F 000 INITIAL COMMENTS F 000
STANDARD SURVEY: 10/06/17 CENSUS: 117
SAMPLE: 24 F 221
SS=E
RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS
CFR(s): 483.10(e)(1), 483.12(a)(2)
§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:
§483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with
§483.12(a)(2).
42 CFR §483.12, 483.12(a)(2)
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s symptoms.
(a) The facility must-
(1) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is
indicated, the facility must use the least restrictive
F 221 11/30/17
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
10/23/2017 Electronically Signed
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards 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.
F 221 Continued From page 1 F 221 alternative for the least amount of time and
document ongoing re-evaluation of the need for restraints.
This REQUIREMENT is not met as evidenced by:
Based on observation, interview and record review it was determined that the facility failed to:
a.) ensure the appropriate use of a physical restraint, and b.) ensure a consent was obtained for the use of the physical restraints.
This deficient practice was identified for 2 of 7 residents (Resident #6 and #7)reviewed for physical restraints. This deficient practice was evidenced by the following:
1. On 10/2/17 at 9:50 a.m., during the initial tour, the registered nurse unit manager (RN/UM) informed the surveyor that Resident #6 was not able to be interviewed due to a poor cognition.
The resident also had a behavior of hitting and utilized a lap buddy (a cushion that positions into the wheelchair, and can pose as a trunk restraint) due to a history of falls.
On 10/4/17 at 9:40 a.m., the surveyor reviewed the medical record for Resident #6. The resident was admitted on 5/12/17 with diagnoses which included dementia with behavioral disturbances, anxiety, and difficulty in walking.
A review of the Admission Note dated 5/12/17 at 12:00 p.m., included that the resident was confused with short and long term memory loss, and had a history of falls and wandering.
Subsequent Health Status Notes (HSN) dated 5/12/17 at 15:30 (3:30 p.m.) and 22:23 p.m.
(10:23 p.m.) included that the resident was ambulatory and ambulated by his/her-self, at
1. An assessment will be conducted on Resident’s #6 and #7 to document that the least restrictive device for each of these residents is being used. The Resident Representative will be educated and informed on the risks and benefits
of the restraint use and informed consent will be obtained and documented.
2. All residents with documented use of
restraints will be assessed to determine whether the device functions as a restraint verses an enablers by using a Device
Decision Guide. The
Resident/resident representative will be educated and
informed on the risks and benefits of the restraint use and informed consent will be obtained and documented.
3. All new admissions, readmissions, or prior to any time a physical restraint is being
considered for a resident an
assessment will be done using the Device Decision
Guide. The Unit Manager will utilize the Device Care Planning Guide as a tool during the monthly restraint reduction meeting to aid in determining whether any
F 221 Continued From page 2 F 221 which time the resident was brought to the nurses
station.
A HSN dated 5/13/17 at 23:14 (11:14 p.m.) indicated the resident was very disoriented and was found wandering into the rooms of other residents and required redirection several times.
A follow-up HSN dated 5/16/17 at 22:46 (10:46 p.m.) indicated, "Lap buddy ordered [because]
resident non compliant with staying in chair, kept getting up and going in others rooms. Not sitting still. Fall risk."
A review of a subsequent fall risk assessment dated 5/17/17 indicated that the resident had no falls/no history of falls. It further indicated that the resident exhibited jerking movements or
instability, gait pattern changes when walking, decline in functional status, and an unsteady gait.
The assessment included that the resident had periods of confusion, lack of familiarity with surroundings, inability to understand/follow directions, and impaired judgment/decision making abilities.
A review of the electronic Physician Order Sheet indicated the corresponding physician order (PO) dated 5/17/17 for a lap buddy for safety, and release it every two hours and as needed for meals, toileting, mobility, and activities.
A review of the Treatment Administration Record (TAR) for October 2017 reflected that nursing staff were signing for the day, evening, and night shift for the use of the lap buddy for safety, and that it was released every two hours and as needed.
of the causal factors that prompted the use of the restraint have been resolved and
a restraint reduction can be
attempted.
4. The Director of Nursing, and/or her designee will do monthly audits on all residents with restraints to ensure the Device Decision Guide was done appropriately and accurately, risks and benefits of restraint use has been explained to the Resident/Resident Representative and an informed consent obtained and documented.
F 221 Continued From page 3 F 221 A review of the resident's individualized care plan
included that the resident was at risk for falls.
Interventions included bed and chair alarms, call bell in reach, and a lap buddy for safety.
On 10/4/17 at 10:25 a.m., the surveyor observed the resident sitting in his/her wheelchair in the dining room for activities. The lap buddy was not in use and in a pouch attached to the back of the wheelchair. The resident was holding a baby doll.
On 10/5/17 at 10:20 a.m., the surveyor observed the resident sitting in a wheelchair in the dining room with the lap buddy in use, positioned across the resident's torso. The resident was unable to independently remove the lap buddy on command.
At 10:35 a.m., the surveyor interviewed the Director of Physical Therapy who stated that the physical therapy department does not order or routinely assess for the use of physical restraints, but that the nurse and physician would determine the appropriateness of the restraint and obtain an order if deemed necessary. The Director of Physical Therapy confirmed that their department would remove the restraint while in therapy but were not routinely involved in the initiation of a physical restraint.
At 11:15 a.m., the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #6. The LPN stated that the resident had a lap buddy because he/she was at high risk for falls. The LPN could not recall if the resident had ever had a fall at the facility prior to its implementation. The LPN stated that the resident had a chair alarm first, then a lap buddy was applied, and confirmed it was a physical restraint
F 221 Continued From page 4 F 221 as the resident could not independently release
the lap buddy on command. She further stated that the RN/UM was responsible to assess the continued need for the use of a lap buddy.
At 11:50 a.m., the RN/UM informed the surveyor that when the resident was admitted to the facility on 5/12/17, he/she was combative with staff and wandered in and out of other resident rooms.
The RN/UM indicated that the staff tried
redirection, but it was unsuccessful. The resident did have both chair and bed alarms. The RN/UM further stated that there was no formal written assessment for a physical restraint performed.
The RN/UM stated that the social worker and herself review the restraints during the monthly restraint reduction committee meetings.
At 12:05 p.m., the surveyor reviewed the monthly Restraint Reduction Committee note for the use of the lap buddy dated 5/16/17 which included under the section titled Comments, that the resident had no falls in the facility, and the lap buddy was applied due to a "potential to wander, [Resident #6] has poor safety awareness, attempts to stand quickly from wheelchair, very impulsive with mood changes. Family aware of order for lap buddy and in agreement with plan."
The comments did not include evidence that the least restrictive measure was trialed prior to the implementation of the lap buddy.
Subsequent monthly Restraint Reduction Committee notes dated 6/2/17, 7/7/17, 8/4/17, and 9/8/17 included that the the lap buddy was indicated for attempts to stand from the wheelchair despite reminders with poor safety awareness. The notes did not include evidence
F 221 Continued From page 5 F 221 of an attempt to reduce the use of the physical
restraint or evidence of a trial of alternative least restricted measures.
At 1:27 p.m., the surveyor met with the Facility Administrator (FA) and the Director of Nursing (DON). The FA informed the surveyor that they no longer have a formal assessment form for the use of physical restraints and that an assessment for the use of a physical restraint would be documented in the HSN notes. She further indicated that the Restraint Reduction Committee met monthly to re-evaluate the use of a physical restraint and justification for the lap buddy would be included in those notes and/or in the HSN notes.
At that time, the surveyor asked the FA for the informed consent for the use of the lap buddy.
The FA stated that the facility did not utilize signed informed consent forms for the use of a physical restraint, but that nurses would document that family was made aware of a physical restraint in the Health Status Notes.
On 10/6/17 at 11:10 a.m., the Administrator informed the surveyor that the resident had a lap buddy because he/she attempted to stand and wander into rooms. The resident was a high risk for falls so a restraint was indicated for safety.
No documentation was provided to the surveyor at this time.
At 1:05 p.m., the surveyor met with the FA, DON, RN/UM. The RN/UM stated that the facility trialed chair alarms, activities and a baby doll but resident continued to get up from chair so the lap buddy was applied. The RN/UM indicated that they do not sequentially document failed
F 221 Continued From page 6 F 221 interventions. The RN/UM and DON was unable
to provide documented evidence for the appropriate use of the lap buddy, other than for the purpose of falls and poor safety awareness.
The RN/UM also confirmed they do not document risks versus benefits discussed with the family for the use of a physical restraint. The RN/UM confirmed that the resident's individualized care plan addressed the use of the lap buddy as an intervention to reduce the risk for falls.
At 1:15 p.m., the FA confirmed that the lap buddy was needed for fall prevention. She also re-acknowledged that there was no informed consent that documented the family was aware of both the risks versus the benefits for the use of the lap buddy. The FA and DON confirmed the resident did not exhibit a fall at the facility, and were unable to provide documented evidence for the appropriate use of the lap buddy.
The surveyor reviewed the facility's Restraint Reduction policy. The policy included that interventions will be put into place to prevent, reduce and/or eliminate the use of restraints whenever possible. The policy further included to explain the detrimental effects and risks
associated with the use of physical restraints to staff, resident, family and/or other responsible parties.
2. On 10/2/17 at 9:50 a.m. during the initial tour, the registered nurse unit manager (RN/UM) stated that Resident #7 was not able to be interviewed due to a poor cognition, had dementia and a lap buddy for a history of falls, including a fall at the facility that occurred approximately
F 221 Continued From page 7 F 221 three months ago.
On 10/3/17 at 12:30 p.m., the surveyor reviewed the medical record for Resident #7, who was admitted to the facility on 4/24/17 and re-admitted on 6/14/17 with diagnoses which included Alzheimer's Disease, dementia, and schizophrenia.
A review of the HSN dated 5/19/17 at 15:33 (3:33 p.m.) indicated that the resident was forgetful and the chair alarm was heard multiple times as he/she was trying to get out of the chair without assistance.
A subsequent HSN dated 5/20/17 at 15:06 (3:06 p.m.) indicated that a lap buddy was on as ordered.
A review of the HSN indicated no documented evidence as to why the lap buddy was ordered and/or applied and what interventions were in place that were ineffective prior to its initiation.
A review of the POS indicated a PO dated 6/14/17 for a lap buddy for safety, release every two hours and as needed for meals, toileting, mobility and activities every shift.
A review of the resident's individualized care plan indicated that the resident had a risk for falls with interventions which included bed and chair alarms and a lap buddy for safety. The care plan included a list of onset dates of 4/24/17, 5/24/17, 5/25/17, and 6/14/17, however, there were no dates corresponding to the use of the lap buddy, or evidence of what interventions have failed or had been discontinued, requiring the use of the lap buddy.
F 221 Continued From page 8 F 221
On 10/4/17 at 10:05 a.m., the surveyor observed Resident #7 in a wheelchair by the nurse's station. The resident had a lap buddy in place and it was positioned across the resident's torso.
He/She was unable to remove the lap buddy on command.
On 10/5/17 at 11:10 a.m., the surveyor
interviewed the LPN assigned to Resident #7 who informed the surveyor that the resident was at high risk for falls and utilized a chair and bed alarm to prevent falls, in addition to the lap buddy restraint. The LPN was unsure when the resident first started wearing the lap buddy, but the LPN confirmed that the resident could not
independently remove the lap buddy.
At 11:55 a.m., the surveyor interviewed the RN/UM who stated she was unsure when the resident first started utilizing the lap buddy as an intervention for the prevention of falls. The resident was transferred from the subacute unit and that the lap buddy had already been ordered.
The RN/UM confirmed there was no assessment for the use of physical restraint in the HSN notes.
At 12:05 p.m., the surveyor reviewed the monthly Restraint Reduction Committee notes for the use of the lap buddy. A review of the Restraint Reduction Committee note dated 5/25/17 included in the Comments section that a lap buddy was indicated as the resident "attempts to stand and is unable to remember to use call bell."
The committee note did not include alternative measures that were trialed or evidence that interventions failed prior to the use of the physical restraint.
F 221 Continued From page 9 F 221 A review of subsequent Restraint Reduction
Committee notes dated 7/7/17, 8/4/17, and 9/8/17 included that the resident made attempts to stand from wheelchair, attempted to remove the lap buddy, and required close supervision.
The Restraint Reduction Committee notes did not specify documented evidence that a lap buddy was the least restrictive device effective for Resident #7.
On the same day 10/5/17 at 1:27 p.m., the surveyor met with the Facility Administrator (FA) and the Director of Nursing (DON). The FA informed the surveyor that they no longer have a formal assessment form for the use of physical restraints and that an assessment for the use of a physical restraint would be documented in the HSN notes. She further indicated that the Restraint Reduction Committee met monthly to re-evaluate the use of a physical restraint and justification for the lap buddy would be included in those notes and/or in the HSN notes.
At that time, the surveyor asked the FA for the informed consent for the use of the lap buddy.
The FA stated that the facility did not utilize signed informed consent forms for the use of a physical restraint, but that nurses would document that family was made aware of a physical restraint in the Health Status Notes.
The surveyor requested for documented evidence that an informed consent was obtained by a resident representative that discussed risks versus benefits for the use of the lap buddy restraint.
On 10/6/17 at 11:10 a.m., the FA and DON
F 221 Continued From page 10 F 221 informed the surveyor that the resident was a
high risk for falls so the lap buddy was indicated for safety.
At 1:10 p.m., the surveyor met with the FA, DON, and the RN/UM in the presence of the survey team. The DON informed the surveyor that the resident needed the lap buddy for falls due to poor safety awareness due a history of falls at home. The DON stated that she had met with the family to discuss the lap buddy, but The DON and FA confirmed there was no documented evidence that an informed consent was obtained that discussed risk versus benefit of the use of the lap buddy with the family or representative.
At 1:15 p.m., the FA confirmed that the lap buddy was needed for fall prevention. She also confirmed that there was no documented evidence of interventions trialed and failed which led to the use of the lap buddy.
The surveyor reviewed the facility's Restraint Reduction policy. The policy included that interventions will be put into place to prevent, reduce and/or eliminate the use of restraints whenever possible. The policy further included that the facility is to explain the detrimental effects and risks associated with the use of physical restraints to staff, resident, family and/or other responsible parties.
NJAC 8:39-4.1 a(6) F 226
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DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES
CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)
F 226 10/30/17
F 226 Continued From page 11 F 226 483.12
(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph
§483.95,
483.95
(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on-
(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12.
(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property
(c)(3) Dementia management and resident abuse prevention.
This REQUIREMENT is not met as evidenced by:
Based on interview and record review, it was determined that the facility failed to implement their abuse policy and procedure by conducting a background screening for licensed employees.
This deficient practice was identified for 2 of 5 newly hired employees, and was evidenced by
1. Criminal background checks were performed on the Registered Nurse and the Licensed Practical Nurse who were hired in the last four months.
2. All residents have the potential to be
F 226 Continued From page 12 F 226 the following:
On 10/6/17 at 10:55 a.m., the surveyor reviewed the facility documents for five (5) employees that were hired in the last four months. Two (2) of the five (5) employee records revealed that one Registered Nurse and one Licensed Practical Nurse were hired in the last four (4) months, and were not screened for a criminal background check prior to hire.
On 10/6/17 at 12:25 p.m., the surveyor interviewed the Human Resources Manager (HRM) in the presence of the survey team. The HRM indicated that she was responsible to ensure background checks were done upon hire.
She further stated that only non-licensed employees receive a criminal background check upon hire. The HRM added that she thought that licensed employees were already checked for a criminal background by the licensing boards.
On 10/6/17 at 12:45 p.m., the surveyor reviewed the facility policy dated October 2016 for "Elder Abuse" which included that as part of the facility procedure, one of the seven elements of Abuse Prevention was screening the background of potential employees. The policy also included that
"All licensed staff must have a criminal background check and, in addition at the discretion of the Administrator, preferably two but at least one positive reference check."
affected by this practice. An audit of all new hires in the last four months was done for any other licensed nurses who did not have a criminal
background check performed.
3. Criminal background checks will be performed on all licensed nurses prior to employment.
4. The HR director will add Criminal Backgrounds Checks for licensed nurses as
part of the standard pre-employment checklist. The DON will sign off on all employment applications to ensure that they are complete with background checks prior to scheduling any new licensed nurse to work.
F 226 Continued From page 13 F 226 On 10/6/17 at 1:00 p.m., the surveyor interviewed
the Administrator and Director of Nursing (DON) in the presence of the survey team with regard to the facility "Elder Abuse" policy. The DON told the surveyor that she thought the policy indicated that only non-licensed employees were to have a criminal background check prior to being hired.
The DON indicated she was not aware that the Elder Abuse policy included that "All licensed staff must have a criminal background check."
NJAC 8:39-9.3 F 371
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FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY
CFR(s): 483.60(i)(1)-(3)
(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.
F 371 10/30/17
F 371 Continued From page 14 F 371 (i)(3) Have a policy regarding use and storage of
foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.
This REQUIREMENT is not met as evidenced by:
Based on observation and interview it was determined that the facility failed to a.) label and date potentially hazardous foods (PHF)
appropriately to prevent food borne illness, b.) discard PHF past their shelf life, c.) store PHF in a sanitary manner to prevent cross-contamination as evidenced by the following:
On 10/2/17 at 9:29 a.m., the surveyor toured the kitchen with the Dietary Director (DD).
At 9:36 a.m., the surveyor and the DD observed the following stored within the reach-in
refrigerator #3:
1. A half gallon container of Almond Breeze nondairy milk labeled as opened 8/7/17. The container indicated to use within 7-10 days after opening.
2. A second half gallon container of Almond Breeze nondairy milk had an expired date of 9/30/17. The DD indicated that the product had expired and should have been discarded.
3. A half gallon container of Shop Rite brand Lactose-Free Whole Milk labeled as opened 8/23/17. The container indicated to use within seven days of opening.
The DD discarded the products.
At 9:45 a.m., the surveyor and the DD observed
1. All expired/unlabeled/uncovered items were discarded. The bag of potatoes
was placed on a shelf for storage.
Dry storage items were dusted off and corn
flake debris cleaned up.
2. All residents have the potential to be affected by this practice. The kitchen and storage areas were inspected an cleaned to ensure no outdated items were present and all items were
labeled and stored properly.
3. The Food Service Director will develop assignments to delineate responsibilities
for checking labels, rotating stock and cleaning food storage areas. In service
education will be provided to all dietary staff on FIFO storage and product usage
practices to ensure that stock is rotated properly and used
4. A QUAPI team has been established on the Dining Experience which meets weekly and will now include monitoring of the systemic changes put into
F 371 Continued From page 15 F 371 in reach-in refrigerator #4 the following:
1. Three quarts of half-and-half with an expiration date of 9/30/17. The DD indicated that the product was expired and should have been discarded.
2. An opened, one quart container of heavy cream. The container was not dated when the product had been opened. The DD could not speak to when it had been opened.
At 9:53 a.m. the surveyor observed a sanitizer bucket below a prep table. The DD tested the sanitizer solution with the appropriate test strips.
The test indicated that the solution registered less than the 100 parts per million (ppm). The DD informed the surveyor that the reading was low, and indicated that a reading of 200 ppm was required for proper sanitation. He could not speak to how the sanitizing bucket had been filled that day. He was unable to provide documented evidence that the sanitizing solution had been tested with the strips that day prior to use.
At 10:00 a.m. the surveyor observed an unlabeled plastic covered bin underneath the steam table.
The DD informed the surveyor the white powder was powdered sugar. The surveyor observed a spoon embedded in the powdered sugar. The DD confirmed the spoon should not be in the container.
At 10:03 a.m., the surveyor and the DD observed a spice rack in the hallway with the following:
1. An opened bottle of lemon juice. The bottle indicated to refrigerate after opening.
place related to food storage, labeling and usage.
F 371 Continued From page 16 F 371 2. Two opened containers of spices exposing the
contents to air.
3. A jug of hickory smoke sauce opened with no lid. The DD confirmed the sauce should have a lid.
At 10:05 a.m., the surveyor and the DD observed the following in the dry storage area:
1. A fifty-pound bag of potatoes stored on the floor.
2. Ten, five-pound boxes of muffin mix that were covered in powdered debris.
3. Seven plastic disposable portion control (pc) containers containing an unknown liquid which were not labeled or dated. The DD stated that he thought the containers were salad dressing.
4. Twenty-three sixteen ounce cans of
mushrooms covered in a caked-on, gray colored debris.
5. A opened box of pc tartar sauce packets. The box contained food debris. The DD indicated that corn flakes had spilled in the box.
6. A bag of split rolls labeled with a use by date of 9/30/17.
7. A plastic bag labeled mini rolls had a hole in the bag.
8. A large bag labeled egg bread had a hole in the bag.
9. Three packages of hot dog rolls which
F 371 Continued From page 17 F 371 indicated to use by 9/27/17.
10. A large loaf of cinnamon raisin bread labeled with a use by date of 8/16/17.
11. Three large loaves of cinnamon raisin bread.
Two were labeled as received on 9/15/17 and one was labeled as received 9/22/17. The DD was unsure the shelf life of the loaves.
The surveyor reviewed the facility's Sanitation/Food Storage Policy. The policy indicated for the dry storage area to "store dry foods in a cool, dry place, off the floor, away from the wall, and not under a sewer line." And to
"keep all containers tightly closed from insects, rodents and dust. Dry foods can be
contaminated, even if they don't need refrigeration."
The policy further stated to "label and date all items (a.) all items should be dated in the walk-in refrigerators (b.) all prep items should include
"date made" and "use by" on label (b.) follow
"First in First Out" rotation (c.) items with an expire date still need to be dated with a date opened (d.) all items in stockroom need date received and bulk items need a date opened."
NJAC 8:39-17.2 (g)
