state of washington josephine caring community€¦ · review of the clinical record on 03/23/18,...

STATE OF WASHINGTON

DEPARTMENT OF SOCIAL AND HEALTH SERVICESAging and Disability Services

Aging and Long-Term Support Administration

3906 172nd Street NE, Suite 100 Arlington, WA 98223

May 15, 2018

AdministratorJosephine Caring Community9901 272nd Place NorthwestStanwood, WA 98292

Dear Administrator:

The Department of Social and Health Services (DSHS), Residential Care Services, isaccepting your electronic Plans of Correction (ePOC) dated April 13, 2018 and April 27,2018 and the credible information submitted by you as evidence that violation(s) datedMarch 29, 2018 and April 6, 2018, (is/are) in fact, corrected effective May 11, 2018.

The Washington State Patrol, Office of the State Fire Marshal (OSFM) has verified thatthe LSC survey(s) deficiencies have been corrected effective April 20, 2018.

Based on this information, DSHS will notify the Centers for Medicare and MedicaidServices (CMS) Region X that your facility is in substantial compliance with participationrequirements effective May 11, 2018, and recommend that your facility's certification forMedicare and/or Medicaid participation continue.

If you have any questions please contact me at 360-651-6864.

Sincerely,

Michelle Reynolds Field Manager - Region 2 Residential Care Services

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X3) DATE SURVEY COMPLETED

PRINTED: 05/21/2018FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

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

505465 03/29/2018C

STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

9901 272ND PLACE NORTHWESTJOSEPHINE CARING COMMUNITY

STANWOOD, WA 98292

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

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG

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

REGULATORY OR LSC IDENTIFYING INFORMATION)

E 000 Initial Comments E 000

This report is the result of an Emergency Preparedness Survey conducted at Josephine Caring Community on 03/26/18.

The survey was conducted by: Nedra Vranish, RN, BSN, MSEdLeslie Watts, RNJonie Roman, RNSteven Kindle, RN, MSNLeslie Martin, BSHSYaya Ly, MA

The survey team is from:Department of Social & Health ServicesAging & Long-Term Support AdministrationResidential Care Services, District 2, Unit C3906 172nd Street NE, Suite 100Arlington, WA 98223

Telephone: (360) 651-6850Fax: (360) 651-6940

No deficiencies found.

F 000 INITIAL COMMENTS F 000

This report is the result of an unannounced Long Term Care and Abbreviated Survey conducted at Josephine Caring Community on 03/21/18, 03/22/18, 03/23/18, 03/26/18, 03/27/18, 03/28/18 and 03/29/18. A sample of 40 residents was selected from a census of 136. The sample

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

04/13/2018Electronically Signed

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete SQH511Event ID: Facility ID: WA02300 If continuation sheet Page 1 of 36

A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 000 Continued From page 1 F 000included 35 current residents and the records of 5 discharged residents.

The following complaint was investigated as part of this survey:#3502488

The survey was conducted by: Nedra Vranish, RN, BSN, MSEdSteven Kindle, RN, MSNLeslie Martin, BSHSYaya Ly, MAJoni Roman, RNLeslie Watts, RN

The survey team is from:Department of Social & Health ServicesAging & Long-Term Support AdministrationResidential Care Services, District 2, Unit C3906 172nd Street NE, Suite 100Arlington, WA 98223

Telephone: (360) 651-6850Fax: (360) 651-6940

F 578SS=E

Request/Refuse/Dscntnue Trmnt;Formlte Adv DirCFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

F 578 5/11/18


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 578 Continued From page 2 F 578

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to address required documentation and communication for advanced directives for 4 of 23 (186, 187, 29 and 120) sample residents reviewed for advance directives. The failed practice placed residents at risk of losing their right to have their preferences/decisions, regarding end-of-life care followed.

ARNP has signed for resident 186 and it is filed in the advanced records tab of the medical record. Completed and signed Advanced Directive was placed in the record for resident 187. Completed and signed Advanced Directive was placed in the record for resident 129. Completed and signed Advanced Directive was


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 578 Continued From page 3 F 578

Findings included...

PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST)Federal regulation defines a POLST as" ...a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration ..." An attending physician, ARNP (Advanced Registered Nurse Practitioner) or PA-C (Physician Assistant-Certified) must sign the form and assume full responsibility for its accuracy.

RESIDENT 186Resident 186 was admitted /18 for strengthening related to weakness from a

Review of the clinical record on 03/23/18, revealed a POLST form under the "Advance Directives" tab of the record. The form had been signed by the resident but not dated and not signed by the attending physician, ARNP or PA-C.

RESIDENT 187Resident 187 was admitted /18 for skilled care and had multiple diagnoses including recent

and

Review of the clinical record on 03/23/18, revealed documentation in the transfer/admission records which stated the resident had completed a POLST and it was included with the paperwork. However, none was found in the clinical record.

placed in the record for resident 120. Completed and signed Advanced Directive was placed in the record for residents 186 and 29. An audit of all residents Advanced Directive was completed and Advanced Directive were filed in the advanced directive tabs of the resident’s charts. An audit of all new admissions will be completed between 24- 48 hours to ensure the Advanced Directive is completed and in the Medical record. All residents will have a review of their Advanced Directive quarterly. All residents advance directives will be reviewed by the SW designee when completing the Comprehensive RAI and with resident during Care Conference to ensure Advance Directives are in place and reflect resident wishes. The facilities will in-service direct care staff on where to find the advanced directives. A Heart Symbol will be in each doorway to signify that a resident wished to have CPR. The staff development coordinator or designee will inservice the health care team and include the information in General Orientation.HIM to complete a RAI audit that includes Advance Directives to ensure doorway stickers match, orders, and Advance Directives.The Facility will add this to the QAPI agenda. The QAPI Committee will review for efficiency and monitor until the Committee determines process is effective.This will be completed 5/11/18.


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 578 Continued From page 5 F 578document was not there, Staff D stated, "oh, it should be here."

On 03/26/18 at 2:32 PM Staff E, LPN, could not find the advanced directive in the chart. Staff E, stated she would call medical records to see if they had them.

RESIDENT 120The resident admitted to the facility on 18 .

In a review on 03/22/18, the resident's POLST form was only signed by the resident (on 02/19/18), even though the form stated it was mandatory to have a signature from a Physician/ARNP/PA-C.

In an interview on 03/27/18 at 1:01 PM, the Director of Nursing Services did not provide any information why the POLST form was not signed by a Physician/ARNP/PA-C.

The facility staff failed to have ready/timely access to the portable medical order form that records the resident's treatment wishes so that emergency personnel knew what treatments the resident wanted in the event of a medical emergency.

Reference: (WAC) 388-97-0280(2), (3)(a-d)F 610SS=D

Investigate/Prevent/Correct Alleged ViolationCFR(s): 483.12(c)(2)-(4)

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged

F 610 5/11/18


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 610 Continued From page 6 F 610violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to thoroughly investigate possible abuse and/or neglect for 1 of 14 investigations reviewed, involving resident 57. This failure prevented the facility from identifying the extent and nature of the occurrence and placed the residents at risk for possible continued abuse and a decreased quality of life.


Resident 57 was admitted to the facility on /11, with diagnosis to include The

resident had short-term memory loss and was forgetful.

On 03/23/18 at 11:12 AM, the resident was observed in his room, sitting in his wheelchair. The resident had purple bruising underneath

When asked about the bruising, the resident was unable to state what happened.

Review of the facility investigation dated 03/21/18, documented the resident had been in

The facility reinvestigated the events that may have occurred during the movie activity that resident 57 attended was completed. All residents that attended the movie were interviewed. The staff member that lead the activity was interviewed. This was completed as soon as it was brought to the facilities attention that further investigation was needed. This investigation lead to the same conclusion that there was no abuse or Neglect. An audit of all investigations that have been done since 2/22/18 will be completed to ensure thorough investigation is thoroughly completed. A review of all incidents will be completed weekly by the Administrator, DNS, ADNS, and QA Nurse in a team approach to ensure a complete and thorough investigation is done.The Facility will add this to the QAPI agenda. The QAPI Committee will review for efficiency and monitor until the


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 645 Continued From page 8 F 645§483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with:(i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission,(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and(B) If the individual requires such level of services, whether the individual requires specialized services; or(ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission-(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and(B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability.

§483.20(k)(2) Exceptions. For purposes of this section-(i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital.(ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 645 Continued From page 10 F 6451 PASRR was completed on the date of admission.

A new Level 1 PASRR dated 02/05/18, was completed by the facility to make corrections. The facility marked the resident as Exempted Hospital Discharge related to the resident being likely to require fewer than 30 days of nursing facility services. A Level II PASRR was not found in the resident's record as of /18 (55 days after admission).

On 03/29/18 at 11:05 AM, Staff I, Social Services Director, stated Resident 82 had not been referred for a Level II PASRR. Staff I acknowledged the resident had a 30 day hospital discharge exemption and should have been referred for a Level II evaluation.

At 12:34 PM, Staff I faxed a request for a Level II and indicated the resident was a long term care resident at the facility.

Reference: (WAC) 387-97-1975

to include a PASARR calendar to ensure level 30 day exception is not exceeded.The Facility will add this to the QAPI agenda. The QAPI Committee will review for efficiency and monitor until the Committee determines process is effective.This will be completed by 5/11/18.Administrator will ensure completion.

F 656SS=D

Develop/Implement Comprehensive Care PlanCFR(s): 483.21(b)(1)

§483.21(b) Comprehensive Care Plans§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -

F 656 5/11/18


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 656 Continued From page 11 F 656(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.(iv)In consultation with the resident and the resident's representative(s)-(A) The resident's goals for admission and desired outcomes.(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to develop and/or implement comprehensive care planning for 2 of 27 residents (284 & 31) reviewed for care planning. Failure to ensure end-of-life care planning for a hospice resident and to ensure care planned interventions were implemented for another resident placed the residents at risk for

The facility had a care conference with resident 284’s family. It was determined that they did not wish for the resident to be on hospice care. The resident will have cares provided based on his wishes for further treatment. All other residents on Hospice services had their care plans updated with Hospice plan incorporated.


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 656 Continued From page 12 F 656unmet care needs.


RESIDENT 284Review of the Hospice Services policy, dated 03/06/18, revealed "There will be an initial Hospice Plan of Care completed in conjunction with the facility. A copy will be provided to the facility within 24 hours of 1.) Its completion, or 2.) The residents admission" to the facility.

Resident 284 admitted to the facility on /18, and was started on hospice on 03/17/18.

On 03/26/18, a review of the resident's care plan and baseline care plan, print/copy date of 03/26/18, revealed there was no end-of-life/hospice care planning.

In an interview at 11:33 AM, Staff F, Registered Nurse (RN)/Resident Care Manager (RCM), stated she thought the resident was already on hospice when he admitted to the facility, so there wasn't any hospice care planning done. She stated she would update the care plan immediately and contact the hospice nurse to see about care planning that hospice may have done.

RESIDENT 31Review of the facility policy "Intake & Output (I & O)," undated, revealed the Licensed Nurse (LN) was responsible for recording residents intake and output every shift when a resident was on a I & O monitor and the Certified Nursing Assistant was responsible for completing the amount of a resident's intake and output at the end of each shift and then gave the total to the LN.

Facility placed Resident 31 on intake and output monitor has been added to resident 31’s Treatment Administration Record. Facility reviewed all residents on Hospice care to ensure the plan of care reflected the hospice care plan which is integral with the facility care plan. Facility to audit all residents with fluid recommendations to ensure intake and output documentation is recorded on the Medication Administration Record. Facility to audit all residents with TED and ensure order is on Treatment Administration Record.Facility will ensure Hospice care plan is received within 24 hours of resident beginning hospice services and incorporate the two care plans at that time. Facility will educate Social Workers & Licensed staff to place all residents on Intake and output monitoring when fluid recommendations are received. Social services will complete a random audit of 4 Hospice cases a week for the first month and then monthly to provide data to the QAPI committee to ensure Hospice and facility care plans are integrated. Facility will revise batch order for the

to be included on MAR to alert nurse of Ted hose order.The facility will train all licensed nurse on how to enter I&O’s. Standing orders to ensure supplemental documentation is in place including I&O’s.Health information will complete I&O order and MAR audit during monthly RAI schedule reviews to ensure compliance.


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 656 Continued From page 14 F 656resident's room to see if there were any she found 1 in the back of the nightstand drawer.

Review of the resident's orders revealed an order, dated 10/06/17, that she needed to drink a minimum of 2000 cc (cubic centimeters)/24 hours. There was no documentation in the TARs that this order was implemented. Staff F reviewed the order entry in the electronic health record and stated it was entered incorrectly (in the computer system), so it never was implemented.

Review of the care plan, print date 03/26/18, revealed a focus area for a potential fluid deficit related to the use and poor fluid intake. A related intervention stated to "Monitor and document intake and output as per facility policy."

Review of the Point of Care documentation with a 30-day look back from 03/29/18, revealed it was set up to document fluid intake, but there had not been any information documented for the last 30 days.

In an interview on 03/29/18 at 10:01 AM, Staff F was not able to provide any information why the fluid intake was not documented.

Reference: (WAC) 388-97-1020 (1),(2)(a)(b)(3)F 697SS=D

Pain ManagementCFR(s): 483.25(k)

§483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services,

F 697 5/11/18


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 697 Continued From page 16 F 697area was sore at other times as well. Short term goals included reduced pain during treatment and overall. Recommendations included a plan to medicate 30 minutes prior to dressing changes.2. A note dated 02/23/18, stated goals were to minimize pain and decrease size. The note indicated pain was present during replacement of the dressing. 3. A note dated 03/13/18, stated the resident had some pain during the dressing change. 4. A note on 03/20/18 ,showed the goals were decreased pain, wound healing, and no infection.

Review of Medication Administration records for February and March 2018 showed no entry to pre-medicate for

On 03/27/18 at approximately 2:00 PM, Staff J, Licensed Practical Nurse (LPN), stated she would be doing wound care on Resident 123 at noon the following day.

On 03/28/18 at 11:56 AM, Staff J informed Resident 123 she was going to do her wound care. The surveyor asked the resident if the dressing changes were painful and she responded they were. The resident denied being offered prior to her dressing change on this date, and was upset about it. Staff J then asked the resident if she wanted something for pain. The resident laughed and said "Forget it! Just do what you have to do and get it over with." The resident cried out and pulled away during the wound care and placement of thenew treatment. When Staff J left the room after completion of the wound care, the resident stated the dressing change was very painful and she was clearly upset. She stated she wanted something for pain ahead of time so it would help


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 697 Continued From page 17 F 697during the wound care.

At 1:00 PM, Staff J stated her usual practice was to offer ahead of doing dressing changes; she said she just forgot. She stated there was not an order on the resident's medication administration record to pre-medicate the resident prior to wound care. She said the resident had not received any medication for pain that day (other than her routine patch).

On 03/28/18 at 1:14 PM, the Director of Nursing Services (DNS) was informed of Resident 123's pain with wound care and dressing changes, and that she had not been pre-medicated for pain. Additionally, when the skin team and weekly wound rounds notes regarding pain and medicating the resident 30 minutes prior to dressing changes was brought to her attention, The DNS stated they had recently made changes in the wound care process and some things had fallen through the cracks. She stated rounds were now made by 2 nurses and one wrote down everything and assured follow-through of recommendations. She said the resident should have been offered prior to wound care.

Reference: (WAC) 387-97-1060(1)F 756SS=D

Drug Regimen Review, Report Irregular, Act OnCFR(s): 483.45(c)(1)(2)(4)(5)

§483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review

F 756 5/11/18


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 756 Continued From page 18 F 756of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to maintain documentation of the monthly pharmacist's Medication Regimen Review (MRR) for 1 of 6 residents (64) reviewed. Failure to ensure the resident's MMR was reviewed monthly placed the resident at risk for unidentified

The facility obtained a note from the pharmacist Clarifying that resident 64 was assessed and no further recommendations were made at the time of review. The facility reviewed the Census to


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 756 Continued From page 19 F 756medication-related irregularities.


RESIDENT 64In a review of Resident 64's clinical record on 03/28/18, there was no monthly MRR report available to review for January 2018.

Review of a pharmacy report with MRR activity between 01/01/18 - 01/30/18, revealed the resident's name was not listed.

In an interview on 03/28/18 at 11:50 AM, Staff A, Licensed Practical Nurse/Assistant Director of Nursing Services, was unable to provide any information why there was no MRR documentation for January 2018 available for review.

Reference: (WAC) 388-97-1300 (1)( c)(iii)

ensure all residents were assessed by the pharmacist. Any missing residents were brought to the pharmacist and a review was completed.The facility will review the pharmacy list against the census report each month to ensure each resident was assessed.The Facility will add this to the QAPI agenda. The QAPI Committee will review for efficiency and monitor until the Committee determines process is effective.This will be completed by 5/11/18Administrator will ensure completion.

F 757SS=D

Drug Regimen is Free from Unnecessary DrugsCFR(s): 483.45(d)(1)-(6)

§483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

F 757 5/11/18


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 757 Continued From page 22 F 757bowel movement.

In an interview on 03/28/18 at 11:29 AM, Staff A was unable to provide any information why the bowel program was not implemented as ordered for Resident 284.

Reference: (WAC) 388-97-1060 (3)(k)(i)F 758SS=D

Free from Unnec Psychotropic Meds/PRN UseCFR(s): 483.45(c)(3)(e)(1)-(5)

§483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug thataffects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:(i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive

F 758 5/11/18


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 758 Continued From page 30 F 758to provide any information how the behaviors being monitored correlated to any of the 3

medications being administered to the resident.

Reference: (WAC) 388-97-1060 (3)(k)(i), (4)F 880SS=D

Infection Prevention & ControlCFR(s): 483.80(a)(1)(2)(4)(e)(f)

§483.80 Infection ControlThe facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:(i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other

F 880 5/11/18


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 880 Continued From page 31 F 880persons in the facility;(ii) When and to whom possible incidents of communicable disease or infections should be reported;(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;(iv)When and how isolation should be used for a resident; including but not limited to:(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to perform proper hand hygiene and glove changes for 1 of 3

Staff G was re-trained that gloves should be changed, and hand hygiene performed when moving from a potentially


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 880 Continued From page 33 F 880parts of the resident and multiple items in the environment. She stated she was going to assure the resident's room was sanitized.

At 1:14 PM, the Director of Nursing Services was informed of the lack of glove changes and hand hygiene during resident care. She acknowledged Staff G had not followed appropriate infection control practice.

At 2:18 PM, Staff G stated the moment she completed resident care, she knew she had forgotten to change her gloves and wash her hands.

Reference: (WAC)388-97-1320(1)(c)F 883SS=D

Influenza and Pneumococcal ImmunizationsCFR(s): 483.80(d)(1)(2)

§483.80(d) Influenza and pneumococcal immunizations§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;(iii) The resident or the resident's representative has the opportunity to refuse immunization; and(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:(A) That the resident or resident's representative

F 883 5/11/18


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 883 Continued From page 34 F 883was provided education regarding the benefits and potential side effects of influenza immunization; and(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

§483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure 1 of 6 residents (101), and/or their designated representative, reviewed for vaccinations, received information on the current

The facility revised the consent form and provided the designated representative for resident 101 a review of the vaccination and information on the current


A. BUILDING ______________________






B. WING _____________________________


505465 03/29/2018C



STANWOOD, WA 98292



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 883 Continued From page 35 F 883recommendations from the Center for Disease and Control and Prevention (CDC) related to

vaccinations, and failed to ensure residents were offered the recommended vaccinations. This failure placed residents at risk for contracting with its associated complications of infection.


Resident 101 was admitted /18 and according to the admission Minimum Data Set assessment, the resident had severe

A family member was a designated decision maker.

Review of the and Vaccine Informed Consent Forms revealed neither form had identification information to indicate they were associated with Resident 101. The forms were signed by someone, signature not clearly legible. The consent indicated the resident had been vaccinated 09/01/17 and the consent indicated the resident had already been vaccinated 05/01/16, but there was no information in the clinical record as to which of the 2 recommended vaccines the resident had received, nor was there information the designated decision maker had been provided with the information.

On 03/27/18 the forms and lack of information were shared with the Director of Nursing Service/Infection Control Coordinator. No further information was provided.

Reference: (WAC) 387-97-1340(1),(2),(3)

recommendations from the CDC. The representative chose to have the Prevnar 13 administered to the resident. The facility revised the consent form to include an information on the current recommendations from the CDC regarding the pneumococcal vaccination and residents printed name. Facility will in-service licensed staff on completing the consent form with the CDC regarding the vaccination and residents printed name. The Infection Control Nurse will complete random audits monthly using Point Click Care Vaccination Audits to ensure policy and consent process is being consistently followed. I recommend monthly ongoing to ensure compliance and to provide data to the QAPI teamThe Facility will add this to the QAPI agenda. The QAPI Committee will review for efficiency and monitor until the Committee determines process is effective.This will be completed by 5/11/18DNS will ensure completion


state of washington josephine caring community€¦ · review of the clinical record on 03/23/18,...

Documents