Department of Veterans Affairs Community Living Center Survey … · Elsevier s Clinical Skills obtained on-line on 07/24/18 and titled, Peripherally Inserted Central Catheter: Maintenance

Department of Veterans Affairs Community Living Center Survey Report

This document or report and the information contained herein, which resulted from the Community Living Center Unannounced Survey, hasbeen de-identified to remove individually identifiable health information (also known as protected health information) in accordance with theHealth Insurance Portability and Accountability Act (HIPAA) Privacy Rule and other federal and state laws. De-Identification was completed inaccordance with guidance published by the Office for Civil Rights to protect the privacy of the Community Living Center's residents.

General Information:

CLC: Castle Point Campus of the VA Hudson Valley Health Care System (Castle Point, NY)

Dates of Survey: 7/17/2018 to 7/19/2018

Total Available Beds: 28

Census on First Day of Survey: 27

F-Tag Findings

F241

483.15(a) Dignity. The facility mustpromote care for residents in amanner and in an environment thatmaintains or enhances each resident’sdignity and respect in full recognitionof his or her individuality.

Level of Harm - No actual harmwith potential for more thanminimal harm that is not immediatejeopardy

Residents Affected - Few

Based on observation, interview and record review, the CLC did not promote care forresidents in a manner and in an environment that maintained or enhanced each resident’sdignity and respect. Findings include:

Resident #204 was admitted to the CLC on [DATE] with a diagnosis of Alzheimer’sdisease. The resident’s admission Minimum Data Set (MDS) dated [DATE] was codedto indicate the resident required total assistance from staff for all activities of daily living(ADLs) including eating. A provider’s order dated 07/16/18 read, “The Veteran[Resident #204] is a feeder [needs assistance from staff with eating] and needs to befed his meals.” A typed sheet of paper signed by the resident’s wife was observedtaped on the wall in the resident’s room throughout the survey. One of the items on thesign read, “Does not like eggs.” The sign also included instructions regarding theresident’s personal care such as using a water pick for oral care.

F281

483.20(k)(3)(i) The services providedor arranged by the facility must (i)Meet professional standards ofquality;



Based on observation, interview and record review, the CLC did not provide services that metprofessional standards of quality. Findings include: Peripherally Inserted Central Catheter (PICC) CareElsevier’s Clinical Skills obtained on-line on 07/24/18 and titled, “Peripherally Inserted CentralCatheter: Maintenance and Dressing Change [extended text]” adapted from Perry, A.G.,Potter, P.A., Ostendorf, W.R. (2014). Clinical nursing skills & techniques (8th edition). St.Louis: Mosby, stated, “Change all add-on devices (i.e., stopcocks, extension sets, needlelessconnectors, inline filters, caps) with each administration set replacement, whenever theintegrity of the device is compromised, or when contamination is suspected.” The Infusion Therapy Standards of Practice: Standard 34 Needleless Connectors datedAugust 2015 was obtained on-line on 07/26/18. The standard stated, “Use of passivedisinfection caps containing disinfecting agents (e.g., isopropyl alcohol) has been shown toreduce intraluminal microbial contamination and reduce the rates of central line-associatedblood-stream infection (CLABSI)….” Resident #104

Resident #104 was admitted to the CLC on [DATE] with diagnoses that includeddiabetes mellitus, peripheral vascular disease, mild dementia, and a left heel diabeticulcer.A provider's order dated 06/21/18 stated, “Contact precautions – MRSA [methicillin-resistant Staphylococcus aureus] in wound. PICC flush protocol….If not covered withswab cap, reclean the needle free valve port with alcohol/chlorohexidine for 30seconds….”

Page 1 of 13 -- Castle Point Campus of the VA Hudson Valley Health Care System -- 7/17/2018 to 7/19/2018

On 07/18/18 at approximately 8:20 a.m., Resident #104 was observed seated in awheelchair just inside the resident’s room. The resident’s left upper arm had a singlelumen PICC that had no protective cap in place as was also observed on 07/17/18 atapproximately 3:26 p.m. during medication administration. At the same time, the nursemanager was interviewed and indicated, “There should be a cap on it [PICC port].”When asked how long the PICC port might have been uncapped, the nurse managerstated, “It’s hard to know.” Upon entering the resident’s room, two empty intravenous(IV) antibiotic bags were hanging on an IV pole. One IV antibiotic was dated 07/17/18and indicated vancomycin infused daily at 1:30 p.m. and the other IV antibiotic wasdated 07/17/18 and indicated ceftriaxone infused daily at 9:00 a.m.On 07/19/18 at approximately 9:15 a.m., the infection control nurse (infectionpreventionist) was interviewed and asked if it was acceptable for a PICC access port tobe without a protective cap that staff referred to as a “Swabcap.” The infection controlnurse responded, “I prefer that there be a Swabcap on [the PICC port].”

F309

483.25 Quality of Care. Each residentmust receive and the facility mustprovide the necessary care andservices to attain or maintain thehighest practicable physical, mental,and psychosocial well-being, inaccordance with the comprehensiveassessment and plan of care. UseF309 for quality of care deficienciesnot covered by §483.25(a)-(m).



Based on observation, interview and record review the CLC did not provide the necessarycare and services for each resident to attain or maintain the highest practicable physical,mental, and psychosocial well-being. Findings include: Bowel Management Resident #102

Resident #102 was originally admitted to the CLC on [DATE] with diagnoses thatincluded stroke and dementia. The resident was readmitted to the CLC on [DATE]following acute care hospitalization for pneumonia.The annual MDS dated 11/28/17 indicated Resident #102 had severely impairedcognitive skills for daily decision making based on staff assessment; was dependent onone staff person for bed mobility, transfers, and hygiene; was incontinent of bowel andbladder; and received nutrition through a feeding tube. The annual MDS did notindicate the resident experienced constipation. The most recent quarterly MDS dated05/15/18 was coded similarly and there were no changes in the above noted careareas; constipation was not an area that would require coding on a quarterly MDS.Resident #102’s care plan last reviewed on 07/06/18 did not address constipation orprevention of complications related to constipation before or after the residentexperienced “constipation” as noted on 03/31/18 (see below).Resident #101 had the following provider’s orders (original order dates were requestedbut not received):

05/09/18: “Renew enema phosphate plain, one enema, [administered rectally]M-W-F [Monday, Wednesday, Friday], at 9:00 p.m.”05/29/18: “Polyethylene glycol...17 gm [gram] (1 packet), g-tube [gastrostomytube], every other day…constipation. Docusate liquid, oral, 200 mg[milligrams/20 ml [milliliters], g-tube, a.m. [morning] constipation.”07/16/18: “Can use colon tube for decompression for abdominal distention dailyprn [as needed].”07/17/18, 8:30 a.m.: “Daily weights. Please inform provider if change of 2 lbs.[pounds] or more daility [daily].”

On 07/17/18 at approximately 1:00 p.m., the resident was observed seated in awheelchair. The resident was able to nod appropriately to simple questions. At 3:20p.m., the resident was observed sleeping while seated in a wheelchair in the resident’sroom, near the side of the bed. The resident was receiving an enteral feeding of “HN[high nitrogen].”During medication administration on 07/18/18 at 9:39 a.m., the RN was observed togently move the gastrostomy tube in various positions to facilitate flow of water anddiluted medications. The RN was asked if there had been any problems with cloggingof the gastrostomy tube and the RN responded, “Not that I know of.”A “PM&R [physical medicine & rehabilitation] Consult” dated 07/17/18, included anaddendum that read, “Abd [abdominal view radiology examination] with single view –03/31/18 – there is extensive fecal material and air suspected throughout the visualizedcolon and extending to the rectosigmoid region, consistent [with] constipation….”On 07/18/18 at 2:05 p.m., the resident’s physician was interviewed regarding theresident’s episode of constipation as noted in the 03/31/18 abdominal view radiologyexamination. The physician indicated the resident was at risk for constipation due toseveral medications that had an “anticholinergic” effect on the resident’s bowelfunction. The physician indicated the resident had orders for bowel medications tomanage the risks of constipation; however, the resident remained at risk forconstipation.On 07/18/18 at 2:20 p.m., the nurse manager, a quality manager, and a registered


dietitian (RD) were interviewed regarding the resident’s bowel habits and monitoring.The RD displayed the daily bowel monitoring in the computerized patient record system(CPRS); the documentation indicated the resident had almost daily bowel movements.The RD indicated she had access to each resident’s bowel history and acknowledgedthat Resident #102 was at risk for constipation. The nurse manager indicated thereshould have been a care plan developed identifying approaches for managing theresident’s history of constipation in consideration of the 03/31/18 abdominal view thatindicated “extensive fecal material and air suspected throughout the visualized colonand extending to the rectosigmoid region, consistent [with] constipation” and theresident’s history of constipation related to medication use.On 07/19/18 at approximately 9:00 a.m., the chief of nutrition and food service and anRD familiar with Resident #102 were interviewed. During the interview, the RD wasunaware that on 03/31/18 the resident was noted to have “extensive fecal material andair suspected throughout the visualized colon and extending to the rectosigmoid region,consistent [with] constipation.” The RD was aware that the resident had medications toassist with bowel management and indicated that if the RD had known about the03/31/18 information, the RD “would have changed [the resident’s] tube feeding to ahigh fiber tube feeding…the one [the resident] has now [HN] doesn’t have sufficientfiber.” The RD acknowledged regularly monitoring the resident’s bowel movements.The RD was not certain as to why the resident would have had “extensive fecalmaterial and air suspected throughout the visualized colon and extending to therectosigmoid region, consistent [with] constipation,” and stated she should have beenadded for co-signature to the note dated 03/31/18.On 07/19/18 at approximately 9:15 a.m., the nurse manager, interim associate chiefnurse for the CLC, attending physician, and CLC medical director were interviewedwhile three quality managers were present. The findings related to the resident’sepisode of constipation on 03/31/18 (as indicated by radiology examination) and thelack of a care plan were discussed with the staff. The nurse manager indicated thatafter it was brought to her attention by the surveyor that there was no care plan toaddress concerns related to constipation, the nurse manager developed a plan of care.The nurse manager indicated that staff monitored bowel movements daily and thisinformation was integrated into nursing assignment sheets.

F312

483.25(a)(3) A resident who is unableto carry out activities of daily livingreceives the necessary services tomaintain good nutrition, grooming,and personal and oral hygiene.

Level of Harm - Actual harm that isnot immediate jeopardy


Based on observation, interview and record review, the CLC did not provide necessaryservices to maintain good nutrition for a resident who was unable to carry out activities ofdaily living. Findings include: Resident #204

Resident #204 was admitted to the CLC on [DATE] with diagnoses includingAlzheimer’s disease. The resident’s comprehensive admission MDS dated [DATE]indicated the resident had severely impaired cognitive skills for daily decision makingbased on staff assessment. According to the MDS, the resident was totally dependenton staff for activities of daily living (ADLs) including eating and had not experienced aweight loss.During the initial tour on 07/17/18 at 9:45 a.m., the charge nurse stated that Resident#204 “has severe dementia and is a choking risk. His wife comes every day and hasbeen approved to feed him. She brings him homemade food from home. He had comeas a respite [admitted needing respite care] but is now long term [receiving long-termcare].”The nutritional assessment dated 06/12/18 indicated the resident’s spouse stated,“Breakfast and Lunch are his better meals as he sundowns [experiences increasedconfusion and restlessness in the evening].” The nutrition assessment stated, “Dietorder geri-soft regular, Ensure Plus 8 oz. [ounces] tid [three times a day]. Possibly givelarger portions at lunch as he does not eat well at dinner.”The resident’s care plan dated 06/14/18 stated, “At risk for choking. [Resident #204]will be fed his meal. He may need tactile cues to his upper lip to open his mouth. Heprefers ketchup on his food. Ensure [nutritional supplement] should be on his tray incase he doesn’t eat the food provided.”The provider’s order dated 07/06/18 stated, “The veteran [resident] should be onchoking precautions. The Veteran is a feeder [requires assistance from staff to eat] andneeds to be fed his meals. The vet [veteran] should have only small amounts of foodplaced into his mouth. The veteran will need to have finger foods added to his meal sothat feeder [food] can be given to him in small [amounts] by hand when he does notwant to eat from a spoon. The veteran will need to be fed his meal. He may needtactile cues to his upper lip to open his mouth….”On 07/17/18 at 3:25 p.m., the resident was observed seated in a Broda chair with his


eyes closed, in the dining room with his spouse seated next to him. When asked aboutthe care of the resident, the spouse stated, “The girls [nursing assistants] try but I amconcerned [about] how much he eats if I’m not here to feed him. I know how to do it.They only do so much. It takes time. I don’t think he has lost weight but I bring things infrom home.”On 07/18/18, at 7:53 a.m., Resident #204 was observed in his room lying in bed; thelights were off, and the resident’s eyes were closed and he appeared to be asleep. At8:15 a.m., a nursing assistant (NA) entered the room with the resident’s breakfast tray.The head of the bed was raised to an approximate 85 degree angle for breakfast. Foodand beverages on the breakfast tray consisted of an omelet, potatoes, cream of wheatcereal, a muffin, and a bowl of mandarin oranges, Ensure (nutritional supplement), milkand a bottle of water. The NA stated, “This is the first time feeding him [the resident]; Iusually work upstairs,” and the NA left the room. The NA returned at 8:25 a.m. to beginto feed the resident. The NA inserted a straw into the Ensure container and held it tothe resident’s mouth; the resident appeared to take a drink. The NA placed a smallamount of cream of wheat on a spoon and the resident accepted three smallspoon-size bites of the cereal. The NA placed ketchup on the omelet and attempted toput it into the resident’s mouth and the resident refused the omelet. The resident’s eyesremained closed and the NA stated to surveyor, “They [staff] said he’s not always agreat eater so I don’t know how long I’ll go [continue attempting to feed the resident].”The resident accepted the straw and took two additional sips of the Ensure. The NAtried to provide another spoon of the cream of wheat, but the resident refused to openhis lips. No additional attempts were made to feed the resident and the NA did notprovide tactile cues to the resident's upper lip to encourage the resident to open hismouth as indicated in the provider’s order dated 07/06/18 and the resident’s plan ofcare dated 06/14/18. At 8:30 a.m., the NA said, “I’m finished for right now. Maybe I’llcome back later and try some more;” the NA removed the tray from the room. At 9:15a.m., nutrition and food service staff removed the meal trays including Resident #204’smeal and carts from the neighborhood. The NA had not returned to the resident’s roomas of 9:47 a.m. when staff entered the resident’s room to prepare the resident for ashower.A typed sheet of paper was signed by the resident’s wife and taped on the wall, withcare instructions. One of the items included stated, “Does not like eggs.”The resident’s weight record indicated the resident weighed 156 pounds on [DATE],146.3 pounds on 07/10/18 and 149.9 pounds on 07/17/18; a 6.1 pound (3.9%) losssince admission.On 07/19/18 at 8:50 a.m. during an interview with the chief of nutrition and food serviceand a dietitian, the dietitian stated, “I was not sure about the weight loss but it [theresident’s weight] had gone down a bit. His wife brings him things in from home, suchas salmon and potatoes.” The dietitian stated she monitors the resident’s weight andnutrition and “relies on the ADL notes in the record.” The chief of nutrition and foodservice and dietitian did not recall that additional food items were requested forResident #204 following the breakfast meal on 07/18/18. According to the dietitian, theresident needed 30 or more minutes to eat and the resident’s lips needed to be“massaged to get him to open his mouth.” The dietitian stated finger foods were addedto the resident’s meal tray such as sandwiches.The resident’s ADL note dated 07/18/18 was provided by the quality manager on07/19/18 at 7:45 a.m. According to the ADL record, on 07/18/18 the resident consumed“75% of breakfast and lunch meals.” It was indicated the NA who assisted the residentduring the meal was not the NA that documented the percent consumed by theresident. (See Clinical Records).In summary, on 07/18/18, an NA providing dining assistance for Resident #204 stated,“This is the first time feeding him [the resident]; I usually work upstairs,” and she left theroom; the NA returned at 8:25 a.m. to begin to feed the resident. The NA inserted astraw into a container with Ensure (nutritional supplement) and held it to the resident’smouth; the resident appeared to take a drink. The NA placed a small amount of creamof wheat on a spoon and the resident accepted three small spoon-size bites of thecereal. The NA placed ketchup on the omelet and attempted to put it into the resident’smouth but he refused the omelet. The resident’s eyes remained closed and the NAstated to surveyor, “They [staff] said he’s not always a great eater so I don’t know howlong I’ll go [continue attempting to feed the resident].” The resident accepted the strawand took two additional sips of the Ensure. The NA tried to provide another spoon ofthe cream of wheat but the resident refused to open his lips. No additional attemptswere made to feed the resident and the NA did not provide tactile cues to the resident’supper lip to encourage the resident to open his mouth as indicated in the provider’sorder dated 07/06/18 and the resident’s plan of care dated 06/14/18. The NA removedthe resident’s meal tray from the resident’s room at 8:30 a.m. (5 minutes after the NAbegan feeding the resident). Finger foods were not provided on the meal tray asindicated in the provider’s order other than a muffin that was not offered to the resident.The resident’s weight record indicated the resident weighed 156 pounds on [DATE],


146.3 pounds on 07/10/18 and 149.9 pounds on 07/17/18; a 6.1 pound (3.9%) losssince admission.

F314

483.25(c) Pressure Sores. Based onthe comprehensive Assessment of aresident, the facility must ensure that(1) A resident who enters the facilitywithout pressure sores does notdevelop pressure sores unless theindividual’s clinical conditiondemonstrates that they wereunavoidable; and (2) A residenthaving pressure sores receivesnecessary treatment and services topromote healing, prevent infectionand prevent new sores fromdeveloping.



Based on observation, interview and record review, the CLC did not ensure that two residentswho entered the CLC without a pressure ulcer received services to prevent development of apressure ulcer. Findings include: The CLC policy titled, “Protocol for Prevention of Pressure Ulcers,” and dated January 26,2016, was provided by the quality manager on 07/18/18. Attachment C Guidelines forPreventing Skin Breakdown Factors at Risk stated, “(1) Pressure a. Pressure Reducing Foammattress….d. place pillows between legs/ankles/knees to maintain alignment and preventbony prominences from touching….(3) Protect Heels a. support entire leg with pillows to allowheels to float above the mattress…provide heel protectors….6) Friction/Sheer- Elevate headof bed 30 degrees or less to prevent sliding down in bed. Protect elbows/heels.” The policyidentified the use of the Braden Scale with scores, “13-15 moderate risk, 10-12 high risk, 9 orbelow very high risk.” In addition, the policy stated, “ NOTE: Specialty mattresses do notsubstitute for turning and positioning [emphasis not added].” Resident #102

Resident #102 was originally admitted to the CLC on [DATE] with diagnoses thatincluded stroke and dementia. The resident was readmitted to the CLC on [DATE]following acute care hospitalization for pneumonia.The annual MDS dated 11/28/17 indicated Resident #102 was severely cognitivelyimpaired as determined by staff assessment; dependent upon one staff person for bedmobility, transfers, and hygiene; incontinent of bowel and bladder; and was at risk ofdeveloping pressure ulcers. According to the 11/28/17 MDS, the resident had nopressure ulcers. The most recent quarterly MDS dated 05/15/18 was similarly codedand there were no changes in the above noted care areas. Both assessments werecoded to indicate the resident had pressure reducing devices for the chair and bed.Resident #102’s care plan with a review date of 07/06/18 included a statement dated09/13/17 that read, “[Resident #102] has limited mobility and is incontinent whichmakes him at risk for skin breakdown.” Approaches dated 09/13/17 included, “Will usepillows to separate pressure points when in bed…Z-Flex booties while inbed…sometimes kicks [the Z-Flex] boots off.”There were no provider’s orders related to pressure ulcer prevention.On 07/17/18 at approximately 11:00 a.m., the resident was observed seated in atilt-in-space wheelchair (as indicated by the nurse manager); the resident was sitting infront of the entrance to the resident’s room and directly across from the nursing station.The tilt-in-space wheelchair was positioned at 45 degrees and the resident was sittingon a pressure reducing cushion. The resident was wearing socks and sneakers.On 07/17/18 at approximately 1:00 p.m., the resident was observed seated in the sameposition and location as noted at 11:00 a.m. and when the surveyor attempted tointerview the resident, the resident nodded appropriately to simple questions. Atapproximately 1:45 p.m., the resident was seated in the same position and location andan individual that indicated she was the resident’s sister was visiting the resident at inthe same position and location.On 07/17/18 at 3:20 p.m., the resident was observed sleeping while seated in the sameposition as noted at 1:00 p.m. in the wheelchair in the resident’s room. The residenthad socks and sneakers on both feet. On 07/17/18 between 11:00 a.m. andapproximately 4:00 p.m., the resident was seated in the wheelchair on a pressurereducing cushion. While the back of the wheelchair had been adjusted, the residentremained in a seated position and had no offloading to the sacrum. The resident’s chairwas positioned at 45 degrees.On 07/17/18 at approximately 4:03 p.m., the resident was awake and observed sittingin the same position in the wheelchair in his room; the wheelchair was positioned atapproximately 45 degrees. When the surveyor entered the room, the resident noddedappropriately to conversation and attempted to move his head to the right to see thetelevision weather alert. A nursing assistant (NA) was interviewed and indicated thatonce the resident’s tube feeding was completed, the NA would “put him in bed.” TheNA stated the resident would generally sit up in the wheelchair during the daytime.On 07/18/18 at 7:50 a.m., Resident #102 was observed lying in bed with the head ofthe bed positioned at approximately 45 degrees while the resident appeared to besleeping. The resident’s heels rested directly on the mattress surface; the resident waswearing white cotton socks. There were no Z-flex booties or other pressure reducingboots observed in the resident’s room and pillows were not used to separate pressurepoints as indicated in the care plan. During hygiene care at approximately 8:30 a.m.,the resident’s sacrum and bilateral heels and feet were observed; the resident had no


areas of skin breakdown. After examining the resident’s heels and toes, the NAreplaced the resident’s socks. The heels of the resident’s feet rested directly on themattress. The resident’s heels were not floated, and no boots were applied or observedin the resident’s room.On 07/19/18 at 7:35 a.m., Resident #102 was observed lying in bed with both heelsresting directly on the mattress. Following the observation, the night shift RN and theday shift RN were interviewed and asked about the resident’s heels resting directly onthe mattress, the night shift RN stated, “They [the resident’s heels] should be elevatedoff the mattress.” The day shift RN entered the resident’s room and elevated both ofthe resident’s heels on pillows. There were no Z-flex boots or other pressure reducingboots observed in the resident’s room.On 07/19/18 at approximately 9:15 a.m., the nurse manager, interim associate chiefnurse for the CLC, attending physician, and CLC medical director were interviewedwhile three quality managers were present. When the findings related to the resident’spositioning and heels resting directly on the mattress were discussed, the nursemanager indicated that the type of mattress referred to as a “Sizewise®” mattress didnot require heels to be offloaded; the nurse manager stated the mattress had a “specialsurface…[with] air distribution.” The mattress was observed with controls for automaticpressure adjustment. When asked about the Z-flex boots, the nurse manager indicatedthat the resident would “kick them off.”In summary, on 07/17/18, 07/18/18 and 07/19/18 when Resident #102 was observedsitting in a tilt-in-space wheelchair, the chair was positioned at 45 degrees and theresident was not repositioned. On 07/18/18 at 7:50 a.m., Resident #102 was observedlying in bed with the head of the bed positioned at approximately 45 degrees. Theresident’s heels rested directly on the mattress surface; there were no Z-flex booties orother pressure reducing boots observed on the resident’s feet or in the resident’s roomand pillows were not used to separate pressure points as indicated in the resident’splan of care. During hygiene care at approximately 8:30 a.m., the resident’s sacrumand bilateral heels and feet were observed; the resident had no areas of skinbreakdown. After examining the resident’s heels and toes, the NA replaced theresident’s socks. The heels of the resident’s feet rested directly on the mattress. Theresident’s heels were not floated, and no boots were applied or observed in theresident’s room. Staff did not consistently use pillows to separate pressure points orplace Z-Flex booties on the resident’s feet when the resident was in bed as indicated inthe resident’s plan of care.

Resident #204

Resident #204 was admitted to the CLC on [DATE] with diagnoses that includedAlzheimer’s disease. The resident’s admission MDS dated [DATE] was coded toindicate the resident had severely impaired cognitive skills for daily decision makingbased on staff assessment and was totally dependent on staff for activities of dailyliving, including bed mobility. According to the [DATE] MDS, the resident was at risk ofdeveloping pressure ulcers and had no pressure ulcers; treatments coded on the MDSincluded a pressure reducing device for the chair and a turning/repositioning program.The care plan dated 06/14/18 included a statement that read, “[Resident #204] at riskfor skin breakdown. Provide incontinent care every 2 hours and prn [as needed],weekly skin assessment, barrier cream with each change, air mattress, turn and repo[reposition] every 2 hours.”The most recent skin assessment dated 07/11/18 included a Braden Scale forPredicting Pressure Ulcer risk score of 13 indicating moderate risk. The skinassessment indicated, “The pressure ulcer protocol was implemented;” interventionsincluded, “Pressure Redistribution measures: turn and reposition every 2 hours while inbed using pillows to separate pressure areas, elevate heels using pillows or foamblocks, raise the knees when elevating the head of the bed, encourage eating withmeals.”On 07/18/18, at 7:53 a.m., Resident #204 was observed in the resident’s room lying inbed. The lights were off and the resident’s eyes were closed; the resident appeared tobe asleep. The head of the bed was elevated approximately 75 degrees. The resident’shead was off the pillow and the resident was leaning against the left padded side rail.The resident was lying on his back with his knees together and would raise and lowerhis legs frequently, rub his heels against the sheet and at times place one ankle overthe other. The resident was not wearing heel protection and did not have pillowsbetween his legs. At 8:15 a.m., a nursing assistant (NA) entered the room with theresident’s meal tray. The NA set the tray down and said, “I need to go get help to get[the resident] up, [the resident] slid down [in the bed].” The NA and another NAreturned to the resident’s room, repositioned the resident in the bed, and raised thehead of the bed to an approximate 85-degree angle for breakfast. The NA removed theresident’s meal tray and left the room at 8:30 a.m., after lowering the head of the bedto approximately 55 degrees. The resident was not repositioned and the resident wasleaning to the left with the resident’s head half off the pillow and resting on the


mattress. The resident’s eyes remained closed during the observation. The residentremained in this position and continued to slide down in the bed until 9:47 a.m., when athird NA entered the resident’s room stating that the resident was going to receive ashower.On 07/19/18 at 7:20 a.m., the resident was observed lying in bed. The head of his bedwas flat and the resident appeared to be asleep with his eyes closed. The resident waslying on his back with heels resting directly on the mattress. The resident did not havepillows between his legs and his feet were bare. The NA that worked the night shiftindicated the resident had a pillow on the left side of the bed and said, “[The resident]leans to the left but doesn’t have any pillows between [the resident’s] legs or feetbecause [the resident] moves his legs around so much in bed. He is constantlykicking.”

F318

483.25(e)(2) Range of Motion. Basedon the comprehensive assessment ofa resident, the facility must ensurethat: A resident with a limited range ofmotion receives appropriatetreatment and services to increaserange of motion and/or to preventfurther decrease in range of motion.



Based on observation, interview and record review, the CLC did not provide appropriatetreatment and services to increase and/or prevent further decrease in a resident’s range ofmotion. Findings include: Resident #102

Resident #102 was originally admitted to the CLC on [DATE] with diagnoses includingstroke, dementia, and seizure disorder. The resident was readmitted on [DATE]following hospitalization for pneumonia.On 07/17/18 at approximately 9:50 a.m., an RN identified as the charge nurse, wasinterviewed during the initial tour, while the nurse manager and quality managers werepresent. The charge nurse indicated Resident #102 had a history of stroke anddementia, required the use of a tracheostomy and a gastrostomy tube, hadcontractures of the hands and required the use of a left hand mitt to prevent theresident from removing the resident’s tracheostomy and gastrostomy tube.The resident’s annual MDS dated 11/28/17 and quarterly MDS dated 05/15/18indicated Resident #102’s cognition was severely impaired for daily decision makingbased on staff assessment and the resident had fluctuating periods of altered levels ofconsciousness. According to the MDS, the resident did not reject care; was dependenton one staff person for bed mobility, transfers, and hygiene; did not experience pain;had a tracheostomy and did not have a restorative nursing program in place. Theannual MDS indicated the resident did not use a restraint; the quarterly MDS indicatedthe resident used a restraint that was coded as “other.” Both assessments indicated theresident had functional limitations in range of motion in the upper and lower extremities.The resident’s care plan with a last review date of 07/06/18 included (but was notlimited to) the following:

09/13/17 – “Restorative Nursing….Passive ROM [range of motion] 15minutes/day....” An approach dated 06/26/18 stated, “Position elbow with pillowto foster extension….Gently open fingers before replacing rolled washcloth andmitt.” The note did not specify the left or right elbow.

An occupational therapy (OT) consult note dated 06/23/18 stated, “Please evaluate forsplint for left hand and arm to prevent contractures. This therapist very familiar withrequests for splinting over the years. [Resident #102] presents with limited elbowextensions which appears to have tone. ? [questionable] resistance with efforts atPROM [passive range of motion]…wrist also present with significant tightness of thewrist flexor with increased tone…when hand taken out of mitt, towel roll inplace…efforts to open fingers resulted in significant discomfort for Veteran so OTstopped and replaced towel roll. OT recommends…use rolled washcloths.”Provider orders included the following:

06/25/18 – “Position with pillow to foster left elbow extension…for left elbowwrist and gentle efforts to open fingers with hold before replacing rolledwashcloth (at least daily) – continue use of rolled washcloths under mitt as thiswill also allow for frequent changes and light skin debridement withreplacement.”07/17/18 written at 9:52 a.m. – “Please put soft splint on left hand. Skin assesevery shift.”

A PM&R (physical medicine and rehabilitation) consult note dated 07/17/18 at 3:50p.m. stated, “Asked to evaluate pt. [patient] for splinting of LUE [left upperextremity]…spoke with provider and OT [occupational therapy]. Pt. has periods inwhich he is more alert and is noted to have increased tone in LUE…has full ROM inLUE except digits 3-5 at mcp [metacarpophalangeal joints]. No pain with ROM, no skinbreakdown in left palm.” The note further indicated, “After speaking with the OT, itwould seem that the pt. has a different exam when more alert…seems to have moretone in the LUE, especially the elbow….Pt. may benefit from a foam block at the elbowto help prevent a contracture…should continue with the palm roll [rolled washcloth] to


help prevent further finger contraction.” The PM&R consult did not address theresident’s right hand contracture.On 07/17/18 at approximately 11:00 a.m., the resident was observed sitting in atilt-in-space wheelchair in front of the entrance to his room and directly across from thenursing station; the resident had a mitt placed over the left hand with mesh thatpermitted visualization of the top of the hand and revealed a rolled washcloth in theresident’s hand. The right hand had a rolled washcloth in place. At approximately 1:00p.m., the resident was observed in the same position and location, and when thesurveyor attempted to interview the resident, the resident nodded appropriately tosimple questions; the resident was not observed moving the upper extremities. Thecharge nurse was interviewed at the same time and indicated the resident required thewashcloths in each hand because of contractures, and the left hand mitt was in userelated to a history of trying to pull out his gastrostomy or tracheostomy tubes. At 3:20p.m., the resident was observed sleeping while in the wheelchair that was located inthe resident’s room; a tube feeding was infusing through the resident’s feeding tube.The resident’s left hand had a light blue colored splint without the mitt and the righthand had a rolled washcloth in place. The resident did not have pillows placed underhis elbow as indicated in the plan of care when observations were made at 11:00 a.m.,1:00 p.m., and 3:20 p.m.On 07/18/18 at 7:50 a.m. Resident #102 was observed lying in bed with the head ofthe bed positioned at approximately 45 degrees while the resident appeared to besleeping. The resident had a light blue, soft splint in place on the left hand and the righthand had a rolled washcloth in place. The resident did not have a foam block or pillowsunder the left elbow.On 07/18/18 at approximately 9:39 a.m., an RN was observed administeringmedications through the resident’s G-tube. When asked about the resident’s left handlight-blue colored soft splint, the RN stated, “[The resident] has this because of thecontracture to his hand.” When asked if a protective splint could be used in the righthand, the RN stated, “I don’t think so” and indicated that a rolled washcloth was to beutilized in the right hand to prevent further contracture. The resident did not have afoam block or pillows placed under the left elbow.On 07/18/18 at 2:15 p.m., Resident #102 was observed seated in a wheelchair insidehis room. The resident did not have a foam block or pillows under the left elbow.On 07/19/18 at approximately 9:15 a.m., the nurse manager, interim associate chiefnurse for the CLC, attending physician, and CLC medical director were interviewed,while three quality managers were present. When asked what was addressed in theplan of care to protect the resident’s right hand from further contracture, the attendingphysician indicated that the most recent “OT evaluation did not recommend anychanges to the right hand;” it was not known why the PM&R consult did not addressthe right hand.In summary, on 07/17/18 at approximately 11:00 a.m., 1:00 p.m. and 3:20 p.m. duringobservations, Resident #102 was sitting in a wheelchair; the resident did not havepillows placed under the left elbow as indicated in the plan of care that stated, “Positionelbow with pillow to foster extension….,” and as recommended in an occupationaltherapy (OT) consult note dated 06/23/18 and a PM&R consult note dated 07/17/18 at3:50 p.m.; the consult notes did not address the contracture of the resident’s righthand. The PM&R consult note dated 07/17/18 at 3:50 p.m. stated, “….Pt. may benefitfrom a foam block at the elbow to help prevent a contracture.” On 07/18/18, Resident#102 was observed lying in bed; the resident had a light blue, soft splint in place on theleft hand and the right hand had a rolled washcloth in place. The resident did not havea foam block or pillows under the left elbow. On 07/18/18 at approximately 9:39 a.m.,an RN was observed administering medications through the resident’s G-tube. Whenasked if a protective splint could be used in the right hand, the RN stated, “I don’t thinkso” and indicated that a rolled washcloth was to be utilized in the right hand to preventfurther contracture. The resident did not have a foam block or pillows placed under theleft elbow. On 07/18/18 at 2:15 p.m., Resident #102 was observed seated in awheelchair inside his room; the resident did not have a foam block or pillows under theleft elbow. Although staff placed a washcloth in the resident’s right hand, it was notevident the CLC conducted a comprehensive assessment including development of aplan of care to address the contracture of the hand.

F323

483.25(h)(2) The facility must ensurethat: Each resident receives adequatesupervision and assistance devices toprevent accidents.

Based on observation, interview and record review, the CLC did not ensure two residentsreceived adequate supervision to prevent accidents. Findings include: Resident #102

Resident #102 was originally admitted to the CLC on [DATE] with diagnoses includingstroke, dementia, and seizure disorder; an RN observed providing care for the resident




during the survey indicated she was not aware of recent seizures. The resident wasreadmitted to the CLC on [DATE] following acute care hospitalization for pneumonia.The resident’s annual MDS dated 11/28/17 and quarterly MDS dated 05/15/18indicated Resident #102 had severely impaired cognitive skills for daily decisionmaking based on staff assessment and the resident had fluctuating periods of alteredlevels of consciousness. According to the MDS, the resident did not reject care; andwas dependent on one staff person for bed mobility, transfers, and hygiene.The resident’s care plan with a last review date of 07/06/18 included a statement dated06/17/18 that indicated the resident had a history of falling and “sometimes he slidesout of bed and wheelchair…[Resident #102] slid out of his wheelchair, no injurysustained.” “A note dated 09/13/17 on the care plan stated, “…continues tooccasionally slide out of his bed to floor. No major injuries from recent falls,” withapproaches that included “landing strips, has hipsters to wear OOB [out of bed],pressure alarm on wheelchair and bed for safety…watches TV and listens to music todistract him.” During the survey, these approaches (other than hipsters) were observedbeing implemented. Approaches dated 06/21/18 stated, “Keep [Resident #102] out ofhis room when he is in wheelchair so he is in a common area. Staff will tilt…wheelchairto prevent him from sliding out accidentally. It is not a restraint as Veteran cannotself-transfer or walk.”The post fall notes for the following dates indicated:

06/16/18 at 3:45 p.m. – Resident #102 experienced an unwitnessed fall from thewheelchair onto the foot rests of the wheelchair while in his room. The notestated the resident had “redness to right anterior axillary/shoulder, left buttock,left back.” The Morse Fall Scale score was 30 suggesting moderate risk forfalling. The note further indicated, “I fell because…I rock and slide in mychair…make sure my chair is tilted and alarms are on and functioning.” After thefall, the plan of care was not updated until 06/21/18 to indicate the chair shouldbe tilted.06/18/18 at 9:45 a.m. – Resident #102 experienced an unwitnessed fall whenthe resident “fell out of bed while attempting to transfer self…no injury.” The planof care was updated on 06/21/18 to indicate staff was to keep the resident “outof his room when he is in wheelchair so he is in a common area;” additionalapproaches were not added to address falls from bed.06/27/18 at 2:20 p.m. – Resident #102 experienced an unwitnessed fall frombed and was “found on the floor on the floor matt by side of bed, fell out ofbed…no injury;” no new approaches were added to the resident’s plan of carefollowing the fall.

On 07/17/18 at approximately 9:50 a.m., an RN identified as the charge nurse, wasinterviewed during the initial tour, while the nurse manager and quality managers werepresent. The charge nurse indicated Resident #102 had a history of stroke anddementia.On 07/17/18 at approximately 11:00 a.m., Resident #102 was observed sitting in atilt-in-space wheelchair in front of the entrance to the resident’s room and directlyacross from the nursing station; the back of the chair was positioned at 45 degrees. Agreen-colored chair alarm device was observed secured to the back of the chair and atab alarm was clipped to the resident’s gown.On 07/17/18 at approximately 1:00 p.m., the resident was observed sitting in the sameposition and location as noted at 11:00 a.m. At 3:20 p.m., the resident was observedsleeping while sitting in the wheelchair in the resident’s room; the resident wasreceiving a tube feeding. The resident’s chair was positioned with the back of the chairat 45 degrees and the resident could be viewed from the nursing station desk where aneighborhood staff clerk was seated. At approximately 4:03 p.m., the resident wasobserved to be awake, seated in the same position in the wheelchair as observed at3:20 p.m., and was tapping his feet as if to music. When the surveyor entered theroom, the resident nodded appropriately to conversation and when the topic of stormyweather was raised, the resident attempted to move his head to the right to see thetelevision weather alert.On 07/18/18 at 7:50 a.m. Resident #102 was observed lying in bed with the head ofthe bed raised approximately 45 degrees; the resident appeared to be sleeping. Thetop side rails were elevated with anti-seizure pads in place; there were floor mats onboth sides of the bed.On 07/18/18 at 2:15 p.m., Resident #102 was observed seated in a wheelchair in theresident’s room and reclined to a 45-degree position. The resident’s feet were visiblefrom the hallway outside the resident’s room. The resident had a humidified oxygencollar in place over the tracheostomy and a tube feeding was infusing during theobservation.On 07/19/18 at approximately 9:15 a.m., the nurse manager, interim associate chiefnurse for the CLC, attending physician, and CLC medical director were interviewed,while three quality managers were present. The observations of the resident in hisroom in the wheelchair were shared with the team; information from the resident’s plan


of care that indicated the resident was to be out of the room and in a “common area”when up in the wheelchair was also shared with staff. The nurse manager stated that“common area” did not include the resident’s room. During the meeting, the nursemanager indicated that the wheelchair used by the resident was adjustable and theseating in the chair would prevent the resident from sliding out of the chair since theresident’s buttocks would be at the “center of gravity.” When asked for additionalinformation regarding how the resident fell from the wheelchair, no additionalinformation was provided. A quality manager indicated that the incident reports relatedto the resident’s falls were not available to the surveyor for review.In summary, Resident #102 was observed sitting in a tilt-in-space wheelchair during thesurvey; the chair was positioned at 45 degrees. On 07/17/18 at 3:20 p.m., the residentwas observed sleeping while sitting in the wheelchair in the resident’s room. Althoughthe resident was visible from the nursing station desk where a neighborhood staff clerkwas seated, the resident was not in a common area (outside the resident’s room) whilein the wheelchair. At approximately 4:03 p.m., the resident was seated in the sameposition in the wheelchair as observed at 3:20 p.m. On 07/18/18 at 2:15 p.m., Resident#102 was observed seated in a wheelchair in the resident’s room. The resident’s feetwere visible from the hallway outside the resident’s room. The resident had three fallssince 06/16/18. On 06/16/18 at 3:45 p.m., Resident #102 experienced an unwitnessedfall from the wheelchair onto the foot rests of the wheelchair while in his room with“redness to right anterior axillary/shoulder, left buttock, left back.” After the fall, the planof care was not updated. On 06/18/18 at 9:45 a.m., the resident experienced anunwitnessed fall when the resident “fell out of bed while attempting to transfer self…noinjury.” The plan of care was updated on 06/21/18 to indicate staff was to keep theresident “out of his room when he is in wheelchair so he is in a common area;”additional approaches were not added to the plan of care to address falls from bed. On06/27/18 at 2:20 p.m., the resident experienced an unwitnessed fall from bed and was“found on the floor on the floor mat by side of bed, fell out of bed…no injury;” no newapproaches were added to the resident’s plan of care following the fall. It was notevident the CLC conducted a thorough assessment to determine causal andcontributing factors to the resident’s falls (e.g., attempts to get to the bathroom,boredom, hunger) and develop approaches to address the cause.

Resident #203

Resident #203 was admitted to the CLC on [DATE] with diagnoses including dementiawith behavioral disturbances and a history of falls. The quarterly MDS dated 06/13/18indicated the resident had severely impaired cognitive skills for daily decision makingbased on staff assessment, had no falls, and used a bed and chair alarm daily.On 07/17/18 at 9:45 a.m., the charge nurse stated that Resident #203 “has not hadfalls and uses a wheelchair without foot pedals as he is able to wheel himself around.”An occupational therapy consult dated 06/04/18 indicated the reason for the consultwas related to a “Velcro with alarm belt for wheelchair, dementia.” The OT consultindicated, “The veteran [Resident #203] was asked if he could buckle and unbuckle thecurrent auto style seat belt which was attached to his wheelchair but not in use. Thevet was able to do so multiple times and therefore projected that he would be able toremove the Velcro seatbelt alarm as well.” There were no other assessments by OT ornursing related to use of the Velcro belt alarm.The resident’s care plan dated 06/06/18 indicated the resident was at risk for falls andthat alarms were used daily.On 07/17/18 at 3:41 p.m., the resident was observed entering the dining roomself-propelling a wheelchair by using his hands on the wheels and shuffling his feet.The resident was observed wearing a blue Velcro alarm seat belt (the Velcrooverlapped approximately 10 inches at the resident’s waist) and a tab string alarm wasattached to the back of the resident’s chair. The resident was observed touching thebelt and moving it up and down but made no attempts to remove the belt, whilepushing the wheelchair back and forth with his feet.On 07/17/18 at 4:15 p.m., an LPN entered the dining room and was asked about thealarms for Resident #203. The LPN stated, “He just got the [new] belt today [07/17/18],” and attempted to demonstrate how the belt worked. When the belt was released,the alarm did not sound. The LPN tested the tab alarm by removing the tab and thealarm sounded. The LPN said, “Well, the tab alarm is working but not the belt. Heneeds the belt for his safety so that when he goes to stand up the alarm sounds.” Anursing assistant (NA) entered the dining room and attempted to get the belt to work;the NA stated, “I don’t know how to work this one but we need the belt to work. This iswhat we need. He needs the belt.” The NA then looked at the tab alarm that was onthe back of the resident’s wheelchair with the string of the alarm clipped to theresident’s shirt. The NA stated, “This string is way too long. It has to be much shorter”as she attempted to adjust the string to a more purposeful length. The string would notadjust appropriately so the NA wrapped the excess string around the wheelchairhandles; the string was estimated to be about 18 to 24 inches. Another NA entered the


dining room and stated that the resident needed the alarm to work for his safety andthat the nonworking belt would be reported to the nurse.On 07/18/18 at 7:55 a.m., the resident was observed in his wheelchair in front of thenursing station desk. The resident had the Velcro belt across his lap. An NA was askedto test the belt to see if the alarm was working; the alarm did not sound when the beltwas unfastened. The nurse manager approached the NA and said, “Take that [belt] off.It is not working;” the nurse manager removed the belt. The tab alarm remained inplace and attached to the resident. When the resident asked about the belt, the NMstated, “You don’t need that [the belt] today.” The NA said to the surveyor that theresident needed the belt because he would attempt to partially stand before sitting backdown.On 07/19/18 at approximately 9:50 a.m., the NM indicated that the alarms (seat beltwith alarm and tab alarm) had been removed from the resident’s wheelchair. Themedical director added that the length of the string on the tab alarm “posed a hazard,especially to this resident.” No documentation was provided to indicate acomprehensive assessment had been conducted prior to removal of the seat belt or tabalarm and to determine why the resident would attempt to stand from the wheelchair(e.g., lack of comfort, boredom, need to use the bathroom/eat) and to identify otherapplicable approaches.

F325

483.25(i)(1) Nutrition. Based on aresident’s comprehensive assessment,the facility must ensure that aresident: Maintains acceptableparameters of nutritional status, suchas body weight and protein levels,unless the resident’s clinical conditiondemonstrates that this is not possible;



Based on observation, interview and record review, the CLC did not ensure that a residentmaintained acceptable parameters of nutrition status such as body weight. Findings include: The CLC’s policy dated 09/23/16 and titled, “Obtaining and Documenting Weights inCommunity Living Centers”, was provided on 07/18/18 by the quality manager. The policystated, “The Charge RN will review the weights daily and request re-weights if there is adiscrepancy from the week before.” Resident #201

Resident #201 was admitted to the CLC on [DATE] with diagnoses including chroniccongestive heart failure (CHF), type II diabetes, and chronic renal failure. Theresident’s quarterly MDS dated 06/19/18 indicated the resident was independent witheating, had a weight gain of 5% or more in the last month or a gain of 10% or more inthe last 6 months; the resident was not on a prescribed weight loss or weight gainregimen.During the initial tour on 07/17/18 at 10:00 a.m., the charge nurse stated the residenthad a “recent decline and his diet was downgraded. He had a choking sensation and ison a pureed diet which he is now accepting.” When asked about a weight loss, thecharge nurse stated, “I’m not sure; he has CHF and has not been eating well.”The care plan included a statement that read, “Weight on 06/18/18 was 216# [pounds].This is an 11-pound weight gain in the last month.” According to the care plan, theweight gain was resolved on 07/14/18 with an approach that stated, “Pureed diet.”The resident’s weight record indicated the following:

05/21/18 - 204.9# (pounds)05/31/18 - 206.3#06/07/19 - 209.5#06/11/18 - 211.8#06/18/18 - 216#06/28/18 - 216#07/11/18 - 218.207/16/18 - 204.3#

A provider’s order dated 07/05/18 stated, “Change weekly weights. Inform provider ifchange of 3 pounds/week to: twice weekly weights. Inform provider if change of greaterthan 3# between weights or greater than 5# in a week.” The weights were notcompleted twice a week as indicated in the provider’s order dated 07/05/18.A speech therapy consult was completed on 07/02/18 and stated, “The resident has afeeling that he is choking.” A pureed diet with regular liquids was recommended andordered on 07/02/18.The most recent nutritional assessment dated 07/14/18 stated, “Monitor weights/labs/intake, no weight gain greater than 2# in one day or 5# in one week.” There was nodocumentation to indicate why the resident was experiencing weight fluctuations (e.g.,edema, change of scale).Resident #201 was interviewed on 07/17/18 at 12:50 p.m. and said, “I have problemswith my sinus and have phlegm in the back of my throat. I think I had choked on apiece of chicken a few weeks ago and now I am on a soft diet.” The resident did notexpress concerns about the taste or texture of the food and was not sure if he hadgained or lost weight since starting the new (soft) diet.


On 07/18/18, the quality manager confirmed that the resident had not been reweighedfollowing the 13.9 weight loss between 07/11/18 and 07/16/18, and that the providerhad not been notified as indicated in the provider’s order dated 07/05/18.On 07/19/18 at 8:50 a.m., the dietitian and chief of nutrition were interviewed. Thedietitian stated that she learned about a resident’s weight loss “from the nurses when Iam out on the floor or in an email. When there is a weight loss I will ask for a reweigh.”The dietitian indicated she expected to be notified of a weight change “immediately orwithin minutes, for sure less than a day.” The dietitian stated she did not know aboutResident #201’s 13.9 pound weight loss until being informed about the meetingleadership staff had with the surveyor on 07/18/18. The dietitian stated after being toldabout the weight loss, “I asked for a reweigh and the loss identified on 07/16/18 wasaccurate so I ordered supplements to be given.”In summary, Resident #201 weighed 218.2 pounds on 07/11/18 and 204.3 pounds on07/16/18; the resident was not reweighed on 07/16/18 following the weight discrepancyas indicated in the CLC’s policy. The weights were not completed twice a week asindicated in the provider’s order dated 07/05/18. It was not evident the CLC conducteda comprehensive assessment to determine the cause of the weight loss and developapplicable approaches.

F328

483.25(k)(6) Standard: RespiratoryCare



Based on observation, interview and record review, the CLC did not ensure that a residentreceived proper respiratory care. Findings include: Oxygen Administration Resident #102

Resident #102 was originally admitted to the CLC on [DATE] with diagnoses thatincluded stroke and dementia. The resident was readmitted to the CLC on [DATE]following acute care hospitalization for pneumonia.The resident’s comprehensive annual Minimum Data Set (MDS) dated 11/28/17indicated Resident #102 had severely impaired cognitive skills for daily decisionmaking as determined by staff assessment and experienced fluctuating periods ofaltered levels of consciousness. According to the MDS, the resident did not reject care;was dependent on one staff person for bed mobility, transfers, and hygiene; andrequired use of a tracheostomy. The most recent quarterly MDS dated 05/15/18 wascoded similarly and indicated there were no changes in the above noted care areas,although the quarterly MDS indicated the resident was receiving oxygen therapy.Resident #102’s care plan dated 09/13/17 with a review date of 07/06/18, included thefollowing statement, “Humidified oxygen 40% via tracheostomy collar.”A provider’s order dated 07/03/18, indicated, “Renew trach [tracheostomy] suctioningTID [three times daily] and prn [as needed] for increased secretions.” There was noprovider’s order for continuous or PRN humidified oxygen 40% through thetracheostomy collar.On 07/17/18 at approximately 11:00 a.m., the resident was observed seated in atilt-in-space wheelchair in front of the entrance to the resident’s room and directlyacross from the nursing station. The resident was observed with a tracheostomy; awashcloth was placed on the resident’s chest under the tracheostomy to absorbsecretions as reported during staff interview. The resident was not receiving humidifiedoxygen 40% by way of the tracheostomy collar as indicated in the care plan. Theresident was observed at approximately 1:00 p.m., 1:45 p.m., 3:20 p.m., and 4:03 p.m.;the resident was not receiving humidified oxygen 40% by way of the tracheostomycollar during the observations. The resident did not appear to have excessivesecretions and would periodically cough a small amount of mucus out of thetracheostomy onto the washcloth. At 3:20 p.m. the resident was observed sleepingwhile seated in the wheelchair in the resident’s room beside the bed. The resident wasnot receiving humidified oxygen by way of the tracheostomy collar. At approximately4:03 p.m., the resident was observed to be awake and sitting in the wheelchair in theresident’s room. When the surveyor entered the room, the resident noddedappropriately to conversation about the weather and attempted to move his head to theright to see the television weather alert. During the observation, the resident was notreceiving humidified oxygen by way of the tracheostomy collar and had periods ofaudible coughing with mucus production without any signs of distress.On 07/18/18 at approximately 8:00 a.m., Resident #102 was observed in bed receivinghumidified oxygen 40% by way of the tracheostomy collar. On 07/18/18 at 8:05 a.m.the RN that worked the night shift was asked if the resident had a change in conditionthat required the use of oxygen since the resident was not observed receiving oxygenby way of the tracheotomy collar on 07/17/18. The night shift RN responded, “Oh? He


[Resident #102] should always have O2 [oxygen] on.” On 07/18/18 at approximately9:39 a.m. during a medication administration observation, Resident #102 was receivinghumidified oxygen 40% by way of the tracheostomy collar.On 07/18/18 at approximately 4:00 p.m. during the daily meeting with staff, thesurveyor requested clarification regarding Resident #102’s use of oxygen indicatingthat the care plan referenced oxygen use, the resident did not have a provider’s orderfor oxygen use, the resident was not observed using oxygen on 07/17/18, and theresident was observed receiving oxygen by way of the tracheostomy collar on07/18/18.On 07/19/18 at 7:35 a.m., Resident #102 was observed lying in bed; the resident wasnot receiving humidified oxygen through the tracheostomy collar. Two RNs wereinterviewed regarding Resident #102’s use of humidified oxygen. The night shift RNstated, “We got a new [provider] order to check [the resident’s] O2 sats [oxygensaturation rate] and [the oxygen saturation] rate was 99% this morning, so [theresident] doesn’t need it [oxygen].”On 07/19/18 at approximately 9:15 a.m., the nurse manager, interim associate chiefnurse for the CLC, attending physician, and CLC medical director were interviewedwhile three quality managers were present. When the findings related to the resident’soxygen use were discussed, the attending physician stated, “The oxygen was used forincreased secretions or distress…used to moisten the secretions. I wrote an order [on07/18/18, following inquiry by the surveyor] to check the pulse ox [oximetry] to clarify.”The nurse manager acknowledged that a provider’s order would be required for anurse to apply oxygen. No additional information was provided regarding the careplanned approaches and the observations made on 07/17/18 and 07/18/18.On 07/19/18, a quality manager provided a provider’s order dated 07/18/18 at 6:24p.m. that stated, “FiO2 [fraction of inspired oxygen/amount oxygen being delivered]40% prn through trach if pulse ox less than 90% or/and respiratory distress. Start time,NOW.”

F514

483.75(l) Clinical Records. (1) Thefacility must maintain clinical recordson each resident in accordance withaccepted professional standards andpractices that are: (i) Complete; (ii)Accurately documented: (iii) Readilyaccessible; and (iv) Systematicallyorganized.



Based on interview, observation and record review, the CLC did not maintain accuratelydocumented clinical records for one resident. Findings include: Resident #204

Resident #204 was admitted to the CLC on [DATE] with diagnoses includingAlzheimer’s disease. The resident’s admission MDS dated [DATE] indicated theresident required total assistance with eating. The resident’s weight was 156.0 poundson admission ([DATE]) and was 149.9 pounds on 07/17/18.On 07/18/18 at 8:25 a.m., a nursing assistant (NA) was observed feeding the residentthe breakfast meal. The NA fed the resident three small spoons with cream of wheatand several sips of Ensure (nutritional supplement).An activities of daily living (ADL) note for the resident’s meal intake on 07/18/18 wasrequested from the quality manager on 07/19/18 at 7:15 a.m. According to the note, on07/19/18 the resident consumed, “75% of breakfast and lunch meals;” the note wassigned by an NA on 07/19/18 at 7:29 a.m.


Documents

Department of Veterans Affairs Community Living Center Survey … · Elsevier s Clinical Skills obtained on-line on 07/24/18 and titled, Peripherally Inserted Central Catheter: Maintenance