PRINTED: 02/08/2018 DEPARTMENT OF HEALTH AND HUMAN … · (x1) provider/supplier/clia department of...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

02/08/2018PRINTED:

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

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

DYER, IN 46311

155220 01/19/2018

DYER NURSING AND REHABILITATION CENTER

601 SHEFFIELD AVE

00

F 0000

Bldg. 00

This visit was for the Investigation of

Complaints IN00246573, IN00247919,

IN00249592, IN00250153, and

IN00250908.

Complaint IN00246573 - Substantiated.

No deficiencies related to the allegations are

cited.


Federal/State deficiencies related to the

allegations are cited at F584.



allegations are cited at F803, F804, and

F842.







Survey dates: January 17, 18 & 19, 2018

Facility number: 000125

Provider number: 155220

F 0000 The facility is submitting plan of

correction in accordance with the

regulatory requirement and is

submitting supporting

documentation and evidence for

your review.

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: 2FUG11 Facility ID: 000125

TITLE

If continuation sheet of 22

(X6) DATE




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AIM number: 100266740

Census bed type:

SNF/NF: 139

Residential: 44

Total: 183

Census payor type:

Medicare: 26

Medicaid: 82

Other: 31

Total: 139

These deficiencies reflect State Findings

cited in accordance with 410 IAC 16.2-3.1.

Quality review completed on 1/22/18.

483.10(i)(1)-(7)

Safe/Clean/Comfortable/Homelike

Environment

§483.10(i) Safe Environment.

The resident has a right to a safe, clean,

comfortable and homelike environment,

including but not limited to receiving

treatment and supports for daily living safely.

The facility must provide-

§483.10(i)(1) A safe, clean, comfortable, and

homelike environment, allowing the resident

to use his or her personal belongings to the

extent possible.

F 0584

SS=E

Bldg. 00

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2FUG11 Facility ID: 000125 If continuation sheet of 22




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(i) This includes ensuring that the resident

can receive care and services safely and that

the physical layout of the facility maximizes

resident independence and does not pose a

safety risk.

(ii) The facility shall exercise reasonable care

for the protection of the resident's property

from loss or theft.

§483.10(i)(2) Housekeeping and maintenance

services necessary to maintain a sanitary,

orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that

are in good condition;

§483.10(i)(4) Private closet space in each

resident room, as specified in §483.90 (e)(2)

(iv);

§483.10(i)(5) Adequate and comfortable

lighting levels in all areas;

§483.10(i)(6) Comfortable and safe

temperature levels. Facilities initially certified

after October 1, 1990 must maintain a

temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of

comfortable sound levels.

Based on observation and interview, the

facility failed to ensure Housekeeping

services were provided to maintain a clean

and sanitary environment related to unclean

floors, walls, furniture, and equipment in

resident rooms and dining rooms on 2 of 3

resident halls and 2 of 4 Dining Rooms.

(East Hall, West Hall, Main Dining Room &

F 0584 DYER NURSING &

REHABILITATION CENTER

PLAN OF CORRECTION

Complaint Survey January 2018

F584

Please accept the following as the

facility’s credible allegation of

compliance. This plan of

correction does not constitute an

01/29/2018 12:00:00AM





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West Unit Dining Room)

During the Environmental Tour, with the

Housekeeping Supervisor, on 1/19/18 at

10:50 a.m., the following was observed:

1. East Hall

a. Room 105: There was an accumulation of

tan spillage on the wall near the head of Bed

1. There was dust and debris on the floor

tacks of the closet door. The floor and the

base of the toilet in the bathroom were dirty.

Two residents resided in the room.

b. Room 108: The base of the toilet was

dirty. Two residents resided in the room.

c. Room 127: There was spillage on the

floor and the floor mat near Bed 2. One

resident resided in the room.

2. West Hall

a. Room 150: Floor tile around the toilet

was missing. The caulking around the toilet

was discolored. Two residents resided in the

room.

b. Room 161: There was dried debris on the

floor mat, dried tube feeding on the tube

feeding pole, and the oxygen canister for

Bed 2. The base of the toilet was dirty.

Two residents resided in the room.

admission of guilt or liability by the

facility and is submitted only in

response to the regulatory

requirement.

What corrective action(s) will

be accomplished for those

residents found to have been

affected by the deficient

practice;

The Facility removed and cleaned

the area with the tan spillage on

the wall near the head of the bed

in room 105. The facility removed

the dust and debris on the floor

and the tracks of the closet doors.

The facility cleaned the the base

of the toilet and the floor in the

bathroom. In room 108 the facility

cleaned the base of the toilet in

108. The facility cleaned the

spillage on the floor and the floor

mat in room 127 near bed 2.

The facility replaced the tile and

caulking around the toilet in room

150. The facility removed the dried

debris on the floor mat and the

dried feeding off the feeding pole

and the oxygen canister room

161-2. The facility also cleaned

the base of the toilet for room 161.

The facility removed the spillage

on the dresser in room 185

nearest to bed 1. The facility

removed the dried spillage on the

wall in the West Unit dinning area.

Resident G’s Broda chair was

cleaned and the two small





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c. Room 185: There was spillage on the

dresser near Bed 1. One resident resided in

the room.

d. Unit Dining Room: There was dried

spillage on the wall.

e. Resident G was seated in a Broda chair in

the hallway by the Nurses Station. There

was an accumulation of spillage and debris

on the bars of the chair.

3. Main Dining Room:

a. There were stains in the two small

couches near each of the entrances.

During the Environmental Tour, the

Housekeeping Supervisor confirmed the

above area were in need in cleaning.

This Federal tag relates to Complaint

IN00247919.

3.1-19(f)

couches in the Main dinning area

were cleaned.

How the facility will identify

other residents having the

potential to be affected by the

same deficient practice and

what corrective action will be

taken;

All residents have the potential to

be affected by the same deficient

practice. The facility staff

completed rounding of all resident

rooms and resident common

areas to identify any areas

affected by the same deficient

practice. If an area was identified it

was corrected immediately.

What measures will be put

into place or what systemic

changes will be made to

ensure that the deficient

practice does not recur

The housekeeping manager will

meet with facility staff daily to

identify areas of concern and

correct identified concerns

immediately.

How the corrective action(s)

will be monitored to ensure the

deficient practice will not

recur, i.e., what quality

assurance programs will be put

into place;





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Administrator/designee will audit 5

resident rooms and 1 common

area five days a week to ensure

that resident have a safe and

clean comfortable homelike

environment . A summary of the

audits will be presented to the

Quality Assurance committee

monthly by

Administrator/designee for 6

months. Thereafter, if determined

by the Quality Assurance

committee, auditing and

monitoring will be done quarterly

and present quarterly at the QA

meeting. Monitoring will be on

going.

Date Certain: 1/29/2018

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=D

Bldg. 00

Based on observation, record review, and

interview, the facility failed to ensure fall

prevention interventions were in place

related to devices not functioning or in place

correctly, residents left unsupervised in the

Dining room, and interventions not






your review.

DYER NURSING &

01/29/2018 12:00:00AM





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implemented for resident positioning for 2 of

3 residents reviewed for falls. (Residents D

and G). The facility also failed to utilize

appropriate, hazard-free assistive devices

related to dining for 1 randomly observed

resident. (Resident J)

Findings include:

1. On 1/17/18 at 6:40 p.m., Resident G was

observed in a Broda chair in the hallway

across from the Nursing Station. Bruising

was present on the resident's left forehead

and temporal areas.

On 1/18/18 at 7:36 a.m., Resident G was

observed in a Broda chair at table in the

Main Dining Room. The resident was

seated near the Kitchen doors which were

located in the back of dining room. The

entrance doors to the Main Dining Room

were at the opposite end of the room. No

staff members were in the room. At 7:37

a.m., a staff member brought another

resident into the Main Dining Room, sat the

resident at table, and left. No staff members

were observed in the Main Dining Room at

7:43 a.m. or 7:48 a.m.

On 1/18/18 at 11:40 a.m., the Hospice

Nurse transferred the resident in the Broda

chair to her room from the hallway The


PLAN OF CORRECTION


F689








requirement.





practice;

The chair alarm for RG is in place

and staff are completing random

checks to ensure this alarm is in

place and that the resident is not

left unsupervised in the dining

room.

RJ is currently in the hospital and

will be evaluated by the Speech

Therapist upon readmission

The floor mattress for RD was

immediately corrected.






taken;







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Hospice Nurse observed the chair alarm

had been in the off position. The Hospice

Nurse indicated he had previously observed

the alarm off on the day after the resident's

most recent fall on 1/8/18.

On 1/18/18 at 1:10 a.m., CNA 1 and CNA

2 were observed transferring the resident

from the Broda chair into bed. The CNA's

lifted the resident from the chair into her

bed. A blue Dycem pad was in place on

top of the white chair alarm pad.

The record for Resident G was reviewed on

1/18/18 at 9:11 a.m. Diagnoses included,

but were not limited to, cerebral

infarction(stroke), dementia, repeated falls,

palliative care, and sleep disorder.

A Care Plan, initiated on 11/21/16 and last

revised on 1/9/18, identified Resident G as

being at risk for falling related to a history of

falls, cerebral infarction, and dementia.

Care Plan interventions included, but were

not limited to, dycem (a pad to prevent

sliding) below chair cushion, bed and chair

alarms, and resident to be on the morning

get up list.

The 1/8/18 Accident/Incident Investigation,

completed by Nursing staff, was reviewed.

The resident resident was seated in the hall

practice. The facility staff

completed rounding of all resident

rooms and residents with fall and

swallowing interventions to ensure

placement and effectiveness.

Deficient areas were corrected

immediately.

What measures will be put into

place or what systemic




All staff were re-in serviced on

interventions for falls, following the

meal cards and safe practices.






into place;

DON/designee will observe 10

random meals weekly and will

observe 5 residents at each meal

to ensure that any interventions

listed on the dietary card are

followed.

DON/designee will observe 10

residents with a history of falls 5

days each week to ensure fall

interventions are in place and to

ensure residents are not leave in

the dining room unattended.

A summary of the audits will be

presented to the Quality

Assurance committee monthly by





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by the Nursing Station and fell. The alarm

was not sounding at the time of the fall. A

Fall Event Note, completed on 1/8/18 at

3:00 p.m., was reviewed. The resident was

in the Broda chair and fell forward out of the

chair. A hematoma was observed the left

forehead area. A Fall Root Cause Analysis

form, completed on 1/9/18, was reviewed

for the 1/8/18. The resident was in front of

the Nursing Station seated in a Broda chair.

The alarm was not on and the resident fell

from the chair.

During an interview with the facility

Administrator and Director of Nursing on

1/18/18 at 3:40 p.m., the Director of

Nursing indicated the fall interventions

should have been in place.

2. The evening meal service in the East Unit

Dining Room was observed on 1/17/18 at

5:20 p.m. Resident J received a plate of

ground meat, mashed potatoes cream corn,

and a bowl of fruit pieces. The dietary tray

card was on the table next to her plate. The

tray card indicated no straws were to be

used. At 5:40 p.m., LPN 1 sat down next

the resident and assisted her with her meal.

The LPN gave the resident her liquid shake

using a straw. The resident took several

sips using the straw.

DON/designee for 6 months.

Thereafter, if determined by the

Quality Assurance committee,

auditing and monitoring will be

done quarterly and present

quarterly at the QA meeting.

Monitoring will be on going.






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The record for Resident J was reviewed on

1/19/18 at 9:15 a.m. Diagnoses included,

but were not limited to, dysphagia (difficulty

swallowing), malnutrition and chronic kidney

disease.

A Care Plan, initiated on 3/24/14 and last

revised on 10/19/17 indicated the resident

had impaired swallowing due to dysphagia.

Interventions included, but were not limited

to, observe for swallowing difficulties, diet

as ordered, observe closely for signs of

choking or aspiration, and safe swallow

strategies.

3. During an observation on 01/18/18 at

11:20 a.m., Resident D was in bed, the bed

was in low position, and a mattress was

leaning up against the hutch stand on the wall

across from the foot of the bed.

Resident D's record was reviewed on

01/18/18 at 3:16 p.m. Diagnoses included,

but were not limited to, amputation of right

foot and dementia

A Quarterly Minimum Data Set assessment,

date 10/20/17, indicated the resident's

cognition was intact, required limited

assistance for transfers, was unsteady with

transfers, and had no falls.

A care plan, dated 10/28/16 and revised on





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1/17/18, indicated he was at risk for falls.

Interventions included, 01/17/18 - 15 minute

checks for 72 hours, 01/15/18 - rearrange

room, 01/08/18 - encourage to lay down

after meals and offer assistance, floor

mattress next to bed, and safety checks.

A Physician's Order, dated 01/09/18,

indicated nursing intervention - mattress next

to bed.

A Fall Event, dated 1/13/18 at 12:40 a.m.,

indicated the resident was sitting in a

wheelchair at the Nurses' Station, fell

forward out of the locked wheelchair onto

the the floor, and received a skin tear above

the right eye.

An Investigation of the fall, dated 01/13/18

at 12:40 a.m., indicated, "...Was the cause

of the fall known? Resident has habit of

leaning forward in Wheelchair...Activity at

time of the fall -fell forward out of chair..."

During an observation on 01/19/18 at 8:20

a.m., Resident D was sitting in his

wheelchair, in his room eating breakfast.


a.m., the resident was sitting in a wheelchair

at the Nurses' Station, a footboard was on

the legs of the chair and the foot pedals





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were lowered. He was leaned forward in the

chair, with his head close to lying on his lap.

The Director of Nursing (DON) was at the

Nurses' Station. The DON indicated at the

time of the observation, the resident and

indicated the intervention for the leaning was

therapy. The DON indicated the resident

would be assisted into bed after his room

was cleaned. The DON approached the

resident and asked him if he was "ok" with

leaning forward, the resident raised his head

up, eyes were closed and stated, "yes". The

DON then asked the resident, "you're not

going to fall forward are you?", then walked

down the hall to check if the room had been

cleaned.


a.m., the resident remained in the wheelchair

at the Nurses' Station, he was leaned

forward in the wheelchair with his head

close to his lap, he reached out and touched

the pad on the foot pedal, then sat up and

leaned forward again.


a.m., the resident was assisted to bed by the

CNA's.

During an interview on 01/19/18 at 10:30

a.m., the Corporate RN Consultant

indicated the mattress was to be on the floor





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next to the bed.

During an interview on 1/19/18 at 11:22

a.m., the DON indicated there were no

interventions initiated for the leaning forward

in the wheelchair.

This Federal tag relates to Complaints

IN00250153 and IN00250908.

3.1-45(a)(2)

483.60(c)(1)-(7)

Menus Meet Resident Nds/Prep in

Adv/Followed

§483.60(c) Menus and nutritional adequacy.

Menus must-

§483.60(c)(1) Meet the nutritional needs of

residents in accordance with established

national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's

reasonable efforts, the religious, cultural and

ethnic needs of the resident population, as

well as input received from residents and

resident groups;

F 0803

SS=E

Bldg. 00





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§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's

dietitian or other clinically qualified nutrition

professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph

should be construed to limit the resident's

right to make personal dietary choices.

Based on observation, review of dietary

menus and serving instructions, and

interview, the facility failed to ensure food

was served in the appropriate portions

related to not using the required size utensils

to provide correct portions as per the

Dietary Spread Sheets for meal service for 1

of 1 Kitchen. (Main Kitchen)

Finding includes:

The Evening Meal service in the Main Dining

Room was observed on 1/17/18 at 5:50

p.m. Dietary staff were serving food from

the steam table in the Dining Room. Dietary

staff 1 was using tongs to pick up a serving

of the pork meat entree. A four ounce ladle

was used to served the corn. A number (16)

blue scoop was used to serve portions of

the mashed potatoes and the pureed meat.

No menu or spread sheet was present when

staff were serving.

Dietary staff 1 indicated she did not have a

spread sheet in place when they were



PLAN OF CORRECTION


F803








requirement.





practice;


be affected by this deficient

practice.






taken;

The facility administrator and

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serving. She indicated they normally use the

blue scoop for meats, potatoes, pureed

foods and mechanically altered diets.

The Daily Spread Sheet for 1/17/18 was

reviewed. The Spread Sheet indicated a

#12 scoop was to used for the pork

shoulder meat to provide a 2 ounce serving.

A #8 scoop was to be used for buttered

mashed potatoes. The Spread Sheet was

signed by the Registered Dietitian.

During an interview on 1/17/18 at 6:56 p.m.,

the facility Administrator indicated the

Dietary staff should have followed the

spread sheets to provide the required

portions.


IN00249592.

3.1-20(i)(4)

kitchen supervisor reviewed the

utensils for portion sizes and the

menu spread sheet to ensure

facility staff have the proper tools

and information for meal service.






All serving kitchen staff were re-in

serviced portion sizes and

appropriate utensils for serving

food. The staff was also in

serviced on the menu spread

sheet and how to use it during

meal prep and serving sizes.






into place;

Administrator/designee will audit

10 random meals each week to

ensure that residents are receiving

the appropriate portion size. A

summary of the audits will be













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The facility is submitting plan of





your review.

483.60(d)(1)(2)

Nutritive Value/Appear, Palatable/Prefer

Temp

§483.60(d) Food and drink

Each resident receives and the facility

provides-

§483.60(d)(1) Food prepared by methods that

conserve nutritive value, flavor, and

appearance;

§483.60(d)(2) Food and drink that is

palatable, attractive, and at a safe and

appetizing temperature.

F 0804

SS=D

Bldg. 00

Based on observation, record review, and

interview, the facility failed to ensure food

was served at palatable temperatures for

foods tested during 1 of 3 meal services

observed. (The Evening meal)

Finding includes:

A test tray was requested to be sent from

Dietary to the East wing at the time room






your review.

DYER NURSING &


PLAN OF CORRECTION


F804


01/29/2018 12:00:00AM





02/08/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


DYER, IN 46311

155220 01/19/2018


601 SHEFFIELD AVE

00

trays were sent for the evening meal on

1/17/18. Temperatures on test tray were

completed and noted as follows:

Meat: 108. 5 F

Potatoes: 113.7

Corn: 108. 0 F

The food on the tray was luke warm to

touch.

The Corporate Nurse Consultant was

present when the food temperatures were

taken and was informed the food was luke

warm to touch.

Random interviews, with two different family

members present during the meal service,

indicated the food was always served cold

to their family members.

This Federal tag related to Complaint

IN00249592.

3.1-21(a)(2)







requirement.





practice;


be affected by this deficient

practice.






taken;

The facility administrator and

kitchen supervisor reviewed the

meal service to observe

temperatures of food coming out of

the oven and again observing

temperature at the steam

table.Room tray pass was

observed to identify deficient food

temperature.










02/08/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


DYER, IN 46311

155220 01/19/2018


601 SHEFFIELD AVE

00

All serving kitchen staff were re-in

serviced on temperature guidelines

for serving food to facility

residents. All staff was re-in

serviced on passing trays to the

units.






into place;

Administrator/designee will audit

all meals 5 days a week to ensure

that residents are receiving the

meals at appropriate

temperatures. A summary of the

audits will be presented to the

Quality Assurance committee

monthly by DON/designee for 6

months. Thereafter, if determined

by the Quality Assurance

committee, auditing and

monitoring will be done quarterly

and present quarterly at the QA

meeting. Monitoring will be on

going.


483.20(f)(5); 483.70(i)(1)-(5)

Resident Records - Identifiable Information

§483.20(f)(5) Resident-identifiable information.

(i) A facility may not release information that

F 0842

SS=D

Bldg. 00





02/08/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


DYER, IN 46311

155220 01/19/2018


601 SHEFFIELD AVE

00

is resident-identifiable to the public.

(ii) The facility may release information that is

resident-identifiable to an agent only in

accordance with a contract under which the

agent agrees not to use or disclose the

information except to the extent the facility

itself is permitted to do so.

§483.70(i) Medical records.

§483.70(i)(1) In accordance with accepted

professional standards and practices, the

facility must maintain medical records on

each resident that are-

(i) Complete;

(ii) Accurately documented;

(iii) Readily accessible; and

(iv) Systematically organized

§483.70(i)(2) The facility must keep

confidential all information contained in the

resident's records,

regardless of the form or storage method of

the records, except when release is-

(i) To the individual, or their resident

representative where permitted by applicable

law;

(ii) Required by Law;

(iii) For treatment, payment, or health care

operations, as permitted by and in

compliance with 45 CFR 164.506;

(iv) For public health activities, reporting of

abuse, neglect, or domestic violence, health

oversight activities, judicial and administrative

proceedings, law enforcement purposes,

organ donation purposes, research purposes,

or to coroners, medical examiners, funeral

directors, and to avert a serious threat to

health or safety as permitted by and in

compliance with 45 CFR 164.512.





02/08/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


DYER, IN 46311

155220 01/19/2018


601 SHEFFIELD AVE

00

§483.70(i)(3) The facility must safeguard

medical record information against loss,

destruction, or unauthorized use.

§483.70(i)(4) Medical records must be

retained for-

(i) The period of time required by State law; or

(ii) Five years from the date of discharge

when there is no requirement in State law; or

(iii) For a minor, 3 years after a resident

reaches legal age under State law.

§483.70(i)(5) The medical record must

contain-

(i) Sufficient information to identify the

resident;

(ii) A record of the resident's assessments;

(iii) The comprehensive plan of care and

services provided;

(iv) The results of any preadmission

screening and resident review evaluations and

determinations conducted by the State;

(v) Physician's, nurse's, and other licensed

professional's progress notes; and

(vi) Laboratory, radiology and other diagnostic

services reports as required under §483.50.

Based on record review and interview, the

facility failed to ensure medical records were

complete related to lack of ongoing

documentation following admission for 1 of

3 residents reviewed for documentation.

(Resident F)

Finding includes:

The closed record for Resident F was

reviewed on 1/18/18 at 12:54 p.m. The



PLAN OF CORRECTION


F842








requirement.

01/29/2018 12:00:00AM





02/08/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


DYER, IN 46311

155220 01/19/2018


601 SHEFFIELD AVE

00

resident was admitted on 12/22/17.

Diagnoses included, but were not limited to,

dementia and high blood pressure.

Nursing Progress notes were completed as

follows:

12/22/17 at 2:59 p.m. The resident was

transported to the facility by family from the

hospital. The resident was alert and

responsive with some confusion. A head to

toe assessment was completed. The

Physician was notified of the admission.

12/23/17 at 12:40 a.m. The Daughter can

be reached at (phone number).

12/24/17 at 6:10 p.m. The resident was

hard to arouse, skin warm and dry, lungs

clear, did not wake up for dinner.

12/24/17 at 6:30 p.m. The resident is alert

and talking to family. Family requests blood

work be done.

12/24/17 at 6:54 p.m. Lab called for stat lab

tests.

12/24/17 at 7:02 p.m. The family states they

have decided to send the resident to the

hospital for an evaluation.

12/24/17 at 7:57 p.m. The resident left the

facility on a stretcher to the hospital.

The only set of Vital Signs was completed

on 12/22/17 at 2:45 p.m. No other resident





practice;

Resident F discharged from the

facility






taken;



practice.






All nursing staff were in serviced

on the following:

Monitoring vital signs for 72 hours

after admission

Monitoring and assessing

residents 72 hours after admission

Documenting vitals and resident

assessments in the clinical

record.










02/08/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


DYER, IN 46311

155220 01/19/2018


601 SHEFFIELD AVE

00

assessments were noted.

During an interview on 1/18/18 at 2:43 p.m.,

the Director of Nursing indicated Nursing

staff are to completed an assessment of the

resident every shift for 72 hours following

new admission.


IN00249592.

3.1-50(a)(1)

into place;

DON/designee will audit all new

admissions and re admissions

daily for 72 hours to ensure

appropriate medical record

documentation is completed. A

summary of the audits will be











The facility is submitting plan of





your review.


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