dph citation #2 ~ dphcit12560

8/3/2019 DPH Citation #2 ~ dphcit12560

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STATE OF CONNECTICUTDEPARTMENT OF PUBLIC HEALTH

IMPORTANT NOTICE - PLEASE READ CAREFULLY

October 6, 2011Andrew Krochko, AdministratorWilton Meadows Health Care Cen439 Danbury Rd Rt 7Wilton, CT 06897Dear Mr. Krochko:On September 28, 2011 multiple complaint investigations visits were concluded at yourfacility by the State of Connecticut, Department of Public Health, Facility Licensing &Investigations Section to determine if your facility was in compliance with Federalrequirements for nursing homes participating in the Medicare and Medicaid programs.This survey found the most serious deficiency(ies) in your facility to be:Isolated deficiencies that constitute actual harm that is not immediate jeopardywhereby significant corrections are required (G).

An Enforcement Cycle has been initiated based on the citation of deficiencies at a"D" level or greater at your facility. All statutory/mandatory enforcement remediesare effective based onSeptember 28, 2011 the beginning survey of the EnforcementCycle. Your Enforcement Cycle began with the September 28,2011 survey. Allsurveys conducted after September 28,2011 with deficiencies at a "D" level orgreater become a part of this Enforcement Cycle. The enforcement cycle will notend until substantial compliance is achieved for all deficiencies from all surveyswithin an enforcement cycle. Facilities are expected to achieve and maintaincontinuous substantial compliance.

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All references to regulatory requirements contained in this letter are found in Title 42,Code of Federal Regulations.

A Plan of Correction (PaC) for the deficiencies must be submitted by the 10th day afterthe facility receives its Statement of Deficiencies (Form CMS-2567). Your PoC serves asyour written allegation of compliance. Failure to submit a signed and dated acceptablePaC by October 20, 2011 may result in the imposition of additional remedies by the 20thday after the due date for submission of a PoC.

@ Phone: (860) 509-7400Telephone Device for the Deaf (860) 509-7191410 Capitol Avenue - MS # 12HSRP.G. Box 340308 Hartford, CT 06134An Equal Opportunity Employer


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STATE OF CONNECTICUTDEPARTMENT OF PUBLIC HEALTH

October n,2011Mr. Andrew Krochko, AdministratorWilton Meadows Health Care Center43 9 Danbury Rd Rt 7Wilton, CT 06897Dear Mr. Krochko..This is an amended edition of the violation letter originally dated Otober 6, 2011.Unannounced visits were made to Wilton Meadows Health Care Center concluding on September 28, 201 I by arepresentatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose ofconducting multiple investigations.Attached are the violations of the Regulations of Connecticut State Agencies and/or General Statutes of Connecticut whichwere noted during the course of the visits.You may wish to dispute the violations and you may be provided with the opportunity to be heard. If the violations are notresponded to by October 20,20 II or if a request for a meeting is not made by the stipulated date, the violation shall bedeemed admitted.Please address each violation with a prospective plan of correction which includes the following components:1. Measures to prevent the recurrence of the identified violation, (e.g., policy/procedure, inservice program.repairs, etc.).2. Date corrective measure will be effected.3. Identify the staff member, by title, who has been designated the responsibility for monitoring the individual plan of

correction submitted for each violation.We do not anticipate making any practitioner referrals at this time.If there are an y questions, please do Dot hesitate to contact this office at (860) 509-7400.m ~ 4 L ! f j ( ~Maureen H. KJett, R.N.,C., M.S.N.Supervising Nurse ConsultantFacility Licensing and Investigations Section . _ . . .. . .. . .MHK:DD:mk

Complaint # CT 12254, CT 12560, CT 12591, CT 12623, CT 12621, CT 12678, CT 12719 & CT12865

Phone: (860) 509-7400Telephone Device/or the Deaf (860) 509-7191

410 Capitol Avenue - MS # 12HSRP.G. Box 340308 Hartford, CT 06134An Equal Opportunity Employer


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FACIL~TY: Wilton Meadows Health Care Cen Page 3 of5DATE(S) OF VISIT: September 28,2011

THE FOLLOWlNG VIOLATION(S) OF THE REGULATIONS OF CONNECTICUTSTATE AGENCIES AND/OR CONNECTICUT GENERAL STATUTES

WERE IDENTIFIEDboth the nursing staff and physician about his/her concern. Interview with MD# 2 on 9/26111 at2:10 PM identified that he/she was aware of Person #2's concern and had educated Person #2 ofthe necessity of the medication. Interview with RN#2 on 9/27/11 at 11:30 AM identified thatPerson #2 objected to the administration of the Keppra and the situation was discussed with1.1])#2. Staff continued to administer the medication as ordered. However, when Person #2 waspresent R#6 would refuse. Review of the Resident Care Plan failed to address the issue withmedication compliance and/or measures to the responsible person's concern and! or the resident'srefusal.

The following are violations of the Regulations of Connecticut State Agencies Section 19-13-D8t(m) Nursing Staff (2)(A).3. Based on clinical record reviews, observation and interview for one resident of three residents (R#6)reviewed for skin issues. The findings include:a. R#6 's diagnoses included cardiovascular accident, dysphagia and seizure disorder. The MinimumData Set (MDS) dated 4/14/10 identified short term memory loss, intact long term memory andmoderately impaired cognition. Review of the Resident Care Plan (RCP) dated 6/20/11 identifiedpotential for alteration in skin integritylbreakdown with related interventions for weekly skinchecks. Review of weekly body audits dated 6 1 7 1 1 1 through 8/9/11 failed to identify a skin issuebehind the right ear. Review of Social Work documentation dated 6/28/11 identified that Person#1 reported to the SociaIWorker that there was a scab behind R#6's ear. Review of nurse's notesdated 8111111identified that R#6 had numerous pin-point scabbed areas behind the right ear withsome redness. Interview with Person #2 on 9/26/11 at 11:00 AM identified that he/she had notedan open sore behind the ear ofR#6 and reported it to the SW#l at the end of June.Interview with SW#l on 10/6111 at 11:45AM identified that the area had been reported tohimlher on 6 1 2 8 1 1 1 and he/she can't recall who he/she reported it to. Review of the nurse's notesand physician orders from 6/26111 through 8111111failed to identify that the area was assessed bynursing until 8/11111, physician notified and a treatment ordered.

The following are violations of the Regulations of Connecticut State Agencies Section 19-13-D8t(m) Nursing Staff (2)(C).4. Based on clinical record reviews, observations and interviews for one of seven residents whorequired staff assistance for transfers (R#9) and/or one of three residents observed for positioning inbed, the facility failed to ensure that residents were transferred in accordance with the plan of care toprevent injury. The findings include:a. R# 9 was admitted to the facility on 1/31/2011 for short term rehabilitation and skilled nursingafter a hospitalization for muscle weakness. The Minimum Data Set (lvIDS) dated 2/20/2011indicated that R#9 required the assistance of two or more staff for transfers and to walk in hislherroom. Physician orders dated March 2011 directed the resident's activity to be


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FAl:lqTY: Wilton Meadows Health Care Cen Page 5 of5DATE(S) OF VISIT: September 28, 2011

THE FOLLOWING V10LATION(S) OF THE REGULATIONS OF CONNECTICUTSTATE AGENCIES AND/OR CONNECTICUT GENERAL STATOTES

WERE IDENTIFIEDwere unsuccessful.

The following are violations of the Regulations of Connecticut State Agencies Section 19-13-D8t(0)Medical Records (2)(1).5. Based on clinical record review and interview for one(R#6) of three residents reviewed for theprovision of care the facility failed to maintain a clinical record that contained sufficient informationthat addressed a continued medication issue. The findings include:a. R#6 's diagnoses included cardiovascular accident, dysphagia and seizure disorder. The MinimumData Set dated 4 1 1 4 1 1 0 identified short term memory loss, intact long term memory andmoderately impaired cognition. Review of the Resident Care Plan (RCP)dated 4/26/10 identifiedat risk for injury due to seizure disorder with interventions to medicate with an anticonvulsant asordered and to notify the physician of any seizure disorder. Physician orders dated 5/2010directed the administration of Keppra 250 mg two times daily. Review of the MedicationAdministration Record (MAR) dated 5/3/10 through 6/2511 0 identified the refusal of 51 doses ofKappa out of a scheduled 122 dose. Interview with Person #2 on 9/26111 at 11:OOAMidentifiedthat he/she wanted the Keppra discontinued and had spoken to both the nursing staff andphysician about his/her concern. Interview with MD# 2 on 9/26111 at 2:10PM identified thathe/she was aware of Person #2's concern and had educated Person#2 with the necessity of themedication. Interview with RN#2 on 9/27111 at 11:30 AM identified that Person #2 objected tothe administration of the Keppra and the situation was discussed with MD#2. Staff continued toadminister the medication as ordered. However, when Person #2 was present R#6 would refuse.Review of the clinical record failed to identify a physician progress note that reflects that themedication issue was addressed and the family educated about the utiliation of the Keppra.


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POC for violation of regulations of Connecticut Agencies Section 19-13D8t (0) MedicalRecords (2) (I):Resident # 6 is receiving Keppa medications as ordered by the attending physician.Residents who refuse medication have the potential to be affected by the identified deficientpractice.

The Director of Nursing will implement this plan of correction.

To assure that this identified deficient practice does not recur we are taking the followingcorrective measures:Attending physicians will be contacted according to our Policy & Procedure when a residentand or family member is refusing administration of prescribed medications to ensure thephysician educates the resident and or family member about the importance of accepting theprescribed medication. A corresponding progress note from the physician will be obtained.Random audits will be conducted weekly for 2 months to ensure the clinical records arecomplete with physician progress note documentation,The results of the audit will be reported to the Quality Assurance Assessment Committee, whichwill recommend any further corrective measures, indicated.

Complete Date: November 2,2011

Sincerely,If you need any further information, please contact me at (203) 834-0199.

~Andrew S. KrochkoAdministrator

Page 1 44 39 D an bu ry R oa d (R ou te 7) W ilto n, C on necticut 06 89 7 P ho ne: (2 03) 834-0199. Fax: (203) 834-2646

dph citation #2 ~ dphcit12560

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