Desert Highlands Care Center

Based on clinical record review, staff interviews and facility policy, the facility failed to ensure procedures were activated timely when the the Resident (#11) failed to return to the facility. The deficient practice may result in unidentified residents who eloped.

Based on clinical record review, staff interviews and facility policy, the facility failed to ensure procedures were activated timely when the the Resident (#11) failed to return to the facility. 

Based on documentation, staff interviews, and policy and procedures, the facility failed to protect other residents from further abuse by one resident (#10).

Findings include:

Review of the 5-day investigation dated November 20, 2024 revealed that on November 17, 2024, between 2:30 p.m. and 3:30 p.m. a licensed nursing aid (LNA/staff #12) informed the Director of Nursing (DON/staff #60) that resident #10 had exposed his private parts to resident #7 in the hallway. A licensed nurse practitioner (LPN/staff #8) stated that they didn't witness the incident and reiterated to with resident #10 that he was not permitted into the hallway. Staff #12 immediately redirected resident #10 back to his room and reported the incident to the Administrator (staff #1). On Monday, November 18, 2024, the Administrator (staff #1) initiated a formal investigation. The Administrator interviewed resident #7, who stated that she did not recall the incident. During the interview with resident #10, he denied intentionally exposing himself, but acknowledged scratching his genital area. On Tuesday, November 19, 2024 resident #10 was discharged from the facility. Given that resident #10 had a similar history of behavior in other facilities, he was discharged promptly.

Review of facility documention and the floor map, revealed that resident #10's room #27 was located on the East Hall along with three female residents (#37, #45, and #58) in rooms #28 and #30. The nurse's station was located in the middle of the building and the resident would need to cross by the nurse's station to access the Central Hall where resident's #7 and #4 reside.

An observation conducted on November 22, 2024 at 10:58 a.m. revealed that the staff had a limited view of the East Hall from the nurse's station. It was observed that residents' #10, #37, #45, and #58 were not visible from the nurse's station.

An interview was conducted with (LNA/staff #12) on November 20, 2024 at 12:22 p.m., who stated that she has received training on abuse, which includes sexual abuse and emotional abuse. She stated that resident #10 visits resident #7 in her room. Staff #12 stated that the door was open and resident #10 was in his wheelchair facing away from the door towards the resident, who was in bed, when she entered the room looking for wipes. She stated that resident #7 looked a little red as if she was blushing and the two residents were talking, but she couldn't hear what they were saying. Staff #12 glanced over and saw resident's #10's penis was out and in his hand. Staff #12 reached up on the dresser to get the wipes and when she turned around, resident #10 had put his penis back in his pants. Staff #12 told resident #10 to leave the room. She asked resident #7 if she knew what resident #10 was doing and the resident was babbling and then said, "well, I told him to put it away." Staff #12 stated that she believes that (LPN/staff #8) told resident #10 not to leave his hallway, not to go past the nurse's station and imagined that he was in his room. She stated that resident #10 has visited another female resident (#4), but doesn't think that she would remember anything because she has severe dementia. She stated that resident #10 wanders up and down the East Hall to the Central Hall.

An interview was conducted on November 20, 2024 at 2:37 p.m. with a registered nurse (RN/staff #2), who stated that (LPN/staff #8) told her that (CNA/staff #12) told her that resident #10 exposed himself. Staff #2 told resident #10 that he had to stay on the East Hall and was not to pass the nurse's station. Staff #2 stated that she informed resident #10 that there was an allegation about him and he didn't ask any questions and seemed nervous. She stated that there were three female residents on the East Hall at the time of the incident where resident #10's room was located. She stated that she has received training about abuse and the staff are supposed to keep the residents safe. The staff were told to keep an eye on resident #10, but no one sat at the nurse's station the entire time and it is possible that resident #10 went somewhere if staff were not present at all times.

An interview was conducted on November 20, 2024 at 2:57 p.m. with a licensed practical nurse (LPN/staff #8), who stated that (LNA/staff #12) told her that resident #7 stated that she was uncomfortable or didn't like it when resident #10 was in her room. Staff #8 stated that resident #10 visits resident #7's room frequently. She stated that (RN/staff #2) told resident #10 that he had to stay in his room and staff #2 said that he kind of looked guilty. She stated that she only had about an hour left on her shift and charting at the nurse's station when resident #10 tried to go down another hall and she told him no.

An interview was conducted with the Director of Nursing (DON/staff #60) on November 21, 2024 at 11:52 a.m. She stated that she has recieved training on abuse and sexual abuse includes masterbating in front of another person and the other person doesn't want it. She stated that staff were told that resident #10 could not be in other residents' rooms, but could be in common areas with supervision. She stated that if staff were sitting at the nurse's station while supervising the resident, it would not be sufficient because staff cannot see down the East Hall where the resident room was located. She stated that there were three to four women in rooms on the East Hall at the time of the incident and if the hall wasn't watched, it is possible that resident #10 could have entered one of the females rooms on the East Hall.

An interview was conducted on November 21, 2024 at 12:14 p.m. with the Administrator (staff #1), who stated that sexual abuse included a person masterbating in front of another person. She stated that she strongly recommended that staff not allow resident #10 back into the hallway, he was to remain in his room. She wanted to protect resident #7 from resident #10 and stated that when the allegation was reported to her, she didn't know about protecting the female residents on the East Hall. She also stated that if the staff were monitoring resident #10 from the nurse's station, staff would not have been able to see down the East Hall.

The facility policy, "Abuse Prevention Program" states that the facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress.

Based on documentation, staff interviews, and policy and procedures, the facility failed to report an allegation of sexual abuse to the state agency within the regulated timeframe.

Findings include:

Review of the online report to the state agency revealed that the facility reported an allegation of sexual abuse that occurred on November 17, 2024 at 3:10 p.m., on November 18, 2024.

Review of the 5-day investigation dated November 20, 2024 revealed that on November 17, 2024, between 2:30 p.m. and 3:30 p.m. a licensed nursing aid (LNA/staff #12) informed the Director of Nursing (DON/staff #60) that resident #10 had exposed his private parts to resident #7 in the hallway. A licensed nurse practitioner (LPN/staff #8) stated that they didn't witness the incident and reiterated to with resident #10 that he was not permitted into the hallway. Staff #12 immediately redirected resident #10 back to his room and reported the incident to the Administrator (staff #1). On Monday, November 18, 2024, the Administrator (staff #1) initiated a formal investigation.

An interview was conducted on November 21, 2024 at 11:52 a.m. with the Director of Nursing (DON/staff #60), who stated that an allegation for sexual abuse should be reported within two hours of the facility becoming aware of the allegation.

An interview was conducted on November 21, 2024 at 12:14 p.m. with the Administrator (staff #1), who stated that sexual abuse included a person masturbating in front of another person and has to be reported to the state agency if it is confirmed as sexual abuse. She stated that she received a call from the facility on November 17, 2024 and reported to the state agency on November 18, 2024.

The facility policy, "Abuse Prevention Program" states that If the events that cause the allegation involve abuse or result in serious bodily injury to a resident, a report must be made immediately and not later than 2 hours after receiving the allegation, If the events that cause the allegation do not
involve abuse and do not result in serious bodily injury, the report must be made within 24 hours
of receiving the allegation. The facility must report the allegation and not wait until confirmed with an investigative process.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that resident (#7) was not exposed to inappropriate sexual behaviors by resident (#10).

Findings include:

Resident #7 was admitted to the facility on January 23, 2024 with diagnoses that included multiple sclerosis, dementia, and generalized muscle weakness.

The minimum data set (MDS) dated September 23, 2024 included a brief interview for mental status score of 9 indicating the resident had a mild cognitive impairment.

An incident note dated November 17, 2024 revealed that a certified nursing assistant (CNA) reported at 2:15 p.m. that resident #10 was in resident #7's room and exposed himself to resident #7.

Review of a progress note dated November 17, 2024 revealed that the central nurse reported on November 17, 2024 at 2:15 p.m. that the nurse's aid observed resident #10 in resident #7's room displaying inappropriate behavior. Resident #10 redirected immediately to stay on the East Hall until further notice . The incident was reported to the Administrator.

A social services progress note dated November 20, 2024 revealed that the facility made a police report.

-Resident #10 was admitted to the facility on September 23, 2024 with diagnoses that included type II diabetes, acute kidney failure, and alcohol abuse.

The minimum data set (MDS) dated October 6, 2024 included a brief interview for mental status score of 14 indicating the resident was cognitively intact.

A progress note dated November 19, 2024 revealed that resident #10 was discharged home with a family member.

Review of the 5-day investigation dated November 20, 2024 revealed that on November 17, 2024, between 2:30 p.m. and 3:30 p.m. a licensed nursing aid (LNA/staff #12) informed the Director of Nursing (DON/staff #60) that resident #10 had exposed his private parts to resident #7 in the hallway. A licensed nurse practitioner (LPN/staff #8) stated that they didn't witness the incident and reiterated to with resident #10 that he was not permitted into the hallway. Staff #12 immediately redirected resident #10 back to his room and reported the incident to the Administrator (staff #1). On Monday, November 18, 2024, the Administrator (staff #1) initiated a formal investigation. The Administrator interviewed resident #7, who stated that she did not recall the incident. During the interview with resident #10, he denied intentionally exposing himself, but acknowledged scratching his genital area. On Tuesday, November 19, 2024 resident #10 was discharged from the facility. Given that resident #10 had a similar history of behavior in other facilities, he was discharged promptly.

An interview was conducted with (LNA/staff #12) on November 20, 2024 at 12:22 p.m., who stated that she has received training on abuse, which includes sexual abuse and emotional abuse. She stated that resident #10 visits resident #7 in her room. Staff #12 stated that the door was open and resident #10 was in his wheelchair facing away from the door towards the resident, who was in bed, when she entered the room looking for wipes. She stated that resident #7 looked a little red as if she was blushing and the two residents were talking, but she couldn't hear what they were saying. Staff #12 glanced over and saw resident's #10's penis was out and in his hand. Staff #12 reached up on the dresser to get the wipes and when she turned around, resident #10 had put his penis back in his pants. Staff #12 told resident #10 to leave the room. She asked resident #7 if she knew what resident #10 was doing and the resident was babbling and then said, "well, I told him to put it away." Staff #12 stated that she believes that (LPN/staff #8) told resident #10 not to leave his hallway, not to go past the nurse's station and imagined that he was in his room. She stated that resident #10 has visited another female resident (#4), but doesn't think that she would remember anything because she has severe dementia.

An interview was conducted on November 20, 2024 at 2:37 p.m. with a registered nurse (RN/staff #2), who stated that (LPN/staff #8) told her that (LNA/staff #12) told her that resident #10 exposed himself and resident #7 told the CNA that she was uncomfortable with what had happened.

An interview was conducted on November 20, 2024 at 2:57 p.m. with a licensed practical nurse (LPN/staff #8), who stated that (LNA/staff #12) told her that resident #7 stated that she was uncomfortable or didn't like it when resident #10 was in her room. Staff #8 stated that resident #10 visits resident #7's room frequently. She stated that (RN/staff #2) told resident #10 that he had to stay in his room and staff #2 said that he kind of looked guilty. She stated that she only had about an hour left on her shift and charting at the nurse's station when resident #10 tried to go down another hall and she told him no.

An interview was conducted with resident #7 on November 22, 2024 at 11:05 a.m. She stated that resident #10 started by coming by her door and then made his way to her room. At first, she told resident #10 that he can't come into her room, but he kept coming by and smiling. She stated that she knew that he was doing something with his private parts and every time, he would have his pants undone and his hand was there. She stated that she is not stupid, she knew what resident #10 was doing and something was wrong. She stated that resident #10 asked her if it bothered her and she told him that it did and he would stop and say that he wouldn't do it again. She stated that when he came to her room, he would do it again. She stated that she couldn't see his penis, but she could see his hand/fingers moving over his crotch. She stated that resident #10's pants were often open and unzipped, but she couldn't see everything because her bed is higher than his wheelchair.

An interview was conducted with the Director of Nursing (DON/staff #60) on November 21, 2024 at 11:52 a.m. She stated that she has received training on abuse and sexual abuse includes masturbating in front of another person and the other person doesn't want it. She stated that staff were told that resident #10 could not be in other residents' rooms, but could be in common areas with supervision. She stated that if staff were sitting at the nurse's station while supervising the resident, it would not be sufficient because staff cannot see down the East Hall where the resident room was located. She stated that there were three to four women in rooms on the East Hall at the time of the incident and if the hall wasn't watched, it is possible that resident #10 could have entered one of the females rooms on the East Hall.

An interview was conducted on November 21, 2024 at 12:14 p.m. with the Administrator (staff #1). She stated that sexual abuse includes masturbation, someone touching themselves in front of someone else. She stated that the allegation was inconclusive because resident #10 stated that he was scratching himself.

The facility policy, "Abuse Prevention Program" states that the facility will not tolerate verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property, by employees, family members, visitors, or other residents.

Based on documentation, staff and resident interviews, the facility policy and procedures, the facility failed to report an allegation of sexual abuse for one resident (#15).

Findings include:

Resident #15 was admitted to the facility on August 25, 2023 with diagnoses that included congestive heart failure, hypertension, and anemia.

The minimum data set (MDS) dated November 27, 2023 included a brief interview for mental status score of 13 indicating the resident was cognitively intact

Review of the activity daily living (ADL) care plan dated September 1, 2023 revealed that the resident needs help with ADLs due to decreased ADL participation and is receiving therapy. Interventions included to assist with ADLs as needed and to reinforce therapy by following occupational and physical therapy instructions. Watch the resident for fatigue.

The order summary included an order dated September 1, 2023 for excoriation to the buttocks, cleanse, with normal saline (NS). Apply Calazinc twice daily until resolved for skin integrity.

Review of the facility work schedules revealed that Certified Nursing Assistant (CNA/staff #22) and (CNA/staff #10) worked on February 12, 2024.

An interview was conducted on February 21, 2024 at 2:36 PM with a (CNA/staff #22), who stated that he provided continence care with (CNA/staff #10) for resident #15, the day before the resident was discharged, and the resident was discharged on February 13, 2024. He stated that the resident had a rash and he applied ointment, while staff #10 helped stabilize the resident on his side. He stated that during this time, the resident said, "I don't do that. You put your finger in my butt hole." Staff #22 said that he immediately apologized for whatever the resident thought had happened.

An interview was conducted on February 21, 2023 at 3:00 PM with (CNA/staff #56), who stated that she has received abuse training. She stated that if a resident reports that staff has done anything to him/her, she is to report it within 2 hours to the supervisor.

An interview was conducted on February 21, 2024 at 3:14 PM with (CNA/staff #10), who stated that she has received abuse training and has 2 hours to report it to the supervisor. She stated that she and staff #22 were providing continence care. Staff #22 was applying cream and the resident said, "Ow" and tugged away and staff #22 explained what he was doing. She stated that the resident said, "That's my butt hole." She stated that the nurse was also in the room assisting the roommate on the other side of the curtain and the resident seemed to calm down.

An interview was conducted on February 21, 2024 at 3:31 PM with a Licensed Practical Nurse (LPN/staff #38), who stated that she went into the room when CNA/staff #22) and (CNA/staff #10) were providing continence care for resident #15 because she needed to hang an IV for the roommate. She stated that she didn't hear the resident make any statements that would indicate that something was wrong, but she left the room while the two CNAs were still providing continence care. She stated that she has received abuse training and if the resident stated, "That's my butt hole, I don't do that", the CNAs should have reported it to her. She stated that she would have removed the staff and interviewed the resident to understand his perception of what happened.

An interview was conducted on February 22, 2024 at 9:50 AM with the Administrator, who stated that she was going to provide staff with additional training on abuse.

The facility policy, "Abuse Prevention Program" revised September 2021 states that any person(s) observing, or having reason to suspect, resident abuse, neglect, mistreatment or misappropriation of resident property, is to report the findings either their supervisor or the charge nurse. If the events that cause the allegation involve abuse result in serious bodily injury to a resident, a report must be made immediately and no later than 2 hours after receiving the allegation.

Based on documentation, staff and resident interviews, the facility policy and procedures, the facility failed to report an allegation of sexual abuse for one resident (#15). The deficient practice could result in residents being abused.

Findings include:

Resident #15 was admitted to the facility on August 25, 2023 with diagnoses that included congestive heart failure, hypertension, and anemia.

The minimum data set (MDS) dated November 27, 2023 included a brief interview for mental status score of 13 indicating the resident was cognitively intact

Review of the activity daily living (ADL) care plan dated September 1, 2023 revealed that the resident needs help with ADLs due to decreased ADL participation and is receiving therapy. Interventions included to assist with ADLs as needed and to reinforce therapy by following occupational and physical therapy instructions. Watch the resident for fatigue.

The order summary included an order dated September 1, 2023 for excoriation to the buttocks, cleanse, with normal saline (NS). Apply Calazinc twice daily until resolved for skin integrity.

Review of the facility work schedules revealed that Certified Nursing Assistant (CNA/staff #22) and (CNA/staff #10) worked on February 12, 2024.

An interview was conducted on February 21, 2024 at 2:36 PM with a (CNA/staff #22), who stated that he provided continence care with (CNA/staff #10) for resident #15, the day before the resident was discharged, and the resident was discharged on February 13, 2024. He stated that the resident had a rash and he applied ointment, while staff #10 helped stabilize the resident on his side. He stated that during this time, the resident said, "I don't do that. You put your finger in my butt hole." Staff #22 said that he immediately apologized for whatever the resident thought had happened.

An interview was conducted on February 21, 2023 at 3:00 PM with (CNA/staff #56), who stated that she has received abuse training. She stated that if a resident reports that staff has done anything to him/her, she is to report it within 2 hours to the supervisor.

An interview was conducted on February 21, 2024 at 3:14 PM with (CNA/staff #10), who stated that she has received abuse training and has 2 hours to report it to the supervisor. She stated that she and staff #22 were providing continence care. Staff #22 was applying cream and the resident said, "Ow" and tugged away and staff #22 explained what he was doing. She stated that the resident said, "That's my butt hole." She stated that the nurse was also in the room assisting the roommate on the other side of the curtain and the resident seemed to calm down.

An interview was conducted on February 21, 2024 at 3:31 PM with a Licensed Practical Nurse (LPN/staff #38), who stated that she went into the room when CNA/staff #22) and (CNA/staff #10) were providing continence care for resident #15 because she needed to hang an IV for the roommate. She stated that she didn't hear the resident make any statements that would indicate that something was wrong, but she left the room while the two CNAs were still providing continence care. She stated that she has received abuse training and if the resident stated, "That's my butt hole, I don't do that", the CNAs should have reported it to her. She stated that she would have removed the staff and interviewed the resident to understand his perception of what happened.

An interview was conducted on February 22, 2024 at 9:50 AM with the Administrator, who stated that she was going to provide staff with additional training on abuse.

The facility policy, "Abuse Prevention Program" revised September 2021 states that any person(s) observing, or having reason to suspect, resident abuse, neglect, mistreatment or misappropriation of resident property, is to report the findings either their supervisor or the charge nurse. If the events that cause the allegation involve abuse result in serious bodily injury to a resident, a report must be made immediately and no later than 2 hours after receiving the allegation.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure infection prevention and control standards were maintained during medication administration.

Findings include:

During medication administration observation with a Registered Nurse (RN/staff #8), conducted on August 31 2023 at 8:05 a.m., the RN dropped a medication on the floor. The RN picked up the medication from the floor and discarded the medication in the sharps' container. The RN then replaced the medication, placed it into the medication cup, then entered the resident's room to administer the prepared medications. The RN did sanitize her hands after removing the medication from the floor and prior to administration of the medications to the resident (#39). The RN entered
the room of another resident (#26) with a wrist type blood pressure monitor, took the resident's blood pressure. She removed the blood pressure cuff from the resident's arm, administered the medication, exited the room and placed the cuff on top of the medication cart. However, the RN did not sanitize the wrist blood pressure cuff after using it and also did not sanitize her hands after exiting the resident's room. The RN then proceeded to preparing the medications for administration for another resident (#25). However, the RN did not sanitize her hands after exiting the previous room or prior to medication preparation for resident #25. She then entered room of the resident (#25) and administered the medications to the resident. The RN did not sanitize her hands prior to entering the resident's room, or after exiting the resident's room.

Continued observation of medication administration with the RN revealed that the RN carried a medication bubble pack into a resident's (#23) room and laid it on the resident's bed. The RN proceeded to take the resident's pulse, removed the tablet from the bubble pack, placed the medication in the medication cup and administered the medication. She then carried the bubble pack back to the medication cart and placed the bubble pack into the medication cart drawer. The RN then removed an inhaler from the medication cart. For the duration of this observation, the RN did not sanitize her hands after taking the resident's pulse or upon exiting the resident's room or prior to removing the inhaler from the medication cart.

An interview with the RN (staff #8) was conducted at 8:37 a.m. immediately following the observation. The RN stated that the facility policy was to sanitize her hands between each resident care/interaction; and that, the wrist blood pressure cuff should also be sanitize after each resident use. However, the RN stated that she did not have any sanitizing wipes on her cart, so she could not sanitize the blood pressure cuff after she used it with the resident. She further stated that she did not have any sanitizing wipes on her cart since January 2023, and did not sanitize the blood pressure cuff. She also stated that she did not ask anyone for more wipes, or tell anyone that she did not have any. The RN stated that the risk of not sanitizing her hands or the blood pressure cuff between residents could result in transmission of infection.

An interview with a licensed practical nurse (LPN/staff #53) was conducted on August 31, 2023 at 8:38 a.m. The LPN stated that blood pressure cuffs were to be sanitized between each resident use.

In an interview with a certified nursing assistant (CNA/staff #45) conducted on August 31, 2023 at 8:43 a.m., the CNA said the wrist blood pressure cuffs should be sanitized between each resident use with an alcohol wipe or sanitizer wipe.

An interview was conducted on August 31, 2023 at 8:47 a.m. with a restorative nurse aide (RNA/staff #77) who stated that the wrist blood pressure cuffs should be sanitized between each resident use; and that, she uses a sanitizing wipe or hand gel and a paper towel.

During an interview with the Director of Nursing (DON/staff #32) conducted on August 31, 2023 at 8:50 a.m., the DON stated that her expectation was for staff to sanitize their hands upon entering and exiting resident rooms; and that, wrist blood pressure cuffs to be sanitized after each resident use. She stated that a nurse carrying a medication card into a resident's room and placing it on the bed did not meet her expectation as the bed would be considered dirty. She further stated that the medication would then be "dirty" and all the medications/card would need to be discarded. The DON also stated that sanitizing wipes should be available on each medication cart. Further, the DON stated that the risk of not sanitizing hands upon entering/exiting rooms, sanitizing blood pressure cuff after each patient use, and taking medication cards into resident rooms could result in transmission of infection.

Review of a facility policy on Cleaning and Disinfection of Resident-Care Items and Equipment, revealed that non-critical items, including blood pressure cuffs, should be sanitized with an EPA registered disinfectant. Reusable resident care equipment is cleaned and disinfected or sterilized between residents.

The facility policy on Handwashing/Hand Hygiene, revealed that the facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub before and after direct contact with residents, before preparing or handling medications, after contact with objects in the immediate vicinity of the resident.

Review of the facility policy titled, Administering Medications, revealed that staff follows established facility infection control procedures (e.g. hand washing, antiseptic technique) for the administration of medications.

Based on clinical record review, resident and staff interviews and policy review, the facility failed to ensure a care plan was revised regarding refusals for turning/repositioning and air mattress for one resident (#22). The deficient practice could result in resident not receiving appropriate treatment to meet their needs.

Findings include:

Resident #22 was admitted on April 25, 2022 with diagnoses of pyonephrosis, sepsis, protein calorie malnutrition, and lack of coordination.

Review of a care plan dated March 21, 2022 included the resident had the potential for skin breakdown.

The wound assessment reports dated June 22, 29, and July 6, 2023 revealed the resident continued to refuse repositioning and air mattress; and that, the resident remained non-compliant.

The care plan dated July 7, 2023 included that a skin breakdown was present.

The quarterly Minimum Data Set assessment dated July 19, 2023, revealed a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The assessment also revealed the presence of one stage 2 pressure ulcer.

Review of wound assessment reports dated July 13 and 20, 2023 included that the resident continued to refuse repositioning and air mattress.

Continued review of the clinical record revealed documentation in multiple progress notes that the resident refused to be turned/repositioned, and refused to use an air mattress.

Review of the care plan reviewed on July 19, 2023 included the resident had a potential for skin breakdown; and that, a skin breakdown was present. Interventions included pressure relieving mattress, frequent repositioning, develop/monitor turning scheduled.

However, there was no evidence that the care plan had been revised/updated regarding the resident's refusal for use of pressure relieving mattress and turning/repositioning.

An interview was conducted on August 30, 2023 at 11:06 a.m. with a certified nursing assistant (CNA/staff #87) who stated that the facility policy was to turn/reposition resident's with pressure ulcers every 2 hours and as needed. She further stated that CNAs do not document this in the clinical record, but that, they would tell the nurses that they completed the task.

An interview with resident #22 was conducted on August 30, 2023 at 11:33 a.m. Resident #22 stated she refuses to be turned/repositioned and to have a low air loss mattress on her bed.

In an interview with a licensed practical nurse (LPN/staff #53) conducted on August 30, 2023 at 12:23 p.m., the LPN stated that resident #22 has a pressure on the coccyx and refuses to be turned/repositioned and also refuses to use an air mattress. She stated that the resident's care plan should be updated with interventions if a resident refused to be turned/repositioned, and refuse to use the air mattress. The LPN said that the risk of not updating interventions on a care plan could result in staff not knowing how to take care of a resident.

During an interview conducted with an Assistant Director of Nursing (ADON/staff #72) on August 30, 2023 at 12:53 p.m., the ADON stated that care plans should be updated every 3 months; and that, if interventions include turning/repositioning and use of an air mattress, the care plan should be updated if the resident refuses these interventions. A review of the resident's clinical record was conducted with the ADON who stated that the resident's care plan was last updated on July 19, 2023 to include interventions to turn/reposition and use an air mattress. However, the ADON stated that the care plan was not revised to include the resident's refusals of the care planned interventions.

Review of the facility policy titled, Comprehensive Person-Centered Care Plans, revealed that the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

-Resident #51 was admitted on June 9, 2023 with diagnoses of anemia, diabetes, atrial fibrillation, and depression.

The standard care plan dated June 2, 2023 included the resident had a potential for skin breakdown related to incontinence and/or immobility. Interventions included treatment per protocol and physician order and to chart effectiveness.

The minimum data set (MDS) assessment dated June 9, 2023 included a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact.

A dermatology visit note dated August 16, 2023 included that an impression of allergic contact dermatitis with unknown/unspecified cause. Per the documentation, the resident had blisters located on the trunk; and the status was documented as inadequately controlled. Plan included a prescription for triamcinolone acetonide (topical steroid) 0.1% topical cream twice daily for 4 weeks.

Regarding prednisone:

A physician order dated August 15, 2023 included for prednisone (steroid) 10 milligrams (mg) tablet give one tablet by mouth daily for seven days.

The order for prednisone was transcribed onto the medication administration record (MAR) for August 2023; and, it had a stop date of August 22, 2023.

However, review of the MAR for August 2023 revealed that prednisone was not marked as administered from August 16 through 20, 2023.

Regarding triamcinolone:

A physician order dated August 18, 2023 included for triamcinolone cream 0.1%, apply topically to affected area twice daily for 4 weeks for skin integrity.

The orders for triamcinolone was transcribed onto the medication administration record (MAR) for August 2023 and had a stop date of September 15, 2023.

However, review of the MAR for August 2023 revealed that triamcinolone was not marked administered until August 21, 2023 (approximately 3 days after it was ordered).

The order for triamcinolone continued to be transcribed onto the MAR for September 2023. It included for triamcinolone acetonide 0.1% apply topically to affected area twice daily for 4 weeks.

However, continued review of the MAR revealed that this medication was not marked as administered from September 1 through 7, 2023

Further review of the clinical record revealed no documentation why prednisone and triamcinolone were not administered as ordered; and that, the physician was notified.

An interview and a review of the clinical record was conducted with a licensed practical nurse (LPN/staff #53) on September 7, 2023 at 8:53 a.m. The LPN said that MAR for August 2023 revealed no evidence that prednisone was administered to the resident's rash was given as prescribed. The LPN also stated that the MAR for September 2023 also showed no documentation that triamcinolone was administered to the resident as ordered. Further, the LPN said that if there was no documentation that it was given, then technically it was not done.

An interview with the Director of Nursing (DON/staff #32) was conducted on September 7, 2023 at 9:54 a.m. During the interview a review of the clinical record was conducted with the DON who stated that the MAR for August 2023 and September 2023 revealed that prednisone and triamcinolone were not administered to the resident as ordered. She stated that there was a risk of the condition worsening when the medications and treatments were not administered.

A review of the facilities Medication Administration policy, revised April 2019 revealed that the facility did not follow the policy to ensure medications are administered in accordance with prescriber orders, including any required time frame and that if a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug or dose.

-Resident #230 was admitted on August 1, 2023 with diagnoses of generalized muscle weakness, unsteadiness on feet, major depressive disorder and severe protein-calorie malnutrition.

The care plan dated August 1, 2023 revealed the resident needed help with daily living activities related to declining condition manifested by decreased ADL participation and receiving therapy.
Interventions included to assist with ADLs (activities of daily living) as needed, reinforce therapy following instructions given by PT/OT (physical-watch for fatigue

The annual MDS (minimum data set) assessment dated August 8, 2023 included a BIMS (brief interview for mental status) score of 15 indicating the resident had intact cognition. The assessment included the resident had no behaviors exhibited and required extensive assistance with one-person assistance with transfer and required limited assistance with one-person physical assistance with personal hygiene. The assessment coded bathing as support provided, ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period.

The facility documentation of the shower schedule revealed that resident #230 had scheduled showers on Tuesdays and Fridays.

However, the ADL assistance and support documentation for August 2023 revealed the resident was not provided with showers multiple times on scheduled days. Further review of the documentation revealed that the resident was provided with bathing twice and had refused showers three times.

An interview was conducted on August 30, 2023 at 3:04 p.m. with a certified nursing assistant (CNA staff #47) who stated that bed bath or shower days are divided by A and B beds. She stated that A-beds receive their showers on Mondays and Thursdays; B-beds receive showers Tuesdays and Fridays; and, Wednesdays and Saturdays were make-up days for residents who refused on their scheduled shower day. She stated if a resident refuses a shower it is written in the shower book and it is confirmed by the charge nurse. The CNA said that staff were to make different attempts throughout the day or on the make-up days. Regarding documentation of showers provided, she stated that code "8" on the bath sheet indicated the activity or bath did not happen; and, the letter "R" indicated the resident refused.

An interview was conducted with Director of Nursing (DON/staff #32) on August 31, 2023 at 11:28 a.m. The DON stated resident showers were documented in two different ADL shower log books for each unit. She stated that the expectation was that residents are offered their showers at minimum 2 days per week; and, if resident requested for an additional shower, then it should be provided by staff. The DON stated if the resident refuses care the CNA was to notify the nurse and the physician; and that, if refusing care including showers was a continuing issue, then it should be care planned. During the interview, a review of the ADL shower sheet documentation was conducted with the DON who stated that based on the shower sheet, resident #230 did not receive showers as scheduled. She stated the risks of not receiving baths or showers would include infection, skin break down, resident odor and not feeling humanized.

The facility policy on Supporting Activities of Daily Living, revealed that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care.

Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure care and services was to promote healing of pressure ulcers was provided for one resident (#22). The deficient practice could result in the development and worsening of pressure ulcers.

Findings include:

Resident #22 was admitted on April 25, 2022 with diagnoses of pyonephrosis, sepsis, protein calorie malnutrition, and lack of coordination.

Review of a care plan dated March 21, 2022 included the resident had the potential for skin breakdown.

The weekly skin assessments dated June 5 and 20, 2022 included the resident had a pressure ulcer. The coccyx area was circled in the body image of the note.

The wound assessment report dated June 22, 2023 included stage 2 pressure ulcer to the sacrum that measured 1.8 cm (centimeters) x 1.3 cm x 0.2 cm, with 100% granulation tissue, well-defined border and normal surrounding skin. Treatment included to cleanse with normal saline, apply alginate over wound bed, cover with 4x4 and change dressing every day until resolved.

The physician order dated June 22, 2023 included to cleanse coccyx wound with normal saline, apply alginate over wound bed, cover with 4x4 and change dressing every day until resolved.

This order was transcribed onto the Treatment Administration Record (TAR) for June 2023.

Review of the TAR for June 2023 included that alginate was not marked as administered as ordered on June 25 and 27, 2023.

The care plan dated July 7, 2023 included that a skin breakdown was present.

The wound assessment report dated July 13, 2023 included stage 2 pressure ulcer to the sacrum that measured 2.3 cm x 1.5 cm x 0.2 cm, with 90% granulation tissue, 10% slough, well-defined border, slight edema and pink surrounding skin. Treatment included to cleanse with normal saline, place promagram prisma to wound bed, cover with foam dressing and change dressing every day until resolved.

The quarterly Minimum Data Set assessment dated July 19, 2023, revealed a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The assessment also revealed the presence of one stage 2 pressure ulcer.

Review of physician's orders revealed an order dated July 25, 2023 for coccyx wound, cleanse with normal saline, Prisma to wound bed, foam dressing, change every other day until resolved.

The wound assessment report dated July 27, 2023 included stage 2 pressure ulcer to the sacrum that measured 1.6 cm x 1 cm x 0.1 cm, with 100% granulation tissue, well-defined border and normal surrounding skin. Treatment included to cleanse with normal saline, place promagram prisma to wound bed, cover with foam dressing and change dressing every other day until resolved.

The order for daily promagram prisma and foam dressing was transcribed onto the TAR for July 2023. However, the TAR revealed that this treatment was not documented as administered on July 18 and 19.

The wound assessment report dated August 10, 2023 included stage 2 pressure ulcer to the sacrum that measured 1.6 cm x 1 cm x 0.1 cm, with 100% granulation tissue, well-defined border and normal surrounding skin. Treatment included to cleanse with normal saline, place promagram prisma to wound bed, cover with foam dressing and change dressing every other day until resolved.

The order for every other day promagram prisma and foam dressing continued to be transcribed onto the TAR for August 2023. However, review of the TAR revealed that the treatment was not marked as administered on August 21, 23, 25, 27 and 29.

Review of the clinical record revealed no evidence that resident refused these treatments on dates not marked as administered in the TAR for June, July and August 2023.

Further review of the clinical record revealed no documentation why the treatment was not administered as ordered; and that, the physician was notified.

An interview and a review of the clinical record was conducted on August 30, 2023 at 12:23p.m. with a Licensed Practical Nurse (LPN/staff #53) who stated that there was no evidence found that the wound treatment to the coccyx was provided as ordered in dates not marked in the TAR for June, July and August 2023. The LPN also stated that there was also no evidence that the resident refused the treatment; and that, the provider was notified. Further, the LPN said that the facility policy was for staff to complete wound treatments as ordered; and that, if the treatment was not completed as ordered or the resident refused, the provider should be notified and there should be documentation in the progress note. The LPN also stated that the risk of not completing wound treatments as ordered could result in infection or deterioration of the wound.

In an interview with a Registered Nurse (RN/staff #72) conducted on August 30, 2023 at 12:53 p.m., the RN said that the clinical record did not have any evidence that the coccyx wound care treatment had been provided as ordered in multiple dates in June, July and August 2023. The RN said that there was no evidence the resident had refused the wound treatments; and that, the provider was notified that the treatments had not been provided as ordered. The RN said that her expectation was that wound treatments are completed as ordered; and, if not, the provider was notified and document in the progress note the reason. Further, the RN stated that the facility policy was to complete wound treatments as written; and, the risk of not completing the wound treatments as written could result in the wound no progressing or worsening.

Review of the facility policy on Administering Topical Medications included to follow the medication administration guidelines in the policy entitled Administering Medications. Notify the supervisor if the resident refuses the procedure.

The facility policy on Administering Medications revealed that medications are administered in accordance with prescriber orders, including required time frame. Topical medications used in treatments are recorded on the resident's treatment record (TAR).

Review of the facility policy titled, Documentation of Medication Administration, revealed the facility shall maintain a medication administration record to document all medications administered. Administration of medication must be documented immediately after it is given.

The facility policy on Protocols for "At Risk" Residents included to complete ongoing documentation by charge/treatment nurses in the medical record to describe the effectiveness of interventions and resident's response to therapy.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure pain management was provided to two residents (#229 and #223). The deficient practice could result in pain not being addressed.

Findings include:

-Resident #229 was admitted on August 24, 2023 with diagnoses the included encephalopathy, sepsis, and acute kidney injury.

The minimum data set (MDS) assessment included a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact.

Review of the pain care plan dated August 24, 2023 revealed the resident was able to verbalize pain. Interventions included pain medication as ordered, monitor/document medication effectiveness; medication side effect, notify the provider if medication is not effective, assess complaints of pain immediately and document pain level.

A physician order dated August 25, 2023 included for oxycodone hydrochloride (narcotic analgesic) tab 5 mg (milligram) one tablet by mouth every 6 hours as needed for pain with a stop date of October 24, 2023. However, the order did not include pain parameter for the medication.

The order for oxycodone and for pain level every shift was transcribed onto the medication administration record (MAR) for August 2023.

Review of the MAR for August 2023 revealed that oxycodone was administered to the resident on August 29, 30 and 31 for pain level of "0."

Continued review of the clinical record revealed no documentation that medication effectiveness and the side effects associated with the medication were monitored.

-Resident #223 was admitted on August 23, 2023 with diagnoses of obesity, sepsis, pneumonia, and tachycardia.

The admission orders dated August 22, 2023 included for the following:
-Tylenol (analgesic) 650 mg by mouth every 6 hours as needed for a pain scale of 1-3; and,
-Oxycodone 10 mg by mouth every four hours as needed for a pain scale of 4-10.

The consent for opioid therapy dated August 24, 2023 included the resident was prescribed with a narcotic analgesic, oxycodone 10 mg every 4 hours as needed.

The 48-hour care plan dated August 24, 2023 included the resident had pain medication, oxycodone.

The standard care plan dated August 25, 2023 revealed the resident was able to verbalize pain. Interventions included pain medication as ordered, monitor/document medication effectiveness; medication side effect, notify the provider if medication is not effective, assess complaints of pain immediately and document pain level.

The order for oxycodone and Tylenol were transcribed onto the MAR for August 2023.

Review of the August 2023 MAR revealed that oxycodone was administered without a documented pain scale on August 24, 25, 27, 28, and 30, 2023. It also revealed that Tylenol was administered without a documented pain scale on August 25, 2023.

An interview was conducted on September 7, 2023 at 8:53 a.m. with a licensed practical nurse (LPN/staff #53) who stated that if she was administering a pain medication as needed, a pain scale was required. The LPN said that generally, Tylenol was for a lower pain level and oxycodone was for a higher pain level. She stated that the pain level should be assessed and documented in the MAR whether it is effective or ineffective. During the interview, a review of the clinical record for resident #223 and #229. The LPN stated that the order for oxycodone for resident #229 did not include a pain scale; and that, for both residents (#223 and #229), there was no documentation that pain level and the effectiveness of the medication were documented. The LPN also said that clinical records of resident #223 showed that the medications (oxycodone and Tylenol) were not administered as ordered. She stated that the monitoring for side effects associated with medications was documented in the MAR/TAR; and, if there was no documentation, then it was not monitored.

During an interview with the Director of Nursing (DON/staff #32) conducted on September 7, 2023 at 9:54 a.m., the DON stated that pain level and the effectiveness of the pain medication should be documented in the MAR when a pain medication is administered as needed; and, the side effects of pain medications are also supposed to be monitored and documented.

The facility policy, "Administering Pain Medications, revised in October 2022 included that when opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effect and potential overdose. Any resident who uses opioids for long-term management of chronic pain is at risk for opioid overdose. The policy also included to document the following in the resident's medical record:
-Results of the pain assessment;
-Medication;
-Dose;
-Route-of-administration; and,
-Results of the medication (adverse or desired).

The facility policy on Administering Medication included that medications are administered in a safe and timely manner, and as prescribed.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure infection prevention and control standards were maintained during medication administration. The deficient practice could result in transmission of infection.

Findings include:

During medication administration observation with a Registered Nurse (RN/staff #8), conducted on August 31 2023 at 8:05 a.m., the RN dropped a medication on the floor. The RN picked up the medication from the floor and discarded the medication in the sharps' container. The RN then replaced the medication, placed it into the medication cup, then entered the resident's room to administer the prepared medications. The RN did sanitize her hands after removing the medication from the floor and prior to administration of the medications to the resident (#39). The RN entered
the room of another resident (#26) with a wrist type blood pressure monitor, took the resident's blood pressure. She removed the blood pressure cuff from the resident's arm, administered the medication, exited the room and placed the cuff on top of the medication cart. However, the RN did not sanitize the wrist blood pressure cuff after using it and also did not sanitize her hands after exiting the resident's room. The RN then proceeded to preparing the medications for administration for another resident (#25). However, the RN did not sanitize her hands after exiting the previous room or prior to medication preparation for resident #25. She then entered room of the resident (#25) and administered the medications to the resident. The RN did not sanitize her hands prior to entering the resident's room, or after exiting the resident's room.

Continued observation of medication administration with the RN revealed that the RN carried a medication bubble pack into a resident's (#23) room and laid it on the resident's bed. The RN proceeded to take the resident's pulse, removed the tablet from the bubble pack, placed the medication in the medication cup and administered the medication. She then carried the bubble pack back to the medication cart and placed the bubble pack into the medication cart drawer. The RN then removed an inhaler from the medication cart. For the duration of this observation, the RN did not sanitize her hands after taking the resident's pulse or upon exiting the resident's room or prior to removing the inhaler from the medication cart.

An interview with the RN (staff #8) was conducted at 8:37 a.m. immediately following the observation. The RN stated that the facility policy was to sanitize her hands between each resident care/interaction; and that, the wrist blood pressure cuff should also be sanitize after each resident use. However, the RN stated that she did not have any sanitizing wipes on her cart, so she could not sanitize the blood pressure cuff after she used it with the resident. She further stated that she did not have any sanitizing wipes on her cart since January 2023, and did not sanitize the blood pressure cuff. She also stated that she did not ask anyone for more wipes, or tell anyone that she did not have any. The RN stated that the risk of not sanitizing her hands or the blood pressure cuff between residents could result in transmission of infection.

An interview with a licensed practical nurse (LPN/staff #53) was conducted on August 31, 2023 at 8:38 a.m. The LPN stated that blood pressure cuffs were to be sanitized between each resident use.

In an interview with a certified nursing assistant (CNA/staff #45) conducted on August 31, 2023 at 8:43 a.m., the CNA said the wrist blood pressure cuffs should be sanitized between each resident use with an alcohol wipe or sanitizer wipe.

An interview was conducted on August 31, 2023 at 8:47 a.m. with a restorative nurse aide (RNA/staff #77) who stated that the wrist blood pressure cuffs should be sanitized between each resident use; and that, she uses a sanitizing wipe or hand gel and a paper towel.

During an interview with the Director of Nursing (DON/staff #32) conducted on August 31, 2023 at 8:50 a.m., the DON stated that her expectation was for staff to sanitize their hands upon entering and exiting resident rooms; and that, wrist blood pressure cuffs to be sanitized after each resident use. She stated that a nurse carrying a medication card into a resident's room and placing it on the bed did not meet her expectation as the bed would be considered dirty. She further stated that the medication would then be "dirty" and all the medications/card would need to be discarded. The DON also stated that sanitizing wipes should be available on each medication cart. Further, the DON stated that the risk of not sanitizing hands upon entering/exiting rooms, sanitizing blood pressure cuff after each patient use, and taking medication cards into resident rooms could result in transmission of infection.

Review of a facility policy on Cleaning and Disinfection of Resident-Care Items and Equipment, revealed that non-critical items, including blood pressure cuffs, should be sanitized with an EPA registered disinfectant. Reusable resident care equipment is cleaned and disinfected or sterilized between residents.

The facility policy on Handwashing/Hand Hygiene, revealed that the facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub before and after direct contact with residents, before preparing or handling medications, after contact with objects in the immediate vicinity of the resident.

Review of the facility policy titled, Administering Medications, revealed that staff follows established facility infection control procedures (e.g. hand washing, antiseptic technique) for the administration of medications.

Based on clinical record review, resident and staff interviews and policy review, the facility failed to ensure a care plan was revised regarding refusals for turning/repositioning and air mattress for one resident (#22).

Findings include:

Resident #22 was admitted on April 25, 2022 with diagnoses of pyonephrosis, sepsis, protein calorie malnutrition, and lack of coordination.

Review of a care plan dated March 21, 2022 included the resident had the potential for skin breakdown.

The wound assessment reports dated June 22, 29, and July 6, 2023 revealed the resident continued to refuse repositioning and air mattress; and that, the resident remained non-compliant.

The care plan dated July 7, 2023 included that a skin breakdown was present.

The quarterly Minimum Data Set assessment dated July 19, 2023, revealed a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The assessment also revealed the presence of one stage 2 pressure ulcer.

Review of wound assessment reports dated July 13 and 20, 2023 included that the resident continued to refuse repositioning and air mattress.

Continued review of the clinical record revealed documentation in multiple progress notes that the resident refused to be turned/repositioned, and refused to use an air mattress.

Review of the care plan reviewed on July 19, 2023 included the resident had a potential for skin breakdown; and that, a skin breakdown was present. Interventions included pressure relieving mattress, frequent repositioning, develop/monitor turning scheduled.

However, there was no evidence that the care plan had been revised/updated regarding the resident's refusal for use of pressure relieving mattress and turning/repositioning.

An interview was conducted on August 30, 2023 at 11:06 a.m. with a certified nursing assistant (CNA/staff #87) who stated that the facility policy was to turn/reposition resident's with pressure ulcers every 2 hours and as needed. She further stated that CNAs do not document this in the clinical record, but that, they would tell the nurses that they completed the task.

An interview with resident #22 was conducted on August 30, 2023 at 11:33 a.m. Resident #22 stated she refuses to be turned/repositioned and to have a low air loss mattress on her bed.

In an interview with a licensed practical nurse (LPN/staff #53) conducted on August 30, 2023 at 12:23 p.m., the LPN stated that resident #22 has a pressure on the coccyx and refuses to be turned/repositioned and also refuses to use an air mattress. She stated that the resident's care plan should be updated with interventions if a resident refused to be turned/repositioned, and refuse to use the air mattress. The LPN said that the risk of not updating interventions on a care plan could result in staff not knowing how to take care of a resident.

During an interview conducted with an Assistant Director of Nursing (ADON/staff #72) on August 30, 2023 at 12:53 p.m., the ADON stated that care plans should be updated every 3 months; and that, if interventions include turning/repositioning and use of an air mattress, the care plan should be updated if the resident refuses these interventions. A review of the resident's clinical record was conducted with the ADON who stated that the resident's care plan was last updated on July 19, 2023 to include interventions to turn/reposition and use an air mattress. However, the ADON stated that the care plan was not revised to include the resident's refusals of the care planned interventions.

Review of the facility policy titled, Comprehensive Person-Centered Care Plans, revealed that the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

REGARDING PAIN MEDICATION

-Resident #229 was admitted on August 24, 2023 with diagnoses the included encephalopathy, sepsis, and acute kidney injury.

The minimum data set (MDS) assessment included a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact.

Review of the pain care plan dated August 24, 2023 revealed the resident was able to verbalize pain. Interventions included pain medication as ordered, monitor/document medication effectiveness; medication side effect, notify the provider if medication is not effective, assess complaints of pain immediately and document pain level.

A physician order dated August 25, 2023 included for oxycodone hydrochloride (narcotic analgesic) tab 5 mg (milligram) one tablet by mouth every 6 hours as needed for pain with a stop date of October 24, 2023. However, the order did not include pain parameter for the medication.

The order for oxycodone and for pain level every shift was transcribed onto the medication administration record (MAR) for August 2023.

Review of the MAR for August 2023 revealed that oxycodone was administered to the resident on August 29, 30 and 31 for pain level of "0."

Continued review of the clinical record revealed no documentation that medication effectiveness and the side effects associated with the medication were monitored.

-Resident #223 was admitted on August 23, 2023 with diagnoses of obesity, sepsis, pneumonia, and tachycardia.

The admission orders dated August 22, 2023 included for the following:
-Tylenol (analgesic) 650 mg by mouth every 6 hours as needed for a pain scale of 1-3; and,
-Oxycodone 10 mg by mouth every four hours as needed for a pain scale of 4-10.

The consent for opioid therapy dated August 24, 2023 included the resident was prescribed with a narcotic analgesic, oxycodone 10 mg every 4 hours as needed.

The 48-hour care plan dated August 24, 2023 included the resident had pain medication, oxycodone.

The standard care plan dated August 25, 2023 revealed the resident was able to verbalize pain. Interventions included pain medication as ordered, monitor/document medication effectiveness; medication side effect, notify the provider if medication is not effective, assess complaints of pain immediately and document pain level.

The order for oxycodone and Tylenol were transcribed onto the MAR for August 2023.

Review of the August 2023 MAR revealed that oxycodone was administered without a documented pain scale on August 24, 25, 27, 28, and 30, 2023. It also revealed that Tylenol was administered without a documented pain scale on August 25, 2023.

An interview was conducted on September 7, 2023 at 8:53 a.m. with a licensed practical nurse (LPN/staff #53) who stated that if she was administering a pain medication as needed, a pain scale was required. The LPN said that generally, Tylenol was for a lower pain level and oxycodone was for a higher pain level. She stated that the pain level should be assessed and documented in the MAR whether it is effective or ineffective. During the interview, a review of the clinical record for resident #223 and #229. The LPN stated that the order for oxycodone for resident #229 did not include a pain scale; and that, for both residents (#223 and #229), there was no documentation that pain level and the effectiveness of the medication were documented. The LPN also said that clinical records of resident #223 showed that the medications (oxycodone and Tylenol) were not administered as ordered. She stated that the monitoring for side effects associated with medications was documented in the MAR/TAR; and, if there was no documentation, then it was not monitored.

During an interview with the Director of Nursing (DON/staff #32) conducted on September 7, 2023 at 9:54 a.m., the DON stated that pain level and the effectiveness of the pain medication should be documented in the MAR when a pain medication is administered as needed; and, the side effects of pain medications are also supposed to be monitored and documented.

The facility policy, "Administering Pain Medications, revised in October 2022 included that when opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effect and potential overdose. Any resident who uses opioids for long-term management of chronic pain is at risk for opioid overdose. The policy also included to document the following in the resident's medical record:
-Results of the pain assessment;
-Medication;
-Dose;
-Route-of-administration; and,
-Results of the medication (adverse or desired).

The facility policy on Administering Medication included that medications are administered in a safe and timely manner, and as prescribed.

Based on closed clinical record review, staff interviews, and facility policy review, the facility failed to ensure medications were administered as ordered by the physician for two residents (#20 and #51).

Findings include:

Resident #20 was admitted on July 17, 2023 with a diagnosis of COPD (Chronic Obstructive Pulmonary Disease), dementia, essential hypertension and status post fall with left hip fracture.

A review of the current active physician orders revealed the following orders for:
-4-ounce health shake with all meals (order date of July 19, 2023); and,
-Colace (laxative) 100 milligrams -daily (order date of September 29, 2022).

These orders were transcribed onto the MAR (Medication Administration Record) and the TAR (Treatment Administration Record) for August 2023.

Review of the MAR and TAR for August 2023 revealed that Colace and the health shake was not documented as administered from August 16 through 20, 2023.

There was no documentation found in the clinical record that the resident refused these medications on dates marked as not administered in the MAR and TAR.

Further review of the clinical record revealed no documentation of reason why these medications were not administered as ordered; and that, the physician was notified.

An interview with the assistant director of nursing (ADON/staff #72) was conducted on August 30, 2023 at 2:22 p.m. The ADON stated that when an order for medication/treatment is written by the provider, the nurse who received the order will administer the medication as ordered. The ADON stated that at the time of the survey, the facility was utilizing a paper MAR; and that, the expectation was that the nurse will transcribe the order onto the paper MAR/TAR as necessary. The ADON stated that orders for supplements should be followed as ordered for the resident; and that, a negative outcome of not following orders could depend on the medication. The ADON said that not administering Colace as ordered could lead to constipation of the resident.