FRIENDSHIP VILLAGE OF TEMPE

§483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. §483.35(g)(2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. §483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. §483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Based on documentation, staff interviews, and facility procedures, the facility failed to ensure that the information posted on the daily staff posting was complete and correct. Findings include: Review of the daily staff posting dated July 4, 2023 did not reveal the number of registered nurses or licensed practical nurses scheduled to work on the day shift, 6:00 a.m. to 6:30 p.m., or the night shift, 6:00 p.m. to 6:30 a.m. Review of the daily staff posting dated August 6, 2023 did not reveal the number of registered nurses or licensed practical nurses scheduled to work on the day shift, 6:00 a.m. to 6:30 p.m., or the night shift, 6:00 p.m. to 6:30 a.m. The total number of hours worked for one certified nursing assistant (CNA) documented was 24 hours for the night shift, 6:00 p.m. to 6:30 a.m. Review of the daily staff posting dated September 16, 2023 did not reveal the number of registered nurses scheduled to work on the day shift, 6:00 a.m. to 6:30 p.m., or the night shift, 6:00 p.m. to 6:30 a.m. During an interview conducted on October 5, 2023 at 8:36 a.m. with Staff Development Coordinator (staff #102), she reviewed the daily staff postings dated July 4, 2023, August 6, 2023, and September 16, 2023 along with the time cards for all the staff scheduled to work. She stated that the daily staff posting dated August 6, 2023 showed one CNA worked a total of 24 hours was incorrect and should have been 12 hours. She stated that the daily staff posting is supposed be updated and corrections made as changes occur. An interview was conducted on October 5, 2023 at 11:04 a.m. with the Staff Development Coordinator (staff #102), Administrative Assistant (staff #62) and the Administrator (staff #90). Staff #90 stated that the night shift supervisor completes the daily staff posting and everything that is required on the posting is on it. Staff #90 and staff #102 agreed that the total number of each category of staff should be documented on the posting. Staff #102 also stated that the total number of hours worked by each staff should be documented on the posting and staff #90 stated that it is her expectation that any changes regarding the information on the posting are penned in by the supervisor as changes occur. Staff #90 stated there is a regulation that the staffing information is posted and the facility doesn't have a policy regarding the posting.

Based on review of clinical records and policy, and staff interviews the facility failed to ensure an order for pain medication was followed as prescribed for Resident #32 by failing to administer medication within the physician ordered parameters. The deficient practice of administering unnecessary medication may result in undesirable medication-induced harm. Resident #32 was admitted into the facility on August 8, 2023 with diagnoses that included fracture of upper end of left humerus, pain, Alzheimer's, dementia, anxiety, and constipation. Review of the physician orders revealed the following: Morphine Sulfate Oral Solution 20 milligram (mg) / 5 milliliters (ml) (Morphine Sulfate) to give 0.125 milliliters sublingually every 4 hours as needed for pain 4-10 with start date of August 21, 2023. Review of Medication Administration Records (MAR) revealed that this medication was administered outside of physician ordered parameters (pain 4-10) on: Thursday August 24, 2023 pain level of 3. Monday September 18, 2023 pain level of 2. Tuesday September 19, 2023 pain level of 3. Friday September 29, 2023 pain level of 0. An interview was conducted on October 10, 2023 at 12:03 PM with LPN (Licensed Practical Nurse) Staff #244. Staff #244 was asked about the process of administering medication and explained that medication is given to residents as per written orders. Staff #244 confirmed that written pain levels on MAR were pain assessments prior to the administration of morphine to Resident #32. Staff #244 verified the MAR and confirmed that the medication was given outside of the parameters of 4-10 pain scale on those selected dates. Staff #244 stated it was inappropriate and giving the medication for the documented pain level was over medicating Resident #32. An interview was conducted on October 10, 2023 at 12:29 P.M. with the Director of Nursing (DON/Staff #190). During this meeting, RN Case Manager (Staff # 111) joined in the interview at 12:55 PM. The DON stated, "I expect nurses are trained and oriented on administration, educated one-time a year and refresh training, regarding doctors' orders, I expect nurses to follow medication order as written." Staff #190 stated, "pain scale should be followed" when asked about pain medication administration. Staff #190 reviewed the electronic medical records, including MAR, and agreed that the pain levels 2, 3, 0, were below the required parameters for morphine. Staff #190 invited Staff #111 to join the meeting and requested full review of medical record including the MAR and progress notes for Resident #32. Staff #111 confirmed that morphine was given at a 2-pain level on September 18th, 3-pain level on September 19th, and 0-pain level on September 29th. Staff #111 stated that the risks for giving morphine outside of the parameters were sedation and fatigue. The document Policy & Procedure # CLIN 165 titled, "Medication Administration" (revised August 23, 2022) was reviewed and revealed, "Medications will be administered within written parameters, I.e.: pain levels".

Based on documentation, staff interviews, and facility procedures, the facility failed to ensure that the information posted on the daily staff posting was complete and correct. Findings include: Review of the daily staff posting dated July 4, 2023 did not reveal the number of registered nurses or licensed practical nurses scheduled to work on the day shift, 6:00 a.m. to 6:30 p.m., or the night shift, 6:00 p.m. to 6:30 a.m. Review of the daily staff posting dated August 6, 2023 did not reveal the number of registered nurses or licensed practical nurses scheduled to work on the day shift, 6:00 a.m. to 6:30 p.m., or the night shift, 6:00 p.m. to 6:30 a.m. The total number of hours worked for one certified nursing assistant (CNA) documented was 24 hours for the night shift, 6:00 p.m. to 6:30 a.m. Review of the daily staff posting dated September 16, 2023 did not reveal the number of registered nurses scheduled to work on the day shift, 6:00 a.m. to 6:30 p.m., or the night shift, 6:00 p.m. to 6:30 a.m. During an interview conducted on October 5, 2023 at 8:36 a.m. with Staff Development Coordinator (staff #102), she reviewed the daily staff postings dated July 4, 2023, August 6, 2023, and September 16, 2023 along with the time cards for all the staff scheduled to work. She stated that the daily staff posting dated August 6, 2023 showed one CNA worked a total of 24 hours was incorrect and should have been 12 hours. She stated that the daily staff posting is supposed be updated and corrections made as changes occur. An interview was conducted on October 5, 2023 at 11:04 a.m. with the Staff Development Coordinator (staff #102), Administrative Assistant (staff #62) and the Administrator (staff #90). Staff #90 stated that the night shift supervisor completes the daily staff posting and everything that is required on the posting is on it. Staff #90 and staff #102 agreed that the total number of each category of staff should be documented on the posting. Staff #102 also stated that the total number of hours worked by each staff should be documented on the posting and staff #90 stated that it is her expectation that any changes regarding the information on the posting are penned in by the supervisor as changes occur. Staff #90 stated there is a regulation that the staffing information is posted and the facility doesn't have a policy regarding the posting.

Based on review of clinical records and policy, and staff interviews the facility failed to ensure an order for pain medication was followed as prescribed for Resident #32 by failing to administer medication within the physician ordered parameters. The deficient practice of administering unnecessary medication may result in undesirable medication-induced harm. Resident #32 was admitted into the facility on August 8, 2023 with diagnoses that included fracture of upper end of left humerus, pain, Alzheimer's, dementia, anxiety, and constipation. Review of the physician orders revealed the following: Morphine Sulfate Oral Solution 20 milligram (mg) / 5 milliliters (ml) (Morphine Sulfate) to give 0.125 milliliters sublingually every 4 hours as needed for pain 4-10 with start date of August 21, 2023. Review of Medication Administration Records (MAR) revealed that this medication was administered outside of physician ordered parameters (pain 4-10) on: Thursday August 24, 2023 pain level of 3. Monday September 18, 2023 pain level of 2. Tuesday September 19, 2023 pain level of 3. Friday September 29, 2023 pain level of 0. An interview was conducted on October 10, 2023 at 12:03 PM with LPN (Licensed Practical Nurse) Staff #244. Staff #244 was asked about the process of administering medication and explained that medication is given to residents as per written orders. Staff #244 confirmed that written pain levels on MAR were pain assessments prior to the administration of morphine to Resident #32. Staff #244 verified the MAR and confirmed that the medication was given outside of the parameters of 4-10 pain scale on those selected dates. Staff #244 stated it was inappropriate and giving the medication for the documented pain level was over medicating Resident #32. An interview was conducted on October 10, 2023 at 12:29 P.M. with the Director of Nursing (DON/Staff #190). During this meeting, RN Case Manager (Staff # 111) joined in the interview at 12:55 PM. The DON stated, "I expect nurses are trained and oriented on administration, educated one-time a year and refresh training, regarding doctors' orders, I expect nurses to follow medication order as written." Staff #190 stated, "pain scale should be followed" when asked about pain medication administration. Staff #190 reviewed the electronic medical records, including MAR, and agreed that the pain levels 2, 3, 0, were below the required parameters for morphine. Staff #190 invited Staff #111 to join the meeting and requested full review of medical record including the MAR and progress notes for Resident #32. Staff #111 confirmed that morphine was given at a 2-pain level on September 18th, 3-pain level on September 19th, and 0-pain level on September 29th. Staff #111 stated that the risks for giving morphine outside of the parameters were sedation and fatigue. The document Policy & Procedure # CLIN 165 titled, "Medication Administration" (revised August 23, 2022) was reviewed and revealed, "Medications will be administered within written parameters, I.e.: pain levels".