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Based on observation, interview, record review and policy review, the facility failed to ensure nursing staff:
- Assessed patients every shift and after a fall to identify fall risk and/or fall interventions, including bed alarms to protect two of two current patients (#15, and #3) and for one of one discharged patient (#14) patients reviewed.
- Assessed and administered pain medications per physician orders for one (#18) of one patient reviewed.
- Consistently removed restraints (any method of applying involuntary restriction on a patient's bodily movement) every two hours for ten minutes, to exercise patients' limbs, for two current patients (#3, #8) and one discharged patient (#16) of four patients reviewed with restraints.
- Consistently provided the Registered Dietitian's (RD) recommendation and physician's orders for a nutritional supplement three times daily for one of one patient (#3) reviewed with an order for a nutritional supplement.
- Consistently followed recommended interventions for keeping heels off of a bed surface (floating heels) for one of one patient (#3) reviewed with interventions to float the heels.
- Performed and documented the universal fall prevention strategies for all patients, including one hour rounding on the 24-Hour Nursing Flowsheet, for six (#3, #5, #10, #11, #8, and #13) of 11 current patients and two of two discharged patients (#14, and #16) reviewed.
- Maintained urinary catheter (a tube inserted into the bladder through the urethra [transports and discharges urine outside of the body]) drainage bags below the level of the bladder to prevent infection for two (#17 and #2) of six patients with urinary catheters.
- Assessed, evaluated, and followed the physician's orders for wound care on one of one patient (#13) reviewed.

Please see A395 for details.

The failures related to fall prevention, pain and restraint management, providing nutritional supplements, skin protection and/or wound care, and urinary catheter management, had the potential to lead to possible harm and/or injury and could affect all patients in the facility. The facility census was 25. The facility identified five patients in restraints, and identified 32 falls over the last six month period, with three patients incurring injuries requiring more than first aid.

The severity and cumulative effect of these systemic failures resulted in the facility being out of compliance with 42 CFR 482.23 Condition of Participation: Nursing Services.

Based on observation, interview, record review and policy review, the facility failed to ensure nursing staff:
- Assessed patients every shift and after a fall to identify fall risk and/or fall interventions, including bed alarms to protect two of two current patients (#15, and #3) and for one of one discharged (#14) patients reviewed.
- Assessed and administered pain medications per physician orders for one (#18) of one patient reviewed.
- Consistently removed restraints (any method of applying involuntary restriction on a patient's bodily movement) every two hours for ten minutes, to exercise patients' limbs, for two current patients (#3, #8) and one discharged patient (#16) of four patients reviewed with restraints.
- Consistently provided the Registered Dietitian's (RD) recommendation and physician's orders for a nutritional supplement three times daily for one of one patient (#3) reviewed with an order for a nutritional supplement.
- Consistently followed recommended interventions for keeping heels off of a bed surface (floating heels) for one of one patient (#3) reviewed with interventions to float the heels.
- Performed and documented the universal fall prevention strategies for all patients, including one hour rounding on the 24-Hour Nursing Flowsheet, for six (#3, #5, #10, #11, #8, and #13) of 11 current patients and two of two discharged patients (#14, and #16) reviewed.
- Maintained urinary catheter (a tube inserted into the bladder through the urethra to transport and drain urine outside of the body) drainage bags below the level of the bladder to prevent infection for two (#17 and #2) of six patients with urinary catheters.
- Assessed, evaluated, and followed the physician's orders for wound care for one of one patient (#13) reviewed with a leg amputation.

The failures related to fall prevention, pain and restraint management, providing nutritional supplements, skin protection and/or wound care, and urinary catheter management, had the potential to lead to possible harm and/or injury and could affect all patients in the facility. The facility census was 25.

The facility identified five patients in restraints, and identified 32 falls over the last six month period, with three patients incurring injuries requiring more than first aid. The facility reported five facility acquired catheter associated urinary tract infections (urine culture gram-negative bacilli, a bacteria located in the urinary tract) in the prior six months.

Findings included:
1. Record review of the facility's policy titled, "Fall Reduction Program," revised on 07/16, showed the following:
- Every patient will be assessed on admission, every shift, and after a fall;
- Documentation will be on a 24-Hour Nursing Flowsheet;
- The nursing staff will identify risk factors and associated fall prevention strategies including bed alarms (a personal alarm that allows a caregiver to monitor the activity of a patient in bed;) and
- Universal fall prevention strategies will be implemented for all patients including hourly rounding.

2. Record review of current Patient #15's History and Physical (H&P) showed that she was a 48 year old female admitted to the facility on 12/16/16 for end-stage-renal disease (final stage of chronic kidney disease in which the kidneys no longer function well enough to meet the needs of daily life).

Record review of Patient #15's 24-Hour Nursing Flowsheets dated 01/03/17, and 01/05/17 showed the following:
- An orthostasis risk (low blood pressure, dizzy, faint);
- An unsteady gait, weak when standing or walking; and
- An alarm on the bed.

Observation on 01/03/17 at 3:45 PM in Patient #15's room, showed no bed alarm was on the bed.

During an interview on 01/03/17 at 3:50 PM, Staff J, stated that Patient #15 should have had a bed alarm on the bed.

Observation on 01/05/17 at 6:00 AM in current Patient #15's room, showed no bed alarm was on the bed.

During an interview on 01/05/17 at 6:05 AM, Staff P, stated that Patient #15 should have had a bed alarm on and she did not see one.

Even though the staff recognized that Patient #15 did not have an alarm on the bed on 01/03/17, as of 01/05/17 staff failed to place an alarm on Patient #15's bed.

3. Record review of current Patient #3's undated Kardex-Plan of Care (a daily informational sheet that shows aspects of care and changes as necessary) showed the patient had a history of falls (typically increased the risk for future falls).

Record review of Patient #3's 24-hour Nursing Flowsheet dated 01/03/17 through 01/05/17, showed staff identified the following:
- The patient needed to have a bed alarm to prevent falls.
- The patient was impulsive and tried to get out of bed.
- The patient was confused (can increase risk for falls).

Observation and concurrent interview, in the patient's room, showed the following:
- On 01/04/17 at 9:52 AM, Staff G, Certified Nurse Assistant (CNA), confirmed Patient #3 did not have a bed alarm attached. Staff G demonstrated how a bed alarm would be plugged into the wall outlet, with a pad on the bed, which had an audible alarm if weight was lifted off of it.
- Staff G also stated that the patient should have a yellow band on her wrist, but there was none.
- On 01/04/17 at 3:47 AM, the patient did not have a bed alarm.
- On 01/04/17 at 4:30 PM, the patient did not have a bed alarm. Staff D, Interim Chief Nursing Officer (ICNO) confirmed that the patient did not have a bed alarm on and that the Registered Nurse (RN) should be overseeing this intervention.
- On 01/05/17 at 5:24 AM, the patient did not have a bed alarm.

4. Record review of discharged Patient #14's medical record showed the following:
- The Progress Note, dated 12/01/16, that the patient was confused and tried to get out of bed.
- The 24-Hour Nursing Flowsheet, dated 12/04/16, showed no bed alarm on the bed and at 4:10 AM the patient fell out of the bed and sustained skin tears to both arms.
- The 24-Hour Nursing Flowsheet, dated 12/05/16, showed at 8:15 AM, the nurse documented that fall prevention interventions would be implemented once orders were received.
- The 24-Hour Nursing Flowsheet dated 12/05/16 at 9:00 AM, showed the physician gave orders for a bed alarm and the nurse placed the alarm on the bed at that time.
- The 24-Hour Nursing Flowsheet dated 12/05/16, showed no documented fall assessment.

5. Record review of the facility's policy titled, "Pain Management, Assessment and Intervention Protocol," revised 07/01/16, showed that all staff were to establish procedures to prevent, assess, diagnose, treat, and evaluate the aspects of pain, including sensory, emotional, cognitive, developmental, and behavioral components of pain.

6. Record review of current Patient #18's H&P, dated 12/27/16, showed a 69 year old male with a past medical history of the following:
- Abdominal wall abscess (painful swelling with bacteria filled pus);
- Stage 4 (a sore that is very deep, reaching into the muscle and bone causing extensive damage) sacral (referring to the bone at the base of the spine) pressure sore measuring 20 centimeters (cm) x 20 cm 12/27/16;
- Osteomyelitis (painful inflammation of the bone) of the sacrum (large, triangular bone at the base of the spine) 12/27/16; and
- Chronic pain.

During an interview on 01/03/17 at 2:47 PM, Patient #18 stated that on the night of his admission 12/27/16, he was in pain and miserable. He stated that Staff S, RN told him that the pharmacy closed around 6:00 PM and they couldn't give him any pain medication. The patient was admitted at 7:15 PM and didn't receive any pain medication until the next morning.

Record review of Patient #18's Physician Orders, dated 12/27/16 at 8:45 PM, showed that Acetaminophen 325 milligrams (mg., one thousandth of a gram), two tablets ordered as needed every six hours for pain rated at a level of one through four (on a scale of one through ten with ten being the worst pain) and Oxycodone (a narcotic pain medication) 5 mg., ordered as needed every four hours for pain rated at a level of five through 10 and not controlled by the Acetaminophen.

Record review of the patient's medication records dated 12/27/16 and 12/28/16 showed staff failed to give Acetaminophen or Oxycodone until 12/28/16 at 6:51 AM, or approximately 12 hours later.

During a telephone interview on 01/05/17 at 6:47 PM, Staff S, RN stated that she told Patient #18 the pharmacy closed at 4:00 PM. She stated that when she assessed the patient's pain at night, she had to have a second nurse signature to remove the medication from the pyxis (automated medication dispensing system). Staff S stated that if the patient asked for pain medication, she would have given it to him.

7. Record review of the facility's policy titled, "Restraints and Seclusion," revised 06/2012, showed the following:
- Restraint is a high-risk, potentially harmful procedure that is intended to be used only when a patient's behavior interferes with medical treatment.
- Documentation must include observations/interventions/findings from periodic observations such as comfort, mobility, and skin integrity.
- Documentation must also include observations every two hours for medical restraints (used to prevent removal of necessary medical tubes/devices).

8. Observations intermittently of current Patient #3 from 01/03/17 at approximately 3:00 PM through 01/05/17 at approximately 9:30 AM showed the patient with bilateral wrist restraints.

During an interview on 01/04/17 at 10:50 AM, Staff F, CNA stated that the RN and/or therapist (professional physical or occupational therapist who provide rehabilitative training) were to remove the restraints every two hours for ten minutes and exercise the limb, and inspect it for injury. Staff F, stated that the RN or therapist should document this activity.

Record review of Patient #3's 24-hour Nursing Flowsheet showed staff failed to document removal of restraints on 01/01/17 at 7:00 PM.

9. Record review of Patient #8's H&P showed a 31 year old male admitted to the facility on 12/21/16 with acute respiratory failure that resulted in a tracheotomy (a tube that is inserted into the windpipe to enable breathing) and was ventilator dependent (mechanical life support because of the inability to breathe effectively).

Observation on 01/03/17 at 2:30 PM in Patient #8's room showed the patient had on bilateral wrist restraints.

Record review of Patient #8's 24-Hour Nursing Flowsheet dated 01/02/17 showed that the nursing staff failed to remove restraints, assess skin integrity, and do range of motion every two hours at 2:00 AM, 4:00 AM, and 6:00 AM.

10. Record review of discharged Patient #16's 24-hour Nursing Flowsheet showed that restraint assessment was not documented for the following days:
- 11/19/16 at 6:00 AM;
- 11/22/16 at 8:00 PM, 10:00 PM;
- 11/23/16 at 12:00 AM, 2:00 AM, 4:00 AM and 6:00 AM;
- 11/24/16 at 7:00 PM;
- 11/25/16 at 3:00 PM, 5:00 PM and 7:00 PM;
- 11/29/16 at 5:00; and
- 12/10/16 at 4:00 AM and 6:00 AM.

11. Even though requested, a policy regarding documentation of nutritional supplements was not provided.

12. Record review of Patient #3's H&P dated 12/01/16, showed the patient was admitted on that date with a diagnosis of severe protein calorie malnutrition and diabetes (a disease when the body cannot rid itself of excess glucose/sugar in the blood and requires insulin to control; can increase risk for development of wounds/pressure sores).

Record review of Patient #3's undated Kardex-Plan of Care, on 01/04/16, showed staff were to document intake and output (I&O) every shift.

Record review of RD assessments dated 12/26/16 and 01/03/17 showed the following:
- The patient was a high risk for poor nutrition.
- The patient consumed 60% of oral intake.
- The RD recommended Ensure High Protein, a nutritional supplement, three times daily, on 01/03/17 at 2:40 PM.

Record review of Physician's orders dated 01/03/17, showed the physician signed an order for Ensure High Protein, three times daily, with meals.

Record review of I&O records showed no documentation that the Ensure was provided for the patient at dinner on 01/03/17, or for breakfast on 01/04/17.

During an interview on 01/05/17 at 6:00 AM, Staff N, RN Supervisor, stated that the CNA or RN should type in the name of the nutritional supplement under the I&O section of the electronic medical record, and document the consumption in milliliters (mls-a measurement of liquid).

During an interview on 01/05/17 at 9:23 AM, Staff Y, Corporate RN, stated that there was no evidence the Ensure High Protein was consumed by Patient #3.

During an interview on 01/05/17 at 10:23 AM, Staff D, ICNO, stated that the RN or CNA were responsible to document the consumption of a nutritional supplement in mls, and put the type of supplement, on the I&O sheet.

13. Record review of Patient #3's 24-hour Nursing Flowsheet from 01/01/17 through 01/04/17 showed the following:
- The patient's heels were to be floated (keeping heels off of the bed surface by placing a pillow under the legs with the heels hanging off the edge of the pillow) for skin protection by reduction of pressure.
- The patient's Braden score (a scoring tool used to identify risk for development of pressure sores) was "11" or a high risk, requiring floating of the heels.
- The patient required staff assistance to be repositioned.

During an interview on 01/03/17 at 3:50 PM, Staff C, Wound Care RN, stated that floating of heels meant that the heels should not touch the pillow or mattress surface.

Observation and concurrent interview, in the patient's room, on 01/04/17 at 10:50 AM, showed the following:
- Patient #3's heels were not floated, but were lying directly on the mattress.
- Staff F, CNA, stated that the patient's heels were directly on the mattress, and not considered to be floated.
- The Patient's heels were extremely dry with large amounts of flaking skin (multiple layers of skin-which could be a risk factor for pressure sore development).

Observation showed staff failed to float the patient's heels on the following days and times:
- On 01/03/17 at 3:28 PM.
- On 01/04/17 at 9:43 AM.
- On 01/04/17 at 10:50 AM.
- On 01/05/17 at 5:24 AM.

14. Record review of current Patient #3's 24-hour Nursing Flowsheet from 12/31/16 through 01/04/17 showed the following:
- Staff were to do hourly rounds.
- On 12/31/16, staff failed to document hourly rounds at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, and 6:00 PM.
- On 01/01/17, staff failed to document hourly rounds at 6:00 PM.

15. Record review of current Patient #5's 24-hour Nursing Flowsheet showed staff were to do hourly rounds. The Flowsheets showed staff failed to document hourly rounds on:
- 12/23/16 at 7:00 AM, 7:00 PM, 9:00 PM, 10:00 PM, 11:00 PM;
- 12/24/16 at 12:00 AM, 1:00 AM, 2:00 AM, 3:00 AM, 4:00 AM, 5:00 AM, and 6:00 AM.
- 01/01/17 at 2:00 AM, 4:00 AM, and 6:00 AM.
- 01/03/17 at 5:00 PM, and 6:00 PM.
- 01/04/17 at 9:00 AM, and 11:00 AM.

16. Record review of current Patient #10's 24-Hour Nursing Flowsheets dated 01/02/17 through 01/03/07 showed staff failed to document hourly rounds on:
- 01/02/17 at 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM, 5:00 PM, 6:00 PM;
- 01/03/17 at 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM and 6:00 PM;
- On 01/04/17 at 4:00 AM, and 6:00 AM.

17. Record review of current Patient #11's 24-Hour Nursing Flowsheets dated 01/02/17 through 01/03/17 showed staff failed to document hourly rounds on:
- 01/02/17 at 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM, 5:00 PM;
- 01/03/17 at 4:00 AM and 6:00 AM, 7:00 AM, 9:00 AM and 3:00 PM.

During an interview on 01/03/17 at 2:55 PM, Staff H, RN, stated that she had no time to
document hourly rounds for Patient #11 on the Nursing Flowsheet, dated 01/03/17 at 7:00 AM, 9:00 AM, and 3:00 PM. Staff H stated that it was the nursing staff's responsibility to document on the rounding on the 24-Hour Nursing Flowsheets.

18. Record review of current Patient #8's 24-Hour Nursing Flowsheets dated 01/02/17 through 01/03/17 showed the following:
- Staff were to do hourly rounds.
- On 01/02/17, staff failed to document hourly rounds at 2:00 AM, 4:00 AM, and 6:00 AM.
- On 01/03/17, staff failed to document hourly rounds at 2:00 AM, 4:00 AM, and 6:00 AM.

19. Record review of current Patient #13's 24-Hour Nursing Flowsheets dated 12/30/16, showed that the nursing staff failed to document hourly rounds at 4:00 PM and at 6:00 PM.

20. Record review of discharged Patient #14's 24-Hour Nursing Flowsheets, dated 12/04/16, showed that the staff failed to make hourly rounds at 7:00 PM, 9:00 PM and 11:00 PM.

21. Record review of discharged Patient #16's 24-hour Nursing Flowsheet showed that the hourly rounds were not documented on the following days:
- 11/24/16 at 7:00 PM, 9:00 PM, 11:00 PM, 1:00 AM;
- 11/25/16 at 3:00 AM, 5:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM and 6:00 PM;
- 11/26/16 at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM and 6:00 PM;
- 11/29/16 at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 5:00 PM and 6:00 PM;
- 11/30/16 at 7:00 PM;
- 12/01/16 at 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM, 5:00 PM, 7:00 PM, 9:00 PM and 11:00 PM;
- 12/02/16 at 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM, 5:00 PM, 8:00 PM and 10:00 PM;
- 12/04/16 at 8:00 AM and 10:00 AM;
- 12/09/16 at 4:00 AM and 6:00 AM;
- 12/09/16 at 4:00 AM, 5:00 AM and 6:00 AM;
- 12/13/16 at 5:00 PM; and
- 12/14/16 at 10:00 AM and 12:00 PM.

During an interview on 1/05/17 at 10:27 AM, Staff D, ICNO, stated that all nurses were expected to do hourly rounds and document, on the 24-hour Nursing Flowsheet.

22. Record review of the facility's policy titled, "Urinary Catheter Management (CAUTI, Catheter-Associated Urinary Tract Infections Reduction Program)," dated 04/01/16, showed that the nursing staff should keep the urinary catheter drainage bag below the level of the bladder to improve drainage and maintain the free flow of urine to prevent infection.

23. Observation on 01/04/17 at 9:20 AM in Patient #17's room showed the patient had a urinary catheter drainage bag placed above the level of the bladder, on the top rail of the bed.

Record review of the laboratory results in the patient's medical record, showed that on 12/20/16 the patient was positive for a urinary tract infection.

Record review of the physician's orders for Patient #17, showed that on 12/22/16 Meropenem (antibiotic commonly used for gram negative urinary tract infections) was ordered and an Infectious Disease (ID) physician was consulted.

During an interview on 01/05/17 at 9:16 AM, Staff W, RN stated that the urinary catheter drainage bag should be placed below the bladder and off of the floor.

24. Observation on 01/04/17 at 3:15 PM showed that Patient #2's urinary catheter drainage bag was placed above the level of the bladder, on the top rail of the bed.

During an interview on 01/05/17 at 10:27 AM, Staff D, ICNO, stated that all staff were expected to keep urinary catheter drainage bags below the bladder, not on a movable part of the bed and not on the floor.

25. Record review of Patient #13's H&P showed the following:
- She was a 52 year old female admitted to the facility on 12/28/16 with history of peripheral artery disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs.)
- She developed a septic embolization (clot in the blood resulting from bacteria) which required a left below the knee amputation (BKA, surgical removal of all or part of a limb); and
- Dry gangrene (inadequate blood flow) to the second right toe, which was in the process of autoamputation (spontaneous detachment of an appendage from the body).

Record review of the Physician's order dated 12/28/16 showed that frequency for wound care to the left BKA should be daily and as needed.

Record review of Patient #13's left BKA wound documentation flow sheet showed no documentation for wound care on 12/30/16 or 12/31/16.

During an interview on 01/04/17 at 1:30 PM, Staff C, Wound Care RN, stated that she only worked during the week. She stated that 12/30/16 and 12/31/16 were on the weekend. Staff C stated she leaves notes for the staff to change the dressings, but she was not responsible for the staff on the weekends for not changing the dressings.

During an interview on 01/05/17 at 10:25 AM, Staff D, ICNO stated that she was the temporary interim Chief Nursing Officer (CNO), and had been since 12/02/16. Staff D stated that the RN was ultimately responsible for all aspects of nursing care, including assessment, interventions and oversight of the CNA. The ICNO confirmed that the 24-hour Nursing Flowsheet served as an assessment tool, a care plan, with interventions based on the assessment, with complete documentation for all assessed systems and/or interventions regarding restraints, rounding, bed alarms, etc. Staff D stated that the 24-hour Nursing Flowsheet should be completed accurately, by the RN each shift. If the 24-hour Nursing Flowsheet showed the need for a restraint, it should be documented as observed, removed, and exercise given every two hours. The ICNO was not sure the 24-hour Nursing Flowsheet was reviewed by anyone for accuracy and/or implementation of care plan interventions.















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