department of veterans affairs community living center

Department of Veterans Affairs Community Living Center Survey Report

This document or report and the information contained herein, which resulted from the Community Living Center Unannounced Survey, hasbeen de-identified to remove individually identifiable health information (also known as protected health information) in accordance with theHealth Insurance Portability and Accountability Act (HIPAA) Privacy Rule and other federal and state laws. De-Identification was completed inaccordance with guidance published by the Office for Civil Rights to protect the privacy of the Community Living Center's residents.

General Information:

CLC: Cincinnati VA Medical Center (Cincinnati, OH)

Dates of Survey: 10/9/2018 to 10/11/2018

Total Available Beds: 48

Census on First Day of Survey: 44

F-Tag Findings

F309

483.25 Quality of Care. Each residentmust receive and the facility mustprovide the necessary care andservices to attain or maintain thehighest practicable physical, mental,and psychosocial well-being, inaccordance with the comprehensiveassessment and plan of care. UseF309 for quality of care deficienciesnot covered by §483.25(a)-(m).

Level of Harm - Actual harm that isnot immediate jeopardy

Residents Affected - Few

Based on observation, interview and record review, the CLC did not provide care and services to attainor maintain the highest practicable physical, mental, and psychosocial well-being of each resident.Findings include: Pain ManagementOn 10/10/18 at 9:35 a.m., the chief nurse executive provided a copy of the Cincinnati VAMedical Center Policy Memorandum 11-95 dated February 2016 and titled, “PainManagement.” Pertinent information from the policy included the following:

“Long-term Care – the screening for the presence and intensity of pain is performed atthe time of admission, readmission from acute care with vital signs, with medicationadministration, and with reports of new pain.”“Positive pain screenings result in further pain assessment…for chronic pain, theprovider does not need to repeat the comprehensive assessment regardless of theVisual Analog Scale (VAS) score, if the level of pain is unchanged and acceptable tothe patient.”“Inpatient (Acute and Long-term Care) – Assessment – a comprehensive painassessment is completed upon admission/transfer with a positive pain screening, if thepatient is receiving PRN [as needed] pain medication, with each new onset of pain.Reassessment – a reassessment is performed at least daily after the comprehensivepain assessment is completed until the patient reports satisfaction with his/her painmanagement. Additional reassessments are conducted when there is: (a) a suddenand/or unusual increase in pain; (b) the patient is not satisfied with his/her pain relief;(c) the pain management plan is modified; (d) one hour after analgesics and/ornon-pharmacological interventions….”“Quality of life is now accepted as a standard measure of effectiveness of treatment ofpain. This concept includes such factors as level of physical and psychosocialfunctioning and treatment satisfaction.”

Resident #202, [LOCATION]

Resident #202 was admitted to the CLC with diagnoses including CVA(cerebrovascular accident) with residual left-sided weakness, aphasia and type 2diabetes mellitus. Other medical conditions according to the history and physical dated[DATE] included bilateral above knee amputations (AKA) and depression.The resident’s most recent comprehensive Minimum Data Set (MDS) dated 08/24/18was coded to indicate Resident #202 scored 15 on the Brief Interview for Mental Status(BIMS) suggesting intact cognition; the resident did not have signs and symptoms ofdelirium; had mood symptoms 12 to 14 days during the assessment period thatincluded trouble falling or staying asleep, and feeling tired or having little energy; hadother behavioral symptoms not directed toward others 1 to 3 days during theassessment period; and required extensive to total assistance with most activities ofdaily living (ADL) including bed mobility, transfers, dressing, locomotion and toilet use.Section J (Health Conditions) of the comprehensive MDS indicated the resident did notreceive scheduled pain medication, received or was offered and declined PRN (asneeded) pain medication, did not receive non-pharmacologic approaches for pain,

of 18 -- Cincinnati VA Medical Center -- 10/9/2018 to 10/11/2018

complained of pain almost constantly at a level of 5/10 (5 out of 10 on a scale of 0 to10 with 10 representing the worst pain possible) and pain affected the resident’s sleepand day-to-day activities.During an initial interview with the RN charge nurse and nurse manager for[LOCATION] on [DATE] beginning at 10:00 a.m., the RN charge nurse reportedResident #202 “returned from ASIH [absent sick in hospital] on [DATE] with a Stage 2pressure ulcer on his coccyx, has complaints of back pain, refuses to be turned….”A statement in the resident’s care plan dated 08/21/18 stated the resident had an“alteration in comfort due to: [Resident #202] has self-report of pain, chronic pain, backpain.” The care plan goal stated, “Resident will have preferred pain relief afterintervention, AEB [as evidenced by] PRN effectiveness.” The care plan approachesincluded the following:

“May apply warm compresses to back for up to 20 minutes every 4 hours forback pain as requested by veteran [resident].”“Assess for and treat pain as ordered. Assess PRN effectiveness, notify MD/NP[medical doctor/nurse practitioner] if ineffective. Refer to CPRS [computerizedpatient record system] pain assessments/interventions and residents preferredpain level.”

The most recent pain assessment dated 09/19/18 included in the CLC weekly LPN/RNnote indicated Resident #202 had “complaints of lower back pain at a level of 5/10;pain radiates and aching and pain affects activity, emotions, and appetite.” The careplan was not updated to address the effects of pain on the resident’s activity, emotionsand appetite as indicated in the pain assessment.The CLC physical therapy inpatient note dated 09/21/18 documented the resident had“complaints of pain for both hips and low back pain impacting quality of life and abilityto tolerate [being] out of bed…patient reports left hip pain rated 5/10 and increases to7/10 when up in chair.”The current provider order sheet dated 10/05/18 included the following:

“Renew nursing may apply warm compresses to back for up to 20 minutes every4 hours for back pain as requested by veteran.”“Lidocaine Patch 5% 1 patch transdermal q [every] day x [for] 12 hours on and12 hours off; apply to right hip for pain x 30 days.”“Oxycodone tab [tablet] 5 mg [milligram] PO [by mouth] q 6 hours PRNmoderate to severe pain [4/10 to 7/10 according to the numerical rating scaleprovided by the nurse manager] x 30 days.”“Acetaminophen 325 tab [tablet] 650 mg PO q 6 hours PRN for mild pain [1/10to 3/10 according to the numerical rating scale provided by the nurse manager];not to exceed 3 gm [grams] acetaminophen/day x [per day for] 90 days.”“Melatonin cap [capsule]/tab 6 mg q bedtime x 90 days for sleep.”“Trazodone tab 25 mg q bedtime PRN for mood/sleep x 30 days, doseincreased 05/05/18.”“Gabapentin cap, oral 100 mg TID [three times a day at 7:00 a.m., 12:00 noonand 9:00 p.m., according to the Bar Code Medication Administration record]neuropathy x 90 days.”

The resident’s pain management plan was reviewed with the nurse manager in[LOCATION] on 10/11/18 at approximately 10:40 a.m.Review of the Bar Code Medication Administration (BCMA) record from 09/10/18through 10/10/18 at 4:52 p.m. determined:

Resident #202 received scheduled doses of gabapentin and Melatonin for sleep,and a lidocaine patch as ordered. The PRN doses of trazodone were notadministered since the resident returned from being ASIH, although trazodonewas administered routinely before the resident went ASIH according to theBCMA record.Resident #202 received the PRN doses of oxycodone on 09/12/18 at 9:17 a.m.(for a pain level of 6/10); 09/13/18 at 6:01 a.m. (6/10); 09/14/18 at 5:11 p.m.(5/10); 09/15/18 at 10:03 a.m. (5/10) and 4:29 p.m. (5/10); 09/16/18 at 8:53 a.m.(5/10); 09/17/18 at 1:45 p.m. (7/10); 09/18/18 at 8:31 p.m. (6/10); 09/19/18 at6:25 a.m. (7/10); 09/21/18 at 7:59 a.m. (7/10) and 8:48 p.m. (7/10); 09/22/18 at6:05 a.m. (6/10) and 8:59 p.m. (5/10); 09/23/18 at 6:42 a.m. (8/10) and 1:55p.m. (5/10); 09/26/18 at 9:05 p.m. (6/10); 09/28/18 at 8:57 p.m. (4/10). No PRNoxycodone was administered in the CLC between 09/28/18 and 10/06/18 (theresident was ASIH 10/01/2018 to 10/05/2018). On 10/06/18 PRN oxycodonewas administered at 8:31 a.m. (7/10) and 8:23 p.m. (4/10); on 10/07/18 at 6:50a.m. (5/10), 4:52 p.m. (6/10), and 9:01 p.m. (5/10); and on 10/10/18 at 8:45 a.m.(4/10).Resident #202 received PRN doses of acetaminophen on 09/13/18 at 8:49 p.m.(for a pain level of 5/10), 10/01/2018 (prior to leaving ASIH) at 12:36 a.m. (5/10),[DATE] (after readmission to the CLC) at 11:41 p.m. (4/10), and 10/07/18 at 9:01p.m. (5/10). There was nothing documented in the resident’s clinical record


indicating why the acetaminophen was given for a pain rating of 4/10 to 5/10;the provider’s order stated acetaminophen was to be administered for mild pain(1/10 to 3/10).

During observations on 10/09/18 at approximately 12:30 p.m., Resident #202 was inthe dining room in a semi-reclined Broda® chair without a pressure reducing cushion;the resident was sitting on an incontinence pad. The resident did not express verbal ornon-verbal indications of pain or discomfort. On 10/09/18 at approximately 4:35 p.m.,the resident was observed in his room being assisted out of bed and into the Brodachair with a ceiling lift. The resident complained of pain as he was transferred out ofbed stating, “[Expletive] my back.” When asked if his back was in pain, the residentfrowned and nodded his head to indicate he was experiencing pain. When askedfurther about pain, the resident stated he experienced pain mostly in his backcommenting, “It [the resident’s back] hurts a little now and I’ll need my pain pill laterwhen I get back to bed. [It’s] mostly when I get up from bed, in the morning, at night. [I]can’t stay long in my chair to do anything.” The LPN assigned to provide the resident’scare was informed about the resident’s concerns related to back pain. At approximately5:25 p.m., the resident was observed in the dining room with his eyes closed. Thenursing assistant (NA) who assisted the resident with the meal stated, “He’scomplaining of being tired.”On 10/10/18 at approximately 8:10 a.m., Resident #202 was observed in the diningroom in a semi-reclined Broda chair without a pressure reducing cushion; the residentwas sitting on an incontinence pad. When asked by a surveyor about his evening, theresident stated he only slept “a couple of hours because of low back pain.” Whenasked if he was still in discomfort, the resident nodded his head to indicate he wasexperiencing pain. The same NA interviewed at 8:10 a.m. stated she would inform theLPN about the resident’s complaints of pain. According to the BCMA, the residentreceived a PRN dose of oxycodone at 8:45 a.m. for pain at a level of 4/10.On 10/10/18 at 9:10 a.m., two NAs assisted Resident #202 to transfer from his Brodachair to bed. As the resident was being transferred to bed, the resident complained ofpain stating, “[Expletive]...” One of the NAs asked the resident, “Are you crampingagain?” The resident responded to the NA and said, “Yes...stump.” Both NAscommented the resident used expletive language to express pain or discomfort. As theresident was being positioned in bed, the resident frowned and said, “Back hurts.”When asked if the resident used a warm compress for his back, both NA’s stated theresident “would request the warm compress depending on his mood.” The residentstated, “It’s [the warm compress is] not always available.” When asked if there wereother approaches that relieved pain, the resident said, “PT.” The same NA who askedthe resident if he had cramps stated, “He wants to have physical therapy again. Theprovider knows about it.” On 10/10/18 at approximately 1:35 p.m., an LPN wasobserved applying a lidocaine patch to the resident’s mid-back as requested by theresident. The resident told the LPN, “My bottom also hurts.”The nurse manager was asked if the resident’s pain management plan had beenevaluated to determine the effectiveness of the pharmacologic and non-pharmacologicapproaches for pain relief. For example, the PRN doses of oxycodone wereadministered mostly in the morning and evening; the nurse manager said, “He usuallycomplains of pain when he wakes and before he goes to bed. He’s also reported hecannot tolerate being up in his chair because of pain. I’ve not heard him complain ofexperiencing muscle spasms [cramping].” When asked if the resident was evaluated byphysical therapy, the nurse manager said, “He’s been discharged from physical therapy[PT]. I will ask for a consult from PT.” When asked about the use of a warm compressand application of the lidocaine patch to the resident’s mid-back and not the right hip asindicated in the provider’s order, the nurse manager said, “I didn’t know he preferredthe lidocaine patch on his back. I will ask the staff about the warm compress.”In summary, Resident #202 was observed on 10/09/18 and 10/10/18 with non-verbaland verbal expressions of pain. Documentation in the resident’s clinical recordincluding physical therapy notes and the most recent pain assessment dated 09/19/18indicated pain impacted the resident’s “activity, emotions, and appetite.” The residentconfirmed pain affected his sleep and ability to remain out of bed; the resident stated,“[I] can’t stay long in my chair to do anything.” Based on record review, the residentreceived PRN doses of oxycodone for a pain level as high as 8/10 daily between09/12/18 and 09/19/18, and 09/21/18 and 09/23/18; following readmission to the CLCon [DATE], the resident received PRN oxycodone on 10/06/18, 10/07/18 and 10/10/18.The PRN oxycodone was administered most frequently in the morning and evening.The CLC did not evaluate the effectiveness of the resident’s pain management planand develop a comprehensive pain management plan to address pharmacologic (e.g.,scheduled pain medication) and non-pharmacologic approaches (e.g., pressurereducing cushion) including approaches the resident indicated were effective.

Non-pressure Related Wound Care Resident #204, [LOCATION]


Resident #204 was admitted to the CLC on [DATE] with diagnoses includingosteomyelitis, end-stage renal disease (ESRD), peripheral artery disease, right foottransmetatarsal amputation (TMA) and type 2 diabetes mellitus.The admission MDS dated [DATE] was coded to indicate Resident #204 scored 15 onthe Brief Interview for Mental Status (BIMS) suggesting intact cognition. The admissionMDS indicated the resident did not have mood or behavioral symptoms of potentialdistress; and required limited assistance with most activities of daily living (ADL)including bed mobility, transfers, and toilet use. Section M (Skin Conditions) of the MDSindicated the resident had an infection of the foot and a surgical wound. According tothe MDS, skin and ulcer treatments included surgical wound care.The wound assessment documentation completed by an RN on 09/06/18 documentedthe following about the resident’s right TMA:

“Location of wound: right TMA.Size (in centimeters): 7.4 cm in length, 10 cm in width, and 0.4 cmdepth….Wound Change: Assessed the wound on 09/06/18 and measured 7.0cm long, slough on 12 o’clock to 6 o’clock and width 3.5 cm, total 40% sloughnoted. [Provider] seen the wound and agreed. Rest of the wound bed red andbeefy.”

A statement in the resident’s plan of care dated 09/11/18 stated the resident was“…admitted with right foot TMA wound.” The care plan approaches dated 09/11/18included but were not limited to, the following:

“Observe and report skin changes to physician, family and nurse.”“Preventative treatments as ordered. Refer to CPRS [computerized patientrecord system], treatment sheet and BCMA for all skin and/or wound careorders.”

The wound care nurse practitioner (NP) note dated 09/13/18 read, “Right lowerextremity NPWT dressing removed. Odor is present. Wound bed is pink with healthygranulation tissue. Slight maceration medial 1/4 of periwound area. Proximal woundedge has intact skin which is soft and fluctuant. Moderate amount of serosanguineousdrainage in woundvac cannister and from the wound. Wound cleansed with NS [normalsaline] and woundvac dressing reapplied. Tolerated well with no complaints of pain ordiscomfort.”The podiatry note dated 10/01/18 documented the resident had “swelling to bilaterallower extremities…s/p [status post] TMA right wound bed granular, two small islands offibrotic tissue, moist wound edges, no active drainage, no clinical signs of infection.”The provider order sheet included an order that stated, “10/03/18 Change NPWTWoundvac Activac [Wound Acti V.A.C® (vacuum assisted closure)] to right foot at 125mm Hg, continuous suction, medium intensity. Change dressing every Mon-Wed-Fri[Monday, Wednesday and Friday] and PRN. Podiatry will change when appts[appointments] are scheduled. Change canister when 3/4 full or every 7 days.”The nurse manager provided a copy of the wound care NP note dated 10/03/18 thatread, “Wound evaluated with nursing during dressing change. Right foot TMA receivingNPWT continuously at 125 mm Hg, tolerated well without complaints of pain. TMAincision healing well with pink granulation tissue in the wound bed. No maceration orepibole. Excoriation open area 1 cm [centimeter] x [by] 1 cm with no depth proximal tothe TMA wound. Wounds cleansed with NS. This area avoided with replacement ofNPWT dressing. No dressing needed. Woundvac dressing reapplied, suction achieved.Tolerated well. Wrapped with Kerlix, secured.”A physician’s note dated 10/04/18 documented the resident had “right footulceration/gangrene S/P [status post] right transmetatarsal amputation with podiatry[DATE] and NPWT wound vac placed on foot after evaluation for admission…continuewound vac per wound care nurse instructions…NPWT reapplied, continue with localwound care…plan to return to OR [operating room] for debridement and split thicknessskin graft in 1-2 weeks.”The 10/05/18 CLC weekly LPN/RN note completed by an RN indicated Resident #204had a right TMA. Under the section on “Skin Problems: Does the resident have anyskin problems such as a wound, bruising, rash, burn or pressure ulcer at this time?” theweekly progress notes read, “Yes, wounds, pressure ulcers or other skin problems.”The CLC weekly LPN/RN notes did not document additional information about the“wounds, pressure ulcers or other skin problems.”During observations of wound care with an LPN on 10/10/18 at approximately 11:10a.m., a Kerlix® wrap on the medial aspect of the resident’s right ankle had a bloodystain. When the LPN removed the Kerlix wrap, a wound dressing identified as anAllevyn dressing by the LPN, was observed on the medial aspect of the right ankle; thedressing was dated 10/08/18. Another dressing identified by the LPN as an Allevyndressing was dated 10/08/18 and observed on the right foot proximal to the TMAwound. When asked about the two wound sites, the LPN said, “Those are two newareas that have opened. I don’t know when they opened….I may say the wrong date,but they opened after he [Resident #204] got here [the CLC].” After removing theAllevyn dressings from the wound sites, the LPN described the wound site on the right


foot proximal to the TMA wound as “open area with odor…wound bed has white sloughand purulent bloody drainage.” The LPN described the wound site on the medialaspect of the right ankle as “open area with odor and purulent bloody drainage…woundbed beefy red with some white slough. Surrounding skin has maceration.” Followingthe wound care observation with the LPN, the RN charge nurse in [LOCATION] wasasked about the resident’s wounds. The RN charge nurse said, “He does not haveother wounds. We’re only treating the TMA wound.” At 1:50 p.m., when asked aboutResident #204’s wound care, the nurse manager in [LOCATION] stated, “We can checkthe treatment book and see if there’s documentation about the resident’s woundtreatment.”On 10/10/18 at approximately 2:15 p.m., the nurse manager in [LOCATION]accompanied the surveyor to interview the RN charge nurse and LPN about theresident’s wound care. Present at the time of the interview was the nurse managerfrom [LOCATION]. The RN charge nurse repeated the information provided earlierstating, “I’m not aware of other wounds. He [Resident #204] only has the TMA woundand the nurses have been changing the dressing and signing off in the treatment book[indicating the dressing change was conducted].” The LPN said, “He has two other[wound] sites in addition to his TMA wound and those were covered with Allevyn[dressing].”The observations during wound care were discussed during the status meeting with theVAMC and CLC leadership team on 10/10/18 beginning at 4:00 p.m. At approximately5:30 p.m., the nurse manager for [LOCATION] stated she talked to the certified wound,ostomy, and continence nurse (CWOCN) and the CWOCN indicated the resident “hadan excoriated area proximal to the wound vac dressing on 10/03/18.” The nursemanager said the CWOCN “thought the excoriated area may have been caused by thewound vac tape and the area was left open to air.” The nurse manager added, “She[the CWOCN] said she does not know where the Allevyn dressing came from becauseshe did not order the Allevyn, but we have a new on-call provider and she [provider]may have ordered something over the holiday. I still have to check it out.” When askedabout the open area to the medial aspect of the right ankle, the nurse manager said, “Iam still looking for information on the other site.”A provider’s order dated 10/10/18 stated, “1502 [3:02 p.m.] Open areas of excoriationproximal to woundvac dressing: avoid plastic in these areas. Cleanse with NS [normalsaline], apply Vaseline gauze over the area, wrap with kerlix.”During a follow-up interview on 10/11/18 at 9:30 a.m., the nurse manager in[LOCATION] provided the following documentation:

The 10/10/18 14:33 (2:33 p.m.) nursing note completed by the LPN observedby the surveyor providing the wound care on 10/10/18 at 11:10 a.m. read, “Tx[treatment] to R [right] TMA done per orders....Surrounding skin white andmacerated. Open area proximal to ankle. Foul odor noted. Opend [open] areawith white slough and mucosy [sic] purulent bloody drainage. Surrounding skinwhite and macerated. Open areas cleansed with NS, Vaseline gauze appliedand area wrapped with kerlix per NP hand. Vet tolerated treatments well. Willcontinue to monitor.”Wound assessment documentation dated 10/10/18 at 17:53 (5:53 p.m.)indicated the following:

“Location of wound: right footSize: 8 cm in length and 8 cm in widthTreatment: AllevynWound base: pinkDrainage: noOdor present: noPeriwound margins: irregular.”

An addendum to the wound assessment documentation dated 10/10/18 at 5:53p.m. read, “Tx [treatment] is not Allevyn. Current tx for area is vasaline[Vaseline] gauze and wrap with Kerlix.” Another addendum written by theCWOCN on 10/11/18 at 8:37 a.m. read, “Clarification: right ankle wound. Area ofvenous discoloration measured 8 cm x 6 cm venous discoloration. Open areameasured 2 cm x 1.5 cm with no measurable depth. Venous stasis leakage withfoot, ankle, and lower extremity edema. Vaseline gauze applied. Wrapped withkerlix.”The wound assessment documentation dated 10/10/18 at 17:56 (5:56 p.m.)indicated the following:

“Location of wound: right footSize: 3 cm in length and 3 cm in widthTreatment: vaseline gauze, wrap with kerlixWound base: pinkDrainage: noOdor present: no


Periwound margins: irregular”An addendum to the 10/10/18 5:56 p.m. wound assessment documentation wasdated 10/11/18 by the CWOCN and read, “Right foot medial distal area.Verification 3 cm x 3 cm area of discoloration with 1.5 cm x 1 cm open area withno depth. Superficial. Vaseline gauze applied.”The wound care NP note dated 10/11/18 at 8:21 a.m. read, “Right foot TMA withNPWT intact dressing at 125 mm continuous suction. Scant amount ofserosanguineous drainage in cannister. Medial distal superficial area ofexcoriation measures 1.5 cm x 1 cm x 0 depth. No drainage and no measurabledepth. Vaseline gauze applied. Avoid adhesive in this area. Anterior ankle areaof discoloration with loss of pigmentation with central area slightly openmeasured 2 cm x 1.5 cm with no depth. This is a new venous stasis open area.Right foot, ankle and lower extremity is edematous, and this wound representsvenous stasis. Vaseline gauze applied. Kerlix gently applied over dressing andTMA wound vac dressing. Change dressing every Mon-Wed-Fri with wound vacdressing changes.”

A provider’s order dated 10/11/18 was written following observation of wound care andinquiry by the surveyor; the order stated, “Change open areas of excoriation proximalto woundvac dressing: Avoid plastic in these areas. Cleanse with NS, apply Vaselinegauze over the area, wrap with Kerlix to Right Ankle and right medial distal foot:Mon-Wed-Fri, cleanse with NS, pat dry, apply Vaseline gauze over open area, gentlywrap with kerlix.”In summary, Resident #204 was admitted to the CLC on [DATE] with diagnoses thatincluded peripheral artery disease and right foot transmetatarsal amputation (TMA).During observations of wound care on 10/10/18, an LPN described a wound site on theresident’s right foot proximal to the TMA wound as “open area with odor…wound bedhas white slough and purulent bloody drainage,” and described a wound site on themedial aspect of the right ankle as “open area with odor and purulent bloodydrainage…wound bed beefy red with some white slough. Surrounding skin hasmaceration.” An Allevyn dressing covered the wounds, although it was not evidentthere was provider’s order for treatment of the areas. The wound care NP note dated10/03/18 read, “Right foot TMA….TMA incision healing well with pink granulation tissuein the wound bed. No maceration or epibole. Excoriation open area 1 cm x 1 cm withno depth proximal to the TMA wound.” The 10/05/18 CLC weekly LPN/RN notecompleted by an RN did not include information about the wounds.” After inquiry by thesurveyor, a provider’s order dated 10/10/18 stated, “1502 [3:02 p.m.] Open areas ofexcoriation proximal to woundvac [wound VAC] dressing: avoid plastic in these areas.Cleanse with NS [normal saline], apply Vaseline gauze over the area, wrap with kerlix.”It was not evident the CLC monitored changes to the resident’s skin and developedapproaches to address skin changes.

Hemodialysis Care


Resident #204 was admitted to the CLC on [DATE] with diagnoses that includedend-stage renal disease (ESRD) and type 2 diabetes mellitus.The resident’s admission MDS dated [DATE] was coded to indicate Resident #204scored 15 on the Brief Interview for Mental Status (BIMS) suggesting intact cognition.The admission MDS indicated the resident did not have mood or behavioral symptomsof potential distress, required limited assistance with most activities of daily living (ADL)including bed mobility and transfers, and required supervision with eating.During observations on 10/09/18 at approximately 1:50 p.m., a note was posted at theresident’s door; the note stated, “750 ml [milliliter] nursing/750 ml dietary.”A statement in the resident’s plan of care dated 09/05/18 stated, “End-stage renaldisease on intermittent hemodialysis Tuesday, Thursday and Saturday.” Another careplan dated 09/11/18 stated, “Resident has kidney failure and needs hemodialysisrelated to end-stage renal disease. Tues, Thurs, Sat [Tuesday, Thursday, Saturday]….”The care plan goal stated, “Resident will have complications prevented and/orminimized.” The care plan included an approach that read, “When the resident returnsfrom dialysis, assess the access site for bleeding and ensure that blood pressure isstable before letting him or her resume activity.”The current provider order sheet included the following orders:

“09/04/18 ESRD with hemodialysis on Tues-Thurs-Sat at 6:00 a.m.”“09/13/18 Heart Healthy, 1500 ml FLD [fluid] (750 nsg [nursing]/750 diet).”“09/20/18 Encourage to drink PO [oral] fluids.”

The nutrition note dated 10/01/18 documented Resident #204 had a “liberalized dietper HD [hemodialysis] RD [registered dietitian]…and was on fluid restriction 1500ml/day [milliliters a day] per HD [hemodialysis] center.”The pharmacy note dated 10/09/18 documented the resident was “recently hospitalizedfrom 08/14[/18] through 08/17[/18] due to hypotension and NSVT [non-sustained


ventricular tachycardia].”On 10/11/18 at 8:20 a.m., the nurse manager in [LOCATION] stated the CLC did nothave a policy addressing hemodialysis care. Resident #204’s clinical record wasreviewed with the nurse manager in [LOCATION]; the CLC resident daily caresummary from 09/28/18 through 10/10/18 indicated there was no documentation aboutthe resident’s fluid intake to determine if the intake was consistent with the fluidrestriction orders. Review of the dialysis treatment summary notes determined theresident had a targeted dry weight of 74 kilograms; the notes indicated the resident hadsigns of hypotension before and after dialysis treatment. For example, the notes statedthe following:

09/29/18, “Pre-dialysis B/P [blood pressure] 80/46 and post-dialysis B/P101/51…amount of fluids removed 2.4 liters.”10/02/18, “Pre-dialysis B/P 86/52 and post-dialysis B/P 95/46…amount of fluidsremoved 3.8 liters.”10/04/18, “Pre-dialysis B/P 96/49 and post-dialysis B/P 99/48…amount of fluidsremoved 2.0 liters.”10/06/18, “Pre-dialysis B/P 89/49 and post-dialysis B/P 98/54…amount of fluidsremoved 2.3 liters.”10/09/18, “Pre-dialysis B/P 80/45 and post-dialysis B/P 111/54…amount of fluidsremoved 2.8 liters.”

On 10/10/18 at 1:50 p.m., the nurse manager in [LOCATION] was asked if the CLChad a policy related to hemodialysis care that included processes for monitoringimplementation of the hemodialysis treatment plan including fluid restrictions. Thenurse manager stated, “We don’t monitor intakes and outputs, but the aides [nursingassistants] write the fluid intake on a sheet of paper and inform the licensed nurse andthe information is passed to the next shift. I don’t know how it’s done on the first floor[LOCATION] where the resident was residing and [LOCATION] but in ourneighborhood, residents who are on fluid restrictions are not supposed to have waterpitchers.”During an initial interview with Resident #204 on 10/09/18 at approximately 1:52 p.m.,the resident stated he was not aware he “needed to limit [his] fluid intake.” During theinterview, a water pitcher dated 10/07/18 was observed on the resident’s overbed table;the water pitcher was one-third full of water. An 8-ounce (240 ml) container of Nepro®was also observed at the resident’s bedside. The resident indicated he drank the Nepromostly after meals.Resident #204 was observed in bed on 10/10/18 at 8:35 a.m. At the time ofobservation, the resident had a water pitcher at the bedside that was one-third full ofwater. The resident stated, “I drank the coffee and my [nourishment] drink. I avoidedthe water last night; I didn’t want to be getting up to go to the bathroom.” Duringobservations of wound care with an LPN on 10/10/18 at approximately 11:10 a.m., awater pitcher two-thirds full of ice and water was observed on the resident’s bedsidetable. The container was dated 10/10/18. The resident stated, “I drank [the] water and itfelt good. I like drinking cold water.”On 10/11/18 at approximately 11:15 a.m., the resident’s hemodialysis care wasdiscussed with the nurse manager in [LOCATION] including lack of a comprehensivecare plan to address the resident’s hypotension before and after dialysis treatment andfluid restriction. The nurse manager said, “There’s a lot of opportunities with dialysiscare. I interviewed the NAs and they indicated the water pitcher [at the resident’sbedside] was a mistake. He shouldn’t have a water pitcher but he got the water pitcherby mistake. I interviewed the licensed nurses and they told me the NAs write the fluidintakes on a sheet of paper, but nobody knows where the papers are kept or if they areeven kept.”

F314

483.25(c) Pressure Sores. Based onthe comprehensive Assessment of aresident, the facility must ensure that(1) A resident who enters the facilitywithout pressure sores does notdevelop pressure sores unless theindividual’s clinical conditiondemonstrates that they wereunavoidable; and (2) A residenthaving pressure sores receivesnecessary treatment and services to

Based on observation, interview and record review, the CLC did not ensure that residents whoentered the CLC without pressure ulcers did not develop pressure ulcers unless they wereunavoidable and residents having pressure ulcers received necessary treatment and servicesto promote healing. Findings include:


Resident #201 was admitted to the CLC on [DATE] with diagnoses including chronicobstructive pulmonary disease (COPD), diabetes mellitus, spinal stenosis, andParkinson’s disease according to the physician note dated 09/24/18. The note indicatedthe resident had “recurrent contact dermatitis and stage 2 sacral decub [decubituspressure ulcer].”


promote healing, prevent infectionand prevent new sores fromdeveloping.

Level of Harm - Actual harm that isnot immediate jeopardy

Residents Affected - Few

The comprehensive Minimum Data Set (MDS) assessment dated 01/19/18 was codedto indicate Resident #201 scored 14 on the Brief Interview for Mental Status (BIMS)suggesting intact cognition; the resident required extensive to total assistance with ADLcare including bed mobility, transfers and toileting; had functional limitations in range ofmotion in the bilateral lower extremities; and was always incontinent of bladder andbowel. Section M (Skin Conditions) of the comprehensive MDS indicated the residentwas at risk of pressure ulcer development and did not have pressure ulcers; skin andulcer treatments coded on the MDS included a pressure reducing device for the bedand applications of ointments/medications other than to feet. The quarterly MDS dated08/30/18 indicated Resident #201 scored 14 on the BIMS suggesting intact cognition,the resident required extensive to total assistance with ADL care including bed mobility,transfers, and toileting; had functional limitations in range of motion of both upper andlower extremities; and was always incontinent of bowel and bladder. Section M of thequarterly MDS indicated the resident was at risk for pressure ulcer development anddid not have pressure ulcers; skin and ulcer treatments coded on the MDS included apressure reducing device for the bed.During an initial interview with the RN charge nurse and nurse manager for[LOCATION] on 10/09/18 beginning at 10:00 a.m. the RN charge nurse reportedResident #201 “has a stage 2 pressure ulcer on the sacrum, has poor appetite, hascontractures of the lower extremities, is at risk for aspiration and requires ContactPrecautions because of an MDRO [multi-drug resistant organism].”Resident #201 was observed during the initial tour of the neighborhood on 10/09/18 atapproximately 10:40 a.m. in his room in a semi-reclined Broda® chair without apressure redistribution cushion in the chair. At the time of observation, the resident wassitting on a transfer sling. At approximately 12:30 p.m., the resident was observed inthe dining room in a semi-reclined Broda chair without a pressure redistributioncushion; the resident was sitting on a transfer sling and a wedge cushion was placednext to the resident’s left hip.A statement in the resident’s care plan dated 06/11/18 stated Resident #201 was “atrisk for pressure ulcers related to impaired mobility, self care deficit, incontinence,obesity, non-compliance with turning….Update 04/2018: pressure injury stage 2 rightischium (healed 05/08/18), pressure injury stage 1 right lateral thigh…updated05/08/18, pressure injury stage 2 right medial thigh, pressure injury stage 1 right lateralthigh…(resolved)….Update: 07/26/18 pressure injury stage 2, right shoulder (healed08/03/18)….Update 09/22/18: pressure injury stage 2 sacrum, also blister on otherareas: right flank, left inner thigh, right mid back.” The care plan goal stated theresident’s “skin will remain intact without signs of pressure ulcers.” The careapproaches included but were not limited to:

“Skin & Wound Apply Clear Zinc to buttocks with each change of brief (05/07/18).”“Preventative treatments as ordered. Refer to CPRS [computerized patientrecord system], treatment sheet and BCMA [Bar Code Medication Administrationsystem] for all skin and/or wound care orders (06/11/18).”“Assist resident with turning, repositioning, and transfers as needed (06/11/18).”“Observe and report skin changes to physician, family and nurse (06/11/18).”“Nursing limit time sitting upright in chair to 40-45 minutes at a time and thenuse tilting mechanism of the Broda chair to alter pressure areas. Total time up inchair to be limited to 2-3 hours. Pt [patient] should return to bed for 1-2 hoursbetween breakfast and lunch and again between lunch and supper. Encouragepatient to get up for evening meal. Pt. should be positioned on one of his sideswhen in bed between meals….(09/24/18).”“Change Stage 2 pressure ulcer to coccyx. Apply Allevyn daily to open area andPRN (09/27/18).”“No plastic chuxs [incontinence pads] or Attends [incontinence brief] to touchskin due to irritant contact dermatitis. Use clotton [cotton] sheets for turning(09/28/18).” (Staff did not indicate how the resident could wear incontinencebriefs and not experience contact dermatitis; the type of briefs was not changedin response to the contact dermatitis and no additional guidance was provided tostaff.)“BLISTERS [emphasis not added]…appear to be an irritant contact dermatitis,likely from contact with plastic. Recommend to avoid plastic pads on the bed,use cotton if turn sheet is needed. Can cover blisters with Allevyn to protect fromrupture. If they rupture on their own, recommend to apply Zinc clear to the area(09/28/18).”

The current provider orders included the following:

“05/07/18 Skin & Wound: Apply clear Zinc to buttocks with each change of brief.”“07/26/18 Unavoidable right lateral thigh moisture related dermatitis. Change


Allevyn dressing on Thursday and PRN [as needed].”“08/01/18 Limit time sitting upright in chair to 40-45 minutes at a time and thenuse tilting mechanism of the Broda chair to alter pressure area.”“09/24/18 Limit time sitting upright in chair to 40-45 minutes at a time and thenuse tilting mechanism of the broda chair to alter pressure area [betweenbreakfast] and lunch and again between lunch and supper. Encourage patient toget up for evening meal. Pt. [patient] should be positioned on one of his side[sides].”“09/28/18 No plastic chuxs [sic] or attends to touch skin due to irritant contactdermatitis. Use clotton [cotton] sheets for turning.”

The wound assessment documentation dated 09/22/18 indicated the resident had thefollowing skin breakdown:

“New right flank fluid filled blister, 2.2 cm [centimeter] length x [by] 1.9 cm width.”“First noted on this date…stage II pressure ulcer sacrum 2.8 cm length, 0.8 cmwidth, 0.1 cm depth; wound base, pink/red; drainage: yes; drainage amount:minimal; drainage type: serosanguineous; periwound margins; irregular,erythemic, no undermining.”

The wound care nurse practitioner [NP] note dated 09/24/18 indicated the resident hada “new stage II pressure injury on the coccyx" that measured "2 cm length x 0.8 cmwidth x 0.1 cm depth; pink wound bed, no drainage. Periwound edges are flat.”The wound assessment documentation dated 10/03/18 indicated the resident had thefollowing skin breakdown:

“Stage II Sacrum: 1.1 cm length, 0.5 cm width, 0.1 cm depth; wound bed: pink;drainage: yes; drainage amount: scant; drainage type: serous; odor present: no;periwound margins: irregular: undermining: no”

The most recent Braden Scale for Predicting Pressure Ulcer Risk score dated 10/08/18in the CLC weekly LPN/RN note indicated Resident #201 scored 12 suggesting a highrisk for pressure ulcer development. Risk factors for pressure ulcer developmentincluded slightly limited sensory perception, very moist skin, chairfast, very limitedmobility and problem with friction. Under the section on skin problems, the notedocumented the resident had “wounds on the left upper back and stage II pressureulcer on the sacrum/coccyx.”On 10/09/18 at approximately 1:05 p.m., the RN charge nurse, LPN and nursingassistant (NA) were observed providing wound and incontinence care for the resident.At the beginning of the observation, the resident was sitting on a transfer sling in hisBroda chair and a wedge cushion was placed next to the resident’s left hip area. TheRN charge nurse and the NA assisted the resident to transfer from the Broda chair tobed using the ceiling lift. The resident used a pressure redistribution mattress in bed(Invacare® Solace® Therapy Mattress). Once the resident was lowered onto his bed, itwas noted the resident wore disposable incontinence briefs. When the resident wasturned to his side, the back of the resident’s thighs were noted with deep, red marksresembling the ridges of the seat of the Broda chair. When the RN charge nurseunfastened the incontinence briefs, it was noted the resident had what appeared to bea dried pinpoint rash on both hips. The RN charge nurse commented the resident hadcontact dermatitis resulting from the skin being in contact with the plastic adhesive ofthe disposable briefs. No clarification was provided regarding how incontinence carewas to be provided so that plastic adhesive and/or incontinence briefs did not come incontact with the resident’s skin. After the NA removed the incontinence brief, it wasnoted the wound (Allevyn) dressing had rolled up so that it no longer covered thecoccyx ulcer. The LPN observed the soiled dressing and stated the dressing hadserosanguineous drainage. When asked to describe the wound bed, the RN chargenurse stated, “The wound bed is pink, red with minimal serosanguineous drainage. Theperiwound margin is macerated.” When asked what caused the maceration, the RNcharge nurse said, “Contact with moisture.”On 10/09/18 at approximately 5:25 p.m., Resident #201 was observed in the diningroom in a semi-reclined Broda chair without a pressure redistribution cushion; at thetime of observation, the resident was sitting on the transfer sling.Resident #201 was observed intermittently on 10/10/18 at 8:15 a.m., 9:35 a.m. and9:50 a.m. in a semi-reclined Broda chair without a pressure redistribution cushion; atthe time of observations, the resident was sitting on the transfer sling. At 10:10 a.m.,the NA who was consistently assigned to the resident was asked if the resident wouldbe assisted back to bed. The NA said, “He was up in his chair at 7:30 a.m. and heneeds to stay in his chair for a couple more minutes. He can stay in his chair for threehours.” When asked if the resident would be assisted to shift position in his chair, theNA said, “He’s a sky [ceiling] lift assist. I can check on him later.” At 11:35 a.m. theresident was observed in his Broda chair in the same position in his room; at the timeof observation, the restorative RN coordinator was assisting the resident with


restorative nursing exercises. The resident was sitting on the transfer sling.Information in the wound assessment documentation dated 10/10/18 described theresident’s pressure ulcer as follows: “Stage II Sacrum: 1.8 cm length, 0.9 cm width, 0.2cm depth; wound bed: pink/red; drainage: yes; drainage amount: minimal; drainagetype: serosanguineous; odor present: none; periwound margins: macerated;undermining: none; wound change: worse, increase L, W, D [length, width, depth].”On 10/11/18 at approximately 8:30 a.m., the observations including the lack of apressure redistribution cushion in the Broda chair, the maceration of the wound edgessuggesting prolonged contact of the skin with moisture, and the lack of consistentimplementation of the resident’s turning and positioning including tilting andrepositioning of the Broda chair were discussed with the nurse manager. The nursemanager did not provide further information but stated education would be provided tothe NAs related to following the resident’s plan of care.In summary, Resident #201 developed a pressure ulcer described on 10/10/18 as“Stage II Sacrum: 1.8 cm length, 0.9 cm width, 0.2 cm depth; wound bed….woundchange: worse, increase L, W, D [length, width, depth].” During observations on10/09/18 and 10/10/18 the resident was observed seated in a Broda chair without apressure reducing cushion; the resident was seated on a transfer sling. The time theresident spent in the Broda chair was not limited to 40-45 minutes and the positioningof the chair was not adjusted for pressure redistribution as indicated in the care planand provider orders. It was also noted that the resident had contact dermatitis and skinbreakdown as a result of contact with plastic and adhesive. The resident’s care planindicated “No plastic chuxs [incontinence pads] or Attends [incontinence brief] to touchskin due to irritant contact dermatitis….” Staff did not indicate how the resident couldwear incontinence briefs and not experience contact dermatitis; the type of briefs wasnot changed in response to the contact dermatitis and no additional guidance wasprovided to staff. During the survey, the resident was observed wearing incontinencebriefs; the resident had a rash on both hips. The RN charge nurse commented theresident had contact dermatitis resulting from the skin being in contact with the plasticadhesive of the disposable briefs.


Resident #101 was admitted to the CLC on [DATE] with diagnoses that includedcholangiocarcinoma/adenocarcinoma, diabetes mellitus and peripheral vasculardisease with bilateral venous stasis ulcers.The resident’s admission Minimum Data Set (MDS) dated [DATE] indicated theresident had a Brief Interview for Mental Status (BIMS) score of 14 suggesting intactcognition; the resident had no signs or symptoms of delirium or behavioral symptomsincluding rejection of care. The MDS indicated the resident required extensiveassistance for activities of daily living (ADLs) including bed mobility, transfers, dressing,personal hygiene, and eating; the resident was incontinent of bowel and bladder.According to the MDS, the resident had occasional pain at a level of 5 (on a scale or 0to 10, 10 being the worst pain possible). The MDS indicated the resident was at risk ofpressure ulcers, had 2 unstageable pressure ulcers that were present on admissionand contained slough and/or eschar, and had MASD (moisture associated skindamage); skin and ulcer treatments coded on the MDS included a pressure reducingdevice for the bed and pressure ulcer care. No venous, arterial, or diabetic foot ulcerswere documented on the MDS.The resident’s care plan dated 08/03/18 and updated on 09/29/18 indicated, “Actualdeep tissue injury pressure ulcers [to the] bilateral heels and had venus [venous] stasisulcers to the lower extremities. The approaches dated 08/03/18 included: “Providewound care as ordered and monitor effectiveness. Assess and treat pain as ordered.Medicate as needed prior to treatment. Assess prn [as needed] and document.Pressure relieving device as ordered. Offload heels from the bed at all times with [by]floating heels or [with] foam boots. Low air loss mattress. Notify physician andsignificant other of any changes in wound status.” The care plan did not indicate theresident refused care or include approaches to address refusals of care. The care plandid not address the development of a left buttock pressure ulcer.A provider’s order dated 07/26/18 indicated, “Comfort care…If actively dying pleaseturn only for comfort;” this information was not added to the care plan.On 10/09/18 at 10:05 a.m., the charge nurse (registered nurse) and nurse managerwere interviewed during the initial tour of the [LOCATION] neighborhood. The chargenurse indicated that Resident #101 was admitted for hospice care; it was not indicatedthe resident was actively dying. It was reported the resident was incontinent of boweland bladder, had a CLC-acquired Stage 2 pressure ulcer on the coccyx, had asuspected deep tissue injury to the right heel, preferred to stay in bed, had pain in hislegs and feet, and received morphine for pain. At approximately 10:30 a.m., the


resident was observed lying in bed on his back.The following pertinent documentation was reviewed:

The 07/26/2018 RN initial skin assessment note indicated the resident had a“Braden [Scale for Predicting Pressure Ulcer Risk] score: 17 – mild risk. Skinproblems: venous stasis ulcers bilateral legs. Pressure ulcer assessment –suspected deep tissue injury – heel right. Heel left, DTI [deep tissue injury]unstageable.” Wounds were described as “left leg posterior, 10 cm by 4 cm by0.2 cm venous pink, red wound base, left lower leg 2 cm by 2 cm by 0.2 cm. leftheel 15 by 15 by 0 cm, DTI, unstageable grayish, purple, right heel 7 cm by 7cm by 0 cm, DTI injury."The 07/26/2018 wound care NP (nurse practitioner) note documented by thecertified wound nurse indicated, “Bilateral heels deep tissue injury [injuries] withecchymosis, left heel also has 1 cm [centimeter] open area. Both areas tender totouch. Right heel ecchymotic area 7 cm by 7 cm without open area. Left heel 15cm by 15 cm with soft, tender eccymotic [sic] area and open area 1 cm by 1cm…Offload heels from bed with floating heels or...boots….”A 07/26/18 wound assessment note written at 2:24 p.m. indicated the residentwas admitted with a right heel “deep tissue injury” wound that measured “7 cm[centimeters] by 7 cm by 0 cm.”A 09/13/18 nursing note written by an LPN indicated, “Vet [Veteran] refusedPrevalon boot on LLE [left lower extremity] due to pain from wound. Educatedon moving BLE [bilateral lower extremities] throughout the day. No complaints ofpain….”A 09/17/18 wound care NP note indicated, “Right heel previously with DTI [deeptissue injury] dry stable eschar now loosened eschar…gently removed looseeschar…pink tissue in wound bed, small amount tan drainage.”A 09/25/18 wound care NP note indicated, “Bilateral heel wounds no longeropen, eschar dry stable.”A 09/29/18 wound assessment note written by an RN indicated, “Coccyx 2 cmby 2 cm by 0.2 cm. Stage 2 wound base red…new area.”The most recent wound assessment note dated 10/04/18 indicated theresident’s coccyx wound remained the same (as on 09/29/18).

On 10/09/18 at 1:00 p.m., Resident #101 was observed lying in bed on his back on alow air loss mattress; the head of the bed was elevated approximately 30-45 degreesand the resident appeared to have slid down in bed, toward the left side with his feetnear the foot of the bed. The low air loss mattress had a white bed alarm pad in placedirectly on the mattress covered by a blue nylon lift pad that was covered by two paperabsorbent pads. The resident was not wearing pressure reducing devices on his feet;his heels were not floated and rested directly on the mattress. A friend who was visitingthe resident indicated that she arrived at approximately 12:30 p.m. The resident wasobserved to have difficulty maintaining wakefulness when attempts were made tointerview the resident. A nursing assistant (NA) entered the room and when interviewedindicated, “He’s been in and out of it today,” and further clarified the resident had beenconfused at times.On 10/09/18 at 1:35 p.m., the same NA interviewed at 1:00 p.m. and a licensedpractical nurse (LPN) were observed providing hygiene care for Resident #101. Theresident was observed lying on his back in the same position at 10:30 a.m. and 1:00p.m. The NA was asked if the resident was able to reposition himself and she stated,“No. We need to help him.” During hygiene care provided by the NA and LPN, theresident was observed to have an intact and dry Allevyn type dressing to the rightbuttock/sacral area. The resident was not observed to assist with repositioning. Eachtime the NA and LPN moved the resident in bed to perform hygiene the resident calledout “Ouch!” The resident cried out each time he was repositioned and in particularwhen his legs were repositioned. The resident was lying on a low air loss mattress witha white bed alarm pad that was on the mattress and covered by a blue nylon lift padand two paper absorbent pads. The resident’s feet rested directly on a green clothabsorbent pad and were not off-loaded from the surface of the pad and mattress. Theresident’s right leg had dark brown discoloration extending from the calf to the feet, andthe right foot was wrapped with a dressing secured by Kling wrap; the dressingappeared to have serosanguineous drainage on the right medial heel. A portion of theright medial aspect of the heel was observed and contained an approximate 1centimeter (cm) round adherent eschar. The left leg was wrapped with a dressingaround the calf secured by Kling wrap; the dressing had what appeared to be amoderate amount of tan and serousanguineous drainage on the posterior, or calf side,of the left leg. After hygiene care was completed, the NA and LPN did not elevate theresident’s feet to promote pressure relief. On 10/09/18 at 2:35 p.m., Resident #101 wasobserved lying in bed on his back while wound care was provided by the charge nurse


(RN), an LPN, and the hospice physician. The resident was lying on a low air lossmattress with a white bed alarm pad that was on the mattress and covered by a bluenylon lift pad and two paper absorbent pads. The LPN stated she “premedicated” theresident before wound care. The LPN and RN performed wound care to both of theresident’s lower legs (the wounds on the resident’s heels were healed). When theresident’s legs were touched or repositioned, the resident called out, “Ouch! My leg!”When the RN and LPN removed the sacral/right buttock dressing, a right buttock openwound measuring approximately 1 cm round was observed. The RN indicated thewound was “healing” and had a “pink wound bed.” When asked how the residentobtained the right buttock pressure ulcer, the physician stated, “He’s not moving…haspoor nutrition.”On 10/09/18 at 4:50 p.m., the resident was observed lying in bed on his left side andappeared to be sleeping; The resident was lying on a low air loss mattress with a whitebed alarm pad on the mattress that was covered by a blue nylon lift pad and two paperabsorbent pads. The resident was not wearing pressure reducing devices on his feet;his heels were not floated and the left trochanter/heel rested directly on the mattress.On 10/10/18 Resident #101 was observed while in bed as follows:

8:00 a.m. and 10:15 a.m. – lying in bed on his back; the resident’s knees wereelevated and what appeared to be a pillow was placed under both knees, sincethe knees were higher than the feet. The resident was lying on a low air lossmattress with a white bed alarm pad that had been placed directly on themattress and was covered by a blue nylon lift pad and two paper absorbentpads. The resident was not wearing pressure reducing devices on his feet; hisheels were not floated and rested directly on the mattress. 10:35 a.m. – lying in bed on his back, with his head facing the windows, and thelegs in the same position as previously observed. The resident was lying on alow air loss mattress with a white bed alarm pad that had been placed directlyon the mattress and was covered by a blue nylon lift pad and two paperabsorbent pads. The resident was not wearing pressure reducing devices on hisfeet; his heels were not floated and rested directly on the mattress. A nursingassistant (NA) stated, “The last time I gave care was at 8:00 a.m.” When askedwhen she planned to provide care again, the NA stated, “In about a half an hourafter I take someone to dialysis.” When asked if another staff person providedhygiene care for the resident, the NA stated, “No. I give the care. She [the otherstaff person] gives the meds [medications].”11:05 a.m. – lying in bed on his back, with his head and legs in the sameposition as during prior observations. The resident was lying on a low air lossmattress with a white bed alarm pad that had been placed directly on themattress and was covered by a blue nylon lift pad and two paper absorbentpads. The NA was interviewed and indicated, “I already did care…I checked him[Resident #101] and he was dry.” When asked if the resident was turned orrepositioned, the NA indicated she had repositioned the resident. The surveyorasked if the resident’s feet could be observed and when the NA uncovered theresident’s legs, two pillows were observed under both of the resident’s kneesand behind the lower legs; the pillows did not elevate the resident’s heels fromdirect contact with the mattress.1:00 p.m. – lying in bed and appeared to be sleeping in the same position asindicated during previous observations.2:05 p.m. – the charge nurse (RN) and LPN were interviewed and asked aboutthe frequency of turning and repositioning for Resident #101. The LPN stated,“He’s [receiving] hospice [care], so we turn him if he lets us…as long as itdoesn’t cause pain.” When asked if the LPN provided hygiene care orrepositioning on 10/10/18, the LPN stated, “No. I help if needed.”2:15 p.m. – lying in bed and appeared to be sleeping in the same position notedpreviously. The resident was lying on a low air loss mattress with a white bedalarm pad that had been placed directly on the mattress and was covered by ablue nylon lift pad which and two paper absorbent pads. The resident’s wife wasasked if staff provided hygiene care or repositioning since the wife had beenvisiting (since approximately 11:30 a.m.); the wife stated, “No, he’s beensleeping.”2:30 p.m. – lying in bed, awake at times, and in the same position as indicatedduring the previous observation. The RN and LPN entered the room andindicated they would provide the resident’s wound care. When the LPN removedthe blankets from the resident’s lower legs, two pillows were observed under theresident’s knees and lower legs, the resident’s heels rested directly on themattress surface. The LPN was asked if the resident wore or used pressurereducing boots to protect the feet and the LPN responded, “No. The [upper]


edge of the boots rubbed on his wounds…it was painful.”On 10/10/18 at approximately 4:00 p.m., during the daily meeting with the CLCleadership team, the observations regarding the lack of turning and repositioning forResident #101 were shared. No additional information was provided during themeeting. Following the meeting at approximately 5:40 p.m., the [LOCATION] NMprovided information and indicated that the resident did “not like having a pillow underthe back of his legs…it was too uncomfortable” due to his lower leg wounds. Whenasked how staff were to follow the provider’s order to off-load the feet, the NM did notprovide additional information other than the following documentation from the NA whocared for the resident indicating care had been provided.

A nursing note written by the NA on 10/10/18 at 4:16 p.m. stated, “Pt. [patient,Resident #101] positioned at 9 AM [9:00 a.m.] on his left side, around 11:45 AMpt. was position[ed] for t [the] second time on his right side but plaining[complaining] of pain on his legs because the legs are touching each other. Pt.requested writer to remove pillows from his left side stat [stating] ‘I am notcomfortable lying on my right side.’ Writer removed the pillows.” An addendumwritten by the same NA at 5:05 p.m. read, “@ [at] 16:45 [4:45] p.m. writer wentto pt. room to reposition, pt. refused, stated ‘I am ok with the same position fornow.”A nursing note written by an LPN on 10/10/18 at 5:15 p.m. stated, “02 [oxygen]placed at 2L [liters] per NC [nasal cannula] for an O2 sat [oxygen saturation] of83%, sat up to 95%. PRN oxy [as needed oxycodone] give at 1:35 p.m. – 1 hourprior to dressing change to BLE. Vet denied the need to be T&R [turned andrepositioned] to right side, some discomfort noted when turning vet from side toside. Perform [performed] peri care. Wife at bedside….”

On 10/11/18 at 7:55 a.m. the resident’s wife and her sister were in the resident’s roomand the resident was awake and answering some questions. The wife indicated shespent the night and staff had come into the resident’s room during the night to providehygiene care and repositioning. The resident was lying on his back and according tothe wife, both lower legs were “up on a pillow.”In summary, a 09/29/18 wound assessment note written by an RN indicated, “Coccyx 2cm by 2 cm by 0.2 cm. Stage 2 wound base red…new area.” During observations on10/09/18 and 10/10/18 the resident was observed lying on his back on a low air lossmattress; the low air loss mattress had a white bed alarm pad placed directly on themattress and covered by a blue nylon lift pad and two paper absorbent pads potentiallyimpacting the pressure reducing qualities of the mattress. Although woundassessments and other documentation indicated the resident’s heels should be floatedto reduce pressure, the resident was not observed wearing pressure reducing deviceson his feet; his heels were not floated and rested directly on the mattress. While staffinterview indicated that the resident refused to wear pressure reducing boots due topainful lower leg ulcers and refused repositioning due to pain, the care plan did notaddress the resident's refusals including approaches to address the refusals ofcare and alternatives for prevention of pressure ulcers.


As determined through review of the resident’s clinical record, Resident #202 wasadmitted to the CLC on [DATE] with diagnoses including CVA (cerebrovascularaccident) with residual left-sided weakness, aphasia, neurogenic bladder and bowel,and type 2 diabetes mellitus. Other medical conditions according to the history andphysical dated 10/05/18 included bilateral above knee amputations (AKA) anddepression.The resident’s most recent comprehensive MDS assessment dated 08/24/18 wascoded to indicate Resident #202 scored 15 on the Brief Interview for Mental Status(BIMS) suggesting intact cognition; the resident required extensive to total assistancewith most activities of daily living including bed mobility, transfers, dressing, locomotionand toilet use; had functional limitations in range of motion of the upper extremities(one side only) and bilateral lower extremities, used an external urinary catheter andwas always incontinent of bowel. Section M (Skin Conditions) of the comprehensiveMDS indicated the resident was at risk of developing pressure ulcers and did not havepressure ulcers; skin and ulcer treatments coded on the MDS included a pressurereducing device for the bed and application of nonsurgical dressings other than to feet.A statement in the resident’s care plan dated 08/21/18 stated the resident “haspotential for skin breakdown due to impaired mobility, self-care deficit, diabetes,incontinence, h/o [history of] chronic stage 4 pressure ulcer of coccyx (healed),declines preventative care: turning/repositioning, weight loss, malnutrition….” The careplan goal stated, “Skin will remain intact without signs of pressure ulcers.” The care


plan approaches included but were not limited to the following:

“Offload pressure from coccyx and ischium as much as possible. Position withpillows and wedges. Turn every 2 hours (07/05/18).”“Air mattress (07/05/18).”“Reposition every 2 hours, up to DR [dining room] for meals TID [three times aday] in chair for no more than 2 hours at a time, then back to bed for rest.Offload pressure from coccyx and left ischium as much as possible withcushions and wedges (07/05/18).”“Healed sacral PU [pressure ulcer]: daily and PRN [as needed], cleanse with NS[normal saline], cover with Allevyn to protect fragile tissue from stool (07/06/18).”“Preventative treatments as ordered. Refer to CPRS, treatment sheet, andBCMA for all skin and/or wound care orders (08/21/18).”

The most recent wound treatment notes dated 10/10/18 documented the resident didnot have any pressure ulcers.The current provider order sheet included the following:

“10/05/18 Renew up in chair with assistance. Change position every two 2hours, chair to bed.”“10/05/18 Skin & Wound. Stage 2 pressure ulcer to coccyx: cleanse daily withnormal saline and PRN; apply Allevyn dressing and change daily and PRN ifsoiled with stool.”“Renew Air Mattress.”“Renew offload pressure from coccyx and ischium as much as possible. Positionwith pillows and wedges. Turn every two hours.”“10/05/18 Renew healed sacral PU [pressure ulcer]: daily and PRN. Cleansewith NS, cover with Allevyn to protect fragile tissue from stool.”

During an initial interview with the RN charge nurse and nurse manager for[LOCATION] on [DATE] beginning at 10:00 a.m., the RN charge nurse reportedResident #202 “returned from ASIH [absent sick in hospital] on [DATE] with a Stage 2pressure ulcer on his coccyx, has complaints of back pain, refuses to be turned, andrequires Contact Precautions.”During initial observation of Resident #202 on 10/09/18 at approximately 12:30 p.m.,the resident was observed in the dining room in a semi-reclined Broda chair without apressure redistribution cushion; the resident was sitting on an incontinence pad. TheRN charge nurse confirmed the observation stating the resident “required the sky[ceiling] lift for transfers.” At approximately 4:35 p.m., the resident was observed in hisroom being assisted out of bed into the Broda chair using the ceiling lift. The residenthad a SenTech Stage IV® 3000 mattress on the bed and two Tranquility® incontinencepads were placed on top of the mattress. At approximately 5:25 p.m., the resident wasobserved in the dining room in a semi-reclined Broda chair without a pressure reducingcushion.On 10/10/18 at approximately 8:10 a.m., Resident #202 was observed in the diningroom in a semi-reclined Broda chair without a pressure reducing cushion; the residentwas sitting on an incontinence pad. When asked why the resident was sitting on theincontinence pad, one of the nursing assistants (NAs) in the neighborhood familiar withResident #202 remarked, “He uses a condom catheter and…he needs theincontinence pad.” At 9:10 a.m., two NAs assisted Resident #202 to transfer from theBroda chair to bed. Three Tranquility incontinence pads were noted on top of themattress. The resident was later transferred to the Broda chair for the noon meal. At1:30 p.m. two NAs were observed transferring the resident from the Broda chair to bedusing the ceiling lift. The NAs also provided incontinence care for the resident. Whenthe NAs removed the incontinence brief, there was no protective dressing noted on theresident’s coccyx. One of the NAs said, “The Allevyn must have come off when we didhis care this morning [at 7:30 a.m.].” At 1:35 p.m. an LPN was observed providingwound care for the resident. The LPN cleansed the coccyx with normal saline andapplied the Allevyn dressing. The LPN stated the coccyx wound was healed.On 10/11/18 at approximately 10:00 a.m., Resident #202’s skin care was discussedwith the nurse manager including use of incontinence pads in the Broda chair, the lackof a pressure reducing wheelchair cushion, and layers of incontinence pads on thepressure reducing mattress. When asked about the layers of incontinence pads(potentially impacting the pressure reducing qualities of the mattress), the nursemanager said, “The use of incontinence pads is discouraged.” The nurse manager saidfurther education would be provided for staff on prevention of pressure ulcers.


F323

483.25(h)(1) Accidents. The facilitymust ensure that: The residentenvironment remains as free ofaccident hazards as is possible;

Level of Harm - No actual harmwith potential for more thanminimal harm that is not immediatejeopardy

Residents Affected - Some

Based on observation, interview and record review, the CLC did not ensure the residentenvironment remained free of accident hazards. Findings include:

On 10/10/18 at approximately 1:45 p.m. the CLC chief nurse provided a copy of a policydated December 2017 and titled, “Department of Veterans Affairs Cincinnati VA MedicalCenter (CVAMC) Water Management Plan.” The policy stated, “Hot water distributionsinks/showers/tubs: Critical control limit – temperature < [less than] 110 degrees Fahrenheit.Monitored at sentinel points, frequency weekly, corrective actions – monitoring data will assistto identify specific areas for future engineering control enhancement. Specificsinclude…opportunity for mixing valves to be installed or repaired. Verification procedure:monthly review by maintenance operations supervisor [and] quarterly review by facility watersafety committee.”

Hot Water

During observations of care for Resident #201 on 10/09/18 at approximately 1:05 p.m.,a surveyor washed her hands at the sink in the resident’s room in the [LOCATION]neighborhood and noted the water to be extremely hot; the surveyor’s hands turnedred within seconds and the surveyor could not hold her hands under the running waterfor more than 1 to 2 seconds. The RN charge nurse who accompanied the surveyorremarked, “He [Resident #201] has the hottest water in this part of the unit[neighborhood].” At the daily status meeting on 10/09/18, the observation of elevatedwater temperature was discussed with the CVAMC and CLC leadership staff. The chiefnurse executive stated, “We have been having problems with hot water with some ofthe rooms....”On 10/10/18 at 9:10 a.m., two nursing assistants (NAs) were observed providing carefor Resident #202. After providing care, the NAs, and the surveyor washed hands inthe hand washing sink in the resident’s room in the [LOCATION] neighborhood. Whenthe surveyor commented on the temperature of the hot water, one of the NAs said,“The water is always hot like that. We developed thick skin because the water’s beenvery hot. We’ve reported it [did not indicate to whom the hot water was reported], butnothing really ever happens.”On 10/10/18 at approximately 9:25 a.m., assistance was requested from CLC safetystaff to obtain water temperatures in resident rooms.On 10/10/18 at approximately 9:50 a.m., the same NA who provided care for Resident#202 reported to the chief nurse executive that the water in the resident’s handwashing sink was “always scalding hot; the NAs have developed thick skin.”On 10/10/18 at 9:55 a.m., the CLC chief nurse was alerted to concerns with elevatedwater temperatures in the above noted resident rooms. Information was requestedregarding the population of residents in each CLC neighborhood including cognition,functional abilities, and limitations that would increase resident risk for scalding fromexcessively hot water.On 10/10/18 at 11:20 a.m., it was indicated that elevated water temperatures in thefollowing resident care areas had been identified and engineering staff had fixed themixing valves at the time of the discovery.

First floor, [LOCATION], resident room 1010 was 120 degrees Fahrenheit at thein-room sink, obtained at 10:12 a.m.First floor, [LOCATION], resident kitchen sink was 116.6 degrees Fahrenheit at10:14 a.m.Second floor, [LOCATION], resident room 2010 was 115 degrees Fahrenheit atthe in-room sink at 10:40 a.m.Second floor, [LOCATION], resident room 2008 was 115 degrees at the in-roomsink, at 10:42 a.m.

On 10/10/18 at approximately 1:40 p.m., the same NAs previously observed and anLPN were observed providing care for Resident #202; following the provision of care,the NAs and a surveyor washed hands using the hand washing sink in the resident’sroom. The water temperature was noted to be excessively hot. The LPN then washedhands using the same hand washing sink; the LPN , “Geez, that is very hot. I wasn’tready for that!” The surveyor informed the assistant chief of engineering about theelevated water temperature in the resident’s hand washing sink. The assistant chief ofengineering said, “That’s disappointing. I thought they fixed the problem.”On 10/10/18 at approximately 2:00 p.m., the associate chief engineer indicated thatresident care area water temperatures were monitored by an external monitoringagency that tested water temperatures at the same time Legionella testing wasconducted on a quarterly basis. If water temperatures were elevated at the time, a workorder was generated and the water temperature and/or mixing valve was adjusted atthe source (e.g., sink, shower). The engineer was unable to provide copies of work


orders since he expected the “tradesmen” to fix them at the time the problem wasidentified. The facility engineer had some difficulty accessing the water temperaturelogs since the person who maintained those files was not available during the survey.Untitled documents were provided by the facility engineer that included data collectedby the external monitoring agency. A summary of elevated water temperatures wasprovided and indicated that elevated water temperatures were noted as follows:

Report 01/26/18: there was no record of elevated resident care area watertemperatures.Report 04/24/18: first floor, [LOCATION], resident rooms included 1022,temperature was 126 degrees Fahrenheit; 1020 was 129 degrees Fahrenheit;and room 1018 was 114 degrees Fahrenheit. Resident rooms located on thesecond floor had water temperatures below 110 degrees Fahrenheit.Report 07/18/18: first floor, [LOCATION], resident room showers included 1008with a water temperature reading of 122 degrees Fahrenheit, 1009 with a watertemperature reading of 120 degrees Fahrenheit, and 1010 with a watertemperature reading of 116 degrees Fahrenheit.

On 10/10/18 at 4:00 p.m., during the daily meeting with CLC and Cincinnati VAMCleadership staff, information was provided regarding elevated water temperatures. TheCLC chief nurse indicated she was aware of the issues with elevated watertemperatures and problems with functioning of the mixing valves in the past; however,the chief nurse was unable to verify if the engineering and safety department wasaware and what, if anything had been done to correct the concern.On 10/10/18 at approximately 5:00 p.m., the CLC chief nurse provided a list ofresidents in each neighborhood that had some level of cognitive limitation and theability to access water at a sink. Each of the three neighborhoods had the capacity for16 residents.

[LOCATION] had a census of 15 residents; 4 residents experienced cognitivelimitations and three of the 4 residents had the ability to access sinks in residentrooms 1009, 1020, and 1021.[LOCATION] had a census of 16; 7 residents experienced cognitive limitationsand three of the 7 residents had the ability to access sinks in resident rooms2012, 2017, and 2022.

In summary, 4 residents in [LOCATION] experienced cognitive limitations and 3 of the 4residents had the ability to access sinks in resident rooms 1009, 1020, and 1021.Seven (7) residents in [LOCATION] experienced cognitive limitations and 3 of the 7residents had the ability to access sinks in resident rooms 2012, 2017, and 2022.During hand washing at sinks in resident rooms in the [LOCATION] neighborhood on10/09/18 and 10/10/18 the water was noted to be very hot; the surveyor could not holdher hands under the running water for more than 1 to 2 seconds. On 10/10/18 at 9:10a.m., an NA said, “The water is always hot like that. We developed thick skin becausethe water’s been very hot. We’ve reported it, but nothing really ever happens.” On10/10/18 at 11:20 a.m., it was indicated that elevated water temperatures wereobtained in [LOCATION] and [LOCATION], and that engineering staff fixed the mixingvalves (and water temperatures) at the time of the discovery. On 10/10/18 atapproximately 1:40 p.m., NAs and a surveyor washed hands using the hand washingsink in Resident #202’s room. The water temperature was noted to be excessively hot.The LPN then washed hands using the same sink and stated, “Geez, that is very hot. Iwasn’t ready for that!” When informed about the elevated water temperature, theassistant chief of engineering said, “That’s disappointing. I thought they fixed theproblem.”

F441

483.65 Infection Control. The facilitymust establish and maintain aninfection control program designed toprovide a safe, sanitary, andcomfortable environment and to helpprevent the development andtransmission of disease and infection.

Level of Harm - No actual harmwith potential for more thanminimal harm that is not immediatejeopardy

Based on observation, interview and record review, the CLC did not consistently maintain aninfection prevention and control program designed to help prevent the development andtransmission of disease and infection. Findings include: On 10/10/18 at 9:35 a.m., the CLC chief nurse provided a copy of the Department of VeteransAffairs Medical Center, Cincinnati, Ft. Thomas Division, Memorandum 111-1 dated January2015. The policy indicated, "Components of transmission-based precautions....ContactPrecautions: Used for patients known or suspected to be infected or colonized withepidemiologically significant organisms that can be transmitted by direct contact with thepatient or indirect contact with contaminated environmental surfaces or patient care items.Examples of illnesses transmitted by contact route include...MDRO [multi-drug resistantorganism] organisms such as MRSA [methicillin-resistant Staphylococcus aureus], VRE[vancomycin-resistant enterococci], and resistant gram negative organisms." The policy


Residents Affected - Fewfurther indicated, "Personal Protective Equipment...wear gloves when entering theroom....Wear a gown when entering the room if contact with patient or environment isanticipated. Remove gloves and gown before leaving patient's environment and perform handhygiene." Resident #201, [LOCATION]

Resident #201 was admitted to the CLC with diagnoses that included chronicobstructive pulmonary disease (COPD) according to the physician note dated09/24/18.The note indicated the resident had “recurrent contact dermatitis and stage 2sacral decub [decubitus pressure ulcer].”The resident’s most comprehensive MDS dated 01/19/18 was coded to indicateResident #201 scored 14 on the Brief Interview for Mental Status (BIMS) suggestingintact cognition; the resident required extensive to total assistance with activities ofdaily living (ADL) care including bed mobility, transfers, and toileting.During an initial interview with the RN charge nurse and nurse manager for[LOCATION] on 10/09/18 beginning at 10:00 a.m., the RN charge nurse reportedResident #201 “requires Contact Precaution because of an MDRO [multi-drug resistantorganism].”During an initial tour of the neighborhood on 10/09/18 with the RN charge nurse andnurse manager, a Contact Precautions sign was posted at the resident’s doorway. TheContact Precautions sign instructed staff to conduct “hand hygiene upon entry and exit,don gloves and gown if the staff had contact with the resident or the environment, anddedicate equipment to a single resident.”On 10/09/18 at approximately 1:05 p.m. the RN charge nurse, LPN and nursingassistant (NA) were observed providing wound and incontinence care for the resident.As the NA provided incontinence care for the resident, the NA wiped the resident’sgluteal fold using repeated movements toward (instead of away from) the coccyxwound.On 10/10/18 at approximately 8:20 a.m. the surveyor observed a nursing assistant(NA) assist Resident #201 to his room. The NA did not conduct hand hygiene uponentering the resident’s room and did not don a gown and gloves as indicated on theContact Precautions sign. Once inside the room, the NA positioned the resident closeto his bed. The NA asked the resident if he wanted the overbed table next to him andthe resident stated, “Yes.” The NA positioned the table in front of the resident. The NAthen washed hands using soap and water at the handwashing sink in the resident’sroom. Once the NA exited the resident’s room, the surveyor asked the NA about theuse of the personal protective equipment. The NA said, “I wasn’t planning to doanything and did not think of putting on the gown. I guess I should have gowned andgloved anyways.”


As determined through review of the resident’s clinical record, Resident #202 wasadmitted to the CLC with diagnoses that included cerebrovascular accident (CVA) andtype 2 diabetes mellitus.The resident’s most recent comprehensive MDS dated 08/24/18 was coded to indicateResident #202 scored 15 on the Brief Interview for Mental Status (BIMS) suggestingintact cognition; required extensive to total assistance with most ADL care includingbed mobility, transfers, dressing, locomotion and toilet use; had functional limitations inrange of motion of the upper extremities (one side only) and bilateral lower extremities,used an external catheter, and was always incontinent of bowel functioning.During an initial interview with the RN charge nurse and nurse manager for[LOCATION] on 10/09/18 beginning at 10:00 a.m., the RN charge nurse reportedResident #202 “requires Contact Precautions” for an MDRO.During the initial tour of the neighborhood on 10/09/18 with the RN charge nurse andnurse manager, a Contact Precautions sign was observed posted at the resident’sdoorway. The sign instructed staff to conduct “hand hygiene upon entry and exit, dongloves and gown if the staff had contact with the resident or the environment, anddedicate equipment to a single resident.”On 10/10/18 at 9:00 a.m., the same nursing assistant, who assisted Resident #201 (asabove), assisted Resident #202 to his room in the resident’s wheelchair. The NA didnot conduct hand hygiene and did not don a gown and gloves as indicated on theContact Precautions sign. Once inside the room, the NA positioned the resident closeto his bed, and pulled the cord of the call light and handed the call light to the resident.As the NA was about to exit the resident’s room, the NA was asked about handhygiene and the use of appropriate personal protective equipment considering staffwas to implement Contact Precaution for the resident. The NA said, “I’m sorry. I wasn’tpaying attention.”


department of veterans affairs community living center

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