F 0641 - IndianaMDS team was educated on the accurate coding of PRN pain medication 5 day look back...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

PREFIX

TAG

IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

TERRE HAUTE, IN 47802

155772 07/03/2018

COBBLESTONE CROSSINGS HEALTH CAMPUS

1850 E HOWARD WAYNE DR

00

F 0000

Bldg. 00

This visit was for a Recertification and State

Licensure Survey. This visit included a State

Residential Licensure Survey.

Survey dates: June 26, 27, 28, 29, and July 2, and 3,

2018.

Facility number: 011906

Provider number: 155772

AIM number: 201114960

Census Bed Type:

SNF: 31

SNF/NF: 23

Residential: 34

Total: 88

Census Payor Type:

Medicare: 25

Medicaid: 18

Other: 45

Total: 88

These deficiencies reflect State Findings cited in

accordance with 410 IAC 16.2-3.1.

Quality review completed on July 12, 2018.

F 0000 The submission of this plan of

correction does not indicate an

admission by Cobblestone

Crossing Health Campus that the

findings and allegations contained

herein are accurate and true

representation of the quality of

care provided and living

environment provided to the

residents of Cobblestone Crossing

Health Campus. The facility

recognizes its obligation to provide

legally and medically necessary

care and service to its residents in

an economic and efficient manner.

The facility hereby maintains it is

in substantial compliance with the

requirements of participation for

skilled health care facilities. To

this end, the plan of correction

shall serve as the credible

allegation of compliance with all

state and federal requirements

governing the management of this

facility. It is thus submitted as a

matter of statute only. The facility

respectfully request from the

department a desk review for

substantial compliance.

483.20(g)

Accuracy of Assessments

§483.20(g) Accuracy of Assessments.

The assessment must accurately reflect the

resident's status.

F 0641

SS=E

Bldg. 00

Based on record review and interview, the facility

failed to ensure the accuracy of Minimum Data Set F 0641 Corrective Action for Residents

Affected by Deficient Practice:

08/02/2018 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclo

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: G3OZ11 Facility ID: 011906

TITLE

If continuation sheet of 37

(X6) DATE




08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

(MDS) assessments for a diagnosis (Resident

250), pressure ulcers (Resident 6), and pain

(Resident 6, 30, 21,and 36), and anticogulant use

(Resident 47) for 7 of 18 MDS assessments

reviewed.

Findings include:

1. Resident 250's record was reviewed on 6/27/18

at 11:19 a.m. A physician's order, dated 6/9/18,

indicated dicyclomine (an antispasmodic) 10

milligrams (mg) by mouth 3 times a day for irritable

bowel syndrome (IBS) (a spastic colon). The order

was electronically signed by the physician on

6/10/18.

A 5 day admission MDS assessment, dated

6/16/18, indicated the resident was cognitively

intact. There was no diagnosis of IBS indicated on

the assessment.

The resident's profile did not indicate a diagnosis

of IBS.

During an interview, on 6/28/18 at 10:24 a.m., the

MDS Assessment Corporate Support indicated

the IBS diagnosis should have been coded on the

MDS assessment, dated 6/16/18, because the

physician had signed the order. The signed

physician's order for dicyclomine indicated a

diagnosis of IBS. The diagnosis was missed

because it was not on the diagnosis list sent from

the hospital.

A copy of Section I of the Centers for Medicare

and Medicaid Services (CMS) Resident

Assessment Instrument (RAI) Version 3.0

Manual, was provided by the MDS Assessment

Support on 6/28/18 at 10:24 a.m. The manual

indicated, "...Steps for Assessment...1. Identify

MDS with ARD of 6/16/18 was

modified to code IBS. MDS

modification submitted when error

was found. (Res 250)


modified to code stage III PU and

vocalization of pain. MDS

modification submitted when error

was

found. (Res 6)


modified to code did not receive

PRN medication in look back

period. MDS modification

submitted after error was found.

(Res 30)


modified to code vocalization of

complaints of pain. MDS

modification was submitted after

error was found. (Res 21)


modified to code no PRN pain

medication given during 5 day look

back period. MDS modification

was submitted after error was

found. (Res 36)

MDS with ARD 6/14/18 was

modified to code no anticoagulant

received in look back period.

MDS modification was submitted

after error was found. (Res 47)

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G3OZ11 Facility ID: 011906 If continuation sheet of 37




08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

diagnoses: The disease conditions in this section

require a physician-documented diagnosis...in the

last 60 days...."

2a. Resident 6's record was reviewed on 6/28/18 at

9:33 a.m. A quarterly MDS assessment, dated

3/29/18, indicated the resident had a moderate

cognitive impairment and an unstagebale pressure

ulcer (an open sore covered with necrotic tissue).

Diagnoses on the resident's profile included, but

were not limited to, pressure ulcer of the right heel

unspecified stage.

A wound management document, dated 2/11/18,

indicated the resident had a new onset

unstageable pressure ulcer to the right heel.

A wound management document, dated 3/23/18,

indicated the resident had a stage 3 pressure ulcer

(a wound that extends into the fatty layer of tissue

below the skin), that originated on 2/11/18, to the

right heel that had improved.

A physician's order, dated 6/13/18, indicated

cleanse area to right heel with wound cleanser and

pat dry. Apply a thin layer of Santyl (a debriding

treatment) ointment, cover with a foam dressing,

wrap with kerlix (a gauze bandage), and change

daily.

A care plan, dated 5/9/18, indicated the resident

had a pressure ulcer to the right heel.

During an interview, on 6/28/18 at 3:09 p.m., MDS

Coordinator 3 indicated the MDS assessment,

dated 3/29/18, was coded incorrectly. The

pressure ulcer should have been coded as a stage

3 pressure ulcer on the assessment. The last

documented wound assessment during the

All residents receiving PRN pain

medications, Plavix, have pressure

ulcers, active diagnosis, and

dental care plans have the

potential to be affected by the

alleged deficient practice. The

most recent MDS for each

resident will be audited for

accuracy. Each Resident on

Plavix has been audited and no

modifications were needed.

MDS team was educated on the

accurate coding of PRN pain

medication 5 day look back period

and accurate coding of the staff

assessment, MDS 3.0 RAI User's

Manual Ch. 3 section J, pgs J-1-

J-2; correct classifications of

anticoagulants, MDS 3.0 RAI

User's Manual Ch. 3 section N, pg

N-7; accurate staging of pressure

ulcers, MDS 3.0 RAI User's

Manual, Ch. 3 section M, pgs

M-12-M-15; coding active

diagnosis accurately, MDS 3.0

RAI User's Manual, Ch. 3, section

I, pgs I-3- I-4; updating care plans

using following company policy on

comprehensive care plan

guideline.

Assessment support nurse or

designee will audit 5 MDS

assessments and 4 care plans

weekly X 4 weeks for accuracy of

section J, M, and N and dental

accurately care planned, then the








08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

look-back period, dated 3/23/18, indicated the

wound was a stage 3 pressure ulcer. The wound

had previously been an unstageable pressure

ulcer, but that was not the most current

assessment.

A copy of Section M of the Centers for Medicare




Support on 6/29/18 at 9:36 a.m. The manual

indicated, "...M0300C: Stage 3 Pressure Ulcers...3.

Identify all Stage 3 pressure ulcers currently

present...Coding Instructions for M0300C:

M0300C1: Enter the number of pressure ulcers

that are currently present and whose deepest

anatomical stage is Stage 3...."

2b. Resident 6's record was reviewed on 6/28/18 at

9:33 a.m. A quarterly MDS assessment, dated


cognitive impairment and received as needed pain

medication during the look back period. A staff

assessment for pain indicated the resident had not

exhibited any indicators of possible pain,

including, but not limited to, vocal complaints of

pain.


were not lmiited to, pressure ulcer of right heel

unspecified stage.


hydrocodone-acetaminophen (a pain medication)

7.5-325 milligrams (mg) by mouth every 4 hours as

needed for breakthrough pain.

A March 2018 Medication Administration Record

(MAR) indicated the resident received

hydrocodone-acetaminophen 7.5-325 mg once on


sections J, M, and N and dental

accurately care planned, then

the Assessment support nurse or

designee with audit 5 new

assessments bi-weekly for 6

months for accuracy of sections

J, M, and N and dental accurately

care planned.

For quality assurance, the ED or

designee will review audit results

and subsequent corrective action

at least quarterly in the campus

Quality Assurance Committee

meeting. The plan will be revised

as warranted. If increased

problems noted, audit frequency

may increase. If no problems

noted after 6 months, the

frequency of the audits may

decrease.





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

3/25/18, once on 3/26/18, and once on 3/27/18. All

of the administrations were given for resident

complaints of back pain at a 7 out of 10 on the

pain scale.

During an interview, on 6/28/18 at 3:09 p.m., MDS

Coordinator 3 indicated the resident received pain

medication 3 days out of the 5 day look-back

period. The staff assessment for pain should have

been coded as vocal complaints of pain because

the resident had, and was treated for pain, during

the MDS assessment look-back period.

3. Resident 30's record was reviewed on 6/28/18 at

2:41 p.m. A quarterly Minimum Data Set (MDS)

assessment, dated 5/17/18, indicated the resident

received an as needed (PRN) medication for pain.

A review of the medication administration record

(MAR), dated May 2018, indicated the resident

did not receive prn pain medication during the 5

day look back of 5/13/18 through 5/17/18.


were not limited to, muscle weakness.


had complaints of acute pain related to decreased

mobility, generalized discomfort and weakness.



she could not find where the resident received a

prn pain medication during the 5 day look back

period for the quarterly assessment dated 5/17/18.

The assessment was coded incorrectly and

should have indicated the resident did not receive

a prn medication.


9:53 a.m. An admission Minimum Data Set (MDS)





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00


received an as needed (prn) pain medication

during the 5 day look back period. The staff

assessment for pain indicated the resident had no

indicators of pain or possible pain, and no signs

were observed or documented during the 5 day

look back period.

A Medication Administration Record (MAR),

dated April 2018, indicated the resident received

Norco (opioid) 5-325 milligrams (mg) tablet, by

mouth every 4 hours prn for pain on 4/9/18 pain

scale 7, 4/10/18 pain scale 6, 4/11/18 pain scale 8,

and 4/12/18 pain scale 6.


were not limited to, acute pain.



the assessment on the admission MDS

assessment, dated 4/12/18, should have indicated

the resident had vocal complaints of pain.


10:09 a.m. A significant change Minimum Data Set

(MDS) assessment, dated 5/30/18, indicated the

resident received prn pain medication.


(MAR), dated May 2018, indicated the resident

did not receive prn pain medication during the 5

day look back period of 5/26/18 through 5/30/18.


were not limited to, chronic pain.

A care plan, edited 5/31/18, indicated the resident

had pain related to chronic pain, and to administer

medications as ordered.





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00


MDS Coordinator 3 indicated the significant

change MDS assessment, dated 5/30/18, was

coded in error. The resident did not receive a prn

pain medication during the 5 day look back period.

A copy of section J of the Centers for Medicare




Corporate Support on 6/29/18 at 9:36 a.m. The

manual indicated, "...J0100: Pain Management (5

day look back)...Code 1, yes if the resident

received or was offered prn pain medications

during the 5 day look back period....code 0, no if

the resident did not receive or was offered and

declined any prn medications during the 5 day

look back period...J0700:Should the Staff

Assessment for Pain be Conducted?(5 day look

back)...Check J0800B, vocal complaints of pain:

included but not limited to if the resident was

observed to make vocal complaints of pain (e.g.

"that hurts," "ouch," or "stop")...."


2:26 p.m. A quarterly Minimum Data Set (MDS)


received an anticoagulant.


(MAR), dated June 2018, indicated the resident

did not receive an anticoagulant medication.

During an interview, on 6/26/18 at 2:33 p.m., the

MDS Coordinator 3 indicated the resident had not

received an anticoagulant during the 7 day look

back period for the quarterly MDS assessment,

dated 6/14/18, and the assessment was coded in

error.





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

A copy of Section N of the Centers for Medicare




Corporate Support on 7/2/18 at 2:47 p.m. The

manual indicated, "...N0400: Medications

Received...Check E, anticoagulant (e.g., warfarin,

heparin, or low molecular weight heparin): if

anticoagulant medication was received by the

resident at any time during the 7 day look back

period...Do no code antiplatelet medications such

as...clopidogrel here.

3.1-31(c)(1)

3.1-31(c)(2)

3.1-31(c)(13)

483.21(b)(1)

Develop/Implement Comprehensive Care Plan

§483.21(b) Comprehensive Care Plans

§483.21(b)(1) The facility must develop and

implement a comprehensive person-centered

care plan for each resident, consistent with

the resident rights set forth at §483.10(c)(2)

and §483.10(c)(3), that includes measurable

objectives and timeframes to meet a

resident's medical, nursing, and mental and

psychosocial needs that are identified in the

comprehensive assessment. The

comprehensive care plan must describe the

following -

(i) The services that are to be furnished to

attain or maintain the resident's highest

practicable physical, mental, and

psychosocial well-being as required under

§483.24, §483.25 or §483.40; and

(ii) Any services that would otherwise be

required under §483.24, §483.25 or §483.40

but are not provided due to the resident's

F 0656

SS=D

Bldg. 00





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

exercise of rights under §483.10, including

the right to refuse treatment under §483.10(c)

(6).

(iii) Any specialized services or specialized

rehabilitative services the nursing facility will

provide as a result of PASARR

recommendations. If a facility disagrees with

the findings of the PASARR, it must indicate

its rationale in the resident's medical record.

(iv)In consultation with the resident and the

resident's representative(s)-

(A) The resident's goals for admission and

desired outcomes.

(B) The resident's preference and potential for

future discharge. Facilities must document

whether the resident's desire to return to the

community was assessed and any referrals

to local contact agencies and/or other

appropriate entities, for this purpose.

(C) Discharge plans in the comprehensive

care plan, as appropriate, in accordance with

the requirements set forth in paragraph (c) of

this section.

Based on record review, observation, and

interview, the facility failed to ensure accuracy of

a dental care plan for 1 of 1 residents reviewed for

dental (Resident 6).

Findings include:

Resident 6's record was reviewed on 6/28/18 at

9:33 a.m. An annual Minimum Data Set (MDS)


was cognitively intact. The resident was not

edentulous (no natural teeth or dentures).


was at risk for malnutrition related to no natural

teeth or dentures (edentulous).

F 0656Resident #6 care plan was

updated to accurately reflect not

being edentulous.

All residents receiving dental care

plans have the potential to be

affected by the alleged deficient

practice. The most recent MDS for

each resident will be audited for

accuracy and if required, their care

plans updated.

MDS team was educated on the

accurate coding of PRN pain

medication 5 day look back period

and accurate coding of the staff

assessment, MDS 3.0 RAI User's

08/02/2018 12:00:00AM





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

An admission assessment, dated 3/1/18, indicated

the resident had full dentures, upper and lower.

On 6/29/18 at 10:05 a.m., the resident was

observed with both upper and lower dentures in

place. At the same time, the resident indicated she

had both upper and lower dentures.

During an interview, on 6/29/18 at 10:34 a.m., MDS

Coordinator 3 indicated the nutrition care plan

should have said the resident was at risk related

to partial dentures. The care plan should not have

said the resident was completely edentulous.

On 7/2/18 at 10:00 a.m., the MDS Assessment

Corporate Support provided a document titled, "

Comprehensive Care Plan Guideline," and

indicated it was the policy currently being used

by the facility. The policy indicated, "POLICY:

Comprehensive Care Plan Guideline. PURPOSE:

To ensure appropriateness of services and

communication that will meet the resident's needs,

severity/stability of conditions, impairment,

disability, or disease in accordance with state and

federal guidelines. PROCEDURES: ...6.

Comprehensive care plans need to remain

accurate and current...."

3.1-35(a)

Manual Ch. 3 section J, pgs J-1-

J-2; correct classifications of

anticoagulants, MDS 3.0 RAI

User's Manual Ch. 3 section N, pg

N-7; accurate staging of pressure

ulcers, MDS 3.0 RAI User's

Manual, Ch. 3 section M, pgs

M-12-M-15; coding active

diagnosis accurately, MDS 3.0

RAI User's Manual, Ch. 3, section

I, pgs I-3- I-4; updating care plans

using following company policy on

comprehensive care plan

guideline.





section J, M, and N and dental

accurately care planned, then the

Assessment support nurse of




sections J, M, and N and dental

accurately care planned, then

the Assessment support nurse or

designee with audit 5 new

assessments bi-weekly for 6

months for accuracy of sections

J, M, and N and dental accurately

care planned.

For quality assurance, the ED or

designee will review audit results

and subsequent corrective action

at least quarterly in the campus


meeting. The plan will be revised






08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00



noted after 6 months, the

frequency of the audits may

decrease.

483.21(b)(3)(i)

Services Provided Meet Professional

Standards

§483.21(b)(3) Comprehensive Care Plans

The services provided or arranged by the

facility, as outlined by the comprehensive

care plan, must-

(i) Meet professional standards of quality.

F 0658

SS=D

Bldg. 00

Based on record review and interview, the facility

failed to ensure the individual who had

administered insulin recorded the administration

on the resident's Medication Administration

Record (MAR) (Resident 11, and Resident 250),

and failed to notify the physician when insulin

was not given as ordered (Resident 11), for 2 of 5

resident reviewed for unnecessary medication.

Findings include:

1a. Resident 11's record was reviewed on 6/27/18

at 11:21 a.m. Diagnoses from the resident's profile

included, but were not limited to,

type 2 diabetes mellitus (a chronic condition that

affects the way the body processed blood sugar,

glucose).

The resident's Medication Administration Record

(MAR), dated April 2018, indicated the resident's

medication regimen included, but was not limited

to, Humalog Kwik Pen Insulin, administer 6 units

subcutaneous with meals three times a day for

type II diabetes. The MAR indicated a Qualified

Medication Aide (QMA) signature was recorded

for administration on the following dates: 4/13/18,

F 0658 F658

What corrective action(s) will

be accomplished for those

residents found to have been

affected by the deficient

practice

Resident # 11’s has been

assessed and does not display

any complication related to

hypo/hyper glycemia. Resident

#11’s Physician has been updated

on Resident blood

sugars.Qualified Medication

Assistant (QMA’s) and licensed

nurses have been re-educated

regarding proper documenting

administration of medication such

as insulin.

How other residents having the


same deficient practice will be

identified and what corrective

action(s) will be taken

All resident Medication

Administration Records (MAR) will

08/02/2018 12:00:00AM





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

4/16/18, 4/18/18, and 4/20/18.

The resident's MAR, dated May 2018, indicated

the resident's medication regimen included, but

was not limited to, Humalog Kwik Pen Insulin,

administer 6 units subcutaneous with meals three

times a day for type II diabetes. The MAR

indicated a QMA signature was recorded for

administration on the following date: 5/21/18.

The resident's MAR, dated June 2018, indicated




times a day for type II diabetes. The MAR

indicated a QMA signature was recorded for

administration on the following date: 6/12/18.


was at risk for hypo/hyperglycemia related to

diabetes mellitus. An approach, dated 4/16/18,

indicated administer medications per orders.


Director of Health Services indicated the

individual who administered the insulin would be

the one required to sign off on the MAR. QMA's

should not give insulin and should not sign their

name on the administration record that it was

administered.

1b. Resident 11's record was reviewed on 6/27/18

at 11:21 a.m. Diagnoses from the resident's profile

included, but were not limited to,

type 2 diabetes mellitus (a chronic condition that

affects the way the body processed blood sugar,

glucose).

The resident's Medication Administration Record

(MAR), dated April 2018, indicated the resident's

be reviewed to identify if other

residents medications are held

without physician notification and

approval, and to ensure that

Qualified Medication Assistans

(QMA) are not recorded as

signatures for administration of

items such as injections or other

items outside of QMA scope of

practice. If Deficient practices are

identified they will be immediately

corrected.

What measures will be put into

place and what systemic

changes will be made to

ensure the the deficient

practice does not recur

An in-service will be conducted for

license nurses and QMA’s with

focus on proper physician

notification related to holding

medications. The in-service will

also focus on proper signing of the

MAR . The Director of Health

Service (DHS), or designee, will

audit the MAR’s and ensure that

medications are not being held

without proper Physician

notification and that QMA’s are

not signing insulin injections or

other items outside of scope of

practice. The audits of the MARs

will be conducted weekly for 4

weeks and then every other week

for 4 weeks and then monthly

thereafter.

How the corrective action(s)

will be monitored to ensure the





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

medication regimen included, but was not limited

to, Humalog Kwik Pen Insulin, administer 6 units

subcutaneous with meals three times a day for

type II diabetes. The insulin was held on the

following dates due to condition of low blood

sugar: 4/25/18, and 4/28/18

The resident's MAR, dated May 2018, indicated




times a day for type II diabetes. The insulin was

held on the following dates due to condition of

low blood sugar: 5/3/18, 5/12/18, 5/20/18, 5/21/18,

and 5/26/18.

The resident's MAR, dated June 2018, indicated




times a day for type II diabetes. The insulin was

held on the following dates due to condition of

low blood sugar: 6/7/18, and 6/19/18.


was at risk for hypo/hyperglycemia related to

diabetes mellitus. An approach, dated 4/16/18,

indicated administer medications per orders.


Director of Health Services indicated when insulin

was held, the physician should have been

notified, and she could not find where the

physician was notified that the insulin was held.

She indicated she had a call out to the physician

to obtain parameters for when to hold insulin, and

at the time the insulin was held there were no

parameters in place. 2. Resident 250's record was

reviewed on 6/27/18 at 11:19 a.m. A 5 day

admission Minimum Data Set (MDS) assessment,

deficient practice will not

recur, i.e., what quality

assurance program will be put

into place

The results of the audit

observations will be reported,

reviewed, and trended for

compliance through the campus


(QA) for a minimum of 6 months

then randomly thereafter for further

recommendations.





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

dated 6/16/18, indicated the resident was

cognitively intact and received insulin injections 6

days of the look-back period.


were not limited to, type 2 diabetes mellitus (a

disease in which the body's ability to produce or

respond to the hormone insulin is impaired)

without complications.


Humalog (a rapid acting insulin) 100 units

(u)/milliliter (ml), administered subcutaenously

(SQ) before meals and at bedtime per sliding scale

for diabetes mellitus.


Tresiba (a long acting insulin) FlexTouch insulin

pen 200 u/ml, 88 u SQ once daily for diabetes

mellitus type 2.

The Medication Administration Record (MAR),

dated June 2018, indicated a Qualified Medication

Aide's (QMA) signature was recorded for

administration of Humalog on the following dates:

2 doses on 6/12/18, 1 dose on 6/20/18, 2 doses on

6/22/18, 1 dose on 6/25/18, 1 dose on 6/26/18, and

2 doses on 6/27/18. A QMA signature was

recorded for administration of Tresiba on the

following dates: 6/12/18, 6/20/18, 6/22/18, 6/25/18,

and 6/27/18.


was at risk of hypo/hyperglycemia (low or high

blood sugar) related to diabetes mellitus.

Interventions included, but were not limited to,

medication per orders.


Director of Health Services (DHS) indicated the





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

nurse should have signed off the insulin

administration on the MAR. Whoever

administered the medication should have signed

for it on the MAR.

During an interview, on 6/28/18 at 9:11 a.m.,

Licensed Practical Nurse (LPN) 6 indicated QMA's

were not allowed to administer insulin. The nurse

who administered the insulin should have signed

it off on the MAR. The QMA's should not have

signed off insulin on the MAR.

On 6/29/18 at 10:28 a.m., the Clinical Support

provided a document titled, "PREPARATION

AND GENERAL GUIDELINES IIA2:

MEDICATION ADMINISTRATION-GENERAL

GUIDELINES," and indicated it was the policy

currently being used by the facility. The policy

indicated, "Policy: Medications are administered

as prescribed in accordance with good nursing

principles and practices and only by persons

legally authorized to do so...C. Refusals of

Medication...5) Continuous medication refusal

must be reported to the prescriber and there must

be documentation of prescriber notification of

such. D. Documentation (including electronic) 1)

the individual who administers the medication

dose records the administration on the resident's

MAR directly after the medication is given...6) If a

dose of regularly scheduled medication is

withheld, refused, not available, or given at a time

other than the scheduled time (e.g., the resident is

not in the facility at scheduled dose time, or a

starter dose of antibiotic is needed), it is

documented on MAR or in the EHR. An

explanatory note is also entered...."

3.1-35(g)(1)





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

483.25

Quality of Care

§ 483.25 Quality of care

Quality of care is a fundamental principle that

applies to all treatment and care provided to

facility residents. Based on the

comprehensive assessment of a resident, the

facility must ensure that residents receive

treatment and care in accordance with

professional standards of practice, the

comprehensive person-centered care plan,

and the residents' choices.

F 0684

SS=D

Bldg. 00

Based on interview and record review, the facility

failed to ensure adequate bowel protocol

guidelines for a resident with an ineffective bowel

pattern for 1 of 1 resident reviewed for

constipation (Resident 21).

Findings include:

During an interview, on 6/26/18 at 11:05 a.m.,

Resident 21 indicated she had trouble with

constipation (infrequent bowel movements, and

small, hard to pass stool) at times and it caused

her pain, and she did not think she received

anything for constipation.


9:53 a.m. A bowel movement document was

reviewed, and indicated the resident did not have

a bowel movement for greater than 72 hours on

5/29/18, 5/30/18, and 5/31/18, and for greater than

72 hours on 6/11/18, 6/12/18, 6/13/18, and 6/14/18.

A review of physician's orders, dated 4/5/18,

indicated may utilize bowel protocol as needed,

and when needed to enter bowel protocol order

set.

A review of the Medication Administration

F 0684 What corrective action(s) will




practice

Resident #21 was assessed to

ensure that resident is not

displaying any further problems

with bowel pattern or any further

signs and symptoms or

complaints of constipation.

Resident #21’s physician was

updated regarding Resident #21’s

bowel pattern.






All Resident bowel management

documents will be evaluated to

identify any other resident that has

greater than 72 hours of no bowel

movement. If other residents are

identified a bowel assessment

shall be completed, the physician

notified, and the bowel protocol

initiated.

08/02/2018 12:00:00AM





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

Record (MAR), dated May 2018, lacked

documentation a bowel stimulant was

administered.

A review of the MAR, dated June 2018, lacked

documentation a bowel stimulant was

administered.


received diuretic medication related to edema, and

observe for constipation.

A review of events, dated 5/29/18 through 6/1/18

and 6/11/18 through 6/15/18, lacked an ineffective

bowel pattern event.

A review of progress notes, dated 5/29/18 through

6/1/18 and 6/11/18 through 6/15/18, lacked

documentation of bowel sounds.


Clinical Support Consultant indicated the resident

did not have a bowel movement on 5/29/18,

5/30/18, and 5/31/18, 6/11/18, 6/12/18, 6/13/18, and

6/14/18, and no bowel protocol was implemented

and should have been. If a resident does not have

a bowel movement within 72 hours, the bowel

protocol should have been started.

On 7/2/18 at 1:22 p.m., the Clinical Support

Consultant provided a document titled, "Bowel

Protocol Guidelines," and indicated it was the

policy currently being used by the facility. The

policy indicated, "Purpose: To provide guidance

for the use of bowel stimulants for residents with

constipation. Procedures: ...3. The ineffective

bowel pattern event should be initiated for any

resident not having a bowel movement (bm) with

72 hours...a. A progress note associated to the

ineffective bowel event, should be completed until






An in-service will be conducted

with nursing staff with focus on

resident bowel management

programand facility policy

regarding bowel management. The

Director of Health Service (DHS),

or designee, will audit the bowel

management documents and

MARS to ensure that residents

are receiving bowel management

interventions according to policy if

the resident has not had a bowel

movement in 72 hours. The DHS

or designee will also ensure that a

bowel assessment is conducted

and the physician is notified for

any resident identified. The audits

of the bowel management and the

MARs will be conducted weekly

for 4 weeks and then every other

week for 4 weeks and then

monthly thereafter.






into place












08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

the resident has a BM or the bowel pattern returns

to normal for the resident. The progress note

should include abdominal distention, pain, and

bowel sounds. 4. Nursing staff shall assess for

effectiveness, orders my be written as follows; a.

If no bowel movement within 72 hours, 2

tablespoons of natural laxative. b. If no results

within 24 hours, after natural laxative give 300 cc

[mililiters] of milk of magnesia [MOM]. c. If no

results within approximately 12 hours after MOM

administer dulcolax suppository. d. If result of

suppository are not satisfactory within 2 hours

give fleets enema...."

3.1-37(a)

recommendations.

483.25(d)(1)(2)

Free of Accident

Hazards/Supervision/Devices

§483.25(d) Accidents.

The facility must ensure that -

§483.25(d)(1) The resident environment

remains as free of accident hazards as is

possible; and

§483.25(d)(2)Each resident receives

adequate supervision and assistance devices

to prevent accidents.

F 0689

SS=G

Bldg. 00

Based on observation, interview, and record

review, the facility failed to provide supervision of

a resident at high risk of falls when the resident

was ambulaitng which resulted in the resident

failling and obtaining a laceration to her head

requiring hospitalization and 3 staples (Resident

5); and failed to provide an elopement assessment

and supervision for a confused resident (Resident

26) for 2 of 2 residents reviewed for accidents.

Findings include:

F 0689 F 689 Free of Accidents and

Hazards

1.Resident #5’s fall risk was

assessed and interventions

reviewed to ensure appropriator

interventions were in place and the

care plan was updated

accordingly. Resident #26 had an

elopement risk and fall risk

assessment completed.

Interventions were reviewed for

08/02/2018 12:00:00AM





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00


2:40 p.m. An event report, dated 4/23/18 at 2:00

p.m., indicated the resident had a fall in the

doorway of her room. The fall was not witnessed,

and the resident was not injured. An intervention

put in place was to monitor resident closely when

ambulating.

An event report, dated 4/23/18 at 6:40 p.m.,

indicated the resident had a fall in her room while

ambulating. The fall was not witnessed, and the

resident was observed to have a laceration to her

head. The wound was cleansed and pressure

applied.

A progress note, dated 4/23/18 at 6:40 p.m.,

indicated the resident was ambulating around her

room when she fell and hit her head on a tray

table. A 5 centimeter (cm) by 0.5 cm gash was

noted to the back of her head. The Medical

Director (MD) was notified and the resident was

sent to the hospital to be evaluated and treated.

A progress note, dated 4/24/18 at 11:53 a.m.,

indicated the nurse had spoke with the hospital

and the resident would possibly return back to the

facility today with a subdural hematoma.

A review of progress, on 4/24/18, did not indicate

the resident had returned from the hospital.

A progress note, dated 4/25/18 at 9:37 a.m.,

indicated the resident had 3 staples to mid back of

head, with slight bruising noted to the area.

A progress note, dated 5/1/18, indicated the

resident had fallen at approximately 6:40 p.m. on

4/23/18, and hit her head on a bedside table.

Resident was sent out to the hospital and

returned with a diagnosis of subdural hematoma

appropriateness and the care plan

revised accordingly

2.All residents at risk for falls

and elopement have the potential

to be effected. All residents will

have fall risk and elopement risk

assessments completed.

Appropriate interventions will be

implemented as indicated and

care plan revised accordingly.

Nurses will be educated on

completing fall and elopement risk

assessments and initiating

appropriate interventions. Staff will

utilize communication tools to

ensure direct care staff are aware

of interventions in place.

3.As a measure of ongoing

compliance, the DHS or designee

will complete an audit to include

five residents to ensure the fall risk

and elopement risk assessments

are completed per policy,

appropriate interventions are in

place, and communicated to staff.

Said audit will be conducted three

times weekly for 4 weeks, then

weekly for 4 weeks, then monthly

ongoing.

4.For quality assurance, the

DHS or designee will review any

findings and subsequent corrective

action at least quarterly in the

campus quality assurance

meeting. The plane will be revised




noted after six months, the

frequency of audits may decrease.





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

(severe head injury). The resident's table was

removed from her room.


were not limited to, Alzheimer's disease,

orthostatic hypotension, vertigo of central origin,

major depressive disorder, mycolonus, transient

cerebral ischemic attack.


was at risk for falling related to Alzheimer's

disease (a progressive disease that destroys

memory and other important mental function),

orthostatic hypotension (a form of low blood

pressure that happened when standing), vertigo

of central origin (a sensation of feeling off

balance), major depressive disorder (mental health

disorder characterized by depressed mood or loss

of interest), mycolonus (sudden involuntary

muslce jerk), transient cerebral ischemic attack

(brain dysfuction caused by an outside force). An

approach, edited on 6/1/18, encourage resident to

assume standing position slowly.



resident went to the emergency room on 6/23/18

for an injury to the head from a fall. The resident

returned to the facility on 6/24/18 with staples and

a diagnosis of subdural hematoma, and it was not

considered to be a major injury.

During an interview, on 7/3/18 at 1:26 p.m., LPN 7

indicated the resident was a fall risk. She could

not recall the fall that occurred on 4/23/18, and

that when an intervention to monitor the resident

closely when ambulating was put in place, she

would ensure someone had visual on the resident

at all times because the resident would attempt to

stand for no reason and was confused.





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

On 7/3/18 at 11:54 a.m., the Director of Health

Services (DHS) provided a document titled, "Fall

management program Guidelines," and indicated it

was the policy currently being used by the

facility. The policy indicated, "Purpose: Trilogy

Health Services (THS) strives to maintain a hazard

free environment, mitigate fall risk factors and

implement preventative measures...Procedure: ...2.

Should the resident experience a fall the attending

nurse shall complete the "Fall event" this includes

an investigation of the circumstances surrounding

the fall to determine the cause of the

episode,...interventions to reduce risk of repeat

episode...7. Discuss risks and

interventions...communicate interventions during

shift report...."2. Resident 26's record was

reviewed on 7/2/18 at 10:21 a.m. A quarterly

Minimum Data Set (MDS) assessment, dated


cognitive impairment. The resident had no

behaviors, including wandering.

The resident was admitted on 11/8/17.


were not limited to, cognitive social or emotional

deficit following cerebral infarction (blocking or

narrowing of the arteries supplying blood and

oxygen to the brain) and cognitive communication

deficit.

An admission assessment, dated 11/8/17,

indicated the resident was not at risk for

elopement.


resident was agitated and turned on her call light

every half hour to an hour to go to the bathroom.

The resident became upset and cursed at the staff





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

when reminded of the time. The resident did not

believe what time it was even when shown a

clock. Resident stated she would talk to a lawyer.

An Interdisciplinary Team (IDT) note, dated

1/3/18, indicated nursing had reported confusion

and agitation through the night. Resident was

unaware of the time of day. The resident used the

call light multiple times through the night to void,

but was unable to.

An IDT note, dated 1/23/18, indicated nursing

reported increased confusion. The resident

attempted to get up unattended and had not

asked for assistance.

A Clinically At Risk (CAR) Review note, dated

1/25/18, indicated the resident had increased

confusion. The resident was on Buspar (an

anti-anxiety medication) twice daily for anxiety.

The resident's family had noticed a change in her

personality. The resident would be seen by

psychiatric services.

A CAR Review note, dated 2/8/18, indicated the

resident was seen by psychiatric services for

increased agitation and depression. A trial of

anti-depressant medication was recommended.

The physician was notified.

A progress note, dated 2/10/18, indicated a new

order was received for Lexapro (an

anti-depressant medication).


resident was toileted 10 times in a shift with little

or no output. The resident continued to be

unaware of time and the last time she went to the

bathroom. When the Certified Resident Care

Assistant (CRCA) encouraged resident to bend





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

her knees when walking to the bathroom, the

resident became agitated and elbowed the CRCA

in her side and called her a name. The nurse talked

with the resident, but the resident continued to be

upset and agitated.


resident was restless and wanted to go to bed

prior to dinner. The resident was reoriented to the

time of day and agreed to eat dinner.


resident had a Deoxyribonucleic Acid (DNA)

swab (a test to see what medications were most

effective) completed related to increased

delusional behavior.

A Social Services Note, dated 3/1/18, indicated the

resident was seen by psychiatric services on

2/27/18 per the family's request related to

behaviors. The resident called her family multiple

times at work. The resident's anxiety had

increased, and her mood went from crying to

anger. Resident had been very hateful to her

family. A DNA swab was completed.


DNA swab results recommended to discontinue

Lexapro and start Pristiq (an anti-depressant) or

Wellbutrin (an anti-depressant). The physician

was notified.

A progress note, dated 3/13/18, indicated a new

order was received from the physician to

discontinue Lexapro and start Pristiq.


resident had gotten up and down and stated she

thought she heard something and came to see

what it was.





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

An IDT note, dated 5/8/18, indicated nursing

reported the resident was confused, agitated, and

uncooperative with care at times. The physician

was notified.

A Social Services note, dated 5/10/18, indicated

the resident was seen by psychiatric services on

5/8/18 and recommended to increase resident's

anti-depressant. The resident had been very

upset, yelling at staff, and wandering the facility.

The resident recently moved to a different room

and thought someone gave her bed away.


resident was verbally abusive and called the staff

liars. When the staff attempted to provide

incontinent care the resident said, "I can lay in

pee if I want to."


resident was restless at night and started on

Melatonin (a supplement to help with sleep) every

evening.


resident was on Buspar 5 milligrams (mg) twice

daily, which was not effective. The physician was

notified and the Buspar was increased to 10 mg

twice daily.

An IDT note, dated 5/18/18, indicated the resident

had increased agitation and cognitive impairment.

She had increased behaviors, and the Buspar was

increased.

A physician's progress note, dated 5/19/18,

indicated the resident was seen for increased

aggressive behavior. The resident had hit a nurse.

The family reported previous anger issues. Added





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

depakote (a mood stabilizer), added hydroxyzine

(an anti-anxiety medication), and taper off Buspar.

A CAR Review note, dated 5/30/18, indicated the

resident remained able to propel herself

throughout the facility.

A Social Services note, dated 6/10/18, indicated

the resident approached the Director of Social

Services (DSS) at the nurse's station and asked,

"Do you know what I am running from?" The

resident stated, "You know that stroke I had, well

I feel like I am running from something." The

resident was tearful.


resident was seen in the dining room at 5:50 p.m.

The resident left the dining room and was enroute

to her room. At 5:55 p.m., a visitor to the facility

saw the front wheel of the resident's wheelchair

go off the sidewalk, and the resident fell to the

pavement. The visitor ran inside the facility to get

staff. An 8 centimeter (cm) X 4 cm hematoma

(solid swelling of clotted blood in the tissue) was

noted above the left eye with an 8 cm laceration (a

deep cut) down the center. The wound was

bleeding freely. There was a 1 cm X 1 cm skin tear

between the left left third and fourth fingers, and a

2 cm X 1 cm skin tear between the left first and

second fingers. The Executive Director (ED),

physician, and family were notified. A

wanderguard (a device to prevent the resident

from leaving the facility) was placed on the

resident.

An alarm device event, dated 2/5/18, indicated the

resident required an alarm device related to poor

safety awareness threatening the resident's safety

and well-being.





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

A fall with elopement event, dated 6/11/18,

indicated the resident had gone outside to look

for her car. She had fallen outside on facility

grounds. The fall risk re-assessment indicated the

resident forgot to comply with safety measures

and was very impulsive.

Observations from 11/8/17 to 7/2/18 were

reviewed, and no elopement risk re-assessment

was observed.

A Social Services Comprehensive Note, dated

2/7/18, indicated the resident had not wandered.

A Social Services Comprehensive Note, dated

5/8/18, indicated the resident had not wandered.

A sample, undated, elopement risk review

indicated a resident was at risk for elopement if

there was a history of exit seeking, voiced

statements of leaving, or exhibited periods of

pacing, agitation, or wandering toward an exit.

Care plans were reviewed, and documentation

lacked for exit seeking, wandering, and elopement

risk at the time of the elopement.

On 6/26/17 at 10:30 a.m., the front door of the

facility was observed to be unlocked. No code

was required to get in or out of the building.

On 6/28/18 at 2:45 p.m., the resident was observed

propelling herself in her wheelchair out of the

dining room.

On 7/2/18 at 10:17 a.m., the resident was observed

propelling herself in her wheelchair up and down

the hall by the therapy gym.

On 7/3/18 at 8:41 a.m., the resident was observed





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

propelling herself in her wheelchair up the hall,

past the recreation room, and turned into the

therapy gym. The resident sat in the therapy gym

for a short time, then left the gym and continued

toward the dining room.


Assistant Director of Health Services (ADHS)

indicated she was not sure if elopement risk

should have been re-assessed routinely or with a

change.


Director of Health Services (DHS) indicated she

was not sure if elopement risk should have been

re-assessed routinely or with a change.


DHS indicated the policy was for an elopement

risk assessment to be completed quarterly and

with any significant change. The quarterly

elopement risk assessments were not completed.

The social services assessment was completed,

but it only addressed wandering. The resident had

gotten out of the building and had fallen outside.


DHS indicated the elopement risk assessments

were not completed as required by the policy. An

elopement risk assessment would be completed.

During an interview, on 7/2/18 at 3:58 p.m., the ED

indicated she was notified by phone after the

resident got out of the building and fell on

6/11/18. The resident's condition had declined.

The doors of the facility were unlocked during the

day.


DHS indicated the door to the facility was





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

unlocked and opened at will throughout the day.

The door automatically locked and required a

code for entrance and exit from 10:00 p.m. to 6:00

a.m.


DHS indicated the wanderguard automatically

locked the doors and sounded an alarm when a

resident got close to the door. The resident had

always wandered, and it was not a new behavior.

She was unsure why the wandering was not

documented. The only elopement risk assessment

that had been completed was on admission.

On 7/2/18 at 3:55 p.m., the DHS provided a

document titled, "Guidelines: Elopement Risk

Assessment and Prevention," and indicated it was

the policy currently being used by the facility.

The policy indicated, "PURPOSE: The campus

strives to promote resident safety and protect the

rights and dignity of the residents. A process to

assess all residents for risk for elopement,

implement prevention strategies for those

identified as an elopement risk...DEFINITIONS:

Elopements occur when a resident leaves the

premises or a safe area without authorization (i.e.,

an order for discharge or leave of absence) and/or

any necessary supervision to do so. A resident

who leaves a safe area may be at risk (or has the

potential to experience) heat or cold exposure,

dehydration and/or other medical complications,

drowning, or being struck by a motor vehicle.

Wandering refers to a cognitively-impaired

resident's ability to move about inside the facility

aimlessly and without an appreciation of personal

safety needs and who may enter into a dangerous

situation. PROCEDURE: 1. Each resident will be

assessed for elopement risk upon admission,

quarterly, and with change in condition...."





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

3.1-45(a)(2)

483.45(c)(3)(e)(1)-(5)

Free from Unnec Psychotropic Meds/PRN

Use

§483.45(e) Psychotropic Drugs.

§483.45(c)(3) A psychotropic drug is any

drug that affects brain activities associated

with mental processes and behavior. These

drugs include, but are not limited to, drugs in

the following categories:

(i) Anti-psychotic;

(ii) Anti-depressant;

(iii) Anti-anxiety; and

(iv) Hypnotic

Based on a comprehensive assessment of a

resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used

psychotropic drugs are not given these drugs

unless the medication is necessary to treat a

specific condition as diagnosed and

documented in the clinical record;

§483.45(e)(2) Residents who use

psychotropic drugs receive gradual dose

reductions, and behavioral interventions,

unless clinically contraindicated, in an effort

to discontinue these drugs;

§483.45(e)(3) Residents do not receive

psychotropic drugs pursuant to a PRN order

unless that medication is necessary to treat

a diagnosed specific condition that is

documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic

drugs are limited to 14 days. Except as

provided in §483.45(e)(5), if the attending

F 0758

SS=D

Bldg. 00





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

physician or prescribing practitioner believes

that it is appropriate for the PRN order to be

extended beyond 14 days, he or she should

document their rationale in the resident's

medical record and indicate the duration for

the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic

drugs are limited to 14 days and cannot be

renewed unless the attending physician or

prescribing practitioner evaluates the resident

for the appropriateness of that medication.

Based on interview and record review, the facility

failed to ensure an Abnormal Involuntary

Movement Scale (AIMS) test was performed for

residents whom received an antipsychotic

medication for 2 of 5 residents reviewed for

unnecessary medications (Residents 19 and 250).

Findings include:

1. Resident 19's medical record was reviewed on

6/28/18 at 9:44 a.m., a diagnosis included, but was

not limited to, obsessive compulsive disorder

(OCD). Resident 19 was initially prescribed

Risperdal, an antipsychotic medication, on 6/28/17

and currently received the medication twice daily

for the disorder. The medical record lacked

documentation a baseline AIMS test had been

completed, when Resident 19 began the

antipsychotic medication.

A Quarterly Observation and Data Collection

assessment, dated 12/1/17, indicated, incorrectly,

the resident did not receive an antipsychotic

medication and an AIMS test was not completed

for the quarterly assessment.

An AIMS assessment was completed for Resident

F 0758 What corrective action(s) will




practice

Resident # 19 and Resident #250

have had an Abnormal Involuntary

Movement Scale (AIMS)

assessment updated. No

abnormal movements or other

complications identified related to

use of anti-psychotic medications.






All residents receiving

anti-psychotic medications will be

reviewed to ensure that an AIMS

assessment has been completed

and is being updated according to

facility policy. If other residents

are identified with lack of AIMS

assessment, one will be

completed immediately, and will

be updated appropriately.


08/02/2018 12:00:00AM





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

19, on 2/26/18 at 12:39 p.m., 8 months after starting

the antipsychotic medication.

A care plan, dated 5/3/18, indicated, Resident 19

presented with a diagnosis of obsessive

compulsive disorder, which was treated with an

antipsychotic medication with the goal of

Resident's diagnosis would not result in injury to

self or others. Interventions included, but were

not limited to, medication per orders and observe

for side effects and effectiveness of the

medication.

The Minimum Data Set Assessments, dated

11/20/17, 1/08/18, 3/13/18, and 5/01/18, indicated

Resident 19 received an antipsychotic medication

7 days a week on all of the assessments.


Clinical Support Nurse indicated, Resident 19

initially started Risperdal on 6/28/17 and currently

received the medication. The AIMS assessment

should have been done shortly after the initial

start of the antipsychotic medication on 6/28/17

and quarterly, but was missed until 2/26/18.2.


11:19 a.m. A 5 day admission Minimum Data Set

(MDS) assessment, dated 6/16/18, indicated the

resident was cognitively intact and received an

anti-psychotic medication 4 days of the look-back

period.

Diagnoses in the resident's profile included, but

were not limited to, bipolar disorder (a mental

disorder marked by alternating periods of elation

and depression) current episode manic (an

extremely elevated mood) severe with psychotic

features (disorganized thinking or behavior).






An inservice will be conducted for

license nurses with focus on

completion of AIMS assessment

according to facilty policies. The

DHS or designee shall review

records of residents receiving

anti-psychotic medications to

ensure that the AIMS assessment

has been completed according to

facility policy. . The audits of the

anti-psychotic medication and the

AIMS assessment will be

conducted weekly for 4 weeks

and then every other week for 4

weeks and then monthly

thereafter.






into place








recommendations.





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

Latuda (an anti-psychotic) 40 milligrams (mg) by

mouth daily.


received psychotropic medication and was at risk

for developing adverse consequences related to

received an anti-psychotic medication for Bipolar

disorder. Interventions included, but were not

limited to, abnormal involuntary movement scale

(AIMS) test per guidelines.

An admission assessment, dated 6/9/18, indicated

the resident was not on an anti-psychotic and the

AIMS assessment was skipped.

Observations from 6/9/18 to 6/27/18 were

reviewed, and no further AIMS assessments were

observed.

A Medication Administration Record (MAR),

dated June 2018, indicated the resident received

Latuda on 6/13/18, 6/14/18, 6/15/18, 6/16/18,

6/17/18, 6/18/18, 6/19/18, 6/22/18, 6/23/18, 6/24/18,

6/25/18, 6/26/18, 6/27/18, and 6/28/18.



AIMS assessment should have been done on

admission if the resident was admitted on an

anti-psychotic medication. The AIMS assessment

included in the admission assessment should

have been completed.


DHS indicated there was not an AIMS

assessment completed since the resident's

admission. The AIMS assessment was missed

because the admitting nurse had not realized

Latuda was an anti-psychotic medication.





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

On 6/28/18 at 10:32 a.m., Medical Records

provided a document titled, "Guidelines for :

Abnormal Involuntary Movement Scale (AIMS),"

and indicated it was the policy currently being

used by the facility. The policy indicated,

"POLICY: Guidelines for: Abnormal Involuntary

Movement Scale...PURPOSE: To assess residents

that have prescribed antipsychotic medications to

identify symptoms that may indicate the presence

of Tardive Dyskinesia; a neurologic disorder

characterized by abnormal involuntary movements

which may occur as an undesired effect of

dopamine blocking medications...PROCEDURES:

...2. The AIMS assessment will be completed...at

the earliest possible time, either after admission;

after medications listed above are prescribed...3.

The AIMS assessment will be repeated for

residents taking antipsychotic medications every

six (6) months...."

3.1-48(a)(3)

483.80(a)(1)(2)(4)(e)(f)

Infection Prevention & Control

§483.80 Infection Control

The facility must establish and maintain an

infection prevention and control program

designed to provide a safe, sanitary and

comfortable environment and to help prevent

the development and transmission of

communicable diseases and infections.

§483.80(a) Infection prevention and control

program.

The facility must establish an infection

prevention and control program (IPCP) that

must include, at a minimum, the following

elements:

§483.80(a)(1) A system for preventing,

F 0880

SS=D

Bldg. 00





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

identifying, reporting, investigating, and

controlling infections and communicable

diseases for all residents, staff, volunteers,

visitors, and other individuals providing

services under a contractual arrangement

based upon the facility assessment

conducted according to §483.70(e) and

following accepted national standards;

§483.80(a)(2) Written standards, policies,

and procedures for the program, which must

include, but are not limited to:

(i) A system of surveillance designed to

identify possible communicable diseases or

infections before they can spread to other

persons in the facility;

(ii) When and to whom possible incidents of

communicable disease or infections should

be reported;

(iii) Standard and transmission-based

precautions to be followed to prevent spread

of infections;

(iv)When and how isolation should be used

for a resident; including but not limited to:

(A) The type and duration of the isolation,

depending upon the infectious agent or

organism involved, and

(B) A requirement that the isolation should be

the least restrictive possible for the resident

under the circumstances.

(v) The circumstances under which the facility

must prohibit employees with a

communicable disease or infected skin

lesions from direct contact with residents or

their food, if direct contact will transmit the

disease; and

(vi)The hand hygiene procedures to be

followed by staff involved in direct resident

contact.





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

§483.80(a)(4) A system for recording

incidents identified under the facility's IPCP

and the corrective actions taken by the

facility.

§483.80(e) Linens.

Personnel must handle, store, process, and

transport linens so as to prevent the spread

of infection.

§483.80(f) Annual review.

The facility will conduct an annual review of

its IPCP and update their program, as

necessary.

Based on observation, record review, and

interview, the facility failed to ensure infection

control procedures were followed during a

dressing change for 1 of 2 residents reviewed for

pressure ulcers (Resident 6).

Findings include:

On 6/29/18 at 10:05 a.m., Licensed Practical Nurse

(LPN) 6 was observed completing a dressing

change to Resident 6's right heel. LPN 6 used

bandage scissors to cut and remove the soiled

bandage, the bandage scissors were not cleaned

after use. The bandage scissors were placed on

the bedside table without a barrier. After the

soiled dressing was removed, LPN 6 removed her

gloves, and new gloves were applied. Hand

hygiene was not completed prior to donning new

gloves. The ointment was applied to the wound,

and a clean dressing was placed. LPN 6 used the

uncleaned bandage scissors to cut the clean

rolled gauze, which was then used to wrap the

resident's foot and ankle. The rolled gauze was

taped in place.


F 0880 Resident #6 was assessed and

noted to be free of complications

such as signs and symptoms of

infection resulting from lackof

handwashing and lack ofcleansing

bandage scissors during the

dressing change. LPN #6 has

been re-educated on infection

control procedures as they relate

to dressing changes.






Observation of dressing changes

will be observed for all residents

requiring dressing changes, if

facility infection control procedures

are not followed the nursing staff

will immediately be

corrected/re-educated and the

resident assessed for potential

complications.



08/02/2018 12:00:00AM





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

9:33 a.m. A quarterly Minimum Data Set (MDS)


had a moderate cognitive impairment and a

pressure ulcer.


were not limited to, pressure ulcer of right heel

unspecified stage.

During an interview, on 6/29/18 at 11:27 a.m., LPN

6 indicated she should have washed her hands

after she removed the old dressing and before she

donned clean gloves. She forgot to wash her

hands. She should have cleaned her bandage

scissors after she used them to remove the soiled

dressing, prior to when she used them again on

the clean dressing. She forgot to clean the

bandage scissors.


Assistant Director of Health Services (ADHS)

indicated the nurse should have washed her

hands when the soiled dressing was removed, and

prior to donning clean gloves. The bandage

scissors should have been cleaned after use, and

prior to being used on the clean dressing.

On 6/29/18 at 10:53 a.m., Medical Records

provided a document titled, "Dressing Changes,"

and indicated it was the policy currently being

used by the facility. The policy indicated,

"OVERVIEW: To ensure measures that will

promote and maintain good skin integrity while

maintaining standard measures that will

minimize/control contamination. SOP DETAILS:

...7. Remove soiled dressing and discard in plastic

bag or trash can. 8. Dispose of gloves in plastic

bag or trash can. 9. Wash hands with soap and

water. 10. Put on second pair of disposable

gloves...13. If using scissors make sure, it is clean




An inservice will be conducted for

license nurses with focus on

infection control practices

according to facilty policies with

attention to dressing changes. The

DHS or designee shall observe

dressing changes to ensure the

nurses are washing hands and

cleaning bandage scissors

according to best practices and

facility policy and procedures.

The observations of the dressing

changes will include 3 residents

with dressing changes weekly for

4 weeks and then every other

week for 4 weeks and then

monthly thereafter.






into place

The results of the observations

will be reported, reviewed, and

trended for compliance through the

campus Quality Assurance

Committee (QA) for a minimum of

6 months then randomly thereafter

for further recommendations.





08/07/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



155772 07/03/2018



00

with antiseptic after contact with soiled

dressings...."

3.1-18(l)

R 0000

Bldg. 00

This visit was for a State Residential Licensure

Survey. This visit included a Recertification and

State Licensure Survey.

Survey dates: June 26, 27, 28, 29, and July 2, and 3,

2018.

Facility number: 011906

Residential Census: 34

Cobblestone Crossings Health Campus was found

to be in compliance with 410 IAC 16.2-5 in regard

to the State Residential Licensure Survey.

R 0000 The submission of this plan of

correction does not indicate an

admission by Cobblestone

Crossing Health Campus that the

findings and allegations contained

herein are accurate and true

representation of the quality of

care provided and living

environment provided to the

residents of Cobblestone Crossing

Health Campus. The facility

recognizes its obligation to provide

legally and medically necessary

care and service to its residents in

an economic and efficient manner.

The facility hereby maintains it is

in substantial compliance with the

requirements of participation for

skilled health care facilities. To

this end, the plan of correction

shall serve as the credible

allegation of compliance with all

state and federal requirements

governing the management of this

facility. It is thus submitted as a

matter of statute only. The facility

respectfully request from the

department a desk review for

substantial compliance.

State Form Event ID: G3OZ11 Facility ID: 011906 If continuation sheet of 37

F 0641 - IndianaMDS team was educated on the accurate coding of PRN pain medication 5 day look back...

Documents

Transcript of F 0641 - IndianaMDS team was educated on the accurate coding of PRN pain medication 5 day look back...