Gadsden Health And Rehab Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the Centers for Medicare & (and) Medicaid Services, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a Significant Change Minimum Data Set (MDS) was completed when Resident Identifier (RI) #23 was discharged from hospice on 5/1/21.
This affected one of two residents sampled for Hospice.
Findings Include:
A review of the Centers for Medicare & (and) Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019, reveled . An SCSA (Significant Change in Status Assessment) is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD (Assessment Reference Date) must be within 14 days from one of the following; 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill.
RI # 23 was admitted to the facility on [DATE] and readmitted on [DATE].
A review of RI # 23's Physician Orders dated 5/1/21 documented: . Discharge from . Hospice services .
A review of RI # 23's medical record did not reveal a Significant Change MDS when RI # 23 was discharged from Hospice on 5/1/21.
On 7/15/21 at 9:21 AM, an interview was conducted with the MDS coordinator Employee Identifier (EI) #1. EI #1 was asked, was RI # 23 on Hospice. EI #1 replied, RI #23 was discharged from hospice. EI #1 was asked, when was RI #23 discharged from hospice. EI #1 replied, 5/1/21 or 5/2/21. EI #1 was asked, did you complete a significant change MDS. EI #1 replied, we are in the process of doing one now for July, the ARD was open now. EI #1 was asked, when RI #23 was discharged should he/she have had a significant change. EI #1 replied, yes. EI #1 was asked, why did RI #23 not have a significant change. EI #1 replied, she just missed it. EI #1 was asked, what was the reason you would do a significant change. EI #1 replied, in case there was a decline or improvement, or need more care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the Centers for Medicare & (and) Medicaid Services, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #36's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/02/2021, did not code RI #36 as receiving an Anticoagulant medication during this assessment period.
This deficient practice affected RI #36, one of 31 residents whose MDS assessments were reviewed.
Findings include:
A review of the Centers for Medicare & (and) Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019, revealed the following:
. Coding Instructions .
NO410E, Anticoagulant (e.g. (for example), warfarin, heparin, or low-molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period . Do not code antiplatelet medications such as . clopidogrel here .
RI #36 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis to include Atherosclerotic Heart Disease.
A review of RI #36's Quarterly MDS assessment, with an ARD of 05/03/2021, revealed RI #36 received an Anticoagulant during this 7-day look back assessment period.
A review of RI #36's April and May 2021 eMAR (electronic Medication Administration Record) revealed RI #36 received the following:
. PLAVIX 75 MG (milligrams) (Clopidogrel Bisulfate) Give 1 tablet by mouth one time a day related to ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS . According the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instruction 3.0 User's Manual Plavix (Clopidogrel) should not be coded as an anticoagulant medication.
On 07/15/2021 at 10:57 AM, the surveyor conducted an interview with Employee Identifier (EI) #1, the RN (Registered Nurse)/MDS Coordinator. The surveyor asked EI #1, when looking at RI #36's medical records, which anticoagulant medication was RI #36 receiving. EI #1 said RI #36 was on Plavix but it is an Antiplatelet. When asked what the RAI classified Plavix as, EI #1 said an Antiplatelet. The surveyor asked EI #1 why it would be important to code the MDS accurately. EI #1 said for accurate patient care and billing purposes. When asked was the Plavix coded accurately, EI #1 said No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of [NAME] & [NAME] Fundamentals of Nursing, the facility failed to ensure Resident Identifier (RI) #99's tube feeding bottle and water bag were labeled. This affected one of five residents sampled for tube feeding.
Findings Include:
A review of [NAME] & [NAME] Fundamentals of Nursing, Ninth Edition, copyright 2017, Chapter 45 Nutrition, page 1082, revealed: . SAFETY GUIDELINES FOR NURSING SKILLS . When performing the skills in this chapter, remember the following points to ensure safe, individualized patient care.
* Label enteral equipment with patient name and room number; formula name, rate, and date and time of initiation; and nurse initials .
RI #99 was readmitted to the facility on [DATE] with a diagnosis of Dysphagia, oropharyngeal phase.
RI #99's Order Summary dated Jul (July) 5,2021 revealed, .Enteral Feed Order every shift Glucerna 1.5 a@ (at) 40 mL/hr (milliliters per hour) over 23 hours . start date [DATE] . H2O flush at 23 ml/hr over 23 hours via peg tube per pump . start dated [DATE] .
On [DATE] at 10:56 a.m., the surveyor observed RI #99's tube feeding infusing. There was no date, time or initials on RI #99's tube feeding or water bag.
On [DATE] at 12:30 p.m. the surveyor observed RI #99's tube feeding infusing and noted there was no label with the date or time noted on RI #99's tube feeding or water bag.
On [DATE] at 4:00 p.m., the surveyor again observed there was no label with the date and time noted on RI #99's tube feeding and water bag.
On [DATE] at 4:04 p.m., an interview was conducted with Employee Identifier (EI) #2, Licensed Practical Nurse (LPN). EI #2 was asked what was wrong with the tube feeding and water bag hanging for RI #99. EI #2 replied, it did not have a label, date, or initials, on the tube feeding or water bag. EI #2 was asked should the tube feeding, and water bag be labeled prior to infusing. EI #2 replied, yes. EI #2 was asked, how could the unlabeled tube feeding, and water bag potentially harm the resident. EI #2 replied, RI #99 could receive expired tube feeding that could make him/her sick. EI #2 was asked what should have been done prior to infusing the tube feeding. EI #2 replied, both should have been labeled prior to infusing.
On [DATE] at 4:20 p.m., an interview was conducted with EI #3, a Registered Nurse/ Unit Manager. EI #3 was asked, what she observed when looking at RI #99's tube feeding. EI #3 replied, there was no label with the date and time on either bag. EI #3 was asked, when was the tube feeding and water bag hung. RI #3 replied they were hung this morning. EI #3 was asked what was the potential concern with not having the bags labeled on the tube feeding. EI #6 replied, the tube feeding could go bad if it has not been dated and timed. The tube feeding could run too long causing the resident to get sick.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and the nursing manual titled, Fundamentals of Nursing, the facility failed to ensure the physician orders were followed for Resident Identifier (RI) #75 for stool specimens to be collected times three for Clostridium Difficile. The deficient practice affected one of the 39 sampled residents whose physician's orders were reviewed.
Findings include:
A review of the nursing manual titled, Fundamentals of Nursing, Ninth Edition by [NAME] and [NAME], Chapter 23 page 311, revealed . Health Care Providers' Orders. Nurses follow health care providers' orders .
RI # 75 was admitted to the facility on [DATE] with the diagnosis of unspecified diarrhea.
The Surveyor reviewed the resident's medical record and discovered the physician's order written on 11/24/2019 for stool specimens to be collect three times for Clostridium Difficile (dated 11/24/2019) and Lomotil Tablet 2.5-0.025 mg (Diphenoxylate Atropine) Give two tablets by mouth every six hours as needed for diarrhea. The resident's Medication Administration Record (MAR) revealed RI # 75 received medication for loose stools. There were no lab reports for stool specimens or documentation of collected stools for C-Diff.
On 12/05/19 at 11:31 a.m., the Surveyor conducted an interview with Employee Identifier (EI) # 4 Licensed Practical Nurse. EI # 4 was asked, were the physician's order written on 11/24/19 followed to collect stool specimens for C- Diff on RI # 75. EI # 4 replied, she did not collect the specimens because RI # 75 wore adult diapers and when RI # 75 had a bowel movement the following day 11/25/19, it was just a smear. EI # 4 was asked, were any stool specimens collected since 11/24/19. EI # 4 replied, she had not collected any specimens and had not heard from the facility's 24 hour report of any specimens being collected. EI # 4 was asked, was medication administered to RI # 75 by her to stop loose stools. EI # 4 replied, she did give RI # 75 (one of the Lomotil); RI # 75 complained of having loose stool. EI # 4 was asked, what was the potential harm with the facility not following the physician's orders. EI # 4 replied, potentially delayed the resident's treatment and spread the C-Diff infection.
On 12/05/19 at 11:57 a.m., the Surveyor conducted an interview with EI # 3, Registered Nurse Infection Control. EI # 3 was asked, what date was the order for RI # 75 stool for C-Diff. EI # 3 replied, 11/24/19. EI # 3 was asked, what was potential harm with the facility not following the physician's order and obtaining stool specimens from RI # 75 for C-Diff. EI # 3 replied, possible delayed treatment for the resident and possibility to spread the C-Diff infection.
On 12/05/19 at 12:09 p.m., the Surveyor interviewed EI #1, Primary Physician. EI # 1 was asked, did he recall writing an order for RI # 75 for stools times three for C-Diff. EI # 1 replied, yes he did. EI # 1 was asked, why did he write the order for RI # 75. EI# 1 replied, to ensure RI # 75 did not have any infection because RI # 75 recently was discharged from the hospital and complaining of diarrhea. EI # 1 was asked, what was the potential harm with the facility not following his physician order. EI # 1 replied, not following his physician order was not wise of the facility. EI # 1 said, because they were unable to ensure they ruled out an infectious disease. EI # 1 continued to say C-Diff spreads quickly in a facility. EI # 1 also said, early diagnosis was key.
On 12/05/19 at 12:38 p.m., the Surveyor conducted an interview with EI # 2 Registered Nurse/ Unit Manager of the Rehabilitation Department. EI # 2 was asked, (while she was viewing the facility's records) what did the order read dated 11/24/19. EI # 2 replied, stool for C-Diff times three. EI# 2 was asked, who signed the order off acknowledging it was received. EI # 2 replied, she did. EI # 2 was asked, what was meant by the order. EI # 2 replied, it meant they were ordered to collect stool specimens from RI # 75 for C-Diff. EI # 2 was asked, was the stools collected for C-Diff from RI # 75. EI # 2 replied, no. EI # 2 was asked, why were the physician's orders not followed and the stool specimens collected on 11/24/2019. EI # 2 replied, there was not enough stool for a specimen. EI # 2 was asked, was the resident given (an as needed) medication to stop diarrhea/ stool on 11/24/2019. EI # 2 replied, yes ma'am. EI # 2 was asked, what time frame are stool specimens obtained once an order was received. EI # 2 replied, the facility liked to obtain specimens as soon as possible, within days. EI # 2 was asked, (while reviewing RI # 75 MAR documentation for the week of 12/1/19) what days did RI # 75 receive medication to stop loose stools. EI # 2 replied, 12/1 - 12/4/19. EI# 2 was asked, what shifts did RI # 75 receive an as needed medication to stop loose stools. EI # 2 replied, all shifts. EI # 2 was asked, what was the potential harm for RI # 75 that the facility did not follow the physician orders collecting the stool specimens. EI # 2 replied, if RI# 75 had C-Diff it could have spread to employees and other patients.

Based on observation, interviews and a review of the facility policy titled, Destruction of Unused Drugs, the facility failed to ensure one and one-half bottle of expired Bismuth (8 ounce) and an expired bottle of Simethicone 80 mg tablets were not left on medication carts beyond the expiration dates.
This deficient practice was observed on two of nine total medication carts.
Findings Include:
A review of the facility policy's titled Destruction of Unused Drugs, dated 11/27/2017, revealed the following:
. Policy Interpretation and Implementation .
3. Non-controlled medications will be audited and inspected for expiration dates on a monthly basis . if a medication is found to be expired the nurse will follow facility procedure on destruction of non-controlled medication.
On 11/1/2018 at 11:34 AM, the surveyor conducted a medication cart review on the 800 Hall. Employee Identifier (EI) #2, Licensed Practical Nurse (LPN), was also present. One and one-half bottle of Bismuth (8 ounce bottle) was observed with an expiration date of August 2018. The surveyor asked EI #2 who was responsible for checking the medication carts for expired medications. EI # 2 stated all nurses working the carts were responsible. EI #2 agreed the Bismuth was expired. The surveyor asked EI # 2 what was the potential harm for using expired medications. EI # 2 stated residents would probably not get their full dose since the medication is expired.
On 11/1/2018 at 11:41 AM, the surveyor conducted a medication cart review on the 700 Hall. EI # 3, LPN, was also present. A bottle of Simethicone 80mg/milligram was observed with an expiration date of September 2018. This medication bottle had an open date of 10/26 written on it. The surveyor asked who was responsible for checking medication carts for expired medications. EI # 3 stated the nurse working on the cart was responsible. EI #3 agreed the Simethicone was expired. The surveyor asked EI# 3, what was the potential harm of using expired medication. EI #3 said the medication may be ineffective.
On 11/1/2018 at 12:50 PM , the surveyor asked EI #4, RN/DON (Registered Nurse/Director of Nursing), who was responsible for checking medication carts for expired medications. EI #4 stated the pharmacy technicians come monthly and check the carts and the nurses working on the carts should also catch any expired medications.

Based on observation and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) did not drop a carton of milk onto the floor, then return it to the refrigerator.
This had the potential to affect all residents receiving supplements from the refrigerator at Station 2.
Findings Include:
On 10/31/18 at 2:59 PM Employee Identifier (EI) #5, a CNA, was observed to drop a container of milk on the floor, pick it up and then return it to the refrigerator at Station 2. The surveyor asked EI #5 what should be done if a container of milk is dropped on the floor. EI #5 said she should have disposed of it because placing the milk back into the refrigerator could cause contamination.