resident 9 as being frequently incontinence or urine. The facility staff documented that resident 9 was not on a toileting program (scheduled toileting or prompted toileting) at the time of admission /readmission or when urinary incontinence was identified. Review of the care plans developed for resident 9 revealed a bladder incontinence care plan that was developed on 3/1/18. The facility staff documented, (Resident 9) has bladder incontinence related to Dementia, Impaired Mobility. The goal developed was, (Resident 9) will remain free from skin breakdown due to incontinence and brief use through the review date. The interventions developed to achieve the goal included, Utilizes briefs lined with incontinence pad, Clean peri-area with each incontinence episode, and Encourage fluids during the day to have adequate urinary output and prevent alterations in hydration. (Note: The bladder incontinence care plan did not include how often resident 9 was to be toileted or checked for incontinence episodes.) Resident 9 was continuously observed for toileting and repositioning on 6/19/18 from 9:52 AM to 12:27 PM. (Note: The survey staff stood outside resident 9's room, across the hall, which allowed for resident 9 to remain in line-of-sight at all times; and observed resident 9 while she was in the dining room.) The following was observed: a. At 9:52 AM, resident 9 was propelled by her hospice Certified Nurse Assistant (CNA) in her wheelchair from the shower room to her room. Resident 9's oxygen was infusing. b. At 9:56 AM, a hospice CNA exited resident 9's room. Resident 9 was observed to be sitting in her wheelchair with a green blanket placed over her. Resident 9's oxygen was infusing at 3 liters/nasal canula. The door to resident 9's room remained open. c. At 11:03 AM, a hospice nurse entered resident 9's room and assessed resident 9. Resident 9's door remained open and no care was provided to resident 9. d. At 11:35 AM, resident 9 remained sitting in her wheelchair with a green blanket placed over her. No personal cares had been provided. e. At 11:53 AM, two CNA's entered resident 9's room. One of the CNA's stated, Oh, she's (resident 9) already up. Resident 9 was propelled to the dining room for her lunch meal. Resident 9 was not observed to be checked for incontinence and resident 9 was not repositioned. f. At 12:27 PM, resident 9 was served cut up chicken, rice, green beans, peaches and milk. The continuous observation ended as resident 9 was eating her lunch. It should be noted that multiple facility employees including the Director of Nursing, housekeeping and the Social Services Worker, entered resident 9's room during the observation time. However, resident 9 was not checked for incontinence or repositioned. On 6/19/18 at 1:25 PM, resident 9 was propelled from the lunch room to her room, accompanied by Certified Nursing Assistant (CNA) 6 and CNA 7. CNA 6 and 7 transferred resident 9 via a mechanical lift. Resident 9's groin area and buttock area was visibly soiled and with a urine odor. CNA 6 and 7 stated that resident 9 was to be toileted after breakfast and lunch. CNA 7 obtained a clean brief and placed an incontinence liner inside the brief and stated that resident 9 was a heavy wetter. Resident 9's urine soaked brief with incontinence pad was weighed by facility staff. The incontinence products weighed 1.4 lbs. On 6/19/18 at 1:50 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 9 was to be toileted every couple of hours between breakfast and lunch and after lunch. On 6/19/18 at 2:22 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 9 was to be toileted every 2 hours to see if she was dry.",2020-09-01
84,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,658,D,1,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined for 1 of 31 sample residents, that the facility did not ensure that services were provided as outlined by the comprehensive care plan. Specifically, a resident was not transferred with a two person assist which resulted in the resident being lowered to the floor. Resident identifier: 9. Findings include: Resident 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's medical record was reviewed on 6/19/18. On 11/15/17, a care plan related to resident 9's risk for falls was developed. The care plan documented that resident 9 had a history of [REDACTED]. The goal developed was, (Resident 9) will not sustain serious injury through the review date. On 3/1/18, an intervention of Staff educated to assist with two assist for transfers/gait belt; encourage the use of the walker was implemented. On 5/28/18 at 2:16 PM, a facility nurse documented in a progress note, Was called to resident room by the aid. Resident laying on the floor by her recliner. No injuries. Residnet (sic) did not hit her head, she was lowered to the floor during transferring from the wheelchair to her recliner. Staff to continue to monitor. On 5/30/18 at 11:18 AM, a facility nurse documented in a progress note, IDT (Interdisciplinary Team) Fall Review: Refer to PT (Physical Therapy) to increase strength to BLE (Bilateral Lower Extremities) and improve safety with transfers. (Note: There was not an investigation into the fall to ensure that the care plan was followed and interventions to prevent resident 9 from falling were implemented.) On 6/19/18 at 9:48 AM, an interview was conducted with the Director of Nursing (DON). The DON was unable to determine who was transferring resident 9 at the time resident 9 was lowered to the floor or whether two staff members were transferring resident 9 as care planned.",2020-09-01
85,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,676,D,0,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined for 1 of 31 sample residents that the facility did not provided necessary services to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrated that such diminution was unavoidable. Specifically, a resident did not receive oral hygiene for two days. Resident identifier: 32. Findings include. Resident 32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18 at 12:29 PM, an interview was conducted with resident 32. Resident 32 was observed to have food debris in her mouth that was light pink in color. There was a hand-written sign taped on the wall with care information documented. The hand-written sign instructed staff to, .Help her brush teeth daily. On 6/19/18 at 8:15 AM, resident 32 was observed. Resident 32 was observed to have light pink in color food debris in her mouth. Resident 32's medical record was reviewed on 6/20/18. Review of the Activities of Daily Living care plan that was developed for resident 32 on 2/2/18 and revised on 4/12/18 revealed that the facility staff were to provide extensive assistance of one staff member for oral care. On 6/19/18 at 12:56 PM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated that resident 32 needed assistance with personal hygiene including oral care. CNA 6 stated that she did not assist resident 32 with brushing her teeth on 6/18/18 or 6/19/18. On 6/19/18 at 1:05 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 32 was to have her teeth brushed twice a day. On 6/19/18 at 1:20 PM, an interview was conducted with CNA 8. CNA 8 stated that she did not assist resident 32 with brushing her teeth.",2020-09-01
86,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,684,D,0,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 31 sample residents, that the facility did not ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, facility staff did not monitor and reassess a resident after the resident experienced a change in condition, causing the resident to experience [DIAGNOSES REDACTED] (low blood sugar), [MEDICAL CONDITION] (high blood sugar) and discomfort. Resident identifier: 93 Findings include: Resident 93 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 93's medical record was reviewed on 6/21/18. An admission Minimum Data Set ((MDS) dated [DATE] revealed that resident 93 had a [DIAGNOSES REDACTED]. The MDS further revealed that resident 93 received 7 insulin injections in the last 7 days. A care plan dated 6/24/18 revealed a Focus of (Resident 93) had Diabetes Mellitus type 1. She is at risk for episodes of hyper and [DIAGNOSES REDACTED]. Signs of [DIAGNOSES REDACTED] are decreased alertness and lethargy. The Goals developed were, (Resident 93) will be free from any signs and symptoms of [MEDICAL CONDITION] through the next review date, . free from any signs and symptoms of [DIAGNOSES REDACTED] through the review date, .will have no complications related to diabetes through the review date. One of the interventions developed was, Diabetes medications as ordered by doctor. Monitor/document for side effects and effectiveness. Resident 93's physician's orders [REDACTED]. a. 6/7/18, Invokana tablet 300 mg (milligrams) one tablet per day for Type 1 diabetes mellitus with other specified complication. Resident's medication was scheduled to be administered at 8:00 AM. b. 6/7/18, [MEDICATION NAME] solution 100 units/mL (milliliter), inject 20 units subcutaneously one time a day related to Type 1 diabetes mellitus with other specified complication. Resident 93's medication was to be administered at 8:00 AM. c. 6/6/18, Vancomyacin HCl ([MEDICATION NAME]) 100 mg. Use 1 gram intravensiously one time a day related [MEDICAL CONDITION], unspecified organism for 14 days. d. 6/6/18, Meropenem solution.1 gram intravensiously every 8 hours for bacterial infection for 14 days. A reviewed of the [MEDICATION NAME] pharmacology information provided by the facility revealed the Onset for [MEDICATION NAME] is 3 to 4 hours with peak amount provided 3 to 9 hours. Reference: http://www.globalrph.com/long-acting-insulins.htm# Resident 93's nursing progress notes revealed the following entries: a. On 6/7/18 at 7:43 PM, Received critical lab (laboratory) values: Glucose 31 Platelets - 938 Hgb (hemoglobin) - 6.8. Able to get BS (blood sugar) up to 114. Call received from (physician) (on call for (resident 93's physician)). Notified house MD (Medical Doctor) in AM (morning). Will CTM (continue to monitor) for any needs or changes. b. On 6/8/18 at 2:45 AM, Left message for spouse at number provided by resident to call facility for update on resident. c. On 6/8/18 at 2:47 AM, .c/o (complaints of) of (sic) abd (abdominal), bloody diarrhea.'something's not right. I want to go to the ER (emergency room ).' Resident 93's Emergency Provider Report from the local hospital dated 6/8/18 revealed a history that .She had complications of DKA (diabetic ketoacidosis) and pneumonia for which she was transferred to (another hospital) for an extended period of time. The discharge/care plan revealed, .The patient will be transported for further care and management or will be moved to an observation or inpatient service. d. On 6/9/18 at 8:55 PM, Resident admitted from (local hospital). e. On 6/11/18 at 7:18 PM, Nurse had started the pt's (patient) IV meropenem .When nurse came in to stop the meropenem and start the IV Vanco, pt was in the same place, and still was not waking up with sound. Nurse tried to wake pt up with touch, and spoke louder. Sternal rub then done, still with no response. Nurse ran and got glucometer, since pt was recently sent to hospital for low blood sugars and other critical labs. Pt's BS was too low to register. Gluco-gel given immediately following. Nurse also got some orange juice with added sugar and began using syringe to administer. The entire time pt was breathing, and pt had been sat up to about 80 degrees. Pt was swallowing the orange juice with prompting. BS checked again, and it registered at 27. Interventions continued, and BS checked one minute later, and it was 20. Ambulance called to get her to the hospital. Pt's family notified. EMTs (emergency medical technician) arrived and did vitals, and gave [MEDICATION NAME] injection to left deltoid. They then transported her to the hospital. MD notified. Resident 93's Emergency Provider Report from a local hospital dated 6/11/18 revealed, This is a [AGE] year-old femal brought in by EMS for low blood sugar. The patient is at a rehab facility receiving chronic antibiotics [MEDICAL CONDITION]. She was found unresponsive in her room by nursing staff. The patient is an insulin-dependent diabetic and was given her normal morning dose of insulin. The report further revealed On arrival we were able to access the PICC line and the patient was given an amp of D50 ([MEDICATION NAME]). After 5 minutes the patient was fully awake and conversant with a normal neurologic exam. With a lot of encouragement she was able to eat a sandwich and some fruit. The report stated that she was transported back to the facility in stable condition. A form titled Discharge Instructions dated 6/11/18 at 10:04 PM revealed, Follow-up: Monitor and write down your blood sugar at least twice daily. f. On 6/12/18 at 1:16 AM, .(Patient had) some confusion but is improving. Pt has a PICC (peripherally inserted centeral catheter) line in her right forearm that is patent and flushes well. Pt seems to be tolerating ABX (antibotics) well with no s/s (signs/symptoms) of A/E (adverse effects) .Pt returned from (local hospital) around 2230. ER staff reported that they gave her D50 IV solution that brought her BS up. Pt was given a sandwich, chips, and some dessert. Pt tolerating medications, treatments, and therapies well WCTM (will continue to monitor) closely. g. On 6/13/18 at 4:01 PM, Pt slightly lethargic and c/o dizziness. BS 37, gave glucose and 120ml of med pass. h. On 6/13/18 at 8:02 PM, Rechecked BS at 1800 and it was 68, gave another 120ml of med pass and BS is currently 101. Pt states she is feeling much better. MD aware. i. On 6/14/18 at 9:51 PM, . Pt BS continue to be low. Pt BS are check frequent and low BS are addressed with orange juice if needed. (Note: There were no additional documented blood glucose levels obtained this day.) j. On 6/14/18 6:21 PM, Hospital called regarding labs that had some critical values. MD called multiple times with no response as of yet, but the office said they would call back.Glucose 45 (L). k. On 6/15/18 at 11:25 AM, .New order to decrease [MEDICATION NAME] to 10 units Subcutaneous QD (daily). WCTM. l. On 6/15/18 at 6:57 PM, .In relation to multiple low blood sugar levels, N.O. (new order) for D50, 50% solution/50mL vial, mix with 100ml NS (normal saline) bag and administer over 1 hr. m. On 6/18/18 at 11:57 AM, Low blood sugar episodes. A Physicians Progress Note dated 6/19/18 that was completed by the Physician's Assistant recommended blood sugar checks three times daily. Resident 93's blood glucose levels documented were: a. 6/11/18 at 7:17 PM, 20.0 mg/dL (milligrams per deciliter) b. 6/12/18 at 7:59 AM, 245 mg/dL c. 6/13/18 at 7:29 AM, 163 mg/dL d. 6/13/18 at 9:38 AM, 88 mg/dL e. 6/13/18 at 4:01 PM, 37 mg/dL f. 6/14/18 at 7:47 AM, 144 mg/dL g. 6/14/18 at 6:21 PM, 45 mg/dL h. 6/15/18 at 7:55 AM, 176 mg/dL g. 6/16/18 at 8:10 AM, 578 mg/dL h. 6/17/18 at 7:01 AM, 279 mg/dL i. 6/18/18 at 8:38 AM, 400 mg/dL j. 6/19/18 at 8:02 AM, 344 mg/dL k. 6/20/18 at 7:55 AM, 295 mg/dL (Note: The above blood glucose levels were all the blood glucose levels obtained at the facility for resident 93. Resident 93's blood glucose was obtained in the evening were 20, 37, and 45. Resident 93's other blood glucose levels were obtained in morning and were elevated except on 6/13/18.) A Facility policy with a (YEAR) reference was retrieved by the CRN. Review of Policy entitled Nursing Care of the Resident with Diabetes Mellitus revealed, Glucose Monitoring: . 2. The physician will order the frequency of glucose monitoring. 3. Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation. .Management of [DIAGNOSES REDACTED] 2. For asymptomatic and responsive residents with [DIAGNOSES REDACTED] ( 3. For symptomatic and unresponsive residents with [DIAGNOSES REDACTED] ( On 6/20/18 at 9:19 AM, an interview was conducted with resident 93. Resident 93 reported that she had not had to use her glucose tablets at home except when she was doing extensive yard work. Resident 93 reported that since admission to the facility her low blood glucose levels were in the late afternoon and early evening. Resident 93 stated that her blood glucose levels were checked by facility staff mostly in the morning. Resident 93 stated that she had received her [MEDICATION NAME] and Invokana in the mornings, in addition to her antibiotics around 8:00 AM and 8:00 PM. On 6/20/18 at 10:55 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that signs and symptoms of [MEDICAL CONDITION] included headaches, dizziness, sweating, thirst, and high blood glucose levels. LPN 1 further stated that signs and symptoms of low blood glucose included dizziness, [MEDICAL CONDITION], nausea, lightheadedness, and low blood glucose levels. LPN 1 stated that she notified the physician when the blood glucose was outside parameters ordered ordered by the physician or if the blood glucose was over 500, or under 60. On 6/20/18 at 3:20 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that blood glucose should have been called to the doctor per order protocol and if glucose is over 400 or under 60. The DON stated that blood glucose less than 60 mg/dL the diabetic medications should be held per nursing discretion. The DON stated that nursing staff were to give a snack or juice, and recheck in an hour. The DON stated there should be a physician's orders [REDACTED]. The DON stated that the protocol for low blood sugar was to give glucose tablets, sternal rub, check vital signs, recheck blood glucose with a different monitor and check the residents code status. The DON stated that an unresponsive resident should not be administered beverages. The DON stated that she did not know if there was a policy to give IV medications, so facility staff would encourage the resident to eat. The DON reported that for Resident 93, we tried to get medication changes and IV [MEDICATION NAME] orders. The DON further stated that, We would get orders to check blood sugars more frequently. On 6/20/18 at 3:30 PM, an interview was conducted with the Corporate Resource Nurse (CRN). CRN stated that there has been no in-service about [DIAGNOSES REDACTED] or [DIAGNOSES REDACTED]. On 6/20/18 at 10:55 AM, an interview was conducted with LPN 1. LPN 1 stated that Resident 93's Invokana could definitely cause lower blood sugar levels along with her antibiotics. LPN 1 stated that resident 93's blood sugar levels should have been checked more often. LPN 1 stated that she notified the physician of a blood glucose on 6/19/18 of 344. LPN 1 stated Sometimes it takes a while for labs. I'll call (the doctor) a couple times a day. LPN 1 stated that the IV emergency kit had [MEDICATION NAME]. LPN 1 stated that resident 93's blood glucose levels were not controlled. LPN 1 stated when resident 93 admitted she was sent to a local hospital for low blood glucose. On 6/20/18 at 11:12 AM, an interview was conducted with LPN 2. LPN 2 stated that if a resident had [MEDICAL CONDITION], she would call the doctor if the blood glucose was over 400 mg/dL. LPN 2 stated that for [DIAGNOSES REDACTED], with blood sugar less than 60 mg/dL, she would follow the protocol to administer glucose tablets or glucose gel. LPN 2 stated that if the resident was not responsive, she would follow the POLST orders if we couldn't get her back up. LPN 2 further stated Now we have orders for D50. LPN 2 stated that Resident 93's blood sugar should be running high due to antibiotic prescriptions. LPN 2 stated that she thought blood glucose was monitored twice daily, but confirmed the order for once daily monitoring. LPN 2 stated that she had notified the Medical Director, who responded OK to the low blood sugars. LPN 2 stated that she did not keep the texts to the physician and did not document communication in a nurses' note. On 6/20/18 at 3:00 PM, an interview was conducted with LPN 3. LPN 3 stated that she contacted the physician regarding the high blood glucose. LPN 3 stated that she was unable to provide documentation and did not create a nurses' note that the physician was notified.",2020-09-01
87,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,689,E,1,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review it was determined for 2 out of 31 sampled residents that the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and that each resident receives adequate supervision to prevent accidents. Specifically, a resident was observed to burn her hair, drop a lit cigarette down the inside of her smoking apron, and then smoke without an apron in place. Additionally, a resident was transferred with a one person assist when they were assessed as requiring two people. Resident identifiers: 9 and 38. Findings include: 1. Resident 38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18 at 1:00 PM, resident 38 smoking was observed smoking. The resident was observed wearing a smoking apron. The resident was supervised by the Social Service Worker (SSW), and the SSW was observed to cue the resident when to ash the cigarette. The resident was observed to be crying, agitated, and stating hurt during the smoke break. The resident was observed to lean forward in her wheelchair (WC) multiple times while holding her cigarette, and her arm and upper body movements appeared spastic. The resident's hair braid was observed to swing forward through her cigarette butt two times, singeing her hair, before the SSW noticed. The SSW was then observed to hold resident 38's hair away from the cigarette. The SSW was then observed to go back inside the building leaving resident 38 to be supervised by the Medical Records staff. The Medical Records staff was observed to stand in front of resident 38 while talking to another resident, and their attention was not focused on resident 38. Resident 38 was then observed to propel herself forward in her WC causing the resident's apron to be caught in her WC legs. This resulted in her upper body being pulled forward towards the ground. The resident was stabilized and the apron was untangled by the Medical Records staff. The resident's cigarette was observed to fall out of her mouth and down the front of her in between the apron and the resident's clothing. The Medical Records staff was observed to frantically search for the missing lit cigarette. The lit cigarette was observed to fall to the ground in front of resident 38. [MEDICAL CONDITION] observed on resident 38. On 6/18/18 resident 38's electronic medical records were reviewed. Review of the Smoking Screen Assessment on 6/15/18 revealed that resident 38 has cognitive loss, dexterity problems, communication deficits, the resident can not extinguish and dispose of the ashes safely, the resident has tremors or uncontrolled movements, and the resident has a condition that could result in a burn or fire to themselves. The Assessment documented that the resident could not light her own cigarette and required a smoking apron while smoking. Review of the Care plan for smoking revealed, .(resident's name) chooses to smoke. Staff have educated on smoking apron and have offered apron during designated smoking times. Refusing to wear apron despite education. (resident's name) is not safe to light her own cigarette related to spastic involuntary movements- staff light cigarette for her; needs supervision during smoking. Interventions identified on the care plan include the following: a. Cigarettes (or other smoking materials) and lighter are required to be stored at the nurse's station. b.Instruct (resident's name) about smoking risks and hazards and about smoking cessation aids that are available. c.(Resident's name) requires SUPERVISION while smoking, staff to light her cigarette for her. d.(Resident's name) smoking supplies are stored in med room. e.Observe clothing and skin for signs of cigarette burns. Notify LN (licensed nurse) immediately if present, f.The facilities smoking policy was reviewed and accepted by (resident's name) and her family. g.Watch for proper oral hygiene. On 6/19/18 at 3:05 PM, resident 38 was observed smoking without an apron on. The cigarette was lit and resident 38's hair was observed to make contact with end of the lit cigarette, singeing her hair. The Medical Records staff was then observed to go inside the building and obtain an apron. Resident 38 was left unattended with a lit cigarette. Resident 38 was observed to state hair to the Medical Records staff. The Medial Records staff then tucked the residents hair into her shirt, and re-secured her hair away from her face. The Medical Records staff was observed to instruct resident 38 to give her cigarette to resident 31 to extinguish. An immediate interview was conducted with the Medical Records staff. The Medical Records staff stated that the supervised smoking procedure was to place the apron on the resident prior to lighting the cigarette, and she forgot to because the resident makes her so nervous. On 6/20/18 at 1:57 PM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated she had supervised resident 38 during smoking previously. CNA 6 stated that smoking supervision was not assigned and it was whoever was available. CNA 6 stated resident 38 wore an apron for smoking. CNA 6 stated that she made sure that resident 38 does not tip over or burn herself during the smoking break. CNA 6 stated that resident 38 needs supervision for everything. On 6/21/18 at 8:25 AM, the Director of Nursing (DON) was interviewed. The DON stated that resident 38 was a supervised smoker. The DON stated that the resident required an apron for smoking and that it was applied prior to lighting a cigarette. The DON further stated that staff are to help her extinguish the cigarette, and attend to resident 38 the entire time she was smoking. The DON was informed of the observations of resident 38 smoking without an apron, singeing her hair and dropping a cigarette down the front of the apron. No additional information was provided. 2. Resident 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's medical record was reviewed on 6/19/18. On 11/15/17, a care plan related to resident 9's risk for falls was developed. The care plan documented that resident 9 had a history of [REDACTED]. The goal developed was, (Resident 9) will not sustain serious injury through the review date. On 3/1/18, an intervention of Staff educated to assist with two assist for transfers/gait belt; encourage the use of the walker was implemented. On 5/28/18 at 2:16 PM, a facility nurse documented in a progress note, Was called to resident room by the aid. Resident laying on the floor by her recliner. No injuries. Residnet (sic) did not hit her head, she was lowered to the floor during transferring from the wheelchair to her recliner. Staff to continue to monitor. On 5/30/18 at 11:18 AM, a facility nurse documented in a progress note, IDT (Interdisciplinary Team) Fall Review: Refer to PT (Physical Therapy) to increase strength to BLE (Bilateral Lower Extremities) and improve safety with transfers. (Note: There was not an investigation into the fall to ensure that the care plan was followed and interventions to prevent resident 9 from falling were implemented.) On 6/19/18 at 9:48 AM, an interview was conducted with the Director of Nursing (DON). The DON was unable to determine who was transferring resident 9 at the time resident 9 was lowered to the floor or whether two staff members were transferring resident 9 as care planned.",2020-09-01
88,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,690,D,0,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined for 1 of 31 sample residents that a resident who was incontinent of urine received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, a resident who was incontinent was not checked or toileted for 3 1/2 hours. Resident identifier: 9. Findings include: Resident 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's medical record was reviewed on 6/19/18. An annual Minimum Data Set (MDS) Assessment was completed by facility staff on 4/17/17. The facility staff assessed resident 9 as being always incontinence of urine. The facility staff documented that resident 9 was not on a toilet program (scheduled toileting or prompted toileting) at the time of admission /readmission or when urinary incontinence was identified. A quarterly MDS assessment was completed by facility staff on 3/28/18. The facility staff assessed resident 9 as being frequently incontinent of urine. The facility staff documented that resident 9 was not on a toilet program (scheduled toileting or prompted toileting) at the time of admission /readmission or when urinary incontinence was identified. Review of the care plans developed for resident 9 revealed a bladder incontinence care plan that was developed on 3/1/18. The facility staff documented, (Resident 9) has bladder incontinence related to Dementia, Impaired Mobility. The goal developed was, (Resident 9) will remain free from skin breakdown due to incontinence and brief use through the review date. The interventions developed to achieve the goal included, Utilizes briefs lined with incontinence pad, Clean peri-area with each incontinence episode, and Encourage fluids during the day to have adequate urinary output and prevent alterations in hydration. (Note: The bladder incontinence care plan did not include how often resident 9 was to be toileted or checked for incontinent episodes.) Resident 9 was continuously observed (the survey staff stood outside resident 9's room, across the hall, which allowed for resident 9 to remain in direct line-of-sight at all times; and survey staff observed resident 9 while she was in the dining room) for toileting and repositioning on 6/19/18 from 9:52 AM to 12:27 PM. The following was observed: a. 9:52 AM, resident 9 was propelled by her hospice Certified Nurse Assistant (CNA) in her wheelchair from the shower room to her room. b. 9:56 AM, a hospice CNA exited resident 9's room. Resident 9 was observed to be sitting in her wheelchair with a green blanket placed over her. The door to resident 9's room remained open. c. 11:03 AM, a hospice nurse entered resident 9's room and assessed resident 9. Resident 9's room remained open and no care was provided to resident 9. d. 11:35 AM, resident 9 remained sitting in her wheelchair with a green blanket placed over her. No personal cares had been provided. e. 11:53 AM, two CNA's approached resident 9's room. One of the CNA's stated, Oh, she's (resident 9) already up. Resident 9 was propelled to the dining room for her lunch meal. Resident 9 was not checked for incontinence and resident 9 was not repositioned. f. 12:27 PM, resident 9 was served cut up chicken, rice, green beans, peaches and milk. The continuous observation ended as resident 9 was eating her lunch. It should be noted that multiple facility employees including the Director of Nursing, housekeeping and the Social Services Worker, entered resident 9's room during the observation time. However, resident 9 was not checked for incontinence or repositioned. On 6/19/18 at 1:25 PM, resident 9 was propelled from the lunch room to her room, accompanied by CNA 6 and CNA 7. CNA 6 and 7 transferred resident 9 via a mechanical lift from the wheelchair to the bed. Resident 9's groin area and buttock area was visibly soiled and smelled of urine. The urine soaked brief and incontinence liner were removed and placed in the garbage can. CNA 7 obtained a clean brief and placed an incontinence liner inside the brief and stated that resident 9 was a heavy wetter. CNA 6 and 7 stated that resident 9 was to be toileted after breakfast and lunch. It should be noted that resident 9's urine soaked brief with incontinence pad was weighed. The incontinence products weighed 1.4 lbs. On 6/19/18 at 1:50 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 9 was to be toileted every couple of hours between breakfast and lunch and after lunch. On 6/19/18 at 2:22 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 9 was to be toileted every 2 hours to see if she was dry.",2020-09-01
89,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,697,G,0,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined for 2 of 31 sampled residents that the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a hospice resident reported that her pain medication was ineffective and her hourly pain medication was not being administered; and a vulnerable resident was observed to be in pain without any observed relief provided. The deficient practices identified was found to have occurred at a harm level. Resident identifiers 23 and 38. Findings include: 1. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18 at 8:16 AM, resident 23 was interviewed. Resident 23 stated her pain was located in the head, neck, and back and was currently a 8/10 (On a numeric pain scale of 0 to 10. With 0 meaning no pain and 10 the worst pain.). Resident 23 stated that [MEDICATION NAME] was recently started for her pain and that the pain was not controlled with medication. On 6/18/18 at 9:00 AM, an observation was made of resident 23 ambulating to the smoking patio for the scheduled smoke time. On 6/18/18, resident 23's electronic medical records were reviewed. Review of the physician orders [REDACTED]. a. [MEDICATION NAME] (Concentrate) Solution 20 MG (milligrams)/ML (milliliter), Give 1 ml (milliliter)by mouth three times a day for pain. The order was initiated on 6/15/2018. b. [MEDICATION NAME] (Concentrate) Solution 20 MG/ML, Give 0.5 ml by mouth every 1 hours as needed for pain, SOB (shortness of breath). The order was initiated on 5/4/2018. c. [MEDICATION NAME] (Concentrate) Solution 20 MG/ML, Give 1 ml by mouth every 1 hours as needed for pain, SOB. The order was initiated on 5/4/2018. d. [MEDICATION NAME] HCl ([MEDICATION NAME]) Tablet 15 MG, Give 1 tablet by mouth every 4 hours as needed for pain. The order was initiated on 5/13/2018. e. [MEDICATION NAME] Tablet 325 MG, Give 2 tablet by mouth every 4 hours as needed for General Discomfort related to PAIN The order initiated was on 12/21/2017. f. [MEDICATION NAME] Tablet, Give 800 mg by mouth every 8 hours as needed for Pain related to PAIN The order was initiated on 12/27/2017. g. [MEDICATION NAME] Patch 72 Hour 75 MCG (microgram) /HR (hour), Apply 1 patch [MEDICATION NAME] every 72 hours for Pain - Moderate related to PAIN The order was initiated on 5/2/2018. h. [MEDICATION NAME] Tablet 10-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth every 6 hours as needed for pain. The order was initiated on 5/4/18 and discontinued on 5/13/18. i. Admit onto Hospice Care with (name of hospice company) for [DIAGNOSES REDACTED]. The order was initiated on 5/1/18. Review of the Medication Administration Record [REDACTED] a. No doses of [MEDICATION NAME] or [MEDICATION NAME] 0.5 ml were administered. b. The [MEDICATION NAME] 1 ml every hour was administered ten times until 6/20/18, and 6 of those administrations had a pre-administration pain score of greater than 4 out of 10. c. On 6/19/18, two doses of [MEDICATION NAME] 1 ml were administered at 1:26 PM and 6:29 PM. The pre-administration pain score at 1:26 PM was documented as a 2 by Licensed Practical Nurse (LPN) 3. The pre-administration pain score at 6:29 PM was documented as a 3 by LPN 3. d. On 6/20/18 at 1:50 PM, the patient reported a pre-[MEDICATION NAME] administration pain score of 10/10, and the documentation indicated that it was ineffective. e. The [MEDICATION NAME] was administered 84 times and 68 of those administrations had a pre-administration pain score of greater than 4 out of 10. Review of the MAR for (MONTH) (YEAR) revealed the following: a. [MEDICATION NAME] was administered 3 times on 5/11/18 with a pre-administration pain score of 6/10, on 5/12/18 with a pre-administration pain score of 6/10, and on 5/15/18 with a pre-administration pain score of 4/10. The medication administration on 5/12/18 was documented as ineffective. b. No doses of [MEDICATION NAME] were administered. c. The [MEDICATION NAME] 1 ml every hour was administered 14 times and 11 of those administrations had a pre-administration pain score of greater than 4 out of 10. On 5/15/18 and 5/24/18, the post pain administration was documented as ineffective. d. [MEDICATION NAME] was administered 71 times and 62 of those administrations had a pre-administration pain score of greater than 4 out of 10. On 5/2/18 at 8:24 AM, 5/26/18 at 2:15 PM, and 5/29/18 at 6:44 PM the post pain administration was documented as ineffective. e. [MEDICATION NAME] was administered 28 times and 22 of those administrations had a pre-administration pain score of greater than 4 out of 10. On 5/12/18 at 5:32 PM the post pain administration was documented as ineffective. Review of the Pain Level Summary for (MONTH) (YEAR) and (MONTH) (YEAR) revealed that resident 23 had 231 episodes of pain with a pain score of greater than 4 out of 10. All values were scored with a numeric pain scale. The summary documented the episodes with a warning of High of 4 exceeded. Review of the Care Plan revealed resident 23 has potential for pain. She has recent back pain related to [MEDICAL CONDITION]. Heat/cold effective at times, pain medication effective at times. Scans and pain medications adjusted to meet needs Interventions listed on the care plan include the following: a. Assist with heat/cold packs to lower back pain. Intervention was initiated on 11/30/17. b. Monitor pain q (every) shift, notify MD (Medical Doctor) if interventions are ineffective. Intervention was initiated on 11/30/17. c. Pain medications as ordered per MD. Intervention was initiated on 11/30/17. d. Watch for nonverbal signs or symptoms of pain. Intervention was initiated on 11/30/17. e. See Hospice Care Plan to coordinate care. Intervention was initiated on 5/9/18. Review of the hospice nursing notes revealed the following: a. On 6/7/18, the note stated, She is anxious, worrying about when her next dose of pain meds (medication) due. Resident 23 reported an acceptable pain level of 4 out of 10. b. On 6/5/18, the note stated, Pt. (patient) reports feeling pain not improved at all. Review of the nursing progress note on 6/19/18 stated, .observed using a wheelchair today per her request. (resident 23) continues to experience a decline r/t (related to) her [MEDICAL CONDITION]. Review of the nursing pain evaluation on 4/30/18 revealed that resident 23 reported left flank pain with a numeric pain score of 7 out of 10. The evaluation indicated that resident 23 reported that medications and heat packs makes the pain better. Resident 23 reported that the pain negatively impacts sleep and rest, social activities, appetite, physical activity and mobility, and emotions. On 6/19/18 at 1:15 PM, resident 23 was interviewed. The resident stated that she feels like she has injured her back and her pain was now a 10/10. Resident 23 requested pain medications from Licensed Practical Nurse (LPN) 3 and LPN 3 was observed to administer [MEDICATION NAME] and [MEDICATION NAME]. On 6/19/18 at 2:56 PM, resident 23 was re-interviewed. Resident 23 stated that her pain was currently still the same, at a 10 out of 10 in her lower back and it radiated all through. Resident 23 stated the medication did not alleviate the pain. On 6/19/18 at 3:00 PM, LPN 3 was interviewed. LPN 3 stated that resident 23's pain prior to the medication administration was a 4 and she obtained that number by observing facial grimacing. LPN 3 stated that resident 23 would not give a number score. LPN 3 stated that the follow-up pain score was a 2 based on the Wong Baker FACES pain rating scale. According to the Wong Baker scale, a score of 4 was Hurts a little more and a 2 was Hurts a little bit. It should be noted that the scale rates pain by asking the person to point to the face that depicts the pain they are experiencing and was originally developed for children to help them communicate about their pain. On 6/19/18 at 3:09 PM, resident 23 was observed stating to the Medical Records staff that her back went out and that she can not walk now. Resident 23 stated she can only walk to the bathroom. Resident 23 stated, it hurts like a [***] . The Medical Records staff was observed to ask resident 23 if the physician had seen her and resident 23 indicated no by shaking her head. On 6/20/18 at 11:37 AM, resident 23 was interviewed. Resident 23 stated that her back pain was a 10 out of 10 and not improving. Resident 23 stated that she can longer ambulate independently and now uses a walker or wheelchair to get around. The resident stated that she received [MEDICATION NAME] 3 to 4 times a day. Resident 23 requested this surveyor to inform the nursing staff that she would like some pain medication now. An immediate interview was conducted with LPN 2. LPN 2 stated that resident 23 only has a scheduled order for [MEDICATION NAME] 4 times a day. LPN 2 stated that resident 23 did not have a PRN (as needed) hourly order for [MEDICATION NAME] and that resident 23 refused liquid [MEDICATION NAME] because she does not like the taste. On 6/20/18 at 11:40 AM, resident 23 was re-interviewed. Resident 23 stated that she did not know she could have [MEDICATION NAME] every hour and that she did not refuse it. On 6/20/18 at 12:55 PM, LPN 2 was re-interviewed. LPN 2 stated that she administered [MEDICATION NAME] and [MEDICATION NAME] to the resident immediately after she requested it at 11:37 AM. LPN 2 stated that the resident reported her pain was a 8 out of 10 prior to the pain medication administration and a 4 out of 10 after administration. LPN 2 stated that the resident always rated her pain using the numeric pain scale. On 6/20/18 at 1:07 PM, a repeat interview was conducted with resident 23. Resident 23 stated that she received her [MEDICATION NAME] earlier and it did not help. Resident 23 stated her pain was still a 10 out of 10. Resident 23 stated that sometimes she got a heating pad for her back and it kind of helps. Resident 23 stated that optimally an acceptable pain level for her would be a 1. On 6/20/18 at 1:46 PM, LPN 2 was interviewed. LPN 2 stated that resident 23's acceptable pain level was none, or a 3 or less. LPN 2 stated that she was unaware of the PRN [MEDICATION NAME] order until this surveyor notified her. It should be noted that the PRN order for [MEDICATION NAME] was initiated on 5/4/18. On 6/21/18 at 8:00 AM, LPN 3 was interviewed. LPN 3 stated that resident 23 does not always provide a numeric pain score rating. LPN 3 stated that if the resident verbalized it's bad then she scored it as a 4 out of 10, verbalized horrible she scored it as 7 out of 10, and verbalized can't stand it scored it as a 9 out of 10. On 6/21/18 at 11:47 AM, the Director of Nursing (DON) was interviewed. The DON stated that resident 23 reported pain in her neck and that overall the resident has had a general decline and was not necessarily related to pain. The DON stated that she thought resident 23 had a PRN [MEDICATION NAME] order, and that it seems to be effective. The DON stated that the resident complains that the [MEDICATION NAME] tastes bad but they give her chocolate or coffee with it and the resident was able to tolerate it. The DON stated that she has had no reports that the pain medication was ineffective in managing resident 23's pain. The DON was informed of resident 23's decline in mobility, complaints of pain, and reports of ineffective pain control. No additional information was provided. 2. Resident 38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18 at 12:20 PM, resident 38 was observed crying during the lunch meal. The resident was observed to be wheeled to her room by the Medical Records staff. At 12:25 PM, resident 38 was observed to exit her room still visibly agitated and crying. Resident 38 was observed to be moaning and stating hurts repeatedly. At 1:00 PM, resident 38 was wheeled outside for a scheduled smoke break by the Social Service Worker (SSW). Resident 38 was observed to be agitated, crying, and moaning hurts. The Medical Records staff confirmed that the resident was in pain and then wheeled the resident to the nurses station to obtain medication. At 1:10 PM, the resident stated to this surveyor yes when asked if she was in pain. At 1:15 PM, LPN 1 was interviewed. LPN 1 stated that resident 38 suffers from chronic back pain, and that the resident only receives Tylenol for her pain. LPN 1 stated this was due to her history of a drug overdose. LPN 1 stated that the resident was due for her scheduled dose of [MEDICATION NAME] and Tylenol; and was observed to administer these medications. LPN 1 stated that they also alternate between ice and hot packs to try to alleviate resident 38's back pain. Review of physician orders [REDACTED]. a. Tylenol Tablet ([MEDICATION NAME]), Give 500 mg by mouth four times a day related to low back pain. The order was initiated on 7/31/2017. b. Tylenol Tablet ([MEDICATION NAME]), Give 500 mg by mouth every 4 hours as needed for pain. The order was initiated on 7/31/2017. c. Question resident about presence of pain or burning including pressure points. Monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible. If resident is not able to answer, use PAINAD scale, every shift. The order was initiated on 7/5/2017. d. Resident to utilize cold packs PRN for comfort, as needed. The order was initiated on 7/5/2017. e. Resident to utilize hot pack PRN- monitor Q (every) 5-10 for skin redness/discoloration to avoid skin damage, as needed for Pain. The order was initiated on 7/5/2017. Review of the MAR/TAR for (MONTH) (YEAR) revealed that resident 38 received the scheduled Tylenol four times a day. No additional PRN doses of Tylenol were administered. Review of the Pain Level Summary for (MONTH) and (MONTH) (YEAR) revealed that resident 38 had 25 episodes of pain with a pain score of greater than 4 out of 10. The summary documented the episodes with a warning of High of 4 exceeded. Values were scored using the numeric pain scale and the Pain Assessment in Advanced Dementia (PAINAD) Scale. The PAINAD scale scores items a number of 1 or 2. Items scored include breathing, negative vocalization, facial expression, body language, and consolability. Total scores range from 0 to 10, with a higher score indicating more severe pain. Review of care plan revealed resident 38 .has pain related to Chronic back pain. She has a history of opioid abuse. Routine pain medication as ordered. Heat/cold packs for lower back. Intervention listed on the care plan include: a. Administer [MEDICATION NAME] as per orders. Give 1/2 hour before treatments or care. The intervention was initiated on 2/6/18. b. Anticipate (resident's name) need for pain relief and respond immediately to any complain of pain. The intervention was revised on 3/21/18. c. (resident's name) prefers to have pain controlled by: Heat packs. Is able to request heat packs from nurses. The intervention was revised on 3/21/18. Review of the nursing progress notes revealed the following: a. On 6/15/17, the note stated, Pt (patient) with increased anxiousness and leaning forward in her W/c (wheelchair) Ice pack placed on back and 1:1 provided X (times) 30 minutes offering reassurance. b. On 5/20/18, the note stated, .Frequent requests for pills/ice/heat/smokes, often within minutes of receiving the same item requested Struggles to communicate by typing with phone which was her easiest way to communicate until recently. Few words are spoken clearly enough to understand. Staff attempts to anticipate needs and she is able to answer yes no questions. c. On 5/2/18, the note stated, Call in to (doctors name)r/t (related to) increase in falls. Resident also states she has increased pain and is unable to stay upright in her chair. Awaiting response. It should be noted that no documentation could be found for a response from the doctor. d. The post pain intervention follow-up documented 8 episodes of hot pack utilization that were effective and 2 episodes that were ineffective for (MONTH) (YEAR) and (MONTH) (YEAR). Review of the nursing Pain Evaluation on 6/17/18 revealed a numeric pain score of 7 on a scale of 0 to 10, with increasing numbers indicating an increase in pain. The evaluation indicated that resident 38 was able to verbalize pain and has a history of back pain, and that medications and heat make the pain better. The evaluation also documented that the pain negatively impacts sleep and rest, social activities, appetite, physical activity and mobility, and emotions. No documentation could be found in the evaluation section of Describe all methods of alleviating pain and their effectiveness. On 6/19/18 at 10:44 AM, resident 38 was observed. Resident 38 was observed to use her legs to wheel herself out of her room in her wheelchair. Resident 38 stated to the DON hurt, hurt. The DON stated that she was asking for her chapstick. The DON was observed to ask Certified Nursing Assistants (CNAs) to get her chapstick. Resident 38 was observed to wheel herself through the hall crying, Hurt, Hurt, Hurt. There were no staff observed to provide interventions for resident 38 when she stated, Hurt, Hurt. Resident 38 was also observed to lean self forward in wheelchair and place hands flat on the floor. A CNA immediately ran down the hall and resident 38 was taken back to her room. Prior to placing her hands palm down on the floor, resident 38 leaned forward, causing a staff member to grab the back of her shirt. Resident 38 then crossed the hall and was using the handrail to propelled self up the hallway while using her right fist to hit the arm rest and side of the wheelchair. On 6/20/18 at 2:05 PM, CNA 6 was interviewed. CNA 6 stated that the resident would repeatedly state it hurts. CNA 6 stated that when she really wanted something she will text or write it for the staff. CNA 6 stated she applied heat packs to the resident's lower back for pain, and stated it's hard to tell if it helps her pain, but it keeps her calm. CNA 6 stated that if it did not alleviate her pain then resident 38 would keep repeating heat. On 6/20/18 at 2:08 PM, LPN 2 was interviewed with LPN 1 present. LPN 2 stated that resident 38 has chronic pain in her back. LPN 2 stated that the resident was bathing her injured husband and slipped and fell , injuring her back. LPN 2 stated that resident 38 was on narcotic pain medication for her back injury and accidentally overdosed resulting in her [MEDICAL CONDITIONS]. LPN 2 stated that interventions for pain control included hot/ice packs and scheduled Tylenol. LPN 2 stated that nothing took away the pain and she had informed the doctor on multiple occasions but the doctor stated she can only be on Tylenol. LPN 2 stated that it is documented in numerous nursing notes. LPN 2 stated that this has been going on for at least 2 years. LPN 2 stated that she has not seen where any intervention has alleviated resident 38's pain and its really sad. LPN 1 stated its just heartbreaking. It should be noted that the nursing progress notes were reviewed from 7/5/17 to 6/19/18 and only one progress note was identified as having informed the doctor of resident 38's pain. On 6/21/18 at 8:00 AM, LPN 3 was interviewed. LPN 3 stated that she scored resident 38's pain by observing her body movements, and back pain was displayed with side to side movements. LPN 3 stated that resident 38 was sometimes able to provide a numeric pain scale, but mostly she utilized the PAINAD scale if I can't understand her. On 6/21/18 at 8:05 AM, LPN 2 was interviewed. LPN 2 stated that she used the PAINAD scale to score the residents pain because she was nonverbal. On 6/21/18 at 9:26 AM, resident 38's physician was interviewed. The physician stated that it was hard to assess the resident's pain and she's really all over the map with her communication. The physician stated that he believed that resident 38's pain was well controlled. The physician stated that it was difficult to assess the resident's pain with her [MEDICAL CONDITIONS], but that he thought the pain was well managed. The physician stated that resident 38 had not exhibited a lot of problems with pain. The physician stated that resident 38 had no complaints of chronic pain and was in the facility for an opioid overdose. The physician further stated that he did not have any problems with ordering pain medications for resident 38 in a clinical setting, but he did not see a need or indication for more pain management. On 6/21/18 at 9:34 AM, the DON was interviewed. The DON stated that resident 38 suffered from chronic low back pain. The DON stated that the resident had Tylenol ordered to cover the pain and it was effective. The DON further stated that resident 38 can have a heat pack and cold pack for pain. The DON stated that the nursing staff had not reported that her pain was not well controlled. The DON stated that staff assessed for pain by asking the resident, and the resident will state hurt. The DON stated that the resident's behavior would also indicate the need for other things such as smoking, chap stick, ice cream, pills (just states pills). The DON stated that the MAR indicated [REDACTED]. On 6/21/18 at 9:56 AM, resident 38's spouse was interviewed. The spouse stated that resident 38 has chronic pain in head and back, and that the facility gave her Tylenol for pain management. The spouse stated that the medication was not effective to alleviate the pain. The spouse stated that he talked to the facility staff about resident 38's pain, all the time. The spouse further stated that he had a discussion with the resident's physician on 6/18/18 and that the physician did not want to prescribe anything stronger with the resident's past history of abuse and an overdose. On 6/21/18 at 10:30 AM, the SSW was interviewed. The SSW stated that resident 38 exhibited behaviors of repeatedly asking for smokes, pills, heat pack, cold pack, and phone. The SSW stated that the heat and cold pack can indicate lower back pain, but it can be a behavior if she already has a heat pack in place. The SSW stated that the resident's short term memory loss required frequent reminders that the heat pack was in place. The SSW stated that requests for a heat pack were considered a complaint of pain if a pack was not already present. The SSW stated that resident 38 had a high level of anxiety and increased behaviors when her needs were not being met. The SSW stated that when resident 38 had 1:1 care her behaviors were reduced, and that the facility administration helped with her care. The SSW stated that resident 38 can communicate verbally, by typing on a phone, or by a written message. The SSW stated that resident 38 was able to communicate her level of pain and the location of the pain. Additionally, the SSW stated that resident 38 was able to state if the interventions was alleviating her pain if asked specifically about it. The SSW stated that she had wondered if the current interventions of Tylenol and heat packs alleviated her pain. The SSW stated that she believed that resident 38's [MEDICAL CONDITIONS] amplifies her request. The SSW stated that resident 38 had an accidental opioid overdose, and that the opiates were for chronic back pain. On 6/21/18 at 11:47 AM, the DON was re-interviewed. The DON was informed of the multiple observations of resident 38 crying and stating hurts, the interviews with facility staff that stated the pain was not well controlled, and the interview with the physician stating he had not been informed of uncontrolled pain. The DON stated, sound like we are not all on the same page, we have a communication problem. No additional information was provided.",2020-09-01
90,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,757,G,0,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose, excessive duration, without adequate monitoring, or without adequate indication for its use. Specifically, 2 residents did not have adequate monitoring of PT/INR ([MEDICATION NAME] ratio/international normalized ratio) laboratory values. One resident was administered 2 additional doses of [MEDICATION NAME] after the INR was high. The findings for resident 15 were cited at a HARM level. Resident 143 was cited at a potential for harm. Resident identifiers: 15 and 143. Findings include: HARM 1. Resident 15 was admitted on [DATE], discharged on [DATE], readmitted on [DATE] and discharged on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. On 6/21/18, resident 15's medical record was reviewed. A care plan dated 3/13/18 and revised on 4/17/18 revealed a Focus of (Resident 15) has an alteration in hematological status. She is at risk for [MEDICAL CONDITION] related to epistaxis (nose bleed). (Resident 15) is also at risk for prolonged bleeding related to anticoagulant medication. Recent transfusion and alterations in labs. The goal developed was, (Resident 15) will remain free of complications related to altered hematological status through the review date. Some of the interventions developed revealed, Monitor/document/report PRN (as needed) following s/sx (signs and symptoms) of [MEDICAL CONDITION]:.low hgb/hct (hemoglobin/hematocrit). and Obtain and monitor lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. Resident 15's History and Physical dated 5/16/18 revealed, CC (chief complaint)/Reason for admission: [MEDICAL CONDITION], hypovolemia. The laboratory values documented were hgb was 8.2 g/dL (grams per deciliter) which was low. The Hct was 27.4% which was low. (Note: There were no reference ranges documented on the History and Physical.) The Assessment and Plan revealed [MEDICAL CONDITION]: Hgb 8.2 on admission, stable from discharge and records from SNF (Skilled Nursing Facility). Resident 15's physician's orders [REDACTED]. a. 6/3/18, [MEDICATION NAME] Sodium Tablet Give 2.5 mg (milligrams) by mouth one time a day every Sun (Sunday), Tue (Tuesday) related to unspecified [MEDICAL CONDITION]. b. 6/2/18, [MEDICATION NAME] Sodium Tablet Give 5 mg by mouth one time a day every Mon (Monday), Wed (Wednesday), Thu (Thursday), Fri (Friday), Sat (Saturday) related to unspecified [MEDICAL CONDITION]. Nursing progress notes revealed the following: a. 6/1/18 at 8:05 PM, Pt (patient) readmitted to (name of nursing facility) from (name of hospital) following weight gain r/t (related to) [MEDICAL CONDITIONS] and [MEDICAL CONDITION].Pt has a bruise to her mid back, and some small bruises to bilateral arms. b. 6/4/18 at 4:08 PM, New order to draw PT/INR ([MEDICATION NAME] time/international normalized ratio) tomorrow r/t [MEDICATION NAME] use. c. 6/6/18 at 6:12 PM, Lab (Laboratory) results from 6/5: PT patient (sic) 42.8 (H) (high), INR 4.4 (H). Results faxed to MD (Medical Doctor) and left message with MD. Response pending. d. 6/7/18 at 1:24 PM, .Pt has had a bloody nose today likely r/t elevated INR. MD called again today about her INR level, with new orders to hold the [MEDICATION NAME] for 2 days and recheck PT/INR on 6/9/18. e. 6/7/18 at 3:06 PM, Pt's nose has continued bleeding despite clamp. MD called. Pt sent to hospital for cauterization or balloon placement. f. 6/7/18 at 5:28 PM, (Local Hospital) just called and stated pt's Hematocrit was low enough that she needed a blood transfusion, so they were sending her to (another hospital) for a blood transfusion, and also so she can get [MEDICAL TREATMENT] in the morning. MD notified. Resident 15's laboratory values completed on 6/5/18 at 6:23 PM were reviewed. Resident 15's PT was 42.8 seconds with a reference range of 8.8-11.5 seconds. Resident 15's INR was 4.4 with a reference range of 1.5-3.5. There was a written note signed by a nurse on the form that revealed, Faxed, noted (and) left message with MD 6/6/18 at 1810 (6:10 PM). An additional written note signed by a nurse with no date revealed, Hold [MEDICATION NAME] re(check) PT/INR (on) 6/9/18. Resident 15's (MONTH) (YEAR) Medication Administration Record [REDACTED]. (Note: Resident 15 had a PT/INR obtained on 6/5/18. The results were high and resident 15 was administered [MEDICATION NAME] on 6/5/18 and 6/6/18.) Resident 15's History and Physical from the hospital dated 6/7/18 revealed a chief complaint of low blood counts and need for [MEDICAL TREATMENT]. The History and Physical further revealed that .She presented to (local hospital) with a chief complaint of epistaxis. Which apparently has been happening now for the past 3-4 days. This apparently was successfully cauterized. Her INR is noted (sic) be approximately 7.8. For [DIAGNOSES REDACTED]. The History and Physical from the local hospital further revealed that resident 15's hgb was 6.0 g/dL which was a panic low with a reference range of 12.1 - 15.2 g/dL. Resident 15's Hct was 19.6 % which was a panic low with a reference range of 36.0 to 15.2%. Resident 15's PT was 72 seconds with a reference range of 9-12 seconds. Resident 15's INR was 7.7 which was a panic high with a reference range of .9-1.2. The Diagnosis, Assessment & Plan revealed 1. Acute blood loss [MEDICAL CONDITION] -will be tranfuse (sic) 1 unit PRBCs (packed red blood cells) now - will hold off on the 2nd unit PRBCs unless necessary. She will definitely need a 2nd unit of blood. But this can be given during [MEDICAL TREATMENT]. In addition, 5. Coagulopathy - INR currently is 7.7 - Will give vitamin K mg p.o (orally) (times) 1. (Note: Resident 15 was readmitted from the hospital on [DATE] with a hgb of 8.2 g/dL which was low and Hct was 27.4% which was low. Upon readmission to the hospital on [DATE] resident 15's Hgb was 6.0 g/dL panic low and Hct was 19.6% panic low. Resident was readmitted to the hospital and received PRBCs for the blood loss and Vitamin K for the high INR.) On 6/20/18 at 8:00 AM, the Director of Nursing (DON) was interviewed. The DON stated that the nursing staff obtained a physician's orders [REDACTED]. The DON stated that nursing staff obtained the blood sample in the early afternoon. The DON stated that [MEDICATION NAME] was administered during Flex hours in the evening with was between 3:00 PM and 7:00 PM. The DON stated that the [MEDICATION NAME] was administered as ordered until the laboratory results were returned and the physician provided new orders. On 6/20/18 at 10:55 AM, a follow up interview was conducted with the DON. The DON stated that she wanted to provide a Homelike environment for residents, so [MEDICATION NAME] was to be administered as ordered until the laboratory results were returned. The DON stated that PT/INR results may not be provided to the facility until the day after the blood sample was obtained. The DON stated that [MEDICATION NAME] was to be administered until the physician provided new orders. On 6/20/18 at 2:35 PM, a follow up interview was conducted with the DON. The DON stated that resident 15 did not have a reference range for the PT/INRs. The DON stated that she did not know why resident 15 received an additional 2 doses of [MEDICATION NAME] after the laboratory results revealed her PT/INR were high. The DON stated there was not a policy and procedure for [MEDICATION NAME] and PT/INR monitoring. On 6/20/18 at 9:18 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that nursing staff obtained blood samples prior to 2:00 PM and the local hospital laboratory picked up the samples around 2:00 PM. [MEDICATION NAME] doses were administered after dinner so the PT/INR results were returned prior to administering the evening dose of [MEDICATION NAME]. POTENTIAL FOR HARM 2. Resident 143 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 143's medical record was reviewed on 6/21/18. Resident 143's Home Discharge - Physician Med (medication) Order dated 9/15/17 revealed to hold [MEDICATION NAME] 5 mg at night. The orders further revealed, INR in AM - on [MEDICATION NAME]. INR on 9/15 was 5.4. [MEDICATION NAME] on hold. In addition, the physician [MEDICATION NAME]([MEDICATION NAME]) 250 mg (1 tablet) po BID (twice daily) for 5 days. There were no INRs in resident 143's medical record for 9/16/17. The facility nursing staff filled out a physician referral form dated 9/19/17. The form revealed that a facility nurse documented, Resident Nurse Observations/Patient Complaints: very, very confused, confusion over hospital orders, need PT/INR drawn today! [MEDICATION NAME]? The Physician documented, [MEDICATION NAME] 2.5 mg M (Monday) W (Wednesday) F (Friday) (and) 5 mg other days. Recheck [MEDICATION NAME] on (sic) wk (week). The form further revealed, INR (equals) 1.4. Resident 143 had a physician's orders [REDACTED]. (Note: Resident 143 completed [MEDICATION NAME] ordered on [DATE]. Resident 143 was ordered a different antibiotic on 10/2/17.) The Nursing (YEAR) Drug Handbook stated that [MEDICATION NAME] and [MEDICATION NAME] medications both have a drug interaction warning with [MEDICATION NAME]. The warning revealed, (MONTH) increase anticoagulant effect. Monitor patient carefully for bleeding. Reduce anti coagulant dosage as directed. (YEAR) Wolters Kluwer. Nursing (YEAR) Drug Handbook. Philadelphia. page 1494. Resident 143's nurses notes revealed the following entries: a. 10/5/17 at 5:27 PM, Pt is alert and oriented x 2 today with confusion. Remains on ABX (antibiotic) for UTI without adverse reactions. HRR (heart rate reserve) lung sounds CTA (clear to auscultation) and bowel sounds active (times) 4.New orders.check PT/INR, CBC and CMP (comprehensive metabolic panel) today instead of tomorrow and abdominal ultrasound on 10/6/17 noted. Blood specimen collected from right hand and sent to lab for analysis. Resting quietly in bed at this time without s/sx (sign or symptoms) of pain or distress. Will continue to monitor. b. 10/5/17 at 11:59 PM, .Received a phone call from (local hospital) lab to (sic) critical results. INR 8.8, NA + (sodium) 120, K+ (potassium) 6.9. (Physician) on call for (Resident 143's physician) gave order to transport to hospital for evaluation and treatment. Daughter notified et (and) agreed with transport.(Local hospital) notified. Resident 143's laboratory results revealed the following: a. 9/27/17, PT was 20 which was high and INR was 2.0. b. 10/5/17 at 4:00 PM, the blood sample was collected. The laboratory received the blood sample at 10:30 PM. PT was 100.4 high and INR was 8.8 PH. The results were called to the facility nurse at 10:57 PM. (Note: According to the laboratory results form the reference range for PT was 8.8-11.5 seconds and the reference range for INR was 1.5-3.5.) A review of resident 143's (MONTH) (YEAR) MAR indicated [REDACTED]. A review of the resident 143's Emergency Provider Report dated 10/5/17 at 11:57 PM revealed, .Sodium 119 PL (panic low), Plasma Potassium 6.9 PH (panic high).INR (1.5 - 3.5) 10.5 PH. I discussed the case with the hospitalist (name of physician removed) and he accepted the patient for admission. Primary Impression: Altered mental status. Secondary Impressions: Coagulopathy, Dehydration, [MEDICAL CONDITIONS]. On 6/20/18 at 9:30 AM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that PT/INR laboratory draws were completed Monday through Friday and sent to the local hospital laboratory. LPN 1 stated that after a blood sample was obtained she tried to call the laboratory prior to administering [MEDICATION NAME] to obtain the PT/INR results. LPN 1 stated that after receiving the results she notified the physician and the physician provided new orders. LPN 1 stated that she called physicians multiple times with laboratory results. LPN 1 stated that if the physician did not respond timely then she called the facility Medical Director. LPN 1 stated that she was the nurse for resident 143 on 10/5/17. LPN 1 stated that she did not remember why she contacted the physician to obtained an order for [REDACTED]. LPN 1 stated that she did not administer the [MEDICATION NAME] the evening on 10/5/17. LPN 1 stated that the night nurse administered the [MEDICATION NAME]. On 6/20/18 at 2:35 PM, the Clinical Resource Nurse (CRN) was interviewed. The CRN stated that [MEDICATION NAME] was to be administered as normal until the results were returned and the physician provided new orders. The CRN stated that if a resident was on antibiotic, then she would have increased monitoring of sign and symptoms of bleeding.",2020-09-01
91,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,758,D,0,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined for 2 out of 31 residents that the facility did not ensure that residents receiving [MEDICAL CONDITION] drugs are not given the medication unless necessary to treat a specific condition as diagnosed and documented in the clinical record and that they receive a gradual dose reduction unless clinically contraindicated. Additionally, as needed (PRN) orders are limited to 14 days unless the physician extends it beyond the 14 day requirement and documents the rationale and duration for the PRN order, and a PRN order for anti-psychotic drugs are limited to 14 days unless the physician evaluates the resident for the appropriateness of that medication every 14 days. Resident identifiers: 23 and 31. Findings include: 1. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18, resident 23's medical records were reviewed. Review of the physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. No documentation could be found of the physician evaluating the resident every 14 days with a documented rationale for the continuation of the medication. On 6/21/18 at 11:47 AM, the DON was interviewed. The DON was informed of the new regulation regarding PRN orders for anti-psychotic medications. No documentation was provided of a physician evaluation every 14 days. The DON was observed to write down the regulation information on a sticky note. 2. Resident 31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of the Physician Rationale for Clinically Contraindicated Gradual Dose Reduction (GDR) for the [MEDICATION NAME] on 5/13/15 and on 6/10/17 revealed the rationale as noted increase/return behaviors with med (medication) changes. Side effects of [MEDICATION NAME] noted. Increased refusal of cares noted as well. On 6/20/18 at 11:11 AM, the Corporate Resource Nurse (CRN) was interviewed. The CRN stated that the [MEDICATION NAME] was reduced and discontinued on 4/2/15. The CRN stated that the nursing progress note on 5/1/15 indicated increase in negative behaviors of refusing cares and being more aggressive and agitated. The CRN stated that initially the [MEDICATION NAME] was discontinued and [MEDICATION NAME] was ordered. The CRN stated that resident 31 had an Adverse Side Effect (ASE) from the [MEDICATION NAME] so it was discontinued and the [MEDICATION NAME] was restarted at the previous dosage. The CRN stated that once the facility received an order that a GDR was contraindicated then a GDR was not tried again. The CRN stated that she would have to look into if a GDR was every attempted with the [MEDICATION NAME] after it was reinstated. On 6/20/18 at 3:34 PM, the CRN was re-interviewed. The CRN stated there was no documentation of the ASE to the [MEDICATION NAME] and no physician documentation of the rationale for why a GDR of the [MEDICATION NAME] would impair the residents function. On 6/21/18 at 8:17 AM, the DON and CRN were interviewed. The DON stated after the [MEDICATION NAME] ASE occurred the [MEDICATION NAME] was ordered again at the previous dosage, and no additional GDR attempts were tried to see if the resident could tolerate a lower dose.",2020-09-01
92,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,760,D,0,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility did not ensure that resident's were free of significant medication errors. Specifically, a resident with an allergy to [MEDICATION NAME] received [MEDICATION NAME] instead of the ordered pain medication. Resident identifier: 14. Findings include: Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 14's medical record was reviewed on 6/20/18. Review of resident 14's ADMISSION RECORD revealed that resident 14 had an allergy to [MEDICATION NAME]. Review of the physician's orders [REDACTED]. On 12/27/17, an order was received to administer [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 7.5/325 mg (milligrams) 2 tablets by mouth every 6 hours as needed for pain. On 5/17/18 at 8:37 PM, a licensed nurse documented in a progress note, .Medication error: Gave 2 [MEDICATION NAME] 10 mg instead of 2 [MEDICATION NAME] 7.5 mg in error, discovered error in narcotic count. Patient has a listed allergy to [MEDICATION NAME]. MD (Medical Doctor) and wife notified. Error was approx (approximately) 2 hours ago and shows no ill effects to medication error. Wife requested we not tell him about error until possible effects would wear off as she feels his knowing would exacerbate his symptoms if any. She could not remember any ill effect to [MEDICATION NAME] in the past. VS (vital signs) stable, L[NAME] (level of consciousness) within normal limits. VS (temperature) 97.8 - (pulse) 71 - (respirations) 16 - (blood pressure) 118/67 Sats (oxygen saturation) 92%. On 6/21/18 at 10:55 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that she did not look at the medication card prior to administering [MEDICATION NAME] to resident 3.",2020-09-01
93,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,761,D,0,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with currently accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, multi-use vials of insulin were not dated with an open date and still available for use and medications were observed unattended on a resident's bedside table. Resident identifier 3. Findings include: 1. On 6/20/18 at 8:55 AM, the medication cart on the south hall was inspected. An observation was made of two multi-use vials of [MEDICATION NAME] opened without an open date labeled. The medication was available for use. An immediate interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 confirmed that the vials did not contain an open date. LPN 1 stated she would discard them and order new ones. 2. On 6/19/18 at approximately 10:00 AM, an interview was conducted with resident 3. There were two pills, appeared to be [MEDICATION NAME] and potassium, that had been placed on resident 3's bedside table.",2020-09-01
94,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,770,D,0,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined for 1 of 31 sample residents that the facility did not provide or obtain timely laboratory services to meet the needs of its residents. Specifically, a resident's blood sample was collected at 4:00 PM and the laboratory did not receive the sample until 10:30 PM. Resident identifier: 143. Findings include: Resident 143 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 143's medical record was reviewed on 6/21/18. Resident 143's nurses notes revealed the following entries: a. 10/5/17 at 5:27 PM, .New orders . check PT/INR ([MEDICATION NAME] time/international normalized ratio ), CBC (complete blood count) and CMP (comprehensive metabolic panel) today instead of tomorrow. b. 10/5/17 at 11:59 PM, .Received a phone call from (local hospital) lab (laboratory) to (sic) critical results . Resident 143's laboratory results form revealed on 10/5/17 at 4:00 PM the blood sample was collected. The laboratory received the blood sample at 10:30 PM. The results were called to the facility nurse at 10:57 PM. (Note: There was a 6 and a half hour delay from the time the blood sample was collected and the laboratory received it.) On 6/20/18 at 9:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that PT/INR laboratory draws were completed Monday through Friday and the blood sample was sent to the local hospital laboratory. LPN 1 stated that the facility staff delivered the blood samples to the hospital laboratory if they were obtained after the laboratory had been to the facility to pick them up. LPN 1 stated she did not know why there was a delay in the collection of the blood sample and when the laboratory received the blood sample.",2020-09-01
95,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,773,E,0,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 2 of 31 sample residents that the facility did not promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinic reference ranges in accordance with facility policies and procedures for notify of a practitioner or per the ordering physician's orders [REDACTED]. Resident identifiers: 4 and 15. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 6/20/18. A laboratory result form revealed that a CMP (comprehensive metabolic panel) was completed on 6/11/18. There was a hand written note at the bottom which documented, 6/18/18 noted (and) faxed to MD (Medical Doctor). On 6/21/18 at 12:14 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that resident 4's physician was not notified timely of the laboratory results. 2. Resident 15 was admitted on [DATE], discharged on [DATE], readmitted on [DATE] and discharged on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Resident 15's medical record was reviewed on 6/21/18. Resident 15 had a laboratory results form dated 6/5/18 at 6:23 PM. Resident 15's PT ([MEDICATION NAME]) was 42.8 seconds with a reference range of 8.8-11.5. Resident 15's INR (International Normalization Ratio) was 4.4 with a reference range of 1.5-3.5. There was a written note signed by a nurse that documented, Faxed, noted (and) left message with MD 6/6/18 at 1810 (6:10 PM). An additional written note signed by a nurse with no date documented, Hold [MEDICATION NAME] re(check) PT/INR (on) 6/9/18. On 6/20/18 at 9:18 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she monitored the laboratory orders and results. The ADON stated that the physicians response to laboratory results was poor. The ADON stated that if a physician did not respond to laboratory results then nursing staff notified the Medical Director. On 6/20/18 at 9:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that when she received laboratory results she called the physician that provided the order. LPN 1 stated that she wished they (physicians) responded sooner. LPN 1 stated that she had to call physicians multiple times and still did not get a response. LPN 1 stated that she would notify the Medical Director if unable to get a response from a physician. LPN 1 stated that she left the laboratory results in the Medical Directors inbox at the facility for the Medical Director to review when he was at the facility.",2020-09-01
96,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,880,E,0,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a peripherally inserted central catheter (PICC) site was not clean, dirty trays were placed in the food cart while clean food trays were on the cart, staff touched clothing and equipment then served residents food, and wound care was not clean. Resident identifiers: 9, 17, 28, 93. Findings include: 1. Resident 93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18 at 11:26 AM, Resident 93's PICC dressing was observed to be with wet blood underneath the dressing at the insertion site. The PICC dressing was not dated. On 6/18/18 at 11:35 AM, resident 93 was interviewed. Resident 93 stated her PICC dressing was changed about a week ago, but could not state when it was changed or by whom. A reivew of resident 93's medical record was completed on 6/20/18. Resident 93's admission paperwork revealed that the PICC was placed before admission to the facility on [DATE]. There was no indication in resisdent 93's medical record that the PICC dressing had been changed while the resident had been in the facility from 6/6/18 through 6/20/18. On 6/19/18 at 9:51 AM, a nurses' note documented that the PICC line dressing was clean, dry and intact. On 6/20/18 at 9:32 AM, a second observation was made of resident 93's PICC dressing. The dressing had wet blood under the dressing and approximately one-fourth of the dressing was pulled up, away from her arm. There was no date on the dressing. On 6/20/18 at 10:55 AM, LPN 1 was interviewed. LPN 1 reported that resident 93 had left the facility for a short time, showered at home and returned to the facility about a week ago with her PICC dressing pulling up. LPN 1 stated that she had changed Resident 93's PICC dressing and put the date on a piece of tape on top of the dressing. She reported that there were no doctor's order to change the dressing, but that it should be changed weekly and as needed if it was dirty, soiled, not sealed, or wet. LPN 1 reported that she changed the dressing today because it was pulling up. On 6/20/18 at 11:18 AM, resident 93's PICC dressing was observed to be clean, dry and intact with the date written on the dressing. On 6/20/18 at 3:20 PM, the Director of Nursing (DON) was interviewed. The DON provided documentation that a PICC dressing kit had been sent from the pharmacy and was delivered to the facility. The DON stated that after a resident is admitted to the facility, the PICC dressing should be changed within 24 hours, then every 7 days, or more frequently as needed for problems. The DON was unable to provide documentation that resident 93's PICC dressing was changed. 2. On 6/19/18 at 11:43 AM, CNA 3 was observed to pass hall trays on the South hallway. A food tray was taken in to room [ROOM NUMBER]. CNA 3 brought the tray out of the room approximately 18 minutes later and put it back in the top of the cart. Afterwards, a tray with food was taken out of the cart and taken into room [ROOM NUMBER]. The resident asked for water and was repositioned. The resident stated that he did not want to eat, so the tray was brought out and placed on the cart. The cart was then taken to residents down the East hallway. On 6/20/18 at 1:51 PM, CNA 4 was interviewed. CNA 4 reported that she had worked seven years as a CN[NAME] CNA 4 reported that if she served meals, and the resident refused to eat, she would put the hall tray back in the specific resident's slot on the hall cart. On 6/21/18 at 11:53 AM, the Dietary Manager (DM) was interviewed. She reported that meals returned on the dining cart are thrown away if they go into a resident's room. DM stated that all trays should be delivered clean before picking up dirty trays. 3. On 6/19/18 12:28 PM, CNA 3 was observed feeding two residents in the dining room simultaneously. CNA 3 fed the residents, touched their clothing, touched silverware, wiped one resident's mouth, and continued to feed both residents without hand sanitizing. On 6/20/18 at 1:51 PM, CNA 4 was interviewed. CNA 4 reported that she had worked seven years as a CN[NAME] CNA 4 reported that she performed hand hygiene after leaving each room, when she changed gloves, and before and after meals, along with after using the restroom. CNA 4 reported that when feeding residents in the dining room, if you touch your radio, you must wash your hands. On 6/20/18 at 1:54 PM, CNA 5 was interviewed. CNA 5 reported that she understood hand hygiene must be performed after touching any resident, after wearing gloves, and upon entering and leaving a room. She reported that she washes her hands before feeding residents, after wearing gloves, and after finished feeding them. On 6/20/18 at 2:01 PM, the DON was interviewed. The DON reported that staff should perform hand hygiene while feeding residents if they touch anything else. The DON stated if the resident also touched the silverware, staff should use hand hygiene. 4. Resident 17 was admitted with [DIAGNOSES REDACTED]. Review of the orders for wound care revealed: a. Left 3rd proximal toe ulcer: Cleanse with NS (normal saline), apply very small amount of hydrogel to the wound bed as the primary dressing, cover with moistened saline gauze that is cut to fit the wound bed, oil [MEDICATION NAME] gauze (also cut to fit wound bed), dry 4 X gauze and 1 inch kling. Change daily. b.Left posterior ankle: Cleanse with NS or puracyn plus. Use cutimed sorbact as the primary dressing. Cover with [MEDICATION NAME], kling, and stockinet as the secondary dressing. Change dressing a daily and PRN (as needed). c.Left posterior proximal ankle: Cleanse with NS and puracyn, use cutimed sorbact as the primary dressing, cover with [MEDICATION NAME], kling and stockinet as the secondary dressing. Change daily and PRN. d.Left Anterior lateral lower leg: Cleanse with NS or puracyn. Cover with cutimed sorbact as the primary dressing and then [MEDICATION NAME], kling and stockinet as the secondary dressing. Change daily and PRN. e.Dressing change to left anterior lower leg: Cleanse with NS or puracyn, cutimed sorbact as primary dressing, cover with [MEDICATION NAME], kling and then stockinet as secondray dressing. Change daily PRN f.Left lateral foot ulcer: Clean; dress with non adhesive foam and wrap with kerlix. Change daily Review of the Wound Rounds Assessment on 6/15/18 revealed the following wounds: a. Left third proximal toe, classified as a venous stasis ulcer, measures 4 centimeters (cm) by (X) 1.5 cm X 0.2 cm b. Left anterior lateral lower leg, classified as a venous stasis ulcer, measures 2 cm X 1.3 cm X 0.1 cm c. Left lower leg anterior, classified as a venous stasis ulcer, measures 7.5 cm X 4 cm X 0.2 cm d. Left posterior ankle, classified as a venous stasis ulcer, measures 2 cm X 1.3 cm X 0.1 cm e. Left posterior proximal ankle, classified as a venous stasis ulcer, measures 1 cm X 0.9 cm X 0.1 cm On 6/19/18 at 11:43 AM, resident 17 was interviewed. Resident 17 stated that the reason his wounds were not healing was because of diminished blood flow, and that he was going to have a stent placed on Thursday. Resident 17 stated that the tip of his left toe was not attached to the bone and was only attached by the muscle. Resident 17 stated that the wound now smells and was no longer healing. On 6/19/18 at 1:20 PM Licensed Practical Nurse (LPN) 3 was observed performing resident 17's dressing change. LPN 3 was observed to assembly all necessary supplies for each dressing order and prepare the materials for access during the wound care. LPN 3 was observed to wash her hands and apply clean gloves. LPN 3 then removed all the old dressings and cleansed the wounds with normal saline and guaze. LPN 3 removed her soiled gloves and washed her hands. New gloves were applied and LPN 3 proceeded to perform wound care and apply all new dressings. At 1:50 PM, LPN 1 entered resident 17's room and requested a set of keys from LPN 3. LPN 3 was still in the process of applying new dressings to resident 17's wounds. LPN 3 then reached into her pocket with her right hand, retrieved the keys, and handed them to LPN 1. LPN 3 was then observed to cut a sterile piece of moistened saline gauze and oil [MEDICATION NAME] gauze. The dressing materials were placed on resident 17's left 3rd proximal toe wound bed. A 2 X 2 dry guaze dressing was wrapped around the toe and secured into place. LPN 3's right hand was observed to touch the dressings and resident 17's wound bed. No observation was made of LPN 3 changing her gloves or washing her hands after she handed LPN 1 the keys. On 6/19/18 at 2:00 PM, LPN 3 was interviewed. LPN 3 stated that she tried to reduce cross contamination during the dressing change by educating the resident not to touch the wounds while she was providing wound care. LPN 3 was informed of the observation of cross contamination with touching her keys. LPN 3 stated, Oh, I did do that. I didn't even think about it. 5. Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 28 was started on hopice services on 11/15/17 and received pressure ulcer wound care. On 6/20/18 at 2:39 PM, LPN 2 was observed performing a dressing change for resident 28. LPN 2 placed the nozzle of the multi-use bottle of wound cleanser on the gauze before cleaning open wound areas. LPN 2 touched her clothing and a marking pen with her gloved hand before she applied two dressings to open areas of skin. 6. Resident 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/19/18 at 1:25 PM, Certified Nursing Assistants (CNA's) 6 and 7 were observed providing incontinence cares to resident 9. Resident 9 was placed in supine in bed after being transferred from the wheelchair to the bed via a mechanical lift. CNA 7 removed resident 9's urine soak pants and the wet mechanical lift sling and placed the soiled garments at the head of resident 9's bed on the left side. On 6/19/18 at approximately 1:45 PM, CNA 7 was interviewed. CNA 7 stated that the soiled clothing should not have been placed at the head of the bed next to resident 9's head. On 6/19/18 at 1:50 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that soiled linens were to be placed in a bag and not next to resident 9's head.",2020-09-01
97,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,923,E,0,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined the facility did not have adequate ventilation to ensure good air circulation. Specifically, there were odors in the facility and some bathroom fans were not functioning. Findings include: 1. On 6/18/18 at 8:10 AM, during the initial tour of the facility there was an observation made in the hallway. There was a strong bowel movement odor that permeated into the hallway from room [ROOM NUMBER] on the east hall. 2. On 6/18/18 at 10:36 AM, the bathroom fan was not be functioning in room [ROOM NUMBER] on the south hall. 3. On 6/19/18 at 9:48 AM, the bathroom fan was not be functioning in room [ROOM NUMBER] on the south hall. 4. On 6/19/18 at 10:44 AM, an observation was conducted in the hallway. There was a strong bowel movement odor that permeated into the hallway from room [ROOM NUMBER] on the east hall. 5. On 6/21/18 at 8:43 AM, an interview was conducted with the Administrator. The Administrator stated he would check to see if the fan was functioning. The Administrator returned and stated that the fan was now working. 6. On 6/18/18 at 1:48 PM, the bathroom fan was not functioning in room [ROOM NUMBER] on the south hall. 7. On 6/19/18 at 10:27 AM, the bathroom fan not functioning in room [ROOM NUMBER] on the south hall. 8. On 6/21/18 at 11:19 AM, an observation was conducted in the hallway. There was a strong bowel movement odor that permeated into the hallway from room [ROOM NUMBER] on the east hall. On 6/21/18 at 8:43 AM, an interview was conducted with the Maintenance Director. The Maintenance Director stated that he checked fan and discovered a broken belt on the roof. The Maintenance Director stated that the belt was essential for all the bathroom fans on the east end of the east hall. On 6/21/18 at 8:07 AM, an interview was conducted with the Administrator and Maintenance Director. The Maintenance Director stated that for non-working bathroom fans, staff tell him in morning meeting. The Maintenance Director stated that the bathroom fans were being replaced. The Maintenance Director further stated, We've been working on them for a while. We still have more to do. The Maintenance Director reported that there was a central fan on the roof that controls the fans in the back hallway that should be on all the time.",2020-09-01
98,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2018-06-21,925,D,0,1,EUNP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility did not maintain an effective pest control program so that the facility was free of pests and rodents. Specifically, the facility had ants, another insect, and spiders in multiple areas. Findings include: The following observations were made: a. On 6/18/18 at 11:03 AM, ants on a piece of food on the floor in room [ROOM NUMBER]. b. On 6/18/18 at 12:37 PM, a spider was observed descending from the door frame in the East hall. c. On 6/20/18 at 11:32 AM, a spider was on the floor in the charting office. d. On 6/21/18 at 8:48 AM, a large spider web observed in room [ROOM NUMBER]'s window. e. On 6/21/18 at 2:15 PM, a spider and an insect were observed during exit conference in the Admissions office. A review of the facility pest control records revealed spraying for pests had been completed monthly. On 6/20/18 at 12:54 PM, an interview was conducted with the Maintenance Director. The Maintenance Director stated that ants come in because of food that was dropped. The Maintenance Director stated that unless you spray a spider directly, you can't kill a spider.",2020-09-01
99,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2019-10-28,697,D,1,0,KWP211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, it was determined, for 1 of 7 sampled residents, the facility did not ensure that pain management was provided for residents who required such services, consistent with professional standards of practice and the residents' goals and preferences. Specifically, one resident did not receive consistent and ongoing pain monitoring and prescribed pain medication while on respite care. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/28/19, resident 1 was observed in his room. Resident 1 stated that he did not receive all the medications he needed. Resident 1 stated that his pain was usually around 4 or 5 when he wasn't moving, but when he got himself out of bed, the pain was 8 or 9 out of 10. Resident 1 stated that his right shoulder was bone on bone so when he moved, he was close to screaming because of pain. Resident 1 stated that he had chronic back pain, and severe pain in his left thigh muscle. Resident 1 stated that the nurses haven't asked me about my pain. Resident 1 stated that he was taking narcotic pain medication twice a day at home, when he needed it. Resident 1 stated that the more he moved, the more pain he experienced. Resident 1 stated that he had been in severe pain dozens of times a day. Resident 1 stated that he could not call for help every time he went to the restroom because it was at least 4 to 5 times a day and he could not wait for staff. Resident 1 stated that he was in real bad pain when they talked to me a few days ago. On 10/28/19 a record review was conducted for resident 1's electronic medical record. Review of resident 1's physician orders [REDACTED]. This order was started on 10/26/19 at 11:00 AM. Review of resident 1's pain scores revealed the following: a. On 10/26/19, no pain scores were recorded for resident 1. b. On 10/27/19 at 12:49 AM, a pain score was recorded at 0/10. c. On 10/28/2019 at 1:05 PM, a pain score was recorded at 5/10. d. On 10/28/19 at 10/28/2019 1:32 PM, a pain score was recorded at 3/10. The Treatment and Monitoring for resident 1 was that nurses were to Question resident about presence of pain or burning including pressure points. Monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible. If resident is not able to answer, use PAINAD scale. every shift. One entry for the morning of 10/27/19 recorded no pain, but non-pharmacological pain interventions were utilized, which included repositioning, reassurance/emotional support, rest period/quiet environment, and laughter/socialization. Review of the Medication Administration Record [REDACTED]. Resident 1's baseline care plan revealed that pain was not addressed. The two focuses included in resident 1's care plan were: a. activities of daily living (ADL) deficit, and b. limited physical mobility. The electronic record revealed that the required tasks for the Certified Nursing Assistants (CNAs) to complete for resident 1 included documentation that assistance required was for resident 1's Activities of Daily Living (ADLs), ranging from supervision to extensive assistance. A nursing note on 10/26/19 at 5:27 PM, revealed Resident did not bring prescription of [MEDICATION NAME] with him. Hospice notified, but they were unwilling to provide more because he is 'on hold with them'. On call provider (name withheld) not answering phone. (Note: The on-call physician was not contacted after the Hospice company stated that resident 1 was not currently receiving hospice services.) Resident 1 was followed by a hospice company, who provided documentation for resident 1's admission. The hospice company included the order for [MEDICATION NAME] 325-[MEDICATION NAME] 10 mg tablet, 1 tablet by mouth every four hours, if needed, on resident 1's orders, and included information that it was not being provided by the hospice comapny. The respite stay was expected to be for 9 days while family was out of town. The hospice company progress notes revealed that resident 1 had a prescription for [MEDICATION NAME] 325-[MEDICATION NAME] 5 mg. The prescription stated: a. On 7/8/19, the order was for 1-2 tablets every 6 hours as needed for pain. b. On 9/24/19, the order one tablet every 6 hours. (Note: This prescription was increased to twice as much [MEDICATION NAME] (10 mg versus 5 mg previously) and the frequency of medication administration decreased from 6 hours to four hours.) c. On 10/11/19, the order was for 325-10, one tablet every 4 hours. The order was completed on 10/20/19, with additional doses that were not provided by the hospice company. On 8/6/18, a hospice company progress note revealed that resident 1 had pain with active ROM (range of motion) of left thigh. Pain is also chronic for resident 1's lower back. On 10/28/19 at 12:20 PM, an interview was conducted with CNA 1. CNA 1 stated that she did not assist resident 1 since he was admitted . CNA 1 stated that she was assigned to the hall, but resident 1 did not require assistance. On 10/28/19 at 12:22 PM, an interview was conducted with CNA 2. CNA 2 stated that she brought resident 1 his breakfast, brought resident 1 a drink at breakfast, and refilled his water, but did not assist resident 1 to the restroom or assist him with any other cares On 10/28/19 at 12:11 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should have attempted more than once to obtain pain medication for resident 1. On 10/28/19 at 12:25 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that all residents' pain was assessed upon admission. RN 1 stated that she was aware that resident 1 had requested pain medications on 10/26/19, but resident 1's narcotic pain medication was not available. RN 1 stated that resident 1 had reported pain at 7, which was not recorded in the medical record. RN 1 stated that resident 1 had reported pain. RN 1 stated that she did not know if resident 1's pain was related to [MEDICAL CONDITION]. RN 1 stated that resident 1 had a list of current orders with pain medication but because staff didn't have a signed prescription, they could not get resident 1's pain medication. On 10/28/19 at 12:18 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 1 had complained of chronic back pain on the weekend. LPN 1 stated that resident 1 did not ask for help most of the time, so he was not assessed when he transferred or ambulated. On 10/28/19 at 12:27 PM, an interview was conducted with the Nurse Practitioner (NP). The NP stated that she was informed that resident 1 required pain medications approximately one hour earlier. The NP stated that the office had been contacted over the weekend, on 10/26/19, due to resident 1's pain. The NP reported that facility staff did not report significant pain for resident 1. The NP stated that pain medication was not provided, but a prescription could have been faxed for narcotic medication if a report of serious pain had been conveyed by staff. The NP stated that weekend on-call providers did not visit residents at facilities.",2020-09-01
100,PIONEER CARE CENTER,465020,815 SOUTH 200 WEST,BRIGHAM CITY,UT,84302,2019-10-28,760,G,1,0,KWP211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility did not ensure that 1 of 7 sample residents was free of significant medication errors. Specifically, a resident was given his roommate's medications, and was subsequently hospitalized . As of 10/27/19, the facility had identified the concern, and had implemented a Quality Assurance (QA) plan which included audits, monitoring, and preventative measures to prevent further incidences. Therefore, past non-compliance at a harm level was cited. Resident identifier: 1. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's medical record was reviewed on 10/28/19. A nurses' progress note on 10/20/19 at 10:56 PM documented .Resident was given [MEDICATION NAME] and [MEDICATION NAME] in error. Resident responsive to stimuli. Neuro (neurological) checks within normal limits. Another nurses' noted dated 10/21/19 at 3:32 AM documented (Resident 1) in 21-B, reports c/o (complaints of) SOB (shortness of breath) with rales and crackles. that began on 10/20/2019 2:30 AM and have gotten worse since the onset. NA (?) make the symptoms worse, while Oxygen 4L (liter) improve the symptoms. Other relevant information - Medication error at about 2000 (10:00 PM) .The relevant areas to the change in condition is: Respiratory Status Changes, Shortness of breath, Abnormal lung sounds, Labored breathing. Assessment : The current problem seems to be related to Cardiac, Respiratory, .Medication error. Recommendation: (name redacted) NP (nurse practitioner) was notified and made aware of the resident's current status. The following orders were received: hospitalization with emergency transport. A follow up nurses' note dated 10/21/19 at 7:35 AM documented REsident (sic) taken to the hospital at about 3:30 am by EMTs (emergency medical transport). Pt (patient) was stabilized on a [MEDICAL CONDITION] (bilevel positive airway pressure) breathing machine and began improving according to ER (emergency room ) nurse sho (sic) also expected his non-responsiveness will pass in the next 12 hours as the medication wears off. (Note: resident 1 was admitted to the local hospital and did not return to this facility.) A hospital progress note dated 10/21/19 at 3:25 AM, documented [AGE] year-old male brought in by EMS (emergency medical services) in severe respiratory distress. According to paramedics the patient allegedly was given his roommates medications by mistake. This happened between 7:00 p.m. and 11:00 p.m. last night. Apparently the year (sic) was recognized right away and they opted to just monitor the patient. Over the last several hours he has apparently had worsening trouble breathing and decreased mental status. Patient is apparently normally alert and talkative. He is a full code. When his breathing became worse and his oxygen saturations began to drop they contacted 911. By EMS arrival the patient was obtunded but breathing on his own. He was placed on [MEDICAL CONDITION] (continuous positive airway pressure) which he fought briefly and then tolerated. EMS states that he was not opening his eyes and was responding only to pain. Medications given in error were [MEDICATION NAME] 10 mg, [MEDICATION NAME] 200 mg, [MEDICATION NAME] 300 mg, [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] 100 mg. It also appears that he was given his usual evening medication including 10 mg of [MEDICATION NAME] 40 mg, and [MEDICATION NAME] 125 mg. A follow up hospital note from a re-evaluation on 10/21/19 at 4:45 AM, documented I discussed this case with poison Control. Based on the medication and amounts that patient received they estimated at least another 10-12 hours of sedation. They were not aware of any potentially useful reversal agents. Patient did have a gag reflex. He did respond to pain but not voice. Over the course of the 1st hour he stayed on [MEDICAL CONDITION] he was moaning more and becoming somewhat more responsive to pain. His ABG (arterial blood gases) done 1 hr after arrival showed PH of 7.33 with pCO2 of 46 and a PO2 of 133. His oxygen saturation remained at or above 97% on [MEDICAL CONDITION]. patient was switched to [MEDICAL CONDITION]. He tolerated this well. Patient was becoming more verbal and moving more. Vital signs remained within the normal range. The on-call respiratory tech is agreeable to staying in the hospital to monitor the patient. I will be available should his respiratory status decline. He will be admitted to our step-down ICU (intensive care unit), where he will be kept on [MEDICAL CONDITION] and monitored. A Quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE] documented under section G, that resident 1 required limited assistance from 1 person for bed mobility, ambulation, and toilet use. Resident 1 was documented as needing extensive assistance of 1 person to transfer from bed, and needed set up and supervision assistance only for eating. A progress note from resident 1's new admitting facility, dated 10/23/19, documented (Resident 1's) current reason for skilled stay is lethargic and weak, confused, requires ext (extensive) assist with cares and staff to anticipate needs, requires assist with eating, nutrition and medication management. Alertness/Cognition/Orientation: responds to loud voice, able to answer simple questions appropriately, speech slurred, drowsy. The resident's functional status ability is: The resident is dependent with bed mobility; transfers did not occur; extensive assist with eating; dependent with toileting; walking did not occur; and locomotion did not occur. An addition progress note, dated 10/27/19, documented Resident in bed this morning during breakfast. He is a total feed. He doesn't attempt to do any help. Staff will attempt to get him out of bed for lunch and take him to the assist dine (sic). On 10/28/19 at 10:31 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that on 10/21/19 an agency nurse who was not familiar with the residents, was administering medications. The DON stated that the nurse went to administer resident 1's medications and got resident 1 mixed up with his roommate. The DON stated that the error was realized about 10 minutes later, the doctor was called and regular vital sign checks and monitoring was started. The DON stated that resident 1 started having a change in condition around 3:00 AM on 10/21/19, the nurse called the doctor, who ordered that the resident be sent to the ER. The DON stated that the facility had since started a 4 point process to correct medication errors. On 10/28/19 at 12:09 PM, a phone interview was conducted with resident 1's family member. The family member stated that resident 1 had not been out of bed, could not move his arms, and could not see as well since the medication error. The family member stated that prior to the medication error resident 1 was able to get up and feed himself which he could no longer do. On 10/28/19 at 1:30 PM, a phone interview was conducted with the Medical Doctor (MD) 1. MD 1 stated on 10/20/19 a nurse gave resident 1 his roommate's medications, which were mostly psychiatric medications. MD 1 stated that the combination of medications resident 1 received would definitely cause sedation and respiratory depression, especially since resident 1 did not usually take any similar medications.",2020-09-01