printed: 09/27/2017 department of health and …date cross-referenced to the appropriate middletown,...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

09/27/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

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

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

PREFIX

TAG

IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

MIDDLETOWN, IN 47356

155486 08/30/2017

MIDDLETOWN NURSING AND REHABILITATION CENTER

131 S 10TH ST

00

F 0000

Bldg. 00

This visit was for a Recertification and

State Licensure Survey.

Survey dates: August 24, 25, 28, 29, and

30, 2017

Facility number: 000343

Provider number: 155486

AIM number: 100289600

Census bed type:

SNF/NF: 28

Total: 28

Census payor type:

Medicare: 3

Medicaid: 19

Other: 6

Total: 28

These deficiencies reflect State findings

cited in accordance with 410 IAC

16.2-3.1.

Quality review completed on August 31,

2017

F 0000 This plan of correction is

submitted to serve as a

credible allegation of

compliance in association

with stated completion

dates. Preparation and/or

execution of this plan of

correction does not

constitute an admission or

agreement, the provider of

conclusion set facts on the

statement of deficiencies.

The plan of correction is

prepared and/or executed

solely because it is required

by state and federal law.

483.12(b)(1)-(3), 483.95(c)(1)-(3)

DEVELOP/IMPLMENT ABUSE/NEGLECT,

ETC POLICIES

F 0226

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 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: 7NH811 Facility ID: 000343

TITLE

If continuation sheet of 22

(X6) DATE




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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.

Based on interview and record review the

facility failed to follow their policy and

complete a thorough investigation after

an allegation of sexual abuse was

reported for 1 of 2 residents reviewed for

abuse (Resident 26).

Finding include:

F 0226 TAG F 226

Middletown Nursing and

Rehabilitation Center

utilizes video survelance

throughout the common

areas of the building both

inside and outside. Upon

notifications of resident #26

allegation, the video was

09/13/2017 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7NH811 Facility ID: 000343 If continuation sheet of 22




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155486 08/30/2017


131 S 10TH ST

00

1.) Interview with the Director Of

Nursing (DON) on 8/29/17 at 9:40 a.m.,

Resident 26 had reported on 6/25/17 an

allegation of sexual abuse to staff and

provided an description of the man. The

facility reviewed the camera's in the

facility for 6/24/17 and 6/25/17 and there

were no visitors, residents or staff that fit

the description that the resident reported.

The facility did not interview staff,

residents or families as part of the sexual

abuse investigation. The allegation of

sexual abuse was not substantiated due to

there had not been any males in the

facility that fit the description of the

alleged abuser.

Review of the record of Resident 26 on

08/29/2017 11:40 a.m., indicated the

resident's diagnoses, included, but were

not limited to, ulna and radius fracture,

atrial fibrillation, heart failure,

hypertension, muscle weakness, major

depressive disorder.

The Quarterly Minimum Data Set (MDS)

assessment for Resident 26, dated

5/10/17, the resident had the ability to be

understood and had the ability to

understand others. The resident had no

delusions, hallucinations or other

behaviors. The resident required

extensive assistance of one person to

transfer and walk in her room.

reviewed and verified the

resident’s allegation was

not substantiated/did not

occur. The resident was

assessed and determined

to be a candidate for

“Assurance Health”, a

mental health facility and

was transferred to that

facility for evaluation and

treatment.

WHAT CORRECTIVE

ACTION WILL BE

ACCOMPLISHED FOR

THOSE RESIDENTS

FOUND TO HAVE BEEN

AFFECTED BY THE

DEFICIENT PRACTICE: All

allegations of abuse, of any

type, be substantiated or

unsubstantiated by other

sources, will be reported

immediately to the

Administrator, DON,

resident’s physician/medical

director, and Indiana State

Department of Health within

24 hours, and an

investigation will commence

immediately. All alert and

oriented residents will be

interviewed as well as all

visitors and staff present at

the time of the incident.

Also the responsible





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The nurses note for Resident 26, dated

6/25/17 at 4:30 p.m., an aide reported the

resident reported someone raped her. The

nurse spoke with the resident and the

resident reported she had not slept good

"last night" because some man tired to

have intercourse with her "between 4-5"

in the evening in the dining room. The

resident provided a description of the

man. The man did not hurt the resident as

she told him, she only had intercourse

with her husband. The resident then

reported he came into her room later and

tried to have intercourse with the resident

again. The Director Of Nursing (DON),

the physician, the resident's family

member and RN 3 was notified.

The resident grievance investigation

report form for Resident 26, dated

6/25/17, the resident reported she had

been raped (attempted) in the dining

room and again came in to her room. The

facility camera showed no one entering

the resident's room during the night or

anyone close to her in the dining room.

The resident was assessed for any

redness, irritation or trauma in her peri

area while toileting her. The resident

voiced no pain or discomfort with

voiding or when she was cleaned up. The

grievance investigation report form was

signed by the DON.

party/family member of the

resident will be interviewed.

This process will be

completed by members of

the administrative team;

i.e., Administrator, DON,

ADON, MDS coordinator,

and social services. The

Administrator will be

responsible for monitoring.

HOW OTHER RESIDENTS

HAVING THE POTENTIAL

TO BE AFFECTED BY

THE SAME DEFICIENT

PRACTICE WILL BE

IDENTIFIED AND WHAT

CORRECTIVE ACTIONS

WILL BE TAKEN: On

9/13/17 at 2:00 p.m. an

all-staff in-service was

conducted. All staff were

re-educated on the

following areas: resident

rights, process for removing

any potential abuser from

the facility and reporting

any alleged observed or

overheard abuse.

Interviewing staff, residents,

visitors regarding any

alleged abuse. Reviewed

Elder Justice Act and

reporting a reasonable

suspicion of a crime against

a resident.





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155486 08/30/2017


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00

The reportable incident report provided

by the DON on 8/29/17 at 10:10 a.m.,

Resident 26 reported on 6/25/17 at 4:30

p.m., "some man tried to have intercourse

with me" in the dining room and then

came to her room later and tried to have

intercourse with her again. The resident

provided a description of the man. The

facility did not have any residents or

employees that fit the description. There

were also no visitors that fit the

description during the evening of 6/24/17

or 6/25/17. The Administrator, physician,

family and DON were notified of the

allegation.

The DON provided a nurses note with no

date or time that the interview was

conducted. The DON indicated this

nurses note was in a file in her office.

The nurses note indicated on Sunday

June 25, 2017 at 4:15 p.m., CNA 4 went

down to Resident 26's room and

overheard the resident telling CNA 5 that

she had been raped and provided a

description of the man. The nurses note

had CNA 4's signature at the end.

The abuse policy provided by the

Director Of Nursing (DON) on 8/29/17 at

12:40 p.m., the following steps are to be

followed when any case of reported,

observed or suspected abuse is reported,

WHAT MEASURES WILL

BE PUT INTO PLACE OR

WHAT SYSTEMIC

CHANGES WILL BE

MADE TO ENSURE THAT

THE DEFICIENT

PRACTICE DOES NOT

RECUR: All allegations of

abuse, of any type, be

substantiated or

unsubstantiated by other

sources, will be reported

immediately to the

Administrator, DON,

resident’s physician/medical

director, and an

investigation will commence

immediately. All alert and

oriented residents will be

interviewed as well as all

visitors and staff present at

the time of the incident.

Also the responsible

party/family member of the

resident will be interviewed.

This process will be

completed by members of

the administrative team;

i.e., Administrator, DON,

ADON, MDS coordinator,

and social services. The

Administrator will be

responsible for monitoring.

HOW THE CORRECTIVE

ACTIONS WILL BE





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included, but were not limited to, an

incident report is completed and as

internal investigation is initiated

immediately; the investigation will

included interview with residents, staff

and family members, observations and

record reviews as appropriate to ensure a

complete, accurate and thorough

investigation.

3.1-28(a)

MONITORED TO ENSURE

THE DEFICIENT

PRACTICE WILL NOT

RECUR, I.E., WHAT

QUALITY ASSURANCE

PROGRAM WILL BE PUT

INTO PLACE: The

corrective actions will be

monitored by the

Administrator and DON.

Attached questions

(attachment 7) will be asked

to staff, residents, and

resident family members

upon any allegation of

abuse. These questions

will also be asked to six (6)

staff, six (6) residents, and

six (6) family members

every week for five (5)

weeks, results will be

reported to monthly QA

meeting to determine if

necessary for monitoring to

continue randomly.

BY WHAT DATE THE

SYSTEMIC CHANGES

WILL BE COMPLETED:

Education and

implementation completed

on 9/13/17. Administrator

and DON responsible to

ensure continued

compliance. (see

attachment 4)





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We are respectfully

requesting paper

compliance for tag F 226.

483.24(a)(2)

ADL CARE PROVIDED FOR DEPENDENT

RESIDENTS

(a)(2) A resident who is unable to carry out

activities of daily living receives the

necessary services to maintain good

nutrition, grooming, and personal and oral

hygiene.

F 0312

SS=D

Bldg. 00

Based on observation, interview and

record review, the facility failed to assist

a resident with routine denture placement

for 1 of 3 residents reviewed for dental

services. (Resident 17).

Findings include:

Resident 17's record was reviewed on

8/29/17 at 12:36 p.m. His diagnoses

documented on his July 2017 physician's

recapitulation orders included but were

not limited to, major depressive disorder,

delusional disorder, and muscle

weakness.

The focus documented on an Activity of

Daily Living plan of care for Resident 17,

revised by the facility on 1/18/17,

included he required assistance daily due

to multiple diagnoses of chronic

obstructive pulmonary disease,

osteoarthritis, hypertension, dizziness,

unsteady gait, and dementia. An

F 0312 TAG F 312

Resident #17 was seen by

his dental provider on

2/17/17 and again in

August 2017 with no new

recommendations for

dentures to be worn.

Dietary notes verify and are

attached to indicate that in

February 2017 the resident

received new dentures and

would not wear the lower

plate. His weight was 186

pounds at the time. As of

8/30/17 the resident’s

weight was 197 pounds

indicating in the 6 months

of not wearing his dentures

he had gained 11 pounds

reflecting no weight loss.

WHAT CORRECTIVE

ACTION WILL BE

ACCOMPLISHED FOR

THOSE RESIDENTS

09/13/2017 12:00:00AM





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intervention revised on 7/11/17, included

he required assistance with oral care.

Documented on A Denture Delivery form

for resident 17 dated 3/31/17, included

his new denture were delivered.

Documented on a Dental Exam for

Resident 17, dated 8/817, included

adhesive should be applied for better

wear on his lower dentures.

On 8/25/17 at 9:31 a.m., Resident 17 was

observed with no dentures. RN 3

explained he had dentures he had worn

during breakfast but had wanted them out

after breakfast.

On 8/28/17 at 12:12 p.m., Resident 17

was observed seated at the dining table

eating and drinking independently. CNA

1 explained Resident 17 only had his

upper dentures in and his lower dentures

were being worked on.

On 8/29/17 at 9:59 a.m., Resident 17 was

observed seated in a recliner. He was

wearing his upper dentures. He voiced

the dentist was making him some bottom

dentures.

On 8/29/17 at 2:27 p.m., the ADON

explained Resident 17's lower dentures

were worked on in March of 2017. He

FOUND TO HAVE BEEN

AFFECTED BY THE

DEFICIENT PRACTICE:

The facility currently has

residents who have either

full or partial upper lower

dentures, some of whom

refuse to wear them. All

have had their care

plans/aide assignment

sheets/assessments

reviewed for compliance.

Any resident that refuses to

wear their dentures have

had this care planned.

HOW OTHER RESIDENTS


TO BE AFFECTED BY

THE SAME DEFICIENT

PRACTICE WILL BE

IDENTIFIED AND WHAT

CORRECTIVE ACTIONS

WILL BE TAKEN: The

facility currently has

residents who have either

full or partial upper lower

dentures, some of whom

refuse to wear them. All

have had their care

plans/aide assignment

sheets/assessments




had this care planned. Also,





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wore partial upper and lower dentures

and they were both at the facility. He

needed to wear adhesive for his lower

denture to fit properly and she didn't

believe he wore the lower denture but

wasn't sure.

On 8/29/17 at 2:43 p.m., CNA 8

explained she had never seen a lower

denture in Resident 17's denture cup, just

his upper denture.

On 8/30/17 at 11:20 a.m., Resident 17

was observed seated in his recliner in his

bedroom and provided an observation of

his lower denture in his mouth. He

voiced they felt "pretty good."

On 8/30/17 at 11:21 a.m., CNA 10

explained she wasn't aware Resident 17

had a lower denture until that morning

when she found them in his night stand

drawer. She had placed them in his

mouth that morning with adhesive.

On 8/30/17 at 12:55 p.m., after Resident

17 was finished eating he explained his

teeth had felt "real good." when he was

eating and they hadn't come loose. He

denied any mouth pain from the dentures.

A Routine Dental Care policy provided

by the DON on 8/30/17 at 2:30 p.m.,

included the following: "...1. The

new admits will be

assessed and care planned

for denture and/or oral care.

WHAT MEASURES WILL


WHAT SYSTEMIC

CHANGES WILL BE

MADE TO ENSURE THAT

THE DEFICIENT

PRACTICE DOES NOT

RECUR: The facility

currently has residents who

have either full or partial

upper lower dentures, some

of whom refuse to wear

them. All have had their

care plans/aide assignment

sheets/assessments




had this care planned.

HOW THE CORRECTIVE

ACTIONS WILL BE

MONITORED TO ENSURE

THE DEFICIENT

PRACTICE WILL NOT

RECUR, I.E., WHAT

QUALITY ASSURANCE

PROGRAM WILL BE PUT

INTO PLACE: The DON,

ADON and Social Services

will monitor for compliance

on a routine ongoing basis.





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nursing care staff will conduct ongoing

oral health assessments to assure each

resident receives adequate oral

hygiene...."

3.1-38(a)(C)(3)

All residents with dentures

or partial plates will be

checked for proper fitting

and wearing of dentures

during meals, three (3)

times per week for six (6)

weeks, then two (2) times a

week for four (4) weeks.

This will be discussed at

QA on a monthly basis and

be determined if monitoring

needs to be continued by

results of audit report. (See

attachement 8)

BY WHAT DATE THE

SYSTEMIC CHANGES

WILL BE COMPLETED: An


conducted 9/13/17

reviewing all

policy/procedure and

regulatory compliance

information related to tag

F312. (See attachment 6)

We are respectfully

requesting paper


483.35(g)(1)-(4)

POSTED NURSE STAFFING

INFORMATION

483.35

(g) Nurse Staffing Information

(1) Data requirements. The facility must

post the following information on a daily

basis:

F 0356

SS=E

Bldg. 00





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(i) Facility name.

(ii) The current date.

(iii) The total number and the actual hours

worked by the following categories of

licensed and unlicensed nursing staff directly

responsible for resident care per shift:

(A) Registered nurses.

(B) Licensed practical nurses or licensed

vocational nurses (as defined under State

law)

(C) Certified nurse aides.

(iv) Resident census.

(2) Posting requirements.

(i) The facility must post the nurse staffing

data specified in paragraph (g)(1) of this

section on a daily basis at the beginning of

each shift.

(ii) Data must be posted as follows:

(A) Clear and readable format.

(B) In a prominent place readily accessible

to residents and visitors.

(3) Public access to posted nurse staffing

data. The facility must, upon oral or written

request, make nurse staffing data available

to the public for review at a cost not to

exceed the community standard.

(4) Facility data retention requirements. The

facility must maintain the posted daily nurse





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staffing data for a minimum of 18 months, or

as required by State law, whichever is

greater.

Based on observation and interview, the

facility failed to include the facility name

on the daily nurse staffing information,

and failed to maintain 18 months of the

staff posting for 5 of 5 survey days. This

had the potential to affect all 28 residents

residing in the facility and all visitors.

Finding include:

During the initial tour, on 8/24/2017 at

10:27 a.m., the nurse staffing information

was observed posted, on a dry erase

board, on a wall behind the nurse's desk.

The information posted on the dry erase

board did not include the facility name.

The nurse staffing information was also

posted on the dry erase board on 8/25/17,

8/28/17, 8/29/17 and 8/30/17 and did not

include the facility name.

On 8/30/2017 at 1:40 p.m., the Director

of Nurses (DoN) said they don't keep a

hard copy of the nurse staffing

information, they use their schedules.

The DoN said they have no policy for the

posted nurse staffing.

3.1-13(a)

F 0356 TAG 356

WHAT CORRECTIVE

ACTION WILL BE

ACCOMPLISHED FOR

THOSE RESIDENTS

FOUND TO HAVE BEEN

AFFECTED BY THE

DEFICIENT PRACTICE:

Middletown Nursing and

Rehabilitation Center has

developed, in accordance

with regulation F356, the

attached form for posting

on a daily basis all

information required per

regulatory compliance. See

attached form.

HOW OTHER RESIDENTS


TO BE AFFECTED BY

THE SAME DEFICIENT

PRACTICE WILL BE

IDENTIFIED AND WHAT

CORRECTIVE ACTIONS

WILL BE TAKEN: The 24

hour staff scheduling form

will be posted in a more

resident accessible location

and contain everything that

is required by law.

WHAT MEASURES WILL


09/13/2017 12:00:00AM





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WHAT SYSTEMIC

CHANGES WILL BE

MADE TO ENSURE THAT

THE DEFICIENT

PRACTICE DOES NOT

RECUR: The 24 hour staff

scheduling form will be

posted in a more resident

accessible location and

contain everything that is

required by law.

HOW THE CORRECTIVE

ACTIONS WILL BE

MONITORED TO ENSURE

THE DEFICIENT

PRACTICE WILL NOT

RECUR, I.E., WHAT

QUALITY ASSURANCE

PROGRAM WILL BE PUT

INTO PLACE: The forms

will be monitored by the

Administrator, DON and

ADON by electronically

scanning the forms and

keeping them on the

Administrators computer.

They will maintained for 18

months. Staffing board will

be monitored for completion

and accuracy four (4) times

per week for four (4) weeks,

then two (2) time per week

for four (4) weeks. If

completion and accuracy is





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obtained no further

monitoring will continue.

Results with be reported to

the QA committee. (see

Attachment 9)

BY WHAT DATE THE

SYSTEMIC CHANGES

WILL BE COMPLETED:

The daily use of the form

was initiated on 9/13/17

after completion of

in-servicing all nursing staff

on the required information

which must be posted for

every shift daily. DON,

Administrator and ADON

will monitor the ongoing

compliance. (see

attachment 5)

We are respectfully

requesting paper


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

F 0371

SS=D

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FORM APPROVED

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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

family and other visitors to ensure safe and

sanitary storage, handling, and

consumption.

Based on observation and interview the

facility failed to ensure the staff removed

their gloves and wash their hands after

assisting a resident and handling dirty

dishes for 2 of 28 residents observed for

dining (Resident 23 and Resident 38).

Findings include:

1. On 8/24/17 at 12:32 p.m., observation

of CNA 2 with gloves on, removed

Resident # 23's tray off of a tray cart and

sat it on the bedside table, she put

resident's hair brush and other items in a

drawer, then prepared residents tray with

gloves on.

An interview on 8/24/17 at 12:45 p.m.,

with CNA 2, stated "Yes, I took the

F 0371 TAG 371

On 9/13/17 CNA #1 was

re-educated immediately on

handwashing procedures

and glove change

procedures related to

resident #23.

WHAT CORRECTIVE

ACTION WILL BE

ACCOMPLISHED FOR

THOSE RESIDENTS

FOUND TO HAVE BEEN

AFFECTED BY THE

DEFICIENT PRACTICE:

The facility has employed

an infection control

preventionist effective

6/27/17. This employee will

monitor for compliance of

handwashing and glove

09/13/2017 12:00:00AM





09/27/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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B. WING

(X3) DATE SURVEY

COMPLETED


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resident to the bathroom, then I got her

lunch tray ready, I forgot to take them

off."

2. On 8/28/2017 at 11:58 a.m., during

the dining observation in the assisted

dining room., CNA 1 was observed to

remove a finished meal tray from the

table and placed it with the rest of the

dirty dishes. Next CNA 1 was observed

to deliver Resident 38's meal tray to her.

After she prepared the meal tray, she sat

down and began feeding the resident. No

handwashing or hand gel use was

observed during this interaction.

The "Handwashing/Hand Hygiene"

policy was provided by RN 3 on

8/29/2017 at 12:12 a.m.. This current

policy indicated the following:

"Policy Statement

The facility consider hand hygiene the

primary means to prevent the spread of

infections.

Policy Interpretation and Implementation

...7. Use an alcohol-based hand rub

containing at least 62% alcohol, or,

alternatively, soap (antimicrobial or

non-antimicrobial) and water for the

following situations:

...l. Before and after contact with objects

in the immediate vicinity of the resident

...o. Before and after eating or handling

food

p. Before or after assisting a resident

use/changing on a routine

ongoing basis for all staff.

HOW OTHER RESIDENTS


TO BE AFFECTED BY

THE SAME DEFICIENT

PRACTICE WILL BE

IDENTIFIED AND WHAT

CORRECTIVE ACTIONS

WILL BE TAKEN: An


conducted 9/13/17 with

re-education to all staff

regarding infection control,

handwashing procedures

and when to, gloves

donning and removing and

when to; use of hand

sanitizers and when to; food

preparation and distribution

from the delivery of food to

the facility, to the cleaning

of the soiled dishes and all

procedures in-between.

Handwashing/hand

hygiene, personal

protective

equipment-gloves, and food

preparation and service

policies were reviewed with

all staff. F 371 requirements

were reviewed with all staff.

WHAT MEASURES WILL






09/27/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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B. WING

(X3) DATE SURVEY

COMPLETED


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with meals...,"

3.1-21(i)(2)

WHAT SYSTEMIC

CHANGES WILL BE

MADE TO ENSURE THAT

THE DEFICIENT

PRACTICE DOES NOT

RECUR: Daily spot checks

will be conducted of aides

providing care to residents,

serving food to residents,

and cleaning up after meals

are done. This will be a

permanent ongoing

process.

HOW THE CORRECTIVE

ACTIONS WILL BE

MONITORED TO ENSURE

THE DEFICIENT

PRACTICE WILL NOT

RECUR, I.E., WHAT

QUALITY ASSURANCE

PROGRAM WILL BE PUT

INTO PLACE: The facility

has employed an infection

control preventionist

effective 6/27/17. This

employee will monitor for

compliance of handwashing

and glove use/changing on

a routine ongoing basis for

all staff. Staff passing of

trays will be observed

during various meal and

with various staff members

for four (4) times per week





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for four (4) weeks, then two

(2) times per week for four

(4) weeks. Will be done

randomly through out the

year as part of infection

control program and

discussed at monthly QA

meeting. (see Attachment

10)

BY WHAT DATE THE

SYSTEMIC CHANGES

WILL BE COMPLETED:

The changes were made by

9/13/17. (See attachments

2 and 3)

We are respectfully

requesting paper


483.45(a)(b)(1)

PHARMACEUTICAL SVC - ACCURATE

PROCEDURES, RPH

(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--

(1) Provides consultation on all aspects of

the provision of pharmacy services in the

facility;

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Based on observation, interview, and

F 0425 TAG 425

WHAT CORRECTIVE

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record review, the facility failed to follow

the manufacturer's recommendations for

performing the control solution tests on

the blood glucose meters to assure proper

functioning and accuracy of residents'

blood glucose results. This had the

potential to affect 7 residents identified

by the facility who received blood

glucose monitoring. (Residents 4, 11, 21,

24, 28, 37, and 48)

Findings include:

During an observation of the medication

room, on 8/30/2017 at 11:14 a.m., with

LPN 9, the current blood glucose meter

check logs for August 2017 were not

located.

On 8/30/2017 at 11:17 a.m., the Director

of Nurses (DoN) said they are not doing

the blood glucose meter checks, and said

there were no blood glucose meter check

logs for August. She said they have no

policy and procedure for checking the

accuracy of blood glucose meters, if they

get an unusual reading they will get

another blood glucose meter and recheck

the reading. If the reading is high or low

they look into it.

The "McKesson True Metrix Pro

Professional Monitoring Blood Glucose

Meter Owner's Manual" was provided by

ACTION WILL BE

ACCOMPLISHED FOR

THOSE RESIDENTS

FOUND TO HAVE BEEN

AFFECTED BY THE

DEFICIENT PRACTICE:

The facility has initiated a

blood glucose monitoring

system quality control

process and record which

was initiated on 9/13/17.

The form is attached and

covers all aspects outlined

in the quality control manual

for use of the facilities

glucometers and per

regulation. The quality

control manual instructions

and form are attached.

HOW OTHER RESIDENTS


TO BE AFFECTED BY

THE SAME DEFICIENT

PRACTICE WILL BE

IDENTIFIED AND WHAT

CORRECTIVE ACTIONS

WILL BE TAKEN: : The

facility has adopted the

policy of checking the

glucometers on 11-7 shift

by a licensed nurse. The

glucometers will also be

checked when: Before

using the system for the





09/27/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


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155486 08/30/2017


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the DoN on 8/30/2017 at 11:20 a.m.,

which included, but was not limited to:

"...We recommend performing Control

Tests to check the performance of the

system. Control Tests should be

performed: Before using the System for

the first time, for practice to ensure

testing technique is good, when opening

a new vial of test strips, if results seem

unusually high or low, based on patient's

condition, if a vial has been left opened

or exposed to extreme heat or cold, or

humidity, whenever a check on the

performance of the system is needed, if

meter damage is suspected (meter was

dropped, crushed, wet, etc.) Note: It is

important to perform Control Tests with

more than one level of control solution.

Three levels of McKesson True Metrix

Control Solution are available for Control

Tests...How to test control solution: Use

only McKesson True Metrix Control

Solution with the McKesson True Metrix

Pro Professional Monitoring Blood

Glucose Meter and Test Strips. 1. Check

dates on control solution label and test

strip vial label. Do not use control

solution or test strips if Expiration Dates

have passed. (Control solution - 3

months after first opening or date next to

EXP on label; test strips - after open vial

date expiration (see test strip Instructions

for Use) or date next to EXP on label.)

Discard expired products and use new

first time, for practice to

ensure testing technique is

good, when opening a new

vial of test strips, if results

seem unusually high or low

based on patient’s

condition, if a vial has been

left open or exposed to

extreme heat or cold or

humidity, whenever a check

on the performance of the

system is needed, if meter

damage is suspected

(meter is dropped, crushed,

wet, etc.)

WHAT MEASURES WILL


WHAT SYSTEMIC

CHANGES WILL BE

MADE TO ENSURE THAT

THE DEFICIENT

PRACTICE DOES NOT

RECUR: The facility has

adopted the policy of

checking the glucometers

on 11-7 shift by a licensed

nurse. The glucometers will

also be checked when:

Before using the system for

the first time, for practice to

ensure testing technique is

good, when opening a new

vial of test strips, if results

seem unusually high or low

based on patient’s





09/27/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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products...11. Compare meter result to

Control Test range printed on test strip

vial label for level of control solution you

are using. If result is in range, system

can be used for testing blood. If result

does not fall within range, repeat test

using a new test strip. Caution: If

Control Test result is outside range, test

again. If result is still outside range,

system should not be used for testing

blood. Call for assistance (see manual

cover for phone number)...."

On 8/30/2017 at 1:11 p.m., with LPN 6, 2

blood glucose meters and 1 opened vial

of test strips were observed on her

medication cart. The second medication

cart was observed with LPN 7 and had 2

blood glucose meters and 1 opened vial

of test strips.

On 8/30/2017 at 2:05 p.m., the DoN

provided a copy of the "Blood Glucose

Monitoring System Quality Control

Record" that had the last date the control

tests had been done. The last date

recorded on the record was 4/27/16.

3.1-49(b)

condition, if a vial has been

left open or exposed to

extreme heat or cold or

humidity, whenever a check

on the performance of the

system is needed, if meter

damage is suspected

(meter is dropped, crushed,

wet, etc.)

HOW THE CORRECTIVE

ACTIONS WILL BE

MONITORED TO ENSURE

THE DEFICIENT

PRACTICE WILL NOT

RECUR, I.E., WHAT

QUALITY ASSURANCE

PROGRAM WILL BE PUT

INTO PLACE: The facility

held an all-staff inservice on

9/13/17 with nurses focus

on checking the monitors,

when, how often, and who

was to do. The form for

documenting the results of

the test is attached. This

will be monitored by the

DON and ADON.

BY WHAT DATE THE

SYSTEMIC CHANGES

WILL BE COMPLETED:

This was implanted on

9/13/17. (See attachment 1)

We are respectfully





09/27/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




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TAG



DEFICIENCY)

(X5)

COMPLETION



155486 08/30/2017


131 S 10TH ST

00

requesting paper



printed: 09/27/2017 department of health and …date cross-referenced to the appropriate middletown,...

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