sibley mem hosp renaissance washington, dc 20016 · 5/3/2011 · 5255 loughboro road nw...

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 05/27/2011FORM APPROVED

OMB NO 0938-0391STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:

(X3) DATE SURVEYCOMPLETED

095030NAME OF PROVIDER OR SUPPLIER

SIBLEY MEM HOSP RENAISSANCE

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

05/03/2011B. WING _

STREET ADDRESS, CITY, STATE, ZIP CODE

5255 LOUGHBORO ROAD NW

WASHINGTON, DC 20016

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SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY

OR LSC IDENTIFYING INFORMATION)

(X5)COMPLETION

DATE

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PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)

F 000 INITIAL COMMENTS

A recertification Quality Indicator Survey wasconducted on April 28 through May 3, 2011. Thedeficiencies are based on observation, recordreview and resident and staff interview for 34sampled residents.

F 156 483.10(b)(5) - (10), 483.10(b)(1) NOTICE OFSS=D RIGHTS, RULES, SERVICES, CHARGES

The facility must inform the resident both orally andin writing in a language that the residentunderstands of his or her rights and all rules andregulations governing resident conduct andresponsibilities during the stay in the facility. Thefacility must also provide the resident with the notice(if any) of the State developed under §1919(e)(6) ofthe Act. Such notification must be made prior to orupon admission and during the resident's stay.Receipt of such information, and any amendmentsto it, must be acknowledged in writing.

The facility must inform each resident who isentitled to Medicaid benefits, in writing, at the timeof admission to the nursing facility or, when theresident becomes eligible for Medicaid of the itemsand services that are included in nursing facilityservices under the State plan and for which theresident may not be charged; those other items andservices that the facility offers and for which theresident may be charged, and the amount ofcharges for those services; and inform eachresident when changes are made to the items andservices specified in paragraphs (5)(i)(A) and (8) ofthis section.

The facility must inform each resident before, or atthe time of admission, and periodically during

F 156 F156 - 483.10(b)(5) - (10), 483.10(b)(1) NOTICEOF RIGHTS, RULES, SERVICES, CHARGESThe facility must prominently display in the facilityrequired information related to Medicare andMedicaid Services. During the most recent survey, aproblem was cited in this report. The following planof correction addresses it:1. No specific residents were identified in this report 04/29/2011

as being affected by this deficient practice. Thedeficient practice has been corrected with contactinformation for Medicare and Medicaid Servicesplaced in display case.

2. All residents who have the potential to be affected 04/29/2011by the same deficient practice will be identifiedupon admission. Compliance will be maintainedthrough direct observation by the Director ofNursing (DON) and the Administrator.

3. The following systemic changes will be put inplace to ensure the deficient practice will notrecur:• The DON/Administrator will monitor compliance

on an ongoing basis and keep informationcurrent.

• Staff will be educated on where to direct 04/29/2011residents/families as to where Medicare andMedicaid Services information is posted.

4. The quality assurance process will be utilized to 07106/2011maintain and sustain compliance. The findings willbe presented at the quarterly meeting of theRenaissance Quality Council.

F 000

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

lJJu;naJt ~ ~(X6) DATETITLE

adrnUn/5'~Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that othersafeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date ofsurvey 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 thesedocuments are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program particlpation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:7EY511 If continuation sheet of 29Facility ID: SIBLEY



OMS NO 0938-0391STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(Xl) PROVIDERlSUPPLIERlCLIAIDENTIFICATION NUMBER:

095030

NAME OF PROVIDER OR SUPPLIER


(><2)MULTIPLE CONSTRUCTION

A.BUILDING

B.WING _


05/03/2011

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(X5)COMPLETION

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F 156 Continued From page 1the resident's stay, of services available in thefacility and of charges for those services, includingany charges for services not covered underMedicare or by the facility's per diem rate.

The facility must furnish a written description oflegal rights which includes:A description of the manner of protecting personalfunds, under paragraph (c) of this section;

A description of the requirements and proceduresfor establishing eligibility for Medicaid, including theright to request an assessment under section1924(c) which determines the extent of a couple'snon-exempt resources at the time ofinstitutionalization and attributes to the communityspouse an equitable share of resources whichcannot be considered available for payment towardthe cost of the institutionalized spouse's medicalcare in his or her process of spending down toMedicaid eligibility levels.

A posting of names, addresses, and telephonenumbers of all pertinent State client advocacygroups such as the State survey and certificationagency, the State licensure office, the Stateombudsman program, the protection and advocacynetwork, and the Medicaid fraud control unit; and astatement that the resident may file a complaint withthe State survey and certification agencyconcerning resident abuse, neglect, andmisappropriation of resident property in the facility,and non-compliance with the advance directivesrequirements.

The facility must comply with the requirements




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F 156

FORM CMS-2567(02-99) Previous Versions Obsolete Even11D:7EY511 Facility ID: SIBLEY If continuation sheet of 29


OMS NO 0938-0391DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES



A. BUILDiNG

STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(Xl) PROVIDERISUPPLIERlCLIAIDENTIFICATION NUMBER:

B. W1NG _095030 0510312011

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


WASHINGTON, DC 20016SIBLEY MEM HOSP RENAISSANCE





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F 156 Continued From page 2specified in subpart I of part 489 of this chapterrelated to maintaining written policies andprocedures regarding advance directives. Theserequirements include provisions to inform andprovide written information to all adult residentsconcerning the right to accept or refuse medical orsurgical treatment and, at the individual's option,formulate an advance directive. This includes awritten description of the facility's policies toimplement advance directives and applicable Statelaw.

F 156

The facility must inform each resident of the name,specialty, and way of contacting the physicianresponsible for his or her care.

The facility must prominently display in the facilitywritten information, and provide to residents andapplicants for admission oral and written informationabout how to apply for and use Medicare andMedicaid benefits, and how to receive refunds forprevious payments covered by such benefits.

This REQUIREMENT is not met as evidenced by:

Based on observation, staff and residents'interviews during an environmental tour of thefacility, it was determined that facility staff failed toprominently display the required information relatedto Medicaid and Medicare service.

The findings include:

Facility staff failed to prominently display therequired information related to Medicaid and

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F 156 Continued From page 3Medicare services: for example, how to apply forbenefits.

F 280 483.20(d)(3), 483.1 0(k)(2) RIGHT TOSS=D PARTICIPATE PLANNING CARE-REVISE CP

An environmental tour of the facility was conductedon May 3, 2011 at approximately 10:00 AM withEmployee #2. He/she identified the facility's displayboard and acknowledged that the facility has onlyone display board for residents, family and thecommunity. The display board was located on thewall across from the day room between the stafflounge and the director of nursing's office.

It was determined that facility staff failed to displayinformation related to Medicaid and Medicareservices on the only display board in the facility.When queried about non-displayed informationrelated to Medicaid and Medicare services,Employee #2 acknowledged that the requiredinformation was not available on the display board.

Facility staff failed to prominently display therequired information related to Medicaid andMedicare services.

The resident has the right, unless adjudgedincompetent or otherwise found to be incapacitatedunder the laws of the State, to participate inplanning care and treatment or changes in care andtreatment.

A comprehensive care plan must be developedwithin 7 days after the completion of thecomprehensive assessment; prepared by aninterdisciplinary team that includes the attending

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F280 - 483.20(d)(3), 483.10(k)(2) RIGHT TOPARTICIPATE PLANNING CARE-REVISE CPComprehensive care plans are developed for SibleyMemorial Hospital Renaissance Skilled NursingFacility residents. During the most recent survey,one (1) of 34 sampled residents did not have asatisfactory care plan. The following plan ofcorrection addresses this important issue:Findings for Resident #3241. The resident was not affected by this deficient 05/13/2011

practice. Care Plan was adjusted and residentdischarged to home.

2. Other residents having the potential to be affected 06/16/2011by the same deficient practice will be identifiedupon admission by review of physician orders andcare plan implementation

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(X1) PROVIDERISUPPLIERlCLIAIDENTIFICATION NUMBER:

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B. WING _05/03/2011






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F 280 Continued From page 4physician, a registered nurse with responsibility forthe resident, and other appropriate staff indisciplines as determined by the resident's needs,and, to the extent practicable, the participation ofthe resident, the resident's family or the resident'slegal representative; and periodically reviewed andrevised by a team of qualified persons after eachassessment.


Based on record review and staff interview for one(1) of 34 sampled residents the facility staff failed toupdate the Nutritional Status care plan for Resident# 324.


The Nutritional status care plan dated April 19, 2011for Resident #324 included the followinginterventions: "serve 6 small meals daily ... "

A review of the tray ticket revealed that Resident #324 receives three (3) meals per day. Physicianorders for April 19, 2011 to May 3, 2011 (daterecord was reviewed) lacked evidence of an orderfor six (6) small meals per day.

There was no evidence that facility staff updated thecare plan interventions to reflect that Resident # 324was to receive three (3) meals per day [as opposedto 6 meals daily].

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F 280

3. The following systemic changes will be put inplace to ensure the deficient practice does notrecur:• The licensed staff will review all physician

orders to ensure all care plans have beenimplemented accordingly.

• The MDS Coordinators will re-educate thelicensed staff on importance of implementingand revising resident care plans accordingly.

• Resident charts will continue to be taken toeach care plan meeting and themultidisciplinary team will review, update, andrevise care plans along with physician orders.

4. The quality assurance process will be utilized tomaintain and sustain compliance. The findings willbe presented at the quarterly meeting of theRenaissance Quality Meeting

06/16/2011

05/4/2011

06/13/2011

05/5/2011

07/06/2011

Facility 10: SIBLEY If continuation sheet of 29




(X1) PROVIDERlSUPPLIERlCLIAIDENTIFICATION NUMBER:

095030


A. BUILDING


B. WING _05/03/2011




5255 LOUGHBORO ROAD NWWASHINGTON, DC 20016

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F 280 Continued From page 5

F 281SS=D

A face-to-face interview was conducted on May 3,2011 at approximately 2:00 PM with Employee #7.He/she acknowledged that the care plan was notupdated to reflect the number of meals the residentwas to receive. The record was reviewed on May 3,2011.

483.20(k)(3)(i) SERVICES PROVIDED MEETPROFESSIONAL STANDARDS

The services provided or arranged by the facilitymust meet professional standards of quality.


Based on a medication pass observation of one(1)of 34 sampled residents it was determined thatfacility staff failed to follow accepted standards ofclinical practice when administering medications viagastrostomy feeding tube (G-tube). Resident #300.The findings include:A medication observation was conducted on May 3,2011 at 10:15 AM with Employee #22.He/she failed to check for placement of the feedingtube prior to administering medication via theG-tube. He/she failed to flush the tubing with atleast 30 cc's of water prior to and after medicationadministration; failed to flush with 5 cc's of waterafter each medication administered, and failed toallow the medication to flow in by gravity by pushingthe medication down the G-tube with a plunger forResident #300.

According to the "Lippincott Manual of NursingPractice Seventh Edition", under "GeneralProcedures and Treatment Modalities for Enteral

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F281 - 483.20(k){3){i) SERVICES PROVIDEDMEET PROFESSIONAL STANDARDSSibley Memorial Hospital's Renaissance SkilledNursing Facility provides services that meetprofessional standards of quality. During the mostrecent survey, a problem was identified that hasbeen cited in this report. The following plan ofcorrection addresses the problem.Findings for Resident #3001. The resident was not affected by the deficient

practice. The nurse at the time was immediatelystopped and 1:1 inservice by senior chargenurse on how to properly check placement, flushtubing pre and post medication and administerby gravity. Other resident on unit with G-tubewas observed to be receiving the feeding andmedication administration per protocol.

2. Other residents with the potential to be affectedby the same deficient practice were identifiedand G-tube management protocols andprocedures were reviewed and found to becompliant.

3. The following systemic changes will be put inplace to ensure the deficient practice does notrecur:• The quality nurse and the charge nurse or

nurse educator will provide inservice educationto nursing staff with return demonstrations.

• G-tube protocol posted in nursing conferenceroom for review.

• Pocket guide for G-tube protocol given to eachnursing staff highlighting method for checkingplacement/residuals prior to medicationadministration and/or tube feedings andspecific H20 flush guideline/amounts.

• Nursing Educator will do pre/post test followed-up by return demonstrations of G-tubefeeding/medication process.

• Re-educate staff to utilize the Sibley intranet fordetailed information ie, Lippincott. Resourceand nursing protocol for tube-feedings.

(X5)COMPLETION

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05/3/2011

05/4/2011

06/16/2011

06/3/2011

06/16/2011

06/24&06/2512011

06/24&06/2512011






095030 05/03/2011NAME OF PROVIDER OR SUPPLIER



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F 323 483.25(h) FREE OF ACCIDENTSS=D HAZARDS/SUPERVISION/DEVICES

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Continued From page 6Feeding: Procedure Guidelines 20-1 step numberseven (7): Using a catheter tip syringe, inject 20cc-30 cc of air while listening with a stethoscopepositioned at the epigastric area (laterally).Rationale: Auscultation of a "whooshing" orbubbling sound assists in confirmation of propertube placement.; After administering the prescribedamount of formula, (medication) flush tubing with atleast 30 cc of water. Rationale: Prevents cloggingof feeding tube. In the "performance phase" steptwo (2): fill catheter tipped syringe with formula(medication) and allow to fluid to flow in by gravity;Rationale: The rate of flow is regulated by raising orlowering the syringe."

A face-to-face interview was conducted withEmployees #2 and #21 on May 3, 2011 at 2:00 PM.After review of the above, both acknowledged thefindings. Employee #2 initiated measures tore-educate Employee #22 regarding G-tubemanagement.

Facility staff failed to follow accepted standards ofclinical practice when administering medication viaa G-tube. The observation was made on May 3,2011.

The facility must ensure that the residentenvironment remains as free of accident hazards asis possible; and each resident receives adequatesupervision and assistance devices to preventaccidents.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:7EY5l1 .

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The quality assurance process will be utilizedto maintain and sustain compliance. Thefindings will be presented at the quarterlymeeting of the Renaissance Quality Meeting

(X5)COMPLETION

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07/06/2011




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F 281 4.

F 323 F 323. - 483.25(h) FREE OF ACCIDENTHAZARDS/SUPERVISION/DEVICESThe facility must ensure that the residentenvironment remains as free of accident hazards asis possible and that each resident receives adequatesupervision and assistance devices to preventaccidents. Based on observation, record review, andstaff resident interview for two (2) of six (6) sampledrooms inspected for hot water temperatures withinacceptable parameters, it was determined thatfacility staff failed to ensure hot water was notgreater than 110 degrees Fahrenheit in rooms 316and 318. The following plan of correction addressesthe deficiencies:





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Based on observation, record review, staff andresident interview for two (2) of six (6) sampledrooms inspected for hot water temperatures withinacceptable parameters, it was determined thatfacility staff failed to ensure hot water was notgreater than 100 degrees Fahrenheit in rooms 316and 318.


Facility staff failed to ensure that hot watertemperatures were within acceptable parameters inresidents' rooms 316 and 318.

During environmental tour of the facility on May 3,2011, Employee #24, using the facility'sthermometer, assessed the hot water temperaturesin residents' rooms 306,315,316, and 318.The hot water temperature in the room 316 atapproximately 12:05 AM was 114 degrees F. at thesink and the shower.The hot water temperature in the room 318 atapproximately 11:55 AM, at the sink was 114degrees F. (Fahrenheit) and 115 degrees F. at theshower.

A face-to-face interview was conducted with theresident in room 316 on May 3, 2011 atapproximately 4:10 PM. He/she stated that he /shecan adjust the water temperature to meet his/herneed. He/she denied any concern with the

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Findings for Residents in Room 316 and Room3181. No specific residents were identified in this report

as being affected by this deficient practice. Thewater temperature was adjusted in the boilerroom, retested in the above stated rooms, andfound to be within the acceptable parameters.

2. Water temperatures were monitored insurrounding rooms and again at the sourcelocated in the boiler room and found to be withinthe acceptable parameters

3. Water temperatures are maintained between 95-110 degrees Fahrenheit for the entire building,thus assuring that the entire unit of patient rooms'water temperatures fall within the desired range.The following systemic changes have been put inplace to ensure the deficient practice does notoccur:

• The boiler room is staffed 24-7. Readings aretaken during each of the three shifts. Domestichot water temperatures are being logged duringeach shift; specified degree ranges from 95-110 degrees are now noted on the log sheet.

• Chief Engineer was instructed to performtraining to his staff to follow procedure asoutlined above for taking temperatures andadjusting them as needed.

• When temperatures are logged by the engineeron duty and the value does not fall within theparameters, immediate action will be taken toadjust the temperature into the proper range.

• Engineers will note their actions on the daily logsheet.

4. For quality assurance, the Chief Engineer'sMonthly Report reviews log sheets and notesproblems and actions taken. The findings will bepresented at the quarterly meeting of theRenaissance Quality Committee

(X5)COMPLETION

DATE

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7EY511

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Facility ID: SIBLEY

05/03/2011

05/312011

05/3/2011ONGOING

05/3/2011ONGOING

ONGOING

ONGOING

\ 0706/2011

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095030


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(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORYOR LSC IDENTIFYING INFORMATION)

F 323 Continued From page 8hot water temperature.

A face-to-face Interview was conducted with theresponsible party of the resident in room 318 onMay 3, 2011 at approximately 4:20 PM. He/shestated that the resident has dementia and that theresident complained that the water was too hotduring shower yesterday when he/she [theresponsible party] gave the resident shower.

A face-to-face interview was conducted withEmployee #1 on May 3, 2011 at approximately 5: 25PM. He/she stated that when facility staff receivedresidents' complaints that the water was too cold,facility staff increase the water temperature in anattempt to meet the resident's need.

A review of the daily engineer's log revealed thatthe hot water temperatures at the boiler level was126, 120, and 113 degrees on 05/03/2011 at11PM-7AM, 7AM-3PM, 3PM-11PM respectively.Employee #1 provided the engineer's log.

A follow-up face-to-face interview was conductedwith Employee #25 [ He/she was the employee incharge of supervising and monitoring the facility'swater temperature identified and brought in toanswer the surveyor's questions by Employee #1]on May 3, 2011 at approximately 6:00 PM. He/shequeried regarding the monitoring of the hot watertemperatures in the residents' room to ensure that itis within acceptable range. Employee #25 statedthat facility staff did not attempt to check individual




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FORM CMS·2567(02-99) Previous Versions Obsolete Event ID:7EY5ll Facility 10: SIBLEY If continuation sheet of 29



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(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORYOR LSC IDENTIFYING INFORMATION)

J= 323 Continued From page 9resident's room to ensure that the hot watertemperature was within acceptable parameter whenthe hot water temperature at the boiler level wasbetween 113 to 126 degrees on May 5, 2011. He Ishe further acknowledged that the facility do nothave a system in place for monitoring watertemperature in residents' room. Employees #1 and#25 both acknowledged that the facility relies on theresident's reports of water temperatures andrespond accordingly.

F 325 483.25(i) MAINTAIN NUTRITION STATUSSS=G UNLESS UNAVOIDABLE

A follow-up assessment of the hot watertemperature was conducted in the rooms 316 and318 on May 3, 2011 at approximately 6:28 PM and6:40 PM. The temperature in room 316 was 110degrees F. atthe sink and 104.6 degrees F. at theshower. The temperature in room 318 at the sinkwas 110.4 degrees F. and 104.6 degrees F. at theshower. The hot water temperatures were obtainedby Employee #26. He/she used the facility'sthermometer.

Facility staff failed to ensure that hot watertemperature in residents' rooms are withinacceptable parameters. The record was reviewedon May 3,2011.

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F325 - 4823.25(i) MAINTAIN NUTRITION STATUSUNLESS UNAVOIDABLEBased on a resident's comprehensive assessment,the facility must ensure that resident (i) maintainsacceptable parameters of nutritional status, such asbody weight and protein levels unless resident'scondition demonstrates this is not possible; and (ii)receives a therapeutic diet when there is anutritional problem.Findings for Resident #1691. There are no further corrective actions as the 01/21/2011

resident has been discharged to the home.2. Other residents having the potential to be affected

by the same deficient practice will be identified 05/412011through the initial nursing admission assessment,ohvsician orders, welcnts. nutrition assessments.

Based on a resident's comprehensive assessment,the facility must ensure that a resident -(1) Maintains acceptable parameters of nutritionalstatus, such as body weight and protein levels,unless the resident's clinical condition demonstratesthat this is not possible; and(2) Receives a therapeutic diet when there is a

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Facility staff failed to follow-up with Resident # 169with documented unplanned weight loss of4.73Kg/10 pounds from December 8,2010 toJanuary 12, 2011.



F 325 Continued From page 10nutritional problem.


Based on record review and staff interview for one(1) of 34 sampled residents, it was determined thatfacility staff failed to identify an unplanned 10lbsweight loss within 30 days (from December 8, 2010to January 12, 2011), a decrease in albumin andtotal protein laboratory values (from December 29,2010 to January 10, 2011), and nutritionalsupplement that was not administered inaccordance with physician's orders for Resident #169 (blanks on the medication record).


A review of Resident # 169's clinical recordrevealed the followings:

The resident was admitted to the facility onNovember 30, 2010 and was discharged onJanuary 21, 2011

A physician signed "History and Physical" reportdated November 30, 2010. The history and physicalreport indicated that the resident had an activemedical problem of recurrent aspiration peg tubeplacement. The resident's admission


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review. of nursing assistant flow sheets, laboratoryvalues for Albumin/Protein Levels. Otherresidents on the unit have been assessed forunplanned weight loss and reweighed, ifindicated. All residents on the at risk list werereviewed and no other resident was identified ashaving a significant weight loss.

3. The following systemic changes will be put inplace to ensure the deficient practice will notrecur:• All weights will continue to be documented into

the clinical record upon completion. Weightloss greater than 5 Ibs will be reweighed in 48hours.

• Residents will continue to be weighed everyWednesday per current weight policy unlessotherwise indicated.

• The Dietician will continue to post list ofresidents in need of weekly weights.

• The nursing staff will participate in an inserviceon how to ensure accuracy of weights and toreview "Monitoring Resident Weights" policy.

• The Quality Nurse and her designee willcontinue the monitoring tool in progress totrace admitting, weekly, and reassessmentweights.

• The Dietician will notify the Charge Nurse ofnutritional recommendations through asupplemental needs tool.

• The physician will notify the family of aresident's unplanned weight loss.

• Random EMAR audits will be done to monitorthat nutritional supplements aregiven/documented.

• Dietician will continue to document caloriecount results in the clinical record oncecompleted.

• The nurse will identify nutritional needs as partof the admission assessment and document inthe clinical record.

• The physician will be notified of any residentwith a significant weight loss of five (5) Ibssince previous weight loss or five percent (5%)weight loss in one month. Albumin levels alongwith other appropriate lab values will be drawnand all lab results report to the physician.

• Inservice on nutritional screening presented tostaff.

• Current weight policy under review for revisionto improve current process.

Facility ID: SIBLEY

(X5)COMPLETION

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05/4/2011

05/4/2011

05/4/2011

06/7/2011

05/4/2011

05/4/2011

06/16/2011

06/16/2011

06/16/2011

05/412011

05/4/2011

OS/24/2011

06/16/2011






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Continued From page 11

diagnoses was SIP [Status post] Front ParietalSubdural Hematoma evacuation; C5-6 (L) facetfracture. The resident's other past medical historyincluded positive history of Hepatitis A, SIPAppendectomy, Osteoarthritis, and Hyperlipemia.

A review of the facility's Chart Review Trend Reportfor Resident #169 revealed the following weights:

Date Weight in Kilograms (kg) Weight in Pounds(lbs.)November 30,2010December 7, 2010December 8, 2010December 15, 2010December 22,2010December 30,2010January 5, 2011January 12, 2010

83.36 kg82.73 kg82.73 kg82.72 kg81.09 kg80.00 kg79.09 kg68.00 kg

1831bs.1821bs.1821bs.1821bs.1781bs.1761bs.1741bs.172lbs.

According to the documentation of weights on thefacility's Chart Review Trend Report,the resident had an unplanned 4.73Kg I 10 poundweight lost [6%: a severe weight loss] betweenDecember 8, 2010 and January 12, 2011 's asfollows:

0.55% from first weight to obtained on 11/30/2010to the weight on 12/15/10.3.83% from the first weight obtained on 11/30/2010to the weight obtained on 12/30/10.6.4% from the first weight obtained on 11/30/2010to weight obtained on 01/12/2011.

A review of the resident's clinical record failed toreveal any documentation that addressed the

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CROSS·REFERENCED TO THE APPROPRIATEDEFICIENCY)

4. The quality assurance process will be utilized tomaintain and sustain compliance. The findingswill be presented at the quarterly meeting of theRenaissance Quality Meeting

(X5)COMPLETION

DATE

07/06/2011






095030 05/03/2011

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F 325 Continued From page 12resident's unplanned weight loss of 10 pounds as asevere weight loss.

On January 10, 2010, the Dietician's nutritionassessment reviewed the resident's weight record.He/she noted: "stable without significant changes."He/she failed to address the resident's progressiveunplanned weight loss of 8 pounds when he/shenoted weights for December 7,2010 as 182 poundsand January 5, 2011 as 174 pounds. In his/herintervention, he/she noted "Continue on current dietorder."

The dietician's nutrition assessment of January 17,2011 failed to identify the resident's unplanned 10pounds weight loss as a severe weight loss. Theresident's documented unplanned weight loss onJanuary 12, 2011 was not reviewed by the dieticianuntil January 17, 2011. The resident lost 10 poundsbetween December 8,2010 and January 12, 2011:a weight loss of 6%.

On January 10 and 17, 2011, the dietician's nutritionlnterventlonnoted "Continue on current diet order:Jevity 1.6 cans per day with 80ml water flush beforeand after each bolus, 1 scoop protein powder TID(Three times daily) ... Weigh weekly ...Encourageand monitor po intake. Recommend initiating 3 daycalorie count to determine po intake. "The resident's clinical record lacked documentedevidence that facility staff followed-up with thedietician's nutrition intervention to obtain 3-daycalorie count to determine po intake. On January20, 2011 at 1447 (4:47PM), the dietician' 5 nutritionconsult noted "Attempted to calculate three daycalorie count results, only bolus


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F 325 Continued From page 13feeding recorded. Scheduled for dischargetomorrow, Friday (1/21 per chart.

In addition the facility's weight policy a resident witha weight loss greater than 5 pounds should bere-weighed within 48 hours. The resident's clinicalrecord lacked documented evidence that theresident was re-weighed after a documented weightloss of 4.73Kg/1 0 pounds between December 8,2010 and January 12, 2011.

The dietitian's interventions after the nutritionconsult/assessment of January 10, 2011 includedweekly weights. There was no evidence in theresident's clinical record that the resident wasweighed on January 19, 2011.

A further review of the resident's clinical recordrevealed the following laboratory results:

Albumin Total Protein3.0 5PreAlbumin 20.32.9 5.6

DateDecember 29,2010December 31, 2010January 10, 2011

Albumin Reference Range [RG]. 3.5-5.0) GMIDLPreAlbumin Reference Range 21.0 - 43.0 Unit:mg/dLTotal Protein Reference Range 5.9 - 8.1 gm/dl

A further review of the resident's clinical recordincluding the Medication Administration Record[MAR] revealed the followings:A review of the resident's MAR lackeddocumented evidence that facility staff consistentlyadministered the protein scoop BID (twice daily) asper the dietician's nutritional intervention asevidenced by facility staff's



FORM CMS-2567(02-99) Previous Versions Obsolete Event 10: 7EY511 Facility ID: SIBLEY If continuation sheet of 29


OMB NO 0938-0391DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES


STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


WASHINGTON, DC 20016SIBLEY MEM HOSP RENAISSANCE





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F 325 Continued From page 14initials across the entry for "1 scoop protein powdervia peg tube bid" on the MAR.

As evidenced by the absence of facility's staffinitials against the entry for " 1 scoop proteinpowder via peg tube bid", a review of the resident'sMAR lacked documented evidence that the " 1scoop protein powder in 4 ounces of water BID"was administered as per the physician's order ofDecember 30,2010 at 1650 (4:50 PM) on thefollowing dates:

F 325

January 1, 2011 at 2000.January 6, 2011 at 2200.January 10, 2011 at 2200

Furthermore, as evidenced by the absence offacility's staff initials against the entry for "Jevity1.5cal 1 can Q4hrs ... " the resident's MAR lackeddocumented evidence that the tube feeding wasadministered as ordered on:

January 7, 2011 at "0400"January 9, 2011 at .•0000 and 0400 .•January 10, 2011 at "2200"

A face-to-face interview was conducted withEmployee # 3 on May 3, 2011 at approximately12:55 PM. After a review of the resident's clinicalrecord including the dietician's notes and the MAR,he/she acknowledged the aforementioned findings.

The dietician's nutrition consult of January 17, 2011stated Labs: no recent labs since 1/10/2011. Theresident's clinical record lacked documentedevidence that facility staff addressed the resident'sprogressive decrease of

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laboratory values for albumin, pre-albumin and totalprotein between December 29,2010 and January10,2011.

A follow-up face-to-face interview was conductedwith Employee #27 at approximately 10:00AM onMay 3, 2011. He/she stated, "I was not aware of theresident's weight loss until January 17, 2011, and Ido not have a record that a re-weigh was assessed.When I returned to follow-up with the resident, I wastold he/she was discharged.

A face-to-face interview was conducted withEmployee #3 on May 3, 2011 at approximately 1:00PM. When queried about the resident's weight lossof 10 pounds between December 8,2010 andJanuary 12, 2011, after a review of the resident'sclinical record, he/she stated that the only reliableweight record for the facility is what is documented,in the computer. Employee #3 stated that per thefacility's policy, when a resident presented with aweight loss of 5 pounds or more within a month thatthe resident must be re-weighed within 48 hours.Employee further added that there's was nodocumented evidence that a re-weigh assessmentwas done after the resident presented with a weightloss of 8 pounds between December 7, 2010 andJanuary 5, 2011 and a weight loss 10 poundsbetween December 8, 2010 and January 12, 2011.When queried regarding the dietician's three daycalorie count intervention to determine PO intake,after a review of the resident's clinical record,Employee #3 replied, "It is not in the record. It wasnot done."A follow-up telephone interview was conducted onMay 5, 2011 at approximately 11 :00 AM, withEmployees # 2 and #5. They both stated that the


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F 328 483.25(k) TREATMENT/CARE FOR SPECIALSS=D NEEDS

F 325 Continued From page 16built-in scale in the resident's bed offered an addedsecurity of obtaining an accurate and consistentweight while he/she is in bed. Both Employees #2and #5 acknowledged that the resident's clinicalrecord lacked a documented evidence that theresident was re-weighed when the residentpresented with a weight loss of 8 pounds betweenDecember 7, 2010 and January 5, 2011 and aweight loss 10 pounds (6%) between December 8,2010 and January 12, 2011. Employee # 5 addedthat the "tech/CNA" weighs the resident and aregistered nurse confirms the weight for accuracy.Employee # 5 further added, both the CNA and thenurse are privileged to view the trend of the weightand should have noted the weight loss and performa re-weigh per the facility's policy for are-weighwithin 48 hours for a weight loss of 5 pound orgreater in a month. When queried regarding thedietician's three day calorie count intervention todetermine po intake, after a review of the resident'sclinical record, Employees #2 and 5 stated "It wasnot done."The facility staff failed to follow-up on the resident'ssevere unplanned weight loss. The resldent'sweight was not obtained after the weight obtainedon January 12, 2011 that indicated a weight loss ofapproximately 10 pounds or 4.73Kg (6%) betweenDecember 8, 2010 and January 12, 2011. Therewas no documented evidence that the responsibleparty was informed of the resident's unplannedweight loss. The record was reviewed May 3, 2011.

The facility must ensure that residents receive


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F328 - 483.25(k) TREATMENT/CARE FORSPECIAL NEEDSSibley Memorial Hospital's Renaissance SkilledNursing Facility provides services that meetprofessional standards of quality. During the mostrecent survey, a problem was identified that hasbeen cited in this report. The following plan ofcorrection addresses the problem.

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F 328 Continued From page 17proper treatment and care for the following specialservices:Injections;Parenteral and enteral fluids;Colostomy, ureterostomy, or ileostomy care;Tracheostomy care;Tracheal suctioning;Respiratory care;Foot care; andProstheses.


Based on a medication pass observation of one(1)of 34 sampled residents it was determined thatfacility staff failed to follow accepted standards ofclinical practice when administering medications viagastrostomy feeding tube (G-tube). Resident #300.

A medication observation was conducted on May 3,2011 at 10:15 AM with Employee #22.He/she failed to check for placement of the feedingtube prior to administering medication via theG-tube. He/she failed to flush the tubing with atleast 30 cc's of water prior to and after medicationadministration; failed to flush with 5 cc's of waterafter each medication administered, and failed toallow the medication to flow in by gravity by pushingthe medication down the G-tube with a plunger forResident #300.

According to the "Lippincott Manual of NursingPractice Seventh Edition", under "GeneralProcedures and Treatment Modalities for Enteral


F 328

Findings for Resident #3001. There are no further corrections needed as this

resident has been discharged home. Otherresident on unit with G-tube was observed to bereceiving the feeding and medicationadministration per protocol.

2. Other residents with the potential to be affectedby the same deficient practice will be identifiedupon initial nursing admission assessment andphysicians orders.

3. The following systemic changes will be put inplace to ensure the deficient practice does notrecur:• The quality nurse and the charge nurse or

nurse educator will provide inservice educationto nursing staff with return demonstrations:

• G-tube protocol posted in nursing conferenceroom for review

• Pocket guide for G-tube protocol given to eachnursing staff highlighting method for checkingplacement/residuals prior to medicationadministration and/or tube feedings andspecific H20 flush guideline/amounts.

• Nursing Educator will do pre/post test followed-up by return demonstrations of G-tubefeeding/medication process.

• Re-educate staff to utilize the Sibley intranet fordetailed information ie, Lippincott. Resourceand nursing protocol for tube-feedings.

4. The quality assurance process will be utilized tomaintain and sustain compliance. The findings willbe presented at the quarterly meeting of theRenaissance Quality Meeting.

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F 328 Continued From page 18Feeding: Procedure Guidelines 20-1 step numberseven (7): Using a catheter tip syringe, inject 20cc-30 cc of air while listening with a stethoscopepositioned at the epigastric area (laterally).Rationale: Auscultation of a "whooshing" orbubbling sound assists in confirmation of propertube placement.; After administering the prescribedamount of formula, (medication) flush tubing with atleast 30 cc of water. Rationale: Prevents cloggingof feeding tube. In the "performance phase" steptwo (2): fill catheter tipped syringe with formula(medication) and allow to fluid to flow in by gravity;Rationale: The rate of flow is regulated by raising orlowering the syringe."

F 329 483.25(1) DRUG REGIMEN IS FREE FROMSS=D UNNECESSARY DRUGS

A face-to-face interview was conducted withEmployees #2 and #21 on May 3, 2011 at 2:00 PM.After review of the above, both acknowledged thefindings. Employee #2 initiated measures tore-educate Employee #22 regarding G-tubemanagement.

Facility staff failed to follow accepted standards ofclinical practice when administering medication viaa G-tube. The observation was made on May 3,2011.

F329 - 483.25(1) DRUG REGIMEN IS FREE FROMF 329 UNNECESSARY DRUGS

The Renaissance Skilled Nursing Facility providesservices that meet professional standards of quality.During the most recent survey a problem wasidentified that has been cited in this report. Thefollowing plan of correction addresses that problemFindings for Resident #3281. The resident identified in this report was not 05/3/2011

affected by the deficient practice. There are nofurther corrective actions as this resident hasbeen discharged.

2. Other residents having the potential to be affected 05/4/2011by the same deficient practice will be identified byriirp.ct nh!,:p.rv:ltinn :Inri rp.vip.w nf nhv!':ir.i:ln nrrip.f!':

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Each resident's drug regimen must be free fromunnecessary drugs. An unnecessary drug is anydrug when used in excessive dose (includingduplicate therapy); or for excessive duration; orwithout adequate monitonnq; or without adequateindications for its use; or in the presence of adverseconsequences which indicate the dose should bereduced or discontinued; or any



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Resident #328 was admitted with a diagnosis of[status post] left hip open reduction and internalfixation [ORIF]. Physician's admission ordersdated April 24, 2011 directed the administration ofKlonopin 0.25 mg by mouth every 12 hours asneeded [prn] for anxiety.



F 329 Continued From page 19combinations of the reasons above.

Based on a comprehensive assessment of aresident, the facility must ensure that residents whohave not used antipsychotic drugs are not giventhese drugs unless antipsychotic drug therapy isnecessary to treat a specific condition as diagnosedand documented in the clinical record; and residentswho use antipsychotic drugs receive gradual dosereductions, and behavioral interventions, unlessclinically contraindicated, in an effort to discontinuethese drugs.


Based on observations, record review andinterview for one (1) of 34 sampled residents, it wasdetermined that facility staff failed to administer "asneeded" medication consistent with the prescribedindication for use. Resident #328


A review of the electronic medication administrationrecord [MAR] for April 2011


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for residents on psychotropic medications. Theindication for use of psychotropic will be clarifiedwith the physician if necessary. Nurses wereinstructed during the survey to assess therecords/EMARS to ensure the indications,behaviors clinical documentation are consistent.

3. The following systemic changes will be put inplace to ensure the deficient practice will notrecur:• The charge nurse will monitor physician orders

to ensure there is a specific condition forresidents on psychotropic medications.

• The nursing staff on each shift will documenton the clinical record the behaviors exhibited bythe resident for the specific medication.

• The quality nurse will continue to utilize theaudit tool to monitor residents on psychotropicand for presence of behaviors in the clinicalrecord.

• The pharmacist will monitor the EMARS toensure the medication/dosage is appropriatefor resident.

• The DON and pharmacist will develop policy formonitoring behaviors for residents receivingpsychotropic medications.

• Re-educate nursing staff that when theyidentify that the resident is on a psychotropicmedication that they must indicate the behaviorin the drop down box in the clinical record(QCPR).

4. The quality assurance process will be utilized tomaintain and sustain compliance. The findings willbe presented at the quarterly meeting of theRenaissance Quality Meeting

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05/4/2011

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F 329 Continued From page 20revealed licensed staff administered Klonopin 0.25mg at 2304 [military time] on April 24th; 2132 onApril 26th; 2114 on April 27th; 2214 on April 28th;2151 on April 29th and 2108 on April 30th.

F 371 483.35(i) FOOD PROCURE,SS=E STORE/PREPARE/SERVE - SANITARY

A review of the nursing shift assessmentsassociated with the administration pm Klonopin asdelineated above, lacked evidence that the residentexhibited symptoms of anxiety. The documentationrevealed the nurse assessed the resident with "appropriate behavior, mood/affect, speech andthought processes. Nonnal intellectual capacity andsleep patterns. No signs or symptoms of anxiety ordepression noted." The shift assessments weredocumented per shift and the clinical record lackedevidence of consistent behavioral monitoring thatcorrelated with the "as needed" administration ofthe psychoactive drug Klonopin.

Licensed staff failed to administer Klonopinconsistent with the prescribed indication for use.The findings were acknowledged during aface-to-face interview with Employee #2 on May 3,2011 at 9:00 AM. S/he stated that nurses documentthe psycho-social status of the resident in the shiftassessment of the electronic record system. Therewas no facility policy associated with the monitoringof behaviors for residents receiving psychotropicmedication. The record was reviewed May 2, 2011.

The facility must -

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04/28/2011

05/31/2011

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:7EY511

PROVIDER'S PLAN OF CORRECTION.(EACH CORRECTIVE ACTION SHOULD BE


F371 - 483.35{i) FOOD PROCURE -STORE/PREPARE/SERVE - SANITARYSibley Memorial Hospital's Renaissance SNF stores,prepares, distributes, and serves food under sanitaryconditions. During the survey, deficiencies wereidentified that have been cited in this report. ThefollOwing plan of correction addresses the deficiencies:1. The following corrective actions were taken to

address the deficient practices:• Finding 1: The shelf surface in the catering area

was dusted• Finding 2: The shelf surfaces in the salad room

area were cleaned of soil and stains.• Finding 3: The exterior surfaces of the sugar, flour,

and rice bins were cleaned of soil and stains.• Finding 4: All food items stored in the reach-in

refrigerators were labeled and dated.• Finding 5: All food items stored in the reach-in

refrigerators were labeled and dated.• Finding 6: All food items stored in the reach-in

refrigerators with expired use-by dates werediscarded.

• Finding 7: All food items stored in the reach-inrefrigerators were labeled and dated.

• Rnding 8: The interior surfaces of all hotel pansstored on shelves were completely dry before use.

2. All other areas affected by the deficient practiceswere corrected as follows:• Finding 1: All shelf surfaces in the catering area

will be cleaned on a continuous basis to ensurethere is no dust.

• Finding 2: All shelf surfaces in the salad room areawill be cleaned on a continuous basis to ensurethere are no soiled areas.

• Finding 3: All three (3) bin surfaces will be cleanedon a continuous basis to ensure there are nosoiled areas.

• Finding 4: Any food items that are opened and/ordo not have a date or label on the package will belabeled and dated by the person putting the fooditem into the cooler.




OMB NO. 0938-0391STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

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Continued From page 21(1) Procure food from sources approved orconsidered satisfactory by Federal, State or localauthorities; and(2) Store, prepare, distribute and serve food undersanitary conditions


Based on observations that were made during atour of the main kitchen on April 28, 2011, it wasdetermined that the facility failed to prepare andserve food under sanitary conditions as evidencedby: two (2) of three (3) shelves were soiled, three(3) of three (3) food storage bins observed soiled;19 of 27 hotels pans stored wet and ready for use;one (1) one (1) of package of pepperoni openedand not dated, one (1) of one (1) roast beef wasobserved with a use by date of 3/30/11, one (1) ofone (1) pack of bologna observed open and nodate, and two (2) of two (2) packages of capicolaopened and not dated or labeled.


STREET ADDRESS. CITY, STATE, ZIP CODE





• Finding 5: Aily food items that are opened and/ordo not have a date or label on the package will belabeled and dated by the person putting the fooditem into the cooler.

o Finding 6: Any food items that are opened andhave an expired date will be discardedimmediately.

o Finding 7: Any food items that are opened and/ordo not have a date or label on the package will belabled and dated by the person putting the foodinto the cooler.

• Finding 8: All hotel pans will be cleaned in thethree (3) bay sinks and completely drie beforestoring.

3. The following system measures will be put in place toensure the deficient practices do not recur and stafftrained on the following:• Finding 1:

- Sanitation staff will be in-serviced on propercleaning of dusty shelves.

- Shelves in the catering area will be added tothe sanitation checklist and will be monitored bydaily rounding

- All shelves in the catering area will be put on arotation for the special cleaning schedule toensure shelves are clear of dust

• Finding 2:- Shelves in the salad room will be put on rotation

for special cleaning schedule to ensurecleanliness.

- Shelves in the salad room will be added to thesanitation checklist and will be monitored bydaily rounding.

• Finding 3:- Bins will be put on rotation for special cleaning

schedule to ensure exterior surfaces arecleaned.

- Bins will be added to the sanitation checklistand will be monitored by daily rounding.

• Finding 4:- All cooks and prep personnel will be re-trained

on the proper way to label and date food itemsstored in the reach-in coolers.

- Management will complete monthly audits anddaily spot checks to ensure all personnel arefollowing policy with label and dating food items.

•• Finding 5:- All cooks and prep personnel will be re-trained



05/31/2011

During a tour or the kitchen on April 28, 2011 - 8:30AM to 9:45 AM the following was observed:

1. One (1) of two (2) shelves observed in thecatering area was soiled with dust;2. One (1) of one (1) shelf (top shelf) in salad roomwas observed soiled;3. One (1) of one (1) flour bin, one (1) of one (1)

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The facility must establish and maintain an InfectionControl Program designed to provide a safe,sanitary and comfortable environment and to helpprevent the development and transmission ofdisease and infection.




sugar bin and one (1) of one (1) rice bin located inthe bake room were observed with soiled exteriors.4. One (1) one (1) of package of pepperoni openedand not dated;5. One (1) of one (1) roast beef was observed with ause by date of 31301116. One (1) of one (1) pack of bologna observedopen and no date7. Two (2) of two (2) packages of capicola openedand not dated or labeled8. Seven (7) of seven (7) 118 hotel pans; One (1) ofone (1) full hotel pan; Eight (8) of eight half hotelpans and three (3) of 11 shot gun pans wereobserved wet and ready for use.

The observations were made in the presence ofEmployee # 15 who acknowledged these findings.

F 441 483.65 INFECTION CONTROL, PREVENTSS=D SPREAD, LINENS

(a) Infection Control ProgramThe facility must establish an Infection ControlProgram under which it -(1) Investigates, controls, and prevents infections inthe facility;(2) Decides what procedures, such as isolation,should be applied to an individual resident; and(3) Maintains a record of incidents and correctiveactions related to infections.


F 441 F 441 - 483.65 INFECTION CONTROL, PREVENTSPREAD, LINENSThe Renaissance Skilled Nursing Facility providesinfection control measures to maintain anenvironment that prevents the development andtransmission of disease and infection. During themost recent survey a number of problems wereidentified that have been cited in this report. Thefollowing plan of correction addresses them:Findings for Residents in Room 316 and Room 3181. The residents/staff were not adversely affected

by this deficient practice. Observations were 05/4/2011made and other residents on the unit receivedLovenox in the appropriate, safe manner. Thenurse at the time was stopped and a 1:1inservice by the senior charge nurse on how toactivate, retract syringes with needles anddispose correctly.

2. Other residents with Lovenox subcutaneous 05/4/2011injections will be identified upon admission andas ordered by the physician.

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- All cooks and prep personnel will receiveServSafe food handling training and be requiredto take and pass the exam.



on the proper way to label and date food itemsstored in the reach-in coolers


• Finding 8:- Staff will be re-inserviced and trained on the

proper way to dry pans.- Extra drying racks will be ordered.- Nutrition Services will complete a monthly audit

on our pans to ensure that proper procedure isbeing followed.

4. The quality assurance process will be utilized tomonitor and sustain compliance. The findings willbe presented at the quarterly meeting of theRenaissance Quality Committee.

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• The charge nurse and quality nurse will utilize 06/16/2011the electronic medication record along withdirect observation/retum demonstration tomonitor safety, competency, and compliance.

• Quality auditing tool for observance of 06/16/2011Lovenox injections will be developed in 10audits per month and done to monitorcompliance.

4. The quality assurance process will be utilized to 07/06/2011monitor and sustain compliance. The findingswill be presented at the quarterly meeting of theRenaissance Quality Committee.




(b) Preventing Spread of Infection(1) When the Infection Control Program determinesthat a resident needs isolation to prevent the spreadof infection, the facility must isolate the resident.(2) The facility must prohibit employees with acommunicable disease or infected skin lesions fromdirect contact with residents or their food, if directcontact will transmit the disease.(3) The facility must require staff to wash theirhands after each direct resident contact for whichhand washing is indicated by accepted professionalpractice.

(c) LinensPersonnel must handle, store, process andtransport linens so as to prevent the spread ofinfection.

Based on a medication pass observation of one (1)Employee, and observation and interview during thekitchen tour it was determined that facility staff failedto decrease the risk for the spread of infection byleaving a needle exposed after a Lovenox injectionwas administered on two (2) different occasions byone (1) Employee and failed to provide a safe,sanitary and comfortable environment as evidencedby one (1) of one (1) drain line from the icemachine in the main kitchen, catering area did nothave sufficient air gap. Employee #22


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A. A medication pass observation was conductedon May 3, 2011 with Employee #22 atapproximately 9:55 AM and 10:38 AM respectively.Employee #22 failed to decrease the risk for thespread of infection by not retracting the needle aftera Lovenox injection was administered on two (2)different occasions.

1. At 9:55 AM Employee #22 administered asubcutaneous injection of Lovenox to the resident inroom 319. After completing the injection theemployee placed the syringe with the needleexposed on the over bed table, covered the residentand walked to the sharps container in the resident's room with the needle exposed.

2. At 10:38 AM Employee #22 administered asubcutaneous injection of Lovenox to the resident inroom 316. After completing the injection theemployee placed the syringe with the needleexposed on the over bed table, covered the residentand walked to the sharps container in the resident's room with the needle exposed. On this occasiontwo (2) staff members entered the room, Employee#22 did not alert either of the staff members of theexposed needle.

A face-to-face interview was conducted withEmployee #2 on May 3, 2011 at approximately12:00 PM. After reviewing the above, he/sheacknowledged the findings.

The observation was made on May 3, 2011.

B. During a tour of the kitchen on April 28, 2011

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F441 - 483.65 INFECTION CONTROL, PREVENTSPREAD, LINENSItemBThe facility must establish and maintain an InfectionControl Program designed to provide a safe,sanitary and comfortable environment and to helpprevent the development and transmission ofdisease and infection. During a tour of the kitchenon April 28, 2011, from 8:30 to 9:45 AM, it wasdetermined that the facility failed to provide a safe,sanitary and comfortable environment as evidencedby one (1) of one (1) drain line from the ice machinein the main kitchen, catering area did not havesufficient air gap. The following plan of correctionaddresses the deficiencies:1. No specific residents were identified in the survey

report as being affected by the deficiency.2. Work order # 25887 was submitted to install

miSSing air gap on the ice machine andaccomplished by cutting pipe 1 W from the lowestpoint of the ice machine's drain to the flood levelof the floor drain that it drains into. Uponreinspection, it was determined that the air gapwas installed correctly.

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Continued From page 25from 8:30 AM to 9:45 AM, it was determined thatthe facility failed to provide a safe, sanitary andcomfortable environment as evidenced by one (1) ofone (1) drain line from the ice machine in the mainkitchen, catering area did not have sufficient airgap.


One (1) of one (1) drain line from the ice machine inthe main kitchen, catering area did not havesufficient air gap.

The observation was made in the presence ofEmployee #18 who acknowledged the finding.

The facility must maintain all essential mechanical,electrical, and patient care equipment in safeoperating condition.


Based on observations and interview during a tourof the Kitchen on May 3, 2011 at 10:00 am, it wasdetermined that the facility's dish machine failed tomeet the acceptable parameters to sanitize dishesand eating utensils.


A tour of the kitchen was conducted on May 3, 2011at 10:00 AM in the presence of Employees # 15 and#20. The dish machine failed to reach 180 degreeson May 3, 2011 at 10:00 am.

F 456 F456 - 483.70(c)(2) ESSENTIAL EQUIPMENT,SAFE OPERATING CONDITIONThe facility must maintain all essential mechanical,electrical, and patient care equipment in safeoperating condition. During the survey, a fewdeficiencies were identified that have been cited inthis report. The following plan of correctionaddresses the deficiencies:1. When the dish machine temperature did not meet 05/3/2011

the required temperature, it was closed down andwe went to paper service for all patients. We alsocalled both service techs, who work on the dishmachine, to come in immediately to fix themachine.

2. Paper products will be used for patient services 05/3/2011until the dish machine is at proper temperature.No patients were affected by this practice ..

3. Nutrition Services employees will be re-trained on 05/3/2011the proper shut down procedures when the dishmachine does not meet temperature. In addition,employees will be in-serviced on retaining propertemperatures at each meal as required by policy.

4. Nutrition Services will monitor the daily log sheets 06/30/2011to ensure procedures are being followed. Also,the steam station will be purchased and installedto ensure that the steam pressure is correct inproviding final rinse temperatures of 180 degreesor higher.

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3. The following systemic changes have been put inplace to ensure the deficient practice does not recur:o Plumbers reviewed 2000 Edition of the "Unified

Plumbing Code" Chapter 8 "Indirect Wastes"Section 801.1 Airgap or Airbreak Required whichstates: "All indirect waste piping shall dischargeinto the building drainage system through an airgap or air break as set forth in this code. Where adrainage air gap is required by this Code, theminimum vertical distance as measured from thelowest point of the indirect waste pipe of the fixtureoutlet to the flood level rim of the receptor shall benot less than one (1) inch (25.4 mm). All plumbinginstallations which require and air gap will adhereto this code requirement.

• All new construction, renovations and existingdrain piping will be monitored to make sure the 1"clearance is maintained.

4. The quality assurance process will be utilized tomaintain and sustain compliance. The findings willbe presented at the quarterly meeting of theRenaissance Quality Committee.

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F 469 483.70(h)(4) MAINTAINS EFFECTIVE PESTSS=E CONTROL PROGRAM

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Continued From page 26During the observation period on May 3, 2011between 10:00 AM - 11:30 AM, the final rinse cyclewas observed to reach temperatures of 159, 172,174 and 179 in four observations.

According to the dishwasher temperature log, rinsecycle temperatures for May 2011 were assessedduring the morning, afternoon and evening hours asfollows:

May 1, 2011 09:45 AM - 1810; 02:45 PM - 1500

;

7:40 PM -1810

May 2, 2011 10:00 AM - 1850; 12:25 PM - 1830

;

7:50 PM - 1600

Employees #15 and #20 acknowledged the findingsduring the time ofobservation on May 3, 2011.

The facility must maintain an effective pest controlprogram so that the facility is free of pests androdents.


Based on observations made during theenvironmental tour of the facility on April 28 thruMay 3, 2011, it was determined that the facilityfailed to maintain an effective pest control programas evidenced by flying insects seen on the nursingunit during the survey and in the pot/pan area of thekitchen.

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5. For quality assurance purposes, nutrition serviceswill monitor the daily log sheets to ensureprocedures are being followed. The findings willbe presented at the quarterly meeting of theRenaissance Quality Committee.

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F 469 - 483.70(h)(4) MAINTAINS EFFECTIVEPEST CONTROL PROGRAMThe facility must maintain an effective pest controlprogram so that the facility is free of pests androdents. During the most recent survey, flying pestswere observed in the kitchen's pot/pan room and thenursing stations on 3 North and 3 South. Thefollowing plan of correction addresses thedeficiencies:1. At the time of observation for each of the 04/28/2011

incidents, the service log was completed and aphone call was made to request follow-upservice from the pest control contract serviceprovider.

2. The pest control contract service provider 04/29/2011periodically inspects the area and takescorrective action as needed on both 3 North and3 South. The kitchen is on a scheduledmaintenance service routine with follow-up forany reported pest control issues noted in theservice log.

3. The following systemic changes will be made toensure that the deficient practice does not recur:

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F514 - 483.75(1)(1) RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLESibley Memorial Hospital's Renaissance SkilledNursing Facility provides services that meetprofessional standards of quality. During the mostrecent survey, a problem area was identified thathas been cited in this report. The following plan ofcorrection addresses the problem:Findings for Resident #3251. Appropriate use for indication was obtained.2. No other resident was receiving oral

chemotherapeutic agents.3. The following systemic changes will be put in

place to ensure the deficient practice does notincur:o Upon admission the nurse will verify that the

correct medication indication is transcribedaccording to the physician order.

• The pharmacist will review all orders and seekclarification from the physician for anymedication/indication combinations which donot appear to be accurate.

• The twenty-four (24) hour chart check will beutilized to verify and ensure medicationindications are correct.

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F 469 Continued From page 27The findings include:

A. On April 28, 2011 during a tour of the kitchenbetween 8:30 AM to 9:45 AM, flying pests wereobserved in the pot/ pan room.

This finding was observed and acknowledged byEmployee # 15 at the time of the observation.

B. On May 29, 2011 at 2:45 PM flying pests were inthe nursing station on 3 South.

On May 2, 2011 at 10:00 AM, flying pests wereobserved in the nursing station on 3 North.

F 514 483.75(1)(1) RESSS=D RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

The facility must maintain clinical records on eachresident in accordance with accepted professionalstandards and practices that are complete;accurately documented; readily accessible; andsystematically organized.

The clinical record must contain sufficientinformation to identify the resident; a record of theresident's assessments; the plan of care andservices provided; the results of any preadmissionscreening conducted by the State; and progressnotes.


Based on record review and staff interview, it wasdetermined that facility staff failed to accuratelytranscribe the indication for use of a

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F 469

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CROSS·REFERENCED TO THE APPROPRIATEDEFICIENCY)

o Routine rounds will be conducted to assessany service requirements for flying insect onboth 3 North and 3 South nursing stationsand the kitchen.

• Window screens will be checked visually toensure there are no gaps or openings thatwould allow for entry

• Visual inspection will be conducted to ensurecompliance.

o Reported incidents will be addressed at thetime, logged into the service log, and follow-up service requested from the pest controlcontract service provider.

4. The quality assurance process will be utilized tomaintain and sustain compliance. The findingswill be reported to the Renaissance QualityMeeting at its quarterly meetings.

FaCility 10: SIBLEY

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F 514 Continued From page 28prescribed medication. Resident #325The findings include: .Physician's admission orders dated April 22, 2011directed the administration of Mercaptopurine 50 mgby mouth daily for chemotherapy for a tumor.A review of the electronic medication administrationrecord [MAR] for the period of April 23 through May2,2011 revealed the order was transcribed as:Mercaptopurine 50 mg daily for ulcerative colitis.The physician's order was inaccurately transcribedon the MAR. The findings were reviewed andacknowledged during review of the electronic MARwith Employee #5 on May 2, 2011 at 3:00 PM.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:7EY511

F 514

• The charge nurse and quality nurse will dorandom audits of the electronic record toensure compliance of appropriate medicationindications have been transcribed perphysician order.

• Pharmacy and the nurses will be inservicedon the importance of ensuring medicationindications are present and correct asprescribed.

4. The quality assurance process will be utilized tomaintain and sustain compliance. The findingswill be reported to the Renaissance QualityMeeting at its quarterly meetings.

06/16/2011

06/16/2011

07/06/2011


sibley mem hosp renaissance washington, dc 20016 · 5/3/2011 · 5255 loughboro road nw...

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