095025 - washington, d.c

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 06/15/2011FORM APPROVED

OMS NO 0938-0391STATEMENT OF DEFICIENCIES (Xl) PROVIDERISUPPLIERiCLIA (X2) MULTIPLE CONSTRUCTION (X3) Dft,TE SURVEYAND PLAN Of CORRECTION IDENTifiCATION NUMBER: COMPLETED

A BUILDING

095025 B.WING05/13/2011

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE

5425 WESTERN AVE NWLlSNER LOUISE DICKSON HURTHOME

WASHINGTON, DC 20015

(X4) 10 SUMMARY STATEMENT Of DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION {X5j

PREFIX (EACH DEFICIENCY MUST SE PRECEDED BY FULL REGULA TORY PREfiX (EACH CORRECTIVE ACTION SHOULD SE COMPLETION

TAG OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATEDEFICIENCY)

F 000 INITIAL COMMENTS F 000

A recertification Quality Indicator Survey IQIS] wasconducted on May 10 through 13, 2011. Thefollowing deficiencies were based on observations,staff and resident interviews and record review.The total sample was 26 residents.

F 157 483.1 0(b)(11) NOTIFY OF CHANGES F 157 F157 Notify of Changes

SS=D (INJURY/DECLINE/ROOM, ETC) (Injury/Decline/Room, etc)

A facility must immediately inform the resident; 1. Immediate Response: 4/18111consult with the resident's physician; and if known. Upon discovery of the lapse in notification.notify the resident's legal representative or an the MD and the RP were immediatelyinterested family member when there is an accident notified of change in skin condition.involving the resident which results in injury and hasthe potential for requiring physician intervention; a 2. Risk Identification:

significant change in the resident's physical, mental, The records of Residents with alteration in

or psychosocial status (i.e., a deterioration in health, skin integrity were reviewed to assure thatmental, or psychosocial status in either life MD and RP's were notified of anythreatening conditions or clinical complications); a changesneed to alter treatment significantly (i.e., a need to 3, Systemlc Changes:discontinue an existing form of treatment due to All licensed nursing staff was in-servicedadverse consequences, or to commence a newform of treatment); or a decision to transfer or on the importance of MD and RP

discharge the resident from the facility as specified notification of any alteration In Resident'sin §483.12(a). skin integrity. I

4. Monitoring: 7/13/11The facility must also promptly notify the resident The DON or desiqnes Will perform aand, if known, the resident's legal representative or random audit for MD/RP notification ofinterested family member when there is a change in

skin alterations. Findings of this audit willroom or roommate assignment as specified in§483.15(e)(2); or a change in resident rights under be presented at the Quarterly Quality

Federal or State law or regulations as specified in Assurance Meeting.paragraph (b)(1) of this section.

The facility must record and periodically update

•..LABORATORY DIRECTd-s:,s OR PR~~PPLIER REPRESENTATIVE'S SIGN.ATURE TITLE ~7~ii/;!<: \l NJljli~\. I "'O\'\Oo\.tJ€:(.- A4(n\f\ \S \-(' (,\ 1..() (Any deficiency statement ending with an asteris~ n denotes a deficiency which the instuutron may be excused from correciing providing If is deterrmned that othe;safeguards provide sufficient protection to the patients. (See mstructions.) Except for nursing homes. the findings stated above are disclosable 90 days following the date ofsurvey whether or not a plan of correction is provided. Fornursmq homes, the above findings and plans of correction are disclosable 14 days following the date thesedocuments are made available to the facility. If deficiencies are cited. an approved plan of correction IS requisite to continued program participation

FORM CMS·2567102·99) Previous Versions Obsolete Even11D:303Ql1 Facility 10: LlSNER If continuation sheet of 25



OMB NO 0938-0391STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(X1) PROVIDERISUPPLIER/CLIAIDENTIFICATION NUMBER:

095025

NAME OF PROVIDER OR SUPPLIER

LlSNER LOUISE DICKSON HURTHOME

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(X3) DATE SURVEYCOMPLETED

05/13/2011

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F 157 Continued From page 1the address and phone number of the resident'slegal representative or interested family member.

This REQUIREMENT is not met as evidenced by:

Based on record review and staff interview for one(1) of 26 sampled residents, it was determined thatfacility staff failed to immediately notify the physicianand responsible party when it was determined thatthe resident sustained an alteration in skin integrity.Resident #9The findings include:A Review of the 24 Hour Report/Change ofCondition Report dated April 15, 2011 revealed thefollowing:"Remarks (Day): [Resident's Name] CNA brought tomy attention that resident has non pressure ulcer onresidents buttocks, skin sheet done, residentstable.""Remarks (Evening): Stable, alert and verbal. ADL[Activities of Daily Living] care provided. Nocomplaints, Due meds [medications] given.""Remarks (Night): Resident care continued forpressure care."A Review of the Nurse's Notes dated April 15,2011 at 3:00 PM revealed " ...C.NA (CertifiedNursing Assistant) brought to my attention that whilecleaning resident, noticed a non pressure ulcer onresident's Lt (left) buttock. Skin sheet completed,denies any pain or discomfort. Non-pressure ulcer2cm (centimeter) width and 1 Y2 length. "Further review of the clinical record revealed aNurse's entry dated April 18, 2011 at 8:20 AM , "MD (Medical Doctor) gave new order for the openarea on the (left) buttocks. Cleanse area

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F 157 Continued From page 2

with wound cleanser, pat dry, apply Bacitracinointment, cover with Allevyn dressing Q [every] 3hours and prn [as needed]."A Nurse's Note dated April 18, 2011 at 3:20 PMrevealed " ...(L) buttocks wound assessed byWound Clinician, recommended Santyl ointmentwith dressing change daily, cleared by MD.[Responsible Party] notified. Deniedpain/discomfort. "The clinical record and the 24 HourReport/Change of Condition Report lackedevidence that the physician and the responsibleparty were immediately notified when the residentwas assessed with an alteration in skin integrity.Approximately 3 days lapsed between the periodthe resident was initially assessed with an alterationin skin integrity on April 15, 2011 and the time ofphysician/family notification on April 18, 2011.Facility staff failed to immediately notify thephysician and responsible party when it wasdetermined that Resident #9 sustained an alterationin skin integrity.

A face-to-face interview was conducted withEmployees #1, 2, and 3 on May 13, 2011 atapproximately 2:00 PM. Employee #2acknowledged the aforementioned findings. Therecord was reviewed on May 13, 2011.

F 279 483.20(d), 483.20(k)(1) DEVELOPSS=D COMPREHENSIVE CARE PLANS

A facility must use the results of the assessment todevelop, review and revise the resident'scomprehensive plan of care.

The facility must develop a comprehensive careplan for each resident that includes measurable

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F279 Comprehensive Care Plans:Oxygen Use

1. Immediate Response:Resident #27's record was reviewed and aspecific care plan to address thisresident's use of oxygen was initiated.

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F 279 Continued From page 3objectives and timetables to meet a resident'smedical, nursing, and mental and psychosocialneeds that are identified in the comprehensiveassessment.

The care plan must describe the services that are tobe furnished to attain or maintain the resident'shighest practicable physical, mental, andpsychosocial well-being as required under §483.25;and any services that would otherwise be requiredunder §483.25 but are not provided due to theresident's exercise of rights under §483.1 0,including the right to refuse treatment under§483.10(b)(4).


Based on observations, clinical record reviews,residents and staff interviews for three (3) of 26sampled residents, it was determined that facilitystaff failed to develop comprehensive care planswith interventions and measurable goals fordental/mouth care for two (2) residents, and for theuse of oxygen for one (1) resident. Residents # 27,#34 and # 49.

The findings include:

1. Facility staff failed to develop a comprehensiveplan for the use of oxygen for Resident #27.

According to an physician's interim order dated andsigned April 30, 2011 directed, "Nasal [oxygenwith] humidity titrate to maintain oxygen [saturation]at or above 94%."

F 279F279 Comprehensive Care Plans:Oxygen Use (continued)2. Risk Identification:All residents currently using oxygen wereidentified and care plans reviewed for thepresence of specific goals andapproaches for the use of oxygen.3. Systemic Changes:Licensed nurses were in-serviced on howto initiate, develop and update anappropriate comprehensive plan of carewith specific interventions and measurablegoals for all residents using oxygen.4. Monitoring:The Director of Nursing or designee willperform a sample audit of records forresidents requiring oxygen to assure thatthe comprehensive care plan is in placewith specific interventions to meet theprescribed use. Findings of this audit willbe presented at the Quarterly QualityAssurance Meeting.

F279 Comprehensive Care Plans: OralCare/Dentures1. Immediate Response:Resident #34 and #49's records werereviewed and a specific care plan for oraland dental care including the use or non-use of dentures.2. Risk Identification:All residents with dentures were identifiedand care plans reviewed for specific goalsand approaches for residents' oral careand use of dentures.

7/13/11

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A physician's interim telephone order dated May 6,2011 and signed May 11, 2011 directed, "Check[oxygen] saturation [every] shift. "

A "Physician Order Record" dated and signedMay 11,2011 directed, "Special Medications ...Oxygen 2 LlMin[ liters per minute]. Every shiftspecial instructions: Nasal [oxygen] with humiditytitrate to maintain 02 (oxygen) saturation at orabove 94%."

The care plan section of the current clinical recordcontained a care plan for "Cardiac output,decreased, potential for cardiac failure, respiratorydistress, and fluid imbalance. Goal: Resident safetywill be maintained and resident will be free ofdiscomfort. Interventions included: oxygen asneeded. " The care plan indicated no goals andinterventions for use of oxygen.There was no evidence that a care plan wasdeveloped for the use of oxygen for Resident #27.A face-to-face interview was conducted on May 13,2011 at approximately 10:30 AM with Employee #6.After reviewing the care plans, he/sheacknowledged that no care plan was initiated withgoals and approaches for the use of oxygen. Theclinical record was reviewed on May 13, 2011.

2. Facility staff failed to develop a comprehensivecare plan with goals and approaches to address theoral health status for Resident #34.

A "History and Physical Examination" signed

F 279

3. Systemic Changes:Licensed nurses were in-serviced on howto initiate, develop and update anappropriate comprehensive plan of carewith specific interventions and measurablegoals for all residents with dentures4. Monitoring: 7/13/11The Director of Nursing or designee willperform a sample audit of records toassure that the comprehensive care planis in place with specific interventions toreflect that resident's individual oral anddental care needs including use ofdentures. Findings of this audit will bepresented at the Quarterly QualityAssurance Meeting.

F279 Comprehensive Care Plans: OralCare/Dentures -continued

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F 279 Continued From page 5December 1,2010 revealed, "ENT[Ear/NoselThroat]: Edentulous [without teeth]. "

A review of the "Nursing Assessment Admission"dated November 30, 2010 revealed, "Dental:Denture in Mouth: Partial [upper/lower], Full[upperllower] were both blank. Condition of Teeth:[greater than three (3) missing] was checked. "

A review of an admission MDS [Minimum Data Set]completed December 12,2010 with revealed inSection L -Oral/Dental Status L0200 -A and B werechecked indicating "broken or loosely fitting full orpartial denture, no natural teeth or tooth fragment(s) (edentulous)." This care area triggered forCare Planning. Section G [Functional Status] G011 0revealed, Resident #34 required extensiveassistance of one staff for personal hygiene andactivities of daily living (ADL). "

According to a "Dental Assessment" treatmentnote dated [December 5,2010] revealed, "Resident has denture that does not fit therefore[he/she] doesn't wear them. A subsequent notedated March 22,2011 revealed, "denturesadjusted attempted. "

Review of the care plans initiated December 1-0,2010, and updated March 16, 2011 revealed a "Self Care Deficit" care plan that did not includedenture care or oral care. .

Further review of the resident's clinical recordlacked documented evidence that a comprehensivecare plan was initiated for

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F 279 Continued From page 6Resident #34 with appropriate goals andapproaches for oral and dental care.

A face-to-face interview was conducted on May 13,2011 with Employee #6 at approximately 1:41 PM.After review of the care plans he/she acknowledgedthe aforementioned findings. The record wasreviewed on May 13, 2011.

3. Facility staff failed to develop a comprehensivecare plan with goals and approaches to addressoral hygiene/denture care for Resident #49.Resident #49 was admitted to the facility on April10, 2008 with diagnoses that included CervicalDystonia, Anemia and Dementia.Review of the clinical record revealed a nurse's"Admission Asssessment " that indicated theresident had "complete upper and lower dentures.

Review of the "Nursing Monthly Summary "sheets revealed the following:July 2010: Oral Cavity: Dentures: Upper and LowerAugust 2010:Oral Cavity: Dentures: Upper andLowerSeptember 2010: Oral Cavity: DenturesNovember 2010: Oral Cavity: DenturesDecember 2010: Oral Cavity: [Left blanked]January 2011: Oral Cavity: [Left blanked]February 2011: Oral Cavity: [Left blanked]March 2011: Oral Cavity: [Left blanked]

Further review of the Annual Minimum Data Set(MDS), with an Assessment Reference Date (ARD)of March 16, 2011, revealed that Resident #49required total assistance for activities of


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F 279 Continued From page 7daily living in Section L.

Review of the care plans revealed a "Self CareDeficit" care plan updated 12/28/10 and 3128/11revealed, "Approaches: Set up and assist withpersonal hygiene as needed. Evaluation:Dependent/extensive assist with ADL ' s (Activitiesof Daily Living). The care plan did not includedenture care / oral care.

During a family interview on May 5, 2011 atapproximately 11:38 AM, resident's [responsibleparty] stated [resident] does not wear denturesregularly ...[he/she] takes them out. "

Observation of Resident #49 on May 9,2011, May12, 2011, and May 13, 2011 revealed that theresident was not wearing dentures.

During an interview on May 13, 2011 atapproximately 1:28 PM, at the time of theobservation, Employee #6 stated "[Resident] doesnot wear dentures. I will ask the nurse who hashim/her today. " CNA (Certified Nursing Assistant)was queried. He/she stated, "He/she does not towant to wear them, he/she removesthem herself. "Employee #6 proceeded to resident's room;he/she found upper and lower dentures in denturecontainer with water in resident's closet.

A face-to-face interview was conducted on May 13,2011 at approximately 2:00 PM with Employee #6.He/she acknowledged that the care plan did notinclude goals and approaches for oral hygiene anddenture care. The clinical record was reviewed onMay 3,2011.

F 281 483.20(k)(3)(i) SERVICES PROVIDED MEET

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F 281 Continued From page 8SS=D PROFESSIONAL STANDARDS

The services provided or arranged by the facilitymust meet professional standards of quality.


Based on record review and staff interviews for one(1) of 26 sampled residents, it was determined thatfacility staff failed to meet professional standards ofquality as evidenced by timely documentation toinitiate treatment for an alteration in skin integrity toResident #9 I S left buttock by the licensed nurse.


According to the "Lippincott Manual of NursingPractice," Seventh edition, nursing assessments areindicated for assessing for risk factors for pressuresore development and alter those factors, ifpossible. Skin is to be inspected several times dailyto prevent pressure sore development.

According to the facility's policy on "Weekly SkinAssessment", "Each resident will be assessed bya licensed nurse on a weekly basis. Thisassessment will consist of a visual assessment ofthe skin condition of the resident. Such assessment,including any abnormal findings, will be documentedby the nurse in the Treatment AdministrationRecord. "

According to the facility's policy on "Skin IntegrityManagement," "Each NF [Nursing Facility]resident I s skin integrity status will be

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F 281F281 Services Provided MetProfessional Standards



1. Immediate Response:Treatment to left buttock of Resident #9was documented and initiated.2. Risk Identification:The medical records of all residents withan alteration in skin integrity werereviewed to assure their treatment anddocumentation was initiated in a timelymanner.3. Systemic Changes:All nursing staff was in-serviced on bothassessing risk factors for pressure soredevelopment and how to alter thosefactors if possible. Additionally, all nursingstaff was in-serviced on reporting anyalteration in skin integrity observed duringdaily care so that skin is assessed severaltimes per day and the treatment is initiatedin a timely manner.4. Monitoring: 7/13111The DON or designee will perform arandom audit of weekly skin assessmentrecords and timeliness of initiation oftreatment. Findings presented at theQuarterly Quality Assurance Meeting.

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April 15, 2011 at 3 PM, "Resident alert [and]verbally responsive .... noticed a non pressure ulceron resident [left] buttock. Skin sheet completed,denies any pain or discomfort. Non pressure ulcer2cm width and 1 1;1 [one and one half] length. "



F 281 Continued From page 9identified along with the need for prevention ortreatment. "

Resident #9 sustained a pressure ulcer to the lefthip subsequent to an alteration in skin integrity onApril 15, 2011 as evidenced by the following nursingnote:

A succesive nurse's entry dated April 18, 2010 at8:20 AM read, " MD [Medical Doctor] gave neworder for the open area on the [left] buttock.Cleanse area with wound cleanser, pat dry, applyBacitracin ointment, cover with Allevyn dressing Q[every] 3 [three] hours and prn as needed]."The subsequent nurse's entry on April 18, 2011 [notime indicated] revealed, "[Left] buttock woundassessed by [Wound Nurse], recommended Santylointment [with] dressing [change] daily, cleared by[Medical Doctor]. [Daughter's name] notified. "The clinical record lacked evidence that facility stafffailed to initiate treatment to the left buttock whenthe resident was initially assessed with an alterationin his/her skin integrity.

The findings were reviewed and confirmed during aface-to-face interview with Employees #2 and #3 onMay 13, 2011 at approximately 11:00 AM. Theclinical record was reviewed on May 13, 2011.

F 309 483.25 PROVIDE CARE/SERVICES FOR


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F309 Provide Care/Services for HighestWell Being- see next page

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F 309 Continued From page 10SS=D HIGHEST WELL BEING

Each resident must receive and the facility mustprovide the necessary care and services to attain ormaintain the highest practicable physical, mental,and psychosocial well-being, in accordance with thecomprehensive assessment and plan of care.


Based on record review and staff interview for one(1) of 26 sampled residents it was determined, thatfacility staff failed to hold Coumadin on April 21,2011 in accordance with the physician's order forResident #34.


Further review of an individual laboratory (lab)report dated April 20, 2011 indicated that theresident's INR was 3.90. Physician documentationon the lab report directed, "Decrease dose[Coumadin] by 1mg (one). Hold one dose today. "

The physician's order dated April 21, 2011 whichdirected, "Hold Coumadin orders today. D/Cprevious Coumadin Orders. Coumadin 1 (one) mg.po (by mouth) daily at 6:00 PM for A-fib(Atrial-fibrillation). Give with Coumadin 2.5m~ daily."

The physician's order dated April 22, 2011

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1. Immediate Response: 4/21/11Attending Physician for Resident # 34 wasinformed of med error on 4/21. MD wroteorders to hold Coumadin on 4/22 andorders were followed as given.2. Risk Identification:Medical records for residents receiving

Coumadin reviewed to ensure orders werefollowed as given.3. Systemic Changes:Licensed nursing staff were in-serviced onCoumadin therapy; medicationadministration and physician orders.4. Monitoring: 7/13/11DON or designee will audit medicalrecords of residents on Coumadin andreport findings of any med error related tothis treatment at the Quarterly QualityAssurance Meeting.


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F 309 Continued From page 11directed, "Hold Coumadin today April 22, 2011. "According to the physician's orders Coumadinshould have been held on April 21 and April 22,2011.

A review of documentation in the Nurse's Notesdated April 23, 2011 at 5:00 PM revealed thefollowing; "Med (Medication) error report: On4/21/11 6pm, Resident was given a dose ofCoumadin 3.5mg that was ordered to be held thatevening. The error was caused by wrong doseentered on the computer. No adverse reactionnoted, 0 (no) s/s (sign/symptom) of Coumadintoxicity. Resident's general condition is baseline.MD (Medical Doctor) notified, new order received tohold Coumadin 3.5mg on 4/22/11 - 6pm. RIP(Responsible Party, (name) made aware. Med errorreport completed. VS (Vital signs) .... "

A review of the resident's Anticoagulant FlowSheet revealed the following:

Date: 4/20/11PT/INR: 49.8/3.90Current Coumadin Dose: 4.5 mgNew Order: Coumadin 3.5mg on 4/21/11Next Lab Date: 4/27/11

Date: 4/27/11PTIINR: 37.7/2.99Current Dose: Coumadin 3.5 mgNew Order: No New OrderNext lab date: 5/4/11

A review of the Anticoagulant Flow Sheet revealedthat the PTIINR decreased from 49.8/3.90 on April20,2011 to 37.7/2.99 on April


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F 309 Continued From page 1227, 2011 despite the administration of theCoumadin on April 21, 2011.

A review of the Medication Administration Recordfor April 2011 revealed a nurse's signature in the6:00 PM box on April 21, 2011 which indicated thatthe resident received one (1) mg of Coumadin with2.5 mg instead of Coumadin (3.5) mg at that time;despite the physician's order to hold themedication.

A face-to-face interview was conducted withEmployee #3 at approximately 1:41 PM. During theinterview the employee reviewed theaforementioned documents and acknowledged thatthe facility staff failed to hold the Coumadin on April21, 2011 in accordance with the physician's order.The record was reviewed on May 13, 2011.

F 314 483.25(c) TREATMENT/SVCS TO PREVENT/HEALSS=G PRESSURE SORES

Based on the comprehensive assessment of aresident, the facility must ensure that a resident whoenters the facility without pressure sores does notdevelop pressure sores unless the individual'sclinical condition demonstrates that they wereunavoidable; and a resident having pressure soresreceives necessary treatment and services topromote healing, prevent infection and prevent newsores from developing.


Based on observation, record review and staffinterview for one (1) of 26 sampled residents, it wasdetermined that facility staff failed to





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F 314 F314 Treatment/SVCS to Prevent/HealPressure Sores

1. Immediate Response:The wound to the left buttock of Resident #9was treated and healed.2. Risk Identification:All residents were assessed during a facilitywide skin check. All alterations in skinintegrity were identified. Those withalteration in skin integrity received recordreview for treatments to promote healing,prevent infection and prevent new alterationsfrom developing,

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F 314 Continued From page 13accurately assess and implement interventions withtimeliness to care for a facility acquired pressuresore for Resident #9.


A review of the clinical record for Resident #9revealed an alteration in skin integrity was identifiedon April 15, 2011. A period of approximately 3 dayslapsed before the physician was notified andtreatment initiated to care for the alteration in skinintegrity. The wound worsened during the period ofApril 15, 2011 through April 18, 2011. The facilityacquired wound was assessed as an "unstageablepressure sore of the left buttocks on April 18, 2011.

According to the history and physical examinationsigned by the physician on February 9, 2011, theresident's diagnoses included "Brittle IDDM (insulindependent diabetes mellitus) , diabeticnephropathy, neuropathy, PAD (peripheral arterydisease), CAD (coronary artery disease), SIP CABG(coronary artery bypass graft), lumber spinalstenosis with myelopathy, and rectal fissure".

According to the quarterly Minimum Data Set signedand dated March 9, 2011, Resident #9 was codedas totally dependent for transfer, bathing andpersonal hygiene and required extensive assistancefor bed mobility, locomotion and dressing in SectionG, Functional Status. According to Section H,Urinary/Bowel, the resident was incontinent ofbowel and bladder. Section M, Skin, revealed theresident had a history of resolved pressure sores.

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F314 Treatment/SVCS to Prevent/HealPressure Sores - continued

to include; accurate assessment of thewound, review of timeliness of physiciannotification and initiation of orders, familynotification, updated care plans, currentand accurate use of the Braden scale,notification of interdisciplinary teammembers for input, use of any pressurerelieving device, and notation for follow-upin 24-hour report.3. Systemic Changes:Facility treatment protocol of skin wasinstituted to assure expedited treatmentorder of wounds upon discovery. In-service with RN supervisors was heldreviewing the following:1. Protocol for skin assessment anddocumentation;2. RN management of all skinassessment and reported alterations inintegrity in a timely manner;3. The importance of inclusion of any

skin changes on 24-hour report to insureproper communication and follow up.

Additionally, an in-service was held for alllicensed staff on the following:1. Prevention of alterations in skinintegrity;2. Timeliness, frequency and accuracy ofassessment;3. Interventions that promote healing;4. Ongoing review and knowledge of careplans and use of assessment tools suchas the Braden scale.

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A review of Resident #9 ' S care plan revealed theinterdisciplinary team identified "Skin breakdown"related to immobility, incontinence, diabetes anddecreased sensation as a problem on April 18,2011,

A review of nurse's notes dated April 15, 2011 at3:00 PM, revealed: " ",CNA [certified nursingassistant] brought to my attention that whilechanging resident, noticed a non pressure ulcer onresident's Lt [left] buttocks '" non-pressure ulcer 2cm width x 1% cm length, "

The successive nurse's entry dated April 18, 2011at 8:20 AM read, "MD (Medical doctor) gave neworder for the open area on the [left] buttocks.Cleanse area with wound cleanser, pat dry, applyBacitracin ointment, cover with Allevyn dressing Q[every] 3 hours and prn [as needed]. "

The subsequent nurse's entry on April 18, 2011 at3:30 PM read, "Buttocks wound assessed bywound clinician. Recommended Santyl ointmentwith dressing change daily, cleared by MD.Daughter [named] notified. "

The record revealed licensed staff initiated adocument entitled "Skin Condition Record forNon-Pressure Ulcer Skin Conditions" that read:"Date of onset -April 15, 2011; comments - woundon Lt buttocks is pink with red lining on the outsideof wound; size - length 1% cm by 2cm width; "0"depth; exudate type - none; exudate amount - none;odor - none; wound bed - pink/beefy red;surrounding skin color - bright red; surroundingtissue/wound edges - normal for

F 314F314 TreatmentlSVCS to PreventlHealPressure Sores (continued)

4. Monitoring:The DON or designee will perform arandom audit of the treatment of resident'swith alteration in skin integrity forcompliance with the facility treatmentprotocol and report findings at theQuarterly Quality Assurance.

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" Skin Condition Record for Non-Pressure SkinConditions" dated April 15, 2011 - wound bed [leftbuttocks] "pink/beefy red. "



F 314 Continued From page 15skin. "

The record revealed a document entitled 'WeeklyPressure Ulcer Healing Record" that included thefollowing: "Date of onset - April 18, 2011; site -[Left] buttocks; comments - covered with 100%yellow slough and no surrounding redness; stage -unstageable; size - 1x1 xO; exudate type - serous;exudate amount - scant; odor - none; wound bed -slough 100%; surrounding skin color - normal;surrounding tissue/wound edges - normal; progress- new; treatment - changed. "

The record lacked evidence that interventions wereimplemented during the period of April 15 - 18, 2011to care for the left buttocks facility-acquired woundsustained by the resident.

The worsening of the site is evidenced by theprogression of the wound, as documented in thenursing assessments; from a "beefy red" woundbed to a 100% slough covered wound bed asfollows:

"Weekly Pressure Ulcer Healing Record" datedApril 18, 2011 - wound bed "slough 100%. "

Further review of the clinical record revealed theresident had a history of resolved pressure ulcersaffecting the left buttocks. According to WeeklyPressure Ulcer Healing Records, the resident wastreated for a Stage 2 pressure ulcer of the


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F 314 Continued From page 16left inner buttocks October 4 - 19, 2010. During theperiod of January 2 - 25, 2011, treatment wasimplemented for a Stage 2 ulcer of the left buttocks.

A review of the facility's pressure ulcer risk tool,the Braden Scale, revealed licensed staff assessedResident #9 as a "mild risk" for the developmentof pressure ulcers. The scoring of the scale depictshigh risk: 10-12; moderate risk: 13-14 and mild risk15-18. The assessment dates and correlatingscores for Resident #9 are as follows:

September 1,2010 - total score: 15; December 8,2010 - total score: 15; March 10, 2011 - total score:18 and April 17, 2011 - total score 16. The riskfactor identified as "sensory perception, " wasassessed as "4" no impairment. However, thescore lacked evidence that the assessor considered" decreased sensation" [noted in care plan] andthe medical diagnoses of neuropathy and diabeticneuropathy [H&P] in the scoring since the scalereflected no impairment.

licensed staff failed to accurately assess thealteration in skin integrity at the time of initialidentification on April 15, 2011. The wound wasassessed as a "non-pressure ulcer" of the leftbuttocks. The location of the wound, in apressure-bearing area [the buttocks] and theresident's history of pressure ulcer(s) in the sameand/or similar site would have lead the assessor toconsider the wound to be of pressure in origin. Theassessment conducted by the facility's woundspecialist on April 18, 2011 identified the wound asa pressure ulcer.

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F 314 Continued From page 17The record revealed the most recent dietaryassessment was documented March 9, 2011 andthe resident's skin was intact. There was noevidence that the dietician was notified regardingthe resident's alteration in skin integrity. Thenutrition care plan was not updated with goals andapproaches to address the resident's skinimpairment from a nutritional perspective.

A review of physician's orders dated May 2, 2011revealed an order for the use of an air mattress forpressure relief. According to documentation on thecare plan that identified Non-compliance as aproblem, a notation dated May 9,2011 revealedthe air mattress was in place. Thepressure-relieving device was implementedapproximately 3 weeks post identification of thefacility acquired pressure ulcer.

A face-to-face interview was conducted withEmployees #1,2 and 3 on May 13,2011 atapproximately 2:00 PM. Employee #2acknowledged the findings and stated that acorrective action plan had been implemented oncethe administration identified concerns with themanagement of Resident #9 ' s facility acquiredwound.

Facility staff failed to accurately assess andimplement interventions with timeliness to care for afacility acquired pressure ulcer. The record wasreviewed May 13, 2011.

F 329 483.25(1) DRUG REGIMEN IS FREE FROMSS=D UNNECESSARY DRUGS

Each resident's drug regimen must be free fromunnecessary drugs. An unnecessary drug is any

F329 Unnecessary Drugs; PsychotropicMedication Side Effects1. Immediate Response:

F 329 Resident #77's record was reviewed and abehavioral monitoring tool was put intoplace to monitor for adverse side effectsfor the use of Seroquel and SertralineHCL.

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F 329 Continued From page 18drug when used in excessive dose (includingduplicate therapy); or for excessive duration; orwithout adequate monitoring; or without adequateindications for its use; or in the presence of adverseconsequences which indicate the dose should bereduced or discontinued; or any combinations of thereasons above.

Based on a comprehensive assessment of aresident, the facility must ensure that residents whohave not used antipsychotic drugs are not giventhese drugs unless antipsychotic drug therapy isnecessary to treat a specific condition as diagnosedand documented in the clinical record; and residentswho use antipsychotic drugs receive gradual dosereductions, and behavioral interventions, unlessclinically contraindicated, in an effort to discontinuethese drugs.


Based on record review and staff interview of two(2) of 26 sampled residents, it was determined thatfacility staff failed to monitor a resident onpsychotropic medications for side effects and failedto administer as needed (prn) pain medicationconsistent with prescribed parameters. Residents#77 and #84.


1. A review of Resident #77 ' s MR (MedicationRecord) revealed that the resident is receiving

F 329F329 Unnecessary Drugs; PsychotropicMedication Side Effects-continued

2. Risk Identification:All records for residents prescribedpsychotropic medications were reviewedfor use of behavioral monitoring toolsincluding documentation of adverse sideeffects.3. Systemic Changes:Licensed staff was in-serviced on the useof psychotropic medications and adverseside effects of the use of such medication.Staff was in-serviced on how to completebehavioral monitoring tools whenresidents are prescribed such medication.4. Monitoring:The Director of Nursing, ConsultantPharmacist or designee will perform asample audit of records for residents'prescribed psychotropic medication toassure that there is a behavioralmonitoring tool including documentation ofadverse side effects present. Findings ofthis audit will be presented at theQuarterly Quality Assurance Meeting.

F329 Unnecessary Drugs; PRNMedication Parameters1. Immediate Response:Resident #84 record was reviewed forphysician orders related to the use of PRNTylenol #3 and parameters foradministration. DON initiated medicationerror reporting for administration ofincorrect dose.

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F 329 Continued From page 19Seroquel Oral Tablet 25 mg PO (by mouth) atbedtime 9:00 PM for Dementia, andSertraline HCLOral Tablet 25 mg PO one (1) time a day forDepression. The order date for both medicationswas February 15, 2011.Review of the CAA (Care Area Assessment) forResident #77 signed on February 22,2011 number17, Psychotropic Drug Use: Note ...Resident onpsychotropic meds (medications) will monitor forside effects" and "to be on the lowest therapeuticdose possible .."

Further review of the clinical record including nursesnotes lacked evidence of a behavioral monitoringtool for adverse side effects of the medications.Facility staff failed to monitor a resident onpsychotropic medications for side effects forResident #77.A face-to-face interview was conducted on May 13,2011 at approximately 9:30 AM with Employee #3.A request was made for the behavioral monitoringtools for the current and previous month. Employee#3 was unable to produce the behavioral monitoringtools. The record was reviewed May 13, 2011.

2. Facility staff failed to administer as needed (prn)pain medication consistent with prescribedparameters for Resident #84.

A review of the resident I s clinical record revealed aphysician I s order dated May 4,2011 whichdirected the following "Tylenol #3 (Acetaminophenwith Codeine) 300-30MG one (1) tablet by mouthevery four hours prn for mild - moderate pain" and" Tylenol #3 two tablets po prn for pain (Pain -severe). "

F 329F329 Unnecessary Drugs; PRNMedication Parameters - continued

2. Risk Identification:The Physician Orders and the MAR's forresidents receiving PRN Tylenol #3 werereviewed for compliance that over the past30 days the pain reported by the residenton the pain scale matched therecommended parameters as noted in thePhysician's Order.3. Systemic Changes:Licensed staff were in-serviced on thefollowing: (1) use of the facility pain scale,assessment of the resident andinterpretation of pain severity; (2)documentation of their clinical assessmentof the pain; (3) the use of PRN painmedication and physician definedparameters.4. Monitoring:

The Director of Nursing, ConsultantPharmacist or designee will perform asample audit of records for residents usingPRN pain medication for parametercompliance. Findings of this audit will bepresented at the Quarterly QualityAssurance Meeting.

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A review of the Medication Administration Record(MAR) for May 5, 2011 revealed that facility staffadministered two (2) Tylenol #3 tablets to theresident for mild pain at 8:00AM on May 5, 2011.Review of the computerized documentationrevealed that the pain scale rating was documentedas 2-3 (mild pain).

According to the pain scale that was utilized by thefacility a rating of 2 - 3 was indicative of mild pain.According to the physician's order one (1) Tylenol#3 was recommended for mild pain. The recordwas reviewed on May 12, 2011.

A face-to-face interview was conducted withEmployee #3 at approximately 1:00 PM on May 13,2011. During the interview the employee reviewedthe record and acknowledged that the residentshould have received one (1) Tylenol #3 tablet formild pain as was ordered by the physician.

F 428 483.60(c) DRUG REGIMEN REVIEW, REPORTSS=D IRREGULAR, ACT ON

The drug regimen of each resident must bereviewed at least once a month by a licensedpharmacist.

The pharmacist must report any irregularities to theattending physician, and the director of nursing, andthese reports must be acted upon.

This REQUIREMENT is not met as evidenced

F 329

F 428 F428 Drug Regimen Review, ReportIrregular, Act On1. Immediate Response:The pharmacy's 'drug regimen reviewsheet' for Resident #77 was faxed to thephysician for review. Physician reviewedand addressed the issues.2. Risk Identification:"Drug Regimen Review Sheet" for other

residents identified by the ConsultantPharmacy was reviewed to make sure allsuggestions had been addressed by MDas requested.

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F 428 Continued From page 21by:Based on record review and staff interview for one

(1) of 26 sampled residents, it was determined thatthe physician failed to act upon pharmacycommunication associated with a medicationregimen review related to the use of antipsychoticmedication for Resident #77.


A review of Resident #77's record revealed that acommunication dated March 3, 2011 documentedby the consultant pharmacist, entitled"Comment/Suggestions" .

The comment/suggestion to the physician read asfollows: "A review of the drug regimen reviewsheet dated March 3, 2011 revealed the pharmacywritten comment "This resident is on the anti-psychotic agent Seroquel as currently there is noapproved psychiatric diagnosis noted on the chartfor its use. Please document that one of thefollowing exists to justify use of this agent: 1.Schizophrenia, H2-affective disorder, 3. DelusionalDisorder, 4. Mood Disorder (including mania, bipolardisorder, depression/psychotics features, andtreatment refractory major depression, 5.Schizophreniform Disorder, 6. Psychosis, 7.Atypical Psychosis, 8. Dementing illness withbehavioral symptoms, 9. Medical illness or deliriumwith mania or psychotic symptoms and/or treatmentrelated mania/psychosis (e.g., thyotoxicosis,neoplasm, high dose steroids)."

A concurrent review of the medical record lackedevidence that the physician addressed thepharmacist comments/suggestions on the drug

F 428F428 Drug Regimen Review, ReportIrregular, Act On (continued)

3. Systemic Changes:Licensed nursing staff was in-serviced on"Drug Regiment Review Sheet" andnecessary physician documentation.4. Monitoring:DON or designee will monitor "DrugRegimen Review Sheets" for physiciandocumentation on a monthly basis andreport findings at the Quarterly QualityAssurance Meeting.

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F 428 Continued From page 22regimen review sheet dated March 3, 2011. Therewas no evidence that he/she disagreed or agreedwith the pharmacist commenUsuggestion.

A face-to-face interview was conducted on May 13,2011 at approximately 1:00 PM with Employee #2.He/she acknowledged the findings. The record wasreviewed on May 13, 2011.

F 441 483.65 INFECTION CONTROL, PREVENTSS=D SPREAD, LINENS

The facility must establish and maintain an InfectionControl Program designed to provide a safe,sanitary and comfortable environment and to helpprevent the development and transmission ofdisease and infection.

(a) Infection Control ProgramThe facility must establish an Infection ControlProgram under which it -(1) Investigates, controls, and prevents infections inthe facility;(2) Decides what procedures, such as isolation,should be applied to an individual resident; and(3) Maintains a record of incidents and correctiveactions related to infections.

(b) Preventing Spread of Infection(1) W hen the Infection Control Program determ inesthat a resident needs isolation to prevent the spreadof infection, the facility must isolate the resident.(2) The facility must prohibit employees with acommunicable disease or infected skin lesions fromdirect contact with residents or their food, if directcontact will transmit the disease.(3) The facility must require staff to wash theirhands after each direct resident contact for which

F 441 F441 Infection Control, Prevent Spread,Linens1. Immediate Response:Employee # 9 was immediately in-servicedon hand washing during dressing changeand good infection control practices.2. Risk Identification:Random observation of staff handwashing and infection control practicesduring dressing changes were conductedon licensed staff by DON and ADON.3. Systemic Changes:Licensed nursing staff was in-serviced oninfection control practices and proper handwashing technique during dressingchanges.4. Monitori ng: 7/13/11DON or designee will continue torandomly observe licensed staff infectioncontrol and hand washing techniquesduring dressing changes and will reportfindings to the Quarterly QualityAssurance Meetings.

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F 441 Continued From page 23 F 441hand washing is indicated by accepted professionalpractice.

(C) LinensPersonnel must handle, store, process andtransport linens so as to prevent the spread ofinfection.


Based on observation, and staff interview of one (1)of 26 sampled residents, it was determined that thefacility staff failed to maintain appropriate infectioncontrol practices during a wound treatment forResident #9.


During a wound treatment observation of resident#9 • s left buttocks, it was observed that the nursefailed to maintain appropriate infection controlpractices during a wound treatment when he/shefailed to cleanse his/her hands during the woundtreatment.

During the wound treatment observed on May 12,2011 at approximately 11:10 AM, the nursechanged his/her gloves several times during thetreatment but at no time did he/she washed his/herhands or utilize hand sanitizer during the treatment.He/she was observed to wash hands before startingthe treatment.

The observations were shared with Employee #3during a face-to-face interview on May 12, 2011 atapproximately 1:00 PM. He/she stated that


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F 441 Continued From page 24Employee #9 was a new hire and that he/she hadnot had the opportunity to observe the employee'streatment practice.He/she provided documentationthat Employee #9 completed a competency fortreatments and infection control. However, he/sheacknowledged the aforementioned findings andstated the employee would be inserviced.



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