HospitalInspections.org

Based on deficiencies cited, the facility failed to protect and promote the rights of 8 (#s 2, 4, 6, 8, 9, 10 and 15) of 21 patients admitted to the facility. Findings include:

The facility staff did not notify the POA when positional devices were initiated for 2 (#s 2 and 8) of 9 patients. (See A131).
The facility staff did not provide care for patients in a safe setting (See A144).
Documentation for 3 (#s 2, 6, and 15) of 9 patients failed to justify the use of restraints or seclusion (See A154, A159, and A162).
The facility staff did not show that the least restrictive interventions were considered or tried prior to placing patients in restraints (See A164 and A165).
The facility staff did not follow the policy on PRN restraint orders (See A169).
The facility did not have a policy to address the use of restraints for non-violent or non-self-destructive patients (See A173).
The facility did not have training for physicians and LIPs regarding the use of restraints for non-violent or non-self-destructive patients (See A176, A194, and A196)
the facility staff did not call the Centers for Medicare and Medicaid Services about a patient's death associated with the use of restraints (See A214).

Based on record review, policy review, and family interviews, the facility failed to allow a patient or representative to make an informed decision regarding the care for 2 (#s 2 and 8) of 9 patients. Findings included.

1. The policy for "Treatment And Positional Supports" was reviewed. Item B stated, "To allow for the patient or person acting on his/her behalf the opportunity to make an informed choice about the use of positional supports, the LIP, RN, or OTR/L will explain:
1. The rationale for and benefits of the positional supports being proposed,
2. Possible negative outcomes of use,
3. The interventions that will be utilized to prevent or reduce the possible negative effects,
4. Alternatives, if any, and
5. The patient or family member/guardian will sign a consent for positional supports."

2. Patient #2 was admitted to the facility on 11/30/09. The patient had diagnoses of Lewy Body dementia, coronary artery disease, hypertension, atrial fibrillation, degenerative joint disease, left carotid stenosis, and chronic obstructive pulmonary disease.

On 4/14/10 at 10:00 a.m., the physician wrote the following orders, "1. Serax 10 mg p.o. TID (excitement). 2. Pt to remain in geri (sic) chair c lap Posey to prevent falls x 7 days.
3. Ambulate pt x 2 in AM & x 2 in PM."

On 4/20/10 at 1:15 p.m., six days after the order was written for the use of a Geri chair and a lap Posey, the following progress note was noted, "Contacted [Name] POA (daughter) about use of positional supports. She has verbally agreed for use and will be here Saturday 4/24/10 to visit [Patient's name] and she will sign consent form then." The POA signed the Consent Form For The Use Positional Supports on 4/24/10, ten days after the order was written by the physician.


27823


3. Patient #8 was admitted to the facility on 2/23/10; diagnoses included dementia, hostility, coronary artery disease, gastritis, duodenitis, hypertension, and hypothyroidism. The patient's son was the POA.

- During review of the patient's medical record, it was noted in the Progress Notes for 2/24/10 at 10:30 a.m., "Exam: Alert, calm, in wheelchair with positional support . . . Plan: I called pts [sic] son at work and on cell and left messages . . ."

The daughter-in-law was interviewed on 8/30/10 at 11:00 a.m. She stated her husband was the POA. She stated they had not been made aware of the patient being in a "restraint" until she received the consent in the mail. She called the facility immediately and spoke with the OT. The OT asked her why it had not been signed and returned to the facility. The physician spoke to her husband later in the day on 2/25/10. At that time, the patient had been in the Posey for over 24 hours.

During review of the patient's medical record, it was noted that on 3/8/10, the patient had a significant decline in status. A urinary tract infection was diagnosed on 3/8/10. Culture results were 10,000 Organisms/ml Proteus species. The patient was not given antibiotics and continued to decline. The daughter-in-law stated that they would have requested the infection be treated.

Based on observations, chart reviews, and staff interviews, the facility failed to ensure that care was provided in a safe environment for 3 (#s 2, 6 and 15) of 9 patient charts reviewed. Findings include:

1. Patient #6 was admitted to the facility on 5/6/10. The patient was admitted with diagnoses of dementia, coronary artery disease, history of falls, cerebral vascular accident, hypertension, and chronic anticoagulation therapy with Plavix. The Plavix therapy was stopped in July 2010.

On 6/24/10 at 4:55 p.m., the physician documented the following order, "Apply positional support in the form of a Posey waist restraint while in chair to prevent injury from fall due to poor balance, inability to maintain position in chair, poor safety awareness, and unsteady gait. Check Q 30 min. Release Q 2 hours. Apply x7 days."

On 6/28/10 at 2:00 p.m., on 7/22/10 at 8:03 a.m., and 8/16/10, the physician documented the following, "Positional support in the form of a Posey waist restraint while in chair to prevent injury from fall due to poor balance, inability to maintain position in chair, poor safety awareness, and unsteady gait. Check q 30 min - release q 2 hours. Apply x 30 days."

The patient overturned his Geri chair while being restrained by a waist Posey on 6/25/10 at 7:40 a.m., 7/7/10 at 12:45 a.m., 7/14/10 at 9:40 a.m., 7/25/10 at 2:45 a.m., 7/28/10 at 4:50 a.m., and 8/20/10 at 8:00 p.m. (See A159)

Patient #6 overturned his Geri chair while being in a waist Posey six times in the months of June, July, and August. According to the physicians orders and notes the patient was placed in the Geri chair with a pelvic Posey to prevent injuries from falls.

Patient #6 died on 8/26/10 at 7:55 p.m.

2. Patient #2 was admitted to the facility on 11/30/09. The patient had diagnoses of Lewy Body dementia, coronary artery disease, hypertension, atrial fibrillation, degenerative joint disease, left carotid stenosis, and chronic obstructive pulmonary disease.

The patient overturned his Geri chair on 4/16/10 at 1:40 p.m., 4/19/10 at 10:45 a.m., and 4/21/10 at 5:12 a.m. (See A159.)

On 4/14/10 at 12:51 p.m., the physician wrote the following order, "Positional support in form of pelvic posey [sic] while in Geri Chair to prevent injury from fall due to poor balance/poor safety awareness x 30 day [check] q 30 [minutes] & release q 2? [hours]. 2. 15 [minute] [checks] for safety position."

The Safety Rounds meeting for the month of March 2010 discussed the patient overturning the Geri chair; no recommendations were made.

Patient #2 overturned his Geri chair while being restrained by a pelvic Posey 3 times in the month of April 2010. The facility completed an Incident Report Form for the fall on 4/19/10. The staff documented that the patient's Geri chair will be placed in an open area so the patient could not grab handrails or other objects. According to the physician's orders and notes the patient was placed in the Geri chair with a pelvic Posey to prevent injuries from falls.


27823


3. Patient #15 was admitted to the facility on 6/5/08 at 12:54 p.m., with diagnoses of dementia with behavioral disturbance, type II diabetes, and hypertension.

On 12/7/09 the patient was placed in, "positional support with pelvic posey [sic] in geri [sic] chair."

During an observation on 8/30/10, the patient was in a Geri-chair with a pelvic Posey. The patient was trying to scoot the chair by rocking his body back and forth. Staff Member U stated patient #15 had the Posey around his waist to keep him from falling. She further stated it was called a "positional support." She stated the positional support was a restraint as the patient was unable to remove the device as it was tied behind the chair. During observation from 12:45 p.m. to 4:00 p.m., no staff approached the patient to check the restraint.

Staff Member H was interviewed on 8/31/10 at 11:15 a.m. She stated the staff assess the positioning device every 30 minutes by putting their hands in between the patient and the restraint to assure it is not too tight. During observation on 8/31/10 the patient was observed in the Geri-chair from 8:00 a.m. to 11:15 a.m., and again from 1:40 p.m. to 3:00 p.m. At no time during the observation did a staff member approach the patient to check the restraint.

Staff Member O was interviewed on 9/1/10 at 9:30 a.m. He stated the chair used for Patient #15 was "new" for him. The chair had belonged to Patient #6. Patient #6 had overturned the chair, hitting his head. Patient #6 had since died. Staff Member O stated he had ordered tip bars for the chair so that it would not tip. He had no idea when the tip bars would be delivered.

Based on record review, staff, and family interviews, the facility failed to provide documentation to justify the application and continued use of restraints for 8 (#s 2, 4, 6, 8, 9, 10, 15, and 21) of 9 medical records reviewed for the use of restraints. Findings include:

1. Patient #2 was admitted to the facility on 11/30/09. The patient had diagnoses of Lewy Body dementia, coronary artery disease, hypertension, atrial fibrillation, degenerative joint disease, left carotid stenosis, and chronic obstructive pulmonary disease.

a. On 4/14/10 at 10:00 a.m., the physician wrote the following order, "1. Serax 10 mg p.o. TID (excitement). 2. Pt to remain in geri [sic] chair c lap Posey [sic] to prevent falls x 7 days. 3. Ambulate pt x 2 in AM & x 2 in PM."

On 4/14/10 at 10:00 a.m., the following progress note was noted, "Psych - Pt continues to fall while trying to get up from wheel chair [sic] despite the use of a lap belt and lap Posey [sic]. He also refuses to wear a helmet. Will start Serax and geri [sic] chair c lap Posey [sic] for patient protection."

b. On 4/15/10 at 4:20 p.m., the physician wrote the following order, "Pt to wear one piece jump suit due to refusal to wear any clothes."

On 4/16/10 at 5:40 a.m., the nurse documented the following progress note, "[Patient's name] was sleeping at change of shift but was up x 2 during the night. He had gotten up & taken his clothes off but redirected easily. He slept after. 15 min [checks] continued."

On 4/18/10 at 9:55 p.m., the following progress note was noted, "...pt was restless and agitated [sic] and was trying to undress himself in the dayhall [sic] this writer went over to him to assit [sic] with dressing him but pt became combative. Another Psych tech came over to assit [sic] and pt was ambulated to his rm and toileted. pt was layed [sic] in bed per pt request..."

The medical record lacked assessments prior to the use of the Geri chair and the lap Posey, and the use of the jump suit that is fastened with a zipper in the back, all of which restricted the patient's activity. The record does not show: that the staff considered the risks for the use of the restraints and that less restrictive measures were considered and tried prior to the use of the Geri chair, lap Posey, and the jump suit. The record does not have documentation to show that an assessment was done to identify the medical justification of these three restraints.

2. Patient #6 was admitted to the facility on 5/6/10. The patient was admitted with diagnoses of dementia, coronary artery disease, history of falls, cerebral vascular accident, hypertension, and chronic anticoagulation therapy with Plavix.

a. On 6/24/10 at 4:55 p.m., the physician documented the following order, "Apply positional support in the form of a Posey waist restraint while in chair to prevent injury from fall due to poor balance, inability to maintain position in chair, poor safety awareness, and unsteady gait. Check Q 30 min. Release Q 2 hours. Apply x 7 days."

On 6/28/10 at 2:00 p.m., on 7/22/10 at 8:03 a.m., and 8/16/10, the physician documented the following, "Positional support in the form of a Posey waist restraint while in chair to prevent injury from fall due to poor balance, inability to maintain position in chair, poor safety awareness, and unsteady gait. Check q 30 min - release q 2 hours. Apply x 30 days."

b. On 6/28/10 at 11:50 a.m., the physician reviewed patient #6's medications and incidents for the past 13 days. The physician documented the following: "Add: jump suit prn for disrobing." The medical record lacked documentation on why the jump suit was needed.

The medical record lacked assessments prior to the use of the Posey waist restraint and the use of the jump suit that is fastened with a zipper in the back. The staff did not document that the risks for the use of the restraints were considered, and that less restrictive measures were considered and tried prior to the use of the Posey waist restraint and the jump suit. The record lacked documentation to justify the use of the restraints.


26492


3. Patient #10 was admitted on 7/30/10 with diagnoses including traumatic brain injury, dementia due to traumatic brain injury, dementia with behavioral disturbance, alcohol dependence, personality disorder, seizure disorder secondary to traumatic brain injury, thrombocytopenia, GERD, and hypertension.

On 8/30/10 at 1:30 p.m., the active medical record for patient #10 was reviewed. The Physician Order Sheet for 8/15/10 at 2020 documented an order for "15 minute checks, lock bedroom door during day time hours. . ." A Physician Order Sheet for 8/16/10 at 0918 documented "Pt. not to have wheelchair in his room.." Documented within the Progress Notes on 8/11/10 at 2020 documented that "patient #10 is in bed wearing one piece suit."

The medical record lacked an assessment prior to the use of the one piece suit that is fastened with a zipper in the back. There was no documentation in the record that the staff considered the risks for the use one piece suit and that less restrictive measures were considered and tried prior to the use of the one piece suit. There was no documentation in the record that there was an assessment to identify the medical justification of the one piece suit that is fastened with a zipper in the back.

4. During review of patient #9's closed medical record, the patient was admitted to the facility on 6/26/10 with diagnoses of dementia, left cerebral vascular infarct, atrial fibrillation, hypertension, abdominal wall hernia, and mitral valve replacement.

The Progress Notes documented that a lap buddy with pommel wedge was placed on Patient #9 on 7/1/10 at 1725 for "treatment/prevention of falls." The lap buddy was discontinued on 7/2/10 at 1500 and a "Geri chair and pelvic Posey to prevent injury from fall.." was ordered. On 7/6/10 at 2300 the progress notes documented "pt. was leaned over the left side of the Geri chair with arms holding self up, his legs were still in the Geri chair with Posey around one leg." On 7/7/10 at 2200, "[patient's name] was able to free himself from his Posey and stood out of his Geri chair. He fell, hitting his head on the wall by the patient phone." Physician Order dated 7/7/10 at 2140, " 1:1 observation for safety." Further review of the documentation on 7/15/10 at 0415, "into jumpsuit at 0420."

The medical record lacked documentation that a restraint assessment was done prior to the use of the lap buddy, pommel wedge, Geri chair, and pelvic Posey. Documentation that the staff considered the risks for the use of these restraints, and that less restrictive measures were considered and tried prior to the use of these restraints was absent in the record. Written justification for the use of these restraints was not found in the medical record.



27823


5.Review of patient #4's medical record shows that the patient was admitted to the facility on 8/13/10 at 7:45 p.m., with diagnoses of dementia with behavior, and hypertension. The record shows that the patient was placed in a pelvic Posey restraint on 8/14/10 at 4:15 p.m., for ". . . cognitive deficits and confusion pt danger to self extremely hostile - combative and unsafe". The pelvic Posey restraint was discontinued on 8/15/10 at 11:40 p.m. Within the Physician Order Sheet on 8/16/10 at 12:22 p.m. was an order for, "Positional support in form of pelvic posey [sic] with geri [sic] chair to prevent injury from fall . . ." The Progress Notes on 8/17/10 at 9:07 a.m. document "Exam: alert in geri [sic] chair with pelvic posey [sic]." On 8/24/10 at 1:50 p.m., the patient overturned the Geri chair over causing a skin tear. The pelvic Posey was discontinued on 8/26/10 at 3:09 p.m.

The medical record lacked a restraint assessment and a medical justification for the pelvic Posey used on resident #4. The documentation in the medical record did not show that the patient was assessed while in the pelvic Posey, that patient #4 was released from the restraint at the earliest possible time, or that a less restrictive intervention had been tried.

6. Review of patient #8's medical record shows that the patient was admitted to the facility on 2/23/10 at 1:30 p.m. with diagnoses of dementia, hostility, coronary artery disease, gastritis, duodenitis, hypertension, and hypothyroidism. The Progress Note indicated the patient was uncooperative with nursing assessments at the time of admit. Within the Physician Order Sheet on 2/23/10 at 5:27 p.m. was an order for, "Positional support in the form of pelvic posey [sic] while in wheelchair to prevent injury from fall . . . poor posture and sliding out of wheelchair . . ." The Progress Notes on 2/24/10 at 10:30 a.m. document "Exam: Alert, calm, in wheelchair with positional support . . . Plan: I called pts son at work and on cell and left messages . . ."

A family member was interviewed on 8/30/10 at 11:00 a.m. She stated her husband was the POA for Patient #8. She stated they had not been made aware of the patient being in a "restraint" until she received the consent in the mail. She called the facility immediately and spoke with the OT. The OT asked her why it had not been signed and returned to the facility. The physician spoke to her husband later in the day on 2/25/10. At that time, the patient had been in the Posey for over 24 hours. The family member further stated that the family did not understand the reasoning for the Posey restraint as the patient was ambulatory prior to being admitted to the facility.

Documentation that a restraint assessment was done prior to the use of the pelvic Posey was not found in the medical record. Documentation that the staff considered the risks for the use of these restraints and that less restrictive measures were considered and tried prior to the use of these restraints was not found in the medical record. Documentation that there was an assessment to identify the medical justification for the use of these restraintswas not found in the emdical record. The documentation in the medical record did not indicate the patient was being assessed and released from pelvic Posey at the earliest possible time.

7. Review of patient #15's medical record shows that the patient was admitted to the facility on 6/5/08 at 12:54 p.m. with diagnoses of dementia with behavioral disturbance, type II diabetes, and hypertension.

The Psychiatric Evaluation on 12/24/09 documents that the patient tripped and hit his head on 12/5/09. On 12/6/09, he fell and hit his head again. The patient was diagnosed with a subdural hematoma. On 12/7/09, the patient was placed in, "positional support with pelvic posey [sic] in geri [sic] chair". The medical record lacked a restraint assessment and a medical justification for the pelvic Posey to be applied to resident #15. The documentation in the medical record did not show that the patient was being assessed while in the pelvic Posey, so that patient #15 was released from the restraint at the earliest possible time, or that a less restrictive intervention had been tried.

During observation on 8/30/10, the patient was observed in a Broda chair with a pelvic Posey in place. The patient was trying to scoot the chair by rocking his body back and forth. Staff Member U stated he had the Posey around his waist to keep him from falling. She further stated it was called a "positional support." She stated the positional support was a restraint as the patient was unable to remove the device as it was tied behind the chair. Staff Member E stated he had ordered the positional support because the patient has severe dementia. The patient had poor safety awareness and unsteady gait.

Staff Member H was interviewed on 8/31/10 at 11:15 a.m. She stated because the positioning device is not considered a restraint, that they are not assessed quarterly to consider a less restrictive device. She further stated the staff do assess the positioning device every 30 minutes bu putting their hand in between the patient and the restraint to assure it is not too tight. During observation on 8/30/10 between 12:45 p.m. and 4:00 p.m., and again on 8/31/10 from 8:00 a.m. to 11:15 a.m., and again from 1:40 p.m. to 3:00 p.m. a staff member failed to check the patient's restraint.

8. During the review of patient #21's medical record, it was noted that the patient was admitted to the facility on 2/26/10 at 10:55 a.m., with diagnoses of schizoaffective disorder, bipolar type, anxiety disorder, and congestive heart failure. It was noted in the Physician Order Sheet on 6/25/10 at 8:22 a.m. "Jump suit."

On 9/1/10 at 9:00 a.m., Staff Members G and U stated the patient was unable to remove the jumpsuit that closes with a zipper in the back. They further stated she was in the jumpsuit so she would not remove her clothes. The documentation in the medical record did not indicate the patient was being assessed while in the jumpsuit, so that patient #21 was released from the restraint at the earliest possible time, or that a less restrictive intervention had been tried.

The patient was observed in the jumpsuit throughout the week of survey 8/30/10 - 9/2/10.

Documentation in the medical record does not show that a restraint assessment was done prior to the use of the jump suit that closed with a zipper in the back. Documentation in the record does not show that the staff considered the risks for the use of the jump suit, and that less restrictive measures were considered and tried prior to the use of the jump suit. Documentation in the record does not show that a physical assessment to identify the medical justification for the use of the jump suit was done.

Based on observations, record reviews, and staff interviews, the facility employed devices that restricted the movement for 7 (#s 2, 6, 8, 9, 10, 15, and 21) of 9 patients whose medical records were reviewed for the use of restraints. Findings included:

1. The policy for Use of Seclusion and Restraints was reviewed. Item D and E under the heading Policy stated, "D. Seclusion and restraint are not treatment and may not be implemented as a behavioral consequence in response to a previously occurring behavior, or imposed as a means of coercion, discipline, convenience, or retaliation by staff. E. Seclusion and Restraint procedures may be used only when clinically justified in accordance with a Physician/Licensed Independent Practitioner (LIP) order and used only when less restrictive interventions have been determined to be ineffective. The type of seclusion or restraint used must be the least restrictive procedure to effectively protect the patient, staff, or others from harm. Seclusion and Restraint procedures must be ended at the earliest possible time." The policy did not specify that the use of seclusion was to be used only for the management of violent and self destructive behavior.

2. Patient #2 was admitted to the facility on 11/30/09. The patient had diagnoses of Lewy Body dementia, coronary artery disease, hypertension, atrial fibrillation, degenerative joint disease, left carotid stenosis, and chronic obstructive pulmonary disease.

a. Per the Physician orders signed on 3/31/10, patient #2 used a seat belt while in the chair during the day. In the nurse's monthly summary dated 4/7/10, the nurse documented, "Pt.'s gait unsteady and uses a seat belt in his w/c to prevent falls."

On 4/9/10 at 2:21 p.m., the physician documented the following order, "1. Ambulate c a minimal of 1-2 q 2? while awake. 2. Positional support in the form of lap buddy to prevent injury from fall due to poor safety awareness/unsteady gait/poor balance x 30 days. [check] q 30 [minutes] release q 2?. 3. Bed alarm."

On 4/12/10 at 9:17 a.m., the physician wrote the following order, "Positional support in the form of lap buddy and pommel wedge while in wheel chair to prevent injury from fall due to poor balance, poor safety awareness & fatigue x 30 days [check] q 30 [minutes] & release q 2?."

On 4/14/10 at 10:00 a.m., the following progress note was noted, "Psych - Pt. continues to fall while trying to get up from wheel chair [sic] despite the use of a lap belt and lap Posey. He also refuses to wear a helmet. Will start Serax and Geri chair c lap Posey for patient protection."

On 4/14/10 at 10:00 a.m., the physician wrote the following order, "1. Serax 10 mg p.o. TID (excitement). 2. Pt. to remain in Geri chair c lap Posey to prevent falls x 7 days. 3. Ambulate Pt. x 2 in AM & x 2 in PM."

On 4/14/10 at 10:18 a.m., the OT documented the following progress note, "Attempted helmet and [Patient's name] refused to wear it or took the helmet off after being repeatedly place [sic] back. He was explain [sic] the need for helmet for safety precaution due to multiple falls (History of) but he stated (no leave it off!) He is very confused attempts to stand up in w/c with lap buddy and pommel wedge. Unable or unaware of safety issues and had poor judgement at this time. Dr had ordered Geri chair with pelvic Posey."

On 4/14/10 at 12:51 p.m., the physician wrote the following order, "Positional support in form of pelvic Posey while in Geri chair to prevent injury from fall due to poor balance/poor safety awareness x 30 day [check] q 30 [minutes] & release q 2?. 2. 15 [minute] [checks] for safety position."

The facility did not assess all problems or issues with the restraint until 4/20/10, six days after placement of the restraint. The facility did not evaluate the risks to the patient being restrained.

Summary:
On 4/21/10 at 5:12 a.m., the patient was crying due to not being able to freely move about. Every time the patient tried to move about freely the facility increased the level of restraint as follows:
-A seat belt in his wheelchair on 3/31/10 that the resident could remove independently;
-Wheelchair with a lap buddy on 4/9/10 that the resident could remove independently;
-Wheelchair with a lap buddy and pommel wedge on 4/12/10 that the resident could remove independently;
-A Geri chair with a lap Posey on 4/14/10 at 10:00 a.m., which the patient could not remove independently;
-A lap buddy and a lap Posey on 4/14/10 at 10:30 a.m. which the resident could not remove independently;
-To a Geri chair with a pelvic Posey on 4/14/10 at 12:51 a.m. which the resident could not remove independently.

b. On 4/15/10 at 4:20 p.m., the physician wrote the following order, "Pt. to wear one piece jump suit due to refusal to wear any clothes."

On 4/16/10 at 5:40 a.m., the nurse documented the following progress note, "[Patient's name] was sleeping at change of shift but was up x2 during the night. He had gotten up & taken his clothes off but redirected easily. He slept after. 15 min [checks] continued."

On 4/18/10 at 9:55 p.m., the following progress note was noted, "...Pt. was restless and agitated [sic] and was trying to undress himself in the dayhall [sic] this writer went over to him to assist [sic] with dressing him but Pt. became combative. Another Psych tech came over to assist [sic] and Pt. was ambulated to his rm and toileted. Pt. was layed [sic] in bed per Pt. request..."

The medical record lacked documentation of the behaviors for which the jump suit being used. The physician ordered the jump suit on 4/14/10 at 4:20 p.m., the staff started writing about issues with the patient disrobing on 4/16/10 at 5:40 a.m. The jump suit restricted the patient's movement.

3. Patient #6 was admitted to the facility on 5/6/10 with admitting diagnoses of dementia, coronary artery disease, history of falls, cerebral vascular accident, hypertension, and chronic anticoagulation therapy with Plavix.

On 6/24/10 at 4:30 p.m., the following progress note was noted, "While ambulating between dayhall and dining room, [Patient's name] fell striking his head on the nursing station counter. The fall was witnessed by staff who immediately responded. LOC or cuts were not documented. He was assisted to a geri [sic] chair and evaluated by staff. [Patient's name] then tried to get up & fell again, this time sliding down the chair to the floor. He was again evaluated by staff." "Assessment: gait instability etiol [etiology]? Plan: 1. Hold prn Ativan unless pt becomes very agitated. 2. Neuro checks Q 1? x 3, then Q 2? x 2, then Q 3? x 3. Notify me if any changes. 3. Positional support in the form of a waist posey [sic]." The physician tried notifying the family; either no answer or the phone was busy.

On 6/24/10 at 4:55 p.m., the physician documented the following order, "Apply positional support in the form of a posey [sic] waist restraint while in chair to prevent injury from fall due to poor balance, inability to maintain position in chair, poor safety awareness, and unsteady gait. Check Q 30 min. Release Q 2 hours. Apply x 7 days."

On 6/25/10 at 7:40 a.m., the nurse documented the following note, "At approx 0705 [7:05 a.m.] heard loud sound in TV room/day hall. Found sitting slouched against wall. body of geri [sic] chair tipped over on floor, legs over back of chair, one leg in posey [sic]. Alert able to move extremities as per his usual ROM, skin intact vs: 118/74, P 114, R 24, T 98.6, O2 sat 96% RA. Assisted by four to standing position, repositioned in Geri chair. no apparent evidence of injury. RN PM notified. Posey reapplied/order."

On 6/25/10 at 9:00 a.m., the facility notified the patient's wife of the need of a pelvic Posey. Also informed wife of recent falls. The facility received verbal consent from the patient's wife for the positional supports.

On 6/28/10 at 2:00 p.m., on 7/22/10 at 8:03 a.m., and 8/16/10, the physician documented the following, "Positional support in the form of a posey [sic] waist restraint while in chair to prevent injury from fall due to poor balance, inability to maintain position in chair, poor safety awareness, and unsteady gait. Check q 30 min - release q 2 hours. Apply x 30 days."

On 7/14/10 at 8:37 a.m., the physician documented the following progress note, "Psych: Pt reviewed & seen. Frequent bandage removal. Hostile/uncooperative c care. Tense/excited/disrobes/attempts to stand in geri [sic] chair yet reluctant to walk...."

On 7/14/10 at 10:55 a.m., the following progress note was noted, "[Patient's name] tipped over gerichair [sic] in west hall way while trying to slip out of geri [sic] chair- tipped chair backwards. No apparent injury and usual level of function & behavior. Will observe."

On 7/19/10 at 1:00 p.m., the nurse noted the patient's vital signs. The patient is in Geri chair c pelvic Posey.

On 7/19/10 at 1:40 p.m., the nurse documented the following progress note, "Redirected x 2 from standing up in Geri chair - pelvic support readjusted and pt placed in area where staff are present...."

On 7/20/10 at 7:30 p.m., the following progress note was noted, "Wife called staff to room. [Patient's name] had become agitated, trying to crawl out of gerichair [sic], pulling at posey [sic]. Unable to redirect, Thorazine 25 mg IM given at 1920 [7:20 p.m.] will monitor."

On 8/20/10 at 9:30 p.m., the following progress note was noted, "At 2000 [8:00 p.m.] Pt sitting in gerichair, restless, straining with arms. Staff nearby assisting another pt. She heard fall and turned to see pt had tipped his chair over backwards and hit his head on floor. Pt sustained cut to back of his head approx 1 in long with bleeding and swelling. Pt remained conscious and struggling to get up. Wound was dressed with gauze, bleeding stopped within a few minutes. Supervisor, medical doctor, and Psychiatrist on call were notified.

On 8/26/10 at 8:20 p.m., the following progress note was noted, "Daughter notified staff at 1955 [7:55 p.m.] that pt had passed away. [Physician's name] notified at 2000. [Physician's name] notified..."


27823


6. During the review of patient #8's medical record, it was noted that the patient was admitted to the facility on 2/23/10 at 1:30 p.m., with diagnoses of dementia, hostility, coronary artery disease, gastritis, duodenitis, hypertension, and hypothyroidism. The Progress Note indicated the patient was uncooperative with nursing assessments at the time of admit. The Physician Order Sheet on 2/23/10 at 5:27 p.m., documented an order for, "Positional support in the form of pelvic posey [sic] while in wheelchair to prevent injury from fall . . . poor posture and sliding out of wheelchair . . ." It was noted in the Progress Notes on 2/24/10 at 10:30 a.m., "Exam: Alert, calm, in wheelchair with positional support . . . Plan: I called pts son at work and on cell and left messages . . ." The use of the pelvic Posey restricted the patient's movement.

The daughter-in-law was interviewed on 8/30/10 at 11:00 a.m. The daughter-in-law stated that they did not understand the reasoning for the Posey restraint as the patient was ambulatory prior to being admitted to the facility.

7. During the review of patient #15's medical record, it was noted that the patient was admitted to the facility on 6/5/08 at 12:54 p.m., with diagnoses of dementia with behavioral disturbance, type II diabetes, and hypertension. It was noted in the Psychiatric Evaluation on 12/24/09 that the patient tripped and hit his head on 12/5/09. On 12/6/09, he fell and hit his head again. The patient was diagnosed with a subdural hematoma. On 12/7/09 the patient was placed in, "positional support with pelvic Posey in Geri chair".

Staff Member U was interviewed on 8/30/10 at 12:45 p.m. She stated the patient had the Posey around his waist to keep him from falling. She further stated it was called a "positional support." She stated the positional support was a restraint as the patient was unable to remove the device as it was tied behind the chair.

Staff Member E was interviewed on 8/30/10 at 1:00 p.m. He stated he had ordered the positional support because the patient had severe dementia. The patient had poor safety awareness and unsteady gait.

Staff Member H was interviewed on 8/31/10 at 11:15 a.m. She stated the facility only used restraints on patients who are hostile and exhibit behavior problems. The facility uses positional supports for patients that are fall risks. She stated because the positioning device is not considered a restraint, that they are not assessed quarterly to consider a less restrictive device. She further stated the staff do assess the positioning device every 30 minutes by putting their hand in between the patient and the restraint to assure it is not too tight.

During observation on 8/30/10, patient #15 was observed with a pelvic Posey tied in the back of the Broda chair from 12:45 p.m. to 4:00 p.m. The patient was trying to scoot the chair by rocking his body back and forth. During observation on 8/31/10, the patient was observed with a pelvic Posey tied in the back of the Broda chair from 8:00 a.m. to 11:15 a.m., and again from 1:40 p.m. to 3:00 p.m. At no time during the observations did a staff member approach the patient to check the restraint. The pelvic Posey restricted the patient's movement.

8. During the review of patient 21's medical record, it was noted that the patient was admitted to the facility on 2/26/10 at 10:55 a.m., with diagnoses of schizoaffective disorder, bipolar type, anxiety disorder, congestive heart failure. Physician Order Sheet on 6/25/10 at 8:22 a.m., stated "Jump suit."

On 9/1/10 at 9:00 a.m., Staff Members G and U stated the patient was unable to remove the jumpsuit. They further stated she was in the jumpsuit so she would keep her clothes on.

The patient was observed in the jumpsuit throughout the week of survey 8/30/10 - 9/2/10.
The use of the jumpsuit prevented the patient from moving her body, arms, and legs freely.











































26492


4. During review of patient #9's closed medical record on 8/31/10 at 3:15 p.m., the patient was admitted to the facility on 6/26/10 with diagnoses of dementia, left cerebral vascular infarct, atrial fibrillation, hypertension, abdominal wall hernia, and mitral valve replacement.

Within the Physician Order on 7/1/10 at 1715 (5:15 p.m.), the physician documented that a lap buddy with pommel wedge was placed on the patient to "prevent injury from fall." The lap buddy was discontinued on 7/2/10 at 1500 (3:00 p.m.) and a "Geri chair and pelvic Posey to prevent injury from fall.." was ordered. Documented within the Progress Notes was the following:
-On 7/3/10 at 2215 (10:15 p.m.) "unable to reposition with Posey in Geri chair, placing arms under Posey ties.." ;
-On 7/6/10 at 2300 (11:00 p.m.) "Pt. was leaned over the left side of the Geri chair with arms holding self up, his legs were still in the Geri chair with Posey around one leg";
- On 7/7/10 at 2200 (10:00 p.m.), "[patients name] was able to free himself from his Posey and stood out of his Geri chair. He fell, hitting his head on the wall by the patient phone";
-On 7/9/10 at 0620 (6:20 a.m.), "attempting to get out of Geri chair";
-On 7/10/10 at 1235 12:35 p.m.), "bent frame of Geri chair..";
-On 7/11/10 at 1006 (10:06 a.m.), "Pt. with [up arrow] tension an agitation attempting to get out of chair..";
-On 7/13/10 at 0545 (5:45 a.m.), "Pt. spent the noc trying to pull off the Posey..";
-On 7/17/10 at 1420 (2:20 p.m.), "Constantly attempting to get out of Geri chair. Posey in place, so cannot [sic] get out of chair and fall.."; and
-On 7/17/10 at 1535 (3:35 p.m.), "Pt.. woke, started to press up into top of Geri chair tipping it backward."

The medical record lacked documentation of an assessment or less restrictive intervention for the use of the pelvic Posey and the Geri chair. Both of these devices prevented the patient from moving his body and legs freely.

Further review of the Observation Flow Sheet documented on 7/15/10 at 2:40 a.m. the patent was placed in a jumpsuit. The chart lacked documentation of an assessment, medical condition, or less restrictive intervention for the jumpsuit. The jumpsuit prevented the patient from moving his body, arms, and legs freely.

5. Patient #10 was admitted to the hospital on 7/30/10 with diagnoses including dementia due to traumatic brain injury, dementia with behavioral disturbance, alcohol dependence, personality disorder, seizure disorder secondary to traumatic brain injury, thrombocytopenia, GERD and hypertension.

The Progress Notes on 8/11/10 at 10:20 p.m. state that "Pt.. currently in bed, wearing a one piece suit...1 piece suit is keeping his hands clean." The medical record lacked an assessment, medical condition or less restrictive intervention prior to using the one piece suit. The jumpsuit restricted the patient's movement.

Based on observation, record review, patient, and staff interviews, the facility failed to properly use seclusion for 1 (#10) of 9 patients whose medical records were reviewed for the use of restraints or seclusion. Findings included:

1. The policy for Use of Seclusion and Restraints was reviewed. Item D and E under the heading Policy indicated, "D. Seclusion and restraint are not treatment and may not be implemented as a behavioral consequence in response to a previously occurring behavior, or imposed as a means of coercion, discipline, convenience, or retaliation by staff. E. Seclusion and Restraint procedures may be used only when clinically justified in accordance with a Physician/Licensed Independent Practitioner (LIP) order and used only when less restrictive interventions have been determined to be ineffective. The type of seclusion or restraint used must be the least restrictive procedure to effectively protect the patient, staff, or others from harm. Seclusion and Restraint procedures must be ended at the earliest possible time." The policy did not specify that the use of seclusion was to be used only for the management of violent and self destructive behavior.


26492


2. Patient #10 was admitted to the hospital on 7/30/10 with diagnoses including dementia due to traumatic brain injury, dementia with behavioral disturbance, alcohol dependence, personality disorder, seizure disorder secondary to traumatic brain injury, thrombocytopenia, GERD, and hypertension.

The Initial Treatment Plan for patient #10 dated 7/30/10 stated the health care problem as "Inability to care for self, r/t CVA and TBI hx of leaving AMA from medical facility," and the intervention was "assist with all ADL's-pivot transfer with 2 staff..."

The progress notes indicated the following:
-7/30/10 documented... "developed seizure disorder stroke [sic], left side paralysis pt is non ambulatory...pt alert and oriented to place...hx of falls...pt needs assist of least [sic] 2 persons..";
-8/14/10 at 2040, "Pt. found between wall et [sic] bed, head on floor, feet tangled in bedding. Pt state he hit his head, lump on L side of head...";
-8/15/10 at 2025, "Pt. on floor, pt. states he was moving from w/c to bed";
-8/15/10 at 2155, "I want my [swear word] wheelchair"
-8/15/10 at 2200, "Pt again pushing call button repeatedly. Asked to have wheelchair next to bed and was told no...";
-8/16/10 at 0622, the Psych note, "will remove wheelchair from room that pt will have assist c transfers";
-8/16/10 at 0940, the OT note, "..place w/c out of room";
-8/17/10 at 0555, "Pt. wanted wheelchair in his room";
-8/23/10 at 1750, "Pt. found on floor, on back, not witnessed by staff"; and
-8/30/10 at 0507, "Pt. upset about w/c being out of room.."

The physician orders indicated the following::
-8/15/10 at 2020, "15 minute checks, lock bedroom door during day time hours.."; and
-8/16/10 at 0918, "Pt. not to have wheelchair in his room so that he can receive assist with transfers."

On 8/30/10 at 1:30 p.m., Staff Member G was interviewed regarding patient #10. Psych tech G stated that "we put [patient #10] in his room on his bed and take the wheelchair because he would attempt to go to the bathroom and fall."

On 8/30/10 at 1:47 p.m., patient #10 was observed lying in his bed and the wheelchair was in the hall.

On 8/30/10 at 1:58 p.m., the Staff Member H stated patient #10 "cannot walk and the wheelchair cannot be in his room. He is dependent on staff for his ADLs."

On 8/30/10 at 3:30 p.m., the wing Staff Member I stated all doors lock from the inside and residents who can open the doors are able to. She further stated that patient #10 "cannot walk and he cannot open the locked door. The staff would have to let him out of his room." When the surveyor asked for a policy on locking residents in their room, she stated "there is not a policy."

On 8/31/10 at 10:00 a.m., patient #10 stated that his "bedroom door is locked during the day because the staff want it locked." He further stated that "when/if I fall out of bed I have to bang and yell really loud. The call button is on the wall. There is no string." He further stated "the staff take my wheelchair and it makes me mad."

There was no indication within the record the patient had violent or self-destructive behaviors requiring the use of seclusion.

Based on medical record review, and staff interview, the facility failed to assess 6 (#s 4, 6, 8, 10, 15, and 21) of 9 patients whose medical records were reviewed to determine if less restrictive interventions would be effective to protect the patient prior to the use of restraints. Findings include:

1. Patient #6 was admitted to the facility on 5/6/10. The patient was admitted with diagnoses of dementia, coronary artery disease, history of falls, cerebral vascular accident, hypertension, and chronic anticoagulation therapy with Plavix.

On 6/24/10 at 4:55 p.m., the physician documented the following order, "Apply positional support in the form of a Posey waist restraint while in chair to prevent injury from fall due to poor balance, inability to maintain position in chair, poor safety awareness, and unsteady gait. Check Q 30 min. Release Q 2 hours. Apply x7 days."

On 6/24/10 at 4:30 p.m., the following progress note was written: "While ambulating between dayhall and dining room, [Patient's name] fell striking his head on the nursing station counter. The fall was witnessed by staff who immediately responded. There was no LOC or cuts. He was assisted to a Geri chair and evaluated by staff. [Patient's name] then tried to get up & fell again, this time sliding down the chair to the floor. He was again evaluated by staff. Accu check was 215. Again, there was no LOC or other injuries that were immediately apparent. Assessment: gait instability etiol [etiology]? Plan: 1. Hold prn Ativan unless pt becomes very agitated. 2. Neuro checks Q 1? x3, then Q 2? x 2, then Q 3? x 3. Notify me if any changes. 3. Positional support in the form of a waist Posey." The physician tried notifying the family; either no answer or the phone was busy.

The medical record lacked documentation of restraint assessment or that a less restrictive intervention was tried for patient #6 prior to the use of the Posey waist restraint.


27823


3. During the review of patient #4's medical record, it was noted that the patient was admitted to the facility on 8/13/10 at 7:45 p.m., with diagnoses of dementia with behavior, and hypertension. The medical record states that the patient was placed in a pelvic Posey restraint on 8/14/10 at 4:15 p.m. for ". . . cognitive deficits and confusion pt danger to self extremely hostile - combative and unsafe". The pelvic Posey restraint was discontinued on 8/15/10 at 11:40 p.m. The Physician Order Sheet on 8/16/10 at 12:22 p.m. ordered "Positional support in form of pelvic Posey with Geri chair to prevent injury from fall . . ." The pelvic Posey was discontinued on 8/26/10 at 3:09 p.m.

The medical record lacked documentation that less restrictive interventions were tried before the use of the pelvic Posey.

4. Patient #8 was admitted to the facility on 2/23/10 at 1:30 p.m., with diagnoses of dementia, hostility, coronary artery disease, gastritis, duodenitis, hypertension, and hypothyroidism. The Physician Order Sheet on 2/23/10 at 5:27 p.m., documented an order for, "Positional support in the form of pelvic Posey while in wheelchair to prevent injury from fall . . . poor posture and sliding out of wheelchair . . ."

The medical record lacked documentation that less restrictive interventions were tried prior to the use of the pelvic Posey.

5. Patient #15's medical record states that the patient was admitted to the facility on 6/5/08 at 12:54 p.m., with diagnoses of dementia with behavioral disturbance, type II diabetes, and hypertension. It was noted in the Psychiatric Evaluation on 12/24/09 that the patient tripped and hit his head on 12/5/09. On 12/6/09, he fell and hit his head again. The patient was diagnosed with a subdural hematoma. On 12/7/09 the patient was placed in, "positional support with pelvic Posey in Geri chair".

The medical record lacked documentation that less restrictive interventions were tried before the use of the pelvic Posey.

6. During the review of patient 21's medical record, it was noted that the patient was admitted to the facility on 2/26/10 at 10:55 a.m., with diagnoses of schizoaffective disorder, bipolar type, anxiety disorder, congestive heart failure. The Physician Order Sheet of 6/25/10 at 8:22 a.m. ordered "Jump suit."

On 9/1/10 at 9:00 a.m., Staff Members G and U stated that the patient was unable to remove the jumpsuit. They further stated she was in the jumpsuit so she would keep her clothes on.

The medical record lacked documentation that less restrictive interventions were tried prior to the use of the jumpsuit.



























26492


2. On 8/30/10 at 1:30 p.m., the active medical record for patient #10 was reviewed. Patient #10 was admitted to the hospital on 7/30/10 with diagnoses including dementia due to traumatic brain injury, dementia with behavioral disturbance, alcohol dependence, personality disorder, seizure disorder secondary to traumatic brain injury, thrombocytopenia, GERD, and hypertension.

It was documented in the medical record, when the patient was placed in his room, that his wheelchair was to be removed and the door was to be locked. The Physician Order Sheet on 8/15/10 at 10:20 p.m. provided an order for, "15 minute checks, lock bedroom door during day time hours.. . ." 8/16/10 at 0918 documented "Pt. not to have wheelchair in his room.."

The medical record lacked documentation that less restrictive interventions were tried prior to the use of seclusion.

Based on record review and staff interview, the facility records failed to indicate that the use of a restraint was the least restrictive intervention for 6 (#4, 6, 8, 10, 15, and 21) of 9 sampled patients. Findings include:

1. Patient #6 was admitted to the facility on 5/6/10. The patient was admitted with diagnoses of dementia, coronary artery disease, history of falls, cerebral vascular accident, hypertension, and chronic anticoagulation therapy with Plavix.

On 6/24/10 at 4:55 p.m., the physician documented the following order, "Apply positional support in the form of a Posey waist restraint while in chair to prevent injury from fall due to poor balance, inability to maintain position in chair, poor safety awareness, and unsteady gait. Check Q 30 min. Release Q 2 hours. Apply x7 days."

On 6/24/10 at 4:30 p.m., the following progress note was written: "While ambulating between dayhall and dining room, [Patient's name] fell striking his head on the nursing station counter. The fall was witnessed by staff who immediately responded. There was not LOC or cuts. He was assisted to a Geri chair and evaluated by staff. [Patient's name] then tried to get up & fell again, this time sliding down the chair to the floor. He was again evaluated by staff. Accu check was 215. Again, there was no LOC or other injuries that were immediately apparent. Assessment: gait instability etiol [etiology]? Plan: 1. Hold prn Ativan unless pt becomes very agitated. 2. Neuro checks Q 1? x3, then Q 2? x 2, then Q 3? x 3. Notify me if any changes. 3. Positional support in the form of a waist Posey." The physician tried notifying the family; either no answer or the phone was busy.

The medical record lacked documentation showing that the least restrictive intervention had been tried for patient #6.


26492


2. On 8/30/10 at 1:30 p.m., the active medical record for patient #10 was reviewed. Patient #10 was admitted to the hospital on 7/30/10 with diagnoses including dementia due to traumatic brain injury, dementia with behavioral disturbance, alcohol dependence, personality disorder, seizure disorder secondary to traumatic brain injury, thrombocytopenia, GERD and hypertension.

It was documented in the record that staff were to remove the patient's wheel chair when the patient was placed in his room, and the door was to be locked. The Physician Order Sheet on 8/15/10 at 10:20 p.m. documented an order for, "15 minute checks, lock bedroom door during day time hours.. . ." 8/16/10 at 0918 documented "Pt. not to have wheelchair in his room.."

The medical record lacked documentation that a least restrictive intervention had been tried before the use of seclusion..


27823


3. Patient #4's medical record states that the patient was admitted to the facility on 8/13/10 at 7:45 p.m., with diagnoses of dementia with behavior, and hypertension. The Physician Order Sheet on 8/16/10 at 12:22 p.m. ordered "Positional support in form of pelvic posey [sic] with geri [sic] chair to prevent injury from fall . . ."

The medical record lacked documentation that the least restrictive intervention was the use of the pelvic Posey.

4. Patient #8's medical record states that the patient was admitted to the facility on 2/23/10 at 1:30 p.m., with diagnoses of dementia, hostility, coronary artery disease, gastritis, duodenitis, hypertension, and hypothyroidism. The Physician Order Sheet on 2/23/10 at 5:27 p.m. ordered "Positional support in the form of pelvic posey [sic] while in wheelchair to prevent injury from fall . . . poor posture and sliding out of wheelchair . . ."

The medical record lacked documentation that a least restrictive intervention had been tried.

5. Patient #15's medical record states that the patient was admitted to the facility on 6/5/08 at 12:54 p.m., with diagnoses of dementia with behavioral disturbance, type II diabetes, and hypertension. It was noted in the Psychiatric Evaluation on 12/24/09 that the patient tripped and hit his head on 12/5/09. On 12/6/09, he fell and hit his head again. The patient was diagnosed with a subdural hematoma. On 12/7/09 the patient was placed in, "positional support with pelvic posey [sic] in geri [sic] chair".

The medical record lacked documentation that the least restrictive use of the pelvic Posey and the use of a Geri chair.

6. Patient #21's medical record states that the patient was admitted to the facility on 2/26/10 at 10:55 a.m., with diagnoses of schizoaffective disorder, bipolar type, anxiety disorder, congestive heart failure. The Physician Order Sheet on 6/25/10 at 8:22 a.m. ordered "Jump suit".

On 9/1/10 at 9:00 a.m., Staff Members G and U stated the patient was unable to remove the jumpsuit. They further stated she was in the jumpsuit so she would keep her clothes on. The medical record lacked documentation that the jumpsuit was the least restrictive intervention.

Based on medical record review, the facility failed to ensure orders for the use of restraints were not written as a standing order or on an as needed (PRN) basis for 1(#6) of 9 patients whose medical records were reviewed for the use of restraints. Findings included:

1. The policy for Use of Seclusion and Restraints was reviewed. Item F under Policy indicated, "F. Orders for the use of seclusion or restraint are never written as a standing order or on an as needed basis (PRN)."

2. Patient #6 was admitted to the facility on 5/6/10. The patient was admitted with diagnoses of dementia, coronary artery disease, history of falls, cerebral vascular accident, hypertension, and chronic anticoagulation therapy with Plavix.

On 6/28/10 at 2:46 p.m., the physician ordered "Jump suit prn for disrobing." The medical record lacked documentation of the patient disrobing around the time of this order.


26492

Based on staff interview and facility policy review, the facility failed to ensure the facility policy addressed the training requirement for physicians and other licensed independent practitioners. Findings included:

On 9/1/10 at 4:30 p.m., during a meeting with Staff Member L, the surveyors asked about the education and training requirements for physicians and other licensed independent practitioners. Staff Member L stated the physicians and licensed independent practitioners received MANDT training. He stated he did not know what kind of education the physicians and licensed independent practitioners received on restraints not related to behavior issues.

The policy for Use of Seclusion and Restraints was reviewed. Item H. indicated, "Trained staff: includes Physician/ LIP, RN, PA or other licensed nursing staff and direct care staff that has been trained in de-escalation techniques, and safe management of seclusion and restraints." The section under Responsibilities indicated, "Staff who had received facility approved training in de-escalation and safe management of seclusion and restraint use and violence in general by utilizing less restrictive measures such as the de-escalation techniques listed in Attachment C... B. Staff Development shall conduct regular training for all staff involved in the use of seclusion or restraints and alternative methods of de-escalation and interventions."

Based on facility policy review, the staff was being trained on restraints utilized with behavior issues. The staff was not being trained on restraints related to non-behavioral issues.

Based on policy review and staff interview, the facility failed to develop and implement a comprehensive training program for all staff providing care to patients in restraints for the management of non-violent and non-self-destructive patient behavior. Findings include:

The facility's policy for the Use of Seclusion and Restraints was reviewed. Item H. indicated, "Trained staff: includes Physician/ LIP, RN, PA or other licensed nursing staff and direct care staff that has been trained in de-escalation techniques, and safe management of seclusion and restraints."

The policy addressing the use of seclusion and restraints included a document titled "Less Restrictive Measures to Seclusion or Restraint Interventions Taught in Mandt Training". The document indicated the goal is to teach staff how to "effectively manage a potentially negative or even dangerous situation by first calming your emotional response and managing your own behavior so you can interact with other people positively." Mandt training teaches how to care for patients with behavioral issues. This training does not train staff on how to care for patients in restraints for the management of non-violent and non-self-destructive patient behavior.

On 9/1/10 at 4:30 p.m., Staff Member L stated he did not know what kind of education the physicians and licensed independent practitioners received on restraints not related to behavior issues.

On 8/30/10 at 12:45 p.m., Staff Member U stated the positional support was a restraint. She stated that staff did not receive training for the care of patients in restraints for the management of non-violent and non-self-destructive patient behavior.

On 8/31/10 at 8/31/10 at 8:35 a.m., Staff Member G stated the positional support was a restraint. She stated that staff did not receive training for the care of patients in restraints for the management of non-violent and non-self-destructive patient behavior.

Based on review of personnel records and staff interviews, the facility failed to ensure staff were trained and able to demonstrate competency in applying restraints, for the management of non-violent and non-self-destructive behavior. Findings include:

The facility trains the staff with MANDT. MANDT teaches how to care for patients with behavioral issues, it does not train on how to care for patients in restraints for the management of non-violent and non-self-destructive patient behavior.

The facility's policy for the Use of Seclusion and Restraints was reviewed. Item H. indicated, "Trained staff: includes Physician/ LIP, RN, PA or other licensed nursing staff and direct care staff that has been trained in de-escalation techniques, and safe management of seclusion and restraints."

On 9/1/10 at 4:30 p.m., Staff Member L stated he did not know what kind of education the physicians and licensed independent practitioners received on restraints not related to behavior issues.

On 8/30/10 at 12:45 p.m., Staff Member U stated the positional support was a restraint. She stated that staff did not receive training for the care of patients in restraints for the management of non-violent and non-self-destructive patient behavior.

On 8/31/10 at 8/31/10 at 8:35 a.m., Staff Member G stated the positional support was a restraint. She stated that staff did not receive training for the care of patients in restraints for the management of non-violent and non-self-destructive patient behavior.

Based on record review and staff interview, the facility failed to report on restraint/seclusion death by the close of business the next business day following the death of 1 (#6) of 5 patient's whose death records were reviewed. Findings include:

On 8/30/10 at 2:00 p.m., when asked by the surveyor, Staff Member D stated no one had died in restraints and no deaths had been potentially related to the use of restraints.

Record review indicated on 8/20/10 at 8:00 p.m. patient #6 was sitting in a Geri chair with a pelvic Posey in place. The patient tipped the Geri chair over backwards and hit his head on the floor. The patient sustained a cut to the back of his head approximately one inch long with bleeding and swelling. Seven days later, on 8/26/10 at 7:55 p.m., the patient passed away.

At the time of the fall, the patient was on an 81 mg extended control aspirin. The night shift psych tech documented on the Flow Sheet Record under Postioning/Chair that the patient was in a Geri chair and pelvic Posey until 8/26/10. The evening shift psych tech documented on the Flow Sheet Record that the patient was in the Geri chair and pelvic Posey until 8/23/10.

Patient #6's death was not reported to the Centers of Medicaid/Medicare offices by the end of the business day on 8/27/10.

Based on clinical record review, the hospital failed to ensure adequate delivery of care for 7 (#s 2, 6, 8, 9, 10, 15, and 18) of 21 sampled patients. Findings include:

1. Patient #s 2, 6, and 9, were placed in Geri chairs with pelvic Poseys. While in the Geri chairs wearing pelvic Poseys, the patients tipped over their respective Geri chairs. Some patients hit their heads, and others suffered skin tears. Documentation of nursing assessments after the falls were absent.

2. Patient #8, 15 and 16 were not assessed for on-going dietary issues.

3. Patient #15 was not assessed for a rash on his legs.

4. Patient #18 complained of tremors in her lower and upper body extremities. The nursing staff did not assess the upper and lower body extremities motor skills.

An Immediate Jeopardy was determined and the facility was notified on September 2, 2010 at 11:45 a.m. An allegation to lift the Immediate Jeopardy was not provided to the surveyors by the end of the survey. (See A395)

Based on record review, policy review, and staff interviews, the facility failed to adhere to professional nursing standards of care regarding patient assessment and documentation of care for 7 (#s 2, 6, 8, 9, 10, 15, and 18) of 21 patient records reviewed. Finding included:

1. The facility's Neuro Assessment policy states "Patients who sustain trauma to the head or who have an unobserved fall or accident with possible head trauma will be assessed for neurological abnormalities or changes." Under the heading Procedure the policy reads: "A. Monitor neuro signs, pulse, respirations, and blood pressure every hour x 2, then every 2 hours x 2, then every four hours x 2, then every 8 hours x 48.

2. Patient #2 was admitted to the facility on 11/30/09. The patient had diagnoses of Lewy Body dementia, coronary artery disease, hypertension, atrial fibrillation, degenerative joint disease, left carotid stenosis, and chronic obstructive pulmonary disease.

Per the Physician orders signed on 3/31/10, patient #2 was to use a seat belt while sitting in a chair during the day.

a. In the Progress Notes dated 4/9/10 at 2:40 p.m., the nurse documented the patient was found on the floor next to his wheel chair. At 2:44 p.m., the nurse assessed the patient's vital signs to be pulse 71, respirations 16 even and unlabored, oxygen saturation 96% on 2.5 L, blood pressure 110/56, and the patient refused to have his temperature to be taken.

On 4/9/10, staff documented the patient's vital signs to be: temperature 96.7, pulse 60, blood pressure 97/52, and oxygen saturations 97%. This entry was not timed.

On 4/9/10 at 3:43 p.m., the patient's family was notified of the fall.

On 4/9/10 at 3:43 p.m., the physician documented the following in a progress note, "Pt c apparent fall from wheelchair. Pt removes safety belt I (independently). Pt evaluated by nursing & OT who thought lap buddy would be safer..."

The facility's Neuro Assessment policy was not followed.

b. On 4/11/10 at 10:30 a.m., the following progress note was noted, "Patient was found in Rm 125 @ app 0955 walking around the room. Pt's wheelchair was tipped over c lap buddy still in place. Pt wanted to go to bed. Staff escerted [sic] him back to his own rm. RN notified."

On 4/11/10 at 10:45 a.m., the nurse documented the following progress note, "No apparent injury. Amb s difficulty."

On 4/11/10, no time recorded, staff documented the following vital signs: temperature 96.9?, pulse 78, respirations 18, oxygen saturations 97%, and blood pressure 104/56.

The facility's Neuro Assessment policy was not followed.

c. Computer charting on 4/11/10 documented, "Friday AM/PM Albuterol 1 unit dose deliver with Neb, 3 x daily, 1000, 1600 et 2100, Ceftin 250mg BID/ [Doctor's name], slid out of chair about 1330 [1:30 p.m.], when attempted to assist back in WC becomes combative loud et angry resisting assistance. Using all extremities, Taken to room, VSS, bed alarm placed. "O" for Ambulation with 2 - q2 hours while awake, lap buddy, bed alarm. PM/NOC productive cough, afebrile. Slept...not up."
"Saturday AM/PM productive cough, much improved form [sic] yesterday, smiling,
PM/NOC"
"Sunday AM/PM Found in the [Patient's name] room out of Wc, W/C and lap buddy on the floor. No apparent injuries."

The medical record lacked documentation of neuro checks for the fall on 4/11/10 at 1:30 p.m. and Sunday AM/PM entry.

f. On 4/16/10 at 1:40 p.m., the nurse documented the following progress note, "At 1315 [1:15 p.m.] noise was heard and [Patient's name] was found on the floor the Geri chair tipped over on it's side. (Posey was still intact) He was sitting beside Geri chair. ROM WNL vs 97, 79, 22, 117/68. O2 sat 94% after. applying O2 at 2.5 L. No apparent injuries noted. [Patient's name] ambulated c assist x2 as per usual.

The facility staff documented on the Graphic Chart form vital signs for 4/16/10 at 7:20 a.m. and 4/17/10 at 5:00 a.m.

The facility's Neuro Assessment policy was not followed.

g. On 4/19/10 at 10:45 p.m., the following progress note was noted, "Pt was in geri chair c pelvic posey when we found him tipped over c left hand still on the handrail. Pt was assisted to his feet, gait even and steady. Pt denies pain pt assisted to bed."

Facility staff documented on the Graphic Chart form vital signs for 4/19/10 (no time recorded) and 4/20/10 at 8:00 a.m.

On 4/19/10, using an Incident Report Form, the nurse documented the immediate corrective action was, "pt was assisted to bed. Pt's geri chair uprighted. Pt will be placed in geri chair in open area when pt cannot grab handrails or other object."

The facility's Neuro Assessment policy was not followed.

3. Patient #6 was admitted to the facility on 5/6/10. The patient was admitted with diagnoses of dementia, coronary artery disease, history of falls, cerebral vascular accident, hypertension, and chronic anticoagulation therapy with Plavix.

a. On 6/22/10 at 12:00 p.m., the nurse documented in the progress note that the patient was unsteady. The patient was grabbing for items in air, yet speech was appropriate to topic. The patient allowed for his pulse, O2 sats, respiration, and temperature to be taken. The patient refused to have his blood pressure taken. The patient's blood sugar this morning was 65. No action was taken. The patient refused food or drink. The nurse would continue to monitor.

The medical record lacked documentation that the nurse notified the physician about the patient's low blood sugar or if the patient received breakfast.

b. Documented within the progress note of 7/7/10 at 12:45 p.m: "Pt fell backwards in Geri chair. 0 injuries were noted. Pt denies injury requested to go to bed. Pt assisted to Geri chair, moved to room, then assisted into bed. Pt currently resting s C/0's (complaints offered)."

The medical record lacked documentation of vital signs or neuro checks after the noted fall on 7/7/10.

c. Documented within the progress notes of 7/14/10 at 9:40 a.m: "Tipped chair over backwards in hallway. No injury noted at this time. RN notified. Is restless trying to stand in chair et constantly moving about."

On 7/14/10 at 10:55 a.m., the following progress note was noted, "[Patient's name] tipped over gerichair in west hall way while trying to slip out of geri chair- tipped chair backwards. No apparent injury and usual level of function & behavior. Will observe."

The facility's Neuro Assessment policy was not followed.

d. On 7/19/10 at 6:05 a.m., the following progress note was noted, "Pt was found sitting on floor soaked c urine et feces. Pt's skin was assessed et intact. Pt has good ROM to extremities. Pt was able to stand et walk to BR c assist. Pt denies pain or discomfort. Drsg to Rt foot [changed]. Pt rested well in bed until 0500 [5:00 a.m.] when he was found on floor. Continues on 15 min [checks]."

On 7/19/10 at 1:00 p.m., the nurse recorded the patient's vital signs. The patient was in a Geri chair c pelvic posey.

The facility's Neuro Assessment policy was not followed.

e. On 8/20/10 at 9:30 p.m., the following progress note stated, "At 2000 Pt sitting in gerichair, restless, straining with arms. Staff nearby assisting another pt. She heard fall and turned to see pt had tipped his chair over backwards and hit his head on floor. Pt sustained cut to back of his head approx 1 in long with bleeding and swelling. Pt remained conscious and struggling to get up. Wound was dressed with gauze, bleeding stopped within a few minutes. Supervisor, medical doctor, and psychiatrist on call were notified. Incident report filed. Orders received for neuro checks Q 2 hrs x 2 and notify MD with any changes. VS within normal limits, pt's behavior unchanged from his usual at this time."

Neuro checks and vitals signs were documented on 8/20/10 at 8:00 p.m. and 10:00 p.m. The facility did not follow the policy for Neuro Assessment.

On 8/26/10 at 8:20 p.m., the following progress note was noted, "Daughter notified staff at 1955 [7:55 p.m.] that pt had passed away. [Physician's name] notified at 2000. [Physician's name] notified..."

From 8/20/10 to the patient's death on 8/26/10 he was combative, aggressive, and trying to get out of the pelvic Posey and Geri chair. The facility staff failed to assess and document patient #6's vital signs or neuro checks. The patient could have been having behavior issues due to a head injury.

4. Patient #18 was admitted to the facility on 3/5/10 at 6:00 p.m., with diagnoses of depression, borderline personality traits, unspecified body tremors, chronic back pain, and hypothyroidism.

The patient was assessed by the nurse on 3/5/10 at 6:00 p.m. The nurse documented on the Nursing Assessment, the patient was unable to ambulate at times and used a wheelchair to get around.

In the progress notes on 3/6/10 at 3:15 a.m., the nurse documented, "The admission process was deferred as she was shaking so badly and just 'wanting to go home.' She was given an IM of Ativan then brought to the unit..."

In the progress notes on 3/6/10 at 3:00 a.m., the nurse documented the patient was in the wheelchair due to full body "shakes." The patient was able to transfer to the bed without help. She continued to have the "shakes" and she requested pain medication; she had only Tylenol ordered, and she refused that medication. Within 30 minutes the shaking had stopped. The patient then fell asleep.

On 4/23/10, the facility filled out the form Abnormal Involuntary Movement Scale (AIMS). The patient had abnormal movement in her jaw and lower extremities. The severity of the abnormal movements was minimal. The patient's documented awareness of abnormal movements was "aware with severe distress."

In the discharge summary dated 6/25/10 under Significant Medical and/or Physical Findings, the physician documented, "The most significant at the present time seem to be the unspecified body tremors which seem to be worse in her right arm which she helped control by holding her right arm with her left arm."

The medical record lacked sufficient assessment of the etiology of the unspecified tremors.


26492


5. During review of patient #9's closed medical record on 8/31/10 at 3:15 p.m., the patient was admitted to the facility on 6/26/10 with diagnoses of dementia, left cerebral vascular infarct, atrial fibrillation, hypertension, abdominal wall hernia, and mitral valve replacement. On 7/7/10 at 2200 "[patients name] was able to free himself from his Posey and stood out of his Geri chair. He fell, hitting his head on the wall by the patient phone." The facility's Neuro Assessment policy was not followed.

6. Patient #10 was admitted to the hospital on 7/30/10 with diagnoses which included dementia due to traumatic brain injury, dementia with behavioral disturbance, alcohol dependence, personality disorder, seizure disorder secondary to traumatic brain injury, thrombocytopenia, GERD, and hypertension.

The Progress Notes on 8/14/10 at 2040 included "Pt. (was) found between wall et [sic] bed, head on floor, feet tangled in bedding. Pt state he hit his head, lump on L side of head...Neuro checks WNL." At 2330 the nurse documented "neuro checks completed."

On 8/15/10 at 2025 "Pt. on floor, pt. states he was moving from w/c to bed." The chart lacked documentation of an assessment or vital signs after the fall.

On 8/23/10 at 1750 "Pt. found on floor, on back, not witnessed by staff. " The chart lacked documentation of an assessment or vital signs after the fall.

On 8/26/10 at 1800 " Pt. found on bathroom floor.. " The chart lacked documentation of an assessment or vital signs after the fall.

The medical record lacked documentation of assessments and vital signs per the facility's Neuro Assessment policy for unobserved falls.


27823


7. Patient #8 was admitted to the facility on 2/23/10 at 1:30 p.m., with diagnoses of dementia, hostility, coronary artery disease, gastritis, duodenitis, hypertension, and hypothyroidism.

a. The patient's medical record of 3/1/10 documented that the patient's appetite was poor. The Physician's Order Sheet dated 3/1/10 at 8:27 a.m., documented an order for 1) weekly weights and record, 2) Ensure - one can if eats less than 50% of meal, and 3) Dietician consult. The Dietician Consult dated 3/1/10 at 1:20 p.m., documented, "Assessment: No height recorded yet. 195 pounds. At risk for skin breakdown and malnutrition, if he does not consume sufficient calories. Plan: Monitor weight, % eaten of meals and give Ensure as ordered, if he eats less than half of his meals. Dietician available PRN". On 3/1/10, the daughter-in-law called the facility stating she was concerned about patient's appetite and his dentures not fitting. On 3/3/10, the nursing staff documented skin breakdown of the buttocks. The patient was started on Prostat. On 3/4/10, oral intake was documented as poor. The Physician Order Sheet dated 3/4/10 at 8:10 a.m., documented an order to "Encourage fluids 1200 ml q am and 1200 ml q pm shift". On 3/9/10, "poor oral intake and likely dehydration" was documented. On 3/10/10 poor oral intake continued was documented. The patient expired on 3/11/10.

No documentation was found indicating fluids were encouraged per physician order.

No documentation was found indicating the patient had been weighed since admit per physician order.

No documentation was found on the MAR indicating the patient received Ensure when meals were refused per physician order.

b. During review of the patient's medical record, it was noted that on 3/8/10, the patient had a significant decline in status. A urinary tract infection was diagnosed on 3/8/10. Culture results were 10,000 Organisms/ml Proteus species. The patient was not given antibiotics and continued to decline. Further review of the record indicated that on 3/4/10, the patient had discharge from the penis. The medical record lacked documentation of nursing assessments.

Staff member D was interviewed on 9/2/10 at 11:00 a.m. She stated the patient had come to the facility "compromised" and had a continuous decline in status. The medical chart lacked documentation of nursing assessments or vital signs on the patient. No vital signs were documented until 3/5/10 when the physician ordered vital signs every 4 hours.

8. Patient #15 was admitted to the facility on 6/5/08, diagnoses included dementia with behavioral disturbance, Type II diabetes mellitus, and hypertension.

During observation on 8/30/10, the patient refused lunch. The patient was observed from 12:45 p.m. to 4:00 p.m. At no time did a staff member offer a snack or fluids. The patient was to receive Lantus insulin 14 Units at dinner. Staff member H was asked if the patient would have his blood sugar tested prior to receiving the Lantus insulin, as he had not eaten. Staff member H stated he would not, as blood sugars were only ordered BID on Saturdays.

During observation on 8/30/10 at 1:30 p.m., patient #15 was noted to be scratching at legs and pulling off his socks. Lower legs appeared to have a rash were bloody from scratching them. On 8/30/10 at 3:45 p.m., surveyor notified staff member H that patient #15 was scratching legs. Staff member H stated he had Benadryl in the past, but that it didn't help and no other therapeutic approach was tried. Within a progress note on 8/31/10 at 3:50 p.m., documentation indicated that patient #15 was on his bed rubbing and scratching legs at 3:30 p.m. At 3:45 p.m., the patient was found on floor. The record lacked documentation of a nursing assessment or vital signs and neuro checks after the fall. Documentation did not indicate that the nurse notified the physician of the rash on the patient's legs.

Based on observation, the facility failed to ensure that unauthorized individuals would not gain access to the x-ray room. Findings include:

On 9/2/10 between 9:37 a.m. and 10:45 a.m., the clinic was observed. During this period of time, the front desk was unattended, and the door to the x-ray room was open. Multiple patient x-rays were observed on an unsecured shelf. These x-rays were accessible to any passerby.

Based on record reviews, the facility failed to ensure that all clinical record entries were completed for 10 (#s 1, 2, 3, 7, 8, 10, 11, 12, 13 and 14 ) of 21 patient clinical records reviewed. Findings include:

1. Patient #2 was admitted to the facility on 11/30/09. The Positional Supports Assessment form dated 4/20/10 was not timed. The Physician Orders dated 3/31/10 were not timed. Two Progress Notes dated 4/19/10 were not timed.

2. Patient #10, was admitted to the facility on 7/30/10. During the review of the patient's medical record on 8/30/10, the Admission History and Physical, Admission Psychiatric Evaluation, Interim Social Assessment and Informed of Resident Rights forms were not timed. The Interim Social assessment was not signed.

3. Patient #7 was admitted to the facility on 1/21/10. During the review of the patient's closed medical record on 8/31/10 the following documents were found to not be timed: the History and Physical, Discharge Summary, Admission Psychiatric Evaluation, and the Interim Social Assessment.

4. Patient #8 was admitted to the facility on 11/12/09. During review of the patient's closed medical record on 8/31/10, the following documents were found to not be timed: the History and Physical, Discharge Summary, Admission Psychiatric Evaluation, and the Interim Social Assessment.

5. Patient #11 was admitted to the facility on 6/25/10. During review of the patient's active medical record on 8/31/10 at 10:30 a.m., the following documents were not timed: the History and Physical, Discharge Summary, Admission Psychiatric Evaluation, and the Informed Resident Rights.

6. Patient #12 was admitted to the facility on 8/4/10. During review of the patient's active medical record on 8/31/10, the following documents were found to not be timed: the History and Physical, Discharge Summary, Admission Psychiatric Evaluation, and the Informed Resident Rights. The Interim Social Assessment was not completed.

7. Patient #13 was admitted to the facility on 8/25/10. The following documents were not timed: History and Physical, Abnormal Involuntary Movement Scale, Admission Psychiatric Evaluation, Initial Social Assessment.

8. Patient #1 was admitted to the facility on 8/21/07. The Discharge Summary dated 5/15/10 was not timed.

9. Patient #3 was admitted to the facility on 4/6/10. The following documents were not timed: Admission Psychiatric Evaluation, Discharge Summary, and Admission History and Physical.

10. Patient #14 was admitted to the facility on 4/22/10. The following documents were not timed: Progress Notes dated 5/20, 6/8, 6/14, 6/15, 6/16, 6/17, and 6/17/10, Interim Social Assessment, Admission Psychiatric Evaluation, and Admission History and Physical.

Based on document review and staff interview, the facility failed to ensure that physician orders for 3 (#2, 13 and 14) of 21 sampled records were dated, timed, and/or authenticated promptly by the ordering practitioner. Findings include:

1. Patient #2 was admitted to the facility on 11/30/09. The time of the Physician Orders dated 3/31/10 was not documented.

2. Patient #13 was admitted to the facility on 8/25/10. The time of the Routine Admission Orders was not documented.

3. Patient #14 was admitted to the facility on 4/22/10. The times of the Physician Orders dated 6/4, 7/2, 7/30, and 8/27/10 were not documented.

Based on deficiencies cited at Standard A-0619 through A-0630, the facility failed to:
- prepare food in a sanitary environment,
- store food in a sanitary environment,
- store food at safe temperatures,
- supervise food service employees for proper food handling,
- provide adequate information for the dietitian to develop a nutritional plan for each patient,
- and ensure the dietitian was following up on the nutritional plans for patients at risk for weight loss. (Refer to the Standards for more information on why this Condition is not met.)

Based on observations, and interview, the facility failed to ensure that food was prepared ina safe and sanitary manner. Findings include:

1. Food stored in freezers was not sealed. (See examples in infection control A747.)
2. Food stored in refrigerators had neither use by or open dates. Temperatures were not monitored in refrigerators and did not ensure food safety. (See examples regarding infection control A747.)
3. Food handled in the tray line service was unsafe. (See examples at A747.)
4. Kitchen sanitation was not ensured through cleaning logs, and supervision of the dietary services. (See examples regarding infection control A622 and A747.)
5. Residents who refused meals and who had medical conditions affected by meal intake lacked substitutions and additional snacks that would maintain the patients' health. (See A 630.)

Based on observation and interview, facility staff failed to properly supervise food service employees to ensure that food was stored, prepared, cooked and served safely. Findings include:

On 9/1/10 at 10:45 a.m., Staff Member N was observed by the surveyor and dietary manager to be working at the tray line for lunch. Staff Member N had started serving lunch. She left the tray line service wearing gloved hands, went into the kitchen, retrieved a cookie, wiped her gloved hands on her apron, came back to the tray line while eating the cookie, placed the cookie on the tray line next to the serving utensils, retrieved a thermometer from her purse, moved the garbage can with her gloved hands to reach the purse, unzipped the purse and retrieved the thermometer. Staff Member N placed the thermometer in the meat loaf. After checking the temperature for each food item (meat loaf, baked potatoes, and gravy), she used a visibly dirty hand towel to wipe the thermometer. The same hand towel was used by staff to wipe her hands, clean the tray line service area and the counter. Staff Member B did not stop Staff Member N. The surveyor asked Staff Member N to stop and to clean the food thermometer properly. Staff Member N stated "I am." At this time, Staff Member B stated that the "kitchen was not allowed to order alcohol wipes, but the dirty hand towel should not be used either." Staff Member N then went to the tray line, retrieved a plate, served baked potatoes by obtaining four of the potatoes with her gloved hands, and placing the potatoes on the plate. Staff Member B did not stop Staff Member N. The surveyor asked Staff Member B to have Staff Member N remove her gloves, wash her hands, and replace all serving utensils. Staff Member B instructed Staff Member N to remove her gloves and wash her hands before placing on new gloves. Staff Member B retrieved new serving utensils.

Based on observation, record review, policy review, and staff interview, the hospital failed to monitor the dietary intake and nutritional status of 3 (#s 8, 15 and 16) of 21 patients. Findings include:

The policy for "Meal/Supplement Intake, Documentation of" was reviewed. Item #3 indicated, "a. Patients who receive special snacks are listed on the supplement list on the front of the flow sheet charts. Time and type of snack are noted there; b. The staff member passing out the snacks should observe how much of the snack or supplement was consumed. This should be charted with a Good, Fair, Poor or Refused on the patient's flow sheet in the supplement/snack section."

The policy for hydration was requested on 8/30/10. The DON stated there was no policy on hydration for the facility.

On 9/1/10 at 9:15 a.m., staff member U stated that in the past, the staff documented fluids and snacks on the flow sheet. Since the night shift assumed responsibility for reviewing the flow sheets, no one assured the accuracy of the sheets. At the nurses station is a list of patients that needed to be encouraged to drink fluids. The list for patients with a snack order was on the refrigerator.

On 9/1/10 at 9:40 a.m., nurse manager H, stated the staff did not document snacks and was unaware of the policy. She stated all patients receive a bed time snack. The nurses document Ensure on the MAR.

1. Patient #8 was admitted to the facility on 2/23/10, diagnoses included dementia, hostility, coronary artery disease, gastritis, duodenitis, hypertension, and hypothyroidism. Patient's height was not recorded and weight was 195#.

During review of the patient's medical record, it was noted on 3/1/10 that the patient's appetite was poor. The Physician's Order Sheet dated 3/1/10 at 8:27 a.m., documented an order for 1) weekly weights and record, 2) Ensure one can if eats less than 50% of meal, and 3) Dietician consult. The Dietician Consult dated 3/1/10 at 1:20 p.m., documented, "Assessment: No height recorded yet. 195 pounds. At risk for skin breakdown and malnutrition, if he does not consume sufficient calories. Plan: Monitor weight, % eaten of meals and give Ensure as ordered, if he eats less than half of his meals. Dietician available PRN." On 3/3/10 the nursing staff documented skin breakdown of the buttocks. The patient was started on Prostat. On 3/4/10, oral intake was documented as poor. The Physician Order Sheet dated 3/4/10 at 8:10 a.m., documented an order to "Encourage fluids 1200 ml q am and 1200 ml q pm shift". On 3/9/10, poor oral intake and likely dehydration was documented. On 3/10/10, poor oral intake continued was documented. The patient expired on 3/11/10.

The flow sheet record for March was reviewed. The patient ate "good" 4 times, "poor" 10 times, and "refused" 7 times out of 30 meals. There was no documentation for 9 meals. The patient was offered an hs snack daily. There was no documentation of the patient being offered a supplement.

No documentation was found indicating fluids were encouraged per physician order.

No documentation was found indicating the patient had been weighed since admit per physician order. Height (to evaluate ideal body weight) was not recorded.

No documentation was found on the MAR indicating the patient received Ensure when meals were refused per physician order.

2. Patient #15 was admitted to the facility on 6/5/08; diagnoses included dementia with behavioral disturbance, Type II diabetes mellitus, and hypertension.

During review of the patient's medical record, it was noted the patient was diabetic, receiving Lantus insulin 14 units SQ q afternoon. Blood sugars were ordered to be obtained every Saturday BID. 1200 ml fluids were to be encouraged BID and ask patient if he is hungry every 2 hours.

During observation on 8/30/10, the patient refused lunch. The patient was observed from 12:45 p.m. to 4:00 p.m. During this time, staff members did not offer a snack or fluids.

3. Patient #16 was admitted to the facility on 8/19/10; diagnoses included schizoaffective disorder and alcoholism. Patient's height and weight on admit was 5'7" and 117.5#.

During review of the patient's medical record, it was noted on 8/20/10 at 2:00 p.m., the Dietitian Consult documented, "Plan: . . . Add High Protein snacks TID between meals. Also add Prostat 1 T BID to help increase intake. Patient should be weighed weekly. Notify RD if patient is not gaining weight or has poor appetite/PO intake to further intervene nutritionally, RD is available PRN to discuss any other nutritional concerns".

The flow sheet record for August was reviewed. The patient ate "good" 20 times, "poor" 2 times, and "fair" 9 times out of 35 meals. There was no documentation for 5 meals. The patient was offered an hs snack 10 times, 2 days were not documented. There was no documentation of the patient being offered a supplement on the 2 days documented as "poor".

The dietitian was interviewed on 9/2/10 at 1:00 p.m. She stated the patient did not like the meals and was now on Ensure up to 5 times a day. The dietitian provided the Diet Order sheet that indicated the patient was receiving high protein snacks TID; "pudding" in the AM, "yogurt" in the PM and "1 high protein snack" at hs. She stated she was unsure how many grams of protein was in the pudding as she was not sure if it was made at the facility or bought elsewhere. She thought the yogurt had about 6 grams of protein. She was unable to determine what the staff gave the patient as a high protein snack at hs. She further stated she was unable to determine if the patient was receiving high protein snacks three times a day. There was no documentation of the patient receiving high protein snacks TID. The dietitian further stated that she did not follow up with patients or monitor them. She stated the medical staff would contact her if they had concerns.

No documentation was found indicating the patient had been weighed since admission per physician order.

Based on observations and staff interviews, the facility failed to ensure the environment was clean and sanitary throughout all the units in the facility. Findings included:

1. On 9/2/10 starting at 9:35 a.m., the following environmental issues were observed on the Spratt unit:
S 38 the women's shower room
- On the outside base of the big and two smaller walk-in showers, areas of missing caulk were identified. The crack and remaining caulk outside of the showers at the base were black in color.

S 39 the second women's shower room
-On the outside of the 3 walk-in showers, areas missing caulk were identified. The crack and remaining caulk outside of the showers at the base were black in color.
-The 3 walk-in showers in room 39 had two holes in the shower surround. The program manger P stated the holes were from the handicap bars being pulled from the showers. She was not aware how long the holes had been in the shower surrounds.

Men's shower room
-The two walk-in showers and tub, on the outside at the base, were missing areas of caulk. The crack and remaining caulk outside the showers at the base were black in color.
-The tub surround was cracked in six different places. The cracks were not sealed and could potentially allow water to penetrate the wall board behind the surround. The program manager P stated for the past two years, maintenance was asked to fix the tub surround.
-The painted wall above the tub surround was missing paint in an area of 3 in. by 4 in.
-The caulking inside the tub was missing or discolored.
-The handicap bar in the tub had an orange substance around the insertion and running down the tub surround.
-The soap dispenser was held together with tape.
-The sink faucet in the men's shower room had a white and green build up.

Observation room #19
-The left hand side of the entry way wall had a hole that measured approximately 2 in. by 3 in.
-The wall that contained an outside window had a hole that measured approximately 4 in. by 3 in.
-There were one and half tiles in the shower at the bottom of the wall that were missing. The board behind the missing tiles was leaning and black in color. Program manager P stated she did not know how long the tiles had been missing.

The wall next to the psych tech's room had two areas that were missing paint and the sheet rock was exposed. The areas measured approximately 8 in. by 8 in., and 15 in. by 8 in.

The wall that contained the exam room sign had two areas that were missing paint and the sheet rock was exposed. The one hole was stuffed with a cotton substance and measured approximately 3 in. to 4 in. round. The other area measured approximately 2 in. round.

The wall en route to the nurse's station had an area approximately 3 in. by 2 in. that was missing paint and the sheet rock was exposed.

In the entry way, there were five areas of missing paint and exposed sheet rock. Program manager P stated the paint started to bubble and then a patient would pick and peel off the paint. The areas were approximately 4 in. by 4 in., 2 ft. by 3 ft., and 3 ft. by 4 ft.


26492


2. On 8/30/10 at 12:30 p.m., the following environmental issues were observed on the B wing:
-The caulking around the tub and toilet was missing;
-Orange and black discoloration around the tub; and
-Orange and black discoloration on the tile floor by the toilet.

3. On 8/31/10 at 10:31 a.m., the following environmental issues were observed on the A wing:
-The caulking around the tub and toilet was missing;
-Orange and black discoloration around the tub, toilet and floor tile;
-The exhaust fan had visible debris hanging from the vent; and
- The shower head and handles had thick covering of white and blue debris.

4. On 9/1/10 at 10:00 a.m., the following environmental issues were observed on the E wing:
-The bathtub and toilet caulking was missing in areas;
-Orange and black discoloration around the bathtub, floor tiles, and toilet;
-The exhaust fan had visible debris hanging from the vents;
-There was a cracked tile on the wall under the toilet; and
-The hand rails around the tub had a thick accumulation of orange and black discoloration.

The female shower room:
-The caulking around the toilet was missing;
-The grout along the shower room had orange, brown and black discoloration build up;
-The exhaust fan had visible debris hanging from the vents;
-The shower head had a thick white debris; and
-The transition strip to the shower was missing caulking and had orange and black discoloration.

The male shower room:
-The caulking around the toilet was missing;
-The grout along the shower room had orange, brown and black discoloration;
-The caulking around the toilet had orange black discoloration;
-The shower head had a thick white debris build up;
-The exhaust fan had visible debris hanging from the vents;
-The shower stall was missing grout;
-The transition strip was missing caulking and had orange and black discoloration.

The living room area:
-The carpet was torn and pulled away from the transition strip; and
-There was a broken video camera hanging from the ceiling.

Based on observations and staff interviews, the facility failed to store supplies according to the manufacturers' recommendations. Findings include:

During the tour of the dental department on 9/2/10 starting at 9:55 a.m., the surveyor observed the following:

In the dental exam room:
-1 Revolution Formula 2 Composite outdated 10/99;
-2 Revolution White Opaque Composite outdated 10/99;
-1 Silux Plus - Dark Yellow paste outdated 8/03;
-1 Revolution A2 Composite outdated 3/08;
-1 Buffered Hemostatic Solution outdated 6/08;
-2 Prodigy A2 Composite outdated 7/08 and 8/08;
-1 Revolution Formula 2 Composite outdated 12/09;
-1 Revolution A3 Composite outdated 12/09;
-1 A 3.5 Composite outdated 4/10;
-1 Prodigy A2 Composite outdated 7/10;
-1 Diamond Twist Polishing Paste outdated 7/10; and,
-1 Prismo Gloss composite polishing paste outdated 8/10.

In the supply room:
-1 Container of ChemFill II outdated 12/92;
-2 Vials of sealant outdated 7/00;
-1 Box of IRM Caps expired 4/03;
-1 Box Nupro Prophylaxis Paste with Fluoride outdated 6/03;
-1 Bottle of Chlorhexidine Gluconate Oral Rinse outdated 11/03;
-1 Box of GelEtch Tooth Enamel outdated 2/05;
-1 Box of Coe-Soft Resilient Denture Liner outdated 8/06;
-2 Containers of Dentsply Repair Material Powder outdated 3/07 and 3/08;
-9 Revolution A3 Flowable Light Cure Composite outdated 3/08;
-1 Bottle of Dentsply outdated 9/08;
-2 Containers of Chairside Reline Material outdated 8/09;
-1 Container of GC Fuji Filling LC outdated 8/09;
-1 Revolution A3 Flowable Light Cure Composite outdated 12/09; and,
-5 Revolution A3 Flowable Light Cure Composite outdated 1/10.

Staff Member W and Staff Member X were interviewed on 9/2/10 at 10:00 a.m. The dental supplies were not thrown out. The supplies were too expensive, so they continued to use the supplies and did not look at the expiration dates.

Surveyor: Dennis, Jolynn

Based on observations, staff interviews, and record review, the facility failed to prepare food in a sanitary environment that would ensure that sources and transmissions of food born illnesses did not occur. Food service employees failed to properly wash hands and change gloves while preparing and serving food to the patients. Food service employees failed to date and seal opened food items. Staff failed to ensure that a functional thermometer was present in the snack refrigerator and to take appropriate action when the temperature in the refrigerator exceeded the safe storage range. Staff failed to ensure that patient food items were not co-mingled with employee food items in the refrigerator. The facility staff failed to ensure that expired food items were not available to be served to patients. Staff failed to ensure food containers, and utensils were stored properly. Findings include:

1. On 8/31/10 at 7:31 a.m., the snack refrigerator temperature was observed with kitchen staff member A to be 50 degrees F. The temperature of the refrigerator cannot be above 35 degrees F.

2. The following problems were identified:
-An open package of lunch meat was not sealed and lacked a use by or an open date;
-A large container of sandwiches that were not labeled with a use by date;
-An open container of cranberry juice was not labeled with an opened on, or a use by date;
-Twelve containers of expired yogurt;
-Two packages of cheese opened and not labeled with an opened on, or use by date; and
-A 5 pound container of cottage cheese was open and lacked an opened on, or use by date.
-Employee food was stored in the snack refrigerator.

During this observation, kitchen Staff Member A stated that the refrigerator temperature had been "off, but she had not reported it yet." The kitchen staff member further stated "we never date snack items," and that she did not know staff food could not be stored in residents' refrigerators.

3. On 8/31/10 at 8:15 a.m., the main kitchen refrigerator was observed with kitchen staff A. The following items all lacked an opened on, or a use by date:
-Two bags of chicken;
-A container of mashed potatoes;
-Unsealed Broccoli;
-Unsealed pancakes;
-Vegetarian meat;
-An unidentifiable container of liquid;
-Fifteen open bags of vegetables;
-Three blocks of cheese; and
-A container of chopped tomatoes.
-Employee food was observed stored in this refrigerator.

4. The main kitchen freezer was observed with kitchen staff A. The following issues were identified:
-Four boxes of frozen french fries were observed resting on the floor;
-Two containers of cooked chicken were observed resting on the floor;

Staff Member A stated, "I know food items should not be stored on the floor of the freezer."

4. On 8/31/10 at 8:41 a.m., the kitchen was observed with the dietary manager B. The surveyor noted a metal container of chicken in the hot holding tray line. The surveyor was informed that kitchen staff member A had placed the container of chicken in the hot holding tray line at 8:30 a.m., to heat the chicken by lunch time. Dietary manager B stated that the hot holding tray line was not to be used to heat up food. The chicken was discarded.

5. The following issues were identified when the kitchen and tray line were observed at 8:45 a.m., with dietary manager B;
- Two uncovered ice scoops were stored on top of the ice machine;
- The top of the ice machine had debris build up;
- A metal container of mixed raw vegetables in the refrigerator lacked an opened on, or use by date;
- The caulking was missing on the self-serve beverage drain and there was brown and black debris build up around the drain; (photo taken)
- There was visible white build up on the ice tea machine;
- Twelve exhaust fans in the ceiling of the kitchen had visible gray debris hanging from the vents and black debris on the outer edges. All of those vents were located above food prep, serving, and equipment areas; (photos taken)
- A speaker in the ceiling was surrounded by damaged ceiling tile; (photo taken)
- Multiple ceiling tiles above the food prep, serving and equipment areas were splattered with debris ; (photo taken)
- The Combi oven had visible debris build up on the outside and top of the oven; (photo taken)
-The Hobart mixer and Hobart meat slicer were not in use and were not covered;
- The rolling rack convection oven had visible debris build up on the outside, top, and inside of the oven; and
- The wall behind the special diet food prep area was splattered with debris.( photo taken)

During this observation, dietary manager B stated that she does have a cleaning schedule and her staff "should be using it." Dietary manager B stated she did not have a policy on food dating.

6. The nourishment refrigerators were observed on the A, B, E, and clinic wings.

a. Wing A was observed on 8/31/10 at 10:13 a.m., with the Staff member F. The following problems were identified:
-Neither the refrigerator nor freezer contained a thermometer;
-The inside of the refrigerator was not clean and contained an open can of corn which was uncovered and lacked an opened on, or use by date;
-An unsealed package of frozen fish was observed in the freezer.
-The sink had white visible build up on the handles and faucet.

During this time, Staff Member F stated she "did not know where the thermometers are kept and that the night shift psych tech's are supposed to be cleaning the refrigerators."

b. Wing B was observed on 8/30/10 at 1:07 p.m., with Staff Member C. The following problems were identified:
-Neither the refrigerator nor freezer contained a thermometer;
-The inside of the refrigerator was not clean;
-Two expired yogurts;
-Two undated containers of unidentified food items;
-Two paper cups containing ketchup lacked use by dates;
-A bag of carrots that was not sealed and lacked a use by date;
-A bag of salad thea was not sealed and it was not dated;
-The freezer had visible debris build up on the inside;
-A package of frozen hash browns was unsealed; and
- Five single servings of ice cream that were not sealed.

During this observation, the Staff Member C stated that the food items are served to the patients as snacks and "did not know items had to be dated."

c. Wing E was observed on 9/1/10 at 9:00 a.m., with Staff Member M. The following problems were identified:
-Neither the refrigerator nor freezer contained a thermometer;
-The inside of the refrigerator was not clean as the shelves were sticky to the touch;
-A container of orange juice was opened and not dated; and
-There were two plastic containers of food items not labeled or dated in the freezer.

During this observation, Staff Member F stated that she "did not know where the thermometers were and that the night shift was supposed to clean the refrigerator."

d. The Clinic refrigerator for medical supplies was observed on 9/2/10 at 9:40 a.m.. The following non-medical supplies were observed within the refrigerator:
-Salad with four bottles of salad dressings, butter, apples, 1 jar of salsa, 2 sodas, sandwich, and a knife wrapped in a paper towel.

Based on observation and record review, the facility failed to monitor handwashing on the units and in the kitchen. Findings included:


27823


Nursing Care
1. During an observation on 9/1/10 at 8:30 a.m., the patient #15 was assisted to the bathroom by three staff. The patient was incontinent of stool. Staff Members G and V stood on each side of the patient while Staff Member U, with gloved hands, provided peri-care. The coccyx and buttocks were extremely red and Staff Member U stated she would check to see if the patient had an order for "something". Staff Member U, with gloves on, left the room. Staff Member U returned 7 minutes later, gloves still on, stating that he had no order. She then wiped the patient three more times and assisted with applying a new brief. The three staff members walked the patient out of the room. Staff Member U removed her gloves when they were walking down the hall with the patient, and she put the gloves in the wastebasket in the hallway. At no time during the observation did the three staff members wash their hands.


Kitchen
2. On 9/1/10 at 10:30 a.m., the tray line food service was observed with Staff Member A. The temperature records for the lunch meal service were observed. She retrieved a thermometer, wiped the thermometer with a visibly dirty hand towel, and placed it in the meat loaf. The thermometer was not cleaned properly prior to placing it in the meat loaf. Staff Member A placed the same thermometer in the chopped meat loaf, and then the gravy. She rinsed the thermometer with water at a sink, used a dirty hand towel to wipe the thermometer, and then placed it in the stewed tomatoes and in the beets. She went back to the sink and rinsed the thermometer with water, wiped the thermometer with the dirty hand towel, and took the temperature of the mashed potatoes. Then she took the thermometer to the oven and took the temperatures of the baked potatoes. She rinsed the thermometer with water and placed it, uncovered, on the counter. Staff Member A did not clean the food thermometer properly before, between, and after each food item.

3. On 9/1/10 at 10:45 a.m., Staff Member N was observed by the surveyor and dietary manager to be working at the tray line for lunch. Staff Member N had started serving lunch. She left the tray line service wearing gloved hands, went into the kitchen, retrieved a cookie, wiped her gloved hands on her apron, came back to the tray line while eating the cookie, placed the cookie on the tray line next to the serving utensils, retrieved a thermometer from her purse, moved the garbage can with her gloved hands to reach the purse, unzipped the purse and retrieved the thermometer. Staff Member N placed the thermometer in the meat loaf. After checking the temperature for each food item (meat loaf, baked potatoes, and gravy), she used a visibly dirty hand towel to wipe the thermometer. The same hand towel was used by staff to wipe her hands, clean the tray line service area and the counter. Staff Member B did not stop Staff Member N. The surveyor asked Staff Member N to stop and to clean the food thermometer properly. Staff Member N stated "I am." At this time, Staff Member B stated that the "kitchen was not allowed to order alcohol wipes, but the dirty hand towel should not be used either." Staff Member N then went to the tray line, retrieved a plate, served baked potatoes by obtaining four of the potatoes with her gloved hands, and placing the potatoes on the plate. Staff Member B did not stop Staff Member N. The surveyor asked Staff Member B to have Staff Member N remove her gloves, wash her hands, and replace all serving utensils. Staff Member B instructed Staff Member N to remove her gloves and wash her hands before placing on new gloves. Staff Member B retrieved new serving utensils.




29244



Based on observation, interview and record review, facility staff failed to wash hands before and after using single-use gloves, and failed to properly supervise food service employees to ensure that food is stored, prepared, cooked and served safely. Findings include:

1. On 9/1/10 at 10:30 a.m., the tray line food service was observed with Staff Member A. The temperature records for the lunch meal service were observed. She retrieved a thermometer, wiped the thermometer with a visibly dirty hand towel, and placed it in the meat loaf. The thermometer was not cleaned properly prior to placing it in the meat loaf. Staff Member A placed the same thermometer in the chopped meat loaf, and then the gravy. She rinsed the thermometer with water at a sink, used a dirty hand towel to wipe the thermometer, and then placed it in the stewed tomatoes and in the beets. She went back to the sink and rinsed the thermometer with water, wiped the thermometer with the dirty hand towel, and took the temperature of the mashed potatoes. Then she took the thermometer to the oven and took the temperatures of the baked potatoes. She rinsed the thermometer with water and placed it, uncovered, on the counter. Kitchen staff A did not clean the food thermometer properly before, between, and after each food item.

2. On 9/1/10 at 10:45 a.m., Staff Member N was observed by the surveyor and dietary manager to be working at the tray line for lunch. Staff Member N had started serving lunch. She left the tray line service wearing gloved hands, went into the kitchen, retrieved a cookie, wiped her gloved hands on her apron, came back to the tray line while eating the cookie, placed the cookie on the tray line next to the serving utensils, retrieved a thermometer from her purse, moved the garbage can with her gloved hands to reach the purse, unzipped the purse and retrieved the thermometer. Staff Member N placed the thermometer in the meat loaf. After checking the temperature for each food item (meat loaf, baked potatoes, and gravy), she used a visibly dirty hand towel to wipe the thermometer. The same hand towel was used by staff to wipe her hands, clean the tray line service area and the counter. Staff Member B did not stop Staff Member N. The surveyor asked Staff Member N to stop and to clean the food thermometer properly. Staff Member N stated "I am." At this time, Staff member B stated that the "kitchen was not allowed to order alcohol wipes, but the dirty hand towel should not be used either." Staff Member N then went to the tray line, retrieved a plate, served baked potatoes by obtaining four of the potatoes with her gloved hands, and placing the potatoes on the plate. Staff Member B did not stop Staff Member N. The surveyor asked Staff Member B to have Staff Member N remove her gloves, wash her hands, and replace all serving utensils. Staff Member B instructed Staff Member N to remove her gloves and wash her hands before placing on new gloves. Staff Member B retrieved new serving utensils.