printed: 05/18/2017 department of health …x1) provider/supplier/clia department of health and...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

05/18/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

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B. WING

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COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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DATECROSS-REFERENCED TO THE APPROPRIATE

INDIANAPOLIS, IN 46227

155780 03/01/2017

MADISON HEALTH CARE CENTER

7465 MADISON AVE

00

F 0000

Bldg. 00

This visit was for a Recertification and

State Licensure Survey.

This visit was in conjunction with the

Investigation of Complaint IN00222755.

Complaint IN00222755-Unsubstantiated

due to lack of evidence.

Survey dates: February 21, 22, 23, 24,

27, 28, and March 1, 2017

Facility number: 012225

Provider number: 155780

AIM number: 200983560

Census bed type:

SNF/NF: 86

Total: 86

Census payor type:

Medicare: 15

Medicaid: 57

Other: 14

Total: 86

These deficiencies reflect State findings

cited in accordance with 410 IAC

16.2-3.1.

Quality Review completed on March 09,

F 0000 Submission of this plan of

correction does not constitute an

admission by Madison Health

Care Center, or their

Management companies, that the

allegations contained in the

survey report are a true and

accurate portrayal of the provision

of nursing care and other

services in this facility. Nor does

this submission constitute an

agreement of the survey

allegations. Madison Health Care

Center respectfully requests a

desk review and paper

compliance.

FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determined that

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: NIBM11 Facility ID: 012225

TITLE

If continuation sheet of 39

(X6) DATE




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2017.

483.10(d)(3)(g)(1)(4)(5)(13)(16)-(18)

NOTICE OF RIGHTS, RULES, SERVICES,

CHARGES

(d)(3) The facility must ensure that each

resident remains informed of the name,

specialty, and way of contacting the

physician and other primary care

professionals responsible for his or her care.

§483.10(g) Information and Communication.

(1) The resident has the right to be informed

of his or her rights and of all rules and

regulations governing resident conduct and

responsibilities during his or her stay in the

facility.

(g)(4) The resident has the right to receive

notices orally (meaning spoken) and in

writing (including Braille) in a format and a

language he or she understands, including:

(i) Required notices as specified in this

section. The facility must furnish to each

resident a written description of legal rights

which includes -

(A) A description of the manner of protecting

personal funds, under paragraph (f)(10) of

this section;

(B) A description of the requirements and

procedures for establishing eligibility for

Medicaid, including the right to request an

F 0156

SS=D

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FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NIBM11 Facility ID: 012225 If continuation sheet of 39




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assessment of resources under section

1924(c) of the Social Security Act.

(C) A list of names, addresses (mailing and

email), and telephone numbers of all

pertinent State regulatory and informational

agencies, resident advocacy groups such as

the State Survey Agency, the State licensure

office, the State Long-Term Care

Ombudsman program, the protection and

advocacy agency, adult protective services

where state law provides for jurisdiction in

long-term care facilities, the local contact

agency for information about returning to the

community and the Medicaid Fraud Control

Unit; and

(D) A statement that the resident may file a

complaint with the State Survey Agency

concerning any suspected violation of state

or federal nursing facility regulations,

including but not limited to resident abuse,

neglect, exploitation, misappropriation of

resident property in the facility,

non-compliance with the advance directives

requirements and requests for information

regarding returning to the community.

(ii) Information and contact information for

State and local advocacy organizations

including but not limited to the State Survey

Agency, the State Long-Term Care

Ombudsman program (established under

section 712 of the Older Americans Act of

1965, as amended 2016 (42 U.S.C. 3001 et

seq) and the protection and advocacy

system (as designated by the state, and as

established under the Developmental

Disabilities Assistance and Bill of Rights Act

of 2000 (42 U.S.C. 15001 et seq.)

[§483.10(g)(4)(ii) will be implemented

beginning November 28, 2017 (Phase 2)]





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(iii) Information regarding Medicare and

Medicaid eligibility and coverage;

[§483.10(g)(4)(iii) will be implemented


(iv) Contact information for the Aging and

Disability Resource Center (established

under Section 202(a)(20)(B)(iii) of the Older

Americans Act); or other No Wrong Door

Program;

[§483.10(g)(4)(iv) will be implemented


(v) Contact information for the Medicaid

Fraud Control Unit; and

[§483.10(g)(4)(v) will be implemented


(vi) Information and contact information for

filing grievances or complaints concerning

any suspected violation of state or federal

nursing facility regulations, including but not

limited to resident abuse, neglect,

exploitation, misappropriation of resident

property in the facility, non-compliance with

the advance directives requirements and

requests for information regarding returning

to the community.

(g)(5) The facility must post, in a form and

manner accessible and understandable to

residents, resident representatives:

(i) A list of names, addresses (mailing and

email), and telephone numbers of all

pertinent State agencies and advocacy

groups, such as the State Survey Agency,

the State licensure office, adult protective

services where state law provides for

jurisdiction in long-term care facilities, the

Office of the State Long-Term Care





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Ombudsman program, the protection and

advocacy network, home and community

based service programs, and the Medicaid

Fraud Control Unit; and

(ii) A statement that the resident may file a

complaint with the State Survey Agency

concerning any suspected violation of state

or federal nursing facility regulation,

including but not limited to resident abuse,

neglect, exploitation, misappropriation of

resident property in the facility, and

non-compliance with the advanced

directives requirements (42 CFR part 489

subpart I) and requests for information

regarding returning to the community.

(g)(13) The facility must display in the facility

written information, and provide to residents

and applicants for admission, oral and

written information about how to apply for

and use Medicare and Medicaid benefits,

and how to receive refunds for previous

payments covered by such benefits.

(g)(16) The facility must provide a notice of

rights and services to the resident prior to or

upon admission and during the resident’s

stay.

(i) The facility must inform the resident both

orally and in writing in a language that the

resident understands of his or her rights and

all rules and regulations governing resident

conduct and responsibilities during the stay

in the facility.

(ii) The facility must also provide the resident

with the State-developed notice of Medicaid

rights and obligations, if any.

(iii) Receipt of such information, and any





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amendments to it, must be acknowledged in

writing;

(g)(17) The facility must--

(i) Inform each Medicaid-eligible resident, in

writing, at the time of admission to the

nursing facility and when the resident

becomes eligible for Medicaid of-

(A) The items and services that are included

in nursing facility services under the State

plan and for which the resident may not be

charged;

(B) Those other items and services that the

facility offers and for which the resident may

be charged, and the amount of charges for

those services; and

(ii) Inform each Medicaid-eligible resident

when changes are made to the items and

services specified in paragraphs (g)(17)(i)(A)

and (B) of this section.

(g)(18) The facility must inform each

resident before, or at the time of admission,

and periodically during the resident’s stay, of

services available in the facility and of

charges for those services, including any

charges for services not covered under

Medicare/ Medicaid or by the facility’s per

diem rate.

(i) Where changes in coverage are made to

items and services covered by Medicare

and/or by the Medicaid State plan, the facility

must provide notice to residents of the

change as soon as is reasonably possible.

(ii) Where changes are made to charges for

other items and services that the facility





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offers, the facility must inform the resident in

writing at least 60 days prior to

implementation of the change.

(iii) If a resident dies or is hospitalized or is

transferred and does not return to the

facility, the facility must refund to the

resident, resident representative, or estate,

as applicable, any deposit or charges

already paid, less the facility’s per diem rate,

for the days the resident actually resided or

reserved or retained a bed in the facility,

regardless of any minimum stay or

discharge notice requirements.

(iv) The facility must refund to the resident or

resident representative any and all refunds

due the resident within 30 days from the

resident’s date of discharge from the facility.

v) The terms of an admission contract by or

on behalf of an individual seeking admission

to the facility must not conflict with the

requirements of these regulations.

Based on record review and interview,

the facility failed to ensure a Notice of

Medicare Non-Coverage (NOMNC) was

provided to a resident or the resident's

representative, and signed by the resident

or the resident's representative, at least 48

hours before the Medicare coverage

ended for 1 of 3 residents who met the

criteria for review of provision of Notices

of Medicare Non-Coverage. (Resident

#57)

Findings include:

1. The clinical record of Resident #57

F 0156 It is the practice of Madison

Health Care Center to assure

that each resident knows his

or her rights and

responsibilities and that the

facility communicates this

information prior to or upon

admission, as appropriate

during the resident’s stay, and

when the facility’s rules

change. Madison Health Care

Center provides a notice of

Medicare non-coverage to the

residents or the resident’s

03/23/2017 12:00:00AM





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was reviewed on 2/27/17 at 1:00 p.m.

Diagnoses for the resident included, but

were not limited to, dementia, high blood

pressure, and chronic obstructive

pulmonary disease.

Review of an undated NOMNC

indicated, "The Effective Date of Your

Current Skilled Nursing Facility Services

Will End 9/9/16 OT [Occupational

Therapy] 9/2/16 ST [Speech therapy]."

A note on the back of the letter, signed by

the SSD (Social Service Director),

indicated the resident's son was notified

of these end dates on 8/31/17. A

signature of the resident nor the resident's

son indicating they had received this

notification was not found on the

NONMC.

On 2/27/17 at 1:23 p.m., the SSD

indicated she had left the information

regarding the end of Medicare covered

services for Resident #57 on the son's

voicemail. The SSD assumed, but did

not know for sure, if the resident's son

received the information, and did not

send the NOMNC to the son for him to

sign, indicating he received the

information.

On 2/28/17 at 11:30 a.m., the Human

Resources Director provided a policy

representative 48 hours prior

to the end of coverage.

1.Resident # 57 is no

longer a Madison Health

Care Center resident.

2.This alleged deficiency

has the potential to affect

all residents presented with

a Medicare Non-Coverage

Notice.

3.Madison Health Care

Center has a policy

regarding Medicare Cut

Letters as mentioned in the

survey results. As per

policy, attempted

notification of NONMC was

made as outlined in the

survey. The social services

director and social service

assistant were in-serviced

on the NONMC notification

requirements and Medicare

Cut Letter Policy by the

Administrator on 3/13/17. A

signature will be obtained

by the resident or resident

representative on the

NONMC notification at least

48 hours before the

Medicare coverage ends. If

an initial phone NONMC





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dated 12/29/14, titled, "Medicare Cut

Letter Policy," and indicated it was the

policy currently used by the facility. The

policy indicated, "...Social Services

Department will notify The Resident

and/or Responsible Party no less that 2

days prior to the End of Medicare

Coverage via face-to-face OR

telephone...Appropriate forms will be

signed by the Resident and/or

Responsible Party..."

3.1-4(f)(3)

notification is given a

witness will be on the call.

The date of the witnessed

call will be documented and

a copy of the letter will be

sent for signature.

4.All potentially affected

residents have been

reviewed with no negative

findings. The Administrator,

or designee, will conduct

quality assurance audits on

all (NOMNC) notifications

for compliance once (1) a

week times three (3)

months. Results will be

reported monthly to the

QAPI committee. Any

negative findings will add

another four (4) weeks of

audits until 100%

compliance is achieved.

5.Date of completion:

3/23/17

483.10(e)(3)

REASONABLE ACCOMMODATION OF

NEEDS/PREFERENCES

(e)(3) The right to reside and receive

services in the facility with reasonable

accommodation of resident needs and

preferences except when to do so would

endanger the health or safety of the resident

or other residents.

F 0246

SS=E

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Based on observation, record review, and

interview, the facility failed to ensure

residents' needs were accommodated

regarding their preferences for receiving

showers (Residents #75 and #88), and

smoking (Resident #75), for 2 of 3

residents reviewed for accommodation of

needs and the facility failed to ensure

resident call lights were within reach for

3 random resident observations (Resident

#87, #119, and #66).

Findings include:

1.a. The clinical record of Resident #75

was reviewed on 2/27/17 at 9:50 a.m.


were not limited to, bipolar disorder and

major depressive disorder.

A quarterly Minimum Data Set

assessment, dated 11/23/16, indicated

Resident #75 was independent in her

ability to make decisions and needed the

assistance of 1 person for bathing.

A care plan for Resident #75, dated

12/19/12 and current through 2/28/17,

indicated Resident #75 needed extensive

assistance with all her activities of daily

living. An intervention was, "Assist

res[ident] with bath/shower twice

weekly..."

F 0246 It is the practice of Madison

Health Care Center to provide

reasonable accommodations

of individual needs and

preferences assisting the

resident in maintaining and/or

achieving independent

functioning, dignity, and

well-being to the extent

possible in accordance with

the resident’s own needs and

preferences.

1.Residents #75 & #88

are receiving showers per

their preferences. Resident

#75 is smoking timely per

the schedule for assisted

smoking. Call lights are

positioned in reach of the

residents with easy

accessibility.

2.This alleged deficient

practice has the potential to

affect all Madison Health

Care Center residents

including those who smoke.

3.Madison Health Care

Center has a policy on

Shower/Bath as mentioned

in the survey findings. The

CNAs were re-educated on

03/23/2017 12:00:00AM





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Another care plan, dated 11/28/12, and

current through 2/27/17, indicated

Resident #75 frequently refused her

showers.

On 2/23/17 at 9:20 a.m., Resident #75

indicated, "We're supposed to get 2

showers a week, which is what I want,

but they always forget my Friday shower,

and my skin starts drying."

Review of Look Back Reports, 11/27/16

- 2/26/17, a 13 week period, indicated

Resident #75 received a shower on the

following Fridays: 12/30/16 and 1/27/17.

Eleven Fridays had no documentation to

indicate a shower had been provided.

There was no documentation which

specifically indicated the resident refused

any showers on the other 11 Fridays.

On 2/28/17 at 11:57 a.m. the Assistant

Director of Nursing indicated she was not

able to find any other Friday showers in

the Look Back Reports for Resident #75.

b. The clinical record of Resident #88



were not limited, anxiety disorder and

depressive episodes.

A quarterly Minimum Data Set

assessment, dated 11/10/16, indicated

the Shower/Bath Policy,

completing showers as

scheduled, reporting to the

charge nurse with refusals

and documenting the

showers when completed

on 3/13/17. In addition, the

facility has completed a

questionnaire regarding

preferences on showers for

all residents. Any

adjustments have been

made to accommodate

those preferences and the

assessment for residents'

bathing/shower preferences

include non-interviewable

residents.

Madison Health Care

Center has a Smoking

Policy as mentioned in the

survey findings. All staff

were re-educated on the

Smoking policy, emphasis

was placed on being timely

and following the schedule,

on 3/13/17.

Madison Health Care

Center has a Call Light

Policy as mentioned in the

survey findings. All staff

were re-educated on the

Call Light Policy and

positioning of call lights so

they are easily accessible





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Resident #88 was independent in his

ability to make decisions, and need the

physical assistance of 1 staff person for

bathing.

A current care plan, with an original date

of 5/3/16, indicated Resident #88 had a

history of refusing showers when offered.

On 2/21/17 at 12:59 p.m., Resident #88

indicated he sometimes has to wait 2 or 3

weeks to get a shower.

Review of Look Back Reports, dated

11/27/17 through 2/27/17, indicated

Resident #88 received only 8 showers

during this 13 week period. There was no

documentation which specifically

indicated the resident refused any

showers.

On 2/28/17 at 11:57 a.m. the Assistant

Director of Nursing indicated she was not

able to find any other Friday showers in

the Look Back Reports for Resident #75.

On 2/27/17 at 2:18 p.m., Resident #88

indicated it had been 2 weeks since he

had a shower and he never refused

showers.

On 2/28/17 at 9:56 a.m., the Director of

Nursing provided a policy dated 10/2013,

titled, "Shower/Tub Bath," and indicated

on 3/13/17.

4.The charge nurses are

monitoring for call light

placement on each shift

seven days a week. The

DON, or designee, will

monitor the documentation

of completed showers and

call light placement three

(3) times a week for three

(3) months; then once (1)

monthly for six (6) months.

The Administrator, or

designee, will interview

assisted smoking residents

three (3) times per week for

three (3) months to confirm

staff adhere to resident

designated smoking times.

Results will be reported to

the QAPI committee

monthly. Any negative

findings will add another

four (4) weeks of audits

until 100% compliance is

achieved.

5.Date of completion:

3/23/17





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it was the policy currently used by the

facility. The policy indicated, "... The

following information should be recorded

on the resident's ADL [activities of daily

living] record and/or the resident's

medical record...If the resident refused

the shower..., the reason(s) why and the

intervention taken..."

2. The clinical record of Resident #75



were not limited to, bipolar disorder and

major depressive disorder.

Smoking Assessments, dated 5/11/16

and November, 2017, indicated Resident

#75 needed to be under the supervision of

a staff member while smoking.

A care plan, created 9/11/15, current

through 5/21/17, indicated Resident #75

was a supervised smoker. Interventions

included, "Staff to go with res[ident]

during smoking times."

On 2/23/17 at 9:20 a.m., Resident #75

indicated it was very difficult to find a

staff person, at 6:30 p.m., to go with her

so she could smoke. She had to, "wait

and wait," and she never got to go out at

8:30 p.m., "no one ever even offers."

On 2/24/17 at 10:00 a.m., Resident #75





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was observed sitting in her wheelchair in

the hallway leading to the smoking exit

door. The resident was not taken out to

smoke until 10:20 a.m.

On 2/23/17 at 10:05 a.m., Resident #26

indicated he had seen Resident #75

falling asleep sitting in her wheelchair

waiting for staff to take her out to smoke.

"She has a terrible time trying to get

someone to take her."

On 2/27/17 at 10:00 a.m., the

Administrator provided an undated policy

titled, "Smoking Policy", and indicated it

was the policy currently used by the

facility. The policy indicated smoking

times for supervised smokers were 10:00

a.m., 1:00 p.m., 3:30 p.m., 6:30 p.m., and

8:30 p.m. "The department staff will be

assigned their times to supervise. They

are required to be prompt and have all

residents' materials at the designated

times."

3). a. On 2/27/17 at 9:45 a.m.,

Resident #87 was observed in bed resting

quietly with both eyes closed. The call

light was on the wall, clipped to the cord,

out of reach of Resident #87. The

Activity Director entered the room.

On 2/24/2017 at 2:00 p.m., during

clinical record review of Resident #87,

The New Madison CAA Worksheet





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indicated Resident #87 requires extensive

assistance bed mobility.

On 2/27/2017 at 10:00 a.m., during an

interview, the Activity Director indicated

the call light should be clipped to the bed

linens so that the resident can reach it and

should not be hanging on the wall out of

the reach of the resident.

b.) On 2/24/2017 at 9:40 a.m., observed

Resident #119 to be awake, sitting in

their room in a wheelchair. The call light

cord was hanging behind the bed and the

call light was on the floor. The resident

was unable to reach the call light. CNA

#1 entered the room.

On 2/17/17 at 10:00 a.m., during clinical

record review of Resident #119, Care

plan dated 2/7/2017 indicated Resident

#119 required assist with Activities of

Daily Living.

On 2/24/2017 at 9:45 a.m., during an

interview, Certified Nursing Assistant

(CNA) #1 observed the call light to be

out of reach, The call light should not be

on the floor and should be in a location

easily accessible to the resident.

c.) On 2/24/2017 at 9:45 a.m., Resident

#66 was observed in bed resting with

both eyes closed. The call light was





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observed not in the reach of the resident.

The call light was hanging from the cord

to the floor at the foot of the bed. CNA

#2 entered the room within 5 minutes.

On 2/27/2017 at 10:45 a.m., during a

clinical record review of Resident #66,

the Annual Minimum Data Set

Assessment, dated 12/23/16, indicated

Resident #66 required extensive assist

with Activities of Daily Living. A Brief

Interview for Mental status indicated a

score of 3 - severely impaired cognition,

rarely/never made decisions.

On 2/24/2017 at 9:50 a.m., during an

interview, CNA # 2 indicated the resident

threw the call light off of the bed herself.

That she always pins the call light to the

residents bed linens so that she reach it.

on 2/27/2017 at 10:30 a.m., during an

interview, the Director Of Nursing

indicated that some of the residents will

throw the call light off of the bed after

the staff pin it in a place that is reachable

for the resident.

On 2/27/17 at 11:20 a.m., the Director Of

Nursing provided a policy and

procedure(undated), titled "Call lights."

The Director Of Nursing indicated it was

the current policy being used by the

facility. "Purpose: To assure each





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resident will have a readily accessible

means to obtain needed assistance. ....2.

Call lights will be kept within reach of

residents."

3.1-3 (v)(1)

483.20(d);483.21(b)(1)

DEVELOP COMPREHENSIVE CARE

PLANS

483.20

(d) Use. A facility must maintain all resident

assessments completed within the previous

15 months in the resident’s active record

and use the results of the assessments to

develop, review and revise the resident’s

comprehensive care plan.

483.21

(b) Comprehensive Care Plans

(1) The facility must develop and implement

a comprehensive person-centered care plan

for each resident, consistent with the

resident rights set forth at §483.10(c)(2) and

§483.10(c)(3), that includes measurable

objectives and timeframes to meet a

resident's medical, nursing, and mental and

psychosocial needs that are identified in the

comprehensive assessment. The

comprehensive care plan must describe the

following -

(i) The services that are to be furnished to

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attain or maintain the resident's highest

practicable physical, mental, and

psychosocial well-being as required under

§483.24, §483.25 or §483.40; and

(ii) Any services that would otherwise be

required under §483.24, §483.25 or §483.40

but are not provided due to the resident's

exercise of rights under §483.10, including

the right to refuse treatment under

§483.10(c)(6).

(iii) Any specialized services or specialized

rehabilitative services the nursing facility will

provide as a result of PASARR

recommendations. If a facility disagrees with

the findings of the PASARR, it must indicate

its rationale in the resident’s medical record.

(iv)In consultation with the resident and the

resident’s representative (s)-

(A) The resident’s goals for admission and

desired outcomes.

(B) The resident’s preference and potential

for future discharge. Facilities must

document whether the resident’s desire to

return to the community was assessed and

any referrals to local contact agencies

and/or other appropriate entities, for this

purpose.

(C) Discharge plans in the comprehensive

care plan, as appropriate, in accordance

with the requirements set forth in paragraph

(c) of this section.


the facility failed to ensure a

comprehensive person-centered care plan

was developed for a resident who

F 0279 It is the practice of Madison Health

Care Center interdisciplinary team,

in conjunction with the resident,

resident’s family, surrogate, or

representative, as appropriate,

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developed a pressure ulcer after being

admitted to the facility for 1 of 1 resident

who met the criteria for review of

pressure ulcers. (Resident #78)

Findings include:

The clinical record of Resident #78 was

reviewed on 2/24/17 at 11:39 a.m.


were not limited to, pressure ulcer, right

toe amputation, and morbid obesity.

Resident #78 was readmitted to the

facility, on 9/6/16, after surgery for

amputation of the great and 2nd toes on

her right foot.

A nursing admission assessment, dated

9/6/16, indicated Resident #78's right

heel was red with 2 scabbed areas. A

pressure reducing mattress was on the

resident's bed.

An interim care plan, developed on

9/6/16, indicated the resident was at risk

for skin breakdown and had a scab on her

right heel. Interventions included but

were not limited to, elevating heels off

bed surface, foam boots, Skin Prep to

heels.

Another interim care plan was developed

on 9/14/16, which indicated the scab on

should develop quantifiable

objectives for the highest level of

functioning the resident may be

expected to attain, based on the

comprehensive assessment.

1.Resident # 78 care plan was

reviewed and revised with new

treatment approaches, current

treatments and services.

Resident # 78 wound has

resolved at this time and an

at-risk care plan to maintain

integrity was initiated on 3/20/17.

2.This alleged deficient practice

has the potential to affect all

residents with wound care

services. All potentially affected

residents care plans have been

reviewed and revised with new

treatment approaches, current

treatments and services.

3.Madison Health Care Center

has a policy regarding Care

Planning. As per policy, a care

plan was present as outlined in

the survey findings. The

Interdisciplinary Team members

were re-educated on the Care

Plan Policy on 3/13/17.



services have been reviewed and

revised with new treatment

approaches, current treatments

and services. The DON, or

designee, will conduct quality

assurance audits on three (3)

residents identified with skin

integrity issues once (1) weekly

for four (4) weeks to ensure the

care plan is current and reflective





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the right heel was now an unstageable

pressure ulcer. Interventions included,

but were not limited to, floating heels,

foam boots, and weekly skin check. An

unstageable pressure is a full thickness

tissue loss, where the wound bed is

covered by slough or eschar, making it

impossible to fully assess the stage of the

pressure ulcer.

A comprehensive ,non-interim care plan

was developed on 11/9/16, 2 months after

the identification of the unstageable

pressure ulcer. This care plan was current

through 3/14/17, with a problem of,

"Resident has a Stage 3 pressure ulcer to

right heel [was admitted with scab area to

heel which opened up to stage 3]." A

Stage 3 pressure ulcer is a full thickness

skin loss, extending below the skin and

forming a crater.

On 2/27/17 at 4:00 p.m., the Director of

Nursing indicated the resident's pressure

ulcer was unstageable, not Stage 3).

Interventions on this care plan were to

assess for pain and treat as needed,

monitor for signs and symptoms of

infection, Nurse Practitioner to follow,

treatment to be done as ordered, and

waffle boot to right foot.

New treatment approaches since 9/14/16

include:

of the appropriate treatment and

interventions; then three (3)

residents once (1) monthly times

six (6) months. Results will be

reported monthly to the QAPI

committee. Any negative findings

will add another four (4) weeks of

audits until 100% compliance is

achieved.

5.Date of completion: 3/23/17





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9/14/16 (start date) (Xeroform dressing to

right heel daily.

11/14/16 (start date) Lidocaine gel to

wound on right heel, then apply silvadene

cream, cover with Xeroform, change

dressing daily.

11/21/16 (start date) clean area with

saline apply Venelex, cover with gauze

and coverall. Change daily for right heel

treatment.

11/26/16 (start date) clean right heel with

normal saline, cover with gauze and

coverall change daily.

The non interim care plan, developed

11/9/16, and current through 3/14/17,

was not updated or revised with any of

these new treatment approaches nor did

the resident's comprehensive care plan

include current pressure sore treatment

and services.

3.1-35(a)

483.21(b)(3)(ii)

SERVICES BY QUALIFIED PERSONS/PER

CARE PLAN

(b)(3) Comprehensive Care Plans

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The services provided or arranged by the

facility, as outlined by the comprehensive

care plan, must-

(ii) Be provided by qualified persons in

accordance with each resident's written plan

of care.


the facility failed to ensure waffle boots,

off loading heels and Skin Prep were

provided, according to an interim plan of

care, for a resident who was admitted to

the facility without a pressure ulcer, for 1

of 1 resident who met the criteria for

review of pressure ulcers. (Resident #78)

Findings include:







facility on 9/6/16 after surgery for


her right foot.

A significant change Minimum Data Set

assessment, dated 9/14/16, indicated the

resident was moderately impaired in her

ability to make decisions, and needed

extensive assistance from 2+ staff


Care Center to ensure a resident's

plan of care is followed related to

help prevent further skin breakdown

for residents who met the criteria

for wound care services.

1.One Resident, Resident # 78,

has a pressure area, daily

prevention was being completed

as outlined in the survey findings.

An order was not transcribed onto

the treatment administration

record.

2.All Residents with wound care

have the potential to be affected

by this alleged deficiency. A

clarification order for Resident

#78 has been received. All

residents with wounds have been

reviewed with no further findings.

3.As noted in the survey

findings, Madison Health Care

Center has a Pressure Ulcer

Prevention Policy. Licensed

nurses have been re-educated on

the aforementioned policy

emphasizing the nursing team will

identify skin issues upon

admission, obtain and transcribe

orders, record wound care in the

treatment administration record

and interventions initiated on the

plan of care on 3/13/17. The

charge nurses will be monitoring

03/23/2017 12:00:00AM





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persons for bed mobility, transferring,

and toileting.

A Pressure Ulcer Risk Assessment, dated

9/6/16, indicated Resident #78 was a high

risk to develop a pressure ulcer.





resident's bed.

Hospital discharge orders, dated 9/6/16,

indicated the resident, "Needs weight

offloading of feet w/ [with] foam boots."

(Offloading with foam boots reduces the

pressure on areas of concern) This order

was not transcribed to the facility Order

Recap Report until 9/14/16.

A physician's order, dated 9/6/16,

indicated Skin Prep was to be applied to

Resident #78's heel every shift. Skin Prep

is a liquid, which when applied, forms a

skin protectant to help prevent irritation

to intact or damaged skin. This order was

not transcribed to the facility Order

Recap Report.

An Interim care plan, created 9/6/16,

indicated a problem of Resident #78

being at risk for, "Break in Skin

Integrity...scab." Interventions included,

on each shift that interventions

are in place seven days a week.

4.All Residents orders related to

wound care have been reviewed.

In addition to the review and

re-education noted above, the

DON, or her designee, is

conducting a quality improvement

audit to ensure a resident's plan

of care and treatment orders are

followed related to wound care for

residents who met the criteria for

wound care services. The DON,

or her designee, will reassess

twenty-four hours (24) after

admission or with a new pressure

area on resident in house to

ensure the care plan treatments

and interventions are in place. All

residents receiving wound care

will be monitored once (1) weekly

for three (3) months, then once

(1) monthly for six (6) months.

Results of these audits will be

reported monthly to the Quality

Assurance meeting. Any

negative findings will add another

four (4) weeks of audits until

100% compliance is achieved.

5.Date of Completion: 3/23/17.





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but were not limited to, "Elevate heels off

bed surface and 'float' heels-no pressure

on heels, Skin treatment: Skin Prep,

weekly skin check, Assess...boots...heel

protectors, offloading bil[ateral] feet

[with] foam boots."

No further assessments of Resident #78's

right heel were found in her record, until

9/14/16 (8 days later). On that date, a

Pressure Ulcer Wound Sheet indicated

the resident now had an unstageable deep

tissue injury pressure ulcer on her right

heel. An unstageable pressure is a full

thickness tissue loss, where the wound

bed is covered by slough or eschar,

making it impossible to fully assess the

stage of the pressure ulcer.

Review of a Treatment Administration

Record for September 6 - 14, 2016, did

not indicate the facility implemented

waffle boots, offloading of feet, floating

heels, or Skin Prep application, to help

prevent further skin breakdown to the

resident's right heel, as indicated on her

Interim plan of care dated 9/6/16.

On 3/1/17 at 11:30 a.m., the DON

provided a policy dated 10/2010, titled,

"Prevention of Pressure Ulcers," and

indicated it was the policy currently used

by the facility. The policy indicated,

"...Routinely assess and document the





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condition of the resident's skin.

Residents identified to be at risk for

pressure ulcer development should have a

skin assessment completed at least

weekly...The care process should include

efforts to stabilize, reduce or remove

underlying risk factors; to monitor the

impact of the interventions; and to

modify the interventions as appropriate."

3.1-35(g)(2)

483.25(b)(1)

TREATMENT/SVCS TO PREVENT/HEAL

PRESSURE SORES

(b) Skin Integrity -

(1) Pressure ulcers. Based on the

comprehensive assessment of a resident,

the facility must ensure that-

(i) A resident receives care, consistent with

professional standards of practice, to

prevent pressure ulcers and does not

develop pressure ulcers unless the

individual’s clinical condition demonstrates

that they were unavoidable; and

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(ii) A resident with pressure ulcers receives

necessary treatment and services,

consistent with professional standards of

practice, to promote healing, prevent

infection and prevent new ulcers from

developing.

Based on observation, record review, and

interview, the facility failed to ensure a

resident who was admitted to the facility

without a pressure ulcer, received waffle

boots, off loading heels, and Skin Prep to

prevent the development of an

unstageable pressure ulcer for 1 of 1

resident who met the criteria for review

of pressure ulcers. (Resident #78)

Findings include:







facility on 9/6/16, after surgery for


her right foot.

A significant change Minimum Data Set

assessment, dated 9/14/16, indicated the

resident was moderately impaired in her

ability to make decisions, and needed

extensive assistance from 2+ staff

persons for bed mobility, transferring,


Care Center to prevent residents

from developing pressure ulcers

unless clinically unavoidable and

that the facility provides care and

services to promote the prevention

of pressure ulcer development;

promote the healing of pressure

ulcers that are present (including

prevention of infection to the extent

possible); and prevent development

of additional pressure ulcers.

1.Resident # 78 were orders

clarified and placed on the

Medication Administration Record

for documentation in the clinical

record. Resident #78 wound has

resolved at this time and an

at-risk care plan to maintain

integrity was initiated on 3/20/17.

2.This alleged deficient practice

has the potential to affect all


services. All potentially affected

residents have been reviewed

without further findings.


has a policy regarding Prevention

of Pressure Ulcers. The nursing

team were re-educated on the

Prevention of Pressure Ulcers on

3/13/17 emphasizing efforts to

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and toileting.

A Pressure Ulcer Risk Assessment, dated

9/6/16, indicated Resident #78 was a high

risk to develop a pressure ulcer.





resident's bed.

Hospital discharge orders, dated 9/6/16,

indicated the resident, "Needs weight

offloading of feet w/ [with] foam boots."

(Offloading with foam boots reduces the

pressure on areas of concern) This order

was not transcribed to the facility Order

Recap Report until 9/14/16 (8 days after

the resident was admitted to the facility).

A physician's order, dated 9/6/16,

indicated Skin Prep was to be applied to

Resident #78's heel every shift. Skin Prep

is a liquid, which when applied, forms a

skin protectant to help prevent irritation

to intact or damaged skin. This order was

not transcribed to the facility Order

Recap Report.

An Interim care plan, created 9/6/16,

indicated a problem of Resident #78

being at risk for, "Break in Skin

Integrity...scab." Interventions included,

stabilize, reduce or remove

underlying risk factors; to monitor

the impact of the interventions;

and to modify the interventions as

appropriate.



services have been reviewed and

revised with new treatment

approaches, current treatments

and services. The charge nurses

are auditing every shift seven

days a week to ensure pressure

ulcer interventions are in place.

The DON, or designee, will

conduct quality assurance audits

on three (3) residents identified

with skin integrity issues once (1)

weekly for four (4) weeks to

ensure the new wound orders are

transcribed, assessments

completed and pain issues

addressed; then three (3)

residents once (1) monthly times

six (6) months. Results will be

reported monthly to the QAPI

committee. Any negative findings

will add another four (4) weeks of

audits until 100% compliance is

achieved.

5.Date of completion: 3/23/17





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but were not limited to, "Elevate heels off

bed surface and 'float' heels-no pressure

on heels, Skin treatment: Skin Prep,

weekly skin check, Assess...boots...heel

protectors, offloading bil[ateral] feet

[with] foam boots."

No further assessments of Resident #78's

right heel were found in her record, until

9/14/16 (8 days later). On that date, a

Pressure Ulcer Wound Sheet indicated

the resident now had an unstageable deep

tissue injury pressure ulcer on her right

heel. An unstageable pressure is a full

thickness tissue loss, where the wound

bed is covered by slough or eschar,

making it impossible to fully assess the

stage of the pressure ulcer.

Review of a Treatment Administration

for September, 2016, did not indicate the

facility implemented waffle boots,

offloading of feet, floating heels, or Skin

Prep application, to help prevent further

skin breakdown to the resident's right

heel, between her readmission on 9/6/16,

when the scabs on her right heel were

first observed, through 9/14/16, 8 days

after her admission to the facility, when

the unstageable pressure ulcer to the right

heel was identified.

On 2/27/17 at 3:58 p.m., the Director of

Nursing (DON) indicated Resident #78's





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right foot was wrapped with a "figure 8"

dressing to protect the toe amputation

areas, but the right heel would have been

visible in order for the nurses to assess it

for further breakdown. She indicated the

resident's record did not indicate the

nurses applied Skin Prep or the waffle

boot for offloading, between 9/6/17 and

9/14/17, when the unstageable pressure

ulcer was identified.

On 3/1/17 at 8:45 a.m., Resident #78's

unstageable right heel ulcer dressing

change was observed with Licensed

Practical Nurse #12. At that time, the

resident indicated the pain from her

pressure was not as bad as it used to be,

but it still hurt, especially when the

dressing was changed.

On 3/1/17 at 11:30 a.m., the DON

provided a policy dated 10/2010, titled,

"Prevention of Pressure Ulcers," and


by the facility. The policy indicated,

"...Routinely assess and document the

condition of the resident's skin.

Residents identified to be at risk for

pressure ulcer development should have a

skin assessment completed at least

weekly...The care process should include

efforts to stabilize, reduce or remove

underlying risk factors; to monitor the

impact of the interventions; and to





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modify the interventions as appropriate."

3.1-40(a)(1)

483.25(g)(1)(3)

MAINTAIN NUTRITION STATUS UNLESS

UNAVOIDABLE

(g) Assisted nutrition and hydration.

(Includes naso-gastric and gastrostomy

tubes, both percutaneous endoscopic

gastrostomy and percutaneous endoscopic

jejunostomy, and enteral fluids). Based on a

resident’s comprehensive assessment, the

facility must ensure that a resident-

(1) Maintains acceptable parameters of

nutritional status, such as usual body weight

or desirable body weight range and

electrolyte balance, unless the resident’s

clinical condition demonstrates that this is

not possible or resident preferences indicate

otherwise;

(3) Is offered a therapeutic diet when there

is a nutritional problem and the health care

provider orders a therapeutic diet.

F 0325

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the facility failed ensure a nutritionally at

risk resident received dietary

supplements for 1 of 3 residents who met

the criteria for review of nutrition.

(Resident #52)

Findings include:


reviewed on 2/23/17 at 3:49 p.m.


were not limited to, dementia, delusional

disorders, high blood pressure, and

chronic kidney disease.

A care plan, created 12/2/14 and current

through 4/6/17, indicated Resident #52

had an increased nutritional risk related

to a therapeutic or mechanically altered

diet.

A review of weights for the resident

indicated the following:

8/9/16 = 143 lb (pounds)

9/12/16 = 137 lb

10/10/16 = 131 lb

11/14/16 = 132 lb

12/7/16 = 136 lb

1/10/17 = 133

2/12/17 123

A dietary progress note dated 2/22/17,

indicated Resident #52 had had a

Care Center to provide nutritional

care and services to each resident,

consistent with the resident’s

comprehensive assessment;

recognize, evaluate, and address the

needs of every resident, including

but not limited to, the resident at

risk or already experiencing

impaired nutrition; provide a

therapeutic diet that considers the

resident’s clinical condition, and

preferences, when there is a

nutritional indication.

1.Resident # 52 allegedly did

not receive dietary supplement.

Order clarified for Resident #52

and placed on the Medication

Administration Record.


Residents who are nutritionally at

risk and receives dietary

supplements have the potential to

be affected by this alleged

deficiency. All dietary supplement

orders have been reviewed and

intakes are being recorded in the

Medication Administration

Record.

3.As mentioned in the survey

findings Madison Health Care

Center has a policy regarding

Nutrition [Impaired]/Unplanned

Weight Loss - Clinical Protocol.

Nursing staff have been

re-educated on this policy on

3/13/17.


dietary supplement orders have

been reviewed without negative

findings. The DON, or her





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significant weight loss of 7.5% in 30

days, and 13.99% in 180 days.

The plan of care for Resident #52's

increased nutritional risk included a

recapitulated physician's order for

February, 2017, with an original order

date of 10/26/16, which indicated

Resident #52 was to receive Mighty

Shakes three times per day for weight

loss.

No documentation was found in the

resident's record for December 2016, and

January and February, 2017, which

indicated the resident received her

Mighty Shakes or how much of them she

was consuming.

On 2/28/17 at 11:50 a.m., the Director of

Nursing (DON) indicated the staff did not

document when Resident #52 was given

a supplement or how much of the

supplement was consumed.

On 3/1/17 at 9:20 a.m., the DON

provided a policy dated December, 2008,

titled, "Nutrition [Impaired]/Unplanned

Weight Loss - Clinical Protocol," and


by the facility.

The policy indicated, "Monitoring 1. The

physician and staff will closely monitor

residents who have been identified as

designee, is conducting quality

assurance audits to ensure

dietary supplements and their

intakes are being documented on

the Medication Administration

Record. This QA audit will be

performed on three (3) residents

three (3) times per week for four

(4) weeks; then once (1) monthly

for six (6) months. Results of

these audits will be reported at

the QA committee monthly. Any




5.Date of completion: 3/23/17.





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having impaired nutrition or risk factors

for developing impaired nutrition. Such

monitoring may include: a. Evaluating

the care plan to determine if the

interventions are being implemented and

whether they are effective in attaining the

established nutritional and weight goals."

3.1-46(a)(1)

483.60(i)(1)-(3)

FOOD PROCURE,

STORE/PREPARE/SERVE - SANITARY

(i)(1) - Procure food from sources approved

or considered satisfactory by federal, state

or local authorities.

(i) This may include food items obtained

directly from local producers, subject to

applicable State and local laws or

regulations.

(ii) This provision does not prohibit or

prevent facilities from using produce grown

in facility gardens, subject to compliance

with applicable safe growing and

food-handling practices.

(iii) This provision does not preclude

residents from consuming foods not

procured by the facility.

(i)(2) - Store, prepare, distribute and serve

food in accordance with professional

standards for food service safety.

(i)(3) Have a policy regarding use and

storage of foods brought to residents by

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family and other visitors to ensure safe and

sanitary storage, handling, and

consumption.

Based on observation, interview, and record

review, the facility failed to ensure staff

performed hand hygiene for 1 of 1 dining

observation in the West Hall Assist Dining

Room with the potential to effect 20 of 86

residents eating in the West Hall Assist

Dining Room. (Resident #7, #16, #25, #28,

#32, #38,# 39, #52, #56, #57, #58, #59, #76,

#80, # 81, #87, #91, #105, #107, and #110).

Findings include:

On 02/21/2017 from 11:45 a.m. to 12:30

p.m., the West Hall Assist Dining Room

meal service was observed: Certified

Nursing Assistant (CNA) #3, # 5, #6, #9, and

#10 did not hand wash or cleanse hands with

sanitizing hand gel prior to placing clothing

protective covers on residents #7, #16, #25,

#28, #32, #38, #39, #52, #56, #57, #58, #59,

#76, #80, #81, #87, #91, #105, #107, and

#110. CNA #3, #5, #6, #9, #10, Restorative

Aid #4, and the Activity Director were

observed opening and closing the doors of

the food cart, removing meal trays from the

food cart, delivering meal trays, and assisting

residents #7, #16, #25, #28, #32, #38, #39,

#52, #56, #57, #58, #59, #76, #80, #81, #87,

#91, #105, #107, and #110 during the noon

meal without hand washing or cleansing

hands with sanitizing hand gel.

Interview with Licensed Practical Nurse

(LPN) #7 on 02/21/2017 at 12:30 a.m.,


Care Center to follow proper

sanitation and food handling

practices to prevent the outbreak of

foodborne illness throughout the

facility’s food handling processes.

1.Staff involved with the food

handling process allegedly did not

hand wash or cleanse hands with

sanitizing hand gel prior to placing

resident’s protective coverings on

them, removing meal trays from

the food cart, delivering meal

trays and assisting residents.

2.All Madison Health Care

Center Residents whose meals

are delivered via food service

distribution procedure have the

potential to be affected.

3.As mentioned in the survey

findings Madison Health Care

Center has a policy regarding

food service distribution. All staff

participating in food service

distribution have been

re-educated on this practice on

3/13/17 with an emphasis placed

on handwashing between contact

with each resident and prior to

removing each resident’s tray

from the food cart.


alternating meal service times

have been reviewed. The DON,

or her designee, is conducting

quality assurance audits to

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indicated facility staff serving and or

assisting residents with meals in the West

Hall Assist Dining Room were required to

sanitize their hands with hand gel prior to

serving and or assisting residents with meals

and between contact with each resident.

Interview with the Dietary Manager on

02/28/2017 at 12:15 p.m., indicated facility

staff assisting residents during meal service

were required to perform hand hygiene prior

to removing each residents' tray from the

food cart.

Review of facility policy titled,

"Handwashing/Hand Hygiene Policy and

Procedure", dated November 28, 2016,

provided by the Dietary Manager on

03/01/2017 at 9:30 a.m. The policy

indicated, " ...Policy: This facility considers

hand hygiene the primary means to prevent

the spread of infections ...All personnel shall

follow the handwashing/hand hygiene

procedures to help prevent the spread of

infections to other personnel, Residents, and

visitors ..."

3.1-21(i)(2)

3.1-21(i)(3)

ensure that employees

participating in meal service are

hand washing or cleansing hands

with sanitizing hand gel when

delivering meals under sanitary

conditions during alternating meal

service times. The charge nurses

are monitoring for appropriate

hand hygiene during meal service

seven days a week. This QA

audit will be three (3) times per

week for four (4) weeks; then

once (1) monthly for six (6)

months. Results of these audits

will be reported at the QA

committee monthly. Any negative

findings will add another four (4)

weeks of audits until 100%

compliance is achieved.

5.Date of completion: 3/23/17.

483.45(b)(2)(3)(g)(h)

DRUG RECORDS, LABEL/STORE DRUGS

& BIOLOGICALS

The facility must provide routine and

emergency drugs and biologicals to its

residents, or obtain them under an

agreement described in §483.70(g) of this

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part. The facility may permit unlicensed

personnel to administer drugs if State law

permits, but only under the general

supervision of a licensed nurse.

(a) Procedures. A facility must provide

pharmaceutical services (including

procedures that assure the accurate

acquiring, receiving, dispensing, and

administering of all drugs and biologicals) to

meet the needs of each resident.

(b) Service Consultation. The facility must

employ or obtain the services of a licensed

pharmacist who--

(2) Establishes a system of records of

receipt and disposition of all controlled drugs

in sufficient detail to enable an accurate

reconciliation; and

(3) Determines that drug records are in

order and that an account of all controlled

drugs is maintained and periodically

reconciled.

(g) Labeling of Drugs and Biologicals.

Drugs and biologicals used in the facility

must be labeled in accordance with currently

accepted professional principles, and

include the appropriate accessory and

cautionary instructions, and the expiration

date when applicable.

(h) Storage of Drugs and Biologicals.

(1) In accordance with State and Federal

laws, the facility must store all drugs and

biologicals in locked compartments under

proper temperature controls, and permit only

authorized personnel to have access to the

keys.





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(2) The facility must provide separately

locked, permanently affixed compartments

for storage of controlled drugs listed in

Schedule II of the Comprehensive Drug

Abuse Prevention and Control Act of 1976

and other drugs subject to abuse, except

when the facility uses single unit package

drug distribution systems in which the

quantity stored is minimal and a missing

dose can be readily detected.

Based on observation, interview, and

record review, the facility failed to ensure

that an account of all controlled drugs

were maintained in 3 of 4 hall medication

carts reviewed.

Findings include:

1.) On 2/28/2017 at 1:55 p.m., during

Medication Storage task, observed

Narcotic/Controlled Substance Shift To

Shift Count/Signature Sheet dated

02/2017, found in narcotic count binder

on 200 hall medication cart. Signature

sheet indicated no count was done for

2/6/2017, 1st shift on coming nurse,

2/22/2017 off going nurse, 2/24/2017 2nd

shift oncoming nurse and 2/24/17

offgoing nurse, as indicated by no

signatures.

On 2/28/2017 at 2:00 p.m., during in

interview, LPN #11 indicated that the

nurses are supposed to count the

controlled substances at the beginning of


Care Center to ensure that an

account of all controlled drugs are

maintained.

1.The controlled medication

accountability records of

02/28/2017 & 02/17/2017 of 100

Hall and 600 Hall carts were

presented and outlined in the

survey findings.

2.All controlled medication

records have the potential to be

affected by this alleged

deficiency.

3.As noted in the survey

findings, Madison Heath Care

Center has a Controlled

Substances/Drug Discrepancies

policy in place. Licensed nurses

have been re-educated on the

aforementioned policy on

3/13/17. All controlled

substances have been reviewed

and accounted for.

4.All controlled medications

have been reviewed. In addition

to the review and re-education

noted above the DON, or her

designee, is conducting a quality

improvement audit to ensure

controlled medications are

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their shift with the offgoing nurse and the

nurses are supposed to count the

controlled substances at the end of their

shift with the oncoming nurse and sign

the Narcotic/Controlled Substance

signature sheet to indicate that this did

occur.

2.) On 2/28/2017 at 2:09 p.m., during


Narcotic/Controlled Substance Shift to


02/2017, found in narcotic count binder

on 100 hall medication cart. Signature

sheet indicated no count was done for

2/28/2017, 1st shift oncoming nurse, as

indicated by no signature.

3.) On 2/28/2017 at 2:10 p.m., during


Narcotic/Controlled Substance Shift to


2/2017, found in narcotic count binder on

600 hall medication cart. Signature sheet

indicated no count was done for 2/17/17

2nd shift oncoming nurse, and 2//17/17

2nd shift offgoing nurse, as indicated by

no signatures.

On 2/28/2017 at 2:30 p.m., during an

interview, the Director of Nursing

indicated that "there should be no empty

boxes on that sheet (Narcotic/Controlled

substance Shift to Shift Count/Signature

reconciled at the beginning an

end of each shift. Medication

carts will be audited for controlled

medication reconciliation three (3)

times per week for one (1) month,

then once (1) monthly for six (6)

months. Results of these audits

will be reported monthly to the

Quality Assurance meeting. Any




5.Date of Completion: 3/23/17.





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Sheet)."

On 2/28/2017 at 2:38 p.m., the Director

of Nursing provided a policy titled:

"Controlled Substances/Drug

Discrepancies" dated 10/2010 and

indicated it was the current policy being

used by the facility. The policy indicated

"Policy Statement: The facility shall

comply with all laws, regulations, and

other requirements related to handling,

storage, disposal, and documentation of

Schedule II and other controlled

substances. ....8. Nursing staff must

count controlled drugs at the end of each

shift. The nurse coming on duty and the

nurse going off duty must make the count

together. They must document and report

any discrepancies to the Director of

Nursing Services."

3.1-25(n)


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