Renaissance Rehabilitation and Nursing Care Center

Based on interview and record review, the facility did not ensure that measurable goals and/or necessary interventions were included in the plan of care to address gastrointestinal problems for Resident #25 and skin impairment for Resident # 41. This was evident for 2 of 33 sampled residents. This had the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #25 has diagnoses that include Gastro Esophageal Reflux Disease (GERD) and Dementia. A review of the resident's Comprehensive Care Plan dated 6/11 revealed that the resident has GERD. The interventions planned for this problem were limited to monitoring for signs and symptoms of the disease and providing medications as ordered. No non-pharmacological interventions to prevent gastro intestinal problems were noted in this plan.

On 7/14/11 at 11:20 AM the Registered Nurse responsible for the development of care plans reviewed the resident's care plan in the presence of the surveyor. She confirmed a lack of non-pharmacological interventions, such as not lying flat after eating, to prevent gastro intestinal problems.

2. Resident # 41 has an admission record of 5/11/11 indicating a skin assessment by an RN. This assessment identified multiple petechiae on both arms with bruises on right arm below and above antecubital space.

There is no care plan addressing these areas with a plan to prevent them from becoming open areas.

Interview with Licensed Practical Nurse (LPN) unit manager on 7/13/11 at 3:52 PM revealed that these areas would not be addressed in the care plan unless they were open as they were not being treated.

415.11 (c)(1)

Based on interview and record review, the facility did not ensure that a resident's care plan was reviewed and revised . Specifically, a care plan for a resident with a diagnosis of Depression did not have the Depression care plan revised to include nonpharmacological interventions that would assist the resident to deal with a situation that was adding to her Depression. This was evident for 1 of 33 residents and resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy (#41).

Findings are :

Resident # 41 has diagnoses including Depression. There is a care plan for Depression, however the resident's significant other died in May 2011 and the care plan was not revised to include any nonpharmacologic interventions to deal with this situation that was causing this resident sadness; and contributing to her increased anxiety with shortness of breath documented in her Psychiatric Consult of 6/27/01.

In an interview with the Licensed Practical Nurse unit manager on 7/13/11 at 8:51AM it was stated that the staff had provided support to this resident, but there was no documented evidence that the care plan had been revised to evidence that this support was provided .

415.11 (c)(2)(i-iii)

Based on observations, record reviews and interviews, the facility did not ensure that acceptable procedures and techniques were practiced by the staff to minimize the potential for the development and spread of infection. Specifically, during dressing changes, acceptable techniques were not observed for 1 sampled resident (#99); and line listings (a system which enables facilities to track and monitor infections and potential outbreaks within the facility and signed off by the infection control nurse) are incomplete and lack diagnoses. This was evident for 1 of 3 residents reviewed for pressure ulcers.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Findings are:

Acceptable practices include: a. handwashing guidelines published by the Center for Disease Control (CDC) that recommends washing hands with soap and water for a minimum of 15 seconds. In addition, b. the Association for Professionals in Infection Control and Epidemiology (APIC) Policy and Procedure Manual. These standards include cleansing the wound by starting at the center and making 1 complete cycle, discarding the contaminated gauze , then using another clean gauze to complete another cycle, discarding this and using another clean gauze and repeating the sequence until the entire wound is cleaned. All ointments/creams meant for the wound surface should be applied with a clean Q-tip to avoid injury to intact skin.

1. Resident #99 has diagnoses including Dementia, Hypertension and Diabetes Mellitus. During 2 dressing change observations on 7/13/11 at 10:30AM, the Licensed Practical Nurse was observed to wash the palmer surfaces of her hands for 8 and 6 seconds. She took a Normal Saline soaked 4x4 gauze and cleansed the Stage III sacral wound by repeatedly going back and forth over the entire wound and then refolded the now contaminated, porous 4x4 gauze into a 2x2 and proceeded to cleanse the wound again by dabbing the surface and again going over the wound surface. The LPN then selected a clean 4x4 gauze and dried the wound by dabbing up and down, thus again recontaminating the wound. The LPN changed the adjacent Stage II ulcer on the left cheek about 2 inches from the rectum using the same techniques of cleansing the wound using a 4x4 gauze , refolding the same porous, contaminated gauze to re-clean the surface, and drying the wound by dabbing over and over, again recontaminating the wound. Lastly, the LPN applied Santyl (an ointment used to dry the wound and promote healing) to the wounds and surrounding intact skin with a gloved finger, which made the delivery to the open wound surface more difficult, and again potentially injuring intact skin.

In an interview with the LPN immediately following this observation, she stated that she thought she had hand washed for 20 seconds. She said that she should have started at the center of the wound and continued outward until the entire surface was covered. She was unable to explain why she refolded the porous, contaminated 4x4 gauze to cleanse the wound again. The LPN said that she did not realize that she should apply the ointment to the wound with a Q-tip but stated that this made sense as it would be easier to contain the ointment to the wound area only.

2. The Line Listing (outcome surveillance) is done to identify and report evidence of an infection. The information provided by the Infection Control Nurse on 7/14/11 at 11:00AM lists only the antibiotics administered to residents and lists some diagnoses, in some cases as "throat or ears, legs". There is no documented evidence of the type of infections for these diagnoses. There is no evidence of documentation provided to the facility as to the cause of infections (does not identify causative agent) or of the possible contributory factors.

The June, 2011 Line Listing provided by the facility did not document the origin of the infections regarding hospitals for which antibiotics have been administered. The number of residents who developed infections in the nursing home could not be determined and this listing does not provide adequate information to enable the facility to determine whether it needs to change practices to minimize the potential for transmission of infections.

An interview with the Infection Control nurse on 7/14/11 revealed that this outcome surveillance was approved by the Infection Control Nurse and the Medical Director and no recommendations were made to change the outcome of the current listing.

415.19(a)(1-3)

Based on interview and record review, the facility did not ensure that a Resident's Health Care Proxy(HCP) was current. Specifically a person designated as a Resident's Health Care Proxy had been deceased for more than 1 month and no attempt had been made to have the resident appoint another person as the Health Care Proxy. This was evident for 1 of 33 Residents and resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy (#41).

Findings are:

Resident #41 has diagnoses including Chronic Obstructive Pulmonary Disease and has a HCP naming her significant other (" my long time friend") as her Health Care Proxy. According to the Psychiatrist note of 6/6/11 the resident's long time friend "had died of pneumonia". ( over 1 month ago)

The resident has a BIMS ( Brief Interview Mental Status) of 12 ; and according to interview with the MDS (Minimum Data Set- assessment) nurse , on 7/13/11 at 8:03AM, the Resident can make her own decisions. There was no documented evidence that any attempt was made to have this Resident designate another Health Care Proxy.
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Interview with the Social Worker on 7/1311 at 8:10AM revealed that she had no explanation as to why the Health Care Proxy had not been revised following the death. Following surveyor intervention the Social Worker met with the resident who appointed another person as her Health Care Proxy.

415.3(e)(2)(iii)

Based on observation, interview and record review, the facility did not ensure that medically related social services; notably, a bereavement care plan with interventions, was developed to assist a Resident deal with her grief. Specifically, the death of Resident # 41's significant other contributed to her already diagnosed Depression and there was no plan to assist her through the grieving process. This was evident for 1 of 33 Residents ( # 41 ) and resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.

Findings are:

Resident # 41 has diagnoses including End Stage Chronic Obstructive Pulmonary Disease and was observed on 7/12/11 at 9:30AM receiving continuous oxygen via a nasal cannula attached to an oxygen concentrator.

Interview with the Resident, at that time, revealed that she was "very sad" that her "special friend" ( significant other) had died and that she was "lonesome".

According to the Psychiatrist note of 6/6/11 per Resident assessment the Resident "found out that a long time friend had died" and "she was very sad about this and cried ".

this Psychiatrist note indicated that the Resident has a diagnosis of Major Depressive Disorder, Recurrent with Psychotic Features.

There was no documented evidence that social service developed a care plan for bereavement with interventions to assist this resident through the grieving process.

Interview with the Social Worker on 7/13/11 at 8:11AM as to why there was no bereavement care plan for this resident revealed that she had been busy dealing with the funeral director,speaking with the person who accepted financial responsibility for the significant others funeral and talking with the resident. (This significant other was not a resident of the nursing home). The Social Worker could provide no written evidence of a plan or interventions to assist this resident to deal with this loss.

415.5 (g)(1)(i-xv)

Based on interview and record review, the facility did not ensure that all alleged violations involving mistreatment, neglect, or abuse are reported immediately to the Administrator of the facility; an investigation conducted; and necessary corrective actions taken. Specifically, an evening nurse received a report of an alleged violation and did not report this violation to the Administrator so that it could be investigated. This was evident for 1 of 33 Residents and resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. ( #41 )

Findings are:

Resident # 41 alleged that (date unknown) a Certified Nurse Assistant (CNA) told her that " she was lazy and refused to push her wheelchair " . This resident is end stage Chronic Obstructive Pulmonary Disease and was told by the unit manager that she was not to push her own wheelchair. The resident would not name the CNA.

Interview with another CNA on 7/13/11 at 8:12 AM revealed that the resident # 41 had told her that this had happened and that she had informed the evening nurse of this resident complaint.

A review of 24 hour reports for May/June 2011 revealed no documentation that this allegation had been reported; neither is there any documentation in the nurses notes for May/June 2011.

Interview with the Licensed Practical Nurse ( LPN ) unit manager and the Director of Nursing (DNS ) on 7/13/11 revealed that they had not received any notification of this complaint.

Interview with the DNS on 7/13/11 at 3:22 PM revealed that neither the evening nurse or the CNA on duty in May/June 2011 were currently employed at this facility.

The resident complaint was not reported to the Abuse Prohibition Coordinator (DNS) so that it could be reported to the Administrator and an investigation done to rule out abuse, mistreatment, or neglect.

415.4 (b)(1)(ii)

Based on interviews and record reviews, the facility did not ensure that the medications and biologicals were discarded when expired, and Emergency boxes were checked to ensure that medications contained in there were current, Units 1 and 2. Specifically, Lantus Insulin was opened and not dated on Unit 2; expired Lantus Insulin was not disposed of on Unit 1, and Emergency box medications were expired in an opened Emergency box on Unit 2. This was evident on 2 of 2 units.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Findings are:

1. On 7/11/11 at 8:40AM, during the initial tour of Unit 2 of the facility, 1 Lantus Insulin was opened and not dated when opened. (Lantus Insulin must be discarded after 28 days of opening). The Emergency box was found to have the following outdated medications: lasix 20 mg. - expired on 7/1/11; levaquin 250mg. expired on 6/7/11; lidocaine inj. expired on 7/11; Epi-pe expired on 4/11; Benadryl 50mg./ml - 2 vials expired on 5/11; Lasix 20mg. - 3 vials expired 7/1/11, 2 expired -2/1/11; 2 haldol 5mg./ml. - expired 6/11; and lidocaine hcl. 2% vial expired 7/11.

In an interview with the RN medication nurse on Unit 2 on 7/11/11 at 8:50AM, she stated the Lantus Insulin had to be discarded since it was not dated. She stated that the LPN Unit Manager was responsible for checking the Emergency box.

In an interview with the Unit Manager Licensed Practical Nurse (LPN) on 7/11/11 at 9:00AM, he stated that the RN/LPN medication nurses are responsible for ensuring that medications are dated when opened and are not expired, and that the Registered Nurse Supervisor (RN) is responsible for checking the Emergency boxes on both units.

In an interview with the RN Supervisor on 7/11/11 at 10:15AM, she stated that she had checked the 3 Emergency boxes located in her office and that they were complete and timely. She stated that she does not check the Emergency boxes on the units. She believed that these were checked by the Unit Managers.

In an interview with the Director of Nurses at this same time, she stated that the RN Supervisor is responible for checking the Emergency boxes, and that "clearly there is some miscommunication."

2. During the initial tour of Unit 1 on 7/11/11, an expired vial of Lantus Insulin was not discarded when it expired on 6/28/11. In an interview with the LPN medication nurse on that unit, she state that the Lantus Insulin should have been discarded.

415.18(c(2)

Based on observation, interview, and record review, the facility did not ensure the necessary treatment of non pressure related skin impairment. Specifically , a resident admitted with multiple petechiae on both arms and bruises on the right arm did not receive treatment to prevent these areas from opening. This was evident for 1 of 33 residents ( # 41) and resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.

Findings are:

Resident # 41 has diagnoses including Chronic Obstructive Pulmonary Disease and Depression and receives Prednisone (anti-inflammatory, steroid) daily.

This resident has an admission record of 5/11/11 indicating a skin assessment done by a Registered Nurse (RN).. This assessment identified multiple petechiae on both arms with bruises on the right arm below and above antecubital space.

Observation of this resident on 7/11/11 at 11:30PM revealed the presence of multiple petechia on both arms as well as scattered bruised areas.

A review of resident # 41's skin assessment of 5/17/11 revealed that there was a "Potential Problem" as " During a move skin probably slides to some extent against sheets, chair".

Interview with Resident # 41, at that time, revealed that she "bumps her arms when being transported out of her room via her wheelchair".

Interview with LPN unit manager on 7/13/11 at 3:52 PM revealed that these areas were not being treated as they were not currently open.

415.12

Based on record review and interviews, the licensed Consultant Pharmacist did not ensure that that the facility's Medical Director and Director of Nursing were notified of an irregularity in that a resident's monthly Physician's Orders contained orders for Tylenol which exceeded the recommended 4 Grams per day to ensure resident safety. Specifically, a resident had orders for Tylenlol 650 milligrams (mgs.) every 4 hours whenever necessary for pain/temperature and Tylenol 975 mgs. 1/2 hour before the Stage IV coccyx dressing change every day, which totals to a potential 4875 mgs. of Tylenol per day, (Resident # 123). This was evident for 1 resident in a sample of 11 residents reviewed for medications.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Findings are:

Resident #123 is 79 years old and has diagnoses including a Stage IV Decubitus Ulcer of the Coccyx, Hypertension and Dysphagia ( difficulty swallowing).

On 7/13/11 a review of the resident's May and June Physician's Orders revealed orders for Tylenol 650 mg. every 4 hours as needed and 975 mg. 1/2 hour prior to the coccyx dressing change. This is a total of 4875 mg. per day, 875 mg. in excess of the recommended maximum dosage for this medication at the current time. The orders for the coccyx dressing change had been twice a day from 6/20/11 through 7/4/11, which could have resulted in a total tylenol dosage of 5750 mg. per day. A check of the the Medication Administration Record to see how often the resident had taken Tylenol revealed that the resident had taken Tylenol 650 mg. only once in the past 10 days, and 975 mg. 1/2 hour prior to the coccyx dressing change every day. She also took 975 mg. twice a day during the period of 6/20/11 through 7/4/11.

In an interview with the Licensed Practical Nurse on this same day at 2:30PM, she stated that this dose of Tylenol exceeded the usual maximum of 4 Grams per day recommended by the pharmacy. She was unable to explain why this order had no safety parameters or why it was not picked up by those checking the orders.

In an interview with the Consultant Pharmacist during the afternoon of 7/13/11, he was unable to explain how this potentially excessive dose was not reported to the Medical Director or Director of Nursing in his Medication Regimen Reviews of 5/23/11 and 6/21/11 as an irregularity.

415.18

Based on observation, interview and record review, the facility did not ensure that a resident's plan of care was implemented to provide the resident with adequate fluids daily to prevent dehydration and other health related problems. This has the potential for more than minimal harm that is not immediate jeopardy(#115).

The findings are:

Resident #115, who was admitted to the facility on 5/28/11, has diagnoses that include Congestive Heart Failure and Dementia. The resident's medication regimen includes a diuretic, Lasix 40mg daily. To prevent dehydration, the resident's Comprehensive Care Plan noted that the resident will be provided 2760 cc of fluids daily (based on the resident's body weight of 285 pounds) and that her fluid intake would be monitored daily.

A review of the fluid intake data for the month of 7/11 revealed that the resident's total daily intake is about 1600 cc daily, to include the consumption of fluids at three medication passes.

The resident was observed during the lunch meal on 7/14/11. She was provided the following fluids for this meal: 12 oz ginger ale, 4 oz apple juice and 8 oz skim milk. The resident drank only the milk. She stated that she did not drink the soda because she had the milk and did not drink the juice because she does not like apple juice. She also stated that she likes tea and does not know why tea was not offered. Her meal ticket which has a section for likes and dislikes to be noted reflected no dislikes of any kind.

The Diet Technician (DT) was interviewed at 1:30 PM on 7/14/11 regarding how much fluid is provided to the resident daily. The meal plan provided by the DT showed that 1680 cc is provided at meal times as follows:

Breakfast- juice 4 oz and 8 oz tea (240 cc).
Lunch - 4 oz juice, 8 oz milk and 12 oz ginger ale (720 cc)
Supper - 12 oz ginger ale, 4 oz juice and 8 oz milk (720 cc)

There was no specific plan to ensure that staff provide additional fluids between meals so that the resident would be provided sufficient fluid in accordance with the above mentioned amount of 2760 cc daily.

415.11(c)(3)(ii)

Based on observation and interview, the facility did not allocate adequate dining space for all residents seated in the Unit 02 dining room. This affected 7 sampled residents (Residents #10, 18, 24, 38, 49, 57, 63).

This resulted in the potential for minimal harm that is not immediate jeopardy

Findings are:

Seven residents (Residents #10, 18, 24, 38, 49, 57, 63) were observed seated by a wall in the Unit 02 dining room on 7/11/11 during the lunch meal. The residents had their lunch trays served to them on a hospital style, over bed tables.

The Unit Manager, Licensed Practical Nurse (LPN) was interviewed on 7/11/11 at 1:00PM. The LPN stated that there was not enough room for all the residents to be seated at tables in the unit 02 dining room.

415.29(e)(1-4)

Based on observation and interview, the facility did not provide a homelike dining environment for 7 residents on Unit 02 (Residents #10, 18, 24, 38, 49, 57, 63).

This resulted in the potential for minimal harm that is not immediate jeopardy.

Findings are:

Seven residents (Residents #10, 18, 24, 38, 49, 57, 63) were observed seated by a wall in the Unit 02 dining room on 7/11/11 during the lunch meal. The residents had their lunch trays served to them on hospital style, over bed tables.

The Unit Manager, Licensed Practical Nurse (LPN) was interviewed on 7/11/11 at 1:00PM. The LPN stated that there was not enough room for all the residents to be seated at tables in the unit 02 dining room.

415.5(h)(i)