PRINTED: 01/22/2018 DEPARTMENT OF HEALTH AND HUMAN ... · (x1) provider/supplier/clia department of...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

01/22/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

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(X3) DATE SURVEY

COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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DATECROSS-REFERENCED TO THE APPROPRIATE

EVANSVILLE, IN 47710

155390 12/20/2017

GOLDEN LIVING CENTER-WOODBRIDGE

816 N FIRST AVE

00

F 0000

Bldg. 00

This visit was for the Investigation of

Complaint IN00242103.

Complaint IN00242103 - Substantiated.

Federal/state deficiencies related to the

allegations are cited at F692, F740, F745,

and F773 .

Survey dates:

December 18, 19, 20, 2017

Facility number: 000438

Provider number: 155390

AIM number: 100274170

Census Bed Type:

SNF/NF: 57

Total: 57

Census Payor Type:

Medicare: 6

Medicaid: 51

Total: 57

These deficiencies reflect State Findings

cited in accordance with 410 IAC 16.2-3.1.

Quality review completed on December 28,

2017.

F 0000 This plan of correction is to serve as

Golden LivingCenter – Woodbridge’s

credible allegation of compliance.

Submission of this plan of

correction does not constitute an

admission by Golden

LivingCenter-Woodbridge or its

management company that the

allegations contained in the survey

report are a true and accurate

portrayal of the provision of

nursing care and other services in

this facility. Nor does this

submission constitute an agreement

or admission of the survey

allegations.

FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclo

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: LPIY11 Facility ID: 000438

TITLE

If continuation sheet of 40

(X6) DATE




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816 N FIRST AVE

00

483.25(g)(1)-(3)

Nutrition/Hydration Status Maintenance

§483.25(g) Assisted nutrition and hydration.

(Includes naso-gastric and gastrostomy

tubes, both percutaneous endoscopic

gastrostomy and percutaneous endoscopic

jejunostomy, and enteral fluids). Based on a

resident's comprehensive assessment, the

facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable

parameters of nutritional status, such as

usual body weight or desirable body weight

range and electrolyte balance, unless the

resident's clinical condition demonstrates

that this is not possible or resident

preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake

to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet

when there is a nutritional problem and the

health care provider orders a therapeutic diet.

F 0692

SS=G

Bldg. 00

Based on interview and record review, the

facility failed to ensure a resident was

weighed on admission; failed to notify the

physician of weight losses; and failed to

monitor fluid intake in a resident with a

F 0692 F692

What corrective action(s) will be

accomplished for those residents

found to have been affected by the

deficient practice: Resident B no

longer resides at the facility. No

01/12/2018 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LPIY11 Facility ID: 000438 If continuation sheet of 40




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816 N FIRST AVE

00

decreased intake and thickened liquids,

resulting in hospitalization with diagnoses

including dehydration, for 1 of 3 residents

reviewed for weight and hydration status, in

a sample of 3.

( Resident B)

Findings include:

The closed clinical record of Resident B

was reviewed on 12/18/17 at 10:10 A.M.

The resident was admitted to the facility on

9/21/17 with diagnoses including, but not

limited to, anterior dislocation of left

humerus (shoulder), severe intellectual

disabilities, cerebral palsy, dysphagia

[difficulty swallowing], and schizoaffective

disorder.

An admission assessment, dated 9/21/17 at

5:00 P.M., indicated Resident B was

"non-verbal," and was able to understand

others. The "Nutritional Risk" section of the

assessment was left blank. The admission

weight was left blank.

An admission Minimum Data Set (MDS)

assessment, dated 9/28/17, indicated

Resident B had a short term and long term

memory problem, and was severely

impaired in cognitive skills for daily decision

making. Behavior assessment 1 (occurred

corrections will be necessary. How

will other residents having the

potential to be affected by the same

deficient practice be identified and

what corrective action(s) will be

taken: Medical records for current

residents admitted within the last

30 days will be reviewed to ensure

admission weights were obtained

and recorded in their medical

record. Any resident who has

admitted within the last 30 days

who does not have a weight

recorded in the medical record will

be weighed and the weight will be

documented in the medical record.

Nutritionally At Risk meeting notes

for the last 30 days will be reviewed

to ensure significant weight losses

were communicated to the

physician and that the facility

received the physician’s

acknowledgement of receipt. If a

significant weight loss was not

communicated to the physician

within the last 30 days, the facility

will notify the physician of the

significant weight loss. Residents

with a significant weight loss and

residents that receive thickened

liquids will be monitored for fluid

intake and will be reviewed daily in

the Clinical Start Up meeting.

What measures will be put into

place or what systemic changes will

be made to ensure that the

deficient practice does not recur:

The DNS or designee will in-service

the staff on weighing residents on

admission, monitoring residents’

weights, the reporting of weight

losses to the attending physician,

receiving physician





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816 N FIRST AVE

00

1-3 days in the previous 7 days) was

Physical 1, Verbal 1, Other 1 and 1

rejection of care. The resident required

extensive assistance of one staff for eating.

There was no weight documented.

The first recorded weight, dated 10/4/17,

was 146 lbs [pounds].

A Nurses Note, dated 10/4/17 at 3:54

P.M., indicated, "Order changed to puree,

she got chocked [sic] on a cookie yesterday

and we are changing diet so res [resident]

can swallow easier."

A Nutrition Assessment, dated 9/28/17 and

"locked" 10/5/17, indicated Resident B's

current body weight was 146#. The

assessment indicated she required

approximately 1991 calories daily, and

required approximately 1991 cc fluid daily.

The assessment indicated, "Admit [with] dx

[diagnosis] of dislocation L [left] humerus

[shoulder]...dysphagia. Diet pureed;

consuming 77% of meals. Fed per staff.

Recent swallowing episode leading to

downgrade of diet to puree...Nutrition

Interventions: Diet per MD, Meds per MD,

Monitor weight, Monitor intake...."

A Nursing Progress Note, dated 10/13/17

at 11:14 A.M., indicated, "Resident

acknowledgement of the weight loss

and fluid intake monitoring for

resident with significant weight

losses and/or receiving thickened

liquids. How the corrective

action(s) will be monitored to

ensure the deficient practice will

not recur, i.e., what quality

assurance program will be put into

place: The ED or her designee will

monitor the admission weights,

physician notification of weight

losses and fluid intake monitoring

on a daily basis, 7 days per week for

two week and then 5 days per week

for 6 months. The results will be

reviewed monthly in QAPI for 6

months and then PRN if no trends

are noted. Date the systemic

change(s) will be completed:

January 12, 2018.

We are requesting paper

compliance for F692.





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816 N FIRST AVE

00

followed due to new admission, weight is

146# on 10-04-2017, no weight this week

due to unable to obtain due to behavior, diet

is pureed, intake 84%, will continue to

monitor...."

The resident's weight on 10/18/17 was

153#.

Nursing Progress Notes continued:

10/26/17 at 10:55 A.M.: "...weight is 148#,

weight loss of 5# in 1 week, diet is pureed,

intake 92%, will continue to monitor...."

Documentation that the physician was

notified of the weight loss was not found in

the clinical record.


11/2/17 at 12:21 P.M.: "...weight is 148#,

no change x 1 week, diet is pureed, fluids

changed to NTL [nectar thickened liquids]

with thin water on 10/31/17, intake 80% will

continue to monitor...."

11/6/17 at 2:42 P.M.: "Resident with

productive cough; light yellow per

therapy...Ordered chest xray stat...."

11/7/17 at 10:16 A.M.: "Resident unable to





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816 N FIRST AVE

00

swallow medications/or eat - currently NPO

[nothing by mouth]. ST [speech therapy]

evaluated...[POA] request send to ER for

evaluation/treatment...."

The resident returned to the facility on

11/7/17 at 6:54 P.M. with no new orders.

Nurses Notes continued:

11/9/17 at 10:45 A.M.: "...Weight is 140#,

down 8# x 1 week, diet is

pureed...recommend [sic] two cal 90 cc

TID [three times daily] will continue to

monitor...."

Documentation that the physician was

notified of the weight loss was not found in

the clinical record.

Nurses Notes continued:

11/16/17 at 10:22 A.M.: "...weight is 141#,

up 1# x 1 week...will continue to monitor...."

11/21/17 at 12:05 P.M.: "Resident having

problems swallowing. Speech therapy

aware...Is still having loose stools. Is on all

liquid diet for next day...will continue to

monitor."

11/22/17 at 2:57 P.M.: "Notified [physician]





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816 N FIRST AVE

00

of refusal of supplements, will review in

NAR [nutrition at risk]...."

11/24/17 at 7:37 A.M.: "...noted more

lethargic compared to baseline...appetite &

hydration have been decreased compared to

baseline, total care with feedings...."

11/24/17 at 3:50 P.M.: "Pt [patient] has

increased congestion, refusing to eat, and

afebrile...New order for [lab work] and

chest x ray...."

11/25/17 at 2:11 A.M.: "Resident has had a

decrease in level of functioning...having

difficulty swallowing...chest x-ray came

back clear...will continue to monitor."

11/27/17 at 8:27 A.M.: "[Name of POA]

returned call regarding refusing supplements.

ST [speech therapy] recommendation for

barium swallow, but resident may be

uncooperative with instructions.

POA...agreeable for placement of a feeding

tube. Will update [physician]."

11/28/17 at 1:50 P.M.: "[Name of

physician's nurse] will contact [surgeon] to

set up an appt [appointment] for feeding

tube. Awaiting reply."

11/28/17 at 2:16 P.M.: "...Having to remind





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816 N FIRST AVE

00

resident to swallow with medication

administration. Ate a little breakfast and

slept through lunch...."

11/29/17 at 6:30 A.M.: "Resident did not

swallow medication. This nurse attempted to

swab mouth clean, resident a little resistive

to clean her mouth."

11/29/17 at 7:27 A.M.: "...Respirations

became very raspy...Suctioned the

resident...called 911...resident sent to ER

per ambulance...."

A hospital history and physical, dated

11/29/17 at 9:53 A.M., indicated, "...Recent

concern for possible aspiration and poor

oral intake on puree diet with nectar thick

liquids...Lab work on admission showed a

sodium of 160 (normal 136-145),

BUN/Creatinine was 42/1.9 (normal

8-23/.4-1.1)...Assessment/Plan: Sepsis -

Likely 2nd to aspiration pneumonia. Chest

x-ray negative but could be dehydrated.

Hypernatremia [elevated sodium level]

Likely 2nd to extreme volume depletion.

Acute kidney injury Likely 2nd to volume

loss...."

On 12/19/17 at 2:40 P.M., the

Administrator indicated there was no intake

and output monitoring for Resident B. The





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816 N FIRST AVE

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DON indicated at that time that the facility

would only do intake and output monitoring

if a resident was on restricted fluids, or if a

resident had a catheter.

On 12/20/17 at 2:05 P.M., the Dietary

Manager (DM) was interviewed. She

indicated Resident B was weighed weekly at

first because she was a new admission, and

then was weighed because her weights were

fluctuating. She indicated, "We monitor food

consumption in our NAR meetings." She

indicated they did not monitor fluid

consumption.

On 12/20/17 at 2:10 P.M., the DM

provided the current facility policy

"Hydration," dated 12/17/15. The policy

included: "The dietician calculates daily fluid

requirements for all patients annually or with

changes in condition. The following are risk

factors for dehydration: Coma/decreased

sensorium, Fluid loss and increased fluid

needs (e.g. diarrhea...), Functional

impairments making it difficult to drink,

reach for fluids or communicate fluid needs

(e.g. aphasia [difficulty communicating],

thickened liquids)...Refusal of fluids...."

This Federal tag relates to Complaint

IN00242103.





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816 N FIRST AVE

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3.1-46(a)(1)

3.1-46(b)

483.40

Behavioral Health Services

§483.40 Behavioral health services.

Each resident must receive and the facility

must provide the necessary behavioral health

care and services to attain or maintain the

highest practicable physical, mental, and

psychosocial well-being, in accordance with

the comprehensive assessment and plan of

care. Behavioral health encompasses a

resident's whole emotional and mental

F 0740

SS=D

Bldg. 00





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816 N FIRST AVE

00

well-being, which includes, but is not limited

to, the prevention and treatment of mental

and substance use disorders.


facility failed to develop and implement a

plan to manage behaviors, for 2 of 3

residents reviewed for behaviors, in a

sample of 3.

(Residents B and F)

Findings include:

1. The closed clinical record of Resident B






disabilities, cerebral palsy, ad schizoaffective

disorder.



"non-verbal," was able to understand others,

was unable to transfer independently, could

ambulate with limited assist, was frequently

incontinent of bladder, and was at risk for

falls and pain. "Immediate Plans of Care"

indicated "Pain, Behavioral, Falls, and

Anticoagulant" were warranted. There were

no interventions documented regarding those

needs.

F 0740 F740






corrections will be necessary. Care

plans, interventions and

documentation will be reviewed for

Resident F and corrected as

indicated. How will other

residents having the potential to be

affected by the same deficient

practice be identified and what

corrective action(s) will be taken:

The medical records of residents

with behaviors will be reviewed for

completed care plans, interventions

and documentation. Corrections

will be made as indicated. What

measures will be put into place or

what systemic changes will be made

to ensure that the deficient practice

does not recur: The DNS or designee

will in-service the staff on the

facility behavior management

policy. Behaviors will be reviewed

daily in the Clinical Start Up

meeting. How the corrective





place: The ED or her designee will

monitor the care plans,

interventions and documentation on

01/12/2018 12:00:00AM





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Nursing Progress Notes included the

following notations:

9/22/17 at 2:44 A.M.: "Resident arrived to

facility from [name of hospital] around 5

PM...having trouble adapting to facility. has

[sic] been grunting and moaning since

arrived. Can walk with assist. Can answer

yes and no questions otherwise

non-verbal...continuously strips self...."

9/22/17 at 12:46 P.M.: "Her previous care

giver [name] gave some insight to keep her

occupied. She likes food that crunches...

She like [sic] to color and look at

magazines...."

9/25/17 at 4:34 A.M.: "Resident is alert not

able to voice any needs or wants yells

all behaviors on a daily basis, 7

days per week for 2 weeks then 5

days per week for 6 months. The

results will be reviewed monthly in

QAPI for 6 months and then PRN if

no trends are noted. Date the

systemic change(s) will be

completed: January 12, 2018







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816 N FIRST AVE

00

screams constantly left arm in

sling...attempts to remove sling as soon as

applied attempts unassisted transfers

constantly gait is unsteady...[Name of

physician] here to visit on Saturday

increased resident routine Xanax

[anti-anxiety medication] to 1 mg QID [four

times a day]...still needs constant 1/1

supervision tonight...total care."

9/26/17 at 2:05 P.M.: "Caregivers here

today, they called and wanted res [resident]

sent to er [emergency room], for eval

[evaluation] et [and] tx [treatment]...."

9/26/17 at 7:05 P.M.: "Res [resident]

returned from er, no new orders...res resting

in bed at this time."

9/28/17 at 6:51 A.M.: "Resident is alert to

self...yells screams throughout

shift...attempts unassisted transfers

numerous times...takes prn [as needed]

Percocet for s/s [signs/symptoms]

pain/discomfort to left arm/shoulder & is

helpful for pain control sleeps only for short

intervals...pulls briefs off constantly...."

A "Weekly Care Management Meeting,"

dated 9/28/17 at 9:23 A.M., indicated,

"...Ongoing issues r/t [related to]

non-compliance [with] sling...crawls on





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floor/restless...res has been more

lethargic/drowsy since ER visit/return - less

participation [with] therapies...."


10/1/17 at 2:36 A.M.: "Resident has been

awake yelling most of night...continuously

takes off clothes and arm immobilizer. Will

continue to monitor."


up most of night. called [sic] MD and

received orders to give 50 mg Benadryl one

time...will continue to monitor."

10/3/17 at 3:43 P.M.: "Alert and orientated

to self only. Staff anticipates all needs. Can

ambulate with assist of one. Continues with

therapy...attempts to get out of wheelchair

& bed without assistance. Pulls clothes and

depends off...Will continue to monitor."


up moaning all night, fighting sleep. MD

faxed about situation to help sleep at night.

Does have staff in room with her.

10/5/17 at 2:17 P.M.: "Notified [name of

physician] of increased agitation, insomnia at

night. Order received increase Trazadone

150 mg [sedative and anti-depressant],





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decrease Xanax 1 mg TID [three times a

day]...."

10/5/17 at 7:24 P.M.: "Res alert &

oriented...she is able to make wants known,

she yells a lot, but is able to be distracted

with coloring and she likes ice cream, and

she loves to walk around the facility, she has

walked up and down the hall today will cont

[continue] to monitor...."

10/7/17 at 7:14 P.M.: "Resident was one on

one with sitter for shift. Resident yelled,

screamed, moaned, kicked & hit staff for

approximately 11 hours of the 0700-1900

[7:00 A.M.-7:00 P.M.] shift. Attempts

made to relax resident...PRN Percocet

given every 4 hours as ordered. Validated

resident's discomfort, gave her distraction

activities, food/drink...no interventions

helped. Will continue to monitor."

10/8/17 at 5:09 P.M.: "Notified by staff

resident continues to be very combative &

not able to distract or console. Medications

given as ordered with being effective...order

received by [name of physician] to sent [sic]

to [name] ER for evaluation...."

10/8/17 at 7:35 P.M.: "Resident staying in

wheelchair much better today. Yelled out a

couple times, but was not a constant.





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Attempts made to get out of chair, but

wasn't near as bad as yesterday. Resident

has not been combative. Will continue to

monitor."

10/10/17 at 11:00 A.M.: "Late Entry: care

conference held at this time with review of

residents [sic] POC [plan of care] and

progress/condition/behaviors...discussed

how the LTC [long term care] facility

atmosphere stimuli is impeding on residents

ability to succeed [with]

therapy...representatives from prior living

setting state resident had those behaviors...in

the past but not for about two years...."

10/11/17 at 11:26 A.M.: "Resident continue

[sic] to be restless at times, attempting to

remove clothes and arm sling. Requested

Geodon [an anti-psychotic] from [name of

physician]. [Name of psychiatrist] contacted

per request to review medications &

suggestion if necessary for additional

meds...."

10/13/17 at 7:34 A.M.: "Resident slept from

1 to 7 am, rest of shift she yelled and kicked

at staff. Staff sat one on one with resident

repositioning and offering snack and

alternative activities with no success."

10/14/17 at 8:17 P.M.: "Pt [patient]





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ambulated x 5 with assist of 2 occasional

boughts [sic] of yelling this shift...Pt engages

with play activities with toys."

10/18/17 at 3:16 A.M.: "...resident noted

more alert last noc [night] answering

questions (yes/no) when staff asks...noted

resident enjoys sucking on blow pop

suckers smiling & talkative with

staff...resting quietly reclined in reclining

chair screams & yells when attempt to put

her into bed...prefers to sleep in chair...."

10/22/17 at 6:24 P.M.: "...Staff anticipates

all needs. Can ambulate with assist of one.

Did not ambulate this shift. Continues with

therapy...Attempts to get out of wheelchair

& bed without assistance. Pulls clothes &


10/26/17 at 4:13 A.M.: "...restless yells out

frequently...given prn Percocet...sleeps for

couple hours then awake & yelling again will

monitor."

11/3/17 at 3:32 P.M.: "...Able to answer

simple yes/no questions... Can ambulate

with an assist of one...Resident attempts to

get out of wheelchair & bed without

assistance. Pulls clothes & depends

off...Will continue to monitor."





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816 N FIRST AVE

00

11/10/17 at 4:20 A.M.: "...noted had BM

played in it put hands into brief pulled out

BM rubbed all over self, face, threw piles in

floor...restless yells out non-stop...all

interventions attempted not helpful...."

11/11/17 at 2:35 A.M.: "Resident slept until

230 am...dug feces out of brief and smeared

all over bed...Will continue to monitor."

11/12/17 at 6:44 A.M.: "...had a large BM

and was playing in it...Will continue to

monitor."

11/14/17 at 2:47 P.M.: "...Pulls clothes &

depends off. Puts hands down pants

frequently. Resident reminded that is not

appropriate behavior...."

11/17/17 at 7:05 P.M.: "11/14/17 at 2:47

P.M.: "...Pulls clothes & depends off. Puts

hands down pants frequently. Resident

reminded that is not appropriate

behavior...."

11/20/17 at 6:31 A.M.: "Repeated attempts

to get up out of chair/bed unless

sleeping...up in reclining chair with assist x 2

propel per staff restless...wakes up

roommate...wakes other resident...all






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816 N FIRST AVE

00


frequently, takes off clothing frequently puts

hands in crotch frequently...."

Documentation of a care plan to manage the

resident's behaviors was not found in the

clinical record.

On 12/19/17 at 11:30 A.M., the Social

Services Designee (SSD) was interviewed.

He indicated there was no care plan

regarding behaviors for Resident B. He

indicated that the Interdisciplinary Team

(IDT) was supposed to meet and discuss

behaviors, and come up with a plan to

manage the behaviors.

On 12/19/17 at 2:45 P.M., the Director of

Nursing (DON) indicated she was very

involved in the care of Resident B. She

indicated staff usually sat "one on one" with

her.

2. On 12/18/17 at 8:45 A.M., during the

initial tour, the DON indicated Resident F

exhibited behaviors, such as cursing.

The clinical record of Resident F was

reviewed on 12/19/17 at 10:30 A.M.

Diagnoses included, but were not limited to,

intracranial hemorrhage, major depressive

disorder, and alcohol abuse.





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A.M., indicated, "Resident is very

demanding when he request [sic] something,

he expects staff to drop what they are

currently doing and take care of him. If

resident is asked to wait, resident will cuss

at staff...."


assessment, dated 11/7/17, indicated the

resident scored a 13 out of 15 on a brief

interview for mental status, with 15

indicative of no memory problems. The

resident exhibited no altered mood or

behavior symptoms in the previous 7 days.


11/8/17 at 1:02 P.M.: "Resident awoke in a

foul mood. Resident stated he was kept

awake by a thumping noise all

night...Resident also blew up at this Nurse

for not having his pain medication...."

11/9/17 at 9:45 A.M.: "IDT note: regarding

behavior on 11/8/2017, resident became

upset r/t [related to] pain medication - pain

medication is prn...resident explained that

medication is on a prn basis...res voiced

understanding."





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816 N FIRST AVE

00

11/10/17 at 8:44 A.M.: "Seen this date by

[name of psychiatrist], for review of

mood/behavior/meds. No new orders to

note at this time."

12/11/17 at 3:36 P.M.: "Resident upset &

throwing foam drinking cups at the CNA's

[sic]...DON & ED [Executive Director]

attempted to find out cause; very difficult to

understand...yelling, cursing, hitting

bathroom door...unable to calm him down.

[Name of physician] updated & given order

to call 911...."

A hospital "Behavioral Health" note, dated

12/11/17, indicated, "...The pt got angry

with an aide on his unit and threw a cup of

cold coffee on her. He admitted he also

made the statement 'If you want to fight me,

come on'...Recommendation:...[Resident F]

will be monitored by medical staff at the

facility for any further deterioration in mood

and behaviors...."


12/11/17 at 9:30 P.M.: "Resident returned

at this time from [hospital]...Alert et

oriented...No mood issues...placed on 15

minute precaution checks."

12/12/17 at 2:51 P.M.: "...Resident had long





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816 N FIRST AVE

00

conversation with this Nurse voicing his

frustrations. Resident stated he would try to

control his temper better...."

Documentation by Social Services regarding

the resident's behavior was not found in the

clinical record.

A plan to manage the resident's behaviors

was not found in the clinical record.



He indicated Resident F exhibited mainly

verbal behaviors. He indicated there was no

care plan regarding behaviors for Resident

F. The SSD indicated the previous Assistant

Director of Nursing (ADON) had changed

his behavior logs, and had taken the

behaviors off and added mood symptoms.

He indicated he was aware that staff did not

fill out those logs.

On 12/20/17 at 9:35 A.M., the

Administrator provided the current facility

policy "Behavior Management Guideline,"

dated 9/26/17. The policy included:

"Guideline Statement: To develop behavior

plans and medication regimens, when

appropriate, to optimize the functional

abilities of patients/residents while

monitoring for adverse side effects and





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816 N FIRST AVE

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improved behaviors...Licensed staff

completes the Plan of Care following

identification of psychotropic medication

usage or behavioral concerns...Identify the

behavior being monitored via the

Antecedent Behavior Monitoring Log...the

log is reviewed...to identify patterns and

causative or triggering events for the

behavior(s) and effectiveness of

interventions...Non-pharmacological

interventions implemented and assessed for

effectiveness, PRIOR to considering

initiation of psychoactive medications...The

use of any medication to control behaviors

should always be considered a last resort to

assist with managing a patient's/resident's

behavior...care plan is developed for

patients/residents exhibiting negative

behavior or with antipsychotic drug use. A

monitoring system is established for targeted

behaviors, interventions, and medication

effectiveness and side effects...."


IN00242103.

3.1-34(a)(1)





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483.40(d)

Provision of Medically Related Social Service

§483.40(d) The facility must provide

medically-related social services to attain or

maintain the highest practicable physical,

mental and psychosocial well-being of each

resident.

F 0745

SS=D

Bldg. 00


facility failed to provide social services to

develop and implement a plan to manage

behaviors, for 2 of 3 residents reviewed for

F 0745 F745





01/12/2018 12:00:00AM





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816 N FIRST AVE

00

behaviors, in a sample of 3. (Residents B

and F)

Findings include:

1. The closed clinical record of Resident B






disabilities, cerebral palsy, ad schizoaffective

disorder.



"non-verbal," was able to understand others,

was unable to transfer independently, could

ambulate with limited assist, was frequently

incontinent of bladder, and was at risk for

falls and pain. "Immediate Plans of Care"

indicated "Pain, Behavioral, Falls, and

Anticoagulant" were warranted. There were

no interventions documented regarding those

needs.








corrections will be necessary. Care


documentation will be reviewed for

Resident F and corrected as

indicated. How will other

residents having the potential to be

affected by the same deficient

practice be identified and what

corrective action(s) will be taken:

The medical records of residents

with behaviors will be reviewed for

completed care plans, interventions

and documentation. Corrections

will be made as indicated. What

measures will be put into place or

what systemic changes will be made

to ensure that the deficient practice

does not recur: The DNS or designee

will in-service the staff on the

facility behavior management

policy. Behaviors will be reviewed

daily in the Clinical Start Up

meeting. Facility will actively seek

to employee a degreed/experienced

social service worker. Until such

time, facility will contract with a

degreed/experienced consultant.

How the corrective action(s) will be

monitored to ensure the deficient

practice will not recur, i.e., what

quality assurance program will be

put into place: The ED or her

designee will monitor the care


documentation on all new

behaviors on a daily basis, 7 days

per week for 2 weeks the 5 days per

week for 6 months. The results will

be reviewed monthly in QAPI for 6








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Nursing Progress Notes included the

following notations:

9/22/17 at 2:44 A.M.: "Resident arrived to

facility from [name of hospital] around 5

PM...having trouble adapting to facility. has

[sic] been grunting and moaning since

arrived. Can walk with assist. Can answer

yes and no questions otherwise

non-verbal...continuously strips self...."

9/22/17 at 12:46 P.M.: "Her previous care

giver [name] gave some insight to keep her

occupied. She likes food that crunches...

She like [sic] to color and look at

magazines...."

9/25/17 at 4:34 A.M.: "Resident is alert not

able to voice any needs or wants yells

screams constantly left arm in

sling...attempts to remove sling as soon as

applied attempts unassisted transfers

constantly gait is unsteady...[Name of

physician] here to visit on Saturday

increased resident routine Xanax

[anti-anxiety medication] to 1 mg QID [four

January 12, 2018







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816 N FIRST AVE

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times a day]...still needs constant 1/1

supervision tonight...total care."

9/26/17 at 2:05 P.M.: "Caregivers here

today, they called and wanted res [resident]

sent to er [emergency room], for eval

[evaluation] et [and] tx [treatment]...."

9/26/17 at 7:05 P.M.: "Res [resident]

returned from er, no new orders...res resting

in bed at this time."

9/28/17 at 6:51 A.M.: "Resident is alert to

self...yells screams throughout

shift...attempts unassisted transfers

numerous times...takes prn [as needed]

Percocet for s/s [signs/symptoms]

pain/discomfort to left arm/shoulder & is

helpful for pain control sleeps only for short

intervals...pulls briefs off constantly...."

A "Weekly Care Management Meeting,"

dated 9/28/17 at 9:23 A.M., indicated,

"...Ongoing issues r/t [related to]

non-compliance [with] sling...crawls on

floor/restless...res has been more

lethargic/drowsy since ER visit/return - less

participation [with] therapies...."







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awake yelling most of night...continuously

takes off clothes and arm immobilizer. Will

continue to monitor."


up most of night. called [sic] MD and

received orders to give 50 mg Benadryl one

time...will continue to monitor."

10/3/17 at 3:43 P.M.: "Alert and orientated

to self only. Staff anticipates all needs. Can

ambulate with assist of one. Continues with

therapy...attempts to get out of wheelchair

& bed without assistance. Pulls clothes and



up moaning all night, fighting sleep. MD

faxed about situation to help sleep at night.

Does have staff in room with her.

10/5/17 at 2:17 P.M.: "Notified [name of

physician] of increased agitation, insomnia at

night. Order received increase Trazadone

150 mg [sedative and anti-depressant],

decrease Xanax 1 mg TID [three times a

day]...."

10/5/17 at 7:24 P.M.: "Res alert &

oriented...she is able to make wants known,

she yells a lot, but is able to be distracted

with coloring and she likes ice cream, and





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she loves to walk around the facility, she has

walked up and down the hall today will cont

[continue] to monitor...."

10/7/17 at 7:14 P.M.: "Resident was one on

one with sitter for shift. Resident yelled,

screamed, moaned, kicked & hit staff for

approximately 11 hours of the 0700-1900

[7:00 A.M.-7:00 P.M.] shift. Attempts

made to relax resident...PRN Percocet

given every 4 hours as ordered. Validated

resident's discomfort, gave her distraction

activities, food/drink...no interventions

helped. Will continue to monitor."

10/8/17 at 5:09 P.M.: "Notified by staff

resident continues to be very combative &

not able to distract or console. Medications

given as ordered with being effective...order

received by [name of physician] to sent [sic]

to [name] ER for evaluation...."

10/8/17 at 7:35 P.M.: "Resident staying in

wheelchair much better today. Yelled out a

couple times, but was not a constant.

Attempts made to get out of chair, but

wasn't near as bad as yesterday. Resident

has not been combative. Will continue to

monitor."

10/10/17 at 11:00 A.M.: "Late Entry: care

conference held at this time with review of





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00

residents [sic] POC [plan of care] and

progress/condition/behaviors...discussed

how the LTC [long term care] facility

atmosphere stimuli is impeding on residents

ability to succeed [with]

therapy...representatives from prior living

setting state resident had those behaviors...in

the past but not for about two years...."

10/11/17 at 11:26 A.M.: "Resident continue

[sic] to be restless at times, attempting to

remove clothes and arm sling. Requested

Geodon [an anti-psychotic] from [name of

physician]. [Name of psychiatrist] contacted

per request to review medications &

suggestion if necessary for additional

meds...."

10/13/17 at 7:34 A.M.: "Resident slept from

1 to 7 am, rest of shift she yelled and kicked

at staff. Staff sat one on one with resident

repositioning and offering snack and

alternative activities with no success."

10/14/17 at 8:17 P.M.: "Pt [patient]

ambulated x 5 with assist of 2 occasional

boughts [sic] of yelling this shift...Pt engages

with play activities with toys."

10/18/17 at 3:16 A.M.: "...resident noted

more alert last noc [night] answering

questions (yes/no) when staff asks...noted





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816 N FIRST AVE

00

resident enjoys sucking on blow pop

suckers smiling & talkative with

staff...resting quietly reclined in reclining

chair screams & yells when attempt to put

her into bed...prefers to sleep in chair...."

10/22/17 at 6:24 P.M.: "...Staff anticipates

all needs. Can ambulate with assist of one.

Did not ambulate this shift. Continues with

therapy...Attempts to get out of wheelchair

& bed without assistance. Pulls clothes &



frequently...given prn Percocet...sleeps for

couple hours then awake & yelling again will

monitor."

11/3/17 at 3:32 P.M.: "...Able to answer

simple yes/no questions... Can ambulate

with an assist of one...Resident attempts to

get out of wheelchair & bed without

assistance. Pulls clothes & depends

off...Will continue to monitor."

11/10/17 at 4:20 A.M.: "...noted had BM

played in it put hands into brief pulled out

BM rubbed all over self, face, threw piles in

floor...restless yells out non-stop...all


11/11/17 at 2:35 A.M.: "Resident slept until





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816 N FIRST AVE

00

230 am...dug feces out of brief and smeared

all over bed...Will continue to monitor."

11/12/17 at 6:44 A.M.: "...had a large BM

and was playing in it...Will continue to

monitor."

11/14/17 at 2:47 P.M.: "...Pulls clothes &

depends off. Puts hands down pants

frequently. Resident reminded that is not

appropriate behavior...."

11/17/17 at 7:05 P.M.: "11/14/17 at 2:47

P.M.: "...Pulls clothes & depends off. Puts

hands down pants frequently. Resident

reminded that is not appropriate

behavior...."

11/20/17 at 6:31 A.M.: "Repeated attempts

to get up out of chair/bed unless

sleeping...up in reclining chair with assist x 2

propel per staff restless...wakes up

roommate...wakes other resident...all



frequently, takes off clothing frequently puts

hands in crotch frequently...."

Documentation of a care plan to manage the

resident's behaviors was not found in the

clinical record.





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816 N FIRST AVE

00

Documentation of a Social Service note

regarding the resident's behaviors was not

found in the clinical record.



He indicated there was no care plan

regarding behaviors for Resident B. He

indicated that the Interdisciplinary Team

(IDT) was supposed to meet and discuss

behaviors, and come up with a plan to

manage the behaviors. The SSD indicated

he had been very busy, and was doing the

best he could, but he did not have anyone

helping him.

2. On 12/18/17 at 8:45 A.M., during the

initial tour, the DON indicated Resident F

exhibited behaviors, such as cursing.

The clinical record of Resident F was


Diagnoses included, but were not limited to,

intracranial hemorrhage, major depressive

disorder, and alcohol abuse.


A.M., indicated, "Resident is very

demanding when he request [sic] something,

he expects staff to drop what they are

currently doing and take care of him. If





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resident is asked to wait, resident will cuss

at staff...."


assessment, dated 11/7/17, indicated the

resident scored a 13 out of 15 on a brief

interview for mental status, with 15

indicative of no memory problems. The

resident exhibited no altered mood or

behavior symptoms in the previous 7 days.


11/8/17 at 1:02 P.M.: "Resident awoke in a

foul mood. Resident stated he was kept

awake by a thumping noise all

night...Resident also blew up at this Nurse

for not having his pain medication...."

11/9/17 at 9:45 A.M.: "IDT note: regarding

behavior on 11/8/2017, resident became

upset r/t [related to] pain medication - pain

medication is prn...resident explained that

medication is on a prn basis...res voiced

understanding."

11/10/17 at 8:44 A.M.: "Seen this date by

[name of psychiatrist], for review of

mood/behavior/meds. No new orders to

note at this time."

12/11/17 at 3:36 P.M.: "Resident upset &





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throwing foam drinking cups at the CNA's

[sic]...DON & ED [Executive Director]

attempted to find out cause; very difficult to

understand...yelling, cursing, hitting

bathroom door...unable to calm him down.

[Name of physician] updated & given order

to call 911...."

A hospital "Behavioral Health" note, dated

12/11/17, indicated, "...The pt got angry

with an aide on his unit and threw a cup of

cold coffee on her. He admitted he also

made the statement 'If you want to fight me,

come on'...Recommendation:...[Resident F]

will be monitored by medical staff at the

facility for any further deterioration in mood

and behaviors...."


12/11/17 at 9:30 P.M.: "Resident returned

at this time from [hospital]...Alert et

oriented...No mood issues...placed on 15

minute precaution checks."

12/12/17 at 2:51 P.M.: "...Resident had long

conversation with this Nurse voicing his

frustrations. Resident stated he would try to

control his temper better...."

Documentation by Social Services regarding

the resident's behavior was not found in the





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clinical record.

A plan to manage the resident's behaviors

was not found in the clinical record.



He indicated Resident F exhibited mainly

verbal behaviors. He indicated there was no

care plan regarding behaviors for Resident

F. The SSD indicated the previous Assistant

Director of Nursing (ADON) had changed

his behavior logs, and had taken the

behaviors off and added mood symptoms.

He indicated he was aware that staff did not

fill out those logs.

On 12/20/17 at 9:35 A.M., the

Administrator provided documentation of

the SSD completing his 48 hour training for

the Social Service Designee Course on

6/16/16. The Administrator indicated the

facility had not had any consultation

regarding social services since 9/25/17. She

indicated the current Marketing/Admissions

Director had a Bachelor's degree in

Sociology, and "sat in on the morning

meeting" and helped out when he could. The

Administrator indicated the facility was

seeking a qualified Social Worker, since the

majority of the facility's residents exhibited

some kind of behavior or mental health





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issue.

On 12/20/17 at 12:30 P.M., during an

interview with the Marketing /Admissions

Director, he indicated he did not do any

care plans regarding behaviors.


IN00242103.

3.1-34(a)(2)





01/22/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155390 12/20/2017


816 N FIRST AVE

00

483.50(a)(2)(i)(ii)

Lab Srvcs Physician Order/Notify of Results

§483.50(a)(2) The facility must-

(i) Provide or obtain laboratory services only

when ordered by a physician; physician

assistant; nurse practitioner or clinical nurse

specialist in accordance with State law,

including scope of practice laws.

(ii) Promptly notify the ordering physician,

physician assistant, nurse practitioner, or

clinical nurse specialist of laboratory results

that fall outside of clinical reference ranges in

accordance with facility policies and

procedures for notification of a practitioner or

per the ordering physician's orders.

F 0773

SS=D

Bldg. 00


facility failed to ensure lab results were

communicated to the physician and

documented in the clinical record, for 1 of 3

residents reviewed for lab orders, in a

sample of 3. Resident B

Findings include:

The closed clinical record of Resident B was


Nurses Notes included the following

notations:

11/24/17 at 3:50 P.M.: "Pt [patient] has

F 0773 F773






corrections will be necessary. How

will other residents having the

potential to be affected by the same

deficient practice be identified and

what corrective action(s) will be

taken: Lab results for the last 30

days for current residents will be

reviewed to ensure results were

communicated to the attending

physician and that the facility

received the physician’s

acknowledgement of receipt. If a

resident’s lab values were not

communicated to the physician, the

DNS or designee will notify the

01/12/2018 12:00:00AM





01/22/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155390 12/20/2017


816 N FIRST AVE

00

increased congestion, refusing to eat, and

afebrile. Pt has very congested cough. New

order for cbc, BMP, and chest x ray...."

The results of the lab work were not found

in the clinical record.

Documentation of physician notification of

the lab results was not found in the clinical

record.

On 12/19/17 at 10:00 a.m., during an

interview with the Director of Nursing

(DON), she indicated she assumed the lab

results had been faxed to the physician. She

indicated she would call the physician's

office to see if they had any results.

On 12/19/17 at 10:15 A.M., the DON

provided a copy of the lab results, sent from

the physician's office. The results indicated,

"Received November 27, 2017." The results

included: "BUN H [high] 27 (normal 8-23),

Sodium H 147 (normal 136-145)...." The

DON indicated that was on a weekend,

which is why the physician probably didn't

receive it until 11/27/17.

On 12/20/17 at 9:35 A.M., the

Administrator provided the current facility

policy, "Notification of Change in Resident

Health Status," dated 10/20/16. The policy

physician of the resident’s lab

results. What measures will be put

into place or what systemic changes

will be made to ensure that the

deficient practice does not recur:

The DNS or designee will in-service

the staff on Lab Processing/Tracking

Guideline. How the corrective





place: The DNS or her designee will

monitor diagnostic lab ordering and

tracking, 7 days per week for 2

weeks the 5 days per week for 6

months. The results will be

reviewed monthly in QAPI for 6




January 12, 2018.







01/22/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155390 12/20/2017


816 N FIRST AVE

00

included: "Guideline Statement: To ensure

that proper notifications are made when a

resident has a change in health status...."


IN00242103.

3.1-49(f)(2)

3.1-49(f)(4)


PRINTED: 01/22/2018 DEPARTMENT OF HEALTH AND HUMAN ... · (x1) provider/supplier/clia department of...

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