The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MOUNTAIN VIEW CENTER FOR GERIATRIC PSYCHIATRY 500 POLK STREET EAST KIMBERLY, ID Oct. 6, 2014
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on staff interview, and review of hospital policies, and IC logs, it was determined the hospital failed to ensure the appointment of a trained Infection Control Officer. This resulted in the failure of the facility to perform surveillance activities, an inability to evaluate and trend results of infections occurring in the facility, and implement education and training to staff. Findings include:

During a phone interview on 10/07/14 at 3:00 PM, the DON introduced an RN as the Staff Educator and Infection Control Officer. Initially, the DON said the facility did not follow national guidelines for infection control. She referred to a policy initiated by the Long Term Care facility the hospital was affiliated with, and stated the policy for infection control was developed with CMS and LTC guidelines in 2010. When questioned further, the DON stated the facility used CDC guidelines. The DON and IC Officer stated they did not have formal infection control training, and the corporate level of the organization had recently paid for a self study course. They stated the self study course had not yet been taken, and a test was required afterwards to obtain credit. The DON confirmed the facility did not have a trained infection control practitioner.

The facility did not have a trained infection control officer.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, staff interview, review of patient medical records, and IC logs, it was determined the hospital failed to ensure an active program was in place for the prevention, control, and investigation of infections and communicable diseases. This resulted in the failure to investigate, identify trends, and educate staff regarding infection control practices. Findings include:

The IC logs for June, July and August were reviewed. The logs included patient names, dates of admission, type of infection, when it occurred, type of medication ordered, and if the patient was placed in isolation. The following data was obtained from the IC logs:

June 2014: 16 infections, (2 skin, 10 UTI, 2 URI, 1 eye, 1 other), with 500 patient days. The IC log noted the percentage of nosocomial infections was noted as 1.4%.

July 2014: 11 infections, (2 skin, 5 UTI, 1 URI, 3 other), with 497 patient days. The IC log noted the percentage of nosocomial infections was noted as 1.2%.

August 2014: 16 infections (4 skin, 7 UTI, 2 URI, 3 other), with 510 patient days. The IC log noted the percentage of nosocomial infections was noted as 1.2%.

The logs did not include information regarding the site of the infection (such as cellulitis right foot, MRSA cultured from wound on face, foley, PICC line, etc).

During a phone interview on 10/07/14 beginning at 3:00 PM, the DON reviewed the IC logs and confirmed there was no indication if the 22 UTI's were related to catheter insertion or other means. She confirmed the site of infection was not identified. She described her method of obtaining the percentage rates, and stated the facility historically had a low infection rate. The DON stated that after the infections have been recorded on the IC log, there was no causal analysis, or source tracking completed. She stated the facility did not monitor for foley catheter days related to infections, or identify central line/blood stream infections.

The DON stated the IC log information was discussed at QAPI meetings, and as the percentage rate of infections have been within acceptable range, no further investigation activities were conducted. She stated the established goal was for 10% or less of patients to develop nosocomial infections while hospitalized . The DON was unable to describe how the 10% goal was determined as acceptable for the facility.

These systemic problems resulted in the hospital's inability to ensure a process in which patients were protected from infections.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records and interviews with family members and staff, it was determined the hospital failed to include the patient, or designated representative, in the development, implementation, and revision of the patient's plan of care for 1 of 6 patients (#2) whose records were reviewed. This resulted in the provision of care that was not individualized to meet the patient's needs. Findings include:

1. Patient #2 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses of dementia with behavioral changes, and psychosis. Patient #2's record indicated he had been admitted from his home where he was cared for by his wife. Additionally, his record indicated his wife was his DPOA, and authorized to make medical decisions for him.

a. Patient #2's record included a "Nursing Admission Progress Note" completed and signed by Staff O, an RN, on 7/11/14 at 3:45 AM, and an "Initial Assessment History" completed and signed by Staff O, on 7/11/14 at 4:00 AM. The assessment indicated the information was obtained from an H & P (History and Physical), however, the only H & P in his record was from a hospitalization at a critical access hospital, 6/04/14 to 6/05/14, 5 weeks prior to his admission to the facility.

The progress note further stated Patient #2 did not know what day it was, where he was, or why he was in the facility. It also stated no family or guardian was present during the admission process. There was no documentation to indicate Patient #2's wife was contacted by phone to provide information about his recent history.

The Initial Assessment History included sections related to social habits, sleep habits, activities of daily living, and history of falls in the last week. The sections were completed, however, it was unclear how the information was obtained, as it was not included in the H & P. The Nursing Admission Progress Note stated care plans were activated.

During an interview on 10/03/14 at 12:45 PM, Patient #2's wife stated the facility sent her a packet of forms to sign, but she did not recall them calling her to obtain information about his social habits, sleep habits, activities of daily living, and history of falls.

During an interview on 10/02/14 at 2:50 PM, the DON confirmed Patient #2's record did not contain documentation to indicate his wife was contacted at the time of admission to obtain information regarding his recent history, or to participate in the development of his plan of care.

Patient #2's plan of care was developed without input from his wife, who was his designated representative.

b. Patient #2's record included a progress note completed by Staff H, an LPN on 9/07/14 at 11:04 PM. The note stated Patient #2's wife called to request he be given a bath as he had a history of disliking showers.

Patient #2's record included a progress note completed by Staff O, an RN on 9/14/14 at 6:30 AM. The note stated Patient #2's wife called the previous night and provided information that he got aggressive with showers and preferred to take baths instead.

Patient #2's record included a progress note completed by Staff G, an RN, on 09/14/14 at 9:30 PM. The note stated Patient #2's wife called and again informed the staff that he preferred baths. She requested they be offered, as she believed it would decrease his agitation.

During an interview on 10/01/14 at 3:55 PM, Staff P, a CNA, stated patients were given showers every other day. She also stated there was a care plan binder for each hall, and the nurse's aides would check the binders for updates on the patients, including any special requests.

A binder, labeled BHT (Behavioral Health Technician), and containing a care plan for Patient #2, was reviewed on 10/02/14. Patient #2's care plan did not indicate he was to be offered a bath instead of a shower.

During an interview on 10/02/14 at 11:15 AM, Staff F, an NCPT, stated her assignment for the day was to provide patient showers. She stated she had given Patient #2 a shower many times, and was scheduled to provide his shower that day. Staff F stated she had not given Patient #2 a bath in the past, and had not been informed he should be offered a bath instead of a shower. She confirmed his care plan in the BHT binder did not indicate he preferred baths.

During an interview on 10/02/14 at 2:50 PM, the DON reviewed Patient #2's record and stated his wife's request for a bath should have been added to his care plan in the BHT book. She confirmed his care plan had not been updated to direct the staff to offer him a bath instead of a shower.

Patient #2's plan of care was not updated as requested by his wife, who was his designated representative.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review and interviews with family members and staff, it was determined the hospital failed to ensure the patient, or designated representative, was given the information necessary to make informed decisions regarding care, for 1 of 6 patients (#2) whose records were reviewed. This interfered with the patient's or designated representative's ability to be involved in the plan of care. Findings include:

1. Patient #2 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses of dementia with behavioral changes, and psychosis. Patient #2's record indicated he had been admitted from his home where he was cared for by his wife. Patient #2's record listed his wife and his son as responsible parties.

a. The facility's policy, titled "SECLUSION AND RESTRAINT-USE", revised 8/11, included, "The use or possible use of seclusion and/or restraint is discussed with the patient and/or family. Every effort is made to encourage the family's participation in the care process in order to limit or halt the use of restraint."

The policy defined a drug used as a restraint as a medication used to control behavior or to restrict the patient's freedom of movement.

Patient #2's record included a physician's order, written and signed by the Psychiatric NP on 7/11/14 at 8:40 AM, and cosigned by the Medical Director. The order was for Haldol 10 mg to be given 3 times a day with the first dose to be given immediately. The order indicated the Haldol was prescribed for psychotic agitation with verbal aggression. However, Patient #2's record did not include documentation of agitation or aggression prior to the time the order was written, or documentation of other interventions attempted prior to the implementation of Haldol.

During an interview on 10/06/14 at 9:30 AM, the Medical Director stated Patient #2 was started on a high dose of Haldol to treat anticipated violent behaviors. He stated he was anticipating violent behavior based on his past history of alcohol use. The Medical Director confirmed he did not know the details of Patient #2's alcohol consumption. Additionally, he confirmed Patient #2 had not displayed violent or aggressive behaviors. The Medical Director stated the Haldol was prescribed as a chemical restraint, to ensure Patient #2 was under control.

During an interview on 10/03/14 at 5:05 PM, Patient #2's son stated he was not consulted regarding the use of Haldol as a chemical restraint. He stated he was a clinical pharmacist and he knew Haldol was used for severe agitation but stated that wasn't the case with his father. He stated the nurses described his father as friendly and cooperative at the time of admission, but he declined rapidly after admission.

During an interview on 10/03/14 at 12:45 PM, Patient #2's wife stated she was not consulted regarding the use of Haldol as a chemical restraint.

Patient #2's responsible parties were not included in the decision to chemically restrain him.

b. Patient #2's record included a progress note completed by Staff C, an LPN on 8/16/14 at 7:32 PM. The note stated Patient #2's son, who was a clinical pharmacist, called to request that 2 medications, Benadryl and Tegretol, be discontinued. The Medical Director was contacted and both medications were discontinued.

Patient #2's record included a progress note completed by Staff M, an LPN on 8/19/14 at 6:50 PM. The note stated, "Pt received a one time dose of Benadryl 50 mg now and is to have Benadryl for the next two days."

During an interview on 10/02/14 at 12:10 PM, Staff M stated he gave a one time dose of Benadryl to Patient #2 on 8/19/14. He stated there was no indication in Patient #2's record that Benadryl should not be given. He stated the family's request should have been communicated in nursing reports between shifts.

A medication was administered to Patient #2 after his responsible party requested the medication be discontinued.

c. Patient #2's record included a progress note completed by Staff O, an RN on 8/31/14 at 11:55 PM. The note stated, "Wife has asked that any and all med [medication] changes be reported to pt's son...".

Patient #2's record included medication changes after 8/31/14, as follows:

-9/01/14 Discontinue Fentanyl and Clonidine patches, give Claritin 10 mg now
-9/01/14 Discontinue Rocephin 1 gram
-9/02/14 Clonidine Patch 0.2 mg every week
-9/05/14 Flomax 0.4 mg every day
-9/06/14 Increase Clonidine Patch to 0.3 mg every 5 days
-9/07/14 Ativan 2 mg now
-9/07/14 Zyprexa 10 mg 2 times per day
-9/16/14 Miralax 17 gm 2 times per day and Senakot-S 2 times per day
-9/23/14 Increase Clonidine Patch to 0.4 mg every week

However, Patient #2's record did not include documentation to indicate the medication changes were reported to his son.

During an interview on 10/03/14 at 5:05 PM, Patient #2's son stated he was not contacted by the facility regarding medication changes. He stated he or his mother became aware of the changes when they called the facility to inquire about Patient #2's status.

During an interview on 10/02/14 at 2:50 PM, the DON stated the family's request to be notified of medication changes should have been communicated in nursing reports and posted on his medical record. She confirmed the requests were not posted on his medical record, and could not determine if they were communicated in nursing reports.

Patient #2's responsible parties were not notified of changes in his plan of care as they requested.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy, record review and staff interview, it was determined the facility failed to ensure restraints were used only when necessary to ensure the immediate physical safety of the patient or others, for 1 of 6 patients (#2) whose records were reviewed. The failure resulted in patients being subjected to unnecessary chemical restraints. Findings include:

The facility's policy, titled "SECLUSION AND RESTRAINT-USE", revised 8/11, included, "Seclusion and/or restraint should be the selected intervention only when used as an emergency measure to control a patient's unanticipated, severely aggressive or destructive behavior which places the patient or others in imminent danger and all less restrictive measures have been determined to be ineffective."

The policy defined a drug used as a restraint as a medication used to control behavior or to restrict the patient's freedom of movement.

The policy stated a physician, psychologist or RN must document they observed the patient's threat of harm to self or others, as well as the less restrictive interventions attempted prior to the use of restraint.

Patient #2 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses of dementia with behavioral changes, and psychosis. Patient #2's record indicated he had been admitted from his home where he was cared for by his wife.

A "Nursing Admission Progress Note" completed and signed by Staff O, an RN on 7/11/14 at 3:45 AM, indicated Patient #2 arrived at the facility at 2:15 AM on 7/11/14. The note stated, "Pt ambulates w/ [with] slow steady gait, bears own wt w/o [without] difficulty. Pt is giggly, polite, cooperative, though confusion is noted."

Behavioral and Physical Assessment logs were completed on each shift to document negative behaviors including physical aggression, verbal aggression, agitation, non-redirectable behavior, trespassing and elopement risk. Patient #2's log indicated none of these behaviors were noted for the first 13 days of his hospitalization .

Patient #2's record included a physician's order, written and signed by the Psychiatric NP on 7/11/14 at 8:40 AM, and cosigned by the Medical Director. The order was for Haldol 10 mg to be given 3 times a day with the first dose to be given immediately. The order indicated the Haldol was prescribed for psychotic agitation with verbal aggression. However, Patient #2's record did not include documentation of agitation or aggression prior to the time the order was written, or documentation of other interventions attempted prior to the implementation of Haldol.

The Nursing 2015 Drug Handbook contains dosing information for Haldol, and states elderly and debilitated patients should be started on 0.5 to 2 mg by mouth, 2 to 3 times a day, increasing the dose gradually as needed. However, Patient #2's initial plan of care on 7/11/14, included Haldol 10 mg, to be given by mouth 3 times a day, beginning on the day of admission.

The Nursing 2015 Drug Handbook includes a black box warning related to Haldol, which states, "Elderly patients with dementia-related psychosis treated with atypical or conventional antipsychotics are at increased risk for death. Antipsychotics aren't approved for the treatment of dementia-related psychosis."

The U.S. Food and Drug Administration's definition of Boxed Warnings states, "Drugs that have special problems, particularly ones that may lead to death or serious injury, may have this warning information displayed within a box in the prescribing information. This is often referred to as a "boxed" or "black box" warning."

During an interview on 10/06/14 at 9:30 AM, the Medical Director stated Patient #2 was started on a high dose of Haldol to treat anticipated violent behaviors. He stated he was anticipating violent behavior based on the history of alcohol use. The Medical Director confirmed he did not know the details of Patient #2's alcohol consumption. Additionally, he confirmed Patient #2 had not displayed violent or aggressive behaviors. The Medical Director stated the Haldol was prescribed as a chemical restraint, to ensure Patient #2 was under control.

Patient #2 was placed on chemical restraints although his behavior was not identified as a threat to himself or others.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy, record review and staff interview, it was determined the facility failed to ensure the use of chemical restraint was appropriately utilized and implemented only after other interventions were proven to be ineffective, for 1 of 6 patients (#2) whose records were reviewed. The failure resulted in patients being subjected to unnecessary chemical restraints. Findings include:

The facility's policy, titled "SECLUSION AND RESTRAINT-USE", revised 8/11, included, "Seclusion and/or restraint should be the selected intervention only when used as an emergency measure to control a patient's unanticipated, severely aggressive or destructive behavior which places the patient or others in imminent danger and all less restrictive measures have been determined to be ineffective."

The policy defined a drug used as a restraint as a medication used to control behavior or to restrict the patient's freedom of movement.

The policy stated a physician, psychologist or RN must document they observed the patient's threat of harm to self or others, as well as the less restrictive interventions attempted prior to the use of restraint.

Patient #2 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses of dementia with behavioral changes, and psychosis. Patient #2's record indicated he had been admitted from his home where he was cared for by his wife.

Patient #2's record included a physician's order, written and signed by the Psychiatric NP on 7/11/14 at 8:40 AM, and cosigned by the Medical Director. The order was for Haldol 10 mg to be given 3 times a day with the first dose to be given immediately. The order indicated the Haldol was prescribed for psychotic agitation with verbal aggression. However, Patient #2's record did not include documentation of agitation or aggression prior to the time the order was written, or documentation of other interventions attempted prior to the implementation of Haldol.

During an interview on 10/06/14 at 9:30 AM, the Medical Director stated Patient #2 was started on a high dose of Haldol to treat anticipated violent behaviors. He stated he was anticipating violent behavior based on the history of alcohol use. The Medical Director confirmed he did not know the details of Patient #2's alcohol consumption. Additionally, he confirmed Patient #2 had not displayed violent or aggressive behaviors. The Medical Director stated the Haldol was prescribed as a chemical restraint, to ensure Patient #2 was under control.

Patient #2 was placed on chemical restraints without determining whether less restrictive interventions would be effective.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on staff interview, review of patients' clinical records, facility policies, and observations, it was determined the hospital failed to ensure nursing services were organized to effectively meet the health care needs of psychiatric patients who had additional medical conditions and needed specialized monitoring of their ongoing health status. This resulted in the failure of the facility to identify patients' initial and ongoing health care needs and provide safe and effective care. The findings include:

1. Refer to A395 as it relates to the failure of the facility to ensure a registered nurse provided each patient with initial and ongoing evaluation of his/her health care needs and supervised the delivery of nursing services.

2. Refer to A396 as it relates to the failure to ensure that patients' care plans were individualized and kept current in order to consistently meet the needs of the patients.

3. Refer to A397 as it relates to the failure to ensure nursing staff was assigned to patients based on competency and patient needs.

4. Refer to A405 as it relates to the failure of the facility to ensure safe medication administration.

The cumulative effect of these negative systemic facility practices placed the health and safety of patients with underlying medical needs at risk.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of clinical records and hospital policies, observations, and staff interviews, it was determined the hospital failed to ensure an RN provided adequate supervision and oversight necessary to ensure appropriate patient care was provided to 3 of 6 patients (#1, #2, and #5) whose records were reviewed. This resulted in deterioration in patients' medical conditions without interventions. Findings include:

1. The facility did not ensure that RN's reassessed patients to determine if nursing care and interventions were appropriate.

a. Patient #2 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses of dementia with behavioral changes, and psychosis. Patient #2's record indicated he had been admitted from his home where he was cared for by his wife. Additionally, his record indicated his wife was his DPOA, and authorized to make medical decisions for him.

i. Patient #2's record included a "Nursing Admission Progress Note" completed and signed by Staff O, an RN on 7/11/14 at 3:45 AM, which stated Patient #2 did not know what day it was, where he was, or why he was in the facility. It also stated no family or guardian was present during the admission process.

Patient #2's record also included an "Initial Assessment History" completed and signed by Staff O, an RN on 7/11/14 at 4:00 AM. It indicated the information was obtained from a history and physical, however, the only history and physical in his record was from a critical access hospital on [DATE] to 6/05/14, 5 weeks prior to his admission to the facility. The assessment history included sections related to social habits, sleep habits, activities of daily living, and history of falls in the last week. The sections were completed, however, it was unclear how the information was obtained, as it was not included in the H & P, and there was no documentation to indicate Patient #2's wife was contacted by phone to provide information about his recent history.

During an interview on 10/02/14 at 2:50 PM, the DON reviewed Patient #2's record and was unable to determine how the history documented by the RN was obtained, and stated it probably came from the records related to his hospitalization 5 weeks prior to his admission.

Patient #2's initial nursing assessment was not accurate and comprehensive to determine his needs.

ii. Patient #2's plan of care was not updated to address his changing status and needs, as follows:

- Information regarding Patient #2's motor skills at the time of his admission to the hospital was obtained from interviews with his family and his hospital record, as follows:

-During an interview on 10/03/14 at 12:45 PM, Patient #2's wife stated she was his primary caregiver prior to his hospitalization . She stated he was walking independently in his home prior to transfer to the hospital. Additionally, she stated on the day he was taken to the hospital he walked out of the house and to the ambulance without assistance.

-During an interview on 10/03/14 at 5:05 PM, Patient #2's son stated he was able to walk independently prior to his admission to the hospital.

- A "Nursing Admission Progress Note" completed and signed by Staff O, an RN on 7/11/14 at 3:45 AM, stated, "Pt ambulates w/ [with] slow steady gait, bears own wt w/o [without] difficulty.

-A progress note, completed and signed by Staff J, an RN on 7/11/14 at 11:11 AM, stated, "Pt about unit at will with steady gait."

-A progress note, completed and signed by Staff K, an RN on 7/14/14 at 6:11 PM, stated, "Spent most of the shift pacing and wandering the unit."

-A progress note, completed and signed by Staff C, an LPN on 7/18/14 at 3:59 PM, stated, "Has been quietly ambulating around unit with steady gait t/o [throughout] the day."

-A progress note, completed and signed by Staff O, an RN on 7/20/14 at 3:07 AM, stated, "He continues to enjoy walking in the halls and remains fairly independent."

-A progress note, completed and signed by Staff O, an RN on 7/22/14 at 5:05 AM, stated, "Pt has been ambulating halls most of shift."

Patient #2's record indicated a decline in his motor skills beginning approximately 2 weeks after his admission, as follows:

-A progress note, completed and signed by Staff M, an LPN on 7/26/14 at 11:06 AM, stated, "Pt requires SBA [stand by assist] with transfers d/t [due to] unsteady gait"

-A progress note, completed and signed by Staff Q, an RN on 7/27/14 at 2:51 AM, stated, "Pt remains unsteady on his feet with ambulation..."

-A progress note, completed and signed by Staff Q, an RN on 7/28/14 at 12:16 AM, stated, "Patient unable to walk and transfers with 2 person assist."

-A progress note, completed and signed by Staff E, an RN on 7/30/14 at 6:29 PM, stated, "WC [wheelchair] for mobility."

-A progress note, completed and signed by Staff D, an LPN on 9/16/14 at 5:10 PM, stated, "Patient is a 2 person assist often and 1-2 with ambulating."

-A progress note, completed and signed by Staff M, an LPN on 9/19/14 at 6:44 PM, stated, "Pt in broda chair throughout most of shift."

On 9/29/14 at approximately 2:55 PM, the DON was asked if Patient #2 could walk. She stated he could walk with 3-4 person assist.

On 9/29/14 at approximately 3:00 PM, Patient #2 was observed seated in a broda chair (specialized reclining wheelchair) in the dining room. He was also observed being taken to his room by Staff R, a NCPT, for toileting. Staff R was unable to transfer him to the toilet by herself and called for additional assistance. Staff K, an RN, came to assist. He was transferred to the toilet with the assistance of the 2 staff members.

On 9/30/14 Patient #2 was observed from 8:51 AM - 9:20 AM. Patient #2 was in the dining area when Staff S, a CNA, attempted to push Patient #2 to his room in his specialized wheelchair. Staff S asked Patient #2 repeatedly to lift up his feet so she could push him, however, he did not do so. Staff S then tried to push him to his room anyway, but was unsuccessful. Staff S then requested the assistance of Staff T, a CNA. Walking backward, Staff T held Patient #2's feet up while Staff S pushed the wheelchair to Patient #2's bedroom. The 2 CNAs then assisted Patient #2 to utilize the bathroom. When done Patient #2 was returned to his wheelchair and Staff T left the room. Staff S then requested Staff T's assistance to return Patient #2 to the dining room. After brief discussion of the options, Staff T suggested walking Patient #2 to the dining room. Patient #2 was assisted by Staff S and Staff T back to the dining area. When asked, both staff stated Patient #2 required two staff to assist him to walk.

During an interdisciplinary team meeting on 9/30/14 beginning at 1:00 PM, Patient #2's mobility was discussed. The Medical Director stated it took 4 to 5 staff members to assist Patient #2 to walk safely.

Staff responsible for Patient #2's treatment and services did not have a clear and common understanding of his mobility needs.

Patient #2's record contained nursing care plans to address identified problems or potential problems. The care plans included interventions to address the problems, as well as short and long terms goals related to resolution of the problems. However, Patient #2's record did not contain a nursing care plan related to motor skills. Therefore, nursing interventions were not developed to address his decline in motor skills and his loss of ability to ambulate.

During an interview on 10/02/14 at 2:50 PM, the DON reviewed Patient #2's record and confirmed nursing interventions were not developed to address the decline in his motor skills.

Patient #2's motor skills declined significantly, however, interventions were not developed to address his decline in motor skills and his loss of ability to ambulate.

iii. Information regarding Patient #2's verbal skills at the time of his admission to the hospital was obtained from interviews with his family and his hospital record, as follows:

-During an interview on 10/03/14 at 12:45 PM, Patient #2's wife stated she was his primary caregiver prior to his hospitalization . She stated on the day he was taken to the hospital he was talking and laughing with the driver. Additionally, she stated she was able to talk to him by phone at the beginning of his admission but he was no longer able to talk to her.

-During an interview on 10/03/14 at 5:05 PM, Patient #2's son stated he was able to talk to his father on the phone frequently prior to his hospital admission, and although Patient #2 exhibited some confusion, he was able to carry on a conversation. Additionally, he stated he visited his father 2 to 3 weeks after his admission and at that time his father was not able to speak to him.

-A Progress Note, dated 7/11/14, signed by the psychiatric NP and cosigned by the Medical Director, listed Patient #2's assets as good verbal skills, intelligent, and supportive family.

-A progress note, completed and signed by Staff K, an RN on 7/14/14 at 10:44 AM, stated, "Received a phone call from his wife this morning, and appeared to have a very appropriate and lucid conversation with her. Phrases he used on the phone were: I love you, I'm ok...I just want to be home with you...there isn't much to do here...and ...alright honey, talk to you soon."

-A progress note, completed and signed by Staff C, an LPN on 7/18/14 at 3:59 PM, stated, "Pt did have a brief phone conversation with his wife after lunch, seemed to enjoy."

Patient #2's record indicated a decline in his verbal skills approximately 10 days after his admission as follows:

-A progress note, completed and signed by Staff G, an RN on 7/21/14 at 12:51 PM, stated, "Pt does not answer questions...."

-A progress note, completed and signed by Staff I, an RN on 7/24/14 at 10:49 AM, stated, "Unable to follow simple commands or answer questions."

-A progress note, completed and signed by Staff M, an LPN on 7/27/14 at 2:12 PM, stated, "Pt is unable to make needs known."

-A progress note, completed and signed by Staff I, an RN on 8/6/14 at 11:15 AM, stated, "Unable to answer questions or follow simple commands."

-A progress note, completed and signed by Staff C, an LPN on 8/11/14 at 10:19 AM, stated, "Pt is unable to make needs known at this time."

-A progress note, completed and signed by Staff I, an RN on 8/21/14 at 10:48 AM, stated, "...1 word statements and nonverbal sounds."

-A progress note, completed and signed by Staff K, an RN on 9/4/14 at 1:24 PM, stated, "...does not have any clarity or make sense."

-A progress note, completed and signed by a social worker on 9/24/14 at 9:13 AM, stated, "Patients [sic] verbal interactions with social services staff are minimal at best due to profound expressive and receptive aphasia." Aphasia is the loss of ability to understand or express speech.

Patient #2's record contained a nursing care plan titled "Altered Thought Process". The care plan did not indicate the date it was implemented, although the first update to the care plan was dated 7/19/14. The interventions listed on the care plan included a referral to PT, ST, OT or dietary as needed. However, Patient #2's record did not include a referral to ST to address his decline in verbal skills and loss of ability to communicate.

Patient #2's verbal skills declined significantly, however, his nursing care plan was not followed to initiate a referral to ST to address his decline in verbal skills and his loss of ability to communicate.

iv. Patient #2 experienced a weight loss of 44 pounds during his hospitalization , however interventions were not implemented in a timely manner to address his nutrition needs. Examples include:

Patient #2's record included a log of his weights, as follows:
-7/13/14 208 pounds
-7/20/14 205 pounds
-8/03/14 187 pounds
-8/10/14 183 pounds
-8/20/14 171 pounds
-8/24/14 168 pounds
-8/31/14 165 pounds
-9/09/14 170 pounds
-9/21/14 170 pounds
-9/28/14 164 pounds

Patient #2's record included OT weekly progress notes dated 7/14/14 to 7/18/14, and 7/21/14 to 7/25/14. The area to record his response to interventions on both notes stated, "Paitent [sic] responds well to the progressive cueing. He does well with finger foods." The updated plan/goals section of both notes stated, "Patient will eat 75% of meal with intiation [sic] cue and finger foods as possible." However, there is no indication in Patient #2's record that he was offered finger foods for his meals.

Patient #2's record included a nursing care plan to address imbalanced nutrition. However, the care plan was not implemented until 9/09/14, 62 days after his admission. On 9/09/14, Patient #2's weight was recorded as 170 pounds, indicating a 38 pound weight loss from his admission weight of 208 pounds.

During an interview on 10/02/14 at 11:55 AM, Staff I, an RN confirmed a nursing care plan to address Patient #2's nutritional needs should have been developed earlier.

During an interview on 10/06/14 beginning at 9:30 AM, the DON stated they do not collect information regarding food preferences from family members as there is not a regulation requiring this. She stated they abided by the diet ordered by the physician.

Patient #2's weight loss and risk of malnutrition were not addressed by the nursing staff. An RN did not provide sufficient oversight of Patient #2's care.

b. Patient #1 was admitted on [DATE] at 2:00 PM. Her flow sheet indicated she had one incontinent urine output that day. On 7/16/14, the flow sheet documented she did not void for 24 hours. On 7/17/14 at 5:13 PM, the nursing progress note documented a foley catheter was inserted and her urine output for 24 hours was 400 ml. (The National Institute of Health defines decreased urine output as less than 500 ml in 24 hours. It includes causes such as kidney failure and dehydration.)

The psychiatric NP wrote an order to place a urinary catheter on 7/17/14 at 1:15 PM.

Patient #1's record included a nursing progress note dated 7/17/14 at 3:13 PM. The LPN noted "Patient had not voided in over 24 hours so I got an order for catheter."

During an interview on 10/02/14 beginning at 2:00 PM, the DON reviewed Patient #1's record and confirmed there was one documented incontinent void over a period of 48 hours since her admission. She was unable to find documentation in Patient #1's record to indicate an RN was aware of the extended period of time without urine output. She confirmed that LPN staff were assigned to Patient #1 until 7/17/14 beginning at 7:00 PM, when an RN assumed her care.

The RN did not evaluate Patient #1's inability to void for 2 days.

i. Patient #1's record documented her refusal to eat or drink, and she received IV hydration. A PICC was placed on 7/25/14 in her left forearm. (The acronym PICC describes a peripherally inserted central catheter, in which the tip of the catheter rests in a large vein close to the entrance of the heart. It allows a higher concentration of medications or IV fluids to be administered, whereas smaller veins could not tolerate the higher osmolarity of the solutions). According to Lippincott Manual of Nursing Practice, eighth edition, a PICC is considered a central line, and extra vigilance must be used to protect the integrity of the line and dressing. If the dressing has become dislodged, or the line has been pulled at any point, the placement must be confirmed, and a sterile dressing change must take place.

The facility policy for PICC line care, revised 12/11, indicated: "If PICC line is found to be torn, loose, damp, soiled or raised, the nurse should complete a sterile dressing change." The policy also stated the nurse was to document findings and actions, and alert the PICC line team of findings. The policy noted the dressing was first changed 24 hours after insertion and every 7 days if intact.

During an interview on 10/02/14 beginning at 2:00 PM, the DON stated PICC line dressings are to be monitored and changed by the RN and not LPNs.

In a nursing note 7/29/14 at 1:45 PM, the LPN noted "Patient has PICC line patent to left forearm, it was noticed during lab draw that patient has lifted the dressing and pulled some of the line out. Patient is to have daily dressing changes, securing displaced line and monitoring for S/S infection."

A verbal order, written by the above LPN, and signed by a physician, was dated 7/29/14 at 1:15 PM. The order noted "PICC line dressing to be changed daily. Watch for S/S (signs or symptoms) infection, monitor line placement."

In a nursing note 7/29/14 at 7:09 PM, the LPN wrote "PICC line dressing change secondary to covering entire line to prevent further displacement. When this nurse removed prior dressing it was discovered the insertion site is approximately 8-10 cm from Y connection suture site."

A social service progress note on 7/30/14 at 4:50 PM, noted that Patient #1 had a PICC line to receive fluids which was not secure, and the nursing staff was monitoring closely.

A verbal order to discontinue the PICC line was dated 7/30/14 at 8:45 AM. The order, written by an RN, included instructions to send the tip to be cultured and to start antibiotics for possible infection of the site.

In an RN progress note on 7/30/14 at 5:39 PM, the nurse wrote that Patient #1's PICC line site had redness surrounding the entire elbow area down the forearm, and it was tender to touch. She noted that the medical physician was notified, and the PICC line was removed and the tip sent for culture.

A lab result in the record noted the cultured PICC tip was positive for MRSA, and the facility was notified of the results on 8/01/14 at 3:01 PM. The report was reviewed and initialed by the medical physician and it was noted on the report that Patient #1's antibiotics were changed to treat the cellulitis (swelling, redness, and tenderness) and MRSA infection.

During an interview on 10/02/14 beginning at 2:00 PM, the DON reviewed Patient #1's record and stated she was called in to see the loose dressing on 7/29/14 around 1:30 PM. She stated the LPN did not perform a sterile dressing change, but applied an occlusive dressing over the line that had been disrupted. The DON stated she instructed the LPN to contact the physician for orders. The DON confirmed that RN's have been instructed to change the PICC dressings, and it was not included as an LPN's duties at this facility. Further, the DON confirmed there was no X-Ray or verification the PICC line remained in good placement for the delivery of IV fluids and medication administration.

During the time that Patient #1's care was provided by an LPN, her PICC line and dressing became dislodged, a sterile dressing change was not performed, and placement was not determined, which resulted in cellulitis and a MRSA infection. An RN did not provide appropriate care and oversight of Patient #1's medical needs.

c. Patient #5 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses of schizophrenia (a severe brain disorder in which people interpret reality abnormally), dementia (a decline in mental ability severe enough to interfere with daily life) with behavioral disturbance, and psychosis (a loss of contact with reality). Patient #5's record indicated he was transferred from an ALF due to aggressive behaviors.

Patient #5's admission orders dated 9/11/14, included Lasix. According to the Nursing 2014 Drug Handbook, "Lasix is a potent diuretic used to treat fluid retention and high blood pressure. It may cause excessive water loss through urination, causing serious electrolyte abnormalities or dehydration." The handbook advises to monitor the serum potassium level closely. Potassium is a chemical (electrolyte) that is critical to the proper functioning of nerve and muscles cells, particularly heart muscle cells.

Patient #5's record included a laboratory report, dated 9/15/14, with results from blood that was taken on 9/12/14. His potassium level was 3.3 meq/L, which was below the indicated reference range of 3.6 - 5.1 meq/L. On the report was written "9/15/14 faxed to [medical doctor's] office." The record did not include further documented communication regarding these test results between nursing and the physician.

On 9/16/14, orders were written by the psychiatric NP for multiple blood tests to be drawn on 9/22/14, however, she did not include orders to check Patient #5's potassium level.

During an interview on 9/30/14 beginning at 2:55 PM, the medical physician confirmed the laboratory results and Patient #5's low potassium level. The physician stated the low potassium level should have been repeated, and it was an oversight the laboratory test was not ordered.

Patient #5's low potassium level was not repeated.

2. A facility policy titled "Admission Assessment," revised 12/08, noted each patient would be assessed by a licensed nurse and the RN would retain responsibility for interpreting the data and identifying patient care needs. The policy noted the patient assessment would include demographic data, past medical history, allergies, biophysical, psychosocial, environmental, self-care, education, and discharge planning needs.

Admission assessments were not performed by an RN as follows:

a. Patient #1 was a [AGE] year old female, admitted to the facility on [DATE]. Her diagnoses included dementia with behavior disturbance and unspecified psychosis. Her record indicated she had been living at home with her husband, then was admitted to an assisted living facility for approximately a week prior to her admisson to this facility. The record noted she had exhibited aggressive behavior towards other residents and staff at the assisted living facility, so she was transferred to the hospital.

Her record included three admission assessment forms, Initial Assessment History, Nursing Admission Progress Note, and Initial BHT Care Guide. The forms were signed by an LPN and dated 7/15/14 at 3:00 PM.

The Initial Assessment History noted information was obtained from Patient #1's husband. It documented behaviors leading to her admission included verbal and physical assault. In the sections of the assessment titled "Significant Medical History/Recent hospitalization s/Procedures," and "Psychiatric History/hospitalization s," the LPN had written "N/A," indicating not applicable. Additionally, the form noted Patient #1's ADLs required physical assistance. A comprehensive biophysical and psychosocial assessment with vital signs was not included.

The Nursing Admission Progress Note included information of Patient #1's status upon admission as assessed by the LPN who completed the admission documentation. It noted she was oriented to her room, staff, meal schedule, and the unit. The note stated Patient #1 was unable to verbalize her reason for admission. The admitting LPN documented Patient #1 arrived on the unit with the ambulance crew and was sedated.

The Initial BHT Care Guide included categories which were marked with an "x" that indicated Patient #1's mental and behavioral status, toileting needs, ambulation, vision, hearing, bathing, diet, and grooming needs. The guide noted Patient #1 was able to walk with assistance, needed help with feeding and grooming.

During an interview on 10/02/14 beginning at 2:00 PM, the DON reviewed Patient #1's medical record and confirmed the admission assessment was performed by an LPN. She confirmed the assessment was not reviewed or co-signed by an RN as the policy indicated. She confirmed the record did not indicate an RN provided care or entered notes in the record until 7/17/14 at 11:59 PM, which was greater than 48 hours after her admission.

The facility did not ensure admission assessments were performed by RN's.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, medical record review, and staff interview it was determined the facility failed to ensure a comprehensive, individualized plan of care was developed, evaluated and revised as patients conditions changed, for 2 of 6 patients (#1 and #2) whose records were reviewed. This failed practice resulted in unaddressed patient care needs, and had the potential to negatively impact all patients receiving services in the facility. Findings include:

1. Patient #2 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses of [DIAGNOSES REDACTED]. Additionally, his record indicated his wife was his DPOA, and authorized to make medical decisions for him.

a. Patient #2's record indicated a decline in his motor skills beginning approximately 2 weeks after his admission, as follows:

-A "Nursing Admission Progress Note" completed and signed by Staff O, an RN on 7/11/14 at 3:45 AM, stated, "Pt ambulates w/ [with] slow steady gait, bears own wt w/o [without] difficulty.

-A progress note, completed and signed by Staff M, an LPN on 7/26/14 at 11:06 AM, stated, "Pt requires SBA [stand by assist] with transfers d/t [due to] unsteady gait"

-A progress note, completed and signed by Staff Q, an RN on 7/27/14 at 2:51 AM, stated, "Pt remains unsteady on his feet with ambulation..."

-A progress note, completed and signed by Staff Q, an RN on 7/28/14 at 12:16 AM, stated, "Patient unable to walk and transfers with 2 person assist."

-A progress note, completed and signed by Staff E, an RN on 7/30/14 at 6:29 PM, stated, "WC [wheelchair] for mobility."

-A progress note, completed and signed by Staff D, an LPN on 9/16/14 at 5:10 PM, stated, "Patient is a 2 person assist often and 1-2 with ambulating."

-A progress note, completed and signed by Staff M, an LPN on 9/19/14 at 6:44 PM, stated, "Pt in broda chair throughout most of shift."

On 9/29/14 at approximately 2:55 PM, the DON was asked if Patient #2 could walk. She stated he could walk with 3-4 person assist.

On 9/29/14 at approximately 3:00 PM, Patient #2 was observed seated in a broda chair (specialized reclining wheelchair) in the dining room. He was also observed being taken to his room by Staff R, a NCPT, for toileting. Staff R was unable to transfer him to the toilet by herself and called for additional assistance. Staff K, an RN, came to assist. He was transferred to the toilet with the assistance of the 2 staff members.

On 9/30/14 Patient #2 was observed from 8:51 AM - 9:20 AM. Patient #2 was in the dining area when Staff S, a CNA, attempted to push Patient #2 to his room in his specialized wheelchair. Staff S asked Patient #2 repeatedly to lift up his feet so she could push him, however, he did not do so. Staff S then tried to push him to his room anyway, but was unsuccessful. Staff S then requested the assistance of Staff T, a CNA. Walking backward, Staff T held Patient #2's feet up while Staff S pushed the wheelchair to Patient #2's bedroom. The 2 CNAs then assisted Patient #2 to utilize the bathroom. When done Patient #2 was returned to his wheelchair and Staff T left the room. Staff S then requested Staff T's assistance to return Patient #2 to the dining room. After brief discussion of the options, Staff T suggested walking Patient #2 to the dining room. Patient #2 was assisted by Staff S and Staff T back to the dining area. When asked, both staff stated Patient #2 required two staff to assist him to walk.

During an interdisciplinary team meeting on 9/30/14 beginning at 1:00 PM, Patient #2's mobility was discussed. The Medical Director stated it took 4 to 5 staff members to assist Patient #2 to walk safely.

Staff responsible for Patient #2's treatment and services did not have a clear and common understanding of his mobility needs.

Patient #2's record contained nursing care plans to address identified problems or potential problems. The care plans included interventions to address the problems, as well as short and long terms goals related to resolution of the problems. However, Patient #2's record did not contain a nursing care plan related to motor skills. Therefore, interventions were not developed to address his decline in motor skills and his loss of ability to ambulate.

Patient #2's nursing plan of care did not identify, or include interventions, to address the significant decline in his motor skills.

b. Patient #2's record indicated a decline in his verbal skills during his hospitalization , as follows:

-A Progress Note, dated 7/11/14, signed by the psychiatric NP and cosigned by the Medical Director, listed Patient #2's assets as good verbal skills, intelligent, and supportive family.

-A progress note, completed and signed by Staff K, an RN on 7/14/14 at 10:44 AM, stated, "Received a phone call from his wife this morning, and appeared to have a very appropriate and lucid conversation with her. Phrases he used on the phone were: I love you, I'm ok...I just want to be home with you...there isn't much to do here...and ...alright honey, talk to you soon."

-A progress note, completed and signed by Staff G, an RN on 7/21/14 at 12:51 PM, stated, "Pt does not answer questions...."

-A progress note, completed and signed by Staff I, an RN on 7/24/14 at 10:49 AM, stated, "Unable to follow simple commands or answer questions."

-A progress note, completed and signed by Staff M, an LPN on 7/27/14 at 2:12 PM, stated, "Pt is unable to make needs known."

-A progress note, completed and signed by Staff I, an RN on 8/6/14 at 11:15 AM, stated, "Unable to answer questions or follow simple commands."

-A progress note, completed and signed by Staff C, an LPN on 8/11/14 at 10:19 AM, stated, "Pt is unable to make needs known at this time."

-A progress note, completed and signed by Staff I, an RN on 8/21/14 at 10:48 AM, stated, "...1 word statements and nonverbal sounds."

-A progress note, completed and signed by Staff K, an RN on 9/4/14 at 1:24 PM, stated, "...does not have any clarity or make sense."

-A progress note, completed and signed by a social worker on 9/24/14 at 9:13 AM, stated, "Patients [sic] verbal interactions with social services staff are minimal at best due to profound expressive and receptive aphasia." Aphasia is the loss of ability to understand or express speech.

Patient #2's record contained nursing care plans to address identified problems or potential problems. The care plans included interventions to address the problems, as well as short and long terms goals related to resolution of the problems. Patient #2's record contained a care plan titled Altered Thought Process. The care plan did not indicate the date it was implemented, although the first update to the care plan was dated 7/19/14. The interventions listed on the care plan included a referral to PT, ST, OT or dietary as needed. However, Patient #2's record did not include a referral to ST to address his decline in verbal skills and loss of ability to communicate.

Patient #2's nursing plan of care did not identify, or include interventions, to address the significant decline in his motor skills.

c. Patient #2 experienced a weight loss of 44 pounds during his hospitalization , however a nursing care plan was not implemented in a timely manner to address his nutrition needs. Examples include:

Patient #2's record included a log of his weights, as follows:
-7/13/14 208 pounds
-7/20/14 205 pounds
-8/03/14 187 pounds
-8/10/14 183 pounds
-8/20/14 171 pounds
-8/24/14 168 pounds
-8/31/14 165 pounds
-9/09/14 170 pounds
-9/21/14 170 pounds
-9/28/14 164 pounds

Patient #2's record included a nutritional risk assessment completed and signed by the registered dietician on 7/14/14. The form included a section to note food/meal preferences. The form indicated the source of information was the patient. It also documented he did not answer many of the questions, including questions about his favorite foods or meats he did not like to eat. There was no indication his wife was contacted to provide information about his food preferences.

The dietary note also indicated Patient #2's meal intakes averaged 23%, meeting 20% of his estimated needs. It stated "At high risk for unintended weight loss and malnutrition with current intakes."

Patient #2's record included a nursing care plan to address imbalanced nutrition. However, the care plan was implemented on 9/09/14, 62 days after his admission. On 9/09/14, Patient #2's weight was recorded as 170 pounds, indicating a 38 pound weight loss from his admission weight of 208 pounds.

On 9/29/14 at approximately 12:00 PM, Patient #2 was observed seated in a specialized reclining wheelchair in the facility dining room. The food on his meal tray was in liquid form and he was being fed the liquids by a staff member.

During an interview on 10/02/14 at 11:55 AM, Staff I, an RN confirmed there was a gap between the dietician's identification of Patient #2's high risk nutritional status and the implementation of a nursing care plan to address his nutritional needs. She stated that to her knowledge, the dietician's risk assessment was not communicated to the nursing staff.

During an interview on 10/06/14 beginning at 9:30 AM, the DON stated they do not collect information regarding food preferences from family members as there is not a regulation requiring this. She stated they abided by the diet ordered by the physician.

A nursing care plan to address Patient #2's nutritional needs was not implemented in a timely manner to prevent significant weight loss and malnutrition.

2. Patient #1's medical record documented a [AGE] year old female, admitted to the facility on [DATE]. Diagnosis included dementia, Alzheimer's type, [DIAGNOSES REDACTED] and a urinary tract infection (UTI.) She was discharged to a long term care facility during the survey on 9/30/14. Patient #1's nursing plan of care was not adequately developed or revised as follows:

Patient #1's record included physician orders for the following changes in her treatment plan:

a. 7/17/14 at 1:15 PM - a psychiatric NP entered an order for placement of a Foley catheter related to urinary retention.

7/25/14 at 6:00 PM - the treating psychiatrist entered an order that included "PICC line dressing per policy."

7/29/14 at 1:15 PM - a verbal order from an MD was entered that included "PICC (peripherally inserted central catheter) line dressing to be changed daily. Watch for s/s infection, monitor line placement."

8/25/14 at 9:00 AM - the psychiatric NP entered an order for a medication, Cogentin, 1 mg, to treat "neck [DIAGNOSES REDACTED]" (Neck/[DIAGNOSES REDACTED] is a painful condition in which the neck muscles contract involuntarily, causing the head to twist or turn to one side.)

9/18/14 at 4:30 PM - the psychiatric NP entered an order to change the Foley catheter the evening of 9/18/14 and monthly thereafter. The order included directions to flush the catheter as needed, with sterile water, using sterile irrigation tray, for the purpose of clearing sediment.

The nursing plan of care for Patient #1 did not identify, or include interventions, to address ongoing management of a patient with a Foley catheter or ongoing management of a PICC line. Additionally, the plan of care failed to include interventions to address or monitor the condition, neck [DIAGNOSES REDACTED].

b. Patient #1's nursing progress notes dated 7/27/14 at 7:41 AM, documented Patient #1 was placed on contact isolation precautions related to frequent loose stools. According to the nursing notes, she remained in contact isolation until 9/13/14 at 11:45 PM.

The nursing progress notes dated dated 7/27/14 at 6:56 PM, stated lab results for Patient #1 indicated a positive test for clostridium difficile ([DIAGNOSES REDACTED].) ([DIAGNOSES REDACTED] is an intestinal bacteria causing infectious diarrhea.)

The nursing care plan for Patient #1 failed to provide a plan or interventions for a patient found positive for [DIAGNOSES REDACTED]. and placed on contact isolation precautions.

c. A progress note, by the medical physician, dated 9/22/14 and untimed, documented " She does have a left foot contracture that might benefit from therapies ... "

The nursing plan of care for Patient #1 did not identify or include interventions for contracture of the left foot.

d. Patient #1's record also included a "Nutritional Care Plan" form, undated and untimed, initiated by a registered dietician (RD.) She recommended that Patient #1 receive a regular diet, PRN snacks and a dietary supplement if meals were refused. The form also documented the following goals for Patient #1: "...consume 75% of meals and maintain a weight between 98-132 pounds." Directions to obtain weekly weights were included as well.

Patient #1's nursing plan of care did not identify, or include interventions, to address nutritional needs.

During an interview on 10/02/14 beginning at 2:00 PM, the DON reviewed Patient #1's record and confirmed the care plans were not updated to include her changing needs and changes in treatment goals.

The hospital failed to ensure Patient #1's plan of care was individualized and revised according to her needs.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure nursing assignments were based on staff competency and patients' needs for 1 of 6 patients (#1) whose record was reviewed. This failure resulted in the failure to ensure a sterile dressing change was performed, inadequate assessment, and poor patient outcome. Findings include:

1. Patient #1 was a [AGE] year old female admitted to the facility on [DATE], with the diagnoses of dementia with behavioral disturbance and unspecified psychosis.

Patient #1's record documented her refusal to eat or drink, and she received IV hydration. A PICC was placed on 7/25/14 in her left forearm. (The acronym PICC describes a peripherally inserted central catheter, in which the tip of the catheter rests in a large vein close to the entrance of the heart. It allows a higher concentration of medications or IV fluids to be administered, whereas smaller veins could not tolerate the higher osmolarity of the solutions). According to Lippincott Manual of Nursing Practice, eighth edition, a PICC is considered a central line, and extra vigilance must be used to protect the integrity of the line and dressing. If the dressing has become dislodged, or the line has been pulled at any point, the placement must be confirmed, and a sterile dressing change must take place.

The facility policy for PICC line care, revised 12/11, stated: "If PICC line is found to be torn, loose, damp, soiled or raised, the nurse should..." and further describes a sterile dressing change. The policy also stated the nurse was to document findings and actions, and alert the PICC line team of findings. The policy noted the dressing is to be changed 24 hours after insertion and every 7 days if intact.

During the time that Patient #1's care was provided by an LPN, her PICC line and dressing became dislodged, a sterile dressing change was not performed, placement was not determined, which resulted in cellulitis and a MRSA infection.

In a nursing note 7/29/14 at 1:45 PM, Staff N, an LPN noted "Patient has PICC line patent to left forearm, it was noticed during lab draw that patient has lifted the dressing and pulled some of the line out."

A verbal order, written by the above LPN, and signed by a physician, was dated 7/29/14 at 1:15 PM. The order noted "PICC line dressing to be changed daily. Watch for S/S (signs or symptoms) infection, monitor line placement."

In a nursing note 7/29/14 at 7:09 PM, Staff N, the LPN, documented that when she removed the loose dressing, the PICC line was pulled out approximately 8-10 cm, and she covered the entire line that was exposed.

In an RN progress note on 7/30/14 at 5:39 PM, the nurse wrote that Patient #1's left arm had redness surrounding the entire elbow area down the forearm, and it was tender to touch. She noted that the medical physician was notified, the PICC was removed, and the tip of the catheter was sent for culture.

A lab result in the record noted the cultured PICC tip was positive for MRSA, and the facility was notified of the results on 8/01/14 at 3:01 PM. The report was reviewed and initialed by the medical physician and it was noted on the report that Patient #1's antibiotics were changed to treat the cellulitis and MRSA infection.

During an interview on 10/02/14 beginning at 2:00 PM, the DON reviewed Patient #1's record and stated she was called in to see the loose dressing on 7/29/14 around 1:30 PM. She stated the LPN did not perform a sterile dressing change, but applied an occlusive dressing over the line that had been disrupted. The DON stated she instructed the LPN to contact the physician for orders. The DON stated the policy of the facility is that PICC line dressings are to be monitored and changed by the RNs and not LPNs. Further, the DON confirmed an X-Ray was not performed for verification the PICC line was positioned properly before resuming IV fluids and medication administration.

The facility failed to ensure an RN performed a sterile dressing change when Patient #1's PICC line and dressing was disrupted.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, it was determined the facility failed to ensure documentation was accurate and included in the record for 1 of 6 patients (#5) whose records were reviewed. This resulted in the lack of ability for those providing care, to properly monitor the patient's changing condition and needs. Findings include:

Patient #5 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses of schizophrenia, dementia with behavioral disturbance, and psychosis. Patient #5's record indicated he was transferred from an ALF due to aggressive behaviors.

Patient #5's record was reviewed and contained a form for snack/meal/fluid output, which was used for a one week period that began on Tuesday and ended on Monday. This form had areas for daily monitoring of weight, food consumption, fluid intake and output, bowel movements, showering, and total hours of sleep.

The first form, for Patient #5, began Thursday 9/11/14 on the date of his admission. A total of 5 days were completed for that week ending 9/15/14, the following Monday. On the second week of his admission, the same form was completed for the first 2 days, 9/16/14 Tuesday and 9/17/14 Wednesday. However, no data was documented for the remainder of the week. A request was made to the RHIT director to copy these forms in Patient #5's record on 9/30/14. On 10/01/14 at 3:00 PM, Patient #5's record was reviewed again. The form with dates beginning 9/16/14, was completed for the remainder of that week

Additionally, on 10/01/14 Patient #5's record included completed forms for the following two weeks, 9/23/14 - 9/29/14 and 9/30/14 - 10/06/14. The form for the current week, starting 9/30/14, had information completed for 9/30/14 and 10/01/14. These forms and data were not present in Patient #5's record on 9/30/14 when copies were originally requested.

During an interview on 10/02/14 beginning at 2:45 PM with the DON, the record was reviewed. She confirmed the original copies of the form obtained on 9/30/14 and compared them to the forms that were in the record. The DON said she could not explain how all of the forms were not originally in the record. She also could not explain how the form dated 9/16/14 to 9/22/14 was completed in the preceding two days, after the original copies were made.

Patient #5's information was not documented in his record appropriately in order to monitor his condition.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, staff interview, review of medical records, and infection control logs, it was determined the hospital failed to ensure a trained IC officer provided oversight of the IC program, and that an active program was in place to track, trend, and analyze infections and infection control practices in the facility. This had the potential for patients to develop infections that could have been prevented. Findings include:

1. Refer to A748 as it relates to the lack of program oversight and direction by a trained IC officer.

2. Refer to A749 as it relates to the failure to investigate, identify trends, and educate staff regarding infection control practices.

The cumulative result of these systemic deficient practices resulted in increased opportunities for patients to acquire infections.
VIOLATION: DELIVERY OF SERVICES Tag No: A1132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records and staff interviews, it was determined the facility failed to ensure OT services were provided under the orders of a practitioner responsible for the care of the patient, for 3 of 6 patients (#1-3) who received OT services. This had the potential to result in lack of physican input and unmet patient needs. Findings include:

1. Patient #2 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses of dementia with behavioral changes, and psychosis. Patient #2's record indicated he had been admitted from his home where he was cared for by his wife.

Patient #2's record included physician admission orders written and signed by the admission nurse on 7/10/14, and signed by the Medical Director on 7/12/14. They included an order for OT to evaluate and treat.

Patient #2's record also included an OT evaluation, completed and signed by the Occupational Therapist on 7/11/14. The evaluation included a plan of care with activities and goals. However, the plan of care was not signed by the physician and there was no documentation to indicate the plan of care was approved by the physician.

Patient #2's record included OT weekly progress notes for 10 weeks, however the evaluation stated OT services would be provided 4 times a week for 4 weeks.

During an interview on 10/02/14 at 9:10 AM, the Occupational Therapist stated the Medical Director usually signed the OT orders once they were placed in the record, however, it was not her practice to discuss the plan of care with the physician. She stated she was in the process of revising the OT program for the hospital, and she was not aware of a regulation regarding physician orders for the OT plan of care.

Patient #2's OT plan of care was not provided under the orders of a physician.





2. Patient #3 was a [AGE] year old male admitted to the facility on [DATE]. His diagnoses include dementia, psychosis, multiple falls, multiple fractures, chronic pain, frequent night time urination, and an enlarged prostate. His H&P documented he was transferred from an ALF for increasing agitation, verbal and physical aggression, and frequent falls.

a. Patient #3's record contained physician admission orders written and signed by the admission nurse on 9/03/14, and signed by the Medical Director on 9/06/14. They included an order for an Occupational Therapist to evaluate and treat.

Patient #3's record also included an OT evaluation, completed and signed by the Occupational Therapist on 9/05/14. The evaluation included a plan of care with activities and goals. However, the plan of care was not signed by the physician and there was no documentation to indicate the plan of care was approved by the physician.

The record included OT weekly progress evaluations for two weeks, however the evaluation stated OT services would be provided 4 times a week for 4 weeks.

Patient #3's OT plan of care was not provided under the order of a physician.

b. Patient #3's record contained an order for a PT consult to assess his physical independence with cares, which was written and signed by the NP on 9/16/14.

The record included a PT evaluation, completed and signed by the Physical Therapist on 9/18/14. The evaluation included a plan of care with interventions, goals, and functional levels. The Physical Therapist also documented the goals and treatment plan were discussed with the patient, family, and staff. However, the plan of care was not signed by the physician or NP and it was not documented the plan of care was approved by the physician or NP. Patient #3's record included 2 additional visits documented by the Physical Therapist, on 9/19/14 and 9/22/14.

During an interview on 10/02/14 beginning at 9:55 AM the Occupational Therapist was on the phone with the Physical Therapist and the chart was reviewed. The Physical Therapist was unaware the plan of care was not signed by the physician or NP. She confirmed the plan of care was discussed with staff but not with the physician or NP.

Patient #3's PT plan of care was not provided under the care of a physician or NP.





3. Patient #1 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses of dementia with behavioral disturbance, and unspecified psychosis. She was discharged to a long term care facility on 9/30/14.

Patient #1's record included physician admission orders written and signed by the admission nurse on 7/15/14, and signed by the Medical Director on 7/19/14. They included an order for OT to evaluate and treat.

Patient #1's record also included an OT evaluation, completed and signed by the Occupational Therapist on 7/15/14. The evaluation included a plan of care with activities and goals. However, the plan of care was not signed by the physician and there was no documentation to indicate the plan of care was approved by the physician.

Patient #1's record included OT weekly progress notes for 7 weeks, however the evaluation stated OT services would be provided 4 times a week for 4 weeks.

During an interview on 10/02/14 beginning at 9:10 AM, the Occupational Therapist stated the Medical Director usually signed the OT orders once they were placed in the record, however, it was not her practice to discuss the plan of care with the physician. She stated she was in the process of revising the OT program for the hospital, and she was not aware of a regulation regarding physician orders for the OT plan of care.

Patient #1's OT plan of care was not provided under the orders of a physician.