The Pines Healthcare Center

Based on observation, review of physician orders, review of medication information from Medscape and interview, the facility failed to ensure medications were administered in accordance with physician orders and manufacturer information. Four medication errors were identified out of 38 opportunities resulting in a 10.5% medication error rate. This affected three (Residents #11, #14, and #28) of three residents observed for medication administration.

Findings include:

1. On 10/02/23 at 8:46 A.M., Licensed Practical Nurse (LPN) #100 was observed administering medication to Resident #14. Among the medications administered was hydralazine (a vasodilator) 25 milligrams (mg).

Review of Resident #14's physician order sheet revealed an order dated 03/22/23 for hydralazine 25 mg with instructions to administer three tablets every eight hours for hypertension.

On 10/02/23 at 10:17 A.M., LPN #100 verified she only gave one of the hydralazine but should have administered three.

2. On 10/02/23 at 9:03 A.M., Registered Nurse (RN) #101 was observed administering medication to Resident #28. Among the medications administered were enteric coated aspirin 81 mg and isosorbide mononitrate (anti-anginal) extended release (ER) 60 mg. The medications were crushed prior to administration.

Review of Resident #28's physician order sheet revealed an order dated 12/18/22 that medications could be crushed unless contraindicated. On 12/18/22 an order was written for enteric coated aspirin 81 mg in the morning. On 12/18/22 an order was written for isosorbide mononitrate ER 60 mg in the morning.

Review of medication information from Medscape revealed enteric coated aspirin should not be crushed because it could release all of the drug at once increasing the risk of side effects. Medscape revealed the extended release isosorbide mononitrate must not be crushed.

On 10/02/23 at 9:08 A.M., RN #101 verified the enteric coated aspirin was crushed, stating Resident #28 did not like the taste of chewable aspirin. At 10:14 A.M., RN #101 verified she also crushed the enteric coated isosorbide mononitrate.

3. On 10/02/23 at 9:26 A.M., LPN #102 was observed administering medication to Resident #11. Among the medications administered was tetrahydrozoline HC 0.05% eye drops with one drop applied in both eyes.

Review of Resident #11's physician order sheet revealed an order dated 02/17/23 for polyvinyl alcohol ophthalmic solution 1.4%: instill one drop in both eyes three times a day. There was no order for tetrahydrozoline eye drops.

On 10/02/23 at 10:25 A.M., LPN #102 verified she had administered tetrahydrozoline eye drops and was uncertain if they were interchangeable with polyvinyl alcohol eye drops.

On 10/02/23 at 10:56 A.M., Pharmacist #103 verified the tetrahydrozoline and polyvinyl eye drops were not interchangeable.

This deficiency represents non-compliance investigated under Complaint Number OH00146516 and is an example of continued non-compliance from the survey dated 09/14/23.

Based on record review and interview, the facility failed to ensure Resident #2's care plan meetings were completed at least quarterly. This finding affected one (Resident #2) of four residents investigated for care planning.

Findings include:

Review of Resident #2's medical record revealed an initial admission date of 11/10/22 with a readmission date of 07/27/23. Diagnoses include acute respiratory failure with hypoxia, hypertensive heart disease and history of falling.

Review of Resident #2's Minimum Data Set (MDS) 3.0 comprehensive assessment revealed the resident exhibited severe cognitive impairment.

Review of Resident #2's Care Conference Review form dated 11/15/22 revealed staff conducted a care conference.

Review of Resident #2's progress note dated 05/11/23 at 3:25 P.M. indicated the daughter was called to discuss the resident's code status and hospice services.

Review of Resident #2's medical record did not reveal other documentation on care planning.

Interview on 09/13/23 at 9:40 A.M. with the Director of Nursing (DON) confirmed care conferences were not completed quarterly to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals who had knowledge of the resident and her needs, and that each resident and resident representative was involved in developing the care plan and making decisions about the care received.

Review of the undated Plan of Care policy indicated it was the policy of the facility to provide resident care that meets the psychosocial, physical and emotional needs and concerns of the residents. The purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and support the goals, choice and presence.

Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5%. A total of 26 medications were administered with five medication errors for a medication error rate of 19.23%. This finding affected three residents (Residents #32, #53 and #66) of six residents observed for medication administration.

Findings include:

1. Review of Resident #32's medical record revealed the resident was admitted on 04/03/19 with diagnoses including heart failure, fibromyalgia and diabetes.

Review of Resident #32's physician orders revealed an order dated 06/18/20 for Cymbalta give 60 mg (milligrams) by mouth in the morning for major depression and give 60 mg by mouth at bedtime for depression; an order dated 11/11/22 for Lasix 20 mg (diuretic) give one tablet by mouth in the morning for edema; and an order dated 01/05/23 for artificial tears instill one drop in both eyes every morning and at bedtime for dry eyes.

Observation on 09/11/23 at 9:57 A.M. with Licensed Practical Nurse (LPN) #801 of Resident #32's medication administration revealed twelve medications were administered. LPN #801 did not administer Resident #32's Cymbalta, Lasix and artificial tears as ordered; however, she documented on the MAR that she had administered the medications.

Interview on 09/11/23 at 12:13 P.M. with LPN #801 confirmed she did not administer Resident #32's Cymbalta, Lasix and artificial tears for a total of three medication errors.

2. Review of Resident #53's medical record revealed the resident was admitted on 12/21/22 with diagnoses including hypertensive heart disease, heart failure and diabetes.

Review of Resident #53's physician orders revealed an order dated 08/10/23 for NovoLog fast acting insulin inject 8 units subcutaneously before meals for diabetes.

Observation on 09/11/23 at 1:52 P.M. with LPN #803 revealed she administered two medications to Resident #53 including NovoLog insulin via a FlexPen. LPN #803 administered 8 units of NovoLog insulin via a FlexPen and did not prime the pen with two units of insulin prior to dialing up 8 units of insulin and administering the insulin to the resident.

Interview on 09/11/23 at 2:22 P.M. with LPN #803 confirmed she did not prime Resident #53's NovoLog FlexPen as required prior to dialing up 8 units of the insulin and administering the insulin to the resident for a total of one medication error.

Review of the undated NovoLog Insulin Using Your FlexPen prescriber instructions indicated to wash and dry your hands, remove the pen cap, gently roll the pen ten times between the hands, wipe the rubber end of the pen with an alcohol swab, remove the seal from the new pen needle and screw it onto the end of the pen, remove the outer needle cap and set aside, remove the inner needle cap and throw away, turn the knob on the pen to a dose of 2 units, hold the pen with the needle straight up, tap the side of the pen to get rid of any air bubbles, push the injection button until you see zero in the dose window, turn the knob on the end of the pen to the desired dose, use an alcohol swab to clean the skin, insert the needle straight into the skin so that it reaches the fatty lay, use your thumb to slowly press the button on the end of the pen all the way in and hold it for 10 seconds to allow time for the insulin to get into the body.

3. Review of Resident #66's medical record revealed the resident was admitted to the facility on 08/21/23 with diagnoses including hypothyroidism, anxiety disorder and epileptic syndromes with complex partial seizures.

Review of Resident #66's physician orders revealed an order dated 08/22/23 for Zonisamide oral capsule 100 mg give three capsules by mouth every morning and at bedtime for convulsion.

Observation on 09/11/23 at 10:16 A.M. with LPN #802 of Resident #66's medication administration revealed eleven medications were administered. LPN #802 did not administer Resident #66's Zonisamide anticonvulsant as ordered.

Interview on 09/11/23 at 12:00 P.M. with LPN #802 confirmed she did not administer Resident #66's Zonisamide anticonvulsant as ordered for a total of one medication error.

A total of 26 medications were administered with five medication errors for a medication error rate of 19.23 percent.

Review of the undated Medication Administration policy revealed the facility would properly assess residents and plan their care to meet these needs. Medications which were ordered by the physician for a specific time will be given as such. Utilization of the liberalized medication administration structure does not imply that any time frame parameter was acceptable for providing medications. Specific medications may still require strict parameters determined by the physician.

Based on observation, record review and interview, the facility failed to ensure Resident #39 received the appropriate food items to meet dietary needs identified on meal tickets. This finding affected one (Resident #39) of two residents reviewed for nutrition. The facility census was 71.

Findings include:

Review of Resident #39's medical record revealed the resident was readmitted to the facility on 03/22/23 with diagnoses including hemiplegia, unspecified dementia and epilepsy.

Review of Resident #39's Minimum Data Set (MDS) 3.0 comprehensive assessment dated 06/30/23 revealed the resident exhibited moderate cognitive impairment.

Review of Resident #39's nutritional care plan revealed an intervention dated 05/12/23 to provide meals per the dietary order.

Review of Resident #39's physician orders revealed an order dated 07/06/23 for a regular diet, pureed texture and regular consistency.

Review of Resident #39's dietary meal ticket dated 09/11/23 for the breakfast meal indicated the resident was to receive pureed bananas foster french toast, pureed breakfast ham with brown gravy, pureed fortified hot cereal of choice, assorted yogurt cup, 2% (percent) milk, hot coffee and orange juice.

Observation on 09/11/23 at 9:20 A.M. with Licensed Practical Nurse (LPN) #802 of Resident #39's breakfast meal tray revealed the resident was served pureed bananas foster french toast, pureed breakfast ham, 2% milk, coffee and orange juice.

Interview on 09/11/23 at 9:24 A.M. with LPN #802 confirmed Resident #39 was not served the pureed fortified hot cereal of choice and assorted yogurt cup as ordered on her dietary meal ticket.

Review of Resident #39's dietary meal ticket dated 09/12/23 for the breakfast meal indicated the resident was to receive pureed baked cheese omelet, pureed sausage patty, pureed oatmeal, pureed English muffin, yogurt cup, 2% milk, hot coffee and orange juice.

Observation on 09/12/23 at 8:16 A.M. with State Tested Nursing Assistant (STNA) #804 revealed Resident #39's breakfast tray was delivered which included a pureed cheese omelet, pureed sausage patty with brown gravy, pureed English muffin, 2% milk, hot coffee and orange juice. No yogurt cup or pureed oatmeal cereal were on the tray and STNA #804 indicated she would get the yogurt cup for the resident.

Interview on 09/12/23 at 8:43 A.M. with the Administrator confirmed Resident #39's pureed oatmeal and yogurt cup were not on the breakfast tray served to the resident.

Review of Meal Distribution policy revised 09/2017 indicated meals were transported to the dining locations in a manner that ensured proper temperature, maintenance, protects against contamination and were delivered in a timely manner and all meals would be assembled in accordance with the individualized diet order, plan of care, and preferences.

This deficiency represents non-compliance investigated under Master Complaint Number OH00146369.

Based on record review, observation and interviews the facility failed to ensure food was served at a palatable temperatures. This had the potential to affect 70 of 70 resident who received food from the kitchen, as Resident #60 received no food by mouth. The facility census was 71.

Findings include:

Interviews on 09/11/23 from 9:00 A.M.. through 11:30 A.M. during the screening process for the annual survey with multiple residents (# 9, #13, #16, #17, #19, #, 26, #36, #38, #45, #58, #64, #171 and #175) revealed concerns with dietary including palatability of meals.

Observation and interview on 09/12/23 at 11:35 A.M. revealed the hot food on the steam table had temperatures over 165 degrees. A test tray left the steam table at 12:15 P.M. The test tray was served last at 12:34 P.M. The culinary director from sister facility (CD) #910 proceeded to take the temperatures of the meal. The chicken thigh was 123 degrees, the mashed potatoes were 130 degrees and the peas were 127 degrees. CD #910 revealed the food should be over 135 degrees.

Review of a list of resident diets revealed Resident #60 received no food by mouth.

Review of the facility policy titled Food Preparation

Based on observation and interview, the facility failed to serve meals in a timely manner. This had the potential to affect 70 of 70 residents who received food from the kitchen. Resident #60 received no food by mouth. The facility census was 71.

Findings include:

1. Review of the facility dining times revealed the lunch meal was to start serving at 11:30 A.M.

Interview on 09/11/23 at 8:30 A.M. with Registered Dietician (RD) #900 revealed three dietary staff called off work today including the cook. She stated the Food Service Director (FSD) #867 was acting as the cook.

Interview on 09/11/23 at 8:47 A.M. with Social Service Designee (SSD) #805 revealed she was assisting with meal service due to three call-offs. She stated other staff have assisted with dietary in the past due to call-offs or insufficient staffing.

Interviews on 09/11/23 from 9:00 A.M. through 11:30 A.M. during the screening process for the annual survey with multiple residents (# 9, #13, #16, #17, #19, #, 26, #36, #38, #45, #58, #64, #171 and #175) revealed multiple concerns with dietary including staffing, temperatures and timeliness of meals.

Interview on 09/11/23 at 9:43 A.M. with FSD #867 revealed she was new to the facility, approximately ten days. She stated she had three call-offs and was acting as the cook. She stated she had a meeting with her team the prior week about her expectations as she stated she had a lot of issues in the kitchen and would most likely be terminating everyone and starting with new staff.

Observation on 09/11/23 from 11:30 A.M. to 2:37 P.M. revealed the lunch meal was not served until 2:17 P.M.

Observation n 09/11/23 at 1:49 P.M. of the dining room revealed Resident #51 was sitting at a table in the dining room. Interview at the time of observation with Resident #51 stated he had been sitting in the dining room since 11:30 A.M. waiting for lunch and he had not yet received lunch.

Observation on 09/11/23 at 2:01 P.M. revealed Resident #16 was coming back from her room after making sandwiches for her and her tablemates (#17 and #19) as they were still waiting for lunch.

Interview on 09/11/23 at 2:04 P.M. with Licensed Practical Nurse (LPN) #870 verified lunch had not been served yet. She stated the hall trays were usually delivered between 12:00 P.M. and 1:00 P.M. and they were running very late this day.

A subsequent interview on 09/11/23 at 3:13 P.M. and on 09/14/23 at P.M. with FSD #867 revealed lunch was late on 09/11/23 due to her being on her own to prepare the meal.

Review of a list of resident diets revealed Resident #60 received no food by mouth.

Review of the facility policy titled Frequency of Meals

Based on record review, observation and interviews the facility did not ensure food was served at a palatable temperatures. This affected 70 residents (except #60, who had orders for nothing by mouth) who received meals from the kitchen. The census was 71.

Findings include:

Interviews on 09/11/23 from 9:00A.M. through 11:30 A.M. during the sreening process for the annual survey with multiple residents (# 9, #13, #16, #17, #19, #, 26, #36, #38, #45, #58, #64, #171 and #175) revealed concerns with dietary including palatability of meals.

Observation and interview on 09/12/23 at 11:35 A.M. revealed the hot food on the steam table had temperatures over 165 degrees. The test tray left the steam table at 12:15 P.M. The test tray was served last at 12:34 P.M. The culinary director from sister facility (CD) #910 who proceeded to take the temperatures of the meal. The chicken thigh was 123 degrees, the mashed potatoes were 130 degrees and the peas were 127 degrees. CD #910 revealed the food should be over 135 degrees.

Review of the facility policy titled Food Preparation

Based on observation and interview, the facility failed to serve meals in a timely manner. This affected 70 residents (except #60, who had orders for nothing by mouth) who received meals from the kitchen. The census was 71.

Findings include:

Interview on 09/11/23 at 8:30 A.M. with registered dietitian (RD) #900 revealed three dietary staff called off work today including the cook. She stated the food service directer (FSD) #867 was acting as the cook.

Interview on 09/11/23 at 8:47 A.M. with social service designee (SSD) #805 revealed she was assisting with meal service due to three call-offs.

Interview on 09/11/23 at 9:43 A.M. with FSD #867 revealed she was new to the facility, approximately ten days. She stated she had three call-offs and was acting as the cook. She stated she had a meeting with her team the prior week about her expectations as she stated she had a lot of issues in the kitchen and would most likely be firing everyone and starting with new staff. A subsequent interview on 09/11/23 at 3:13 P.M. and on 09/14/23 P.M. with FSD #867 revealed lunch was late on 09/11/23 due to her being on her own to prepare the meal.

Interviews on 09/11/23 from 9:00A.M. through 11:30 A.M. during the sreening process for the annual survey with multiple residents (# 9, #13, #16, #17, #19, #, 26, #36, #38, #45, #58, #64, #171 and #175) revealed concerns with dietary including timeliness of meals.

On 09/11/23 at 2:04 P.M., interview with Licensed Practical Nurse (LPN) #870 verified lunch had not been served yet. She stated the hall trays were usually delivered between 12:00 P.M. and 1:00 P.M. and they were running very late this day.

On 09/11/23 from 11:30 A.M. to 2:37 P.M., observations revealed the lunch meal was not served until 2:17 P.M.

On 09/11/23 at 1:49 P.M., observation of the dining room revealed Resident #51 was sitting at a table in the dining room. Interview at the time of observation with Resident #51 stated he had been sitting in the dining room since 11:30 A.M. waiting for lunch and he had not yet received lunch.

On 09/11/23 at 2:01 P.M. Resident #16 was observed coming back from her room after making sandwiches for her and her tablemates (#17 and #19) as they were still waiting for lunch.

Review of the facility dining times revealed the lunch meal was to start serving at 11:30 A.M.

Review of the facility policy titled Frequency of Meals

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.

Based on medical record review, review of hospital discharge records, fall investigation and root cause analysis review, resident and staff interviews, facility policy review, and manufacturer's guideline review, the facility failed to provide Resident #50 with a safe transfer using a mechanical lift. Actual harm occurred to Resident #50 when the resident received assistance from two staff members, who failed to use the proper weight capacity lift and used the mechanical lift incorrectly by not widening the base of the lift prior to use, resulting in an avoidable fall with injury including a fractured left distal radius. This affected one resident (Resident #50) of three residents reviewed for falls. The facility census was 65.

Findings include:

Review of Resident #50's medical record revealed an admission date of 06/23/21 with diagnoses that included congestive heart failure, severe morbid obesity, chronic obstructive pulmonary disease, and diabetes mellitus.

Review of the fall risk assessment dated 04/14/23 indicated Resident #50 was at a high risk for falls.

Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated 05/11/23 revealed Resident #50 had an intact cognition level and required total dependence of two staff persons for transfers using a mechanical lift.

Review of Resident #50's care plan dated 06/24/21 revealed she was at risk for falls due to decreased mobility and was to utilize a mechanical lift.

Review of the physician's orders for Resident #50, dated 12/01/22, the resident was to be transferred using the mechanical lift with the assistance of two staff members.

Review of the weights for Resident #50 revealed on 05/05/23 the resident had a weight of 438.8 pounds.

Review of Resident #50's nursing notes revealed on 05/10/23 a late entry progress note stated during a transfer utilizing a mechanical lift with two staff members the lift tipped over causing Resident #50 to fall to the floor and the lift landed on the resident. At this time, Resident #50 was assessed by the nurse. Resident #50 complained of pain to her left wrist. Resident #50 was sent to the emergency room for evaluation. Upon returning to the facility Resident #50 was found to have a fracture to the left distal radius with a new splint applied for immobilization.

Review of the hospital discharge records 05/10/23 including orthopedic evaluation revealed a new left distal radius fracture after falling from a mechanical lift. A new splint for immobilization was applied. Hospital records indicated Resident #50 had a current weight of 452.3 pounds.

Review of the facility fall investigation completed on 05/10/23 revealed Resident #50 was being transferred by a mechanical lift and two State Tested Nurse Aide (STNA) #133 and STNA #141. The lift tipped over causing Resident #50 to fall and the lift fell on the resident. Resident #50 was assessed, the physician notified and the resident was sent to the hospital.

Review of the facility Root Cause Analysis of the fall incident dated 05/10/23 revealed staff members failed to use the correct size mechanical lift and also failed to widen the base of the lift which caused the lift to tip over during transfer of the resident.

Interview with Resident #50 on 06/13/23 at 11:05 A.M. revealed last month during a mechanical lift transfer from bed to wheelchair with two staff members, the lift tipped over due to staff not widening the base of the lift and using the wrong size lift. Resident #50 indicated the lift tipped over causing her to fall to the ground and then the lift fell on top of her. She was sent to the hospital and found to have a fracture to the left wrist.

Interview with STNA #133 on 06/14/23 at 2:00 P.M. revealed she was assisting another STNA in transferring Resident #50 using a mechanical lift and the base legs where not widened prior to lifting and moving the resident.

Interview with the Administrator and Director of Nursing (DON) on 06/13/23 at 12:25 P.M. revealed Resident #50 suffered a fall during a mechanical lift transfer with two STNAs due to staff members using the wrong size mechanical lift and not widening the base of the mechanical lift. The fall resulted in a fracture to the resident's left distal radius. They indicated the 450-pound lift was utilized when the resident was determined to be 452 pounds at the hospital. They indicated staff should have used the 600-pound lift.

Review of the undated facility policy titled Mechanical Lifts and Transfers indicated staff are to use the appropriate size lift and when transporting a resident from one location to another using a lift, the legs of the lift must remain in the maximum open position for optimum stability and safety while the lift is moving.

Review of the undated mechanical lift manufacturer's guidelines indicated the following: Lifting the Patient - When using an adjustable base lift, the legs must be in the maximum opened/locked position before lifting the patient.

The deficient practice was corrected on 05/10/23, when the Administrator and DON provided staff education of mechanical lift procedures to 54 staff members and the facility implemented the following corrective measures:

On 05/10/23, Resident #50 was sent to the local emergency department for evaluation and treatment.

On 05/10/23 a Root Cause Analysis was completed by the Administrator which determined staff failed to follow mechanical lift policy and procedure by using the incorrect size mechanical lift and not widening the base of the lift.

On 05/10/23 all medical staff including 38 STNA and 16 licensed nurses were educated on the mechanical lift policy and procedure.

On 05/10/23 all medical staff that were in the facility completed an in-person competency check with the DON.

On 05/10/23 medical staff not available in the facility completed an online mechanical lift training and policy review.

On 05/10/23 medical staff not available in the facility completed a verbal competency check with the DON.

On 05/10/23 maintenance staff completed an inspection of all mechanical lifts.

On 05/10/23 medical staff were educated to only use the 600 pound lift for Resident #50.

On 05/10/23 Resident #50's care plan was updated to indicate using only the 600 pound lift.

On 05/10/23 weekly audits were initiated for 30 days to include monitoring of staff members following the mechanical lift policy and procedures. No evidence of any incorrect mechanical lift use was observed during audits completed on 05/11/23, 05/19/23, 05/24/23, 06/02/23, 06/07/23 and 06/13/23.

There were no unsafe resident transfers from 05/10/23 to 06/14/23 (the time of the onsite complaint investigation).

This deficiency represents non-compliance investigated under Complaint Number OH00143330 and OH00143300.

Based on record review,observation, and interview the facility failed to demonstrate proper hand hygiene before donning gloves when giving intravenous (IV) catheter flushes for Resident #28. This affected one of one resident in the facility with IV access (Resident #28). The total census was 68.

Findings include:

Record review of Resident #28 revealed she was admitted to the facility 03/07/23 with IV access for antibiotic administration. Her diagnoses included left femur fracture, infection due to internal fixation device, and MRSA (methicillin resistant staphylococcus aureus, a form of infection). She had contact isolation orders in place for her MRSA.

Observation of an IV flush procedure for Resident #28 by Registered Nurse (RN) #203 on 03/09/23 at 8:20 A.M. revealed RN #203 did not wash or sanitize her hands anytime between donning her gown to enter the room, donning her gloves in the bathroom, or administering the flush. She did wash her hands before exiting the room after removing her protective equipment.

Interview with RN #203 on 03/09/23 at 8:34 A.M. confirmed she did not wash her hands before donning gloves and administering the flush.

Record review of the venous catheter flush policy dated 02/2019 revealed staff were to wash hands before applying gloves when providing an intravenous flush.

This deficiency represents noncompliance investigated under OH00140455.