Nhc Healthcare - Greenwood

Penalty

Inspection fine: $14,433

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free from significant medication errors when a nurse administered another resident's medications to the resident. The incident involved a resident with multiple diagnoses, including chronic respiratory failure, dementia, Parkinson's disease, and heart failure. On the morning of the incident, the resident was mistakenly given medications intended for another resident, which included Lantus, Humalog, Cetirizine, Cymbalta, Depakote, Gabapentin, Losartan, and Metformin. The error was identified by the nurse in training, who realized the mistake after administering the medications. Following the medication error, the resident was monitored for any adverse effects. Initially, the resident's vital signs were stable, and there were no immediate signs of distress. However, later in the day, the resident was observed to be dizzy and not feeling well, with an elevated pulse rate. The nurse practitioner was contacted, and due to the change in the resident's condition, a decision was made to send the resident to the emergency room for further evaluation. At the hospital, the resident was found to have pneumonia, which was unrelated to the medication error. Interviews with the staff involved revealed that the nurse in training was aware of the error and took steps to monitor the resident closely. The supervising nurse and the nurse practitioner were informed, and the resident's family was also notified. The facility's policy on medication administration was reviewed, and it was noted that the nurse should have ensured the correct patient was receiving the medication. The incident highlighted a lapse in following the facility's medication administration guidelines, leading to the significant medication error.

Removal Plan

• RN1 was reeducated on medication administration to include the 5 rights of medication administration.
• RN1 continued training under supervision.
• RN1 completed a competency check and demonstrated competency.
• LPN1, the supervising nurse of RN1 was under supervision.
• LPN1 was educated on supervision of employees training.
• Medication administration in-service was conducted for all nurses.
• Any nurse that has not been educated will be educated before clocking in for their shift.
• All new nurses will be educated on this guideline before working a medication cart.
• The medication administration policy was reviewed by the Administrator, DON and Regional Nurse.
• A QAPI meeting was held with Administrator, DON, Assistant DON, Nurse Managers, and social services to review event and ensure the safety of all residents.
• A conference with the Medical Director was held for further discussion on the alleged events and to assure the utmost in patient care and safety.
• A review of the medication administration guideline was conducted.
• An audit of resident records was conducted. No other events were noted for medication administration errors.
• DON or their designee will continue weekly audits or records and monthly audits.
• Monitoring will be conducted by the DON or their designee with med pass observations occurring at random weekly.
• Pharmacy will continue med pass observations monthly.
• Overall compliance will be monitored by the Administrator and Director of Nursing and reported to the QAPI meeting.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a history of falls and a high risk for future falls. The resident, identified as R3, had a medical history that included a displaced transverse fracture of the left femur, a history of falling, end-stage renal disease, vitamin D deficiency, and anemia. Despite being assessed as high risk for falls using the Morse Fall Scale and having a care area assessment that triggered the need for further assessment, the resident's care plan did not address the risk for falls. Interviews with facility staff revealed gaps in the care planning process. Nurse Manager #4 admitted that a baseline care plan for falls was not completed upon the resident's admission in October 2023, and the care plan viewed in June 2024 was the same since admission. Nurse Manager #2, who also served as the Falls Coordinator, stated that a care plan would not always be completed for residents at high risk for falls, and that transfer assessments were the responsibility of the therapy department. This information was communicated verbally and placed on a CNA worksheet, rather than being formally documented in the care plan. The Director of Nursing acknowledged that the care plan should have addressed the resident's risk for falls, given the resident's history and high-risk status. The Administrator also expected interventions to be in place to minimize fall risks and related injuries. However, the care plan did not reflect the necessary interventions, indicating a failure to align the care plan with the resident's assessed needs and risks.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper hygienic practices among kitchen staff, as observed during multiple instances. Staff members were seen not wearing appropriate hair nets and beard guards, with hair exposed while handling food. Specifically, Cook1 and DA3 were observed without beard guards, and several dietary aides had hair nets that did not fully cover their hair. Additionally, DA4 was seen touching her face and hair net without performing hand hygiene before continuing to handle food, and DA1 was observed touching food items with bare hands while preparing plates for residents. These actions are in direct violation of the facility's policy on hygienic and safety practices, which mandates the use of hair restraints and proper hand hygiene to prevent food contamination. The facility also failed to ensure that food items in one of the nutritional refrigerators were properly labeled and dated. During an inspection, several items, including yogurts, strawberries, apple slices, a tart, and various ice cream products, were found without labels or dates. This refrigerator was designated for resident use, and the lack of proper labeling and dating was confirmed by a CNA and the Assistant Director of Nursing. The Director of Dietary acknowledged that it was the responsibility of the dietary department to clean the refrigerator and freezers, but all staff were responsible for labeling and dating food items. These deficiencies have the potential to affect 131 residents who receive an oral diet from the kitchen. The facility's failure to adhere to its own policies on food safety and hygiene practices poses a risk of food contamination and compromises the overall safety and quality of care provided to the residents. The Director of Dietary confirmed the expectations for staff to cover all hair, use beard guards, and perform hand hygiene after touching non-food items, but these practices were not consistently followed by the kitchen staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow the Resident Assessment Instrument (RAI) manual's transmittal requirements, which mandate that within 14 days after completing a resident's assessment, the facility must electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Center for Medicare & Medicaid Services (CMS) System. Specifically, the facility did not transmit the MDS data for four residents (R22, R34, R67, and R35) within the required timeframe, with delays extending over 120 days for some residents. This deficiency was identified through a review of the residents' electronic medical records and confirmed during an interview with the Nurse Manager/MDS Coordinator (NM4/MDSC1), who acknowledged that the assessments were missed despite batching and submitting MDS data daily. For Resident 22, the discharge MDS dated 11/05/23 was not signed by a Registered Nurse (RN) and was not transmitted to the CMS system. Resident 34's annual MDS dated 12/21/23 also lacked an RN's signature and was not transmitted. Resident 67's annual MDS, signed on 03/08/24, was transmitted late. Lastly, Resident 35's quarterly MDS dated 12/27/23 had not been transmitted at all. These failures indicate a significant lapse in the facility's adherence to federal requirements for timely MDS data transmission.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to serve food that was palatable and at a safe and appetizing temperature for seven residents reviewed for food palatability. Residents reported that their meals were often served cold when they should have been hot, and some meals were overcooked or unappetizing. Specific complaints included cold grits, cold coffee, hard meat, hard biscuits, and meals that were burnt or lacked proper condiments. One resident showed pictures of meals that were either burnt, greasy, or missing key components like sauce for fettuccine alfredo. Despite complaints to the staff, no improvements were noted by the residents. During a test tray evaluation, the food temperatures were found to be below the required levels. The cowboy chili mac was at 108 degrees, breaded chicken at 115 degrees, and French fries at 105.3 degrees. The food was described as being at room temperature and not appetizing. The facility's Director of Dietary confirmed that the food should have remained at 120 degrees when served but acknowledged the issues with food complaints and attempted to address them by talking to residents and trying to accommodate their wishes. Interviews with staff revealed that there was a lack of communication and follow-through regarding residents' food preferences and complaints. One resident's request for over-light eggs was not communicated to the dietary staff, despite the facility having the capability to prepare them. The Director of Dietary and other staff members confirmed that they were aware of the food concerns but had not effectively resolved them. The facility's failure to address these issues had the potential to affect all 131 residents who consumed food prepared in the facility's kitchen.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to assess a resident for self-administration of medications, leading to medications being left at the bedside. The facility's policy requires an interdisciplinary team assessment and a prescriber's order for residents who wish to self-administer medications. However, the resident in question, who was cognitively intact with a BIMS score of 15 out of 15, did not have a care plan, assessment, or order for self-administration of medications. Despite this, an LPN left medications at the resident's bedside upon the resident's request, intending to return later to confirm the medications were taken, which is against the facility's policy of observing medication administration directly. During an interview, the LPN admitted to leaving the medications at the bedside and was unaware of the self-administration assessment requirements. The Director of Nursing confirmed that the facility's policy mandates observing residents taking their medications and that a self-administration assessment and a lock box are required for residents who wish to self-administer. The DON also confirmed that no residents in the facility currently had a self-administration assessment, including the resident in question.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop comprehensive care plans for two residents, specifically regarding the use of an indwelling urinary catheter and Tubigrip stockings. Resident 63, who was admitted with diagnoses including iron deficiency anemia, chronic diastolic heart failure, and unspecified atrial fibrillation, had a physician's order for an indwelling urinary catheter due to a neurogenic bladder. Despite this, the resident's care plan did not include any focus, goal, or interventions related to the catheter. Both the Director of Nursing and the MDS Coordinator confirmed that the catheter should have been included in the care plan but was not. Similarly, Resident 1, admitted with a primary diagnosis of atrial fibrillation and co-morbidities including venous insufficiency, had an order for Tubigrip stockings to manage lower extremity edema. The resident's care plan, however, did not include the use of Tubigrips. The Director of Nursing confirmed that the purpose of Tubigrips was for lower extremity edema and clot prevention and acknowledged that the care plan should have included this information but did not.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the resident care plan was revised to accurately reflect the current plan of care for a resident with unspecified dementia. The resident was considered a fall risk and the care plan directed staff to place a fall mat at her bedside. However, multiple observations over two days revealed that no floor mats were present at the resident's bedside. Interviews with CNAs confirmed that the resident did not use floor mats, and the Director of Nursing stated that the care plan should accurately reflect the current status of a resident, which it did not in this case. Additionally, the facility failed to ensure that another resident, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, was invited to her quarterly care conference. The resident had not had a care conference since admission, and the facility's MDS Coordinator confirmed that a care conference should have been held in February but was not. The MDS Coordinator did not provide a reason for the missed care conference.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to apply Tubigrip stockings per physician orders for a resident with significant medical conditions, including hypertensive chronic kidney disease, orthostatic hypotension, and nonrheumatic aortic valve stenosis. The resident was severely impaired in cognitive skills and dependent on staff for lower body dressing. Despite a physician's order for Tubigrip socks to be applied in the morning and removed in the evening, observations on multiple occasions revealed that the resident did not have the Tubigrip socks on, and her feet were not elevated as required. The resident's feet were observed to be edematous, and the Tubigrip socks were found in her bedside table drawer, unused. The Medication Administration Record inaccurately documented that the socks were applied, and there was no documentation of refusal or intolerance in the Progress Notes. The Director of Nursing confirmed that the Tubigrip socks were not included in the resident's care plan and that the staff failed to execute the physician's orders. The Director of Nursing and a Registered Nurse acknowledged the importance of the Tubigrip socks in controlling edema and confirmed that the nurses were ultimately responsible for ensuring the socks were applied. The failure to apply the Tubigrip socks as ordered and the lack of accurate documentation and care planning led to the deficiency identified in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident (R14) was competent to perform suprapubic catheter care independently. R14 was admitted with a suprapubic catheter and had diagnoses including morbid obesity, atherosclerotic heart disease, hypertensive chronic kidney disease, stage two, neuromuscular dysfunction of the bladder, and osteoarthritis. Despite having a physician's order for suprapubic catheter site care to be performed twice daily, there were no orders for R14 to complete the care independently. Additionally, there was no documentation in R14's care plan or medical records indicating that R14 had been assessed as competent to perform the catheter care independently. During an observation, R14 confirmed that he completed his catheter care without nursing staff present at times, and RN1 stated that she had observed R14 performing the care and found him competent, but had not completed a written assessment or evaluation of R14's capabilities. The Director of Nursing (DON) confirmed that the facility did not have a policy or formal assessment for residents performing their own skilled care, such as suprapubic catheter care. The DON stated that typically, nursing staff completed such care and that it was not common practice for residents to perform their own skilled care. The DON acknowledged that if residents were to perform their own care, a policy review, competency demonstration, and monitoring system would be necessary. The DON also confirmed that it would be good practice to include any resident self-care in the resident's care plan. The lack of proper assessment, documentation, and physician orders for R14 to perform his own catheter care independently led to the deficiency identified in the report.