DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0164 Keep each resident's personal and medical records private and confidential. Level of harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to maintain privacy of 1 resident in the 100 hallway (#93). Findings: On 1/22/17 at 11:05 AM, resident #93 was in bed and visible from the hallway. He only wore a tee shirt an adult brief and a sheet did not cover him. The call light was put on and certified nursing assistant (CNA) J answered it, confirmed the resident's privacy was not maintained, and covered him with a sheet. Residents Affected - Few F 0224 Level of harm - Immediate jeopardy Residents Affected - Few Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to keep residents free from neglect by failing to provide care and services for treatment of [REDACTED].#258). Resident #258 did not receive the necessary treatment and care to prevent a painful pressure ulcer and infected wound for 15 days. As a result of this neglect, the resident endured severe pain and required re-hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her right elbow. The resident was diagnosed with [REDACTED].[MEDICAL CONDITION] is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. (www.cdc.gov/sepsis). The failure to prevent neglect resulted in Immediate Jeopardy, starting on 11/29/16 with Substandard Quality of Care. The Immediate Jeopardy was ongoing as of 1/28/17. Findings: Cross Reference to F281, F309, F314 Resident #258 was a [AGE] year-old female who was admitted to the nursing home on 11/29/16 for surgical aftercare. She fell at home, sustained a right hip and right elbow fracture, and was hospitalized from [DATE] to 11/29/16. The hospital record revealed that the resident had an open reduction internal fixation (ORIF) surgical repairs to the right hip and right elbow resulting in 3 incisions with staples, right hip, right thigh, and right elbow. ORIF is a type of surgery in which the fractured bones are stabilized and are fixed in place by screws, plates, wires, or nails. (www.hopkinsmedicine.org) The admitting registered nurse (RN) N, on the 3-11 shift, noted the resident's [DIAGNOSES REDACTED]. The admitting nurses note dated 11/29/16 documented the resident had blister on the coccyx, the right upper extremity was in a soft cast and sling, and the right hip had 8 staples and 3 staples (in the right thigh). The resident had an abrasion to the right posterior thigh. The note did not contain any observation or description of the right elbow. The note indicated dressing care was done, but a review of the treatment order handwritten on the physicians order sheet and the treatment record revealed it was written for the left hip, not the right. Review of the physicians orders' and treatment records for November and December revealed inconsistent and inaccurate evidence of any treatment to the right hip, right thigh, and right elbow. Review of the physicians orders' and treatment record for November and December revealed the blister pressure wound on the coccyx did not receive any treatment and the right thigh abrasion did not receive any treatment in December. On 1/27/17 at 4 PM RN N, the resident's admitting nurse, stated that there was as soft cast on the arm and that she could not look at/observe the right arm surgical wound because she did not have a doctor's order to do so. The nurse stated that the resident did not have any admission orders [REDACTED]. When the nurse was asked what she does if residents do not have wound treatment orders at admission, she then said that the dressing should be removed to look at the wound/surgical sites regardless of whether or not they had treatment orders upon admission. She stated that she would ask the physician how the wound should be treated, but she did not recall if she called the physician for wound treatment orders for resident #258. She said that she did not remove the soft cast to the right elbow because it was a fresh post-operative wound and she thought it was not to be removed until the resident is seen for the follow up appointment. She could not explain why she removed the dressings to the post-operative wounds on the right hip, but not the right elbow. The Daily Skilled Nurse's Notes noted, 12/07/16, 7-3 pt. (patient) has been crying out in pain. On 12/08/16, 7-3 pt. yelling out in pain . pt cont. (continued) to moan with pain. 12/09/16, c/o (complaint of) pain. 12/10/16, Late entry - pt. crying out in pain, medicated . no relief . 12/11/16, 7-3 p.t crying out in pain . grabbing at right hip . medicated . pt. cont. to cry out . pt. again crying out in pain. 3-11 pt. seems unhappy. 12/12/16, 7-3 - late entry. Pt. has been crying out in pain, medicated .increased yelling out in pain. 12/13/16 at 2:30 AM, Pt. crying and holding elbow stating, it hurts. 4 AM pt. conts.(continues) To voice pain in right elbow. 7-3 - late entry. Pt crying out in pain . pt not showing any relief. 12/15/16, 7-3 pt. crying out in pain. Medicated .pt. cont. to cry out in pain. On 12/14/16 the resident went to a follow up appointment at the Orthopedic Surgeons office. The surgeon's notes indicated the staples to the right elbow were removed and the resident returned to the nursing home. The orthopedic surgeon noted, 'elbow surgical wound open/pressure sore, s/p (status/post) ORIF R (right) elbow, R hip. The surgeon gave the following orders: 1. Hyperbaric treatment R elbow 2. Wound VAC (vacuum assisted closure) R elbow wound 3. PT (physical therapy) with ROM (range of motion) only Rt elbow 4. No splint on R elbow 5. PT R hip - WBAT (weight bearing as tolerated) 6. Daily PT/OT (occupational therapy) There was no evidence that the orthopedic surgeon's orders pertaining to the right elbow were followed by the nursing home staff after the resident returned from the appointment with the orthopedic surgeon. Treatment instructions to change dressing to right elbow and clean with [MEDICATION NAME] were written and signed off as completed on 12/13/16 the day before the appointment with the surgeon, but the surgeon noted the dressing and splint the residents right elbow had not been changed at all during the time the resident was in the nursing home until he saw her on 12/14/16. There were still no physician's orders for treatment to the right hip and thigh incisions as of 12/14/16. Instructions to clean right hip staples with normal saline, place Xeroform and cover with border gauze was handwritten on the Medication Administration Record [REDACTED]. The medical record revealed a wound care physician note with the same instructions for treatment, but they were never written as treatment orders and they were intended for the right posterior thigh, not the right hip. Other handwritten instructions for treatment to the right elbow either did not have a corresponding physician's order or they were documented incorrectly. Handwritten instructions on the medication record read remove staples to right hip, place LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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 Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 1 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0224 (continued... from page 1) steri strips, but had no corresponding physician's order. They were initialed as completed, but the staples were not removed. On 12/15/16 the resident was transferred to the hospital. The nursing home transfer form noted that the resident was lethargic, altered mental status, labored breathing and the right elbow surgical site was open. Nurse's note dated 12/15/16 at 7:30 PM read, Received return call from MD (medical doctor) r/t (related to) labs. MD states sodium is very high. Described resident's current condition. New order to send resident out 911. Resident appears lethargic, labored breathing and AMS (altered mental status) (MD aware) completed transfer paperwork and called 911. Hospital assessment dated [DATE] at 21:55 (9:55 PM) noted that the resident appeared to be uncomfortable, unkempt and uncooperative. The resident smelled of urine and foul odor. The resident presented with a right elbow open wound with exposed metal hardware. The site was red and hot to touch. The resident still had staples to her right hip and thigh. On 12/16/16 Hospital staff met with the resident's family. Per the family, resident had some dementia but was pretty independent at home. The resident used a front wheeled walker for ambulation and could complete most activities of daily living without assistance. The resident was only in the nursing home for rehabilitation a for recent hip and right upper extremity injury. The resident's admitting [DIAGNOSES REDACTED]. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. (www.cdc.gov/sepsis) [MEDICAL CONDITION] is a diffuse, acute bacterial infection of the skin and subcutaneous tissue characterized most commonly by local heat, redness, pain, and swelling and occasionally by fever, malaise, chills, and headache. Abscess and tissue destruction usually follow if antibiotics are not taken. The infection is more likely to develop in the presence of damaged skin, poor circulation, or diabetes mellitus . (Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier.) MRSA is a bacteria that is resistant to many antibiotics. (www.cdc.gov/mrsa) Bacteremia is the presence of bacteria in blood. (McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.) On 12/19/16 the right elbow wound measurements were 3.0 centimeters (cm) x 2.0 cm x 1.4 cm. Hospital staff noted full thickness wound, with exposed hardware entire wound bed. No granulation noted. Moderate serous yellow drainage noted on dressing upon removal. No odor. Peri-wound with [MEDICAL CONDITION] and [DIAGNOSES REDACTED] and the resident/patient was moaning with palpation. Further review of the hospital record revealed that a wound vac to the right elbow was used to treat the wound. The wound vac was the same treatment ordered by the surgeon on 12/14/16, but it was not initiated as ordered in the nursing home. On 12/20/16 the hospital consult note read, Orthopedic consultation report noted from (orthopedic surgeon): History of Present Illness: The patient is known to (orthopedic surgeon) from previous admission with s/p (status [REDACTED]. She was seen in our office on Wednesday with X-rays. The patient had been in rehab at (nursing home). She was accompanied in the office by her family. The patient has severe dementia. When her dressing from the elbow was removed it was found that this had not been changed and the patient had been still wearing splint. She acquired a pressure wound to the R elbow. None of her staples had been removed. (orthopedic surgeon) saw the patient in the office. All staples were removed (to right elbow) and sterile dressing placed. Orders were written for (nursing home) for wound care and wound vac placement and PT/OT (physical therapy/occupational therapy). The patient presented yesterday to the ER (emergency room ) and was subsequently admitted and (orthopedic surgeon) was reconsulted. Photos on chart to support findings, report called into DCF (Department of Children and Families) . DCF is the program responsible for investigating allegations of neglect. Hospital clinical notes dated 12/21/16 indicated that the resident was discharged to a hospice house for end of life services and pain management. On 1/25/17 at 3:25 PM the Unit Manager (UM) F stated that on 12/13/16 the resident #258 had drainage from the right elbow area. The UM said she called the attending physician and obtained orders to clean the right elbow wound with [MEDICATION NAME]. She said the doctor told her to remove the soft cast and she observed a stage III pressure wound. A stage III pressure ulcer is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. (State Operations Manual appendix PP guidance to Surveyors for Long Term Care Facilities). She indicated the staples were intact and that the pressure wound was not on a staple or the surgical suture lines. Her recollection of the events on 12/13/16 contradict the evidence from the surgeon who noted the dressing and splint had not been changed on 12/14/16. The hospital admission note indicated the resident had a right elbow open wound and exposed metal hardware. This type of wound is not a stage III, but it is classified as a stage IV pressure ulcer, Full thickness tissue loss with exposed bone, tendon or muscle. (State Operations Manual appendix PP guidance to Surveyors for Long Term Care Facilities). The UM F stated she called the Wound Care Physician (WCP) and informed the WCP of the stage III pressure wound. The UM pointed to the second telephone order dated 12/13/16 with time ordered written as 11:32 AM. She stated that the order was from the WCP. The WCP treatment order dated 12/13/16 was for the Xeroform to the staples and Maxsorb to the pressure sore on the right elbow. The order included to remove the soft cast and apply the new treatment. The UM F was aware that the resident had a follow up appointment with the Orthopedic Surgeon on 12/14/16. The UM F stated that the surgeon wanted a wound vac to the right elbow, but this was not followed. The medical record was further reviewed by UM F and she stated that the resident did not have admission orders [REDACTED]. When asked how she could complete the weekly skin checks without observing the right elbow and checking the surgical wound for signs/symptoms of infection without removing the soft cast, the UM replied, I don't know how you would monitor it if you don't look at it. On 1/25/17 at 4:45 PM the Director of Nursing (DON) discussed resident #258 and the facility's investigation of the issue. The DON stated the resident was discussed during the morning clinical meeting on 12/13/16. It was reported that the resident had some drainage from the right elbow and UM F called the physician for treatment orders. She said the resident was admitted on [DATE] and had an admission order for orthopedic follow up appointment in 1 week. This information was listed in the discharge instructions, but it was not written in the admission physicians order sheet on 11/29/16. She said there was an issue about getting authorization from the Orthopedic Surgeons office, for insurance purposes, before the resident could be seen for the follow up appointment. The DON stated that the facility staff had been working on getting the authorization since admission, but were unable to make the appointment as directed in the discharge instructions. The DON stated that she found admission orders [REDACTED]. She stated that these orders were from the orthopedic surgeon. Review of the admission orders [REDACTED]. The DON was not aware if these orders were present at the time of the resident's admission. One of the orders noted wound drainage - call provider. The DON stated that the facility did not have an order to remove the soft cast until 12/13/16. The DON could not explain why neither the nurses, nor the physician or nurse practitioners observed the resident's elbow or obtained a treatment order from the attending physician. She stated, I can't tell you why, I can only speak about what happened from 12/13/16 forward. I am not going to comment for other staff or what they should have done. I will only comment from 12/13/16. The DON did not discuss how the documentation on 12/13/16 contradicts the notes and observations from the orthopedic surgeon on 12/14/16 indicating the splint was not removed and the dressing was not changed from 11/29/16 until the resident saw the surgeon on 12/14/16. The DON did not investigate why the resident was not receiving wound care to the right elbow and the circumstances that caused a 15-day delay for assessment and wound care to the resident's surgical areas. She said that the facility could not get authorization from the orthopedics surgeon's office so that the resident could have a follow up appointment. She said that the facility was not to be blamed for the resident's lack of wound care to the right elbow and that the fault should be placed upon the orthopedic surgeon's office for delay in the follow up appointment. On 1/26/17 at 1:43 PM the WCP was interviewed at the nursing home. The WCP reviewed the telephone orders and her notes that were in the medical record. The WCP recalled observing the elbow wound on 12/15/16, after the resident had the follow up visit with the surgeon. She stated she was responsible for only treating the wound to the posterior thigh, not any of the surgical sites. The staff asked her to look at the elbow wound to determine if the resident needed a wound vac. The WCP told the facility staff that the resident did not need a wound vac and that the resident should go back to the orthopedic surgeon to have the wound surgically closed. A telephone order dated 12/13/16 timed at 11:32 AM, was discussed with the WCP. The order was for the Xeroform to the staples and Maxsorb to the pressure sore on the right elbow. The order included to remove of the soft cast and apply the new treatment. The WCP stated she never gave that order. She stressed that she would have never gave an order to remove the orthopedic surgeon's soft cast and provide treatment to a surgical site. The WCP stated she did not sign the telephone order dated 12/13/16 and that she always signs her orders. Observation of the telephone order revealed that it had not be signed by a physician. The WCP stated she would have told the staff to contact Level of harm - Immediate jeopardy Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 2 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0224 (continued... from page 2) the orthopedic surgeon for an order to remove the soft cast and provide treatment. On 1/27/17 at 4:40 PM the resident's attending physician was interviewed via phone. He said did not recall looking at the right elbow, but he said he looked at the right hip. He stated there were admission orders [REDACTED]. This contradicts the orders on the physicians order sheets for November and December in which there are not any orders for treatment to the right hip. The attending physician stated that orthopedic surgeons can be very picky on how wounds are to be treated. He said, we wanted to contact the surgeon about how to treat the right elbow wound, but I do not know if the nursing home staff were able to get through to him. The attending physician stated he did not give any orders for the right elbow. He stated that he was an internist not a wound care doctor. He said he thought that there was a report that the resident had drainage to the right elbow. He stated, I am not 100%, but I don't think they called me about it. I don't recall them telling me it was pressure wound. The attending physician stated that he might have ordered a treatment, but told the nursing home staff to contact the wound care doctor. A second interview was conducted with UM F on 1/27/16 at 6:10 PM. She recalled the events that she said took place on 12/13/16. She stated that the 11 PM-7 AM nurse observed the drainage from the right elbow. The UM stated that she arrived at the facility at 5:00 AM and looked the right elbow wound. She said that the attending doctor gave her an order to remove the soft cast and cleanse the right elbow area with [MEDICATION NAME]. After she cleansed with [MEDICATION NAME] she took measurements of the pressure sore. Several minutes into the interview the UM attempted to clarify her statements. She stated that the attending doctor was on the phone when she removed the soft cast and he told her to paint the entire wound with [MEDICATION NAME]. When asked if she informed the Attending Doctor of the pressure wound, the UM stated, He didn't know there was a pressure wound because I hadn't removed the dressing yet. The UM stated that on 12/13/16 she also spoke with the WCP and received orders for Xeroform to the staples and Maxsorb for the pressure sore to the right elbow. The UM stated that the WCP asked her to stage the pressure wound. The UM clarified how she documented the telephone orders for 12/13/16. She stated the first telephone for the 12/13/16 was from the Attending Doctor to paint the right elbow with [MEDICATION NAME]. The second telephone order dated 12/13/16 with the time ordered as 11:32 AM has orders from both the WCP and attending doctor in the same order. The UM sated the Xeroform and Maxsorb treatments to the right elbow were from the WCP, then below the treatment order on the same telephone order she documented the attending physician's order to remove the soft cast. When asked about conflicting order from the WCP and Orthopedic Surgeon, the UM stated that the Medical Director should have been called. Further review of the medical record together with the facility staff interviews it was determined that no one on resident #258's care team attempted to contact the Medical Director to obtain orders for treatment or clarify the conflicting physicians' orders. Review of the Nursing Home Federal Report initiated on 12/20/16 confirmed the facility did not consider the lack of care and treatment to the surgical wounds, pain, and pressure ulcer prevention as neglect. Their investigation found neglect did not occur as related to setting up an appointment. It did not address any concerns regarding the care and treatment of [REDACTED]. Level of harm - Immediate jeopardy Residents Affected - Few F 0241 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few F 0253 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567(02-99) Previous Versions Obsolete Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality. Based on observation and record review, the facility failed to maintain 1 of 36 sampled residents' dignity during dining (#95). Findings: On 1/26/17 at 12:16 PM, resident #95 was at a table in the East wing dining room with three tablemates, one who finished lunch. The other two tablemates were halfway finished with lunch. Resident #95 did not have any food in front of him, and watched his tablemates eat. Review of the facility's meal service schedule indicated that lunch on the East wing would start at 11:45 AM. At 12:20 PM, a meal cart arrived in the dining room with resident #95's lunch. At that time, certified nursing assistant (CNA) W said resident #95 usually eats in his room but the resident's room was being deep cleaned today. CNA W stated she did not know if staff had finished with the deep cleaning. At approximately 12:25 PM, resident #95's room was observed. Resident #95's roommate and family member were in the room. The family member stated the resident was in therapy this morning, and they just got back to the room. She stated they returned to the room about 30 minutes ago, and were waiting for lunch. The family member stated that room meal trays arrive anywhere from 12:15 PM to 12:45 PM. On 1/27/17 at 1:30 PM, CNA W explained that resident #95's room was being deep cleaned yesterday. She stated that the East wing unit manager told her to put resident #95 in the Starlight Program in the East wing dining room while his room was being cleaned. CNA W said she was aware resident #95's lunch tray was late yesterday. She was aware that the other residents at the table where resident #95 sat, had their meals. She was aware that it was a dignity issue because resident #95 did not have his meal and had to watch his tablemates eat. CNA W indicated they kept resident #95 out of the room due to the odors from the cleaning chemicals. CNA W was informed that resident #95's roommate ate lunch in the room. CNA W stated she should have checked the room to see if was ready because resident #95 usually eats in his room. Provide housekeeping and maintenance services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide effective housekeeping and maintenance services necessary to maintain 13 resident bathrooms (900, 806, 809, 702, 707, 402, 407, 502, 605, 200, 213, 308 & 310), 1 shower room (100 hallway), and 1 hallway (500-502) in good repair and clean condition. Findings: On 1/26/17, observations with the facility's maintenance director found the following environmental concerns, which were validated by the maintenance director: 1. At 3 PM, room 900's bathroom flooring had two large rust colored stains. The stains surrounded the base of commode and measured about one foot in circumference. The caulk seal at the base of the toilet was broken with several missing sections. The maintenance director validated that broken toilet seals could potentially allow water to go underneath the vinyl flooring causing the rust colored stains. 2. At 3:05 PM, room 806's bathroom flooring had multiple areas of rust colored stains. The stains surrounded the commode. The caulk seal at the base of the toilet was broken. 3. At 3:07 PM, room 809's bathroom flooring was peeled off in 5 areas, each about a quarter in size. 4. At 3:11 PM, room 702's bathroom flooring had yellow and rust colored stains that covered half of the flooring around the commode. The caulk seal at the base of the toilet was broken and missing in sections. 5. At 3:15 PM, room 707's bathroom flooring had yellow and rust colored stains surround the commode. There was no caulk or grout seal around the base of the toilet. There were gray-brown colored stains where an old seal may have been. The toilet rocked slightly from side to side when pushed against it. 6. At 3:20 PM, room 402's bathroom flooring had yellow stains by the toilet. There was no caulking seal around the base of the toilet. There were stains where an old seal may have been. 7. At 3:23 PM, room 407's bathroom flooring had rust colored stains surrounding the toilet where the flooring met the wall. 8. At 3:26 PM, room 502's bathroom flooring had rust colored stains around the commode area. There was no caulk seal around the base of the toilet. There were gray-brown colored stains where an old seal may have been. The toilet rocked slightly from side to side when pushed against it. 9. At 3:30 PM, a ceramic tile in the hallway between rooms 500 and 502 was cracked and broken. 10. At 3:40 PM, room 605's bathroom had multiple broken and cracked baseboard ceramic tiles. The flooring had spots of rust colored stains in front of the bathroom sink. 11. At 3:42 PM, room 200's bathroom flooring had diffuse rust colored stains around the base of the commode. 12. At 3:45 PM, room 213's bathroom did not have any caulk seal around the base of the toilet. Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 3 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0253 (continued... from page 3) 13. At 3:50 PM, room 308's bathroom flooring had mottled gray-brown stains surrounding the toilet. There was no caulk seal around the base of the toilet. 14. At 3:52 PM, room 310's bathroom flooring had diffuse areas of mottled gray/brown and rust colored stains surrounding the toilet. 15. At 3:55 PM, the 100-hallway shower room had cracked and broken tile at the doorway's entrance threshold. There were 3 shower stalls in the community bathroom. Each of the stalls had rust colored stains covering the bottom half of the tile walls. On 1/26/17 at 3:35 PM, the assistant maintenance director stated that he had been at the facility for about [AGE] years. He stated that much of the bathroom flooring was very old, especially the bathroom flooring, which had been in the resident bathrooms since he started at the facility. On 1/26/17 at about 4:15 PM, the administrator stated to his knowledge there was no verbal or written plan for the repair of the bathrooms. Level of harm - Minimal harm or potential for actual harm Residents Affected - Some F 0271 Level of harm - Immediate jeopardy Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Provide doctors orders for the resident's immediate care, at the time the resident was admitted. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents had physician orders for immediate care upon admission to address wound care needs for 1of 12 sampled residents reviewed for wounds (#258). Resident #258 did not have admission orders [REDACTED]. The resident became septic, was hospitalized and then transferred to a hospice house for end of life care. The failure to provide physician's orders for immediate care for resident #258 resulted in Immediate Jeopardy starting on 11/29/16. Immediate Jeopardy was ongoing as of 1/28/17. Findings: Resident #258 fell at home injuring her right arm and right hip. The resident was admitted to the hospital on [DATE] where she had a surgical repair of the right hip and right elbow. On 11/29/16, the resident was admitted to the nursing home for rehabilitative services. Her [DIAGNOSES REDACTED]. ORIF is a type of surgery in which the fractured bones are stabilized and are fixed in place by screws, plates, wires, or nails. (www.hopkinsmedicine.org) The physician's order sheet dated 11/29/16 to 11/30/16 noted she did not have any orders for treatment to the right elbow. Orders were present for daily wound care to the left hip, but the resident's surgical wounds were not on the left hip, they were on the right. Orders were also present for a posterior left thigh abrasion, but the abrasion was on the right thigh. The admitting nurse, registered nurse (RN) N documented on the Admission Data Collection form that the resident had an abrasion to the right posterior thigh, staples to the right hip, a blister to the coccyx and a bruise to the left arm. The nurse's admission note dated 1/29/16 for the 3 PM-11 PM shift indicated that the resident's right upper extremity was in a soft cast and a sling. The nurse documented that she cleansed the blister on the coccyx and applied barrier cream, but there were no orders for treatment to the coccyx. There were no orders for splint and sling to the right arm. Hospital discharge instructions that came with the resident to the nursing home indicated that the resident was to follow with the orthopedic surgeon in one week. Other instructions in the hospital records dated 11/24/16 indicated the resident's pain was under control at that time and the staples to the ORIF to the right hip and right elbow were to be taken out by rehab (facility) in 10-12 days. These orders were not included in the admission physicians order sheet in the facility. The Minimum (MDS) data set [DATE] noted that the resident had a stage II pressure sore upon admission. A stage II pressure ulcer May also present as an intact or open/ruptured blister. (State Operations Manual appendix PP guidance to Surveyors for Long Term Care Facilities). On 1/27/17 at 4:00 PM, the admitting nurse, RN N, stated that the resident did not have any wound care orders at admission. When asked where she got orders to treat the right hip and posterior thigh, the nurse stated she did not remember. Review of the record revealed there were no physician orders for treatment to the right hip and right posterior thigh. On 1/25/17 at 3:25 PM, the Unit Manager (UM) responsible for resident #258 stated that the resident did not have any treatment orders for the right elbow surgical wound upon admission. The resident was in the facility for 15 days without any treatment orders for the right elbow incisions, dressing, splint, or sling. The UM stated the resident had a follow up with the orthopedic surgeon on 12/14/16 and returned to the facility with treatment orders. The orthopedic surgeon noted, Elbow Surgical wound open/pressure sore. On 12/15/16, the day after the resident was seen by the orthopedic surgeon, the resident was transferred to the hospital. The nursing home transfer form dated 12/15/16 noted that the resident was lethargic and had altered mental status with labored breathing. The hospital assessment dated [DATE] at 9:55 PM noted that the resident appears to uncomfortable, unkempt and uncooperative. The resident smelled of urine and foul odor. The resident presented with a right elbow open wound with exposed metal hardware. The site was red and hot to touch. The hospital admitting [DIAGNOSES REDACTED]. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. It is difficult to predict, diagnose, and treat. Patients who [MEDICAL CONDITION] have an increased risk of complications and death. www.cdc.gov. Center for Disease Control and Prevention Online. 16 Sept. 2016. [MEDICAL CONDITION] is a diffuse, acute bacterial infection of the skin and subcutaneous tissue characterized most commonly by local heat, redness, pain, and swelling and occasionally by fever, malaise, chills, and headache. Abscess and tissue destruction usually follow if antibiotics are not taken. The infection is more likely to develop in the presence of damaged skin, poor circulation, or diabetes mellitus . Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier. MRSA is a bacteria that is resistant to many antibiotics. www.cdc.gov Center for Disease Control and Prevention Online.) Bacteremia is the presence of bacteria in blood. McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc. On 12/20/16 the hospital consult note read, Orthopedic consultation report noted from (orthopedic surgeon): History of Present Illness: The patient is known to (orthopedic surgeon) from previous admission with s/p (status [REDACTED]. She was seen in our office on Wednesday with X-rays. The patient had been in rehab at (nursing home). She was accompanied in the office by her family. The patient has severe dementia. When her dressing from the elbow was removed it was found that this had not been changed and the patient had been still wearing splint. She acquired a pressure wound to the R elbow. None of her staples had been removed. (orthopedic surgeon) saw the patient in the office. All staples were removed (to right elbow) and sterile dressing placed. Orders were written for (nursing home) for wound care and wound vac placement and PT/OT (physical therapy/occupational therapy). The patient presented yesterday to the ER (emergency room ) and was subsequently admitted and (orthopedic surgeon) was reconsulted. Photos on chart to support findings, report called into DCF (Department of Children and Families) . DCF is the program responsible for investigating allegations of neglect. Hospital clinical notes dated 12/21/16 indicated that the resident was discharged to a hospice house for end of life services and pain management. On 1/25/17 at 4:45 PM, the director of nursing (DON) stated that the resident was to have a follow up appointment with the orthopedic surgeon after she was admitted to their facility, but there was a delay because the nursing home could not get authorization from the orthopedic surgeon's office. She indicated that their investigation demonstrated facility's due diligence in setting up an appointment and meeting the resident's needs. When asked about lack of admission treatment orders for the right elbow surgical sites, splint, and sling, the DON stated, I am not going to answer for other staff or what they should of done. Review of the facility's policy and procedures (P&P) for Physician Orders/admission orders [REDACTED]. Policy: A Clinical Nurse shall transcribe and review all physician orders in order to affect their implementation: -admission orders [REDACTED]. Transcribe all orders from the transfer form to the facility admission physician order for [REDACTED]. -The Attending physician shall review and confirm the orders. The nurse shall document the date, time, physician's name and that the orders were confirmed on the order form: i.e. 12/01/98 11:00 AM Dr. Brown; Green, RN. Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 4 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0271 (continued... from page 4) -Routine Orders: The order shall be repeated back to the physician for his/her verbal confirmation. The order sheet shall be signed as follows: T.O. Dr. Brown/D. Green, RN 12/01/98 11:00 AM. The order must then be transcribed to all appropriate areas (MAR, TAR, etc.). The nurse shall sign off the orders upon completion or verification of transcription as follows: noted D. Green, RN, 12/01/98 11:45 AM. Nursing staff failed to follow their policy and procedures (P&P) for Physician Orders/admission orders [REDACTED]. Nursing staff failed to transcribe all orders from the transfer form to the Facility Admission Physician order for [REDACTED]. The nurse did not document the date, time, physician's name or that she had verified the orders with a physician on the facilities order form. The nurse also did not obtain orders for the residents wound care for her elbow or coccyx. Level of harm - Immediate jeopardy Residents Affected - Few F 0280 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few F 0281 Level of harm - Immediate jeopardy Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Allow the resident the right to participate in the planning or revision of the resident's care plan. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update Nutrition/Hydration care plans for 1 of 1 tube fed residents (#3). Findings: Resident #3 was admitted to the nursing home on 10/09/14. The resident was fed by a gastrostomy tube (GT) and did not eat by mouth. The January 2017 Physician order [REDACTED]. The resident's Nutrition/Hydration care plan indicated that the GT would be flushed with 180 cc. of water, four times a day. The Registered Dietician (RD) notes, dated 12/20/16, revealed that the RD had recommended increasing the GT flushes to 250 cc for times day. On 1/25/17 at 12:10 PM, the Care Plan Coordinator stated that staff are to notify her of any changes so she can update the care plans. She confirmed that the current care plan indicated the resident GT flushes was 180 cc., four times a day. Make sure services provided by the nursing facility meet professional standards of quality. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide nursing care to meet professional standards of quality for 1 of 12 sampled residents reviewed for wounds (#258). Resident #258 did not receive quality nursing treatment and care for surgical wounds and prevention of a painful, infected pressure ulcer. As a result of the lack of professional nursing judgement and failure to follow nursing policies and procedures and care plans, the resident required hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her elbow. The resident was diagnosed with [REDACTED].[MEDICAL CONDITION] is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. www.cdc.gov/sepsis. The failure to provide quality nursing care and judgement according to standards of nursing practice resulted in Immediate Jeopardy, starting on 11/29/16 with Substandard Quality of Care. The Immediate Jeopardy was ongoing as of 1/28/17. Cross Reference to F224, F271, F309, F314 Findings: The Florida Statutes Chapter 464 The Nurse Practice Act. (ss. 464.001-464.027) defines the Practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a)The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. (b)The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (c)The supervision and teaching of other personnel in the theory and performance of any of the acts described in this subsection. American Nurses Association Standards of Practice include: Standard 1. Assessment - The registered nurse collects comprehensive data pertinent to the healthcare consumer's health or the situation. Standard 2. Diagnosis - The registered nurse analyzes the assessment data to determine the [DIAGNOSES REDACTED]. Outcome Identification - The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation. Standard 4. Planning The registered nurse develops a plan of care that prescribes strategies and interventions to attain expected outcomes. Standard 5. Implementation - The nurse implements the interventions identified in the plan. Standard 5A. Coordination of Care Standard 6. Evaluation - The registered nurse evaluates progress toward attainment of outcomes. (Scope and Standards of Practice-Nursing 2nd Edition, American Nurses Association, 2010 Edition.) Resident #258 was admitted to the nursing home on 11/29/16 with [DIAGNOSES REDACTED]. ORIF is a type of surgery in which the fractured bones are stabilized and are fixed in place by screws, plates, wires, or nails. (www.hopkinsmedicine.org) On 11/29/16 the Admission Data Collection form, Section M/Skin, the admitting nurse, RN N, did not indicate that the resident had a right elbow surgical incision/soft cast in a sling, but later in her Nurse's Notes on the same document she wrote, RUE (right upper extremity) soft cast and sling Blister coccyx cleaned and covered with barrier cream. The nurse documented an abrasion to the right posterior thigh. RN N, did not provide a description of the wounds, presence of redness or drainage, the amount of staples, or the condition of the wounds/incision. Review of the facility's policy and procedures (P&P) for Admissions Assessment, effective 1/27/16, noted the following: Upon admission and/or readmission to the facility, the nurse shall complete a Data Collection Form to facilitate the beginning and/or revisions of the plan of care. Procedure: . Pertinent information shall be collected by physical review, interviews with resident and family and review of the resident's available medical records. A complete head to toe review must be done on the resident during the admission process. RN N failed to follow this policy, when she did not complete a head to toe review to include all resident #258's surgical wounds, pressure wounds, and other alterations in skin integrity. Review of the P&P for Physician Orders/admission orders [REDACTED]. Policy: A Clinical Nurse shall transcribe and review all physician orders [REDACTED]. -admission orders [REDACTED]. Transcribe all orders from the transfer form to the facility admission physician order [REDACTED]. -The Attending physician shall review and confirm the orders. The nurse shall document the date, time, physician's name and that the orders were confirmed on the order form: i.e. 12/01/98 11:00 AM Dr. Brown; Green, RN. -Routine Orders: The order shall be repeated back to the physician for his/her verbal confirmation. The order sheet shall be signed as follows: T.O. Dr. Brown/D. Green, RN 12/01/98 11:00 AM. The order must then be transcribed to all appropriate areas (MAR (medication administration record), TAR (treatment administration record), etc.). The nurse shall sign off the orders upon completion or verification of transcription as follows: noted D. Green, RN, 12/01/98 11:45 AM. The admission data collection for did not contain any information that RN N called the physician to confirm the orders or obtain any and all wound care orders necessary for resident #258. She documented a treatment to the blister on the coccyx, but there were no orders for treatment to the coccyx. The resident did not have orders for treatment to the coccyx at any time during her 16 days in the nursing home. The resident did not have orders for the wound on her right elbow, right thigh and hip, or right thigh abrasion. On 01/27/17 at 4:00 PM, staff RN N stated she did not unwrap or assess the resident's arm. She stated she did not have any wound care orders for the resident's right hip, thigh, coccyx, or elbow when the resident came to the facility, and she did not call the attending physician for orders. She said, The Unit Manager (UM) should have gone through and made sure everything was there (in the Medical Record). Many times they (residents) will come in with orders, and we write those Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 5 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0281 (continued... from page 5) orders and follow up appointments on the Medication Administration Record [REDACTED]. One of the unit nurses or charge nurses should have followed up on it. RN N, failed to follow the P&P for Pressure Ulcer Record and Non-Pressure Skin Condition Record. RN N should have initiated a Non-Pressure Ulcer Record, per policy, upon resident #258's admission on 11/29/16, to include the surgical wounds to her right hip and right elbow, as well as any other non-pressure areas. Review of the P&P for Pressure Ulcer Record and Non-Pressure Skin Condition Record, Effective Date 11/30/14, noted the following: Pressure Ulcer Record Policy, Effective Date 11/30/14 .document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the site is healed. Procedure: Residents will have a Pressure Ulcer Record completed for each skin impairment that is related to Pressure. - Mark the pressure area on the body description identifying the site. - Enter the date - Enter the stage of the pressure ulcer - Enter the size of the pressure ulcer - length x width x depth in centimeters - Enter the tissue type and color - Enter the wound edges and drainage - Enter the peri-wound information - Licensed nurse to sign the appropriate area RN N failed to follow this policy. She did not document the resident's pressure ulcer to the coccyx on the Pressure Ulcer Record upon admission. No other licensed nurses documented the coccyx pressure ulcer per the P&P at any time during her 16 days in the facility. The Non-Pressure Skin Condition Record, Effective Date 11/30/14 read, .document the presence of skin impairment/new skin impairment not related to Pressure when first observed and weekly thereafter. This includes skin tears, surgical sites, etc. Procedure: - Residents will have a Non-Pressure Skin Condition Record completed for each skin impairment that is not related to Pressure. - Enter the initial identification information. - Mark the area on the body description identifying the site. - Enter the date, size, drainage information description of the wound edges and the per-wound area. - Enter the size of the non-pressure ulcer skin condition - length x width x depth in centimeters - Each week the non-pressure skin condition is to be evaluated and the information recorded until healed. The licensed nursing staff failed to follow the P&P for non -pressure skin conditions for the surgical wounds on her right elbow and right hip and right thigh abrasion upon admission. In an interview with RN N, on 1/27/17 at 4 PM, she was asked about the handwritten the orders for the wound care to the resident's left hip/thigh and left posterior thigh abrasion and she stated she could not remember. A review of the physician's orders [REDACTED].#258's left hip/thigh and left posterior thigh abrasion. The orders do not contain an order date or time. A review of the Physician Telephone Orders sheets revealed there were no telephone orders for wound care. RN N did not acknowledge the orders incorrect. The resident's wounds were on the right hip and thigh, not the left. Interviews with RN/Unit Manager (UM) F were completed on 01/25/17 at 3:25 PM and a second interview on 01/27/16 at 6:10 PM. UM F stated when the resident came into the facility she did not have wound care orders. UM F reviewed the medical record, and stated that RN N did not assess the resident's surgical wounds. She said newly admitted residents are reviewed the following morning by the Director of Nursing (DON), Assistant Director of Nursing (ADON) and the UMs. It includes a review of the medical records to determine what needs to be completed and follow up if orders are missing. UM F confirmed they had an order to follow-up with the Orthopedic surgeon, but no orders for the right elbow surgical wound. The review by the DON, ADON, and UM did not result in any follow up with a physician regarding the care and treatment for [REDACTED]. Interviews with RN/Unit Manager (UM) F were completed on 01/25/17 at 3:25 PM and a second interview on 01/27/16 at 6:10 PM. Resident #258's Care Plan was reviewed with UM F. On the care plan, under Skin/Wound: Right Elbow Open Reduction Internal Fixation (ORIF), it read, Administer treatments as ordered & observe for effectiveness. Observe Skin areas around casts, splints, adaptive devices; remove as needed to check skin condition, and weekly skin checks. The UM confirmed nurses did not follow the plan of care. She said they should have called the physician for instructions regarding the care of the surgical wound on the resident's right elbow. She confirmed the initial assessment and weekly assessments were not documented per facility policy and procedure and the care plan. UM F stated the facility was having difficulty getting a follow-up appointment with resident #258's orthopedic surgeon, and told the attending physician several times that the resident did not have wound care orders, but he did not give any wound care orders for the resident. She said the attending physician had come into the facility multiple times to see the resident, but he did not remove any of the resident's dressings on her right elbow. UM F confirmed she should have called the Medical Director when she couldn't get wound care orders for the resident, but she never called him. She said she spoke with the DON and ADON about the resident not having wound care orders, but she cannot remember the date. Review of the medical record revealed conflicting and contradictory information regarding the care and treatment for [REDACTED]. Interviews with UM F were completed on 01/25/17 at 3:25 PM and on 01/27/16 at 6:10 PM. She said 11 PM-7 AM nurse, Licensed Practical Nurse (LPN) T told her the resident had drainage from her arm on 12/13/16, and asked UM F to come into the facility and evaluate the resident's arm. UM F said she did not know why the LPN called her and did not follow the care plan for Skin/Wound, Notify physician for change in condition. UM F said she assessed the elbow wound when she came into the facility at 5 AM on 12/13/16. She said the staples were intact, but there was also a Stage III pressure wound. The wound was on the residents elbow, but not on the surgical line. UM F said she called the attending physician for orders, and he told her to remove the resident cast and look underneath, paint the wound with [MEDICATION NAME], and order X-rays. A review of the Nurses Progress Notes dated 12/13/16 6:20 AM, stated, Resident in bed c/o (complaint of) pain, drainage not to R elbow & odor. MD notified, new order to clean area with [MEDICATION NAME] now and cover, xray 2 views for R (right) elbow & r hip s/p surgery. Area to R elbow cleaned as ordered . Another note from UM F dated 12/13/16 at 11:32 AM stated, notified MD of new order from wound doctor for Xeroform and Maxsorb to open area remove soft cast & reapply after treatment applied. UM F confirmed these were her notes and the orders to remove the soft cast and treat the resident's elbow with Xeroform and Maxsorb came from the Wound Care Physician. A review of the Physician's Telephone Orders form for 3 orders dated 12/13/16 was completed with UM F. Two of the orders did not include the time. One of the orders included a time for 11:32 AM to remove the soft cast and apply new treatment to right elbow. This contradicts the previous information provided by UM F in which she said the spoke with the attending physician at 6:20 AM. The orders were written as follows: 1. 12/13/16: 2 view R (right) elbow Xray. 2 view R hip Xray. Indication: Pain/ s/p (status [REDACTED]. 2. 12/13/16: Clean area with [MEDICATION NAME] to R Elbow Now. Wound Consult. It was signed by UM F, did not include the time ordered and it was not signed by the physician. 3. 12/13/16 at 11:32 AM: New order from wound doctor. Apply Xeroform to staples & Maxsorb to open area to R Elbow. Remove soft cast apply new treatment to R Elbow and reapply soft cast. It was not signed by the physician. UM F said she did not know why she didn't include the time in the orders, and confirmed that they should have been timed. She stated the order to remove the cast was not from the Wound Care Physician, as she wrote it on the order. She said the attending physician told her to remove the cast and use the [MEDICATION NAME]. She said that she wrote the order from the attending physician and wound care physician together as one order. An interview with the Wound Care Physician (WCP) on 01/26/17 at 1:43 PM, she stated she only saw the resident #258 twice while the resident was admitted . The first time was when she was consulted on 12/07/16 and was asked to look at a blister the resident had developed on the back of her right thigh. The WCP denied speaking with UM F on 12/13/16. She reviewed Telephone Order dated 12/13/16 for the right elbow, which UM F stated came from the WCP. The WCP stated, That is not my order, I did not give that order. The TAR for December listed handwritten instructions for treatment to the right hip as follows: Clean R (right) hip staples Level of harm - Immediate jeopardy Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 6 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0281 (continued... from page 6) with NS (normal saline), pat dry. Place Xeroform and cover with border gauze Q (every ) day & PRN (as needed) 12-07-16. The record shows the treatment was not completed 12/09/16 and 12/14/16. A wound care note dated 12/07/16 was the identical treatment, but it was for the right posterior thigh. It read, Wound #1 Right, Posterior Thigh Blister; Wound Cleansing & Dressing: Clean wound with Normal Saline, pat dry, apply Xeroform gauze and dry drsg daily and prn. Review of the physician's orders [REDACTED]. Other instructions for treatments in December 2016 are conflicting and other evidence as follows contradict the treatments. The treatments for December are written on a record that reads Medication Administration Record [REDACTED] 12/13/16: Change Dressing to R (right) elbow now. Clean with [MEDICATION NAME]. It was initialed as completed by UM F on 12/13/16. 12/14/16: Change dressing to R elbow clean with [MEDICATION NAME], apply Maxsorb to open area elbow. It is initialed as completed on 12/15/16. Review of the physicians order timed for 11:32 AM revealed the order was written by UM F on 12/13/16. The order was not transcribed accurately to the treatment record. As stated above in the interview with the WCP, she denies ever giving that order for treatment to the right elbow. Remove Staples to R hip. Place Steri-strips is initialed as being completed on 12/15/16. This entry was not dated and there was no evidence of a physician's orders [REDACTED]. In an interview with the Attending Physician (AP) on 01/27/17 at 4:40 PM, he confirmed he remembered the resident and had looked at resident #258's right hip surgical wound, but not the right elbow. He stated he did not remember the facility calling him about the wound on 12/13/16. He confirmed the order on 12/13/16 may have been his, and it sounded like something he may have written, but he was not sure it was his order. He did not recall the facility telling him the wound was a pressure ulcer. He said the resident arrived at the facility without any wound care orders when she was admitted , but wound orders would have to come from the surgeon or the wound care doctor, not him. A review of the resident medical record indicated that the resident was seen by the AP twice during Resident #258's stay, 11/30/16 and 12/02/16. The visits on 12/5, 12/7, 12/12, and 12/14/16 were completed by the physician's assistant (PA). All of the notes indicate that the resident right arm is in a shoulder sling. The physicians note on 12/14/16 stated the resident's cast was removed from the right arm with serosanguinous fluid, no warmth or odor present and the dressing was changed. This contradicts the Daily Skilled Nurse's Note on 12/13/16, that stated there was brown-red drainage and a foul odor. There were no other recommendations made by the PA about the resident's arm. The treatment to the resident's right elbow as it was documented is contradicted by the notes from the Orthopedic Surgeon (OS) for the office visit on 12/14/16. The resident was sent out of the facility to the OS's office on 12/14/16 at 3:00 PM Resident #258 was seen for a surgical follow-up appointment. The Consultation Report from the hospital dated 12/17/16 documented the events from the 12/14/16 office visit as follows: The patient has been in rehab .When her dressing from the elbow was removed it was found that this had not been changed and the patient had been still wearing splint. She had acquired a pressure wound to the R elbow. None of her staples had been removed All staples were removed and a sterile dressing placed. Orders were written for wound care and wound vac (vacuum assisted closure) placement and PT(physical therapy)/OT(occupational therapy) An Interdisciplinary Progress Notes from the OS for the 12/14/16 office visit read as follows: Post operative right elbow ORIF now has pressure wound from splint. New elbow surgical wound opening/pressure sore status/post ORIF R elbow. 1. Hyperbaric treatment R elbow 2. Wound VAC R elbow wound 3. PT with ROM (range of motion) only Rt elbow 4. No splint on R elbow 5. PT R hip - WBAT (weight bearing as tolerated) 6. Daily PT/OT A review of the Physician's Telephone Orders from 12/14 to 12/15/16 revealed that the orders from the OS for the hyperbaric treatment and wound vac to the right elbow were not implemented. A note from the WCP dated 12/15/16 indicated she was asked by UM F to evaluate an area of concern to the resident's right elbow, post cast removal. She wrote Open surgical wound with hardware visible, very little granulating tissue noted, needs surgical intervention. Staff to call surgeon to appointment for elbow, ASAP, may use Maxsorb Ag and dry drsg until seen by surgeon. We are unable to effect any healing for this type of wound. She needs surgical closure of the elbow wound. Until then Maxsorb Ag will assist in controlling drainage. There was no evidence in the medical record that the surgeon was called ASAP. During the resident's admission from 11/29/16 to 12/15/16 she regularly complained about the pain in her right arm. A review of the Pain Flow Sheet was completed and showed the resident regularly rated her pain high on the pain scale. The pain scale is 0 being no pain and 10 as the worst pain you can imagine. On 12/05/16 at 9:40 AM and 12:30 PM, 12/07/16 at 8:45 AM, and 12/08/16 at 8:30 AM, the resident rated her pain as an 8 out of 10. On 12/08/16 at 2:30 PM, 12/10/16 at 8:30 AM, 12/11/16 at 8:00 AM and 1:00 PM, 12/12/16 at 7:45 AM and 12:20 PM, 12/13/16 at 9:05 AM, 11:00 AM, and 12/15/16 at 8:30 AM and 10:30 AM., she rated her pain level as a 10 out of 10. The documentation on the flow sheet revealed the resident's pain relief was not consistently obtained, and her pain was level was checked as not acceptable on 12/05, 12, 13, and 15/16. The residents Non-Verbal Indicators of pain was listed as, A=Non-Verbal Sounds and C= Facial Expressions. The care plan for pain dated 12/07/16 noted the nursing staff was to Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain The resident's pain was not consistently controlled during her stay, and was not being adequately managed. The effectiveness of the resident's pain medication was not evaluated after it was given. The nursing staff did not communicate with the resident's attending physician that the resident was still having severe pain, without relief, even after she was medicated, and then her pain was not consistently being controlled. From 12/07/16 to 12/15/16, the resident rated her pain a 10 out of 10, and was moaning out in pain, even after medications were given. On 12/15/16, the resident was found to be lethargic, short of breath, and had an altered mental status. She was transferred to the hospital via 911 for treatment. When the resident arrived at the hospital she was diagnosed with [REDACTED]. Her prognosis was listed as poor, a hospice consult was ordered. Hospital clinical notes dated 12/21/16 indicated that the resident was discharged to a hospice house for pain management and end of life services. On 01/25/17 at 4:45 PM, an interview was completed with the Director of Nursing (DON). She said that after reviewing resident #258's chart on 12/13/16, she discovered the resident did not have orders for her right elbow wound. She said, I had no knowledge prior to 12/13/16 that there was any issues with this resident. I was told by our prior Case manager that we were waiting for prior authorization from the insurance company before the resident could be seen (by the orthopedic surgeon). I told UM F to call the Orthopedic Surgeons Office immediately, and they said we didn't need prior authorization for the resident to be seen. They scheduled an appointment the next day, 12/14/16. The facility then called the attending physician and told him what was going on. Per the UM the attending physician came in and saw the resident, agreed to the dressing removal and to clean the wound. The interview with the DON contradicts the medical record and interview with the attending physician. He said he did not see the resident on 12/13/16. The DON was asked about the expectations for wound care and she stated, I can't speak about what the nurse should have done. She confirmed the resident had a soft cast, and did not have orders for the wound orders for her elbow until 12/13/16. I don't know why they didn't look at it for 13 days. I can't tell you why, I can only speak about what happened from 12/13/16 forward. I am not going to answer for other staff or what they should have done. I will only comment from 12/13/16. The DON said that when the resident returned from her appointment with the Orthopedic Surgeon on 12/14/16, she received a call from the surgeon very upset because he said he sent specific orders for the dressing to be changed daily, but it was not done. The DON stated during her investigation she was never told that the resident's wound was a pressure sore. She reviewed the Pressure Ulcer Sheet dated 12/13/16, and confirmed that it was written by UM F, but she said, I don't know where that sheet came from. I didn't see it during my investigation. I was only told about this just now. The DON stated she did not speak with the RN N about the admission. but she spoke with UM F. She indicated that her investigation demonstrated that the facility did their due diligence in setting up the follow up appointment with the surgeon to meet the resident's needs. The DON did not acknowledge the failure to follow the standards of practice according to the Florida Nurse Practice Act and Level of harm - Immediate jeopardy Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 7 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0281 (continued... from page 7) the American Nurses Association Standards for incomplete admission orders [REDACTED]. Level of harm - Immediate jeopardy Residents Affected - Few F 0285 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few F 0309 Level of harm - Immediate jeopardy Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. Based on record review and interview, the facility failed to ensure the Pre-Admission and Resident Review (PASRR) was correctly filled out for 1 of 40 sampled residents (#88). Findings: Resident #88's medical record revealed a PASRR form was not completed. It had the resident's name, social security number (SSN), date of birth (DOB), present location of the individual evaluated and street address. The remainder of page 1 was blank. Page 2 only had the resident's name and DOB. The rest of the page was blank. Page 3 had only the name and DOB at the top. The rest of the page was blank. Page 4 had the resident's name and DOB at the top and midway down the page, typed in was a local hospital's name. On 1/25/17 at 4:15 PM, the corporation nurse said, It should not be blank. She said it should be filled out prior to the resident coming to the facility. On 1/26/17 at 9:30 AM, the Social Services Director (SSD) confirmed that PASRRs should be filled out in its entirety. At 11:40 AM, the SSD revealed she had the form filled out. She said the advanced registered nurse practitioner (ARNP) was in the building yesterday and filled it out. She said she had it dated for yesterday. She said if a resident comes from the hospital without a PASRR, they ask the field admissions person to go to the hospital and get it. If it was after business she said they would place a call to that person and have her go to the hospital and get it. Otherwise, they would send the resident back to the hospital. She said she did not know why their procedure wasn't followed for this resident, and said as far as she knows this has never happened before. She then provided the new PASRR. On 1/27/17, when reviewing resident #88's medical record, the new form was still not in the medical record. Provide necessary care and services to maintain the highest well being of each resident **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide necessary treatment and care to maintain the highest practicable well-being for 1 of 12 sampled residents reviewed for wound care, pain management, and skin care management (#258). Resident #258 did not receive the necessary treatment and care to her surgical wounds to prevent the deterioration of her condition. The resident endured severe pain and required re-hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her right elbow. The resident was diagnosed with [REDACTED].[MEDICAL CONDITION] is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. www.cdc.gov/sepsis. The failure to provide necessary care for wound care, pain management, and skin care management resulted in Immediate Jeopardy, starting on 11/29/16 with Substandard Quality of Care. The Immediate Jeopardy was ongoing as of 1/28/17. Based on observation, record review and interview the facility failed to coordinate, provide and monitor care and service relating to [MEDICAL TREATMENT] for 1 of 1 sampled residents reviewed for [MEDICAL TREATMENT] (#116). Findings: Resident #258 was a [AGE] year-old female who was admitted to the nursing home on 11/29/16 for surgical aftercare. She fell at home, sustained a right hip and right elbow fracture, and was hospitalized from [DATE] to 11/29/16. The hospital record revealed that the resident had an open reduction internal fixation (ORIF) surgical repairs to the right hip and right elbow resulting in 3 incisions with staples to the right hip, right thigh, and right elbow. ORIF is a type of surgery in which the fractured bones are stabilized and are fixed in place by screws, plates, wires, or nails. (www.hopkinsmedicine.org) Registered Nurse (RN) N, admitted resident #258, to the facility on [DATE] at 7:30 PM. She documented that the resident had 3 surgical wounds, one to the right elbow and two incisions to the right hip/thigh. She had an abrasion to the right posterior thigh. The resident arrived at the facility without any wound care orders or interventions listed on her hospital discharge paperwork. On the Admission Data Collection form, Section M/Skin, RN N, did not indicate that the resident had a right elbow surgical incision/soft cast in a sling. In her Nurse's Notes, on the same document, she writes, RUE (right upper extremity) soft cast and sling . A description of the wound, the presence of redness or drainage, the amount of staples, and the condition of the wounds/incisions were not documented. A review of the medical record did not indicate that any nurse called the physician or the surgeon to obtain wound care order orders for the surgical wounds or the abrasion on the resident's right posterior thigh. On 1/27/17 at 11:10 AM, the occupational therapist described splint to resident #258's right arm. The resident had staples to the incisions on her elbow with a dressing. She had a hard support/removable splint that ran from her mid forearm and curved around the end of her elbow that was held in place with an ace wrap. Her right arm was immobilized with a sling at all times. On 01/27/17 at 4:00 PM, RN N stated she did not remove any of the bandages to inspect the resident's arm on 11/29/16. She said that in her experience the surgeon did not want a nurse to remove any dressings or splints until the patient was seen by the surgeon. She stated she did not have any wound care orders for the resident's right hip, thigh, or elbow when the resident came to the facility, and she did not call the attending physician for orders. She did not have any orders for a follow up appointment with the surgeon. When asked what she should do if a resident does not have wound care orders and has surgical dressings, she stated, You should call the attending physician, let them know the resident has wounds, and ask how they would like to treat the wounds. She said the nurse should remove any dressings to be able to see the wound. She stated that it is the Unit Manager's responsibility to follow up on new admissions and obtain the orders from the physicians if they are missing or unclear. During the resident's admission from 11/29/16 to 12/15/16 she regularly complained about the pain in her right arm. A review of the Pain Flow Sheet was completed and showed the resident regularly rated her pain high on the pain scale. The pain scale is 0 being no pain and 10 as the worst pain you can imagine. On 12/05/16 at 9:40 AM and 12:30 PM, 12/07/16 at 8:45 AM, and 12/08/16 at 8:30 AM, the resident rated her pain as an 8 out of 10. On 12/08/16 at 2:30 PM, 12/10/16 at 8:30 AM, 12/11/16 at 8:00 AM and 1:00 PM, 12/12/16 at 7:45 AM and 12:20 PM, 12/13/16 at 9:05 AM, 11:00 AM, and 12/15/16 at 8:30 AM and 10:30 AM., she rated her pain level as a 10 out of 10. The documentation on the flow sheet revealed the resident's pain relief was not consistently obtained, and her pain was level was checked as not acceptable on 12/05, 12, 13, and 15/16. The residents Non-Verbal Indicators of pain was listed as, A=Non-Verbal Sounds and C= Facial Expressions. The Daily Skilled Nurse's Notes noted, 12/07/16, 7-3 pt. (patient) has been crying out in pain. On 12/08/16, 7-3 pt. yelling out in pain . pt cont. (continued) to moan with pain. 12/09/16, c/o (compliant of) pain. 12/10/16, Late entry - pt. crying out in pain, medicated . no relief . 12/11/16, 7-3 p.t crying out in pain . grabbing at right hip . medicated . pt. cont. to cry out . pt. again crying out in pain. 3-11 pt. seems unhappy. 12/12/16, 7-3 - late entry. Pt. has been crying out in pain, medicated .increased yelling out in pain. 12/13/16 at 2:30 AM, Pt. crying and holding elbow stating, it hurts. 4 AM pt. conts.(continues) To voice pain in right elbow. 7-3 - late entry. Pt crying out in pain . pt not showing any relief. 12/15/16, 7-3 pt. crying out in pain. Medicated .pt. cont. to cry out in pain. A review of Therapy Notes indicated resident #258 complained of pain in her right upper extremity on 11/30/16, 12/01/16, and 12/09/16. The therapy notes stated the resident's pain was a 5/10 and constant. The therapy notes indicated, Patients progress has been slower than initially anticipated due to patients pain level . On 12/06/16, Resident's pain level was discussed with RN in regards to current pain medications. A review of the Attending Physician Note dated, 12/05/16, it reads, Staff reports no new complaints. Shows slow progress at PT (physical therapy) due to pain. The physician did not write any orders for new pain medications to control the resident's pain. The physician wrote his Care Plan: Continue present medications. The resident's pain was not consistently controlled during her stay, and was not being adequately managed. The effectiveness of the resident's pain medication was not evaluated after it was given. The nursing staff did not communicate with the Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 8 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0309 (continued... from page 8) resident's attending physician that the resident was still having severe pain, without relief, even after she was medicated, and then her pain was not consistently being controlled. From 12/07/16 to 12/15/16, the resident rated her pain a 10 out of 10, and was moaning out in pain, even after medications were given. The Minimum Data Set (MDS) assessment dated [DATE], noted a fracture under Section I, Musculoskeletal. Her active [DIAGNOSES REDACTED]. Section M, Skin Conditions, indicated the resident had an unhealed Stage II pressure ulcer and surgical wounds. In Section J, Health Conditions/ Pain Management, the resident stated that she had pain in the last 5 days, and it was occasionally. The resident was then asked, if her pain made it hard for her to sleep or if it limited her day-today activities, the facility marked the resident was, unable to answer. When questioned about pain intensity, using the resident verbal scale, a ruler that has 0 to 10 on it, and the resident can point to where her pain level is, is marked unable to answer. The next question In Section J asks, Should the Staff Assessment for Pain be Conducted? It is marked, No. If it had been marked Yes, the assessment instructs the nurse to continue to the Indicator of Pain or Possible Pain Section. The entire section under Staff Assessment for Pain is blank. In the Indicators of Pain or Possible Pain in the last 5 days, the instructions direct the nurse to observe a resident for Non-Verbal sounds (crying, whining, gasping, moaning, or groaning), Vocal Complaints of pain (e.g. that hurts, ouch, stop), Facial expressions (e.g. grimaces winces wrinkled forehead, furrowed brow), Protective body movements or postures (e.g. bracing, guarding, rubbing or massaging). If the section had been completed, the facility would have reviewed the resident's Pain Flow Sheet. On 12/05/16 at 9:40 AM, the resident was complaining of pain at an 8 out of 10, and the resident's Non-Verbal Indicators are labeled AC (A= Non-verbal sounds and C= Facial Expressions) After being medicated the resident stated the pain intervention was not acceptable. The resident's Care Plans (CP) were initiated on 12/07/16 for Skin/Wound, Pain/Comfort, Activities of Daily Living (ADL), Nutrition/Hydration, and Safety. The Skin/Wound CP, Implemented (IMP) 12/07/16: Etiology; Fragile skin, impaired mobility, R (right) Hip Fx (fracture) ORIF (Open Reduction Internal Fixation), R Fx Elbow ORIF NWB (Non-Weight Bearing), Pressure Ulcer coccyx. As Evidenced By (AEB): Surgical Wound. The goals were: The resident will have intact skin, free of redness, blisters or discoloration through next review, The resident will not develop additional skin integrity problems or wounds through next review, The resident will be free from impaired skin integrity through next review. The Interventions were listed as: Administer medications as ordered, Inform the physician of any new area of skin breakdown, Notify nurse of any new area of skin breakdown: Redness, Blisters, and Bruises, discoloration noted during bath or daily care, Observe for pain during treatment. Treat pain as per orders prior to treatment to ensure the residents comfort, Observe skin areas around (R soft) casts, splints, adaptive devices. Remove as needed to check skin condition. Use Sling, Weekly Skin Checks, Notify physician for change in condition, Keep Skin Clean and Dry. The Pain/Comfort CP IMP 12/07/16: Etiology; The resident has the potential for alteration in pain/comfort, Postoperative discomfort r/t (related to) R Hip ORIF & R Elbow ORIF, Fracture r/t R Hip Fx /R Elbow Fx. AEB: C/O (complaint of) pain or discomfort R Elbow & R Hip. The Goals included: The resident will not have an interruption in normal activities due to pain ., The resident will not demonstrate decline in over all function r/t pain. Interventions included: Observe & report any s/sx (signs/symptoms) of non-verbal pain: Changes in breathing, Vocalizations, Mood/behavior changes, Face grimacing, Body tensing, Identify previous pain history and management of that pain and impact on function . including pain relief ., Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain, Anticipate the resident's need for pain relief and respond to any c/o pain. The ADL (Activities of Daily Living) CP, Impl. 12/07/16. Etiology: The resident has an ADL Self Care Performance Deficit r/t Limited ROM (range of motion), Musculoskeletal, decreased mobility, R Hip Fx & L (should be right) Elbow fx. The Goal is: The resident will receive appropriate staff support with .Personal Hygiene. The Intervention is : Observe skin for redness, open areas, scratches, cuts, bruises, and report changes. The Nutrition/Hydration CP, Impl. 12/07/16. Etiology: The resident has potential for imbalanced nutrition, s/p fracture. The Goal is: The resident will maintain adequate nutritional status AEB maintaining weight within 105-115. with no s/sx (signs/symptoms) of skin breakdown . The Intervention is: Weight: Per Melbourne IDT Protocol; Weekly. The Safety CP, Impl. 12/07/16. Etiology: The resident has an injury, Deconditioning, Hx of Falls, [DIAGNOSES REDACTED]. The Goal is: The resident will not sustain serious injury through next review. The Intervention is: Skin Checks Weekly. The facility did not provide the care, services and treatments as stated in the interventions sections on the Care Plans. A review of the resident's medical record was completed and there was no documentation to support that the resident's skin areas around her casts/splints were checked or that the cast/splint was removed to check skin conditions underneath. The facility did not notify the physician when pain interventions were unsuccessful, to include but not limited to, pain relief. They did not complete weekly skin checks to the resident's right elbow or weekly weights. Review of the facility's policy and procedures (P&P) for Physician Orders/admission orders [REDACTED]. Policy: A Clinical Nurse shall transcribe and review all physician orders [REDACTED]. -admission orders [REDACTED]. Transcribe all orders from the transfer form to the facility admission physician order [REDACTED]. -The Attending physician shall review and confirm the orders. The nurse shall document the date, time, physician's name and that the orders were confirmed on the order form: i.e. 12/01/98 11:00 AM Dr. Brown; Green, RN. -Routine Orders: The order shall be repeated back to the physician for his/her verbal confirmation. The order sheet shall be signed as follows: T.O. Dr. Brown/D. Green, RN 12/01/98 11:00 AM. The order must then be transcribed to all appropriate areas (MAR, TAR, etc.). The nurse shall sign off the orders upon completion or verification of transcription as follows: noted D. Green, RN, 12/01/98 11:45 AM. Nursing staff failed to follow their policy and procedures (P&P) for Physician Orders/admission orders [REDACTED]. Nursing staff failed to transcribe all orders from the transfer form to the Facility Admission Physician order [REDACTED]. The nurse did not document the date, time, physician's name or that she had verified the orders with a physician on the facility's order form. The nurse also did not obtain orders for the residents wound care for her elbow or coccyx. The policy and procedure for Non-Pressure Skin Condition Record, Effective Date 11/30/14 included .document the presence of skin impairment/new skin impairment not related to pressure when first observed and weekly thereafter. This includes skin tears, surgical sites, etc. Procedure: -Residents will have a Non-Pressure Skin Condition Record completed for each skin impairment that is not related to Pressure. -Enter the initial identification information. -Mark the area on the body description identifying the site. -Enter the date, size, drainage information description of the wound edges and the per-wound area. -Enter the size of the non-pressure ulcer skin condition - length x width x depth in centimeters -Each week the non-pressure skin condition is to be evaluated and the information recorded until healed. The nursing staff failed to follow this policy in regards to the surgical wounds. A review of the Non-Pressure Skin Condition Records dated, 11/29/16, 12/5/16, and, 12/13/16 and Weekly Skin Integrity Review sheets dated, 11/29/16, 12/05/16, and 12/12/16 did not show that the resident had a surgical wound on her elbow. On 12/14/16, the resident was seen outpatient by her surgeon. In a hospital note, dated 12/17/16 the surgeon referred to that office visit on 12/14/16, The residents dressing had not been changed and the patient was still wearing the same splint. None of the staples had been removed, and the resident now had an open pressure wound to the right elbow with hardware exposure. At the office visit the surgeon removed the staples to the incisions around her elbow and applied a new sterile dressing. The resident returned to the facility with new wound care orders. On 1/27/16 at 6:10 PM, the unit manager (UM) said that on 12/13/16 the staff observed drainage coming from the right elbow on the day before the resident's follow appointment with the Orthopedic Surgeon. The UM stated that she called the attending physician and he ordered to 'paint' the right elbow with [MEDICATION NAME]. She stated she removed the soft cast and observed a stage III pressure sore. The UM stated that she spoke to the wound care physician (WCP) on 12/13/16 and received an order for [REDACTED]. The UM's statements directly contradicts the Orthopedic Surgeon's observation of the right elbow. The surgeon noted that the resident's right elbow dressing had not been changed. During a phone interview on 1/27/17 at 4:40 PM the resident #258's attending physician stated that he recalled that there was a treatment order for the right hip at admission. He stated that there were not any treatment orders for the right Level of harm - Immediate jeopardy Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 9 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0309 (continued... from page 9) elbow. He stated that he instructed the staff to contact the orthopedic surgeon about the right elbow wound, but the staff was not able to contact the surgeon. He was aware that there were conflicting orders between the WCP and the Surgeon. He stated, They were asking me to pick between two experts, and I couldn't make that decision. The responsibility would lie with the orthopedic surgeon. He said that he was not going to change the surgeon's orders. The attending physician stated that he talks to the medical director off and on but he did not discuss resident #258 with the medical director. On 1/26/17 at 1:43 PM the WCP reviewed the treatment orders and her notes regarding resident #258. She stated she only looks at the wounds that the facility refers to her. She indicated that she was only responsible for the wound that was on the resident's leg. The WCP stated that she saw the resident's right elbow wound on the 12/15/16 when the resident did not have a soft cast, the day after she went to the surgeon's office. The WCP stated the resident needed to go back to the Orthopedic Surgeon because, We couldn't treat it (the wound). The WCP reviewed the 12/13/16 telephone order written with her name. The WCP stated that she never gave the order. She pointed out that the order did not have her signature and she stated that she always signs her orders. On 12/15/16, the resident was found to be lethargic, short of breath, and had an altered mental status. She was transferred to the hospital via 911 for treatment. When the resident arrived at the hospital she was diagnosed with [REDACTED]. Her prognosis was listed as poor, a hospice consult was ordered. Hospital clinical notes dated 12/21/16 indicated that the resident was discharged to a hospice house for pain management and end of life services. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. It is difficult to predict, diagnose, and treat. Patients who [MEDICAL CONDITION] have an increased risk of complications and death. www.cdc.gov. Center for Disease Control and Prevention Online. 16 Sept. 2016. [MEDICAL CONDITION] is a diffuse, acute bacterial infection of the skin and subcutaneous tissue characterized most commonly by local heat, redness, pain, and swelling and occasionally by fever, malaise, chills, and headache. Abscess and tissue destruction usually follow if antibiotics are not taken. The infection is more likely to develop in the presence of damaged skin, poor circulation, or diabetes mellitus . Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier. MRSA is a bacteria that is resistant to many antibiotics. www.cdc.gov Center for Disease Control and Prevention Online.) Bacteremia is the presence of bacteria in blood. McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc. On 12/16/16 hospital staff met with the resident's family. Per the family, resident had some dementia but was pretty independent at home. The resident used a front wheeled walker for ambulation and could complete most activities of daily living without assistance. The resident was only in the nursing home for rehabilitation a for recent hip and right upper extremity injury. 2. Resident #116 was admitted to the facility on [DATE] and goes to the [MEDICAL TREATMENT] Center three times a week for [MEDICAL TREATMENT] treatments. The facility failed to interchange information with the [MEDICAL TREATMENT] Center necessary for the resident's care and failed to monitor the resident's fluid restriction. Review of resident #116's medical record noted that the attending physician had ordered Milk of Magnesia (MOM), 30 milliliters (ml), to be given as needed for constipation and [MEDICATION NAME] suppository, 10 milligrams (mg) to be given as needed. The physician also ordered Fleets Enema, as needed, if no result from the MOM and suppository. On 1/24/17 at 2:03 PM the resident's Direct Care Licensed Practical Nurse (LPN) II explained the facility's communication process with the [MEDICAL TREATMENT] Center. She explained that on the morning of the [MEDICAL TREATMENT] there is a form that the nursing home staff fill out and that form goes with the resident to the [MEDICAL TREATMENT] Center. The [MEDICAL TREATMENT] Center will fill out their section and the form comes back to the nursing home when the resident returns. The form is put in the [MEDICAL TREATMENT] Communication Book. LPN II stated that she checks the resident [MEDICAL TREATMENT] access for bruit and thrill, but she was not aware that MOM was contraindicated for [MEDICAL TREATMENT] residents. On 1/24/17 a call was placed to the resident's [MEDICAL TREATMENT] Center. The [MEDICAL TREATMENT] charge nurse stated that resident #116 should not get MOM. The resident's other medications were discussed with the [MEDICAL TREATMENT] charge nurse and she stated the resident should not be getting the Fleets Enema. The [MEDICAL TREATMENT] charge nurse stated that the [MEDICAL TREATMENT] Center did not have the MOM or the Fleets Enema on the resident's list of home medications. Further review of the medical record revealed that there was a physician's telephone order dated 1/06/17 that indicated the resident was to be on a 1,000 ml fluid restriction. On 1/24/17 at 12:36 PM, resident #116 was in the Main Dining Room eating lunch. She was eating a chicken salad sandwich and she had a 12 (353.88 ml) to 16 (473 ml) ounce bottle of black cherry flavored water. The resident stated she can't have coffee or orange juice and that she buys the flavored water her self by the twelve Pak. On 1/24/17 at 1:25 PM, Certified Nursing Assistant (CNA #E) that her and (CNA #K) worked in the Main Dining room during lunch today. CNA #E and CNA #K work on the facility's West Wing and resident #116 resides on the East Wing. CNA #E stated that after the meal the meal tray tickets are thrown away. She stated that had not documented her resident intake meal percentage yet. CNA #E could not explain how and by whom the meal percentage intake is documented for East Wing residents that eat in the main dining room. CNA #E stated that no one that ate in the Main Dining room that day was on a special diet or a fluid restriction. On 1/24/17 at 2:40 PM, resident #116's direct care CNA explained how resident food and fluid intake is documented in the Activities of Daily Living Book. The CNA explained that the following codes for food intake consumed: G = 75-100% F = 50-74% P = 25-49% R = 0-24% The CNA indicated that the actual fluids consumed are not documented. The nurses aide document how many times a resident was offered fluid. On 1/24/16 at 2:45 PM the resident's fluid restriction was discussed with the facility's Registered Dietician (RD) and Assistant Director of Nursing. The RD stated that the kitchen sends out fluid on the residents' meal trays and then nursing staff provide fluids as well. The staff were informed that in the Main Dining room fluids are not on the residents' meal trays. The CNAs in the Main Dining room pour out fluid from pitchers for each resident. The staff had no answer when they were asked how are the CNAs in the main dining room going to know how much fluid to give a resident on a fluid restriction. On 1/26/16 at 12:55 PM the RD detailed the breakdown of the residents fluid restriction. She stated that 600 ml would come from dietary and 400 ml would come from nursing. The 600 ml was divided between Breakfast, Lunch and Dinner. The resident was only to get 120 ml of fluid for lunch. The 400 ml is divided between all three nursing shifts. The RD stated the fluid provided by nursing was for medications and a 240 ml Nepro supplement. The RD did not account for the resident's personal beverages that she purchases herself or the fluids given to the resident by CNAs between meals. On 1/27/16 at 4:42 PM stated that she usually eats lunch and dinner in the Main Dining Room but eats breakfast in her room. She stated that fluids do not come on her meal tray in the Main Dining Room. She stated the staff in the Main Dining Room pour fluids from pitchers and you ask for what you want. At breakfast she will drink her own beverages or ask the staff for hot chocolate. The resident also stated that the CNAs pass out water in white Styrofoam cups. The resident stated she does not like the Styrofoam cup, so she pours the water into her personal plastic tumbler. On 1/27/17 at 5:13 PM the East Wing Unit Manager (EWUM) stated that water is passed out by the nursing staff and not by the kitchen. In the supply room the EWUM retrieved a white Styrofoam cup. This cup is 16 ounces which equates to 473 ml of fluid. The facility did not have a process to account for how much fluid resident #116 was drinking each day. The staff would not be able to determine if the resident was actually meeting the physician's orders [REDACTED]. The staff did not ensure that the kitchen, nursing and CNAs were working together to manage resident #116's fluid restriction. Level of harm - Immediate jeopardy Residents Affected - Few F 0314 Level of harm - Immediate jeopardy Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent an avoidable pressure ulcer and failed to provide Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 10 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0314 (continued... from page 10) treatment for [REDACTED].#258). Resident #258 did not receive necessary care to prevent an avoidable stage IV pressure ulcer to her right elbow. She developed a painful stage IV pressure ulcer that became infected and exposed the bone and hardware from surgery to her right elbow requiring re-hospitalization within 16 days of admission. She was diagnosed with [REDACTED].[MEDICAL CONDITION] is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. www.cdc.gov/sepsis. The failure to assess and implement preventive measures for pressure ulcer development resulted in Immediate Jeopardy, starting on 11/29/16 with Substandard Quality of Care. The Immediate Jeopardy was ongoing as of 1/28/17. Based on observation, interview, and record review the facility failed to identify the accurate stage of pressure ulcer for 1 of 6 residents reviewed for pressure ulcers (#95). Findings: Resident #258 was a [AGE] year-old female that was admitted to the nursing home on 11/29/16 for surgical aftercare. She fell at home, sustained a right hip and right elbow fracture, and was hospitalized from [DATE] to 11/29/16. The hospital record revealed that the resident had an open reduction internal fixation (ORIF) surgical repairs to the right hip and right elbow. ORIF is a type of surgery in which the fractured bones are stabilized and are fixed in place by screws, plates, wires, or nails. (www.hopkinsmedicine.org) The admitting nurses' note dated 11/29/16 documented the resident had blister on the coccyx, the right upper extremity was in a soft cast and sling, the right hip had 8 staples and 3 staples (in the right thigh), and she had an abrasion to the right posterior thigh. The note did not contain any observation or description of the right elbow or the coccyx. On 1/27/17 at 11:10 AM, the occupational therapist described splint to resident #258's right arm. The resident had staples to the incisions on her elbow with a dressing. She had a hard support/removable splint that ran from her mid forearm and curved around the end of her elbow that was held in place with an ace wrap. Her right arm was immobilized with a sling at all times. On 1/27/17 at 4 PM, RN N stated she did not assess the resident's right arm when she was admitted on [DATE]. She confirmed that she did not have any wound care orders for any of the resident's wounds upon admission, and she did not call the attending physician to obtain orders. She said she did not remove the splint and dressing to the right elbow because she did not have any physician's orders [REDACTED]. Review of the physicians orders' and treatment record for November indicated the resident did not receive any treatment to the right elbow. Review of the physicians orders' and treatment record for December revealed inconsistent and inaccurate evidence of any treatment to the right elbow. Review of the physicians orders' and treatment record for November and December revealed the blister pressure wound on the coccyx did not receive any treatment. Review of the Minimum Data Set assessment dated [DATE]. Under Section I, Musculoskeletal that the resident has a fracture. Her active [DIAGNOSES REDACTED]. The Skin/Wound care plan was implemented on 12/07/16. The etiology was listed as fragile skin, impaired mobility, R (right) Hip Fx (fracture) ORIF (Open Reduction Internal Fixation), R Fx Elbow ORIF NWB (Non-Weight Bearing), Pressure Ulcer coccyx. As Evidenced By (AEB): Surgical Wound. The goals were: The resident will have intact skin, free of redness, blisters or discoloration through next review, The resident will not develop additional skin integrity problems or wounds through next review, The resident will be free from impaired skin integrity through next review. The Interventions were listed as: Administer medications as ordered, Inform the physician of any new area of skin breakdown, Notify nurse of any new area of skin breakdown: Redness, Blisters, and Bruises, discoloration noted during bath or daily care, Observe for pain during treatment. Treat pain as per orders prior to treatment to ensure the residents comfort, Observe skin areas around (R soft) casts, splints, adaptive devices. Remove as needed to check skin condition. Use Sling, Weekly Skin Checks, Notify physician for change in condition, Keep Skin Clean and Dry. Review of the record revealed no evidence to support any of the interventions were implemented in regards to the goal of the care plan. The facility could not provide any documentation to support that they observed the residents skin areas around casts/splints and removed them as needed to check skin conditions. The facility did not complete weekly skin checks of the resident's elbow or the coccyx. The record contained no evidence of any treatment to the resident's coccyx stage II pressure ulcer. There was no evidence of any treatment to prevent a pressure to the right elbow even though the facility was aware the resident had risk factors for developing a pressure ulcer. Resident #258 was seen by the attending physician or the physician assistant a total of 6 times during her stay in the nursing home. No orders for care or treatment to the right elbow or coccyx were written during those visits. On 1/27/16 at 4:40 PM the attending physician confirmed he saw the resident during her stay, but he did not examine her elbow wound, and did not give wound care orders upon admission. A review of the Weekly Skin Integrity Review sheets revealed the resident's wound on her elbow was not documented and it was not observed per the plan of care for skin integrity. Nursing staff failed to follow their policy and procedures (P&P) for Physician Orders/admission orders [REDACTED]. Nursing staff failed to transcribe all orders from the transfer form to the facility admission physician order [REDACTED]. The nurse did not document the date, time, physician's name or that the orders were confirmed on the facilities order form. The nurse also did not obtain orders for the residents wound care for her elbow or coccyx. The Pressure Ulcer Record Policy, Effective Date 11/30/14 read .document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the site is healed. Procedure: Residents will have a Pressure Ulcer Record completed for each skin impairment that is related to Pressure. - Mark the pressure area on the body description identifying the site. - Enter the date - Enter the stage of the pressure ulcer - Enter the size of the pressure ulcer - length x width x depth in centimeters - Enter the tissue type and color - Enter the wound edges and drainage - Enter the peri-wound information - Licensed nurse to sign the appropriate area On 12/14/16, the resident was seen outpatient by her surgeon. In a hospital note, dated 12/17/16 the surgeon referred to that office visit on 12/14/16, The residents dressing had not been changed and the patient was still wearing the same splint. None of the staples had been removed, and the resident now had an open pressure wound to the right elbow with hardware exposure. At the office visit the surgeon removed the staples to the incisions around her elbow and applied a new sterile dressing. The resident returned to the facility with new wound care orders. The surgeon ordered Hyperbaric treatment and a Wound VAC (vacuum assisted closure) for the resident pressure wound to the right elbow. The treatments were not initiated as ordered. On 1/25/17 at 3:25 PM the Unit Manager (UM) F stated that on 12/13/16 the resident #258 had drainage from the right elbow area. The UM said she called the attending physician and obtained orders to clean the right elbow wound with [MEDICATION NAME]. She said the doctor told her to remove the soft cast and she observed a stage III pressure wound. A stage III pressure ulcer is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. (State Operations Manual appendix PP guidance to Surveyors for Long Term Care Facilities). She indicated the staples were intact and that the pressure wound was not on a staple or the surgical suture lines. Her recollection of the events on 12/13/16 contradict the evidence from the surgeon who noted on 12/14/16 the dressing and splint had not been changed. The surgeon's note on 12/14/16 indicated the resident had a right elbow open wound and exposed metal hardware from her surgery to repair the fractured bone. This type of wound is not a stage III. It is classified as a stage IV pressure ulcer, Full thickness tissue loss with exposed bone, tendon or muscle. (State Operations Manual appendix PP guidance to Surveyors for Long Term Care Facilities). During her stay in the nursing home her condition deteriorated until on 12/15/16 the resident was found to be lethargic, short of breath, and had an altered mental status. She was transferred to the hospital via 911 for treatment. When the resident arrived at the hospital she was diagnosed with [REDACTED]. Her prognosis was listed as poor. She was transferred to a hospice house for pain management and end of life care. Level of harm - Immediate jeopardy Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 11 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0314 (continued... from page 11) Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. It is difficult to predict, diagnose, and treat. Patients who [MEDICAL CONDITION] have an increased risk of complications and death. www.cdc.gov. Center for Disease Control and Prevention Online. 16 Sept. 2016. [MEDICAL CONDITION] is a diffuse, acute bacterial infection of the skin and subcutaneous tissue characterized most commonly by local heat, redness, pain, and swelling and occasionally by fever, malaise, chills, and headache. Abscess and tissue destruction usually follow if antibiotics are not taken. The infection is more likely to develop in the presence of damaged skin, poor circulation, or diabetes mellitus . Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier. MRSA is a bacteria that is resistant to many antibiotics. www.cdc.gov Center for Disease Control and Prevention Online.) Bacteremia is the presence of bacteria in blood. McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc. 2. On 1/28/17 at 3:10 PM, a coccyx pressure ulcer treatment observation was conducted for resident #95 with the assistant director of clinical services (ADCS), Licensed Practical Nurse II, and Certified Nursing Assistant HH. The observation revealed that the coccyx pressure ulcer had yellow slough in the center of the wound bed obscuring the total depth of the wound. Review of the facility's pressure ulcer record grid for resident #95's coccyx pressure ulcer revealed that on 1/25/17, the pressure ulcer was measured at 2.5 (centimeters) cm in length times (x) 1.0 cm in width x 0 cm in depth. It was documented as an unstageable pressure ulcer. The unstageable status of the wound was validated by a wound care note dated 1/25/17 10:30 AM. The coccyx pressure ulcer grid also revealed that two days later, on 1/27/17, the pressure ulcer was measured at 4.0 cm in length x 2.0 cm in width and x 0 cm in depth. It was documented as a stage III pressure ulcer. Review of wound care rounding nurse's note written by the unit manager on 1/28/17 at 9:30 AM, revealed that the primary physician was called and told that the stage of the coccyx pressure ulcer was changed to a stage III. (Per the National Pressure Ulcer Advisory Panel, NPUAP, and unstageable pressure injury is: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed ) (Per the CMS guidelines a Stage III pressure ulcer is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) On 1/27/17 at 4:00 PM, interview with resident #95's RN unit manager while reviewing the resident's pressure ulcer grid stated that the wound care physician had staged the pressure ulcer on 1/25/17 as unstageable because it had slough in it. The unit manager stated that she had rounded with the wound care physician when she staged it. She stated that she had written the 1/25/17 at 10:30 AM above nursing note. She then stated that the director of nursing (DON) and she had then restaged the pressure ulcer as a Stage III on 1/27/17. She did not have an explanation as to why the DON had changed the unstageable staging done by the wound care physician, to a stage III. The unit manager then stated that she had called the primary physician on 1/28/17 and described the coccyx wound over the phone to him and told him that they had restaged it to a stage III. Review of the wound rounding nursing note dated 1/28/17 at 9:30 AM validated that the unit manger had written the note and had called the physician to notify him of the change. She stated that the primary physician had told her it would be a stage III if it had slough. She stated that he never saw the pressure ulcer to determine the stage, just that she had described it over the phone. The unit manager stated that she had not really been trained with staging pressure ulcers, just had pressure ulcer prevention training. On 1/28/17 at about 4:30 PM, interview with the ADCS, who had been present during the 3:10 PM pressure ulcer treatment observation for resident #95, validated that there yellow slough in the wound bed and to the extent that it had obscured the total depth of the wound and was not a stage III. She stated that it was unstageable coccyx pressure ulcer and that she was an accredited wound care nurse. Level of harm - Immediate jeopardy Residents Affected - Few F 0318 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that residents with reduced range of motion get propertreatment and services to increase range of motion. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 of 1 sampled residents reviewed for positioning received appropriate placement of positioning devices to prevent decrease in range of motion (#3). Findings: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum (MDS) data set [DATE], reflected the resident was totally dependent on staff for bed mobility, transfer, and locomotion on and off the unit. The resident does not walk on his own but uses a wheelchair with the assistance of staff. On 1/23/17 at 2 PM, the resident was observed in the hallway in his wheelchair near his room. The resident has difficulty articulating and was motioning and pointing down at his feet. The Foot Drop Pad was incorrectly attached to the wheelchair and the front end of the pad was on the ground. The resident's feet were dangling and his heels were barely touching the front end of the Foot Drop Pad A nearby certified nursing assistant (CNA) was instructed to get a therapist. About 8 minutes later, two other CNAs arrived and the therapist arrived after them. The two CNAs attempted to adjusted the Foot Drop Pad, and the therapist confirmed that the Foot Drop Pad was not attached to the wheelchair correctly. A Foot Drop Pad has two surfaces, and when positioned correctly, the two surface are at 90 degrees and form a solid foot rest. After several minutes, staff was able to correctly attach the Foot Drop Pad to the wheelchair and position the resident's feet on the pad. The therapist stated that the resident is still on their therapy case load, and the therapy staff train the CNAs and nurses how to apply positioning devices. On 1/23/17 at 2:30 PM, the resident's direct care nurse and direct care CNA were interviewed. The CNA stated that she placed the resident in the wheelchair at 1 PM that day. She stated that resident is a mechanical lift transfer from bed to wheelchair. The CNA did not answer when she was asked how the Foot Drop Pad should be attached to the resident's wheelchair. On 1/25/17 at 1:47 PM, the Rehabilitation director stated that resident #3's Drop Foot Pad was implemented last Friday, 1/20/17. She added that the CNA staff have now been in-serviced on how to apply/attach the Foot Drop Pad to the wheelchair and how to position the resident's feet. The Rehab Director stated that the Therapy Department would provide further in-services, to the CNAs/floor staff, for positioning as needed. F 0334 Develop policies and procedures for influenza and pneumococcal immunizations. Level of harm - Minimal harm or potential for actual harm Based on observations, staff interviews and medical record review, the facility failed to ensure that all residents identified as needing influenza and or pneumococcal immunizations received such immunizations within the timeline for 2 of 10 sampled residents (#24 & 81). Findings: 1. Resident #24's medical record did not contain consent for influenza and pneumonia immunizations. The Infection Control Practitioner, Nurse Manager I, confirmed the finding on 1/27/17 at 8:45 AM. 2. Resident #81's medical record contained a signed consent for vaccines but not dated. Nurse Manager M validated that the consent was not dated. The medical record reflected the resident received the pneumonia vaccine in November 2016 and the Influenza vaccine in October 2016. On 1/26/17 at 9 AM, the Infection Control Practitioner stated that the facility procedure for obtaining a consent for vaccines was to have the resident sign and date a two sided consent form during the admission process. If resident is confused, the facility speaks with the family member. The facility educates residents and family about the importance of the immunization but does not force any one to receive the vaccine. She said that every year the pharmacy alerts the nurses when long-term care residents are due for the vaccine, and the nurses speak to the residents or families and obtain a new consent for the vaccine. On 1/27/17 at 9 AM, the Infection Control Practitioner could not relay how the facility knows this consent was for the current year. Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 12 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0334 (continued... from page 12) Level of harm - Minimal harm or potential for actual harm Residents Affected - Few F 0353 Level of harm - Immediate jeopardy Residents Affected - Few FORM CMS-2567(02-99) Have enough nurses to care for every resident in a way that maximizes the resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed ensure the nursing staff demonstrated appropriate competencies and skill sets relating to surgical wound care, prevention of pressure ulcers, care and treatment for [REDACTED].#258 & 95). Resident #258 did not receive the necessary treatment and care to her surgical wounds to prevent the deterioration of her condition. The resident endured severe pain and required re-hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her right elbow. The resident was diagnosed with [REDACTED].[MEDICAL CONDITION] is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. www.cdc.gov/sepsis. The failure of the nursing staff to demonstrate the competency and skill to promote residents' physical, mental and psychosocial well-being resulted in Immediate Jeopardy, starting on 11/29/16 with Substandard Quality of Care. The Immediate Jeopardy was ongoing as of 1/28/17. Based on observation, interview, and record review, the facility failed to ensure 1 of 1 residents reviewed for positioning received appropriate placement of positioning devices to prevent decrease in range of motion (#3). Findings: Cross reference to F224, F281, F309, F314, F318. Resident #258 was a [AGE] year-old female who was admitted to the nursing home on 11/29/16 for surgical aftercare. She fell at home, sustained a right hip and right elbow fracture, and was hospitalized from [DATE] to 11/29/16. The hospital record revealed that the resident had an open reduction internal fixation (ORIF) surgical repairs to the right hip and right elbow resulting in 3 incisions with staples to the right hip, right thigh, and right elbow. ORIF is a type of surgery in which the fractured bones are stabilized and are fixed in place by screws, plates, wires, or nails. (www.hopkinsmedicine.org) Registered Nurse (RN) N, admitted resident #258, to the facility on [DATE] at 7:30 PM. She documented that the resident had 3 surgical wounds, one to the right elbow and two incisions to the right hip/thigh. She had an abrasion to the right posterior thigh and a blister on her coccyx. RN N, did not provide a description of the wounds, presence of redness or drainage, the amount of staples, or the condition of the wounds/incision. The resident arrived at the facility without any wound care orders or interventions listed on her hospital discharge paperwork. On 1/25/17 at 3:25 PM the Unit Manager, RN M, stated that the resident did not have any wound treatment orders for the right elbow at admission. She indicated that the RN N, did not assess the wound. RN M stated that every day new admissions from the day before are reviewed at the morning meeting. She stated that both the Director of Nursing (DON) and Assistant Director of Nursing are at the morning meeting as part of the review team. She said that the admission paper work from the hospital is reviewed to determine what is missing and what needs to be done. There was no evidence the nurse review team found that resident #258 did not have wound care orders for the right elbow and that the resident needed a follow up appointment with the Orthopedic Surgeon within 1 week of discharge from the hospital. The facility failed to keep residents free from neglect by failing to provide care and services for treatment of [REDACTED]. Resident #258 did not receive the necessary treatment and care to prevent a painful and infected pressure ulcer wound to her right elbow for 15 days. As a result of this neglect, the resident endured severe pain and required re-hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her right elbow. The resident was diagnosed with [REDACTED].[MEDICAL CONDITION] is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. www.cdc.gov/sepsis. The facility failed to provide nursing care to meet professional standards of quality. Resident #258 did not receive quality nursing treatment and care for surgical wounds and prevention of a painful, infected pressure ulcer. As a result of the lack of professional nursing judgement and failure to follow nursing policies and procedures and care plans, the resident required hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her elbow. The resident was diagnosed with [REDACTED]. The facility failed to provide necessary treatment and care for wound care, pain management, and skin care management to maintain the highest practicable well-being. The resident endured severe pain as the worst pain you can imagine and it was not adequately relieved. Resident #258 did not receive necessary care to prevent an avoidable stage IV pressure ulcer to her right elbow. She developed a painful stage IV pressure ulcer that became infected and exposed the bone and hardware from surgery to her right elbow requiring re-hospitalization within 16 days of admission. She was diagnosed with [REDACTED]. Resident #95 did not receive accurate staging of a pressure ulcer to the coccyx. On 1/27/17 at 4:00 PM, interview with resident #95's RN unit manager while reviewing the resident's pressure ulcer grid, she stated that the wound care physician had staged the pressure ulcer on 1/25/17 as unstageable. She then stated that the DON restaged the pressure ulcer as a Stage III on 1/27/17. She did not have an explanation as to why the DON had changed the staging done by the wound care physician. The unit manager stated that she had not really been trained with staging pressure ulcers. On 1/28/17 at 1:55 PM, RN I said the nurses complete wound care demonstration upon hire and they do not demonstrate any other competencies unless a problem is identified. The nursing staff did not provide the care, services and treatments as listed in the interventions sections on the Care Plans for skin/wounds and pain. The nursing staff did not follow the policies and procedures for Admissions Assessment, Physician Orders/admission orders [REDACTED]. The medical record revealed conflicting and contradicting documentation of treatment to wounds to include treatment to the wrong site and treatment performed without physician order. The resident experienced excruciating pain with inadequate pain management. The nursing staff did not communicate with the attending, medical director, and orthopedic surgeon for orders for care and treatment for [REDACTED]. On 1/25/17 at 4:45 PM, the Director of Nursing (DON) stated she did not speak with the RN N about the admission, but she spoke with the Unit Manager F. She indicated that her investigation demonstrated that the facility did their due diligence in setting up the follow up appointment with the surgeon to meet the resident's needs. The DON did not acknowledge the failure to follow the standards of practice according to the Florida Nurse Practice Act and the American Nurses Association Standards for incomplete admission orders [REDACTED]. She said that the facility was not to be blamed for the resident's lack of wound care to the right elbow and that the fault should be placed upon the orthopedic surgeon's office for delay in the follow up appointment. On 12/15/16, the resident's condition deteriorated so that she was found to be lethargic, short of breath, and had an altered mental status. She was transferred to the hospital via 911 for treatment. When the resident arrived at the hospital she was diagnosed with [REDACTED]. Her prognosis was listed as poor, a hospice consult was ordered. A hospital assessment dated [DATE] at 21:55 noted that the resident appears to uncomfortable, unkempt and uncooperative. The resident smelled of urine and foul odor. Hospital records indicated on 12/16/16, the hospital staff met with the resident's family. Prior to her admission to the nursing home they said the resident had some dementia but was pretty independent at home. The resident used a front wheeled walker for ambulation and completed most of her activities of daily living without assistance. The resident went to the nursing home for rehabilitation for her recent hip and right upper extremity injury. Hospital clinical notes dated 12/21/16 indicated that the resident was discharged to a hospice house for pain management and end of life services. On 1/23/17 at 2 PM, resident #3 was observed in the hallway in his wheelchair near his room. The resident was motioning and pointing down at his feet. The Foot Drop Pad was incorrectly attached to the wheelchair and the front end of the pad was on the ground. The resident's feet were dangling and his heels were barely touching the front end of the Foot Drop Pad A nearby certified nursing assistant (CNA) was instructed to get a therapist. About 8 minutes later, two other CNAs arrived and the therapist arrived after them. The two CNAs attempted to adjusted the Foot Drop Pad, and the therapist confirmed that the Foot Drop Pad was not attached to the wheelchair correctly. On 1/25/17 at 1:47 PM, the Rehabilitation director stated that resident #3's Drop Foot Pad was implemented last Friday, 1/20/17. Staff had not received training for proper Event ID: YL1O11 Facility ID: 105861 If continuation sheet Previous Versions Obsolete Page 13 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0353 (continued... from page 13) application of the positioning device-foot drop pad. Level of harm - Immediate jeopardy Residents Affected - Few F 0363 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. Based on observation, record review and interview, the facility failed to follow the menu for lunch on 1/22/17. Findings: On 1/22/17 at 11 AM, observation of the kitchen found corn, chicken breast and rice on the steam table. Review of the facility menu revealed that the lunch alternate meal for 12/22/17 would consist of grilled chicken breast, rice and Brussel sprouts. The menu indicated that the desert for the lunch meal would be chocolate cake with frosting. On 1/22/17 at 11:30 AM, the lunch tray line was observed. The cook had placed all the food on the steam table but there Brussel sprouts was not on the steam table and the chocolate cake did not have any frosting. At that time, the Certified Dietary Manager (CDM) stated the cook had informed her that they were out of Brussel sprouts. The CDM confirmed that the cake did not have any frosting. On 1/22/17 at 11:55 AM, the walk-in freezer was observed with the CDM and Regional Manager. In the freezer was a case of Brussel sprouts. The CDM and Regional Manager confirmed that the case of Brussel sprouts would have been enough for the lunch alternate meal. Several minutes later, cake frosting was found on the self the dry storage area. F 0366 Offer other nutritional food to each resident who will not eat the food served. Level of harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the facility failed to substitute food of the same nutritional value. Findings: On 1/22/17 at 11 AM, the cook stated that ham, peas and sweet potatoes would be served for lunch today. Review of the facility menu revealed that the alternate meal would be grilled chicken breast, rice and Brussel sprouts. On 1/22/17 at 11:30 AM, the food for lunch was on the steam table except for Brussel sprouts. At that time, the Certified Dietary Manager (CDM) stated that the cook had informed her that the facility was out of Brussel sprouts and that the cook had substituted the Brussel sprouts with corn. The CDM confirmed that the corn did not have the same nutritional value as Brussel sprouts. Brussel sprouts are a good source of Vitamin K and Vitamin C. A serving of Brussel sprouts provides 24% of the daily value for Vitamin A and Folate. In contrast, corn in negligible for Vitamin K, Vitamin C, Vitamin A and Folate when compared to Brussel sprouts. On 1/22/17 at 11:55 AM, the walk-in freezer was observed with the CDM and Regional Manager. A case of Brussel sprouts was on the self. The facility also had Broccoli in the walk-in freezer, which would have been a better substitute instead of the corn. Residents Affected - Some F 0371 Store, cook, and serve food in a safe and clean way Level of harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to serve and store food under sanitary conditions. Findings: On 1/22/17 at 11 AM, an initial kitchen inspection was conducted. the following observations were seen: 1. On the steam table was corn, rice and chicken breast. The cook stated that food on the steam table is for the alternate meal and the main lunch meal would consist of ham, peas and sweet potatoes. The cook stated the lunch tray line would start at 11:25 AM. 2. The walk-in freezer was zero (0) degrees Fahrenheit and all foods were solidly frozen. However, boxes of food items were on the freezer floor. There was no indication the facility received a delivery that day, and staff were not actively putting the boxes on the freezer shelves. Food needs to be stored six inches from the ground. 3. In one of the prep areas, dietary aide A was platting chocolate cake. Review of the facility menu indicated chocolate cake with frosting would be the desert for lunch. Dietary aide A had a full beard but did not wear a beard guard/restraint. Dietary Aide B was in the kitchen, had a full beard but did not wear a beard guard/restraint. Dietary Aide B also had a 'U' shaped nose piercing sticking out from the center of his nose. Dietary aide C had facial hair and did not wear a beard/restraint. 4. At 11:30 AM, the cook placed the food on the steam table and started to take holding temperatures. At that moment, the Certified Dietary Manger (CDM) arrived and told one of the male dietary aides to put on a beard guard/restraint. Using the facility's bayonet style thermometer, the cook pierced through several pieces of sliced ham and stated the holding temperature was 161 degrees Fahrenheit. The cook was instructed to take the temperature of one piece of ham and the holding temperature dropped to 131 degrees Fahrenheit. The CDM told the cook to reheat the ham. The holding temperatures of the green peas and puree sweet potatoes was 116 degrees Fahrenheit and 112 degrees Fahrenheit, respectively. The temperature for hot food holding should be 135 degrees Fahrenheit or greater. The CDM instructed the cook to reheat the green peas and puree sweet potatoes. The CDM was asked why the dietary aides were not wearing beard guard/restraints but did not know. At 11:55 AM, the walk-in freezer was observed with the CDM and Regional Manager. The staff could not explain why there were several boxes of food on the floor of the freezer. There was cake mix in white package that had dark chocolate like stains in the dry storage area. The regional manager threw out the cake mix. On the shelf were three clear wrap packages of tortillas. One of the tortilla packages was open but was not dated or labeled. The Regional Manager threw out the open tortilla package, as well. Residents Affected - Many F 0372 Dispose of garbage and refuse properly. Level of harm - Minimal harm or potential for actual harm Based on observation and interview the facility failed to maintain the dumpsters and the surrounding areas in a clean and sanitary manner. Finding: On 1/22/17 at 11 AM, the initial kitchen inspection was conducted. At approximately 11:25 PM, the facility's dumpsters were observed with dietary aide C. The lids of the first dumpster were open and there were several bags of garbage in the dumpster. The dietary aide could not explain why the dumpster doors were open and he did not attempt to rectify the issue. Dietary aide C stated he needed to go back to the kitchen because he had to prepare beverages for the lunch meal. The area surrounding dumpster #1 had an empty milk carton, plastic spoons, individual condiment packages and other paper debris on the ground. The facility's second dumpster doors were open. A closer observation on this dumpster revealed that one of the dumpster doors was completely missing. There were several garbage bags in this dumpster and the surrounding area was not clean. On the ground was empty milk cartons, an aluminum beverage can and paper debris. At approximately 12:20 PM, the both dumpster were observed again with the Regional Manager. He confirmed that the dumpster lids were open and that dumpster #2 had a missing lid. Residents Affected - Many F 0385 Level of harm - Immediate jeopardy Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Make sure that a doctor approves a resident's admission in writing and that each resident remains under the care of a doctor. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a physician was participating and supervising the medical care for 1 of 12 sampled residents reviewed for wound care (#258). Resident #258 did not have orders for wound care and treatment upon admission to the facility. The attending physician did Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 14 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0385 (continued... from page 14) not provide treatment for [REDACTED]. Resident #258 did not receive treatment to a right elbow surgical wound and developed a painful, infected pressure ulcer that exposed the bone and hardware from surgery to her elbow. The resident became septic, was hospitalized and then transferred to a hospice house for end of life care. The failure to ensure that a physician was participating and supervising medical care for resident #258 resulted in Immediate Jeopardy starting on 11/29/16. Immediate Jeopardy was ongoing as of 1/28/17. Finding: On 11/29/16, resident #258 was transferred from the hospital to the nursing home. Prior to her hospital admission, the resident fell at home fracturing her right hip and right elbow. The resident was status [REDACTED]. ORIF is a type of surgery in which the fractured bones are stabilized and are fixed in place by screws, plates, wires, or nails. (www.hopkinsmedicine.org) The physician's orders [REDACTED]. Orders were present for daily wound care to the left hip, but the resident's surgical wounds were not on the left hip, they were on the right. Orders were also present for a posterior left thigh abrasion, but the abrasion was on the right thigh. Hospital discharge instructions that came with the resident to the nursing home indicated that the resident was to follow with the orthopedic surgeon in one week. Other instructions in the hospital records dated 11/24/16 indicated the resident's pain was under control at that time and the staples to the ORIF to the right hip and right elbow were to be taken out by rehab (facility) in 10-12 days. On 1/27/17 at 4:00 PM, registered nurse (RN) N stated that upon admission, the resident's right elbow was in a soft cast and sling. She confirmed that there were no orders for care and treatment for [REDACTED]. RN N indicated that she did not observe the resident's right elbow area because she did not have a physician's orders [REDACTED]. She said that the Unit Manager (UM) F should have followed up with the physician to get treatment orders for the right elbow and follow up appointment with the orthopedic surgeon. The Attending Physician's (AP) progress note dated 11/30/16 documented that the resident's right elbow was in an immobilizer. The AP noted the right hip and right elbow were status [REDACTED]. There was no documentation of any follow up appointment with the orthopedic surgeon. The AP's progress note dated 12/02/16 documented that the visit was unremarkable and to continue current medications and therapy. There was no documentation of any communication regarding any treatment for [REDACTED].#258. On the 12/05/16, the Physician Assistant (PA) saw the resident. The PA noted, Ongoing follow up for the patient on the current regimen. Continue Physical therapy. Monitor labs. Continue present medications. On the 12/07/16, the PA noted no new complaints from the resident and that she is showing slow progress in physical therapy. The PA noted to continue present medications and therapy. The PA did not note any new wounds the resident acquired or if the Wound Care Physician (WCP) was treating any of the resident #258's wounds. The note did not indicate there was any communication regarding the lack of orders for the resident's wounds or the resident crying out in pain. A WCP progress note dated 12/07/16, indicated the resident had a new open blister to the right posterior thigh. The WCD noted that the UM F asked her to evaluate and treat an area of concern to the posterior right thigh. The WCP ordered to clean wound with normal saline, pat dry and apply Xeroform gauze and a dry dressing, every day and as needed. The WCP noted that the resident had an ORIF to the right hip and right elbow, but did not examine or treat those areas. The PA's progress note dated 12/12/16 indicated that the resident's husband stated that his wife was not eating food. The PA ordered nutritional shakes between meals and a Dietitian consult. The PA wrote to continue present medications, labs and therapy. There were no new wound care orders or attempts to discuss wound care orders with the orthopedic surgeon even though neither the attending physician, nor the wound care doctor were treating and monitoring the resident's wounds and pain management. On 12/14/16, the PA noted the resident was to have a follow up appointment with the orthopedic physician that day. The PA noted the resident was uncooperative with transfers, but it did not include any documentation of pain despite the nurses notes indicated the resident was crying out in pain and received no relief from medication. The note documented that the resident denied any new complaints. The note did not indicate any communication regarding the resident's lack of wound care. In the afternoon on 12/14/16, the resident had her follow up appointment with the orthopedic surgeon at his office. The resident returned to the nursing home with the surgeon's progress note and new wound treatment orders. The surgeon noted, post op R (right) elbow ORIF now has pressure wound from splint. The wound treatment orders for the right elbow were: 1) hyperbaric treatment to right elbow, 2) wound vac to right elbow wound, 3) physical therapy and range of motion only to right elbow, 4) no splint on right elbow. Later that evening on 12/15/16 at 5 PM, the nurse's note indicated that the resident was restless and grimacing in pain. The dressing to the right elbow was saturated and the dressing was changed. The area was noted to be red and warm to touch and the nurse called the AP. The AP did not answer the phone at that time. Two and half hours later at 7:30 PM, the AP called back and informed the nurse that the resident's sodium was very high. The physician gave new orders to send the resident to hospital 911. The nurse noted that the resident appeared to be lethargic, had labored breathing and altered mental status. At 8 PM, the nurses' note indicated the resident was transferred to hospital via stretcher by the emergency medical services (EMS). The hospital assessment dated [DATE] at 9:55 PM noted that the resident appeared to be uncomfortable, unkempt and uncooperative. The resident smelled of urine and foul odor. The resident presented with a right elbow open wound and exposed metal hardware. The site was red and hot to touch. The resident's admitting [DIAGNOSES REDACTED]. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. (www.cdc.gov/sepsis) [MEDICAL CONDITION] is a diffuse, acute bacterial infection of the skin and subcutaneous tissue characterized most commonly by local heat, redness, pain, and swelling and occasionally by fever, malaise, chills, and headache. Abscess and tissue destruction usually follow if antibiotics are not taken. The infection is more likely to develop in the presence of damaged skin, poor circulation, or diabetes mellitus . (Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier.) MRSA is a bacteria that is resistant to many antibiotics. (www.cdc.gov/mrsa) Bacteremia is the presence of bacteria in blood. (McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.) On 12/20/16 the hospital consult note read, Orthopedic consultation report noted from (orthopedic surgeon): History of Present Illness: The patient is known to (orthopedic surgeon) from previous admission with s/p (status [REDACTED]. She was seen in our office on Wednesday with X-rays. The patient had been in rehab at (nursing home). She was accompanied in the office by her family. The patient has severe dementia. When her dressing from the elbow was removed it was found that this had not been changed and the patient had been still wearing splint. She acquired a pressure wound to the R elbow. None of her staples had been removed. (orthopedic surgeon) saw the patient in the office. All staples were removed (to right elbow) and sterile dressing placed. Orders were written for (nursing home) for wound care and wound vac placement and PT/OT (physical therapy/occupational therapy). The patient presented yesterday to the ER (emergency room ) and was subsequently admitted and (orthopedic surgeon) was reconsulted. On 1/26/17 at 1:43 PM, the WCP indicated that she observed the resident #258's right elbow pressure wound on 12/15/17. The WCP stated that she was treating the resident's wound to the right leg and that the right elbow wound was not been referred to her until 12/15/17. The WCP indicated that the staff should have contacted the AP for any orders for the right elbow wound prior to 12/15/16. The WCP stated, I can only look at the wounds that they recommend me to look at. The lack of wound treatment orders for the right elbow was discussed with the WCP. The WCP stated that she can't come between (resident) and her surgeon. The WCP reviewed the telephone order dated 12/13/16. This order was for Xeroform to the staples/surgical incision and [MEDICATION NAME] for the pressure wound on the right elbow. The WCP stated that she did not give the order. She stressed, It is not my hand writing. The WCP added, I didn't sign it. I always sign my orders, and I didn't sign that, because I didn't give it. On 1/27/17 at 4:40 PM, the AP was contacted by phone. He stated that he did not look at the resident #258's right elbow, but remembered looking at the right hip. He stated there were wound treatment orders for the right hip, but not the right elbow. This contradicts the evidence in the record showing there were no orders for treatment to the right hip. The AP stated that initially there were no reports that the resident was having drainage from the right elbow. The AP stated that later there were reports about right elbow drainage and that the resident had a follow up with the Orthopedic Surgeon. He Level of harm - Immediate jeopardy Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 15 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0385 (continued... from page 15) stated that he was not sure that he ordered the [MEDICATION NAME] treatment to the right elbow, but said that he may have ordered it if there was drainage. The AP stated he did not recall if the nursing home staff informed him that the resident had a pressure sore on the right elbow. The AP acknowledged that there was a conflict of orders between the orthopedic surgeon and the WCP. The AP stated, ' .they were asking me to pick between two experts, and I couldn't make that decision. The AP stated the responsibility for the treatment to the wounds is with the Orthopedic surgeon in reference to the resident's right elbow. The AP stated that he talks with the nursing home's Medical Director off and on but he did not discuss resident #258 with the Medical Director. Resident #258 was seen by the attending physician or the physician assistant a total of 6 times during her stay in the nursing home. The physician did not supervise the care and treatment of [REDACTED]. The resident's condition the deteriorated until she became septic, was hospitalized , and then transferred to a hospice house for pain management and end of life care. Level of harm - Immediate jeopardy Residents Affected - Few F 0441 Level of harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567(02-99) Previous Versions Obsolete Have a program that investigates, controls and keeps infection from spreading. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy reviews, the facility failed to ensure hand sanitation during wound care for 2 of 12 sampled residents (#101 & 270). Facility staff failed to demonstrate knowledge and understanding of infection control practices for hand sanitation, care of resident equipment, resident environment, personal clothing and linens, and cleaning equipment in order to prevent cross contamination for all residents. Findings: 1. On 1/24/17 at 12:46 PM in the East wing medication room freezer were 3 frozen unlabeled water bottles, and one unlabeled TV dinner. The nurse manager confirmed there is to be nothing in this freezer. 2. Review of facility's Pharmacy Services and Procedures Manual under Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles. effective date 12/01/07 revision date 05/10/10, read, Facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medications and biological are stored. 2. On 1/24/17 at 9:35 AM on the Rehab Unit 700, 800 and 900 hallways, observation with the nurse manager found two red biohazard bags containing IV pumps awaiting pick up by pharmacy in the medication room. The nurse manager confirmed that the two red bags contained IV pumps used on residents, waiting return to the pharmacy. The nurse manager confirmed the facility process is to store the dirty equipment in the clean medication room. On 1/24/2017 at 10:18 AM, nurse HH stated, When we are done with IV pumps, we clean them and put them in whatever colored bag pharmacy sends us. Sometimes it is red and sometimes it is yellow. Sometimes we will place it on the desk at the nurses' station, in the dirty utility room, or in the mediation room, until pharmacy picks them up. On 1/24/2017 at 10:05 AM, the West wing nurse manager stated when the facility is done using the IV pump; staff bags it in red bag and places it in the dirty utility room. Then pharmacy picks it up. On 01/24/17 at 12:46 PM, the East wing nurse manager stated the IV pumps are returned to pharmacy when they are not in use. The IV pumps are cleaned and placed in red bag, then placed in the dirty utility room. Pharmacy picks them up from there. On 1/25/17 at 3 PM, the corporate nurse stated IV pumps are to be cleaned with bleach, wiped and placed in a red bag for pharmacy to pick up. The facility uses the red bags because they are heavier and tells pharmacy to clean the pump. She said the facility does not have a policy on cleaning equipment. When asked about yellow bags, she stated the facility does not use yellow bags. On 1/26/17 at 9 AM, registered nurse (RN) 1, who has worked at the facility for the last 7 months in the role of assistant director of nursing (ADON) and infection control nurse, said red bags mean the equipment is dirty and should be placed in dirty utility room. 3. On 1/22/17 between 12:20 PM and 1 PM, while watching dining in restorative and tray passing on hallway 400 and 700, staff did not wash their hands between residents. Three staff members were in the East wing dining room passing out trays, one staff member moved the resident's wheelchair, then picked up another resident's lunch tray off the cart, placed it in front of another resident, then assisted the resident with meal set up. Another staff member delivered a tray to a resident, assisted them with meal set up, and patted her on the shoulder. She then proceeded to pick up another resident tray and assisted that resident with cutting her meat. There was a sink located at the front of this dining room and hand sanitizer hanging on the wall next to the double doors. On 1/22/17 between 11:30 AM and 12:30 PM on the 400 halls and 700 halls, staff passed trays to residents dining in their rooms. Staff assisting a resident with set up of meal after moving items in the resident rooms and before they washed their hands. Staff touched items in one resident room, going to the tray cart, picked up another resident's tray, and delivered it. Staff did not wash their hands on either hallway. On 1/23/17 between 9 AM and 5 hallways 700, 800, 900 and East 400, 500, 600 were observed multiple times. Both certified nursing assistants (CNAs) and nurses carried solid linen and trash to the dirty utility room. The Dirty Utility door never closed, and staff were able to be observed in the room. Staff used one hand to punch in the code while holding trash/dirty linen in the other. Once inside the room, they lifted the lid on the trash/linen container and put linen/trash into it. Staff did not wash hands upon leaving the dirty utility room. The policy on Handwashing, effective date 9/06/2016 read, Purpose: To reduce the spread of germs in the healthcare setting. Process: Hand hygiene should be performed After contact with inanimate objects (including medical equipment) in the immediate patient vicinity On 1/26/17 at 4:25 PM, CNA AA, who has worked at the facility for one month, said, In orientation, they talked about hand washing and infection control. We are to wash our hands after each time we do anything with the resident. When we pass trays, we have are to wash our hands between residents. On 1/26/17 at 4:35 PM, CNA CC, who has worked at the facility for 3 years, said she does education annual, thinks her last education related to handwashing was about a month ago. She stated, We are to wash our hands before and after we do patient care. CNAs do not clean any equipment. On 1/26/17 at 9 AM, RN I, who has worked at the facility for the last 7 months in the role of ADON and infection control practitioner, stated when passing meal trays, hands are to be washed or sanitizer before tray passing on the units and in the dining room. Staff is to wash hands or use sanitizer between each tray pass if they have contact with any resident or equipment. She said red bags means the equipment is dirty and should be placed in dirty utility room. 4. On 1/26/17 at 11:45 AM, resident #101's dressing change by licensed practical nurse (LPN) U was observed. She did not wipe the resident's bedside table prior to placing three paper towels on the table. She washed her hands, donned gloves, pulled up the resident's pant leg, opened the sterile gauze dressing package, placed the gauze on the paper towels, removed the resident's old dressing, which had a large amount yellowish drainage, removed her gloves with the solid dressing inside, placed gloves in a clear plastic bag and then into the trash can. She started to replace the dressing but stopped, and went to bathroom to wash her hands again, donned clean gloves, then reached into her scrub jacket, pulled out her personal scissors and placed them on paper towel on bedside table. She then irrigated the wound with Normal Saline solution. Without cleaning her scissors, she cut the sterile wound dressing, which was then applied directly to the wound. She covered the site with a clean dressing, and dated it. She picked up her dirty supplies, put them in the clear plastic trash bag with the dirty dressing, tied it up, washed her hands, and took the dirty supply bag to the dirty utility room. She used her right hand to punch in the numbers on the key pad, while holding the dirty supplies in her left hand. She opened the dirty utility room and placed the dirty bag in the trashcan. The door to utility room never closed and was able to be observed that she did not wash her hands. LPN U then went back to her treatment cart, picked up her MAR/TAR (medication administration record/treatment administration record) book, walked back to her medication cart where another resident was standing. She started interaction with the resident, who asked for pain medication. LPN U unlocked her medication cart, reached into the cart to get the medication the resident had requested. LPN U never washed her hands or used hand sanitizer before she continued with her duties. On 1/27/17 at 09:15 AM, resident #101 was in bed lying on top of the sheets with blankets pulled back. The resident's right knee did not have a dressing on it and there was a small amount yellow drainage. LPN V was called to the room. He said the resident takes off the dressing sometimes. Nurse V was asked if he was going to cover the wound and stated, I will get to it. I am working my way down there. 5. On 1/26/17 at 2:45 PM, tour of the laundry room was conducted with the director of housekeeping. He said he has been at Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 16 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0441 (continued... from page 16) this facility for one year. Eight resident pillows were stacked on top of containers of cleaning chemicals. The director stated, I think these are to be thrown away Really not sure where those pillows came from. The director describe the process for cleaning mop heads. He said the mop heads were washed according to manufacturer's recommendation. They are not to be placed in a dryer. The mop heads are spun as dry as possible then placed in plastic bags which are then tied shut and place in the clean area of the laundry for the housekeeping staff to pick up the next morning and use while cleaning resident rooms and other areas of the facility. The director stated they do not have room to air dry mop heads. A table contained a large stack of unfolded residents' clothing half covered by a sheet. A rusted ceiling vent was located directly above the residents clothing. Four rust wet streaks ran down the wall toward the pile of residents clothing. The director said, I guess nothing except the sheet is protecting the residents' clothing but indicated he did not think the sheet would protect the clothing from the wet drainage. 6. Resident #270' medical record revealed she was admitted into the facility on [DATE] after an open reduction and internal fixation of an ankle fracture in three places, on 1/17/17. A physician's telephone order on 1/22/17, no time listed, read, DC (discontinue) previous treatment order to ankle. Cleanse incisions to right ankle with NS (normal saline). Pat to dry. Paint with [MEDICATION NAME], cover with abdominal (ABD) pads. Wrap with Kerlix and secure with tape. Change daily and prn (as needed). On 1/26/17 at 11:15 AM, observation was conducted of the wound care, performed by nurse U. She had the treatment cart outside of resident #270's room. She gathered some supplies and went into the resident's room. She went to put the supplies on the overbed table but there were items of the residents' on the table. Holding the supplies in one hand/arm, next to her body, she removed the items from the table, got a few paper towels from the bathroom and set it on the table. She did not completely cover the area on the table she was going to put the supplies on. She did not clean the area of the table where she was going to put her supplies. After setting these items on the table, she went to the bathroom to wash her hands. Nurse I was assisting her by holding up resident #270's right lower extremity (RLE). She donned a pair of gloves, took out a handful of 4x4 gauze pads from the community bag of 4x4s. These pads are not sterile individually wrapped. She held the bag with her left hand and took out the 4x4s with her right hand. She put the 4x4s into a plastic cup. She picked up a bottle of [MEDICATION NAME] and squeezed the liquid into the cup containing the 4x4s. She went to get her scissors to cut off the old dressing but she had forgotten them. As she said she needed to get her scissors, Nurse I took her scissors out of her pocket and handed them to her. She then to cut off the dressing on the resident's RLE, and put the dressing into a bag she had previously prepared. She got a squeezable vial of NS and a 4x4 and squeezed the NS onto both incision lines, one on each side of the ankle. She took dry 4x4s and patted the incision dry. She then picked up a couple of [MEDICATION NAME] soaked 4x4s and wiped one side of the ankle incision. She threw the 4x4 into the garbage bag. She grabbed another couple of [MEDICATION NAME] soaked 4x4s and wiped down the other side of the ankle where the incision was. She did all this while wearing the same pair of gloves. At this time, she took off her gloves and used hand sanitizer on her hands. While nurse U was doing the above, nurse I had on a pair of gloves. She held the resident's leg while nurse U did the dressing change. With the same gloves, nurse I took a couple of 4x4s out of the open bag and started to wash off dried [MEDICATION NAME] still present from surgery. She did not remove her gloves and wash her hands when she went back to holding the resident's leg. Nurse U donned another pair of and opened two bags of ABD pads. She placed one on each incision line on both sides of the ankle. Nurse I held the ABD pads in place while nurse U wrapped the area with Kerlix wrap. She secured the wrap in place with a strip of tape. She marked on it the date, time and her initials. Nurse U and nurse I cleaned up the area, both wearing the same gloves, and made the resident comfortable. Nurse I grabbed the garbage bag, tied it up and threw it away. They both took off their gloves before leaving the room. Nurse U also washed her hands before leaving the room. Later that day, at approximately 4:20 PM, the director of nursing (DON) and the corporate nurse were told of the above procedure. They both said the nurses violated the infection control process for dressing changes. The policy Dressing Change, effective date 11/30/2014, read, A clean dressing will be applied by and Clinical Nurse to an open wound as ordered to promote healing. Sterile dressing will be used only if specifically ordered. Licensed therapy staff will follow the same protocol. Procedure: Identify resident. Explain procedure, provide privacy. Assemble the following equipment: Disposable gloves; dressings needed to apply to wound; gauze to clean wound; applicators; bag for dressing disposal per Universal precautions; tape. Perform hand hygiene. Put on disposable gloves. Untie tape or loosen disposable tape. Remove soiled dressings and dispose of per Exposure Control policy. Remove gloves. Perform Hand Hygiene. Apply new disposable gloves. Assess the wound for type, color, amount of drainage. Obtain wound culture if indicated. Cleanse wound as ordered. Using gauze, cleanse the wound. Dry the wound with dry gauze. Apply clean dressings and secure. Discard gloves per Exposure Control policy and Perform hand hygiene. Document in medical record. Level of harm - Minimal harm or potential for actual harm Residents Affected - Many F 0490 Level of harm - Immediate jeopardy Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Be administered in an acceptable way that maintains the well-being of each resident . **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the administration failed to use resources effectively to ensure residents were free from neglect and failed to provide timely and effective wound care to maintain the resident's highest practicable physical, mental and psychosocial well-being in accordance with professional standards of practice for 1 of 12 sampled residents (#258). Resident #258 did not receive the necessary treatment and care to prevent a painful pressure ulcer and infected wound for 15 days. Resident #258 did not have admission orders [REDACTED]. The Quality Assessment and Assurance Committee (QAAC) failed to identify quality deficiencies and develop and implement appropriate plans of action regarding resident care and services. As a result of this neglect, the resident endured severe pain and required re-hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her right elbow. The resident was diagnosed with [REDACTED].[MEDICAL CONDITION] is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. (www.cdc.gov/sepsis). The failure of the administration to use its resources effectively resulted in Immediate Jeopardy, starting on 11/29/16 with Substandard Quality of Care. The Immediate Jeopardy was ongoing as of 1/28/17. Findings: Cross Reference to F224, F271, F281, F309, F314, F353, F385, and F520. Resident #258 fell at home and fractured her right hip and right elbow. The resident had surgery to the right hip and right elbow and was admitted to the nursing home on 11/29/16. The admitting registered nurse (RN) N noted the surgical areas to the right hip and right elbow. RN N documented that the resident's right upper extremity was in a soft cast and that arm was in a sling. The Physician order [REDACTED]. However, the attending physician did not give any orders to treat the right elbow and the nursing staff did not contact any physician to obtain orders for care and treatment. The hospital discharge paper work in the resident's nursing home medical record revealed an orthopedic surgeon's progress note, dated 11/24/16 and written before the resident was admitted to the facility. The surgeon wrote, Follow up with (orthopedic surgeon) after DC (discharge) for RUE (right upper extremity) and R (right) hip. Staples out by rehab in 10-12 days. The resident remained in the nursing for 15 days, without treatment orders for the right elbow. The resident went to a follow-up appointment with the orthopedic surgeon on 12/14/16. The surgeon wrote, Post-op R elbow ORIF (open reduction internal fixation) now has pressure wound from splint. The orthopedic surgeon's assessment and plan included hyperbaric treatment to right elbow, wound vac to right elbow wound, and no splint on right elbow. The resident returned to the facility with the orthopedic surgeon's treatment plan. However, there was no evidence the facility staff arranged and scheduled hyperbaric treatments or obtained a wound vac for the right elbow wound. On 12/15/16, the resident transferred to the hospital. The Nursing Home to Hospital Transfer Form dated 12/15/16, timed at 8 PM, noted the resident as lethargic, had altered mental status, and labored breathing. The hospital assessment, dated 12/15/16 at 9:55 PM noted the resident appeared to be uncomfortable, uncooperative, and smelled of a foul odor. The resident presented with a right elbow open wound and exposed metal hardware at that site. The Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 17 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0490 (continued... from page 17) site was red and hot to touch. The hospital's consultation note, dated 12/20/16, read, S/p (status [REDACTED]. When her dressing from the elbow was removed, it was found that this had not been changed and the patient had been still wearing splint. She acquired a pressure wound to the R elbow. None of her staples had been removed all staples were removed and sterile dressing placed. Orders were written for (nursing home) for wound care and wound vac placement and PT/OT (physical therapy/occupational therapy). The patient presented yesterday to the ER (emergency room ) and subsequently admitted and (orthopedic surgeon) was re-consulted. Photos on chart to support findings, report called into DCF (Department of Children and Families) Hospital clinical notes, dated 12/21/16, indicated the resident was discharged from the hospital to a hospice house. On 1/25/17 at 3:25 PM, the resident's unit manager (UM), Registered Nurse (RN) F confirmed the resident did not have any treatment orders for the right elbow at the time of admission. UM F indicated admitting RN N did not assess the resident's right elbow at the time of admission. UM F stated at the morning meeting, the reviews admissions from the previous day. UM F stated she has to check every resident's skin from head to toe. She stated a physician must order the removal of the soft cast. UM F could not explain how a complete head to toe skin assessment would be conducted if the resident did not have a physician's orders [REDACTED]. UM F stated, I don't know how you monitor it (right elbow) if you don't look at it. I guess you should call the doctor and see if he wants us to look at it. UM F stated that anytime there is a resident without treatment orders, the doctor should be called to find out how to take care of the wound. UM F stated that on 12/13/16, the resident had drainage from the right elbow, so she called the attending doctor and obtained an order to remove the soft cast. She said the staples were in place but the resident had a stage III pressure wound on the right elbow. The resident went to the orthopedic surgeon's office for follow-up on 12/14/16. UM F's interview and recollection of the facility's wound care treatments to the right elbow were not what the orthopedic surgeon's hospital notes reflected when the resident was seen at his office. The orthopedic surgeon noted that the dressing to the right elbow had not been changed when he examined the resident on 12/14/16. On 1/25/17 at 4:45 PM, the director of nursing (DON) said she was aware resident #258 needed a follow-up appointment with the orthopedic surgeon. She stated that there was required pre-authorization from the insurance company before the resident could have the follow-up appointment. She said she contacted the orthopedic surgeon's office and found out a pre-authorization was not needed. The resident had a follow-up appointment with the orthopedic surgeon on 12/14/16. The DON stated she was informed of resident #258's condition on 12/13/16. The DON said she was not aware that UM F had documented that the resident had a pressure sore on 12/13/16. She stated the facility conducted their own investigation. She was aware Department of Children and Families was investigating allegations of neglect concerning resident #258. She stated the facility had attempted to get a follow-up appointment for the resident with the orthopedic surgeon. She said the facility's investigation regarding the lack of care to the post-op area of the right arm and right hip was caused by the delay with the orthopedic surgeon's follow-up appointment. The DON stated the facility did it's due diligence in setting up the appointment and meeting the resident's needs. On 1/26/17 at 1:43 PM, the wound care physician indicated she observed resident #258's right elbow pressure wound on 12/15/16. She stated the wound was very shallow and a wound vac would not have worked, and that the resident needed to go back to the orthopedic surgeon because, We couldn't treat it. The wound care physician stated she treated the resident's wound to the right leg, but the right elbow wound was not referred to her until 12/15/16. She indicated that the staff should have contacted the attending physician for any orders for the right elbow wound prior to 12/15/16 because, I can only look at the wounds that they recommend me to look at. The lack of wound treatment orders for the right elbow was discussed with the wound care physician. She stated she can't come between (the resident) and her surgeon. She reviewed the telephone order dated 12/13/16 for Xeroform to the staples/surgical incision and [MEDICATION NAME] for the pressure wound on the right elbow. The wound care physician stated she did not give that order, It is not my hand writing. Look, I didn't sign it. I always sign my orders, and I didn't sign that, because I didn't give it. On 1/27/17 at 4 PM, admitting RN N stated the resident had a soft cast on the right elbow upon admission. RN N stated the resident did not have wound treatment orders for the right elbow, from the hospital. RN N explained that if a resident doesn't have treatment orders, you are supposed to remove the dressing and look at the wounds. She added, that if there was any confusion with the wound, she would have the wound care physician look at it. She could not recall if she received wound care treatments from the doctor at the time of admission. She remembered that she did not remove resident #258's soft cast, Because it was a fresh post-op wound and you aren't supposed to remove (soft cast) until it was seen by the physician. RN N stated the unit manager should have followed-up to get the wound treatment orders for the right arm, and the follow-up appointment with the orthopedic surgeon for resident #258. On 1/27/17 at 4:40 PM, resident #258's attending physician was contacted by phone. He recalled observing resident #258's right hip but not the right elbow. He stated there were treatment orders for the right hip but not the right elbow. He said orthopedic surgeons give specific orders for treatment to post-operative areas. He stated that the wound care physician was seeing the resident and that the orthopedic surgeon had written wound treatment orders after the resident's follow-up appointment. He was aware of the conflict of orders between the wound care physician and the orthopedic surgeon. The wound care physician did not want the wound vac. He stated the responsibility would lie with the orthopedic surgeon. The attending physician stated, I did not talk to (the medical director) about this resident. The facility did not effectively use the services of the medical director. The medical director is ultimately responsible for the care and treatment of [REDACTED]. Assessment, care and treatment was non-existent for the right elbow wound for 15 days since the resident's admission. On 1/28/17 at 4:07 PM, a meeting was held with the administrator, UM F and the clinical consultant RN. The administrator did not offer any additional information regarding his involvement to ensure that the highest degree of quality care can be provided to residents at all times. An interview was conducted to determine if the facility had an effective QA process. The staff identified several tools such as the Grievance log, Guardian Angel Rounds, Mock Survey Audits, Wound Audits, and Admission Order Audits to help identify quality of care and resident rights issues. The staff stated that anything identified as an issue during morning meeting, 24-Hour report, and any verbal concerns are put on the Homework Sheets, and given to the unit managers. The Executive Director's job description, acknowledged on 8/30/16, read, The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. You are entrusted to provide .responsible healthcare Among the Duties and Responsibilities are, Schedule regular meetings with direct report staff to provide supervision, ensure communication and to monitor facility operations. The Medical Director's responsibilities read, The Medical Director shall generally be responsible for the oversight and delivery of medical services at the Care Center The Director of Clinical Services' (DON) job description, acknowledged on 11/29/16 read, The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Executive Director to ensure that the highest degree of quality care is maintained at all times. You are entrusted to provide .responsible healthcare The Unit Manager's job description read, The primary purpose of tour position is for managing the staffing needs and providing supervision for nursing staff providing direct resident care to ensure quality resident care on the assigned unit. You are entrusted to provide .responsible healthcare Among the Duties and Responsibilities are, to Maintain ongoing communication with physicians concerning resident care The facility administration failed to efficiently and effectively utilize the resources for physicians services and nursing services to ensure quality of care and use the input and recommendation of the QAAC to provide responsible healthcare. Level of harm - Immediate jeopardy Residents Affected - Few F 0520 Level of harm - Immediate jeopardy Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 18 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:12/19/2017 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105861 NAME OF PROVIDER OF SUPPLIER 01/28/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD MELBOURNE, FL 32934 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0520 (continued... from page 18) Based on record review and interview, the facility failed to maintain an effective Quality Assessment and Assurance Committee (QAAC) to identify quality deficiencies, and failed to develop and implement appropriate plans of action for surgical wound care and services and neglect to provide wound care and service to 1 of 12 sampled residents (#258). Resident #258 did not receive the necessary treatment and care to prevent a painful pressure ulcer and infected wound for 15 days. As a result of this neglect, the resident endured severe pain and required re-hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her right elbow. The resident was diagnosed with [REDACTED].[MEDICAL CONDITION] is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. (www.cdc.gov/sepsis). The failure to prevent neglect resulted in Immediate Jeopardy, starting on 11/29/16 with Substandard Quality of Care. The Immediate Jeopardy was ongoing as of 1/28/17. Findings: Cross Reference to F224, F271, F281, F309, F314, F353, F385, F490. Resident #258 was admitted to the nursing home on 11/29/16. On 11/29/16, the admitting registered nurse (RN) N's documentation included that the resident had an open reduction and internal fixation (ORIF) of the right arm and right hip. The right hip had staples on the surgical incision, and the right elbow had a soft cast and was in a sling. RN N also noted a blister to the resident's coccyx and an abrasion to the right posterior thigh. A blister on a bony prominence is a stage II pressure sore by definition. The Physician order [REDACTED]. RN N's admitting note revealed the stage II coccyx pressure sore was cleansed and covered with barrier cream. Review of the medical record failed to produce any evidence of treatment orders for both the stage II coccyx pressure sore, the right elbow and the right hip. On 12/15/16, the resident was transferred to the hospital. The nursing home's Transfer form, dated 12/15/16, noted that the resident was lethargic, had altered Mental Status, and labored breathing. The hospital assessment, dated 12/15/16 at 9:55 PM, noted the resident presented with a right elbow open wound and exposed metal hardware. The site was red and hot to touch. On 1/25/17 at 3:25 PM, resident #258's unit manager RN F stated the resident did not have wound treatment orders from the hospital at the time of admission. RN F said the facility did not have orders to remove the soft cast. She said the facility conducts weekly skin checks for all residents residing in the facility. RN F could not explain how a thorough, comprehensive weekly skin check is done without removing the soft cast. She stated that on 12/13/16, the resident had drainage from the right elbow, and she called the attending physician who ordered treatment to the right elbow area. The Treatment Administration Record (TAR), dated 12/13/16, reflected the treatment to the right elbow was done. However, RN F's recollection of the series of events for 12/13/16, and the right elbow treatments that the resident received contradicts the orthopedic surgeon's findings from 12/14/16, who documented that the dressing to the right elbow wound was not changed. On 1/25/17 at 4:45 PM, the director of nursing (DON) stated that she was made aware of resident #258's right elbow wound on 12/13/16. The DON stated facility staff started an investigation, and provided a summary of the investigation. The facility's investigation focused on the difficulty of getting resident #258 a follow-up appointment with the orthopedic surgeon. The DON could not verify that the resident had treatment orders to the right elbow at the time of admission. She was not aware that RN F had noted a stage III pressure sore on the resident's right elbow on 12/13/15. The DON indicated that it was her understanding that the surgical wound had opened. She stated facility staff attempted several times get a follow-up appointment with the orthopedic surgeon. She said there was difficulty obtaining authorization before the follow-up appointment could be scheduled. The facility's investigation on the Agency for Health Care Administration's (AHCA) Five Day Report, dated 12/20/16, noted, Facility did its due diligence in setting up an appointment and meeting the residents need. No new measures were implemented, as findings were unsubstantiated. On 1/27/17 at 4 PM, RN N recalled that resident #258 had a soft cast to the right elbow but did not look at the surgical incision on the right arm. RN N stated she did not have a physician's orders [REDACTED]. She stated she could not remember if she called the physician to get treatment orders for the stage II coccyx pressure sore. She said on 12/14/16, the resident saw the orthopedic surgeon, and he wrote, Elbow Surgical wound open/pressure sore, s/p (status [REDACTED]. The surgeon ordered a wound vac to the right elbow wound and no splint to the right elbow. The resident returned to the facility but the facility staff did not implement the wound vac. On 1/28/17 at 4:07 PM, a meeting was held with the administrator, Unit Manager Registered Nurse F and the clinical consultant RN to discuss the facility's Quality Assessment and Assurance (QAAC) program. They indicated the QAAC consisted of the medical director, administrator, DON, unit managers, social services, rehabilitation, activities and dietary representatives. The staff did not provide any QA Meeting notes and data collection documents. An interview was conducted to determine if the facility had an effective QA process. The staff identified several tools such as the Grievance log, Guardian Angel Rounds, Mock Survey Audits, Wound Audits, and Admission Order Audits to help identify quality of care and resident rights issues. The staff stated that anything identified as an issue during morning meeting, 24-Hour report, and any verbal concerns are put on the Homework Sheets, and given to the unit managers. Review of the facility's survey history revealed that on 6/30/15, the facility was cited at the Immediate Jeopardy level for non-compliance with F224, F225, F281, F309, and F490. The facility's Quality Assessment and Assurance program, F520, was also cited at the Immediate Jeopardy Level for the QAAC's failure to identify quality deficiencies in resident care, safety and wellness. At that time, the facility's corrective action included the Prevention of Deviation in Care Processes and Correct Inappropriate Care Processes. The QAAC failed to recognize and identify the issues that led to resident #258 acquiring an avoidable right elbow pressure sore, exposing the surgical hardware inserted during the ORIF. Based on the medical record and interview with staff, there was a delay obtaining an orthopedic follow-up appointment. The facility is responsible for care and treatment to the resident's right elbow. The QAAC failed to identify that lack of treatment orders at the time of admission and for 15 days, resident #258 did not receive any wound care to the right arm and right hip. The resident had excruciating pain without relief. Based on the facility's investigation, the administrative staff concluded that the facility acted accordingly and met resident #258's care needs. However, the QAAC failed to identify and prevent substandard quality of care exhibited by the professional medical and nursing staff. Level of harm - Immediate jeopardy Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 105861 If continuation sheet Page 19 of 19