printed: 11/01/2018 department of health and human

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

11/01/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

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

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIE

(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)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

CRAWFORDSVILLE, IN 47933

155419 10/01/2018

HICKORY CREEK AT CRAWFORDSVILLE

817 N WHITLOCK AVE

00

F 0000

Bldg. 00

This visit was for the Investigation of Complaints

IN00274288 and IN00275185.

Complaint IN00274288 - Substantiated. Federal

deficiencies related to the allegations are cited at

F760 and F761.

Complaint IN00275185 - Substantiated. Federal

deficiencies related to the allegations are cited at

F695 and F790.

Survey dates: September 26, 27, 28, and October 1,

2018

Facility number: 000533

Provider number: 155419

AIM number: 100267230

Census Bed Type:

SNF/NF: 26

Total: 26

Census Payor Type:

Medicare: 1

Medicaid: 19

Other: 6

Total: 26

These deficiencies reflect State Findings cited in

accordance with 410 IAC 16.2-3.1.

Quality review completed October 9, 2018.

F 0000 F000

This Plan of Correction constitutes

the written allegation of

compliance for the deficiencies

cited. However, submission of this

Plan of Correction is not an

admission that the deficiency

exists or that one was cited

correctly. This Plan of Correction

is submitted to meet requirements

established by state and federal

law.

Attached for your review and

approval, is the completed Plan of

Correction for the recent

Complaint Survey , Event ID

I28E11, conducted on October 1,

2018 at Hickory Creek at

Crawfordsville. Please be advised

that is our intent to have this Plan

of Correction also serve as our

allegation of compliance.

Compliance is effective on October

29, 2018.

Hickory Creek at Crawfordsville

also respectfully requests a desk

review for this Plan of Correction.

483.25(i)

Respiratory/Tracheostomy Care and

Suctioning

§ 483.25(i) Respiratory care, including

F 0695

SS=D

Bldg. 00

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 determin

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

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 disclo

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: I28E11 Facility ID: 000533

TITLE

If continuation sheet of 34

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tracheostomy care and tracheal suctioning.

The facility must ensure that a resident who

needs respiratory care, including

tracheostomy care and tracheal suctioning,

is provided such care, consistent with

professional standards of practice, the

comprehensive person-centered care plan,

the residents' goals and preferences, and

483.65 of this subpart.

Based on observation, interview, and record

review, the facility failed to ensure adequate

cleaning of suction and nebulizer equipment for 1

of 1 residents observed with respiratory distress

(Resident J).

Findings include:

On 9/28/18 at 8:58 a.m., Resident J was observed,

lying in bed, coughing, and stated he was not

breathing well that morning. The resident was

coughing up thick greenish tinged secretions,

then using his bedside suction machine with

yankauer (hand held suction tip attached to large

lumen suction tubing) that was on the bedside

table. The yankauer and attached tubing were

soiled with wet and crusted secretions in the

tubing and on the outside of the hand piece. A

nebulizer mask was lying on the bedside table,

un-bagged, with a clear sticky substance

observed inside the mask, the nebulizer packaging

lying beside the mask was dated 9/21/18. The

resident indicated, he had not had assistance

earlier that day in suctioning when needed. A

family member and Certified Nursing Assistant

(CNA) 9 indicated, the resident's yankauer that

goes into the mouth had been lying on the floor at

bedside earlier, with no covering.

Record review was completed for Resident J, on

9/28/18 at 11:00 a.m. The record indicated, the

F 0695 F 760 It is the policy of Hickory

Creek at Crawfordsville to ensure

that residents are free of any

significant medication errors.

What corrective action will be

accomplished for those

residents found to be affected

by the deficient practice?

For Resident J there are new MD

orders in place. Clean nebulizer

mask and let air dry after each

use. Change nebulizer mask every

shift. Change irrigation set q night

shift. Change younker every night

shift. Observe resident suction

canister daily and change if soiled.

Director of Nursing will reeducate

all nursing staff including any

agency nurses about the

appropriate care of respiratory

equipment and the documentation

needed to show that the

physician’s orders for cleaning and

changing the equipment have been

completed.

How other residents having the

potential to be affected by the

same deficient practice will be

identified and what corrective

actions will be taken?

No other residents were affected

10/29/2018 12:00:00AM

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resident was re-admitted to the facility on 2/13/18,

with diagnoses to include but were not limited to:

cough, spastic diplegic cerebral palsy (affects

body movement and muscle coordination), other

generalized epilepsy, intellectual disabilities, sleep

apnea, obstructive hydrocephalus (accumulation

of cerebrospinal fluid within the brain),

gastroesophageal reflux disorder, contracture,

disturbance of salivary secretion, benign

intra-cranial hypertension.

Review of Physician's Orders for Resident J,

included, but were not limited to:

a. 10/2/15 May suction as needed for increased

secretions. May leave suction machine at bedside

b. 2/1/16 Albuterol Sulfate Nebulizer Solution

(bronchodilator) 2.5/3 ml (milliliters) 0.083%. 1 vial

daily related to extrinsic asthma

c. 9/28/18 Sent to ER (emergency room) for

evaluation and treatment due to congestion at

family request

Review of Resident J's Progress Notes, dated

9/28/18, included, but were not limited to:

a. On 9/28/18 at 6:28 a.m., "g-tube (gastric tube)

patent, feeding and meds well tolerated. No

complaints. Has productive cough."

b. On 9/28/18 at 8:44 a.m., resident aunt had told

the nurse she wanted him sent to the ER. Nurse

assessed resident, oxygen saturations 92% on

room air, respirations 20, pulse 77, and

temperature 97.4 F (Fahrenheit). Resident had

productive cough producing white sputum, but

appears to be in no distress. Received orders to

send to the ER per family request.

c. 9/30/18 at 9:44 p.m.," resident was re-admitted

from the hospital yesterday. On oral antibiotics for

bronchitis ...."

On 10/1/18 at 10:00 a.m., the Nurse Manager

by the alleged deficient practice.

Currently, no other residents have

suction catheters or routine

nebulizer orders.

What measures will be put into

place and what systemic

changes will be made to

ensure that the deficient

practice does not recur?

MD orders will be in placed in

point click care on MAR/TAR for

care of respiratory equipment. An

audit sheet titled “Respiratory

Equipment Audit” (Attachment A)

has been created by Nurse

Manager for respiratory equipment

to monitor for compliance in

changing and cleaning of

respiratory equipment. The

auditing of the respiratory

equipment began on October 2,

2018. The audit sheets will be

completed by Administrator,

Director of Nursing or charge

nurse at least 5 times a week in

guardian angel rounds for 4

weeks, then twice weekly for 4

weeks and then twice monthly.

Any concerns that are identified in

cleaning or documentation of the

respiratory equipment will be

addressed by re-training the staff

involved regarding the facility

policy. Continued noncompliance

will be addressed by written

counseling as indicated by the

situation.

How the corrective actions will

be monitored to ensure the

deficient practice will not





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provided a report, titled, "History and Physical",

dated 9/28/18, and indicated the report was from

Resident J's hospital admission. The report

indicated, "Assessment: acute bronchitis?

Pneumonia? Chest x-ray negative ...consult

speech due to concerns for aspiration ...Acute

respiratory failure with hypoxia: 84% on room air

likely secondary to the above ...According to the

patient for the last 2 days he has been coughing,

green colored phlegm and today he was short of

breath ...Clinical Impression: aspiration pneumonia

due to inhalation of vomitus ..."

Review of quarterly Minimum Data Set (MDS),

dated 8/2/18, indicated: Resident J had the ability

to make himself understood and to understand

other. BIMS score 15 indicated, no cognitive

deficit. No signs or symptoms of delirium, no

behaviors, or rejection of care. Extensive

assistance of 1 person for bed mobility, dressing,

and personal hygiene. Shortness of breath or

trouble breathing with exertion or when lying flat.

Oxygen and suctioning while a resident. 7 days of

respiratory therapy for at least 15 minutes, in the

past 7 day assessment period.

Review of Resident J's Care Plans, indicated, "1.

Focus: I have diagnosis of asthma and sleep

apnea. I require oxygen during the night and

breathing treatments throughout the day. Goal: I

will remain free of acute respiratory distress daily.

Interventions: Check my oxygen saturations as

ordered and as needed. I will sometimes take my

respiratory equipment off [i.e. nebulizer mask and

percussion vest] prior to completing my treatment.

I will wear my oxygen at night as ordered by my

doctor. Notify my physician of any respiratory

issues or concerns. Nursing staff to assess my

lungs before and after treatment and as needed.

Routine breathing treatments daily and as ordered

recur?

The Nurse Manager or Director of

Nursing will bring the results of the

monitoring activities for

compliance in changing and

cleaning of respiratory equipment.

Once the time elements for

monitoring have been completed

and when 100% compliance has

been achieved, the QAA

Committee may decide to stop the

paper audits; however, the Nurse

Manager and the Director of

Nursing will continue to monitor

the care and documentation of the

respiratory equipment on an

ongoing basis as part of their

routine rounds. The Nurse

Manager and Director of Nursing

are responsible for the

implementation and monitoring of

this plan.

Date of compliance: October 29,

2018





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by my physician. Staff to physically assess for

signs or symptoms of respiratory distress ...2.

Focus: I have pain or am at risk to experience pain

related to my diagnosis of spastic cerebral palsy

and frequent respiratory infections ..."

Review of Grievance Logs, dated July - September

2018, regarding respiratory care concerns for

Resident J:

a. On 9/15/18 the aunt reported, she took the

residents' "pickle" (acapella mucous cleaning

device) out of his bag from the day services

program, and the pickle was ordered to keep at

bedside

b. On 9/20/18 the aunt reported nebulizer's were

being given late and interfering with lunch.

On 9/27/18 at 11:42 a.m., Resident J's aunts

indicated, they had multiple complaints and had

told the Executive Director. They had spoken to

the previous ED about his late treatments, it had

caused him to have to push back his treatments

and eating cold food.

On 9/28/18 at 8:43 a.m., Resident J's aunt

indicated, she was upset at the condition she had

found the resident in that morning. He was

crossways in the bed, with his buttocks on the

side of the bed, and his legs off the bed. The

resident also was not feeling well that morning

and on his way out to the ER, possibly with a

respiratory issue. He had been coughing

frequently that morning, and she had told the

nurse the day before he wasn't feeling well. When

the resident coughed up mucus, he had the ability

to suction himself if the machine was within his

reach. This morning his machine was observed

out of reach at the head of the bed, and the hose

with the mouth piece was on the floor at the head

of the bed.





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On 10/1/18 at 10:30 a.m., CNA 9 indicated, on

9/28/18 she was working with Resident J's

roommate, when she overheard the aunt saying,

"Why are you coming out of the bed". The

resident was positioned with his buttock on the

edge of the bed, and his feet were positioned

straight out. The resident did not mention not

feeling well, but was overheard with a deep cough

with noisy congestion, and his yankauer was

observed on the floor between the bed and the

bedside table uncovered. The aide picked up the

yankauer and placed it on the bedside table into

the plastic sleeve. She knew the yankauer

probably needed cleaned but that was a nurse job.

It should not have been on the floor to begin with,

so she just picked it up. The resident could not

have reached the yankauer from his position in

the bed

On 10/1/18 11:35 a.m., Resident J's aunt indicated,

the hospital thought originally the resident had

aspiration pneumonia and admitted him overnight

for observation, but Saturday they determined

probably it was just bronchitis.

On 10/1/18 at 2:40 p.m., the Nurse Consultant

indicated, the resident did not have an order or

documentation for cleansing and changing of the

nebulizer mask and tubing, cleaning of the suction

machine, or cleaning and changing of the

yankauer and tubing before going to the hospital.

On 10/1/18 at 2:51 p.m., the Nurse Consultant,

DON, and Nurse Manager indicated, there were

no orders to clean or change out the nebulizer or

yankauer supplies. The Nurse Manager indicated,

the nebulizer mask was changed out on Monday,

Wednesday, Friday, and Saturday overnight, and

the yankauer was changed out on Saturday





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overnight.


provided a document, titled, "Respiratory

Therapy", undated. The document indicated,

"Oral suctioning is a frequent nursing home

procedure. If it is likely that the hands will come

into contact with saliva or oral secretions,

caregivers should wear gloves...Unlike tracheal

suctioning, the suction catheter may be used for

more than one series of oral suctioning. It should

be rinsed well with tap water after each period of

suctioning and changed on a regular basis. If the

suction catheter or tubing used for oral suctioning

become visibly contaminated with material which

cannot be flushed it should be

discarded...Medication Nebulizer's. Small-volume

medication nebulizer's which are used for

administration of bronchodilator's, including

nebulizer's that are hand-held, can produce

bacterial aerosols. Hand held nebulizer's have

been associated with nosocomial pneumonia,

including Legionnaires' disease...Between

treatments on the same resident, the nebulizer's

should be disinfected or rinsed with water and

air-dried..."

3.1-47(a)(6)

483.45(f)(2)

Residents are Free of Significant Med Errors

The facility must ensure that its-

§483.45(f)(2) Residents are free of any


F 0760

SS=E

Bldg. 00


review, the facility failed to ensure residents

received prescription medications per physician's

orders, and were free of significant medication

error for 6 of 7 residents reviewed for medication

errors (Residents D, E, C, B, G, and H).

F 0760 F 760 It is the policy of Hickory


that residents are free of any




10/29/2018 12:00:00AM





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Findings include:

1A. During a random observation of the

medication room on 9/26/18 at 12:49 p.m., with

Registered Nurse (RN) 5, the following 5

medication cards were observed from the

pharmacy on the counter for Resident D:

a. On 7/8/18 the pharmacy sent 8 tablets of

warfarin (generic for Coumadin, an anticoagulant)

2 mg (milligrams), 4 tablets remained on the card

b. On 8/14/18 the pharmacy sent 8 tablets of

warfarin 2 mg, 2 tablets remained on the card

c. On 8/27/18 the pharmacy sent 8 tablets of


d. On 9/7/18 the pharmacy sent 4 tablets of


e. On 9/12/18 the pharmacy sent 6 tablets of


During a random observation of the medication

cart on 9/26/18 at 12:55 p.m. with RN 5, the

following medication card was observed for

Resident D:

a. 9/20/18 the pharmacy sent 14 tabs of warfarin 3

mg, 13 tablets remained on the card

b. There was no observation of warfarin 2 mg

tablets in the medication cart

Observation of the medication cart on 9/27/18 at

9:25 a.m. with Licensed Practical Nurse (LPN 7),

the following medication card was observed for

Resident D:

a. 9/20/18 the pharmacy sent 14 tablets of warfarin

3 mg, 12 tablets remained on the card

Record review was completed for Resident D on

9/27/18 10:05 a.m. The record indicated the

resident was admitted on 10/2/17 and had current

diagnosis, to include but were not limited to: atrial



For Resident D, Resident E,

Resident C, Resident G, and

Resident H, the Director of

Nursing, Nurse Manager and

Nurse Consultant audited the

medication cart and removed

medication that had expired, been

discontinued, had a change in

dose, or was left from the last

cycle refill.

All nursing staff will be in serviced

by 10/29/18 about removing the

expired medication, discontinued

medication and dose change

medication from the cart whenever

the physician orders have changed

or discontinued medication, or

whenever medications are found to

be expired.






All residents have the potential to

be affected by this practice. For all

other residents the Director of

Nursing or designee will audit the

medication cart to remove

medication that has expired, been

discontinued, had a change in

dose, or was left from the last

cycle refill.










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fibrillation, history of pulmonary embolism,

Parkinson's disease, chronic kidney disease, major

depressive disorder, and seizures.

Review of Physician's orders included:

a. 9/20/18 warfarin 3 mg 1 tablet by mouth in the

evening related to history of pulmonary embolism

b. 3/23/18 PT/INR (prothrombin time/international

normalizing ratio, test to help detect bleeding

disorder and to monitor how well the thinning

medication is working to prevent blood clots)

monthly

Review of the quarterly Minimum Data Set (MDS),

dated 7/20/18, indicated, Resident D had the

ability to make himself understood and to

understand others. BIMS (Brief Interview for

Mental Status) score 13 indicated cognitively

intact, with no signs or symptoms of delirium or

behaviors. Medications received included

anticoagulants and diuretics 7 of 7 days and

antibiotics 3 of 7 days during the assessment

period.

Review of Resident D's Care Plans indicated, "1.

Focus: I am at risk for bleeding and increase

bruises related to my daily use of Coumadin. Goal:

I will maintain normal lab (PT/INR) levels and my

medication dose will be changed as needed based

on my lab draw (PT/INR) results. Interventions:

Fill out Coumadin Flowsheet with each result. I

need to be monitored for signs or symptoms of

internal bleeding (dark tarry stools, blood in

stools, emesis or urine). I need any abnormalities

reported to my MD immediately. I will be given my

medication as directed by my doctor. Labs as

ordered and MD and family notified of results.

Notify pharmacy and family of changes made to

Coumadin. Weekly skin sheets..."

Pharmacy has conducted a QA

and has reeducated their staff

about the cycle fill process to

make sure that all previous

month’s expired medication, extra

medication, and dose change

medication will be removed as the

new cycle medications are placed

in the medication cart.

A medication cart audit titled

“Medication Cart Audit”

(Attachment B) began October 1,

2018 and will be conducted by

Nurse manager or designee 5

times a week for four weeks, then

2 days a week for 4 weeks and

then weekly for 4 weeks and then

twice monthly until 100 %

compliance is achieved. Any

issues identified at that time will

be addressed with either the staff

or pharmacy - whoever was

involved with the concern. If staff is

identified as being noncompliant,

the Director of Nursing will re-train

the nurse(s) regarding the facility

policy for handling expired or

discontinued medications, change

in dosages, or medications left

over from the previous cycle fill. If

it appears that there has been a

problem with the pharmacy

process, the Director of Nursing

will monitor for documentation that

there has been process

improvement as needed for the

pharmacy staff.








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On 9/28/18 at 9:45 a.m., the Nurse Consultant

provided documents, titled, "Long-Term Care

Pharmacy Shipping Manifest", indicated, warfarin

delivery on the following dates:


warfarin 3 mg


warfarin 3 mg


warfarin 3 mg tablet


warfarin 3 mg, and 4 tablets of warfarin 2 mg



f. On 6/28/18 the pharmacy sent 6 tablets of


g. On 7/10/18 the pharmacy sent 6 tablets of


h. On 7/21/18 the pharmacy sent 6 tablets of


j. On 8/15/18 the pharmacy sent 8 tablets of

warfarin 2 mg

k. On 8/16/18 the pharmacy sent 6 tablets of

warfarin 3 mg

l. On 9/12/18 the pharmacy sent 6 tablets of

warfarin 3 mg

m. On 9/21/18 the pharmacy sent 14 tablets of

warfarin 3 mg


provided documents, titled, "Medication

Administration Record" dated, April - September

2018. The records indicated, warfarin 3 mg was

documented as 98 tablets administered, and

warfarin 2 mg was documented as 81 tablets

administered during the time frame.


provided documents, and indicated they were

physician's orders for PT/INR, and coagulation

recur?

The Director of Nursing will bring

the results of the medication cart

audits to the monthly QAA

Committee meeting for further

review and recommendations. The

QAA Committee may decide to

stop the paper audits at the end of

the time period specified

previously and when 100 %

compliance is reached. The

Director of Nursing or designee will

continue random audits of the

medication carts at least monthly

on an ongoing basis.

The Director of Nursing is

responsible for the implementation

and monitoring of these

processes.


2018





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laboratory results for Resident D, dated March -

September 2018. The laboratory results included:

a. 3/23/18 PT 25.0 high (normal 9.5 - 11.8), INR 2.3

high (normal 0.9-1.1)

b. 4/4/18 PT 21.1 high, INR 2.0 high

c. 5/8/18 PT 20.8 high, INR 2.0 high

d. 5/24/18 PT 30.9 high, INR 2.9 high

e. 5/31/18 PT 34.6 high, INR 3.2 high

f. 6/12/18 PT 22.1 high, INR 2.1 high

g. 7/10/18 PT 28.6 high, INR 2/7 high

h. 8/14/18 PT 23.6 high, INR 2.2 high

j. 9/11/18 PT 11.8, INR 1.1

k. 9/18/18 PT 10.7, INR 1.0

l. 9/26/18 PT 17.9 high, INR 1.7 high

1B. During a random observation of medication

cart 1 on 9/26/18 at 1:13 p.m. with RN 5, the

following 6 medication cards were observed from

the pharmacy for Resident E:














9:37 a.m. with LPN 7, the following medication

cards were observed for Resident E:










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Record Review completed on Resident E on

9/27/18 at 10:53 a.m. The record indicated the

resident was admitted to the facility on 12/29/17,

and had diagnoses to include, but were not limited

to: persistent atrial fibrillation (a-fib), chronic

congestive heart failure, old myocardial infarction,

iron deficiency anemia, and cardiomegaly long

term use of anticoagulants.


a. 9/27/18 warfarin sodium tablet give 3 mg by

mouth in the evening every Tuesday, Thursday

related to persistent a-fib

b. 9/27/18 warfarin sodium 2 mg tablet give 1 by

mouth in the evening every Sunday, Monday,

Wednesday, Friday, Saturday related to persistent

a-fib.

Review of the quarterly MDS, dated 8/31/18,

indicated, Resident E had the ability to make

herself understood and to understand others.

BIMS score 11 indicated moderate cognitive

impairment, no signs or symptoms of delirium or

behaviors. Medications include insulin injections,

anticoagulants, and diuretics 7 of 7 days during

the assessment period.

Review of Resident E's Care Plans, indicated, "1.

Focus: I am at risk for bleeding and increase in

bruises related to my daily use of Coumadin due

to my diagnosis of a-fib. Goal: I will maintain

normal lab (PT/INR) levels and my medication





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dose will be changed as needed based on my lab

draw (PT/INR) results. Interventions: labs as

ordered and MD and family notified of results.

Weekly skin assessments ...2. Focus: I am at risk

for blood clots and decreased cardiac output

related to my diagnosis of A-fib. Goal: I will be

free of blood clots and abnormal cardiac function

through next review. Interventions: Administer my

medications as ordered. I will report any chest

pain or discomfort to nurse who will notify my

doctor. Staff will observe for shortness of breath

..."



Pharmacy Shipping Manifest", indicated, warfarin

delivery on the following dates:


warfarin 3 mg


warfarin 4 mg


warfarin 3 mg


warfarin 3 mg


warfarin 3 mg


warfarin 2 mg



Administration Record" dated, April - September

2018. The records indicated, warfarin 2 mg was

documented as 29 tablets administered, warfarin 3

mg was documented as 111 tablets administered,

and warfarin 4 mg was documented as 12 tablets

administered during the time frame.






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provided documents, and indicated they were

physician's orders for PT/INR's, and the

coagulation laboratory results for Resident E,

dated March - September 2018. The laboratory

results included:

a. 4/5/18 PT 28.5 high, INR 2.7 high

b. 4/12/18 PT 27 high, INR 2.6 high

c. 4/19/18 PT 22.6 high, INR 2/1 high

d. 4/26/18 PT 35.2 high, INR 3.3 high

e. 5/3/18 PT 30.2 high, INR 2.8 high

f. 5/10/18 PT 40.4 high, INR 3.7 high

g. 5/17/18 PT 33.3 high, INR 3.1 high

h. 5/24/18 PT 32.0 high, INR 3.0 high

j. 5/31/18 PT 27.4 high, INR 2.6 high

k. 6/7/18 PT 37.8 high, INR 3.5 high

l. 6/14/18 PT 29.4 high, INR 2.7 high

m. 6/21/18 PT 28.5 high, INR 2.7 high

n. 6/28/18 PT 21.5 high, INR 2.0 high

o. 7/5/18 PT 28.6 high, INR 2.7 high

p. 8/1/18 PT 52.1 high, INR 4.8 high

q. 8/3/18 PT 23.0 high, INR 2.24 high

r. 8/8/18 PT 17.0 high, INR 1.6 high

s. 8/15/18 PT 52.1 high, INR 4.7 high

t. 8/17/18 PT 41.2 high, INR 3.7 high

u. 8/23/18 PT 35.7 high, INR 3.3 high

v. 8/29/18 PT 26.5 high, INR 2.5 high

w. 9/5/18 PT 29.0 high, INR 2.7 high

x. 9/12/18 PT 39.5 high, INR 3.6 high

y. 9/19/18 PT 14.3 high, INR 1.4 high

z. 9/26/18 PT 14.5 high, INR 1.4 high

1C. During a random observation of Medication

Cart 1 on 9/26/18 at 1:03 p.m. with RN 5, the

following 2 boxes of medication were observed

from the pharmacy for Resident C:

a. On 8/14/18 the pharmacy sent 1 box containing

4 tablets of alendronate sodium 70 mg (generic for

Fosamax, used to treat osteoporosis), there was 1

tablets in the box

b. On 9/10/18 the pharmacy sent 1 box containing





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4 tablets of alendronate sodium 70 mg, the box

was unopened

Record review was completed on Resident C on

9/26/18 at 3:05 p.m. The record indicated, the

resident was admitted on 1/11/18, with current

diagnoses to include, but were not limited to:

osteoarthritis, dementia with behavioral

disturbance, type II diabetes mellitus, and

polyarthritis.

Review of Resident C's Physician's orders

included:

a. 1/13/18 (Fosamax) alendronate sodium 70 mg

tablet, give 1 tablet by mouth in the morning every

7 days related to unspecified osteoarthritis and

take with 6-8 oz. of water.

Review of the Significant Change MDS, dated

8/10/18 indicated, Resident C had the ability to

usually make herself understand, and usually

understood by others. Her BIMS score 2 indicated

severe cognitive impairment. She required limited

assistance of 1 person for bed mobility, transfers,

walking in room and corridor, locomotion on and

off the unit, and extensive assistance of 1 for

dressing, toilet use, and personal hygiene. Her

mobility devices included a walker.

Review of Resident C's Care Plans indicated, "1.

Focus: I am at risk for falls with injury related to

my impaired mobility and history of falls. Goal: I

will free of injury through next review.

Interventions: Assistive devices within reach at

all times. Ensure I have an enabler bar to my bed.

Ensure my walker handles have neon orange tape.

Ensure that I have dycem in my recliner ...

Pharmacy to review my meds routinely...2. Focus:

I have pain or am at risk to experience pain related

to my diagnosis of Osteoarthritis and Neuropathy.





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Goal: I will be free from pain within 30 minutes of

pain relief interventions...Interventions: I need my

medications administered as ordered or requested

(if ordered as needed). I need pain assessments

done quarterly yearly, and with any significant

change and as needed....I need staff to monitor me

for signs and symptoms of non-verbal pain....11.

Focus: I have diagnosis of osteoarthritis and

arthritis. Goal: I will maintain my current level of

mobility and have no abnormal pain from arthritis.

Interventions: Encourage adequate nutrition and

hydration. Encourage me to maintain weight in a

normal range for height. Monitor/document/report

to MD prn signs or symptoms of complications

related to arthritis: joint pain, joint stiffness,

usually worse of wakening, swelling, decline in

mobility, decline in self-care ability, contracture

formation/joint shape changes, crepitus (cracking

or clicking) with joint mobility, pain after

exercising or weight bearing..."



Pharmacy Shipping Manifest", dated 4/3/18,

5/1/18, 5/26/18, 6/21/18, 7/19/18, 8/13/18, and

9/10/18. The manifests indicated, 4 tablets of

alendronate sodium 70 mg (substitute for

Fosamax) were delivered monthly.


provided a document, titled, "Order Entry", dated

1/13/18. The order indicated, "Alendronate

Sodium Tablet 70 MG. Give 1 tablet by mouth in

the morning every 7 days related to Unspecified

Osteoporosis ..."



Administration Record" dated, July - September

2018. The records indicated, alendronate sodium

70 mg tablet was administered every Thursday for





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the 3 month period.

1D. During a random observation of medication


following 2 boxes of medication were observed

from the pharmacy for Resident B:

a. On 8/7/18 the pharmacy sent 1 box containing 4

tablets of alendronate sodium 70, the box was

unopened


4 tablets of alendronate sodium 70 mg, there were

3 tablets in the box


9:23 a.m. with LPN 7, indicated:


tablets of alendronate sodium 70, the box was

unopened




Record Review was completed Resident B on




osteoarthritis, age related osteoporosis, iron

deficiency anemia, contracture of right hand,

history of falling, and chronic inflammation

demyelinating polyneuritis(chronic inflammation

of the nerves that may cause numbness).


a. 8/12/16 (Fosamax) alendronate sodium 70 mg

tablet, give 1 tablet by mouth in the morning every

Monday related to unspecified Osteoarthritis and

take with 6-8 oz. of water.

Review of the quarterly MDS, dated 7/5/18,

indicated, Resident B had ability to make herself





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understood and understands others. A BIMS

score of 8, indicated she had moderate cognitive

impairment. She required supervision of 1 for bed

mobility, transfers, locomotion on and off the unit,

and toilet use. She was independent with set up

help only for walking in the room and corridor. Her

mobility devises included a walker.

A review of Resident B's Care Plan indicated, "1.

Focus: I have diagnosis of osteoporosis and have

had fractures in the past. I take medication for this

but am still at risk for fractures. Goal: I will have no

fractures through next review. Interventions: Give

my medications per my physician's order. Notify

my physician if I have any signs or symptoms of a

fracture. Observe me for signs or symptoms of

fractures i.e. swelling, pain, deformity, etc. Provide

me with any labs my physician may order ..."




5/19/18, 6/15/18, 7/12/18, 8/7/18, and 9/10/18. The

manifests indicated, 4 tablets of alendronate

sodium 70 mg were delivered monthly.


provided a document, titled, "Order Entry", dated

3/19/15. The order indicated, "Alendronate

Sodium Tablet 70 MG. Give 1 tablet by mouth in

the morning every Monday related to Unspecified

Osteoporosis..."



Administration Record" dated, July - September

2018. The records indicated, alendronate sodium

70 mg tablet was administered every Monday for

the 3 month period.





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1E. During a random observation of medication


following the following 3 medication cards were

observed from the pharmacy on the counter for

Resident G:


furosemide (diuretic) 40 mg, 12 tablets remained

on the card


furosemide 40 mg, 28 tablets remained on the card


furosemide 40 mg, 14 tabs tablets remained on

card


3:30 p.m. with LPN 6, the following medication

cards were observed for Resident G:


furosemide (diuretic) 40 mg, 6 tablets remained on

the card


furosemide 40 mg, 28 tablets remained on the card


furosemide 40 mg, 14 tabs tablets remained on

card

Record review was completed for Resident G on




essential hypertension, age-related osteoarthritis,

history of falls, cerebral infarction, stage 3 chronic

kidney disease, and a stage 2 pressure area

(shallow crater in the skin) on the left buttock.


a. 5/4/18 furosemide Tablet 40 mg give 1 tablet by

mouth two times a day related to essential





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hypertension

Review of the annual MDS, dated, 8/30/18,

indicated, Resident G had the ability to make

herself understood and to understand others. A

BIMS score of 3 indicated severe cognitive

impairment. She required supervision and 1

person assist for toilet use, and physical

assistance of 1 in part of the bathing activity. Her

mobility devices include a wheelchair. She was

always continent of bladder and occasionally

incontinent of bowel, and had significant weight

loss while not on a prescribed weight loss

program. Medications given included diuretics

and opioids for 7 of 7 days during the assessment

period.

Review of Resident G's Care Plan indicated, "1.

Focus: I am at risk for the development of low

potassium levels related to my daily use of

non-potassium sparing diuretic, Lasix. Goal: I will

be free from signs and symptoms of low

potassium levels and maintain a normal potassium

level through next review. Interventions: I will be

observed for signs and symptoms of low

potassium levels such as nausea/vomiting, muscle

cramps, or weakness. I will be weighed as ordered,

physician will be notified of weight gains or

losses. I will have my labs drawn as ordered with

all lab results reported to my doctor and family. I

will receive my meds as ordered ..."



Administration Record," dated August -

September 2018. The records indicated,

furosemide 40 mg tablet was administered two

times daily during the reviewed dates, with doses

missed on 8/17/18, 8/23/18, and 9/2/18.





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1F. During a random observation of medication

cart on 9/26/18 at 12:45 p.m. with RN 5, the

following the following medication card was

observed from the pharmacy for Resident H:

a. On 9/8/18 the pharmacy sent 1 capsule of

vitamin D capsule 50000 Units (supplement), 1 cap

remained on the card.


9:30 a.m. with LPN 7, the following medication

card was observed for Resident H:

a. On 9/8/18 the pharmacy sent 1 capsule of

vitamin D capsule 50000 IU (1.25 mg, supplement),

1 cap remained on the card.

Record review was completed on Resident H on




vitamin D deficiency, history of fractures,

acquired absence of part of the digestive tract,

and anemia.


a. vitamin D tablet give 1 by mouth in the morning

every 30 days related to vitamin D deficiency, give

50000 IU every 30 days

Review of Resident H's Care Plan indicated, "1.

Focus: I have a history of fracture [right femur]. I

am at risk for pain due to my history of fracture. I

take Vitamin D due to my diagnosis of Vitamin D

deficiency. Goal: I will be free from pain within 30

minutes of receiving pain medication.

Interventions: Call my MD [physician] if pain

persists. Encourage me to use my assistive device

as needed. Give me my medications per my MD

order. Keep my call light within reach. Offer me my

prn pain medication per my MD order ..."





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5/19/18, 6/16/18, 7/14/18, 8/11/18, and 9/8/18. The

manifests indicated, 1 tablet of vitamin D 50000 IU

was delivered monthly.



Administration Record" dated, August -

September 2018. The records indicated, Vitamin D

Capsule 50000 Units 1 capsule had been

administered on 8/21/18 and 9/20/18.

On 9/26/18 at 12:50 p.m., RN 5 indicated,

documentation on the MAR indicated, the Vitamin

D capsule had been administered on 9/20/18.


indicated, there was no documentation that

Vitamin D laboratory levels had been ordered or

obtained to monitor Resident H.

On 9/26/18 at 4:30 p.m., LPN 6 indicated, she was

an agency nurse, and could not speak to the

reason for multiple cards with different and the

same dosages of medications for residents.


indicated, staff should have administered

medication per physician's orders, and destroyed

medications when the order was discontinued.

Nurses were trained on medication administration

and medication destruction upon hire, and

re-educated as needed when issues arose. The

Director of Nursing (DON) was ultimately

responsible for assuring medications were passed

and destroyed appropriately.

On 9/27/18 at 2: 52 p.m., the Nurse Manager

indicated, any time there was a change in the dose





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of a medication such as Coumadin, the pharmacy

would send a new card if the nurse sent the order

to the pharmacy. If the dose changed, or the

directions were changed, such as 2 mg to 3 mg, a

direction change sticker was placed on the card,

and the old card would be held in the cart flipped

around for overflow. Medication cards were

pulled from the medication cart when the order for

the medication was discontinued. A Pharmacy

representative visited monthly for cycle fill, review

of the medications, to pull medications residents

had no order for, and to assure routine

medications were available. The nurse taking a

discontinue order should pull medication cards

from the cart. The night shift nurses filled out

disposition sheets, sent medications back to the

pharmacy for credit as indicated, and filled out

disposition sheets for medications that were not

to be sent back and were destroyed on site. The

Nurse Manager was responsible for monitoring

the nurses.

On 9/27/18 at 3:14 p.m., the Executive Director

(ED) indicated, in her past 5 weeks of employment

she had observed the pharmacy in the facility one

time doing the monthly review. The pharmacy

also sent someone who was following different

nurses observing the medication pass, and she

checked the carts. She was not aware of what

happened with the medication storage and

disposition in the past. The nurses should be

following the policies of the facility regarding

medication pass and medication destruction. The

DON was ultimately responsible for assuring

medication policies were followed.

On 9/27/18 at 3:29 p.m., the Director of Nursing

(DON) indicated, nurses were signing out

medications on the MAR as given, which would

indicate the medication had been given. She could





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not assure the medications were given as ordered.

Any nurse who wrote an order, or got a change in

direction for a medication, should have put a

sticker on the card, and the card stayed in the cart

until the new card arrived, then the card was

removed and returned to pharmacy, or put in the

tote for the night nurse to return. If the order was

discontinued, the card should have been removed

from the cart and returned to the pharmacy. There

were multiple card for multiple residents to include

warfarin in the cart, this would indicate the

process had not been done appropriately. The

DON was ultimately responsible to ensure the

nurses were following the process. As the DON

was interim, the responsibility was being shared

with the Nurse Manager, who was responsible to

check the medication carts.


(ED), Nurse Consultant, DON, and Nurse

Manager, indicated, they could not answer for the

discrepancies between the number of medications

sent from the pharmacy, the documentation of

medications signed as given, the amount of

medications still remaining on the bingo cards,

and the ability of staff to be sure residents were

getting their medications as ordered with the

current system of storing multiple cards, new and

old, in the medication cart. The Nurse Manager

indicated, Resident G's family brought

medications from home and asked that the facility

use those first. She would have to investigate,

she had spoken with pharmacy this month with

concerns on cycle fill. The DON had no comment

on the concerns of the medication discrepancies.

The ED indicated, she was not aware of the

current concerns with medication discrepancies,

and her understanding was that the pharmacy was

assisting with concerns. The DON was ultimately

responsible for assuring residents get their





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medications correctly, and medication storage and

disposal policies were followed.


provided a policy, titled, "Medications-General

Policies", revised 5/13. The policy indicated,

"Purpose: Medications are given to benefit a

resident's health. Designated staff members will

give medications only as ordered by the

physician...Bring medication to the bedside and

explain to resident what you are going to do.

Administer the medication...Record the medication

given on the medication sheet ..."


presented a policy, titled, "Medication

Disposition", revision date 8/17. The policy

indicated, "It is the policy of this facility to ensure

proper disposal of prescription and over the

counter drugs that do not qualify for return to the

pharmacy for credit, including controlled

substances, as per the Drug Enforcement

Administration and the Office of National Drug

Control Policy [ONDCP] guidelines...Any

medication for which there is no active order shall

be disposed of as soon as possible, but no later

than 7 days of becoming inactive...Within 7 days

of a medication becoming inactive, the nurse shall

remove all supplies of the drug from stock, count

the remaining doses, and fill out the medication

disposition form..."

3.1-25(b)(3)

3.1-25(b)(9)

3.1-25(e)(2)

3.1-25(o)

483.45(g)(h)(1)(2)

Label/Store Drugs and Biologicals

§483.45(g) Labeling of Drugs and Biologicals

F 0761

SS=D

Bldg. 00





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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.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(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.

§483.45(h)(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.


review, the facility failed to ensure medications

were stored, were reconciled, and were destroyed

per policy in 1 of 2 medication carts, and 1

medication room. This deficient practice had the

potential to affect 4 or 7 residents reviewed for

medication storage (Residents D, C, B, and E).

Findings include:

1. During a random observation of the medication

room on 9/26/18 at 12:49 p.m., the following 5

medication cards were observed from the

pharmacy on the counter for Resident D:

F 0761 F761 It is the policy of Hickory

Creek at Crawfordsville to drugs

and biologicals used in the facility

are labeled in accordance with

currently accepted professional

principles.





For Resident D, Director of



medication carts and removed all

10/29/2018 12:00:00AM





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warfarin (generic for Coumadin, an anticoagulant)

2 mg (milligrams), 4 tablets remained on the card









2. During a random observation of Medication

Cart 1 on 9/26/18 at 1:03 p.m., the following was

observed:

A. 2 boxes of medication were observed from the

pharmacy for Resident C:

a. On 8/14/18 the pharmacy sent 1 box containing

4 tablets of alendronate sodium 70 mg (generic for

Fosamax, used to treat osteoporosis), there was 1

tablets in the box


4 tablets of alendronate sodium 70 mg, the box

was unopened

B. 2 boxes of medication were observed from the

pharmacy for Resident B:


tablets of alendronate sodium 70 mg, the box was

unopened




C. 6 medication cards were observed from the

pharmacy for Resident E:





the expired Coumadin cards from

the cart. All the medications were

disposed as per company policy.

For resident C, Director of Nursing

will in-service all the nursing staff

about the administration of

medication, storage and labeling

and medication disposition as per

facility policy.

For Resident E, Director of



medication carts and removed all

the expired Coumadin cards from

the cart. All the medications were

disposed as per company policy.

The Director of Nursing will also

in-service all the nursing staff

about the administration of

medication, storage and labeling

and medication disposition as per

facility policy by October 29,

2018.






All residents receiving medication

have the potential to be affected.

The Director of Nursing audited all

the medication carts for every

resident and made sure all the

expired medication, discontinued

medications were removed from

the cart and all the medications

were disposed as per facility





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indicated, staff should have administered

medication per physician's orders, and destroyed

medications when the order was discontinued.

Nurses were trained on medication administration

and medication destruction upon hire, and

re-educated as needed when issues arose. The

Director of Nursing (DON) was ultimately

responsible for assuring medications were passed

and destroyed appropriately.

On 9/27/18 at 2:52 p.m., the Nurse Manager

indicated, any time there was a change in the dose

of a medication such as Coumadin, the pharmacy

would send a new card if the nurse sent the order

to the pharmacy. If the dose changed, or the

directions were changed, such as 2 mg to 3 mg, a

direction change sticker was placed on the card,

and the old card would be held in the cart flipped

around for overflow. Medication cards were

pulled from the medication cart when the order for

the medication was discontinued. A pharmacy

representative visited monthly for cycle fill, review

of the medications, to pull medications residents

had no order for, and to assure routine

medications were available. The nurse taking a

discontinue order should pull medication cards

from the cart. The night shift nurses filled out

disposition sheets, sent medications back to the

pharmacy for credit as indicated, and filled out

disposition sheets for medications that were not

policy.

Any concerns identified as a result

of this audit will be addressed by

the Director of Nursing with the

nurse(s) involved. She will re-train

them regarding the facility policy

for the removal of expired and

discontinued medications from the

cart, as well as the proper

disposal of each.






A medication cart audit titled

“Medication Cart Audit”

(Attachment B) began October 1,

2018 and will be conducted by /b>

5 times a week for four weeks,

then 2 days a week for 4 weeks

and then weekly for 4 weeks and

then twice monthly until 100 %

compliance is achieved. Any

issues identified at that time will

be addressed with the staff

involved as indicated in the prior

section.




recur?


the results of the medication cart

audits to the monthly QAA

Committee meeting for further

review and recommendations. The

QAA Committee may decide to

stop the paper audits at the end of

the time period specified





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to be sent back and were destroyed on site. The

Nurse Manager was responsible for monitoring

the nurses.


(ED) indicated, in her past 5 weeks of employment

she had observed the pharmacy in the facility one

time doing the monthly review. The pharmacy

also sent someone who had followed different

nurses observing the medication pass, and she

checked the carts. The nurses should be following

the policies of the facility regarding medication

pass and medication destruction. The DON was

ultimately responsible for assuring medication

policies were followed.


provided a policy, titled, "Medication

Disposition", revision date 8/17. The policy

indicated, "It is the policy of this facility to ensure

proper disposal of prescription and over the

counter drugs that do not qualify for return to the

pharmacy for credit, including controlled

substances, as per the Drug Enforcement

Administration and the Office of National Drug

Control Policy [ONDCP] guidelines...Any

medication for which there is no active order shall

be disposed of as soon as possible, but no later

than 7 days of becoming inactive ...Within 7 days

of a medication becoming inactive, the nurse shall

remove all supplies of the drug from stock, count

the remaining doses, and fill out the medication

disposition form ..."

3.1-25(e)(2)

3.1-25(o)

previously and when 100 %

compliance is reached. The

Director of Nursing or designee will

continue random audits of the

medication carts at least monthly

on an ongoing basis. The Director

of Nursing is responsible for the


these processes.


2018

483.55(a)(1)-(5)

Routine/Emergency Dental Srvcs in SNFs

§483.55 Dental services.

F 0790

SS=D

Bldg. 00





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The facility must assist residents in obtaining

routine and 24-hour emergency dental care.

§483.55(a) Skilled Nursing Facilities

A facility-

§483.55(a)(1) Must provide or obtain from an

outside resource, in accordance with with

§483.70(g) of this part, routine and

emergency dental services to meet the needs

of each resident;

§483.55(a)(2) May charge a Medicare

resident an additional amount for routine and

emergency dental services;

§483.55(a)(3) Must have a policy identifying

those circumstances when the loss or

damage of dentures is the facility's

responsibility and may not charge a resident

for the loss or damage of dentures

determined in accordance with facility policy

to be the facility's responsibility;

§483.55(a)(4) Must if necessary or if

requested, assist the resident;

(i) In making appointments; and

(ii) By arranging for transportation to and from

the dental services location; and

§483.55(a)(5) Must promptly, within 3 days,

refer residents with lost or damaged dentures

for dental services. If a referral does not occur

within 3 days, the facility must provide

documentation of what they did to ensure the

resident could still eat and drink adequately

while awaiting dental services and the

extenuating circumstances that led to the

delay.

Based on observation, interview, and record F 0790 F790 It is the policy of Hickory 10/29/2018 12:00:00AM





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review, the facility failed to ensure routine dental

care services were preformed to meet resident

needs for 1 of 1 resident interviewed for dental

care (Resident J).

Findings include:

On 9/27/18 at 11:42 a.m., Resident J's aunts

indicated, they had multiple complaints and had

told the Executive Director (ED). His oral

condition was poor, and the staff were not taking

care of him. The topic of the resident's teeth had

been discussed at every care plan meeting due to

ongoing concerns they felt were never resolved.

The resident indicated, he was not getting his

teeth brushed at night, and he had toothpaste that

was to be used by the nurse, prescribed by a

specialist at least 2 years previously.

On 9/27/18 at 12:20 p.m., observation of Resident

J's bottle of Colgate Prevident 5000 Paste 1.1%,

order date 8/2/18 was made. The label indicated

there were 3.4 fluid ounces in the bottle, for 100

pastes. Directions indicated, brush onto all tooth

surfaces using a pea sized amount with soft

brush; spit out excess; no food or drink for 30

minutes. The bottle was white, and unable to

visualize the exact amount of fluid left in the

bottle. When squeezed, little effort for liquid to

come out of the top. The aunt holding the bottle

indicated, the bottle felt heavy as if still full.

A record review was completed for Resident J, on

9/28/18 at 11:00 a.m. The record indicated, the

resident was re-admitted to the facility on 2/13/18,

with diagnose to include but were not limited to:

cough, spastic diplegic cerebral palsy (affects

body movement and muscle coordination), other

generalized epilepsy, intellectual disabilities, sleep

apnea, obstructive hydrocephalus (accumulation


that residents receive outside

services including but not limited

to dental services.




by the deficient

An audit paper tool “dental

services” (Attachment C) for

Resident J was created by

Director of Nursing, which will be

completed every morning and

night shift by charge nurse and

tool will be audited by Director of

Nursing 4 times a week for four

weeks, then 2 days a week for 4

weeks and then weekly for 4

weeks and then twice monthly

until 100 % compliance is

achieved. If we fail to achieve full

100% compliance then we will

restart the dental audit back to 4

times a week for 4 weeks, then 2

days a week for 4 weeks and then

weekly for 4 weeks and then twice

monthly until 100 % compliance is

achieved. We will review the audit

tool in monthly QA practice.How

other residents having the





All residents have the potential to

be affected by this practice. Any

issues noted by the charge nurse

regarding dental care will be

addressed at that time with the

staff involved, and the charge





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of cerebrospinal fluid within the brain),

gastroesophageal reflux disorder, contracture,

disturbance of salivary secretion, benign

intra-cranial hypertension.

A review of Resident J's Physician's Orders, dated

5/2/17, indicated:

a. Prevident 5000 toothpaste twice daily with soft

brush, spit out excess, nothing by mouth 30

minutes after two times a day related to dental

caries (permanently damaged areas in teeth).

Nurse to brush teeth, not resident

b. ACT fluoride mouth rinse daily, swish for 30

seconds and spit. Nothing by mouth 30 minutes

after in the morning for caries related to dental

caries

Review of Resident J's Medication Administration

Records (MAR's), dated 8/1/18 - 9/28/18,

indicated, Prevident 5000 toothpaste was

documented as having been used to brush the

residents teeth twice daily during the reviewed

dates.

Review of quarterly Minimum Data Set (MDS),

dated 8/2/18, indicated: Resident J had the ability

to make himself understood and to understand

other. A BIMS score of 15 indicated no cognitive

deficit. He had no signs or symptoms of delirium,

no behaviors, or rejection of care. He required an

extensive assistance of 1 person for bed mobility,

dressing, and personal hygiene; and was a total

dependence of 1 for toilet use and bathing

activity.

Review of Resident J's Care Plans, indicated, "1.

Focus: I require staff assistance with completing

my daily care/needs ADLs [Activities of Daily

Living] such as toileting, bed mobility,

transferring, eating ...Goal: I will be up for meals, in

nurse will make sure that the

resident receives the needed

dental care. The Director of

Nursing will also follow up with

re-training of the staff involved, as

well as written counseling for

instances of continued

noncompliance.






Director of Nursing will conduct an

in service by 10/29/18 for nursing

staff to ensure all resident’s oral

care to be performed as ordered or

standard of practice of care.

A dental audit tool (Attachment D)

was created by Director of Nursing

will be used as needed for any

resident, which will be completed

every morning and night shift by

charge nurse and tool will be

audited by Director of Nursing 4

times a week for four weeks, then

2 days a week for 4 weeks and

then weekly for 4 weeks and then

twice monthly until 100 %

compliance is achieved. If we fail

to achieve full 100% compliance,

then we will restart the dental

audit back to 4 times a week for 4

weeks. then 2 days a week for 4

weeks and then weekly for 4

weeks and then twice monthly

until 100 % compliance is

achieved. We will review the audit

tool in monthly QA






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clean clothes and without odor daily.

Interventions: Assist me with bed mobility. I can

help by moving with my trapeze on my bed ...I

need dental/oral care four times daily ...2. Focus: I

have some of my own teeth, they are in poor

condition. I am at risk for infection. I require

assistance from staff to brush my teeth. I need to

be sedated for dental work due to my gag reflex. I

see an outside dentist for my care. My dentist has

ordered a prescription toothpaste, mouthwash,

and spry gum to chew. Goal: Staff will provide me

with oral care four times a day thru next review.

Interventions: Assist me 4 times daily with oral

care. Ensure I have my teeth cleaned routinely at

DDS office [physician's name] my family will set

up appointments for this. Ensure I have

transportation set up to DDS appointments.

Observe my oral cavity for any abnormalities.

Report any abnormalities to my nurse immediately.

Provide toothpaste, mouthwash and gum as

ordered by my dentist. Refer me to a dentist as

needed..."

On 9/27/18 at 11:51 a.m., the ED indicated, that

was the first day the aunts had come to her about

Resident J's teeth. She had immediately directed

the issue to the Nurse Manager, and a concern

form was filled out. The facility was using agency

at that point, therefore care was not as consistent.

On 10/1/18 at 11:35 a.m., Resident J's aunt

indicated, although there had been a discussion

on Thursday 9/27/18 regarding Resident J's teeth,

they had yet to be brushed on the current date.


provided a policy, titled, "Medications-General

Policies", revised 5/13. The policy indicated,

"Purpose: Medications are given to benefit a

resident's health. Designated staff members will



recur?


the results of the audit tool to the

monthly QAA Committee meeting

for further review and

recommendations by the

Committee members. When the

time element/frequency of audits

as described previously has been

completed and when 100%

compliance has been achieved,

the QAA Committee may decide

to stop the written audits.

However, the charge nurse and

Director of Nursing will check for

proper dental services as part of

their rounds during each

scheduled tour of duty. Any

identified concerns will be

addressed as indicated in

question #2. The Director of

Nursing is responsible for the


this plan.


2018





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give medications only as ordered by the physician

...Bring medication to the bedside and explain to

resident what you are going to do. Administer the

medication ...Record the medication given on the

medication sheet ..."

3.1-24(a)(1)


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