From: 06/04/201212138 #109 FROM (THU) MAY 24*! 2012 13: #3 T839851 0&4 5 D5I.24-I201 DEPARTMENT OF HEALTH AND HUMAN SERVICES. mam CENTERS FOR 8. SERVICES TA OMB srnremsm or oerrcrencnsa on) PROWDERISUFPLIENCLIA om MULTIPLE consmuonon no) mm surw-er AND PLAN or CORRECTION rnerm rraanow conrcerso . auiLomo .w 0 0 195701' "3 -n5!15l2012 NAME OF PROVIDER OR SUPPLIER a smear ADDRESS. cm. come 0 515? PARK owe DRIVE TARPON POINT NURSING AND REHABILJTATION CENTER FL ":35 pm}, ,9 sunnaev srnrenenr or DEF-ICIENCIES no . 0. war (anon DEFICIENCY MUST as PRECEDED av FULL PREFIX non - comeya ii mg. i neouunonv on Lee i:oenn:=vrno insonnwioui -me. cnosseerenenceo To me APPROFMATE OAT oericrencm 33;: . 000 COMMENTS 090 0 This is to report the results of an unannounced complaint. 2012004256, survey conducted, on at Tarpon Point Nursing and 4 - . - Rehabilitation Center, in Sarasotasupervisory review, the survey was extended oompiaint with 2 allegations substantiated with . . . citations. can! Money Fe-neitiee wili he '5 *0 39- the this - State and Federal guidelines. Ir on o+ There is a discretionary no opportunity to correct compliance or agreemenr with 3 Der instanoe CMP associated with this survey'. 3 Surveyor. findings' bu? does i Tarpon Point Nursing and Center include required QI sfeps. This 3 was not in compliance with the requirements of - - 5 42 CFR part 483 and 488. Subpart B. 0'50 as "Te Requirements for Long Term Care. ?f Wm' rhe alleged citations herein. The following is 3 description of the i "noncompliance: 0 281 i SERVICES MEET 281 281 Completion 6.15.12 6 45.12 33:5) PROFESSIONAL - I - I i The services provided or arranged by the facility 1 mosimoet professional standards of quality. i No specific correction action This REQUIREMENT is not me: as evidenced could be performed for . Based on staff interviews. medical record review res'dem3 1 and 6 as way and record review for 3 (Residents. 0 CW3 00* in The fGCli|*Y. and of 7' sampled residents the failed 3 Resident #3 has had his "reinform the attending physician regarding the - '3dm'35'?" Char? feedingidietary administration inconsistent with included a focus on the physician order for1 (Resident of the 7 i_ mnorw 0 siorwune nus nnonre -T -- fig"! S__1or A Any deiicienw in ending -if an asterisk notes a_ defioienoy which the insmu?iion maybe excused from correcting providing it is oeuannined that other safeguar. Rio suificient protection to The patients. (See instructions.) Exceplfor nursing homes, iha findings stated above are discioaabie 90 days touowing the date ofsurvey whether or not a plan or correction is provided. For nursing homes. the-above findings and piano of oorreofion are ciiscrosame 14 days foiiowing the date these documents are made to the it deficiencies are cited. an engraved pian of correciion is requisite to continued program participation. . -- Prerrioos Event 1' Facility I if continuation sheet Page 1 of 45 From: #109 FROM 21$ 21312 113145/$7. 3 DEPARTMENT OF HEALTH AND HUMAN- cemens ma a. MEDICAID sggvaggs Dug smremenr or: MULTIPLE. consmucnow (xx) AND PLAN OF CORRECTION IDENTIFSCATION A. . I 105702 Wm n5i15i2012 NAME OF snow DER on suppuea star-.51 menses. crw, STATE. cons 5167 PARK CLUB DRIVE TARPON POINT NURSING AND CENTER SARASOTA, FL 3-4235 9(4) sumanv srnremsm' ofoasucleucaes so 1 PLAN 0? consecnou (EACH MUST as Pnecaoec av mu. paenx (axon can-necnv-am-non snoum as comgignow TAG 0" L59 INFORMATKJN3 TAG . CROSS-REFERENCED TO THE APPROPRIATE DATE I . 28%. Continued page 1 281? ,9a""P'edi nufrifion/physician orders, 2. Glanfy :nc_c:mpiete- orde.-is for 2 . . (Residents #1 and cf the residants Care sampled; 3- Provide an interim care plan to meet the 5 resident care needs for 2 (Residents #1 and 1 at the 7 residants sampled. and i Mefhod To Assess Other' 4. Provide the physician notificatien of change in Residems conditions for 3 (Rasldents #3 and of the 7 residents sampled . A 1007:. audit of all in-house According to: . 1. The Americansociety forParenteral &Enteral has been Performed Nutrifion - Jaurna! of Parenteral and Enteral to evaluate if any other 33, No. 2, MarchJApriJ 2009 slams an page 126: "e5ide"J'5 have been "Elements.ofthe Order ?a-tient-specific EN 1 affected by alleged practices. orders should include 4 elements: 1} patient demographics, 2} formula type, 3) delivery The focus on 5-llaldevlcze. and method and enleral/dIelary/ 'ate-" nutrition/physician orders, 52. LTC Health Information Practlcafi Care and Change Documentafion Guidelines Version 1.0 in condifion no'r:fica1'ion_ September Sysfemafsc Review . states, "s.4.a 3. Care Plan: Upon admission, a brief initial cane plan should be developed to carry 3 and through until the comprehensive r-evjsjon was performed 1'0 assessment and care plan have been davalo-pad. . l. - The care plan should address the primary reascm 3 M1 The for admission and treatment and the residanrs nutritional system for newly most immediate care needs. Usually the plan - - lnclu-d-es clinical andior rehab needs and - ?dm'fie'_d res'der?t3 and 'nutritional needs." wI'I'h The FORM Pravicaus veminns cltaenlata Event Facility ID: 35819 lfcontlnuatlan shecl Fag: 2 of 45 From: 06/04/2012 12:39 #109 FROM 24 .2012 13: 45/81'. 13: B6.v'No. TSOSGETQQA 7 PRINTED: 05/2442012 OF HEALTH AND HUMAN SERVICES CENTERS FOR 8i MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEHCIENCIES (X1) (K2) CONSTRUCTION um ante SURVEY AND RAN or-' CORRECTION NUMBER: COMPLETED A. BUILDING I . 0 105702 8' Wm . o5rl5l2e1.2 NAME OF OR STREET ADDRESS. criv, STATE. ZIP some 5157 PARK cuss DRNE TARPON POIHT NURSING AND REHABILITATION CENTER FL muss (xi; .9 sLii.ii.i?inv' STATEMENT OF-DEFICJENCIES ID 7, OF oaanacnon ixsi (EACH ai-: pnsceoso av FULL (EACH CORRECTIVE Action SHOULD as COMPLETION TAG REGULATORY on L86 INFORMATION) to THE Arnaorninrs W5 231 Contmued From page 2 231 dietician. Included in This new .3. American Medical Directors Association format is process to include Acute change of condition in the - if - - long-term inane setting. Columbia (MD): American Pcmen enfeml Medical 23 formula Wise. delivery p. states: site/device' and ma-had and "Acute Change of Condition STEP 1 identify ?f A individuals at risk forACDCs, STEP 2 Describe brief admission interim plan and document andior condition 3 . . changes, STEP aaefineihapaiienis stability ?f _be and identify why the situation is problei-natlci reviewed during new M-F daily STEP 4- Determine this feasibility {if identifying the - - - causeis) of the ACOC in the snap 5 identify and document the likely causes of the EVCIIUCITIOH PFOCBSS ll'lS'il'i'UTed 5 Determine theisasibility of to include the primary managing the A006 in the facility, STEP T. I . . identify appropriate treatment goals and i 9 0 3" -obiectives that consider the patient's wishes. Treatment for most immediate 5 STEP 8 Manage-the ACDC, STEP 9 Monitarths - i patients progress STEP in Adiusl interventions Care needs um" and goals based. on the patients responseto by the comprehensive plan of treatrnent, STEP 11 Reviswthe facility's - - - 1 management of M3005 and unplanned hospital Care place' he chmcal {r3n3fgf'5"' process to support p_ identification of clinical risk, i 4. Hearth C:-are Jersey I. . (HCANJ). Medication management guideline. ""933: Hamilton (NJ): Health CareA.ssociation at New evaluate residenf stability, 2007 Mar' 33 evaluate feasibility To manage i 5 The condition in house or slatesinot limited to}: "Risk Points and Risk 2 1- - Reducing Stratsgies: Medication Reconciliation . mnsfer,' an rnomfor we and clarification 1. Admission from home: I Change has been Reconcile proposed new artists with past I shaped info a dag iy new medication usage. a. Review labels of all i medication aonlainers from home including over-the-counter medicatian.s and supplements. admission and change in condition clinical risk review. 1. FORM Previous vaisicms oi;-mieie Event lD7BiMiD1l in 85510 if continuation shoot Page 3 of 415 From: FROM 06/04/2012 12:40 24 $012 8 05124/2012 DEPARTMENT or-' HEALTH AND HUMAN senvices mm CENTERS FOR MEDICARE 3. MEEHCAJD SERVICES oMggNo,gg3g_g3g1 or DEFIGIEHGAE8 {Xi} PRGVIDERISUPPLIERICUA our urumr=ie comsrnucrron (x3;'oAtg'5uRvgy AND PLAN or CORRECTION A Bmwma i 05!15l2D*12 NAME 0" SUPPUER smear ADDRESS, oimarnre. ZIP cone TA Rpoii POINT nunsmo AND REHABILITATION cenren ""15 -s._nRAsoTA, FL 34235 (X4, lg summer OF DEFICJENOIES JD Pnovioen-e PLAN or oonneonou Pfififfilx (EACH nusrr ee PRECEDED ev run. Pnarix lance conneonve ACTJON snow: as common no REGULATORY OR LSC IDENTIFYING INFORMATION) TAG THEAPPROPRIATE i WE i 7 FFGW P899 3 28-1 Physician . order review has 13. Review all community physician documentation 5 - available. o. Clarify any discrepancies or been mplememed as pa" of - medication orders with clinical stafi from transferring when necessary. c. medical record and clarify any dieorepancles. Do i laboratory reports. 5. Transfer Document; diagnosis (indications for use) and relevant laboratory data. i. Inter-iecilityiprogram "transfer care pian with physician's orders. d. Receiving questionable orders with original source as . necessary' 2. from hospitals- and other facilities: Reconcile o. Obtain and review copy oi' Medication Administration Record transfer form. and Physicians Order Shoals information with transfer -form and P-08 if available. Do not i rely solely on transfer form. b. Clarify all See item 5 below 3. Readmisoions: a. Compare transfer orders and lniorriiation -with previous not administer previously ordered medications without a renewal order. Consultant initial review: 23, initial orders faxed (fax original documents, not copies) to pharmacy oonsulta in for timely review and wnrien comments which are faxed back to the facility for inclusion in the medical record. i. Facility communicates the following information to the pharmacy consultant resident's full name and 1 date of weight, allergies, full medication orders, doses. diagnosis (indications for use) and Reconcile a. Transfer forms wiil include printed, up~to-date medication orderswifh related form signed by physician b. Transfer form will include current and historic influenza and pneumonia vaccine information. o. Tran-siier documents will include up~to-rlate patienilresident nurse./physicians or pharmacists will review medication-s. and immunization i the new daily clinical risk review wiih a change in hospital continuity form-3008 also uiilized for new admissions. The new daily clinical risk review for new admissions, residents who demonstrate an acute change or concern, and change in physician orders includes clinical inrerdisciplinary team. Quality Assurance The DON will be responsible To ensure compliance to this system by full record review of six residenrs, ihreeper unit per month To be reporfed on during The risk management/quality assurance meeting. -Ill" . OHM Previous '.lersion.s Obsolete Even-I ID: BWSD11 Facilillr 35319 ll coniinuatlon shoal Page 4 of 46 #109 From: 06/04/201212240 #109 FROM 26 3012 QGIST. 73333511 0614 8 PR NT 1 -: DEPARTMENT or-1' HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 3 OMB NO. 093841391 armament or osriciencses (K1) PRCWIDERJSUPPLIERICUA ii-:23 MULTIPLE (xx) DATE suawr AND PLAN or connecnour IDENTIFICATION NUMBER: A commfreo '"3579? . 8' Wm . 9511512912 NAME PROVIDER OR SUPPLIER 31-R551 cf-fin 5-rm-E_ 231:. G095 5157 PARK CLUB DRIVE PO NT AND ABILITATI TARPON I SJNG EH 1 CENTER FL 34235 (X4) in SUMMARY STATEMENT or DEFTGIENCIES in PRDVIDEREPLAN OF CORRECTION 2 ms; PREFIX :m-tricieucv MUST as pnecsaso av mu. PREFIX . (EACH CORRECTNE ACTIUN snouun as COHFLETMJN ms nsrsumromr on LSC ms canes-nereaeucsn TO THE APPROPRIATE DATE 2 281 From page 4 281: information with resident ancilor I-znowiedgeabie and authorized resident" representative to ccnfirm accuracy of information. i. Ask famiiy to bring at -home mediciaticins. supplements. and i over--the-counter (OTC) drugs to the facility to reconcile past medicafions usage with proposed. new erders. e. Receiving c-iariiy ail medication orders by crossmhecking medications shown on MAR, POS and Transfer . Form. Contact the ciinicai staff of the transfming 5 iiospiiai/facility to clarify the orders as necessary. f. Recanciie proposed. new orders with past medication usage. g. Transfer pmi-ocoi for transfers wit! include a verbal communication cf the resident's current. I physicai and manta! status, review of the medications and the-care plan. Receiving nurse . will document evidence of me clinical report, 5. American Medical Directors Association (AMDM and the National Guideline Ciearinghouse (NGC): The origlnai full-text guideline provides an algorithm on "Head aiiure in the Long Term Care Setting" siaies (not 3 iimited to)? "Step 6 Decide if interventions for risk 1 factors or treatment for reversibie etiolcigies are 1 appropriate. After conducting a detailed cardiopuimanary history, perfarrning a careful 2 physicai exaimination, reviewing laboratory data. and compieiing orabtaining the resuits of an i imaging may (if indicated)._ the next step is to 1 determine whether interventions for risk fact-cirs or treatment for reversibie etiologies are apprapriate. avaiiabie, and consistent with {he patients or advocateis wishes. Treatment :11' reversitiie causes of heart faiiure (see Table 6 in the original guideline document) and some FORM Previous Wrsions Event ID: Facliiff 15135219 If cuminuation sham Page 5 of 45 From: 06/04/2012 12:40 #109 34 2012 1.3 i . - PR or HEALTH AND HUMAN SERVICES '$33 C-ENTERS FOR MEDJCARE 8: MEDICMD SERWCES OMB M0. 0938-0391 or (X1) om MULTIPLE coiismucnon um-5 SIJRUEY AND PLAN or-' A. -I 1?57 ?3 Bl Wm 05i15i'2i.i12 NAME or PROVIDER on SUPPUER zip was . 5957 PARK CLUB naive PO-IN A i . TARPON REHABILITATION CENTER FL 3'235 mi [0 sumnav STATEMENT as ID 3 Pnoviosws PLANIQF cofiascnou i ms; (EACH must as PRECEDED av FULL PREFIX 3 (EACH CORRECTIVE A.-snow suouw as mg i nesumvoav on use irismimnrs ma To . we i 281 Continued From page 5 231 exacerbations of chronic. heart failure may require transferring the patient to an acuie-cs-are setting (refer to AliilDA's -practice guideiine on transitions i of care). Treatment Step 7 Develop an. individualized care plan and define treatment goais. Step 8 Treat the chronic underlying cardiac. 2 condition. Treat exacerbating conditions such as - anemia, diabetes. da.rdi;ac- fever. i- infection. lschamic heart . disease, and uncontmiied nypertensinn. A330 3 address the consequences nf the -palienfs failing heart. Specific phannacutherapy be based on the presenceor absence at fluid volume dverlciad and the nature. oi' the ventricuiar ciy.stunotion_ Nonpharmacoiogic interventions that may be co-nsiclereci in patients with heart failure inciucie cardiopulmonary rehabilitation, increasing physical activity. decreasing smoking and alcoiml consumption, and and spiritual I support. Because patients with heart failure who develop bacterial er viral iegpiraiury infections may deccimpeinsate, ali patients with heart failure should be offered pneumoposcal vaccine and annual influenza vaccinations; Salt and fluid restriction may ha helpful in patients who have heart faiiure with evidence of volume overload. Step 9 Treat fluid volume overload -if present. 6. Professional Standard oi' Care is defined in Chapter ?65.'iiJ2( 1) Florida Statutes as, "the prevailing professional standard at care for at given health care provider shall be that level of care, and treatment which, in light of all re ievant surr-ounding circumstamzes, is recognized as and appropriate by reasonably prudent similar health care proviciars." i The findings include: i FORM versions otmiete Event ID: Facility 35019 if continuation sl1ceiPage 6 of 46 From: FROM DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE St MEDICND SERVICES 06/04/201212311 24 2012 #10_9 11 PRWTED: 9512412012 FORM APPROVED OMB N0. 1 STATEMENT OF UEFIGIENCSES AND PLAN OF QQRRECTIQN NAME OF enovmee on suppuee TARPON POWT AND REHABILITATION CENTER FOENHFICATION NUMBER: 057 92 (K2) MULTWLE CONSTRUCTION A. BUILDING B. WING cm, STATE. come 51.57 M315 CLUB nerve SARASOTA. FL 34235 may mm: Sumter 2 (Xi) ID PREFIX TAG SUMMARYISTHATEMENT or -DEHCIENCIES (EACH DEFIEIENCY MUST ee PRECEDED av rum. REGULATORY on xoemnerune unrzormarsouy 113 PREFEX TAG DEFIUIENCYI paevroerrs emu or CORRECTION (EACH Arman SHOULD as CROSS-REFERENCED 1'0 THE APPROPRWIE t-V5) COMPLEHON . DATE 1 1 I 281 Continued From page 6 i I 1 1 The record for Restdent#1 documented the factmy received and transcribed an incemptete physician order. The order was originally obtained" from the hospital. The 3008 formftiospitet discharge form documented 'Wepro 4 canstday (feeding soluttorr}." The order for Resident #1 was incomplete and tacking a route of administrat?en of Negro. i A review of the Medication Administration Re-card (MAR) was conducted on 4126112. The order did not include the type of Ne.-pro as defined by "Carb Steady." Areview of the MAR was eunducted on 4l26.i*t2. The MAR is documented 'as "Nepru 4 cans QED (four times an day] flush with 60 cc - before anti after. This entry is not accurate and is lacking the type of flush This is lacking the mute of admints-tratian and the amount does not match the Nepm 4 cans fday as written on the 3008 form from the hospital. The 4 cans of Nepro 4 times a day was documented as administered on the MAR. The facility nurses pieced their initiate the inaccurate amount of the feeding was administered starting on 10126111 to 10129111. A Ctarification order was written as "'10i29111 Ctartficattcn: Give Nepro Car?b Steady one can Q10 via peg tube (Feeding tube placed dtrectty into the stemach) flush with 61} mt (mii1ttiter} 2 0; before and after administration)' Another order was written, on '-1012911 1. afle-r the arwatl physician was notified Nepro was not aveilabte, "Give Jevity 1.2 Get {Calorie} one can I OH) via peg tube until Nepro becomes aveitabte. 281 i FORM Previous Versions Obsolete Event 35819 if continuation ehaetPage 7 of 45 From: 06/04/201212141 #109 FROM (THU) MAN 24 201-2 1:3: 47191' . 1:3: 3:9/no. 7533551084 1 2 or HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8. MEDICAID SERVICES OMB no' 093543391 SFATEMENT OF DEFECIEHCES (K1) PROVIDERISUPPLIERJCLIA MULTWLE CONSTRUCTION I (K3) DATE SURVEY AND PLAN OF CORRECT ION IDENTIFICATION A BUILDING -- I - B. IMNG -no-5702 I can 5i201 2 NAME OF PROVIDER -OR SUPPLIER C11-V, zip C055 5157 PARK CLUE DRIVE TARPON POINT NURSING AND CENTER FL 34235 go SUMMARY srarremeur or ID Pnomceirs Pam or CORRECTION ms; DEFICIENCY war as PRECEDED av FULL PREFIX . suouLr> as -coimanoiu mg, on IDENTIFYING INFORMATION) ms TO THETAPPROPRIATE WE I - Continued page 7 231 Flush with 60 mi 2 0 before and after administration." 1 An interview with the Risk Manager (RM) was conducted. on M26112. The RM was asked for ciccumentaiion regarding physician notificaticin of the transcription error, from 1; the original 3008 incomplete brrler, and the i nurses' MAR ciocurnentation indicaatin-g the overfeeding of the residenl. The RM comrnented - the physician. was notified A review of the nursing notes, date-id ii reveal the nurse on duty. during the evening nhift. coniacied the physician on can regarding the facility did not have enough Resident I The nurse documented, atcizoo on 10i29i1'i. "3 cans of Neprc avaiiabie cailed MD (Medical Dcctor) Orders rec'd (received) to substitute Javiiy 1.2 cal (calorie) until Nepro arrives." At 5:00 the nurse dormments the Jevity 1.2 calorie 1 can was administered. A .. -. A review of the 'fciicw-up investigation to the quesiionahie in'accu.ra.te amount. delivery of the Neprc reveaied the physician was informed of the transcription error oniy. According to the document entitled "Medication Error Report." the reported. to the resident's facility physician. The error report describes the error as 'Transcription Error - should read NEDFO 1 can qid via peg tube." 1 The physician was interviewed, on 511 5H2, at 6:00 pm The physician was not on call on '10i29ii1. He stated. "i was not iniormed or the potential far cverfeecii=ng." The physician commented the physician on can wouici FORM OMS-256302-99) Previcus Viva;-ans 35319 if continuation shear Page 8 of 46 From: 06/04/2012 12:41 #109 P.0i0/077 FROM :24 2912 13: 46/31'. 1:3: 38/No. 7633561084 :DEPARTMENT or HEALTH AND HUMAN SERVICES POEM CENTERS FOR MEDICARE MEDICAID SERVICES 0938-D391 smranenr or DEF-ICIENCIES (X1) (x2; consmucnon nan) DATE sum/Ev AND PLAN or A BUILDING coamerao 105702 3- 0511512912 NAME or pnovaosn on isurmen smear cm, stare, ZIP cone 0 5157 PARK CLUB DRIVE TARPON POINT NURSING AND REH CENT 0 A SARASOTA, FL 34235 in srnremanr or DEFICIENCIES an PLAN or nnenx xenon nusr an pmzceneo av ruu. PREFIX {anon snow: an comssnon 1-Ag nenuuronv on LSO IDENTIFYING no cnoss-n ersasncen TD run APPROPRIATE We nencrencn 281 iconhnued From page 8 i 231 have taken that caii, but continued by commenting the omcali physician did. not express this type cif error when repnrting the on-call 0 events of the weekend. The facility physician" stated. "She did not report anything like that to me on the morning 'rep-art," The potentiai for the cwerffeeding of Resident #1 was not included in the report to the physician on call per the nursing. notes. This was verified, at 5:45 on with an interview with the Director cf Nursing (DON). The SON commented the facility documents did not contain evidence the attending or cnvcali physician were notified of the potential mrarfeeding of Resident The DON referred to the Medication Error Reports and stated, "No it is not there." The RM anti the DON were asked if they could provider information regarding the ciinicai staff or administration statf notified the attending phiysicnia-n nfthe potantiai overfeading, At 6:15 on 4126/12, the RM, DON, and the Administrator were unable to provide evidence the facility notified the physician of both the error and the potential far the ovarfeeding of Resident The provided statements cbtained from the nursing staff administering the Nepro tn Resident The statement-documented the nurses did not administer more than 1 can of Negro to Resident #1 per administration. A review of Resident #6's medical record was conducted on 5111, at 1:40 pm. The resident was admitted as a respite care for Hospice care. The resident has -a malignant rnetanoma secondary to lung cancer and 3 upper right i FORM Previcus Versiana Obs-ointa Event ID: BWQD11 Fsrciilty in 85819 If sh-egg page 9 or 45 From: FROM 06/04/201212242 #109 an 2012 1s:sexH.o. 7538651064 9 14 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: o5124r2m2 FORM APPROVED OMB N0. STATEMENT OF AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: 105702 TARPON POINT NURSING AND REHA-BILJTATIDN ENTER (X2) MULTIPLE -CONSTRUCTION A. BUILDHIIG B. MNG cm, arms. zu= cope 5157 PARK CLUB naive SARASOTA, FL 34235 I (X3) DATE SURVEY COMPLETED PROVIDERS PLAN or-' CORRECTION minute (Medical Dootur)." . fungating tumor of the mouth, Re-siden-I #6 was admitted to the on 511 3-J12- The ordars 3 and the nurses.' notes were reviewed' The physician orders documented for ''02 (Oxygen) via nfc. [nasal caflnuia) 2~4 Um (2-4 Liters per minute) pm (as needed)" The interim care ptan identtfios the need for oxygen therapy as 2 via at 24 per The 5!13Jt2 nurse's note. at 10:30 identifies I Resident #6 was admitted under a facility doctor': Care. The note documents the Bilateral Lung I sounds are dimmished with saturation of oxygen at 93% on room air. The nurse documents 3 "Mods (Medications) reviewed and faxed to MD I The Respiratory Therapist (RT) was interviewed, on 5I15a'12, at'1:5G pm. The RT explained this was a new Resident and she had gone into the An interview with a floor nurse was conducted . on SM 5112. after the record review. The nurse stated the 2 would be administered between 2-4 Liters depending on :the.sym-ptoms or the resident. When asked how the decision would be made, the nurse stated "This woutd be assessed - by the 2 saturations." The nurse than commented if the saturattons were higher the resident would require less oxygen. The -nurse was asked what parameter would be needed for -a resident with a saturation of 90%. The nurse Indicated that she would start at the lower dose of i oxygen and go up according to the resident response. butthen stated, see the order could probably use .9 sumumv or ID I (X5, pfifmx . renew DEFICI an ow MUST as PREGEDED av FUH. r-ramx CORRECTIVE ACTION srtaum as COMPLETION mg I REGULATGRY on use rnronmnon) no TO THE APPROPRIATE ME 1 7 281 Continued From page 9 23-1 FORM Previous Versions Obsolete EVEN ID: BUIIQDH Focifity ID: 85819 If oontlnuation sheet Page 10 of 48 From: FROM DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 3: MEDICAID SERVICES 06/04/201212242 #109 24 2012 1:5 PRINTED: 05f24f20I2 roan APPROVED one N0. 09.33-0391 STATEMENT OF GEFIGIENCIES AND PLAN OF CORRECTION PROVIDERISUPPLIERICUA -IDENTIFICATION NUMBER: 105792 I may MULTIPLE CONSTRUCTION A BUILIJING I3. WING (X3) DATE SURVEY COMPLETED 512012 TARPON NAME OF PROVIDER DR EUPPLIER POINT NURSING AND REHABILITATION CENTER STREETADDRES5, STATE. ZIP CODE 515? PARK CLUB DRIVE SARASOTA, FL 34235 PREFIX pm) in T.-AG swmahr or DEPIGIENCIES (EACH DEFICIENCY MUST SE pneceaso ev rum. DR LS5 IDENTIFYING INFORMATION) so PREFIX we 9 vnovrnerrs PLAN or coaeecrrou I I (EACH CORRECTNE ACTION SHOULDEE To rueepenornrare {xsr COMPLETION DATE 281 - I as soon as possible. Continued From page to residenfs mam to evaluate the day before, but i the resident was requesting toiieting assist. and she did not perform a Rwpiratory The RT explained the evaiuation had yet to be completed; When asked about the expectation of: the new admission resplratcry evaluations, the RT rxamrnented she likes to get the evaluations I The Respiratory Therapist commented normaiiy she would go In to look at the resident. and review the urders. The RT reviewed the current orders and stated "Theda would need ciarificetidn because of the :0 2 at 2.-4 liters." The RT stated "Need to get more information from hospice, too" regarding past needs and past history of respiratory treatments. The RT stated, can work on this now." 3.) A review or the medical record for Resident #1 was eonducted on M26112. The review of the medical record for the resident documented the resident was origirraliy admitted to the facility in July, 2011 and was readmitted to the facility from i the hospital on l0i'22i"l1 and 1CiI26li1. On 10-i2.2r1t and 102%! 11., interim care pians were initiated. RBSICIEDI #1 has a history inciuding, but not limited in. Cardiac Disease. Congestive Heart Failure (CHF), Renal insufficiency and Dementia. The interim care plan. dated 10/22/11 includes. but not limited to: "Resident is at nutritional an-ziidr hydration risk: Othar:PO {nething by meuth} IT ube feed" "Other: Hx (history) CI-ii-' (congestive heart failure). {nasai cannula) pm (as needed)" ''02 Sat (Saturation; will remain -92% or F281 FORM Previous Versions Obsolete Event it): 8lu"V5iD1'i ID. 85819 if continuation sheaf Page 11 0H6 From: 06/04/201212242 #109 FROM (Tl-tu>uAv 24 2012 13:33/no. 7533561034 1: DEPARTMENT OF HEALTH-AND HUMAN SERVICES CENTERS FOR MEDICARE SERVICES 0 - OMB i STATEMENT OF (X1-5 MULTIPLE DATE SURVEY AND PEAN OF CORRECTIGN QDENTIFICKTION NUMBER: COMPLETED FE. 0- 105702 0 05:1 512012 NAME or Pawns? OR SWPLIER -i smear ADDRESS. cm. s'rA'rE. cons 0 0 5157 PARK CLUB DRIVE . -nsuenmanr-: 1:1 IONCE ER rmponpom NU I man AT NT 34235 PROVIUERS PLAN on GDRRECTION 0 STATEMENT OF DEFICIENCIES - ID i as, pfigfix 2. (men DEFICIENCY MUST as PRECEOEZD av FULL i paemx (EACH SHOULD as i TAG REGULATORY on menriiwsne TAG A CROSS-REFERENCED TO "rue APPROPRIATE WE DEFICIENCY) 281 Continued From page 11 281 above" ''02 via n.-1c pm, 02 sat shift (every shift) and pm monitor for S08 (shortness of The resident was readmitted to the hospitai, on '101'24f1'.i, after tn' cardiac and respiratory deoiine. Resident #1 was returned to the on 10f26Ji3. The interim care pian included, but not iimited to: "Res_ident_ is at nutritional andlor hydration 1 risk" "Swaiidwing risk" "Other. Peg Tube" The care pian 'dated does not include Resident #1's history oi cardiac nr respiratory risk, the need fur oxygen or the monitoring of tha cardiac respiratory difficuity as previously identified from the care plan -dated 10/22m. 4. A review of the record for Resident #1 was 2 conducted on 4426112. record I inciuded documentation the resident family' representative signed the hospice benefit forms on iomm, and hospice staff conducted - assessments on iozzem. The resident family had not signed a Do Not Re-suscitate (ONE) order. 3 The review of the record incIuded'ti1e nurse notes. dated 10l26-10130111. The record i reveais the resident experienced a statusmondition deciine an 10129111. A nurse's 1: note, dated 10I29i11, at8:00 p.rn., documented the family reported a: "csurgly sound in the chest" A The nurse assessment was docurnanted as ii "phiegrn in the upper throat." 3 FORM Prav-;ous Versidns Obsolete Event Inzawemi Faditity 85319 if otmlinuatinn sheet Page 12 of 46 From: 06/04/2012 12:43 #109 P.0i4/077 FROM 2-4 T3: 335 17 DEPARTMENT or-' HEALTH AND SERVKZES CENTERS FOR MEDQCAR 3: MEDICAID SERVICES OMB NU. T0933-D391 STATEMENT OF DEFICIEHCIES PROWUEWSUPPLIEWCUA MULTIPLE. CUNSTRUCTIUN DATE AND PLAN or CORRECTION NUMBER: A. BUILDING 7 1?57"? W6 NAME OF PRUWDER OR SUPPUER Spry! STATE. I I 5'3 B7 PKRK CLUB DRIVE . PONT nuasm At 11.11' i ATION cemen SARASOTA FL 34235 (X4) :0 sumw STATEMENT or DEHCIENCJES ID PLAN or ms; pggpix (EACH DEIFICJENCY MUSTBE PRECEDED BY FULL PREFIX (EACH ACTION SHOULD BE -mg REGULATORY OR LSC INFORMATEOM TAG CROSS-REFERENCED TO THE APPROPRIATE DEF-ICREHCY) i 281 Continued From page 12 231 . A1822 pm.. on i0l29ll1. the nurse: documents I the Respiratory Therapist was at bedside providing respiratory The oxygen was . being delivered at 4 via nasal cannula (nose apparatus for oxygen deiivety). At 3:45 the nurse assessment inciudas edema (swelling) to the let hand with siight purplish moitling tn the feet bilaterally. Congestion is ncted tzuatween periods of treatment by the RT. The nurse documents speaking with the family regarding the declining condition and documented, "Advised family that condition had declined ever a period Of time advised signs present indicative ofa worssening in condition are present Such. as the rnoitling to the feet." The nurse decuments the-facility declined Hospice crisis care at this time. The Respiratory Therapist (RT) note is documented an at "8-:30 pm. - 8:45 pm. Nursing called me in pt (patientiroom to assess. RR (Respiratory Rate) 24 HR (Heart Rate) 78 (Oxygen saturation level) .92 .96 on at (4 liters of oxygen) BBS (Bilateral Breath 3 Sounds) dirninishecl with rhonchi {type all Breath soundilgurgling in trachea. orally sx (suction) 5 deeply with catheter 14 fqtube with size identifier); for lg amt (large amount] white thin sec . (secretions) pt continued to cough. very 5, congested loose cough, oraliy sx several more - times for lg amt white subslaince, -pt hall I 3 (iaieratedi sit well RR 22 HR 73 .92-.95 cm I 4 02 after sic. but did not completely clear. The 9:10 pm. RT entry documents "orally and sx for copious amounts ofwhiie substance pt appears I more relaxed. 92 on 441i-iFi 79 RR 24." 1 FORM ems-zsenoz-Ba) Pm-inns versions Dbsoiate Event Facility 85819 if continuation sheet Page 13 ofds From: #109 On 10129111: FROM 24 2012 19 OF HEALTH AND HUMAN samnces CENTERS FOR MEDICARE MEDICAID OMB NO. 0938-0391 STATEMENT OF l>-Ml nu} MULTIFLE coustnucnon 0(3) mm gufivfiy - AND man or CORRECTION NUMBER: A BUILDING a 1?57"? 3' Wm 05l15I20't2 NAME smear ADDRESS, cm: an-we. zap cone TARPON POINT nun me AND REHABILIT on can 5 ant-znsom, Ft. :-.4235 W, "3 STATEMENT or are lo Pnouloatrs raw: or CQRREGTION (is) . Pfifisix (EACH DEFICIENCY must Be eneceesn av FUU. Pnerrx (Ema nennacnvr-: ACTION as . common i REGUIJATORY OR LSD HJENTIFYENG ENFORMATJON) TAG CROSS-REFERENCED APPROPRIATE DATE - 3 281 Cdntinued From page 13 3 281 i At 9;-15 the nurse entry documents the RT completed her treatment. The ndte doeurnented the 'removed coplous amt (amnunt) of secretions, no gurgling sounds noted. family at bedside." The oxygen was being delivered at 4 tltersiminute vie nasal mnnule (nose apparatus for oxygen delivery). . - At 9:45 pm, the nurse documents the famlly was leaving the fior home. The oxygen was being delivered at 4 via nasal cannula. (nuae apparatus for oxygen delivery). At10:15 pm, the nurse documents she entered the room and mud the resident "wheezing noted on The nurse docurnents the vital signs as blood pressure of 92152. Heart Rate of to, Axillary temp of 99.2%. 92% 02 eat {oxygen saturatlons levels tn the I btood) with respirations at greater than per a minute and larboredu The oxygen. was being delivered at 4 literaiminute via nasat cannula (nose apparatus for uxygen delivery). The nurse documents the "10 pm. 'lube feeding held." The nurse documents the on call hdspice services i were carted and requested RN {Registered Nurse) to come out for assessment. The daughter was called with a message left on the telephone noting a decfine in the Resident status. 5 At 10:45 the nurse documents another cell i was made to the daughter with a message regarding. the continued decttne, that hospice was in route to the facility to evaluate and requested 3 i return catlfrom the famlty. I At" 11:10 pm. The nurse documents the Hdspice RN was at the tacilihr to evaluate and provide recommendations for orders. pomm crus.a5a7(o2.99) Previous Versions Ohm-late Event ID: Faoithr ll): 65519 If continuation shad! Page 14 ofda From: FROM DEPARTMENT OF HEALTH AND HUMAN SERWCES CENTERS FOR MEDICARE MEDICAID #109 24 2012 13 PRINTED: FORMAPPROVEB OMB no. 0938-0391 3 or oericlemcias PRCNIDERISUPPLIERJC LIA AND OF CORRECTION IDENTIFICATION 105702 NAME OF PRDVIDEROR SUPPLIER TARPON POINT NURSING AND REHABILITATION CENTER A SUILDING . B. WING (X2) MULTIPLE CONSTRUCTION STREET ADDRESS. cm'. STATE. 21? CODE 5157 PARK CLUB DRIVE SARASOTA. FL 34235 (X3) DATE SURVEY COMPLETED 0511-5201 2 (344; gr) SUMMARY OF DEFICIENCIES pfilgfix . (EACH DEFIGIVENCY MUST BE FRECEDED BY FU Lt Tgc, IREGULATORY OR LSC IDENTIFYING n: PREFIX i=novioEn's PLAN or connection (EACH CORRECTIVE sHoULn BE TAG CROSS-REFERENCED To THE APPROPRIATE DATE I COMPLEHOH 281 Continued From page 14 - At 11:20 pm, lhe, nurse documents "Hospice nurse assessed, provided with chart for review of I orders informed this writer ifaclliiy nurse} she will I call Hospice MD (medics! doctor) for orders per recommendation,.." The oxygen was being delivered at 4 liiersiminute via nasal cannula '2 (nose apparatus for oxygen delivery). I Respirations are at 36 even and labored. I - At 11:3!) pm, the nor:-rye documents, "Phoned I on call service of Dr. (insen physician name), Dr. {insert on call physician name) on call. roquesled return call to advise of Res. (Resident status At 11:59 om" the nurse documents the aide I while -atternpling_ to obtain vital sounds notified her I had "stopped brea'thing.i" The nurse documents no pulses present, ceased to breath, CPR {Cardiopulmonary Resuscitation) initiated imrnecliateiy at approximately midnight. j' EMS acrtivaied CPR cont. (continued) after 3rd cycle faint puI$E noted, cont. with CPR until paramedics arrived and took over. Time of death pronounced at 12:14 am." I The Risk Manager (RM) was.iniorviewed on 1. 4l'26i'I1, at approximatley 300 p.rn-, regarding the facility contact with the attending or on-call physician after the assessments initiated at 8:00 I pm. on 'iCil2'Q!11. "The RM roviewed Rosi-dent I#1's record and commenter} there was no I documentation about physician contact until the 11:20 pm. note, which indicates the Hospice I nurse was going to call the Hospice physician. The RM pointed to the 11:30 pm. documentation, which documented the on call-physician was called with a return cail roquesied. The RM was 3 asked if the "facility ever contacted the attending or on call physician with the decline in Resident I 231 I i FORM Pmlriou-a Versions Obsolete Event ID: BWBO1 1 FQCIIW ID: 35319 if continuation shoe! Page 15 or 45 From: 06/04/2012 -12:44 #109 FROM 24 2012 1 S1 1'3: aeruo. 759955-pggq, 30 DEPARTMENT or HEALTH AND HUMAN SERVICES CENTER-S FOR MEDICARE 8-. MQDIJCAID SERWCES (ma No' 993343391 STATEMENT OF DEFICIENUSES fxi} i=novio?RrsUePLlERJcLin (x2: MULHPLE CONSTRUCWON (X3) DATE suzwev AND Pow os cone ECTEQN 0 Numaen: . A BUILUING "?57?3 aims D5i15i2m2 NAME or PROVIDER oncsuppu ER I STREET ADDRESS. cm. stare, ZIP cone 515? PARK CLUE DRIVE RP HPOINT NURSINGAND RESARASOTIRFL 34235 W, in summny sinreuem or Deficiencies it, em: or DEFIGIEHCY MUST as PRECEDED av FULL (anon BORRECTHVE SHOULD ea com?xf?nou -mg REGULATORY OR LSC TAG CROS3-REFERENCES TD. THE APPROPRIATE W75 DEFICIENCY) i. 281 Continued From page 15 231 status and lor with the information regarding . the discrepancy in the tube feeding amounts i identified just prior to the Rwidonfs documented decline. The RM stated "You have the record for that time." The records do not include evidence the airtenciing, the on Cali physician or hospice 3 physician were contacted regarding the decline in i Residents #1's condition on 10329111. i 4. A review oi the recomi for Resident #3 was I conducted on M5112, at4:5D pm. The reooro documents the resident was originally admitted to i, the facility on with the diagnoses of, but 1; not limited to, Brain injury, Hypertension, i Depressive--Disorcierand Convulsione. The resident has a Peroutaneous Endoscopic I Gastrostomy (PEG) Tube (a tube Inserted' into the stomach for nutritional and medication adminimration access}. The resident receives Jevity "i .5 calorie give 240 mi via peg 6 times per . day at 5:00 9:00 am, 1:00 p.rn., 5 00 em', 9:00 pm. and 1:00 am. The MAR for May! 2012 was reviewed with the DCBN, at 4:55 pm, on 511 5112. The record I reveais 2 of the lobe feedings (TF) were held (not I administered) on May 8, 2312. The held feedings were the 9:00 am. and the 1:00 pm. administrations. On 5i1 0112 one tube feeding at 1:00 pm. was noted -as held-. The DON was asked about the hold feedings. The DON stated "We would have . to look at the resident's record." The nurse notes for 513! 12 were reviewed. The record reveals Resident #3 had radiology diagnostic on 518112 (Lumbar Punoture).. The 5i8'ii2, at 1:20 pm, entry documented the resident had an episode of 1 I 1 FORM Previous 'Versions Obsolete Event Facility ID: 35519 if continuation sheet. i?age 15 of 45 From: #109. FROM 24 2012 13: 31137. 13:33/No. 7539851964 it -21 DEPARTMENT or HEALTH AND HUMAN SERVICES CENTERS FUR MEDICARE 31 MEUIGAID SERVICES .. I OMB N0. 0933-D391 or DEFICIENCIES (X2) oonsmuonon mm: sunvsv AND .Puw or IDENTIFICATION NUMBER: A. BUILDING 105792 ms osnsizorz NAME 0" PRUWDER 05' STREET Aoonfiss. cm. STATE. ZIP cons I 5151 PARK CLUB DRIVE I INT RURSIN AND REHABILITATION CENTER TAR ON 0 I SARASOTA, FL 34235 our .9 SUMMARY srnremonr or DEFICIENCIES I an rmowoms Pun or oonnecnou . IKSI pg Em (anon nusr as PRECEDED av ruu. rasrix {anon corn: ACTION st-touw as COMPLETION TAG neouwonv on Lsc: IDENTIFYING me cnossmreaencso TO THE APPROPRIATE We DEFICIENCY) 281 Continued From page 16 231 amesis (vomiting) after the procedure and another episode of emasis on -return to the -, facility. The nurse documents the physician was called foras needed phenergan orders (orders for an antiemetio nausea control). A 2:30 p.m.,on 518112, nurse entry documents "Ftesidont had a large amount of brownish amesis around. 1345 (1:45 p.m mother at bedside awaiting from the MD'si {doctors} orders. All his rneds (medication) and food were heid per order." I I On 5115112, at approxirnatleiy 4:30 porn. the Unit Manager was asked about the order. The Unit Manager stated she would took tor the order and commented the holding of the Tube Feeding on muitipia occasions were a nursing judgment. At approximately 5:30 pm., on -511312, a M05 (Minimum Data Set) Coordinator returned with i the copied records and stated "these are the orders the nurse was referring to regarding the hold of medications and feedings." The Coordinator pointed to a highiig hted area on the document entitied "Discharge instruction Summary the entry documents "Aiter 1533 (3:30 pm), pt (patient) may resume osuai activity," The was unabie to provide -physician notification documentation aiter muitipia episodes of ernesia for Resident 4. A review of the -medicai record for Resident #4 was conducted on The record I reveais the resident has a history including, but I not limited to. Chronic Obstructed Pulrnoraary -I Disease (COPE), Congestive Heart Failure and urinary retention. i roam cus-25e7(o2-99) Previous Versions Obsolota Event to; swam: Facility 35519 rr continuation sheet Page 17 of 43% Pfizfiil 12:6 2012 13382187. 7533331004 PRINTED: 0512412012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FQRM cemggs son MEDICAID SERVICES oM_p no. 0938-p391 STATEMENT oi-' OEFIOIENCIES om PROVIDERISUPPLIERIGLJA GONSTHUOVON (X3) DATE SURVEY AND mm or IDENTIFIOATION women-. A commerce . 105102 9511512012 NAME or ianovaoea on SUPPLIER STREET ADDRESS. cm. some. ZIP cone TARPON POINT NURSING AND REHABILITATION CENTER m1 PARK CLUB DRIVE SARASOTA, FL 34235 [0 PREHX TAG srxreuanw or DEFSCIENCIES (anon DEFICIENCY must sit PRECEOED BY FULL on use ioeunmno msomnnom PLAN OF CORREGTTON (EACH GORRECTIVE ACTION SHOULO BE TO THE APPROPRMTE ID PREFIX TAG (153 DATE F281 322 Continued From page 17 A physician's ctarification order. dated #4112. includes. "Adjust 02 up to 10 liters to 02 Sate 90v94 via nlc. check 02 sets (every) shift and pm (as needed). if02 sat goes beiow 88. administer 02 at 10 titer vie non-breather untii O2 eats The plan was updated on 414112 retieoting this order. On 4126112. at 10:45 the RT documents the residents heart rate at . 101, Respiratory Rate 20. breath sounds "extremely diminished with little air movement." The RT documents the "nurse aware of status and affened medication The foiiow~up RT .notes document. on 4f26I12, at 12:05 pm, the 02 saturation is at 89%. on 10 Liters of 02 Heart Rate 102. Respiratory Rate 20. The 12:15 pm. saturation is at 91% on 10 Liters of D2, and HR and Respiratory Rate 70. The RT did not document the residents treatment and oxygen therapy was delivered by the route of the rebreather or nasal oannuia as ordered by the physician and as documented on the care plan. N8 TREATMENTISERVICES RESTORE EATWG Based on the comprehensive assessment of a 3 resident. the facitity must ensure that a res tdent who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metaboiio abnormalities. and nasatpharyngeat ulcers and to restore. it possible. normai eating skins. - This REQUIREMENT is not met as evidenced bifi . Based on staff interviews, rnedicai record review .. . 4' I --U-nth-I4 - 281 i 1 F322 Completion 6.15.12 3221 Specific Correction Action No specific corrective action couid be performed for resident 1. Resident #3 has had his rc- odrnission chart audited. Audit included a focus on enterol/dictorw nutrition/physician interim and core. pion. orders, Method Residents to Assess Other FORM Previous Versions Obsoietn Event Fenian; it): 35319 if continuation sheet Page 18 of 46 Cu' 5 .. From: FROM DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEINCAR MEDICAID 06/04/201212245 #109 24 2012 23 PRINTED: 052412012 FORM APPROVED OMB no. 093343391 provide and ensure residents receiving tube feedings received the appropriate treatment and services to prevent complications for 2 (Resident #1 and of the 7 residents sampled. The facility failed to provide the treatmeni and serviced to meet residents' needs due to facility approaches to notification of the physio-ion regarding oondi-lion changes, the potentials for medication and tube feeding ad ministration errors, physician order transcribing. obtaining . physician orders. clarification of physician orders. The findings include: 1 1. The record for Resident #1 revealed the facility received and transcribed an incornplate physician order. The order was originally' obtained from ihe hospital. The 3008 form. (hospital discharge - form) documented "Nepro 4 censlday {feeding 3 solution)." The order for Resldontm was incomplete and lacked a route of administration of Ncpro, On 4I26l"l2, a review of the Medication Administration Record (MAR) revealed, "Nepro 4 . cans QID (iour times a day) flush with 50 on before and after." This entry is not accu rate: it lacks identification regarding the type of flush, the route of administration, and the amount' does not match the dosage on the hospital form (Noon: 4 oansiday versus four limes a day). The :i came of Nepro 4 times a day was documented as administered on the MAR. The facility nurses have placed their initials indicating the inacourale amount of the feeding was I 1 STATEMENT OF UEPICIENCEES (X1) FRGVIDEFUSUPPUEWCLIA MULWPLE CONSTRUCTION DATE SURVEY AND PUSN OF AL BWLDING COMPLETED 0 105702 fa' 05l15l2012. NAME OF PROVIDER OR STREET Aooness. orrv, STATE. ZIP cone' 5157 PARK owe oruve TARPON PGINT nunsmo mo REHABILITATION CENTER SARASOTA FL M235 if . (X4, .9 sumuariv srnremewr or ID PLAN or' con-Hermon zxsi page"; uancn DEFNZIENCY MUST as Pneceoeo av mu. -PREFIX snotuu: are 1. <LenoM_ mg nzoum-oav on LSC: no mo TO THE We -nenczeucn 322 Continued From page 22 322 0 before and after administration Another order was written. on 'Give Jevity 12 Cal (Ca!orie} one can (110 via PEG tu be until Nopro becomes available-. Flush with 60 ml 2 0 before and after adminislration."' 3.) On at 4:50 pm. a review of Resident - #35. records revealed the was orfginafiy admitted to the facility on own. with the i diagnoses of, but not Iimited to: Brain Injury, 3 Hypertension,. Depressive Disorder and Convuzsions. The resident has a Porcutanoous Endoscopic Gostrostomy (PEG) Tube. The res:-dent receives Jovity 't.5 calories. give 240 mi via PEG 6 times per day at 5:00 am." 9:00 1:00 pm., 5:00 9:00 pm. and 1'00 am. The MAR for May. 2012 was reviewed with the DON at 4:55 The record reveals 2 of the tube feedings. (TF) nwere- held (not administered) on May 8, 2012. The held feedings were the 9:09 am. andthen1:00 pm. doses. -On 5110112 one tube feeding at 1:00 pm. was also noted as hefd. when asked abourthe held feedings, the DON stated, "We would have to Hook at Resident #3's record." The nurse's notes for revealed the resident had a radiology diagnostic iumbar 3 puncture on 51Bf12. The SW12, 1:20 pm. entry documented the resident had an episode of 3 . emesis (vomiting) after the procedure and anoiher episode of emesis on return to the facility. The nurse documents the physician was . cafled for as needed pnenorgan orders (orders for an antiemeticinausea control). A 2:30 pm. -on 5f8l12, the nurse's entry documents, "Resident had a large amount of brownish emesis around FORM CM s.2as7(o2.so5 Previous moons Obsolete Evan! Facimy 10: 35319 ormfinuailon sneak Page 23 of From: 06/04/201212146 #109 FROM 24 3D12 23 OF HEALTH AND HUMAN senvices CENTERS FOR MEDICARE QMEDICAID SERVSCES OMB M0. 0938-0391 OF DEFIGIENCIES (X1) PRUWDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION ixsi om-: or-'c nneonon oz 0 - i 0 AND PLAN i UMBER A BUWNG COMPIETEIJ e. WING 0 1?57"? A NAME OF PROVEDER OR SUPPUER srneemooaess. cm, STATE. ZIP code 5157 PARK owe DRIVE POINT NURSING AND CENTER 3 ARAS OT A FL 34235 mi in i suumixnv STATEMENT or -no i=-novioaa-3 PLAN or GORRECTJON (X5) pfifipgx (anon ogrioiswovmusr as moor-zoeo av FULL PREFIX (EACIH ACTION SHOULD BE common 1-AG neour.-rronv on LSC INFORMATION) 'mo To THE WE 322 =Con'tinued From page 23 322? - 1345 (1:45 pm.) at bedside awaiting the . MD's orders; All his meds medication) and food were held per order." in an interview, the Unit Manager was asked about the order and stator! she would took for the order and commented the holding of the TF on multiple occasions was a nursing judgment. At approximately 5:30 p.m. on 5f1-5:12. the MDS (Minimum. Data Set) Coordinator returned with the copied records and stated, 'Those are the orders the nurse was referring to regarding the radio or medications and feedings." The M-DS Coordinator pointed to a highlighted area on the document titled Discharge instruction Summary, which states, "After 1530 (3:36 pt (pationi) may resume usual activity."' The facility was unable to provide physician notification documentation -after multiple episodes of ornesis - for Residont#3. i 514 mr?irim Res 514 514 Complefiori 5.15.12 5%/2 35:13 . . LE Specific Corr-action Action The facility must maintain clinical records on each resident in accordance with accepted professional - standards and practices that are complete; i N0 C?Uld 2 accurately documemed; readiiy accessible; and 2 be performed for residenfs organized' 1. 4. 6. as They are no longer The ciinioai record rnustconlain sufficlent in The facility. Residenl #3 information to identify the resident; a record of the - - - 's resident's assessments; the plan of care and has_had his re char? i services provided; tho results of" any Al-Id" i preadmission SGFBEHERQ conducted by the State; - focus on and progress notes. i FORM Previous versions. otisoseia Event ID: Birilaoii Facility 35319 if continuation shoal Page 240143 From: 06/04/2012 12:46 #109 FROM (THU) 24 2013 an -. . 13: QBIHDI 71539 101:4 as PWNTED: DEPARTMENT or HEALTH AND HUMAN SERVICES FURMAPPROVED CENTERS FOR lviEolcA1o OMB NO. 0938-0391 STATEMENT OF NQULTIPLE QJKTE SURVEV 4 I AND PLAN OF CORRECTION NUMBER: COMPLETED A. BUILDING 105702 0511512012 NAME or PROVIDER on sueruee smersr orrv. STATE. ZIP cone 7 5157 PARK cwa DRIVE - . SING ANU ITA ON ER FL 34235 W, 19 SUMMARY STATEMENT or DEHCIENCIES in Pnovloews PLAN or connection [:51 Pt-tEFlx (EACH DEFICIENCY MUST BE PHECEOED av mu. PREHX (ENZIH CGRRECTWEAGTIDN suouto as 3 coMPLs*rIon TAG aaoumtoav OR PDENTIFYING TAG W5 3 F514 nutrition/physician orders, EM Continued From page .24 1 i . interim and care plan. This REQUIREMENT is not met as evidenced i by: f- Based on staff interview and medical record I Melhod 1'0 AS5853 Other review. the facility failed to obtain complete and Res,-dams accurate physician orders. for a dietary feeding to 3 include the correct feeding .-solution, route, amount and TFBQUEWY Ffiquired to A 100% audit of all in-house 'been 11:3) of the7re.sidents sampled. to evaluate if any other residents could have been affected by alleged practices. A review of the medical record for Resident #1 The focus on; was conducted on 4126112, The record . documented the diagnoses for Resident #1 inoluded, butwe-re not limited to; ician orders, (difficulty swaliowing). Congestive: Heart Failure, interim Care plan' and Change and Rena! lnsufficiency. d_ - in con ltion noti ication. The findingo include: I The records docurnenwd Resident #1 experienced multiple hospitalizations with readmisslonslrotums to the facility during the Systematic Review month of October, 2011. The readmission to the facility, on 'lOl26i11, required physician orders for . a PEG tube feeding (tube inserted into the . 5Y5l'em?l'C stomach for nutritional and medication revision was performed to administration access). A review of the Hospital . . . Discharge orders included', but not limited to: mclude lhe .4 4. .. . . . Noon) 4 cans per day (feeding solution). The nutritional system and PEG tube- The hospitat order lacked instructions feed Vla enleml ll-lb?-5 for checking the tube for placement prior to 1-0 include the die.Hcian_ 5 access, water flushes before and after access. . . and water flushes before and after medication Included '5 me new ladministratton. facility format process to FORM Previous vwilons obsolete Event lD:Bw901i Faclilty inc 85819 ll continuation sheet Page 25 of 46 From: DEPARTMENT OF HEALTH AND HUMAN SERVSCES CENTERS FOR MEDICAID SERVICES 06/04/20l212:47 #109 24 2012 30 PRINTED: 0512412012 FORM APPROVED OMB NO. 0938-0391 STATEMENT or (X1) PROVIDERISUPPLIEPJCLIA ixza CONSTRUCTION (X5) DATE suiivev mo PLAN os CORRECTION IDENEFSCATION A BUWNG COMPLETED I iisiisizoiz NAME OF PROVIDER OR STREET ADDRESS. CITY, STATE, CODE i I 5157 PARK ewe DRIVE TARPON POINT NURSING AND REHABILITATION CENTER SARASOTA FL 34235 W, .9 summer STATEMENT or in PLAN or CORRECTION (EACH MUST BE av mu. sane;-ix (EACH CORRECTIVE .n.c-non SHOULD as COMPLETION TAG on LSC 5 no CROSS-REFEREHCED TO THE Ji DEFICIENCY) - 514 Continued From page 25 i 514 PW"-ll' d3""?9"?Pl"C5. 3 enteral formula type, delivery 1 The 4 cans of Nepro 4 times st/die, th documented as administered on the Medication I av an_ _me m_d Administration Record (MAR). The facility nurses Vale Of IS 1 have Placed malt indicating We lfiacwfale included. To su ort that amount of the feeding was adniinistered starting .d .1_h pp I . on resi en 5 wi enterci feeding the fa 3 tubes receive and have he MA documented oi iv nurses signe as administered eleven times between 10I26lt2 documemed Th"? they have to 10i29!'12. This total of 14. administrations of the appropriate treatment ll"? 4 TOW "met? 3 $33" W5 and services to avoid documentation was incomplete as docurnenied I. . on the MARs. The; 1Gl291'i1, 4:00 entry 05 area ll"? the A W6 5 able, a brief admission interim note reveals the resident received Nepio 250 ml I . . I Th. via bolus without difi. (EURlitTicuity)." This note i an '3 Care '5 '3 indicates the nurse administered 1 can of Nepio process is confirmed during (237 ml) plus 1.3 mi to equal the 250 mi total i - . . mus feed. the. daily admission resident record evaluation The 10f29}'i1: - At 1:50 pm. entry d--ocumen'ls tube process unw mpmcemem wfih feed (Nepro oarb steady) and flushes Care The l-administered tier clinical process to support -- At 4:00 the nurse documents cans .more available called toMD (insert physician he" - name} on call. Orders redo (received) to anges, ocumentcition is substitute Jovity 1.2 oal (calorie) until Nepro incmded in The new daily arrives: A2 4:45 pm. The nurse enters admission and change in i ma!" 33' 1-2 93" W3 5'53 condition clinical risk review until Nepro arrives, then give Nap-to can qid, . . land i which includes Physician order At5;00 pm. the nurse documents "Jevity 1.2 review has been ifnmemenfed i cal one can via PEG tube, resident To include oxygen tolerated well. 2 medications, treatments, etc. FORM Priivloiis Versions Obsolete Event BWQD11 Fasting EJ785819 ll' continuation Sheet Page 26 of 48 From: 06/04/2012 12:47 #109 24 3912 :1 an DEPARTMENT car HEALTH AND HUMAN SERVICES CENTERS FOR MEDJICARE 8. MEWCAID . OMB No. 0938-0391 - STATEMENT or (X1) (x2) 9:3) QATE suavev AND MAN CORRECWON IDENTIFSCATION NUMBER: COMPLETED A BUILDING weenie NAME 04" PROWDER DR SUPPUER smear noun:-:ssi share. 21? (zone 5157 PA RK DFWE FONT 0 me mszeou i was AND REHABNJTATIGN camera FL ":35 in or DEFICIENCIES in i PROVIDERS PLAN or ow) pgffix {amen nereicieucv MUST as rnecaoao av FULL PREFIX (EAGH CDRRECTIVE ACTION snoum BE cemsnou REGULATORY on LSC INFORMIWON) mg 1 Egg%E APPROPRLATE . em': 5'14 CONMUBG FFDIT1 page 25 514 Assurance The MAR indicates this Carder with the times of administratirzn 9:00 1:00 pm. 5:00 pm. and The DON will be responsible I - The 5:08 pm. Javlty administration is biank 1.0 ensure 1.9155 3 - ysfem SIX 3 without entry on the MAR. 3 According :9 the facility nurse?>> note the fu|| records review. three per i was adn3ni??ra4d at 5:O09:.3m. I250 ft"; 00 uni1' reported on and during . i 1' . -i am. 13:30:>> 5:00 me "'5k i The MAR indicatfii ?13 10tO10ha.m. was 3 management/qualify assurance administered 4 cans in epro. are is no - 3 nursing note entry for 10:00 am. 1 On a Ciarification order was written as "10i29!2011 Cisrimsatianz Give Neprc Carb Steady one can QID via PEG tubs flush with 60 mi (mifliliter) 2 O. beforehand after administration." Ancither order was written, on 10i'29i1 1, after the o'n~cali physician was notified Nepro was not avaiiabie. "Give Jevity 1.2 Ca! (Calorie) one can QID via peg tube uh-'til Nepro becomes availabie. Flush with 60 m! 2 0 before and after 3 administration." The MAR documents the 10129111 ciarifiad Carder far Nepro 1 can QID (four times a day) was documented as "Hold." The updated MAR, on 10129111, dcacurnentied the new order for Jevity 1.2 ca-I-orie '5 can Oil). The MAR has no entry as administered, ye: the nursing note for 5:00 pm', on documented the Jevity 1.2 - 1 can was 0 administered. The facility faiied to clarify and obtain an FORM P:ev:ousvessims Obsolete Evani Faclimrlo. 3.5319 if oontinuatian shaa: Page of 46 From; 06/04/2012 12:47 #109 P.o29/077 FROH (THU) Maw 24 2012 13: 32 . PWNTEDZ or HEALTH mo HUMAN SERVICES FORM CENTERS FOR MEDICARE 8. MECNQAID SERVICES OMB NO. 0933-0391 STATEMENT OF PROWDEWSUPFLIEWCLM MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN or: IDENTIFFEATION NUMBER: A Eumms c: 3. WM 105702 NAME OF PROWJER OR SUPPUER smear ADDRESS. om. owns. ZIP CODE marou norm NURSING mo REHABILSTATHJN -camera l':L'f5 mi, in sumunnv STATEMENT or UEFJCIENOIES in Pnovlosws or CQRRECTIDN (X5) PREFIX (EACH DEFICIENCY MUST 3E PRECEDED FULL PREFIX CQRREGTWE SHOULD 5E GIJMPLEHON REGUMTURY OR LSC IDENHFYING INFORMAWON) TIK3 TO APPROFRLATE DATE 3 514 Continued From page 27 514 complete order on admission to the facility, on 10126111. for Resident The facility -oiarified the order on 10/2911 1, aflerthe "facility" documented 1'1 administrations of the inaccurate physician order. During an interview with the Medical Director and attending Physician on 511 5H2, at a review was completed of the Physician's Order Shaet, including Nepro 4 cans QID, thatwas signed on 'l-1i2l*l1. The Attending Physician was asked if the facility nursing staff discussed with him the incorrectly transcribed Nepro 4 cans QID order, which was on the Physicians Order Sheet that was signed on 11r2i11. The Amending was not sure of his recollection of what the nursing staff did or did not inform him about the incorrect Nepro' order. 1 This is a failure of nursing staff to review and communicate with the physician in a i manner that ensures clarification of medication administration orders prior to the Attending Physician signing. The facility provided statements obtained from -. the nursing staff administering the Nepro to . Resideni The statements dooumelnteothe nurses did not aldrninister more than 1 can of Nepro to Resldentiri per administration. 2. A review orthe medical record for Resident #1 - was conducted on 4!26f'l 2. The review of the medical record for the: resident documented an 3 -- original admission to the facility in .Ju'ly,201'1 and .readmission to the facility from the hospital on 10/22l11. and 1Dl26i'11. On 10122111 and 10f26/11 interim care plans were initiated. Resideni #1 has a history including, but not rr0RM Siravious Versions Obsolete Event ID. swarm Facr1iiylD:' 35819 If ooniinuailioin sheet Page 28 of 46 From: 06/04/2012 12:48 #109 FROM 24 2012 19:53:51', 7333551334 .3 93 DEPARTMENT OF HEALTH AND HUMAN CENTERS FOR MEDICARE 5. OMB NQ. 093843391 STATEMENT OF DEHGIENCEES (X1) CON-STRUGTICN (X33 AND PLAN OF coFlREc11oN NUMBER: A. Bulwlne 5 10570? 8' Wm NAME OF PRUMDER OR SUPPLIER STREETADDREBS, CITY. STATE. 21? CODE 5157 PARK cwa 1:-Riva PO -PG NT NURS ATION EHTE SARASOTA. FL M235 .0 snmsusm or uericiencies so Paownews pm or comm>> cm PREFIX (EACH MUST as mecaneo av ruu. {anew ACTION suoum as -couatrnon ms REGULATORY on INFORMATION) TAG To APPROPRIATE we 514 1: Continued From pag? 28 iimitad to. cardiac disease, congestive heart failure, Renal insufficiency and dementia. 5'14 The interim care plan, datad 10l2.2i'11, includes, but not limited 10: "Resident is at nutritional andfor hydration risk. Other: PC) (nothing by moulhiflube feed?' "Other: Hx (history) CHF (congestive heart failure), 02 (oxygen) via nit (nasal. cannula) pm (as "02 Sat {Saturation} will remain 92% or above, and" ''02 via n.lt: pm, 02 sat shift (every shift) . and pm rnonitur for S08 {shortness of - Resident #1 was readmitted to the hospital on after of c-andiac and respiratory decline. Resident #1 was returned to the facility on 10i26111. The: interim care plan included. but not limited to: "Resident is. at - nutritional andlor hydration risk; Swallowing risk," and "Other: PEG Tube." The care plan, dated 1D!26l1'i, clues not include the. resident history" of Cardiac or respiratory risk, the need foroxyger: or the monitoring of the 'Cardiac respiratory as previously identified from the care plan dated he care plan. dated 'lO!26m, does not address the need for mon.itoring Resident #1's in put and output, including mraasurement of residual, bnwel 3 sounds. lungs sounds, and palericy of the PEG tube before each tube feeding. since the PEG tube was placed during hospitalization prior to the 'l0l26i'l1'l facility admisslon.. .. .. The facility failed to provide an i-nterrlm care plan FORM Previous Versions Obsolete Event awenn Facility $5819 if continuation sheet P395 29 of From; 06/04/2012 12248 FROM 24 20 1 2 1 3: 53/91' . 38'/No. 75436531094! 34 i F. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICAR 5: MEDICAID SERWCES NO. 9938-0391 srnremaur or DEFJGIENGIES rm PRDVIDERISUPPLIERICLIA mi MULTIPLE consmucnon one eunvewr AND PLAN OF CDRRECTION IDENTIFICATION NUMBER: COMPLETED A. 1?57" NAME OF OR eraser richness. cm'. STATE. some 5157 PARK GLUE DRNE TARPON POINT AND REHABIUTATJON CENTER FL 3?235 {X4).ifl i SUMMARY DEFJCIENCIES ID i PLAN or conaecnon PREFIX 1 DEFICIENCY MUST BE PRECEDED av sun. PREFIX. (EACH conaecm-re suouw -as 'rm; REGULATORY on use msonwmoni TAG T0 AFPFIOPR IATE CW5 DEFICIENCY) 5&4 Continued From page 29 514. containing care and services based on diagnoses and conditions impacting Resident #i '5 outcaomes. 3' A review of Resident #1-is medioei record was- cenducted. on 5!15i1j1, at 1:49 pm. The resident was admitted as a respite care for hospice care. The resident" has a maiigh ant melanoma eecc:ind'ary to lung cancer and an upper right i fungating tumor of the mhuth. Resident #6 was 3 admitted to the facility on 5.f13i12. The orders i and the nurses' nuteswere reviewed. The physician efcieis documented an order as (oxygenivia nit: (nasm -cannuia) 2-4 Um (2-4 Liters per minute} pm (as needed)!' The interim care plan the need for oxygen therapy minute 3 i The 5i13}12 n.urse's noiel at 10:30 am, ideniiflesi Resident #6 was admitted under a facility iiootors care. The new documgents the Lung sountis are diminished with saturation of oxygen at 93% an roam air. The nurse documents "Mecis (Medications) reviewed and faxed MD (Medical Doctor)?' An interview with a floor nurse was conducted, on 5115211, et 1:45 after the record review. The nurse stated the 2 wouid be administered between 24: iitere depending on the of Resident When asked how the decision wouid be made, the nurse stated "This would be 3 assessed by the 2 saturaiions." The nurse then commented if the saiurations were higher, the resident wouid require less. oxygen The nurse was asked what paraxneter wouid be FORM Previous Versions obseiele Eveni. BWSD11 in 35519 if continuation sheai Fags .39 ml 45 From: 06/04/2012 12:48 #109 FROM 24 ecnz 13167/8'1 . 1 3 as/Na', 71593551 n94 .35 DE-PARTMENIT 0: HEALTH AND HUMAN sem/Ices CENTERS FOR 8: MEDICAID SERVICES OMB No. 0938-0391 STATEMENT QF DEFICPENCIES (X1) PRQVIDERISIJPPLIERICLIA MULTIPLE CONSTRUCTION ppm: sulwgy AND PLAN or coRREC'l'lOl-l IDENTIFICATION NUMBER: couprgmu A. 3. WING I osmr/2012 NAME 0F PROWDER UR BUPPUER cm. ll!' code 5157 PARK CLUB DRIVE TARPON POINT NURSING AND REHABILJTATION CENTER sARAsoi*A, FL 34235 ,3 sumnmi srnrauem of ass Iclencies ID PLAN cs conaacnosr 9:5) pfigfix (EACH DEFICIENCY MUST as mscanen av FULL PREFIX ACHON SHOULD as -mt; REGULATORY on LSC IDENTIFYING INFORMATION) ms To me We DEFIMENCYI 2 . 514 Continued From page 30 514; needed fora resident with a saturation of 90%. 3 The nurse that she would start at the I I lower doses of oxygen and go up according to the I residen-t response, but than stated. "i see, the I order could probably use clarification." Respiratory Therapist was interviewed. ion 514.5111, a'r1:5D pm. The RT explained this was a new resident and she wentinto Resident #85 room to evaluate the day befcre. but the I resident was requesting tailetlng assist. and 3he did not perform a Respiratory Evaluation. The RT explained the evaludation had yet to be completed. When asked about the expectation of the new admission respiratory eval-uatlond. the RT commented she likes to get the as men as possible. The Respiratory Therapist crommenlad normally she would go in to look at - the resident, and review the The RT i reviewed the current orders and stated, "These would naecl clarification because ofthe 2 at 2-4 liters." The RT stated, "Need to get more information from hospice. too." regarding past needs and past history of respiratory treatments. The RT stated can work can this now." i The facility continues to accept and fax I or inaccurate. oxygen and respiratory I care orders atte.r the trainings provided to the 3; nursing staff in November, 2011. 4. A review of the medical record for Resident #4 was conducted on 4I26'l'12. The record documented the resident has a histoty of including, but net limited to, Chronic Obstructed Pulmonary Disease (COPD), Congestive Heart Failure and urinary retention. FORM Previous Veryions Obsolete Facility ID. 35319 if ddnfinuation she-at Page Si oi 46 From: #109 24 2012 1 3: -57131'. 133: 7533531084 86: DEPARTMENT or HEALTH AND HUMAN SERVICES CENTERS FOR 5: -SERVICES OMB N0. 0938-U391 or my (X2) CONSTRUCTION :13; mars SIJRVEY AND pun OF CORRECTJON NUMBER: A BUILDWG comemeu i II A 3' me fl5_f15i2012 I NAME OF 0" SUPPLIER STREETIADDRESB, cnv, STATE. com: 5157 PMIK CLUB DRIVE TARPON NURSING AND REHABILITATION CENTER FL 34235 'mm or coaaecrion (X4) :0 suiemrw STATEMENTIUF neeacneucies In I . oes- MUST as PREGEOED av FULL . PREFIJC 3 (EACH coeaacrivs as coim?noiu TAG FIEGUWDRY OR LSO me 2 caossmereaeucen 1'0 THE APPROPRIATE W515 i 1 i 514 Continued From page 31 F. -514 A physician order. dated 414/1 2, 1 includes, "Adjust 02 02 Sets 9--0~94 via nivc, Check 02 ears :4 (every) shift and 3 pm {as needed). if 02 set goes below 88, i 'administer 02 at 1-0 liter via nan-breather untii 02 eats The care pian was updated on 414/12 reflecting this order. On 4128/12. at 10:45 am, the RT eecuments Resident heart rate at 101, Respiratory Rate 20, breath sounds "extremeiy diminished with i little air movement." The RT documents the "nurse aware of status and offered medication The RT notes are documented on i 4l26!12 as, at.12:O5 the RT documents the 2 02 saturation is at 89%. on 10 Liters cf 02 Heart 3 Rate 102, Respiratory Rate 20, and the 12:15 p.m. saturation is at 91% on 10 liters of Q2, and . HR 101 and Respiratoiy Rate 70. 1 The foilow~up RT notes are documented on -#261 12. at 12:05 the RT documents the 02 saturation is at 89%, en: 10 of 02 Heart Rate 102, Respiratery Rate 20. The 12:15 pm. i saturation is at 91% on 10 Liters of O2, and HR 101 and Respiratory Rate 70. The RT did net document the resident treatment and oxygen therapy was deiivereri by the route of the rebreather or nasal cannula as ordered by the physician and as documented on the care plan. The failed to document the provision of i respiratory care and services as prescribed by the physician per a written physician order and as outlined on the care plan for Resident 4. i i i i FORM (mutate Evan: If continuation sheet Page 32 one From: 06/04/201212249 #109 24 2?12 39/Nona 37 I 5: 1201-2 DEPARTMENT or AND HUMAN senvrces CENTERS FOR MEDHCARE a. senvuces omano. 093343391 STATEMENT U5: QEFICIENCSES I MULTIPLE CONSTRUCTQON -QATE SURVEY AND PLAN OF CDRRECNQN COMPLETED A. I NAME OF OR SUFPUER ADDRESS, cm. STATE. ZIP CODE I 5157 PARK CLUB DRIVE TARPDP-I POINT NURSING AND REHABILETATION CENTER SAR FL :!'235 0.54, an suwmav STATEMENT or IE) '3 Paovroews PLAN or com-scnnu 0:5; mam {emu uusr as nnscenen av FULL PREFIX {anon -conaecnvz ACTION snouua as comrnermu mg REG-UUXTORY on nnemuwmcs znrnamrtony TAG 1 CROSS-REFERENGED To THE WE nerccrencm Continued From page 32 514 514' I 5. A review of the record for Resident #3 was conducted on 5!15t12 at-4:50 p.m. The. record reveals the maiden: was original-Iy admitted to the 1 facility on 611111, with the diagnosis of, but not limited be, Brain Injury, Hypertension, Depressive Disorder and Convuisions. The residarrt has a PEG tubeIGastrostomy (tube inserted into the stomach for nutritlonai and medication administration- access), The resident receives Jevity 1.5 calorie give 240 ml via PEG 6. times per day at5:0O am, 9:00 a.rn-, 1:80 5:00 9:00 pm. and 1:00 am- - I I 1 The MAR _for May, 2012 was reviewed with the -Director or Nursing (DON), at 4:55 p. on 5f'i5f'I2. The record reveals 2 oi the tube readings (TF) were held ("not-administered) on May 3. 201.2. The held feedings were the 9:00 am. and the 1:03 pm. administrations. On 5110112, one tube feeding at 1:90 pm. was noted as held. .. The was asked abeut the hold feedings. The DON stated "We would have to look atthe 3 Residents record." The nurse notes for 513132 i were -revtewed. The necord documented Resfient #3 had radiology diagnostic on 518112 (Lumbar The entry", dated 518112. at 1:20 revdated the resident had an episode of amesis (vnrniting}- after the procedure and another episode of eme$ts an return tn the The nurse documents the physician was netted for as needed phenergan orders (orders fur an antiernetic-nausea controi). 3 The entry dated 518112, a-?2130 p.rn., documents "Resident 'had a large amdunt of brownish emasis i around 1345 (1:45 pm.) at 'bedside i FORM isms-zatmoa-99) Previous Versions absolute Event ID: IBWBD11 Facility ID: 88819 If continuation sheet Page 33 of 46 From: 06/04/2012 12:49 #109 24 20-12 13:33/st. 7533361034 are DEPARTMENT or HEALTH mo HUMAN ES CENTERS FOR MEDICARE 8-A iD SERVICES OMB N0. srnremem or on} (X2) itiiUt.Tl.PLE consrnu CTION [mg mg; 3-ugvgy AND PUKN OF EDENTINCATION NTUMBEH: oumomc; COMPLETED I 3, wins in 0" PRWWER 0'1 smear crrv. snore. zip coma TA on POINT RURS-EHA urea SARASOTA, FL M235 out to SUMMARY STATEMENT or no Pnovioaws PLAN oriconnecnou - (x5) pa at-ix oarlciencv MUST as PRECEDED BY pnearrx (anon CORRECTIVE ACTIDN Si-tOULfl BE coMr=Le'rioM TAG REGULATORY OR L56 IDENTIFYING TAG CROSS-REFERENCED To rue APPROPRIATE WE 514 Continued From page 33 514 awaiting. from the MD's (doctors) orders. Ali his meds (medication) -and food were held per order. The Unit Manager was asked about the order. The Unit Manager stated she would look for the order and cornmented the holding of the TF on multiple occasions wero a nursing judgment. - i . On at approximately 5:30 pm., 3 M05 1 (Minimum Data Set} Cormciiriator returned with the copied records and stated "these are the ordors the nurse was referring to regarding" the hold of medications and iiaedings." The MDS Coordinator pointed to a highlighted area on the document titled Discharge Instruction Summary 3 which states, "After 1530 (3:30 pt (patient) may res.um13-usualaotivity." The facility was unable to provide physician notification i documentation an-at multiple episodes of omesis - for "Resident The facility failed to provide notification of the physician regarding a change of condition and obtain orders to hold multiple tube feedings for Resident - . .. The '-facility administration was unable to provide evidence of appropriate analysis -'mciudlng root cause and faoflity process evaluation. The facility administration was aware of facility practice inconsistencies andifaileci to institute quality 5 indicator lrwesligations and inform the Quality 5 Assurance Comrnittee to ovaluate facility i practices and to -correct and prevent future incidents. 2:33 520E for 520 to begin on 'o"5 - I .1 i QUARTERLYIPLANS 3 following page.** - I I i FORM Previous Wrsions Obsoierta Event iv: BWQD11 Facility ID: 85319 if continuation sheet Page 34 of 48 From: FROM #109 24 2012 as PRINTED: 05f24f2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES F0 RM APPROVED OMB NO. Q938-0391 CENTERS FOR gag DICARE SERWCES STATEMENT or -DEFICIENGJES (xi: PROVIDERJSUPPLIERJCLIA NAME or pnovioen on suppusn rxzi MULTIPLE cousraucnou i no; awe SURVEY AND PLAN OF IDENTTFICATIONT HUHBER: A. BUILDING I3 8. WING 105702 0Sl15i2D12 STREET ADDRESS, CITY, STATE. ZIP cone 5157 PARK CLUB DRIVE facility, and at least 3 other members of the ,5 facility's staff. and assurance activities are nooessary; and 5 develops andi _implements appropriate pians of Afaoility must maintain a quality assessment and assurance committee consisiing of the director of nursing services; a physician designated by the The quality assessment and assurance committee meets at ieast quarterly to ideniify issues with respect to which quality assessment action to correct identified quality deficiencies. A State or the Sooreiary may not require disclosure of the records of such commitiiee except insofar as such disciosure is rotated to the compliance of such committoe with the requirements of this section. Good. faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions. . This REQUIREMENT is not met as evidenced Based on Sta?! inmrview and facility record review. the Quality Assessment -and Assurance Committee failed to identify issues which quality assessment. and assurance activities are necessary. The facility faiiad to doveiop appropriate examination of care processes related to 4 (Residents #4 and of the 7 residents sampled. The facility failed to provide effective Quality Assurance Performance improvement resource management to promote UTATION CE TE TARP URS HAB1 FL 34235 W, in 3. SUMMARY srxrem-Eur or osricisnoiss in rnovioens PLAN or conn?onou 9:53 PREFIX (EACH DEFICIENCY MUST as PRECEDED av mu. Pm-:F1x (EACH oonnecnvs Acnon SHOULD BE COMPLETION . mg on mro Rmmon; mo ro THE APPROPRIATE 3 i . . i 520 Continued From page 34 520 520 6-15-12 Specific Corrective Acfion The facility has designed and restructured qualify assurance performance improvement programs. The facility has invesiigafed and now signed up to parficipofe in The Advancing Excellence Campaign and has selected The Three focused areas to initiate. The facility has contracted with a Florida based known consulfing group To supporf changes. Meihod To Residents Assess Oiher Based on The quality concerns a comprehensive audit has been implemenred which includes the oufside consulionrs. The audit includes a 100% record audit of all in--house residents to Form curs-2 savioa-so) Previous Versions Oboolaio Event ID: BWRD11 Facility ID: 85819 if continuation sheet Page 35 of 46 From: FROM DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE SERWCES 06/04/2012 12:50 #109 5:4 2012 13:53/37. Tieraae-:51-034 I5 40 PRINTED: 05124/2012 FORM APPROVED OMB NO. 0938-U391 Aiifiargmii Si: W) W) Mumpif imemumuo 105702 5' 0511512012 0' 0* SUPPUER -STREET ADDRESS, GUY, STATE-, 21$' cone 0 POINT was . . 5151 PARK owe DRIVE INS REHAELITATION CENTER SARASOTA, FL 34235 (X4) in SUMMARY STATEMENT or DEFICJENCIES ,0 - or W, - PREFIX - (EACH DEFICIENCY Must as av FULL -PREFIX ierioii CORRECTIVE ACTIQN SHOULD ea COMPLETION ma REGULATORY OR TAG cRms.aamE 'Eg 1-HE gppfiopamfg DATE won 520 Continued From page 35 52:) evaluate am' and ensure the health wellbeing of all facility 'l re5'de"f5 hm'? been residents. The facility faielnd to ensure a complete, i affected by alleged practices and thorough investigation was conducted - . . resulting-in the lack of Quality Assurance and Sfaf?d me Survey Performance lmprovementexaminatlon and root A focus was placed on cause analysis resulting in a continuation ofthe 1. - - i systems failure regarding facility approaches and is fm,dm9 and i all nursing staff had demonstrated understanding *0 Care i of facility expectetiaas in lne notification. of the services for those receiving physician regarzjing changes, the d. . potentials tor medication and lube feeding ea lube: administration errciriir-=. Phgisloian order acute change in condition with rd . . . ph;';ig9a? gig}? am' and interim care ans. The findings include: 1 1. Ai"eview.of the med.ica'I record was conducted . 3 on #26112 for Resident The facility records 3 reveal the facility did not conduct an "Incident 5 . . 1 Report" investigation for the potential of error Y5 emaflc "eV'eW and I E?ube in excess revision was performed fiansioribed alum eedinggiygigizia?fi ?'l1e oiiginai bl" physician order require-:3 clarification of route to facilit nutritional stern ini . ti 'fh he aim' 'stored The faoirty nursing staff documented Resident #1 was administered 4 W1 focus on we newly cans of the tube feeding solution ateecn and those acirninlistratiori four times per day. The originai feed via feeding order indicated the Resident should receive 4 'r I . . cans of Negro (feeding per day. The 65- 3 '5 nurses documented on the Medication communi cati on with the Administration Record (MAR) the administration - - - . . of 4 cans of Neon: four times a day. a_"d dewsmg new communication technique and During an interview with the Director of Nursing 1-00] Th-5 - (DON), including the review of the facility, "Quality format '3 Assurance Meeting Minutes for the Udes Pcmem roam Previous versions Obsolete Event 10: eiivaoit Facility lflr. B6819 If oonliri uetion sheet Page 36 of 46 From: 06/O4/20l2 12:50 #109 <-ruu>mw :4 2012 1:3; Ba/No. 7593361034 9 4.1 DEPARTMENT OF HEALTH AND HUMAN SERWCES CENTERS FOR MEDICAID SERVICES om ND. 0933-0391 STATEMENT or (X1) PRDVIDEFUSUPPLIERICLIA oor~i5TRUcTioi~i (xa) ants suave! - - AND PLAN OF CORRECTION IDENTIFECAIFON NUMBER: A ENDING a was I I I osnaizaiz 0" PROWDER QR smear Aoomass. om. STATE. ZIP cone 5157 PARK CLUB DRIVE TARPON POINT NURSING AND REHABHJTATION CENTER SAFUXSGTA, FL 34235 in sumunm or DEFICIENCMES ID it PLAN or connection pm) PREFIX (EACH DEFICIENCY MUST BE PRECEDED av FULL PREFIX I (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG LSO IDENTIFYING wrommowi mo CROSS-REFERENCED to ruenrmopainta we 2 3 520 Cammued From page 36 520 emographics, enteral formula Month of October, 2011 Meeting Held on type, delivery site/ device, and November 10, 2011" document. The DON had a mefhod and of i explained the facility did report the incidmt to the . . . Quaiity Assurarioa Committee. The meeting T0 minutes DON report inoiuded. but that residents receive . cfasinot gm; Em em" for" em" appropriate treatment and I2 services to avoid i in the. afternoon a 4' 6112, at approximate! 5:00 - - - pm, the DON denied conducting an "lncim:nt as IRBPOITJ investigation. The ooiistaiea, "l . able, a brief admission interim conducted an informal i=nvestigation.." plan of care Wm be in mace An interview with the DON, R-it-tit Manager (RM) l"C|"di"9 ldelmfled CONCBWIS was conducted at 6:90 pm, on . related to enteral feeding. The DON was uriabie to provide . . . . documentation the attending physician was 1 Th'5 be rewewed notified oitne ootantiai at {additional feeding 5 the new M--F daily admission soiution. The documentation of the informal resident record evahmfion report and nursing notes indicated the attending . I ;was info-rmad the facility did nothave the - process instituted to include 7 appropriata amount at Nepro feeding solution in 1 the facility for Resident when asked about I documentation -notifying. the attending physician the primary rationale for admission and treatment for I ofthe potential additions? feedings the DON 3 most immediate Cape needs 3 stated. "No. I do not havethat documentation." I gThe Administrator commented the facility rep "came"? bi' lhe ;ide~ntlt'iedthe transcription errorand, "We fixed I comprehensive plan of care in piece>> The +0 ierrorand the potential ofthehlepro feeding Identification of 3 solution administered in excess ofthe order at Ciingcai risk' document Chm-cal the time the potantiai for the error was identified ion10i2E~3!12. The Administrator commented the. 3 nurses itnvolvefi' wefg?ngwiewe?lhangghey d'eni:d stabi lity, evaluate feasibility - . . . . rail :19 nnizlgiasra rl To manage The ginvoived oocurrod house or transfer includes 5 i Foam Prwiaua wmionu Obsoiete Event uzc. 35319 It continuation sheet Page 37 one From: FROM 06/04/2012 12:50 <'rHU>mw 24 2012 3':3:86fNo. 7533561034 -42 PRINTED: 051242012 #109 DEPARTMENT OF HEALTH AND HUMAN SERVICES FQRM App;Rc.yED CENTERS son MEDICARE 3. MEDJCAJD sr5RvicEs ours N0.-0938-D391 STATEMENT OF DEFICIENGJES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE AND PLAN OF CORRECTION IDENTIFICATION NUMBER: - COMPLETED A. BUILDING 105702 9' 05:1 5:201: NAME 05-' paovio?s on SUFPLEER TARPON POINT NURSING AND REHAELITATION CENTER 3 smear mosses. crrv. arms. coo: 51.57 PARK CLUB DRIVE SARASOTA. FL 31235 W) in 5 SUMMARY srnreueur as aerrcreucies no I i Paaviossrs PLAN or conizscnou pus) (sacs MUST as PRECEGED av suu. PREFIX (EACH ACTSON SHOULQ as comtenor-r 'mg REGUUWORY OR INFORMATJON) TAG CROSS-REFE-RENCED T0 DEFICIENCY) 5205 Continued From page 37 520 those feed via enter-al Tube The facility "Medication Error Report' documents feec_imgf and Wm mclud_e the error occurred on rorzsm In The Medication montrorlng for change In 3? 'fig-Elgetdti 35 4 'lid condirion which has been Via - is u, . . shaped info the new daily THE 30.03 'Griff discharge f0fi_T1l admission and change in .a condition clinical review. route of administration. and was not clear Physician order review has regarding the amount of Negro Resident #1 - required per day. A review of the MAR was bee." 'mp|ememed' The . conducted on 4126112. The MAR is documented fC1ClliTY has evaluated and as. "Nepro 4 cans QED (four times an day) flush determined the benefif with 60 cc: before and afler." . the Advancing Excellence The Facility "rlliifledication EITOI Pr-ogr-am demonsfrafgg and the error as' . ranscriptioa error our rea . Nepro 1 can aid via PEG tube." The report 'therefore has up and. included "Outcome to resident and care provided" Selected The three areas "Nana, transcription error only, Resident rec'd - - - (recewem 1 can mm, planned To parricipaie in. Oursrde clinical 2"lSk and roof The MAR was reviewed withthe DON, Risk Cause and sis framin 3 Manager (RM). and Administratorcommented. "The nurses documented they '1 5? 33" 7? administered 4 cans. i don't know why theyhdid registration for June 12' II it 7 'dam Knoww 5' 2012, four hour program given by a Srare recognized During Medical Director and A - - - a Resident attending Physician, on 5:15:42, at "?mey i 5:30 a review was oompieted of the Manager' Physician's Order Sheet, including Nepro 4 cans schedmed. QED, tiratwas signed on 11,l2I1'i. The Attending Physician was asked if the facility nursing star? discussed with him the inoorrecily transcribed Quality Assurance 3 Nepro cans QID order, which was an ihe i . . Previous Versions Obsolete Eveni iD: BWSD11 H): 55819 if continuation shoal? Page 38 of 48 From: 06/04/2012 12:51 #109 Fm" 24 2012 14: ooze-Ir. 'l$:$3INo. 7159955139,' 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 3. MEDICAIB SERVICES ems No, o93a-o39--; 1?57"? I 8' Wm iJ5I15l20'l2 NAME or PROVIDER on SUPPLJER eraser ADDRESS. cm', sure. ZIP coo:-: I TARPON POINT uunsmc AND cemen Pm' "Rm FL 34235 (xi) in or oartcieucias ID 5. PLAN or conaecnon gxsi mam tenor} DEFICIENCY MUST as PRECEDED av ruin recon CORRECTIVE ACTIDR sfiamg BE no OR 1.56 INFORMATION) mo cnoss-rierenencec rd THE APPROFRMTE WE DEFIDIEHCY) Physician's Order Sheet that was signed on to ensure compliance to this 11/2111. The Attending Physician was not sure of 3 Sysfem' she will do so during his recoilecticn of what the nursing staff did or did I not inform him about the incorrect Nepro order. This is 3 failure Of the facility nursing staff it? resjdenfs clinical records with review and obtain needed clarification of . . medication administration orders prior to the . fhree Per "rm Per momh Attending Physician signing. 2 addition to daily updates by Qrhe facility obtain from-the - DON 'nursing staff administering the Nepro to Resident and NHA. All will be followed The statement documented the nurses did up on by the NHA and included and reported on and not administer more than 1 can of Noon: to i 5 Resident #1 per aclrninistration. The Quality Assurance and Pariormarioe dumng me m.?mh1y risk Improvement failed to ensure the implementation of a system to identify similar transcription and meeting. need for medical order clarification issues, develop .a system to corrected identified issues and a method to monitor for the effectiveness of implementation of systems changes and the need for further system changes to ensure the highest I . quality health- services are prcivlde to all facility residents. full record review of six 2. A review of the medical record for Resident #1 3 was conducted on 4126112, The review of the I medical record tor the resident documented original admission to the facility in July, 2011 and I was readmitted to the facility the hospital on tofzzitt and On 16122111 and tEURlf26I"l1, interim care plans were initiated. The - resident has a history including, but not iimited to, cardiac disease, Congestive Heart Failure (C-HF), Renal insufficiency and dementia. The interim care plant dated ii3l2.2f11, includes, Previous Versions Obsolete Event ID: BW9011 Facliliv ID: 85319 It continuation sheet Page 39 of 46 From: FROM DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8; SERVICES #109 '24 2012 9 44 PRINTED: 0572412012 A FORM APPROVED QMB No. 0933-0391 OF i AND HAN OF CORRECTTON mama or pnowoesi on (X1) IUENTIFICATKDN NUMBER: '1 05102 TARPON POINT NURSING CENTER a. wine A 5157 PARKCLUB DRIVE STREET ptooraiass. cm, STATE. ZIP cost>>: may DATE no (X41) PREHX TAG SUMMARY STATEIH ENT OF UEFICIERCFES MUST BE PREGEDED HY FULL REGULATORY OR ID I PREFIX TAG PHOVIDEWG PLAN OF GORREICTION (EACH CORRECTIVE ACTION BE CROSS-REFEREMCEO TO THE APPROPRIATE (X26) coamsnou one 520 nutritional anclior hydration risk, swallowing risk," Continueel From page 39 but not iimimd to: "Resident is at nutritionai ianolor hydration risk. Other, PC. (nothing by feed?' 'Other: l-'ix (history) (congestive heart failure). 02 (oxygen) via nic (nasai cannula) pm (as needed)?' "02 Satnisaturatiom will remain 92% or above. andshift (every shift) and pm monitor for SOB (shortness of The resident was readmitted to the hospital on 1OI24lt1_, after of cardiac and respiratory decline. was returned to the. facility on l10I26/11, The interim care plan i included, but not limited' to-. "Resident is at and "Other, The care pian, dated does not include Resident #1 's history of'G'ardiac.or reopiral:or_y_ - risk-. the need for oxygen orthe moniioririg of the respiratory dmiculty ast-previously - identiflei:l_from the careplanj dated 1OI22111. The facility failed.-to provide an. interim care oian .conta_ining care and services _based4 on diagnoses and conditions impacting the resident outcomes; The Quality Assurance and Performance improvement failed to-ensure the implementation ofa system to identify similar issues of interim care plan development and timely Respiratory evaluations. doveio-p= a system to -corrected Identified issues and a method to monitor for the effectiveneiss of implementation of systems 1 changes and the need for further system changes 5 to ensure the highest quality health 'services are . .. . Foam Previous Versions Obsolete Event io:B.W9o1 1 in: ass: 9 if continuation sheet Page 40 onto From: 06/04/2012 12:51 #109 FRDM <'rnu> mufr 2-4 2012 14: 01 113 as Ii-lo, F. DEPARTMENT or HEALTH AND HUMAN SERWCES CENTERS FOR MEDICARE 3. SERVICES i om ml 093343391 STATEMENT or DEFECIENCJES rxu cowsmucnow mm gut-way AND PLAN or CORRECTION YDENTIFICAHON mums Em A SUWNG cl 5. WING I '"5793 0511512012 NAME OR Armness. cm'. STATE. zla=- coas- 5157 PARK CLUB DRNE TARPON palm NURSINGAND . rum - REHAB CENTS sanasdrn. FL 34235 our ID SUMMARY STATEMENT OF UEFICIENCIES ii) Pnovioefis PLAN or CORRECTION (25) LEACH DEFICIENCY MUST BE PRECEDED av FULL i (EACH SHOULD as DOMPLEHON ms REGULATORY on LSC lnrottmmoni ma DROSSJREFERENCED To THEAPPROPRJATE DATE . DEFICIENCY) 520 Continued From page 40 520 provide to all facility residents. A review of Restdent#fi'a medical record was conducted on 5115311, at 1:40 pm. The resident was admitted as a. respite" care far hospice care. The resident has a malignant melanoma secondary to lung sander and a. upper right fungating tumor of the mauth. Resident #6 was admitted to the facility on The orders and the nurses:-' notes were reviawedl The physician orders documented an order as ''02 (Oxygen) via nic (nasal cannula) 2-4 um (24 Liters per minute) pm (as needed)." The interim care plan identifies the need for oxygen therapy as 2 via we at 24 per minute The nurse n_ote, dated 05I13lf2. at-10:30 identifies Resident #6 was admitted under 3 5 v_ facility dactofs care. The note documents tha Bilateral Lung sounds are diminished with saturation of oxygen 'at 93% on room air. The nurse documents "Meds (Medicaticin-s) reviewed 5 and faxed to MD (Medical An interview with a. floor nurse was conducted 3 Earlier the record review, on 5I'l5.f11, at 1:40 I I I 'The 'nurse stated the 0 2 would be administered i between 2-4 liters depending on the of I the resident When asked how the decision would be made. the nurse stated "This would be assessed by the -O 2 saturations." The nurse than commented if the were higher the i resident would require less oxygen. The nurse i was asked what parameter would be needed for a resident with a saturation uf 90%. The nurse indicated she would start at the lower dose or FORM Pmvtout Vbraions Obsolete Event ID: BWBD11 Facility lo: 55819 if shes. paw of 45 06/04/2012 12:52 #109 Fm" 24 2?12 14=mf$T- 13: as/No. as DEPARTMENT or HEALTH AND HUMAN SERVICES CENTERS FOR 8. MEDICAID SERVIQES QMB NQ 99350391 OF DEFICIENQE 3 i AND PLAN OF CORRECTION (X1) (X3) gs-Lfipisgfguavgy i '?57?l2 W6 in 0511512012 NAME 9" OR SWPUER STREET ADDRESS. cmr. ZIPCGDE TARPON POINT nu RSING me cemen 5157 PARK CLUE SARASOTA, rt. 34235 W) 19 STATEHENT or an PLAN or CORRECTION (X5, PREFIX (EACH SE PRECEDED BY FULL PREFEX (EACH SHGULO BE OOMPLETEOH TAG REGUUXTORY OR L56 INFORMATION) TAG CROSS-REFEREMCED TD DATE i 520 Continued From page 41 520: oxygen and go up according to the resident response. but then stated, see, the order could probe-bty use clarification." The Respiratory Therapist (R1) was interviewed, on 5I15J12, at 1:50 pm. explained this was a new. resident and she had gene into the residents room to evaluate the day before. but Resident #6 was requestingiteileting assist. and did net perfelm a Rapiratery Evaiuetien. extpiained the evaluation had yet to be completed. When asked about the expectation of the new admission respiratory evaluations, the RT commented she to get the evaluations as soon as peesibie. The Respiratory Therapist commented norrnaliy she would go in look, at the resident, and then review the <oso.la.tc Event iD:BwaD11 Facility it}. 85! is It confirmation sheet Page 42 of 46 From: #109 FROM 24 2012 13:35/No. 9'47" DEPARTMENT or HEALTH AND HUMAN SERVKZES . CENTERS FOR MEDICARE 8: SERWCES OMB NO. I SHATEMENT OF (X23 MULTIPLE CONSTRUCTION DATE SURVEY AND OF CORRECTION NUMBER: A COMPLETED . 105702 8" WW9 053132912 OF PROVWER 0" SUFPUER cm: sms, ZIP case 5157 PARK CLUE DRWE TARPON FIDINT NURSINGAND REHABIUTATION CENTER SARASOTA. FL 34235 W) :0 or Darrcrenclas in Pnovlfl?nls PLAN 01-' CORRECTION I 1 prs) pfifir-'rx (EACH omclencv MUST as FRECEDED av FULL FREFLX . (EACH cor-mEc?Ms ACTION SHOULD as TAG REG ULATOIW osz IDENTIFYING TAG CROSS-REFEHENCED TO THE DATE 1 DEFWIENCY) i 520,? Continued From page 42 520 4. A review of the medical record for Resident #4 was conducted on 4/26.' 12- The record reveals the resident has a history of including but not iimited to, Chronic Obstructed Pulmonary ,2 Disease Congestive Heart Failure (CHF). and urinary retention. A physician clarification order, dated 4i4f12, inc.h.-fies: "Adjust 02. up to 19 liters to 02 Sats 9{3-94 via Check 02 sats (every) shift and pm (as needed), and if 02 sat goes below 38 administer 02 at 10 liter via non-breather until 02 3 sats The. care plan was updated. on 414112. reflecting this order. On <<#26112. at 10:45 a.rn._ the RT documents Resident #4's heart rate at 101, Respiratory Rate 20, breath sounds "extremely diminished with lime air movement with little air movement." The RT "nurse aware of status and . offered medication." The fellow up RT notes are dacumentad on "At 12:05 pm. the RT documents the O2 saturaiion is at 39%, on 10 Liters of.a2 Heart Rate 102, Respiratory Rate 20." and "The 12:15 pm. saturation is at 91% on 10 Liters of O2, and HR 101 and Respiratory Rate 70." The notes do not include a follow-up collabaration with the nursing staff post treatment. The RT did not ducument Resident #4's treatment and oxygen therapy was delivered by the route of the rabreather as ordered by the physician and as .:1clc:urnentaed' on the care plan. The facility failed to provide care and services as prescribed by the physician per a written physician order and as outlined on the FORM Previous 'versions Obsale.-ie Event ID: BWSD11 f-'acfiitv 1'9 35319 If oantinuaucm sheet Page 43 of 46 From: 06/04/2012 12:52 #109 24 2012 43 DEPARTMENT OF HEALTH AND HUMAN senvices -CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. D938~Ci39'i . STATEMENT OF (Xi) PROVIDERISUPPLIERICLIA MULTPLE I 1043) DATE SURVEY NOF .- . - AND 0 SDEN NUMBER A COMPLETED 105702 WING Q2312 NAME OR SUPPLIER STREET ADDRESS. cm. isms. i 5167 PARK CLUB TARPON NURSING AND REHABILITATION CENTER FL 34235 (M SUMMARY os nei=::ci eucsas ID mowosnfs PJAN or coanscriou pa) (eiicii DEFICIENCY mum as rm;-ceoso av r-uu. CGRRECTNEACTION suomn as mg n2s.ir..-womr on LSC IDENTIFYING mmamriom CROSS-REFERENGED Io ms APPROPRIATE we DEFICIENCY) 520 Continued From page 43 528 care plan for Resident The administration had provided insetv-ices for nursing staff in November. 2011 regarding physician orders, but failed in evaluate the effectiveness of the e-ducation provided. The administration faiieci to determine his need fur additional evaiuat-ioh and intervention to provide optimal practices. rasuitihg in an incomplete Quality Asaurame and Performance inteweniion. 5. A review of the record for Resident #3 was i conducted on 5/15:12 at 4:59 pm. The record 5 reveals the resident was on-ginaiiy admitiecl to the on 611."! 1, with the diagnoses of, but not iimited to, Brain Injury, Hypertension, Depressive Disordar and Gonvuisions. The resident has :3 PEG iubefgastrorstomy. The resident receives Jevity 1.5 calorie give 240 mi via peg 6 times per 1 day at 5:00 9:00 1:00 pm, 5:00 j. 2 9:00 pm. and 1:00 am. i The MAR for May, 2012 was reviewed with the ai4:55 an 5i15.l12. The record documented 2' of the tube feedings were heid {not adrninistared) on May 8, 2012. he held feedings were the and the 1:00 i pm. administrations. On 5l1Dl'l2, one tube feeding at 1:00 pm. was noted as heid. The DON was Bskfid about the held feedings. The DON stated, "We would have to look 3% the residents record." The nurse notes, for 51811 2, i were reviewed. The record reveais Resident #3 had a radioiogy diagnostic on 548112 (Lumbar Punchire). The entry dated, 5/8/12. at 1:20 pm, documented the resident had an episode of emesis (vomiting) after the procedure and another episode of emesis on return to the I I i 1&1 roam Pmviuiis Vazslofis Event 55519 if vnntinuatioh sheet Page 44 of 46 From: DEPARTMENT OF HEALTH AND HUMAN CENTERS FOR MEDICARE 8: MEDICND SERWCES 06/04/2012 12:53 #109 24 2012 43 PRINTED: D5f24-[2012 ORMAPPROVED OMB 100.0938-0391 STATEMENT OF OEFNDIENCJES (K1) PROVIDERJSIJPFLIERICLEA AND PLAN OF CORRECTION MENTIFICATIOH NUMBER: 105702 MAME or PROVIDER ea surmaeni TARPON POINT NURSING AND CENTER . (X29 MULTIPLE CONSTRUCTION A. WING 0 STREETADDRES5. cm, STATE, ZIP code 515? PARK CLUB DRIVE SARASOTA, Ft. 34235 DATE SURVEY COMPLETEQ 0511512012 suumnv smrausnr or DEFICIENCIES (EACH MUST are raeecanen av FULL or: 1 0:4} in PREFIX TAG PREFIX TAG PROVIDERS PUW OF CORRECTION BE APPROPRIATE L851 COMPLETION DATE I 520 Continued From page 44 5 facility. The nurse documents the physician was I oeiled fior as needed phenergan orders (orders for an antiametic- nausea ttontroii. A 2: 30 Slam 2. a nurses entry documents "Resident had a iarge amount of brownish emesis around 1345 (1:45 pm.) at bedside awaiting firom the M135 (doctors) orders. Ail his made {medication} and food were head per order." The Unit Manager was asked about the order. The Unit Manager stated she wnuid luck for the i order and commented the holding of the TF on multiple-ocsesions were a nursing judgment. At appreximafeiy 5:30 on 511 5l1'2, a MDS 1 (Minimum Data Set) Coordinator returned with the copied records and stated "these are the orders the nurse was referring to regarding the I hoid of medications and feedings." The Mills 3 Coordinator pointed to area an the ddcurnent titled. Discharge instruction Summary 3 which states. "After153U (3:30 pm), pt (patient) may resume usual activity." The facility was unabie te provide physician notification documentation after muitiple episodes of emeeis I for Resident-#3-" The failed to renew their incident policy, failed in notify ihe physician of the potentiai consequence of the transcription error, and failed to invesiigafte the "facility process integrity to :i prevent future incidents. The facility key staff members failed to identify and report appropriateiy quaiity deficiencies and potential consequences of those deficiencies tie the Quality 1 Assessment and Assurance Committee. The i me mbere of the Quaiity Assessment and 1 Assurance Committee and Administration {aired 0 to examine incidents as quality indicators and 520 0 RM CM3-25a7(02--e9) Versions Event Facmty IQ 85819 if continuation sheet Page 45 or 46 06/04/2012 12:53 #109 From: FROM z-s 20$: 1 4: as 19 66!!-Io. 7833331034 so PRWTED: 032412012 DEPARTMENT or HEALTH AND HUMAN ssm/ices CENTERS FOR MEDICARE 8: MEDICMD SERWCES OMB N0. STATEMENT or on -- MULTIPLE consmucncm one suausv - Arm mm or IDENTFFICAHON NUMBER: A coamsrau 13. wins 1 '"5702 A osrisizmz NAME OF PROVIDER OR SUPPUER cmr. arms, coo: . 5157 PARK CLUB DRIVE 1 TARPON POINT NURSING AHO REHABIUTAT ON CENTER SARASGTA FL 34235 (x4; 10 i srnremsur as in Pnoxhneivs pum =oi= 4,453 PREFQX _i (EACH musr as mecsoeo av FULL PR-Eslx (EACH connemwe ACTION s-Houw as comsnon me I REGULATORY on aueamnvme INFORMAT-ION) TAG CROSS-REFERENGED 1-o ms WE 5 3 5 520 Continued From page 45 identify issues associated with events and incidents. to correct quality deficiencies. i 6. The facility submitted, on in the 5 Agency field office. the prncess implemented after 10131111, modified to address the hospiml discharge medicaticn orders and health care servica delivery: The admission chart would be brought :0 the 5 . moming QAA rneeiing and reviewed for accuracy; 6 - The review would now inciude comparing the 3008, to the Medial Reconciliation Form. and the charge nurse was to can the Dietician to discuss 'the tube feeding orders. This does not address the needed tn monitnr to ensure that this has been effective and when ongoing issues are identified how the - systam win he modified, how to identify nursing - care deiivery that is comrnunicated to the 1 - physician for medical orders and direction on the need far revision to nursing care deiive ry. 5 I i F0 RM Previous '9/zrsions Obsnieia Event ID: 85319 If continuation Sheet Pegu 48 of 46 From: 06/04/2012 12:53 #109 (THU) 24 2012 1 4: 1:3: 7638361084 51 PRNTED: 0512412-D1 2 FORM APPROVED Agency for Health Care Administration srmeuearr or i . .. - AND PLAN DF CORRECTION (X1) my MULTIPLE consmuc non A. auitome B. i 85319 n5:1aIzo1gfl NAME OF FROWDER on SUPPLIER STREET ADDRESS. Cm'. STATE. 21? CODE 5157 PARK CLUB DRIVE TARPON PGINT nu Rsme AND FL M35 (M sumnmr or uencsmeaes .9 mm or connecnau 9:5} pagpgx - DEFICIENCY MUSTBE PRECEDED BY FULL. - PREFIX (EACH CORREETNEACTJON mg . aeauwronv on Lee INFORMATION) mg. i moss-serenencso To me AFPROPRLATE om: DEFICIENCY) INITIAL COMMENTS coo 3. This is to report the iesuits of an unannounced .. eampiaint, 2032004256. survey conducted, t. on 4.126112. at Tarpon Point Nursing and Rehabilitation Center. in Sarasota, Fl. Due to supervisory review. the survey was exiended to $15112. There were 3 allegations in the complaint with 2 aiiegations substantiated with citations. Thefollowlngisedescription ofthe 4 noncompiience: S331 F.A.C. Facility Policy Components N041 59A-4, 1 96(4) Specific Corrective Action Each facility shall maintain policies and procedures in the following areas: Activities; i The facilify has revised 1 - policies and procedures (an oeazn of residents ih the facility; *0 performing (8) Deflialsewioefi; complete accurafe physician Staff education. inciuding training; (9) Diagmsficsewiwsi orders for enferal feeding (M Dietary service-'s; Tube fed residents which Disaster preparedness; - . 0) We prevenmn am Includes The correct soluhon, (R) route, appropriate amount and U) frequency required, plans of Laundry service; 1_ . in) hose of power, water. air conditioning or far" Grid Of' Improve function' nofificafion Medina' rawms; of change, and Implementahon (sq) Meni.alh_ealth; of qualify assurance and fig) performance improvement. TITLE gm; - 301': BWQD11 sheet 1 pr 30 From: '06/04/2oi2 12:53 #109 FROM 24 2012 14: O-GIST. 13:86/Mg. 32 NTED: OHM APPROVED Aqen cy for Hegjitl Care Adm nistratlon STATEMENT 0? ix!) sou 0 DATE SURVEY AND PLAN OF CORR ECWN IDENTI r-'lemon NUMBER: 0(2) WLTIPLE 5 RUG A, 8. wine 3 55319 NAME as PROVIDER on SUPPUER smear Aoones-st. em, sure. 23? came 7 9 mnpon POINT uunsmr.-: AND REHABILITATN W, ,9 summnv stntemzm i .0 snovloenrs PLAN or CORRECTION pig, PREFEX -DEFICFENCY MUST as msceoeo av FULL PREFIX l?AcH CORRECTIVE ACTION suoum as cow-um: TAG nseuwonv on LSC SDENTIWING m3 CROSS-REFERENCED To THE APPROPRIATE mm DEFICJENCY) 041 Continued From page 1 04'! Podiatry same" Residents 1., 3., 4., and 6. care Resident care planning; and services is being (W) evaluated with physician Ramenrs "gm" review included No 5 ecific Safety awareness; (2) Soclaiservices; ti correction action reiated to igaeilfiiggclalzad rehabilitative an restore ve I prior Care and Services was {bblvolunteer services; and able to be addressed for reporting of accidents or unusual those same "shad r.e3iden.rS_ incidents involving any resident, staff member, volunteer or visitor. These policies shall include reporting within the facility and to the Mefhod to Assess Q-rher. Residents A comprehensive audit has been implemented which This Statute or Ruie is not met as evidenced by: - Based on stafi interview and medical record mc ludes The review, the facility faiied follow facility policies and consultants. The audit and rd -f d'i:afeed'it'lde. . . ?f 0" "e3'd3"T5 *0 amount and frequency required to develop care evaluate if any other ta rnaintain or improve the functional abilities, - notification in change of condition and reS'dem3 Comd have been imptemenmtion ofthe quality Assurrence and affected by alleged practices i, stated in' the survey findings. i 7 A primary procedural The findifigsinfiiudef emphasis is on compliance to 1. Areviewof the medical record for Resident #1 PhY5i?i?" was -conducted on_4126l12. Therecord care/services for those receiving enteral tube, acute (difiicuitv swallowing), Congestive Heart F'aElu.re, change in condition with 1 and Renal lnsuificiencyr. AHCA Form STATE FORM I if uonifnualion than! 2 of 30 06/04/2012 12:54 #109 From: IWROM (Tuutwnv 24 2012 1 . 13: Bfifflo. 53 FORM APPROVED Agency for Health Care Adrn'nis'tration STATEMENT or oenciencies - . . (X3) DATE sunvcv AND MM OF COR RE mm om {x23 MULTIPLE oonsmucnon cw FLEED A. suuoino B. WING '3 85319 05i15l2-012 PROVIDER on surmuan STREET AUDRES5. oirv. srnra, ZIP CODE 5157 PARK CLUB DRIVE mnpoiu Point NURSING AND FL 34235 (X4, .5 . STATEMENT or in or connection 9:5, p-Rgfix DEFICIENCY MUST BE PRECEDED BY FULL 1:35;; p; (EACH CORRECTIVE ACLTION SHOULD BE EOHPLETE. mg I acouurrohv-on INFORMATION) -mg cnossnereneuceo To THE Arpnopnune we 041 041 Continued From pago 2 The records documented Resident #1 experienced multiple hospitalizations with readrnissionslretums to the facility during the month of October, 2011. The readmission to the facility, on required physician orders for . 3 PEG tube feeding (tube inserted into the stomach for nutritional and medication dministration access). A roviewof the Hospital Discharge orders included. but not limited to: hiepro 4 cans per day ('feeding solution). The 1 hospital discharge note was incomplete and I lacked the route of administration, such as via PEG tube. The hospital order iaoksd instructions for checking the tube for placement prior to 3 access, water flushes before and alter access. and water flushes before and after medication administration. The 4 cans of'Nepro~4 times a day was documented -as. administered on this Medication Administration Record (MAR), The nurses have placed their initials indicating the inaccurate amount of the feeding was .administered starting on 10126-i'iOf29I1'i. The MAR docurnented the facility nurses signed as administered eleven times betvveen 30126/12 i to 10/29112. This total of 11 administrations of the 4 cans, of Nepro four times a day. This documentation was incomplete as documented on the MARS, The 4:00 entry'- aroa in the MAR is blank. A review of the nursing note reveals the resident received "Nepro 250 mi i via bolus without diff. (difficulty)." This note I indicates the nurse administered 1 can of Nepro (23? mi) pius 13 mi to equai the 250 mi total hoius feed. The OIQQI11: notification, and interim care plans. Systematic Review Systematic review and revision was performed to include but not limited to: the facility nutritional system with focus on the newly admitted residents and those feed via enteral feeding tubes. Included in system is communication with the dietician and devising new communication technique and tool. This new format is process includes patient demographics, enteral formula type, delivery site/device, and method and rate of administration. To support that residents receive appropriate treatment and services to avoid complications as medically able, a brief admission interim plan of core will be in place Form 3020-M501 STATE FORM Bwabu ii continuation sheet 3 0! so From; 06/04/2012 12 54 #109 P.05i/077 FROM 24 2012 1 4: 04/51" a 1 3.5 l3$/Nth 75338561034 64 PRINTED: 0Ei[24l2Cl12 FORM APPROVED Aqencv for Health Care Adm STATEMENT OF xi ROVIDERISUPPL ERJGLIA - MULTIPLE CONSTRUCTION W3 W75 SURVEV AND PLAN OF CORRECTION ll ml WMPLETED - -, BUILDING B, . B5819 0511 512012 NAME op QR suppugk STREET ADDRESE. STATE. CODE . 5157 PARK CLUB DRIVE (K4) in SUMMARY STATEMENT or ossicieivcies A it] OF 003350710" I oisi (EACH MUST as vnsceoao av FULL mm; snouw as comers mg; neauwonv on Lee IDE iinrvina 'ma TO THEAPPROPRWE W5 I UEFICIENCYJ 041 Continued From page 3 0'41 At 1:50 pm. entry documents tube mcludmg ldenhfled Concerns feed (Nepro cart: steady) and flushes related to enteral feeding. 2 3dml'l'll3t'=F9d This will be reviewed during i At 4:00 the nurse documents 3 cans of Mepro available called to MD (insert physician 1' 9 new 0' Cl Hamel 0" Call Orders rec'd trficeivedl to resident record evaluation . i. I . . . Jew" 2 ca We) um" Nepm process instituted to include the primary rationale for admission and treatment for and most immediate care needs At5:t}0 pm. the nurse documents ".levity1.2 uni," re lacememi the cal one can administered via PEG tube, resident to,e,a,Bd weal comprehensive plan of care in place. The clinical process to The MAR indicates this order with the times of administration 9;oi.i a.-rri., we 5:00 pm. identification 0i' and 9:00 pm: b! clinical risk, document clinical The 5:00 pm- Jevity administration is an . without entry on the MAR. changes, evaluate resident According to the faaitity nu-rse's note the stability. evaluate feasibility Nepra was administered at 5:00 am. -250 ml. to mam 8 fhe Candi"-on in 1:50 pm. as ordered (4 cans 948 ml's), at 5:00 9 pm. and 1 can ahlavity -1.2 at 5:00 pm, and Oi' lf'0n5l'EURF' includes Thfit MAR indicates the 10200 8.lTi. W435 Those feed via gn1'era| tube administered 4 cans of Nepro, There is no nursing note entry l'ar10:O0 am. feeding, and will include monitoring for change in condition which has been On a Clarification order was written as "t 0I29i2D'l1 Clanfiaation: Give Nepro Cam 3 Steady one can via rec; tulzie flush with so shaped into the new daily 2 and Efier admission and Change in admm'slrat'?n' condition clinical risk review. AI'lOfl')8l" order W33 IEI0f29l'1'l, after the Physician gfidgp review has 2 an-can physician was nati epra was no . -p available, 'Give Jevlty 1.2 Cal (Calorie) one can bee_"_ 'mPleme"l3d~ The 1 QID via peg tube until Nepto becomes available. facility has evaluated and j. Flush with 6-0 ml 2 0 before and after AHCA Form 3t320-0091 sums FORM liaontinuatian 4 of so From: 05/04/2oi2 12:54 #109 24 2012 1 1:3: 98/Mo. 7seg5:51og4 as l35I24i20 12 FORM APPROVED Aqency for Heaith Cgre Adm nistration (X1) !gF?g?:gf: (X2) LE cons . RUCTION (7533 A B. WING . 55519 . D511 5l2012 mm: or i=-novioaa on SUPPLJER STREETADDRI-L58. onv. am-re. Coos TARPON POINT NURSING AND ni2HAi3ii.ITA1ii W, in STATEMENT or in PLAN on conitficriou (ms) (mu oerioisiior MUST as meceoso av puu. pa (ma as com-ms T-M5 REGULATORY on 1.56 TAG DATE 1 041 . 04 mm page 4 determined the benefit that i the Advancing Excellence The MAR docurnents' me ioizom clarified order Program and for Nepro 1 oan (four times a day) was therefore has signed up and dowmemed Eslwoma selecied The Three areas' The updated MAR, on documented the PM-med to participate igmogirxgreifizg The clinical risk and mo? nursing note for two pm, on 'iDr29i1*i. cause analysis 'training has documented the Jevity 1.2 can was - - i admmtemd' also been committed to via for June 12, i The facility failed to clarify and obtain an 2 - appropriate completed faadingidieiaryi order on 201 four our program 9_wen admission to the on iorzam, for Resident by 0 The facility clarified the order on 'W29/r11, A1-1-or-nay and c|gni?a| Risk i Manager scheduled. During an interview with the Medical {Director and 2 Res'ideni#1's attending Physician, on 5f15I12. at - i 5:30 pm, a review was completed of the Qualify Assurance Physicians Order Sheet, including New: 4 cans Qifl, that was signed on 11127111, The Attending. Ph'ysioia.n was asked if the facility nursing staf! The DON will be "e5P?"5lble him the incorrectly transcribed 1'0 ensure 1'0 Nepro 4 cans Q10 -order. which was on the St Sh . Physician's O-rider Sheetthaiwas signed on em 3 5? 'l1l2i11. The Attending Physician was not sure of full record review of six i with This is a failure of the facility nursing -staff to Three per' uni? per month in review and c:ommu=riicate with the physician in a addmon To daily updm-es by manner that ensures ciarifiomioin of medication . administration orders prior to the Attending l? DON Physician signing. and NHA. All will be followed up on by The NHA and 'Die facility provided statements obtained from the nursing staff adrninistaring the Napr-o to AHGA Form 3020-0301 STATE FORM BWQD11 Ii sheet 5 o1'3o From: FROM Aqency for Hea_Iih Care 06/04/201212155 24 2012 16:33/Ha, #109 7638581034 are 0512412012 FORM APPROVED STATEMENT OF DEFJCIENCIES X1 PR Vi PPL AND PLAN OFCORRECTION 0 DE SU 1 ?5819 NAME OF PROWDER on SUPPUER TARPON PGIHT NURSING AND CLEA (X2) MULTIPLE CONSTRUCTIGN A BUMILDWG B. STREET Asjnruass. cm'. STATE. code i 5157 PARK CLUB DRIVE SARASOTA, FL 34235 (X3) DATE SURVEY COMPLETED C- 'l}5!15!2012 W, .9 ?ummnv srnranenr or PREFDE . mg naeuucronv on LSC IDENTIFYING mro GEHCEEMCY MUST BE PRECEDED BY FULL ID PREFIX TAG o5i=ici ENCY) mm or coaascnoisr (EACH ACTION Susan 35 cnossnersnancau T0 THE APPROPRIATE ixsi COMPLETE DATE 041 Continued From page 5 Nepro to Resident" #1 per administration. i i 2. Are 10i22f'ii and 'i0!26ii'i. On 10122114 and 10126111 interim care plans were initiated. failure. Renal lnsufficiency and dementia. but not limited to: "Other: Hx (history) CHF (congestive -(as above. and" i - ''02 via n.!c pm, 02 sat shift (every and monitor for S08 (shortness of Breath)ICyancisis." 1 after of cardiac and respiratory decline. Resident #1 was ram and "Other: PEG Tube." Resident The statements documented the nurses did not administer more than 1 can of View of the medical record for Resident #1 was conducted on 4126112. The review of the 1 medical record for the resident documented an i original admission tn the facility in July, 2011 and readmission to the facility from the hospital on Rasldem #1 has a history including, but not limited in. cartzliar; disaasa. congestive heart The intarlm care plan. dialed 10I22f1'l', includes. - "Resident is atnuiritional and!-or hydration 'f risk, Qlher: PO by mouthlifrube feed?' 5 failure), 02 (oxygen) via (nasal cannula) pm "02 Sat (Saturation) will remain 92% or Resident #1 was re-admitted to the hospital on the facility on 1-0f26Jl'll1. The interim care plan included, but not limited to: "Resident is at nuirilionai andlor hydration risk; Swallowing risk," The care plan, dated 10i26./11, does not include the resident history ofcardiac or respiratory risk, the need for oxygen or the mcinlionng of the Cardiac respiratory difficulty as previously N041 during The meeting. head shift) med to included and r-eporfed on and mancigemenl/quality assurance risk AHCA Form 302043001 STATE FORM SE98 EWQDI1 iroominuation shoes! 5 N30 From: FROM Age-ncv for__Heaith Care Administration #109 (THUDHAV 24 2012 :3 57 PRINTED: O5!24i2,012 FORM APPROVED STATEMENT OF DEF ICHENCIES AND PLAN OF CORRECTION NAME or movmen ma SUPPUER TARPON POINT NURSING AND REHABILITATH (X1) EERICUA NUMBER: 135313 B. WW6 {x23 MULTIPLE CONSTRUCTEON A. auawms (X3) ISVKFE SURVEY STREET ADDRESS. CITY, STATE. ZIP CODE 5157 PARK CLUB DRIVE SARASOTA, FL 34235 ID PREHX TAG svuimtv STATEMENT OF - (am:-4 MUST BE FRECEDED av FULL aaeumronv on LSC IDENTIFYING I PREFIX TAG PFIOVIOERSPLAN OF (EACH CORRECTIVE ACTION snoum BE To cxsi COMPLETE one DEFICIENCY) 041 Continued From page 6 identified from the care plan dated 10122111. The care plan, dated 10126111, does not address the need far monitoring Resident #1's input and output, including measurement of reaidual. bowel sounds, IUIIQS sounds, and patiancy of the PEG Luibe befare each tube fending, since the PEG tube was placed during hospitalization prior to the i 10126111'! facility admission.. The faiied to pravicle an interim care pian containing care and services based ondiagnases and condilicms impacting Resident #1 's outcomes. 3. A review of Resident #89 medical record was canducied (in 5115/11, at 1:40 pm. The resident was admitted. as a respite care for hospice care. i The resident has a -rnaiignant melanoma i secondary to lung cancer and 3 upper right fungating tumor of the mouth. Reside-n=t #6 was i admitted to me facility can 5113112. The orders i and the nurses' nates were reviewed. The physician orders documented an order as ''02 I (Oxygen) via mic (nasal cannuia) 2-4' L./rn Liters per -minute) pm (as needed)." The interim care pian identifies the need for oxygen "therapy as "0 2 via nic at 2-4 per minute The 511311-2 nurse's note, at 10:30 identifies Resident #6 was admitted under a dcictofs -care. The note documents the Biiafieral Lung sounds are diminished with saturation of oxygen at 93% on room air. The nurse documents "Meds (Medications) reviewed and faxed to MD (Medical Doctor)." An interview with a floor nurse was conducted, on 5115111, at 1:45 afier ihe record review. VNO41 AHCA Form 3020-0001 STATE FORM E583 BWQD11 Ifoontinuation shes! I of 30 From: 06/04/2012 12:55 #109 24 2012 14: 433/231. 13: 33 PRINTED: t}5!24i2012 FORM APPROVED Aqencv tor Heatth Care STATEMENT OF DEFICIENCFES R9: 5 0 1 x3) sufiugy AND PLAN OF CORRECTION (X1) consraucrion CGWLETEB A e. WING 0 35319 0 I. =05f15!2012 NAME or PROWDER on suppuen STREET omv. STATE. ZIP cone rraarson i=-omr NURSING AND or.) .9 -SUMMARY STATEMENT or DEFICIENCIES - in nnoviosrvs mm or CORRECTION . DEFIWENCYM UST BE PRECED ED BY FULL PR5-jp|x (EACH CORRECTIVE AGTION SHEGULQ fig mg REGULATORYOR LSC mg GROSS-REFERENCED ro rnenppnoraums i om: 0 DEFICIENCY) I 041 Continued From page 7' 041 - The nurse stated the -O 2 would be administered between 24: titers depending on the of Resident When asked. how the decision would be made. tho nurse stated "This would be assessed by the 2 satura-ttoris.." The nurse then cornmentod if the saturations were higher, the resident wo=u-id require less oxygen, The nurse was asked what parameter wouid be needed" for a resident with a saturation of 90%. The nurse indicated that she would start at the . lower dose of" oxygen and go up according to the i residoznt response, but than stated, see, the 0 order could probably use oiarification." The Respiratory Therapist (RT) was imerviawed. on 511 5I11, -at1:5O pm. The RT expiained this was a new resident and she went into Resident #85 room to evaluate the day before, but the resident was requesting toiteting assist, and she did not perform 3 Respiratory Evaiuation- The RT explained the evaluation had yet to be cornpicted. When asked about the expectation of the new admisoion respiratory evaluations, the RT commented she likes to get the -evaluations as soon as possible. The Respiratory 'Therapist commented normally she would go into look at -the resident. and review the orders. The RT reviewed the current orders and stated' "These wouid need ciarification because. of the 2 at 2-4 titers." The RT stated. "Need to get more informafion from hospice, too," regarding past needs and past history of respiratory treatments. -l The RT stated can work on this now." The facility continues to aocept and fax incomplete or inaccurate oxygen and respiratory care orders atter the trainings provided to the nursing staff in November, 2011. .4. A review of the medical record for Resident #4 AHGA Form 3020000? STATE FORM BWQD11 sheet 3 at 30 From: #109 FROM 24 2012 1 4: oezsr. 13: no so PRINTED: 0512412012 FORM APPROVED Aqencv for Health Care or DEFICIENCSES mag 51 ipp . rm nnra sunvnr mo PLAN or coanficnan Ix" MUWPLE CONSTRUCTION BUILDING 3. 35319 051"! 51201 2 NAME Pnovrnen on SUPPIJER smear ADDRESS. cm', ZIP com: 5157 PARK CLUB DRIVE norm NURSING AND FL 34235 (X4, in srnremem or DEFICIENCIES in PLAN or CORRECTION 0:5, psafinx (EACH IJEFICIENCY MUST as PRECEDED av FULL PREHX CORRECTIVE ACTIGN SHOULD as ma on ioanrirvine annonwmoni . me T0 one DEFICIENCY) 041 Continued From page I 041 was conducted on 4I26i12. The record documented the resident has a history of including, but not limited in. Chronic: Obstructed Pulmonary Disease (COPE), Congestive Heart 'Faiiure and urinary naiention. A physician clarifiuation order, dated <<#4112, includes, "Adjust 02 up to 19 liters to 02 Sats 90-94 via nfc, Check 02 said (every) shift and pm (as needed), if 02 sat goes-below 8.8, administer 02 at 10 liter 'via non-breather until 02 sats The care pian was updated on refiecling this order. On 4126112, at 10:45 am, the RT documents Resident heart rate at 101. Respiratory Rate 2:3, breath sounds "extremeiy diminished with little air movement.-" The documents the "nurse aware of status and oifered medication." The follow-up RT mates are documented on 426112 as, at 12:05 pm., the RT documents the . O2 satumticm is at 39%, on 10 Liters of 02 Heart - Rate 102, Respiratory Rate 2D. and the 12:15 p.m. saturation is at 91% on 10 liters of 02, and HR 101 and Respiratory Rate 70. The follow-up RT notes are documented on 41261112, at 12:05 pm, the RT documents the O2 saturation is at 89%, on 10 liters of 02 Heart Rate 102, Respiratory Rate 20. The 12:15 pm. 1 saturatiun is at 91% on to Liters of O2, and HR 101 and -Respiratary Rate 70. 1 The RT did not document the resident treatment and dxygeri therapy was delivered by the mute of I the rebreather or nasal ca-nnula as ordered -by the physician and as documented on the care plan. I The facility failed to document the provisidn or Form STATE FGRM sheet 9 oi3Ci From: #109 FROM (THU07/9? . 1 :3 m:wI-Io. 73s9ss-Ioe4 ,9 ao PRINTED: 05:'2Af2Q'i2 FORM APPROVED Aden-cv for lfijth Care Administration STATEMENT or DEFICIENCIES - i - Awe-m~ovcroaascrio~ A. BUVLDING B. WING 35519 0511512012 NAME or PROVIDER on TARPON NURSING AND STREET ADDRESS, CITY, STATE. CODE 515? PARK GLUE DRIVE SARASOTA, FL 34235 SUMMARY smrenersrr or respiratory care and services as prescribed by i outlined on the care plan for Resident 4. 5. A review otthe record for Resident #3 was conducted on 5i'15!12 at:i:5O pm. The record facility on 6i'lI'i'l, with the diagnosis of, but not Disorder and Convulsions. The resident has a PEG ti.ibelGastrostomy (tube inserted into the 1 stomach for nutritional and medication administration access). The resident receives Jevity 1.5 caloria give 240 ml via PEG 6 times per day at 5:00 ant. 9:00 am, 1:00 6:00 pm. 9:00 pm. and 1:00 am. The MAR for May. 2012 was reviewed with the i Director of Nursing (DON), at 4:55 on Sit 5112. The record reveals 2 of the tube feedings were held (not ad.mi.nisi:ered) on May 8, 2012. Tho held feedings were the 9:00 am. and the.1:D0 p.rn. administrations. On 5l10!12,onetuhe feeding at 1:00 pm. was noted as held. The DON was asked about the held feedings. A The DON stated "We would have to look at the Residents record." The nurse -notes for 5l8fl 2 were reviewed. The record documented Resident #3 had radiology diagnostic on 518112 {Lumbar Puncture). The entry, dated at 1:20 revealed the resident had an episode of emesis (vomiting) after the procedure and another episode of omesis on return to the facility. The nurse documents the physician was called for as needed phenergan orders (orders for an antiometicmausea control). The entry dated 518112, at 2:30 documents the physician per a written physician order and as' reveals the resident was originally admitted to the limited to, 'Brain Injury. Hypertension, Depressive (x4; to in movinews PLAN OFCORRECTION M, PR sirix lEACt-l. ossiciancv BE PRECEDED av mu. ACTION SHOULD as -camera mg 5 REGULATORY on use EDENTIFYENG Tm caoss-asrsaeucao TO rnenppnopnme one - DEFICIENCY) 041 Continued From page 9 041 AHCA Form 3020-0001 STATE FORM Gilli BW9f)'l 1 lfoonllnualion sheet 10 at 30 From: 06/04/2012 12:56 #109 (THU) mw 24 2912 14: -01 /31. 3'3/No. 7333351334 PRINTED: O5!24.i2012 FORM APPROVED Aqencv for Health Care STAVEMEMT DEFKHENCIES (xi) coflsmucfion (xa) oprre SURVEY AND PLAN OF CORREWON lost-mslcialrlou NUMBER: W) comrurrso A. BUILDING B. WING 35.819 . 0511 92012 mm: or mow DER on SUPPUER STREETADDRESS. cm, stare. ZIP cons . 5157 mar-on POINT AND (X4) :9 SUMMARY oefrlciewclfis la PLAN -OF connection . (x53 PREFM (Emu MUST as PRECEDED FULL PREFIX coanecmrs snoutn BE COMPLETE TAG aeeumronv on IDE nrimurs inronm.-mo.m mg THE one 5 nericieucv; 041 Continued FfCifl"l page 10 041 - "Resident had a iarge amount of brownish emesis around 1345 (1:45: pm.) at bedside awaiting from the MD's (doctcra) orders. Ali his meds (medication) and feed were held per order. The Unit Managerwas asked about the order. The Unit M-anager stated she would lack for the nrder and commented the holding of the TF on multiple occasions were a nursing }udgment, On 5I15l'!2, at approximately 5:30 5: M05 (Minimum Data Set) Coordinator returned with 1 the copied records and stated "these are the 1; orders the nurse was referring to regarding the 3 hoid of medications and feedings." Tha MOS Coordinator pointed to a imhilghted area on the - document titled Discharge instruction Summary . which states, "After 1530 (3:30 pt (patient) . may resume usual activity." The facility was unable to provide physician notification documentadon after multiple episodes of emesis i for Resident The failed to provide notification of the physician regarding a. change of odnditian and . obtain orders to hold muitiple tube feedings for Resident The facility zadministratinn was unable to provide evidence of appropriate analysis including rioot cause and facility process evaluation. The administratinn was aware of faczility practice inconsistencies and failed to institute quality indicator investigations and inform the Assurance Committee to evaluate facility practices and to correct and prevent future irmidents. isolated Class AHCA Form 3020~000"l STATE FORM BWBD1-1 ifconunuailon street 11 of 30 From: 06/04/2012 12:57 #109 FROM 24 2012 .32 PRINTED: 0512412012 FORM APPROVED Agency for Health Care STATEMENT OF PROVIDERJSUFPLIERICL - Ola oars surwev AND PLAN CORRECTION I 1) IDENTIFICATION nausea?' (X2) WWPLE CONSTRUCWH 1 A. a wine 35519 05i15l2012 NAME or-' PROVIDER on surr-rues: STREETADDRES8. CITY. smre, 211: code 5157 TARPON POINT nunsms AND REHAaiLl.m'rn W) in suumnav STATEMENT or DEFICIENCIES ,0 PLAN or PREFIX (EACH DEFICIENCY MUST as enecraoeo av FULL pfigpgx {anon connective ACTION SHD um 85 coup-me. nzaamronv on was To me APPROPRIATE we . 041 Continued From page 'l1 041 Correction Date: 5135/12 054 5 FAG. Follow Ph ician Orders 054 5 3'6 054 Completion 6.15.12 Specific Corrective Actions All physician orders shall be foilowecl as- prescribed and if not followed. the reason shalt be recorded on the resident's medical record during No specific C0l"f'eC1'lOl'l action thalshm could be performed for residents 1 and 6 as they are not in the facility. This Statute or Rule is not met as evidenced by: Reside" #3 h?5 had his Based on stair interview and medical record admission chart audited. Audit review the facility failed to obtain complete and - accurate physician orders for a dietary feeding to mcluded 0 focus 0" include the correct feeding solution, route, appropriate amount 'and frequency required in orders develop care to maintain or improve the . . functional abilities for 2 (ResidentResidents sampled. The findings mmde; Method to Assess Other Residents 1. Areview or the medical record for Resident #1 was conducted on The medical record reveals the raciliiy failed to clarify and A 100 /o audit of all In-house A Physician Offiiefs regarding 8 residents has been performed dietary feeding sent to the lecrliiy from the . 1 discharging hospital. to evaluate if any other i . residents could have been by < as 1 comrrusra my, REGULATORY on LSC IDENTIFYING INFORMATION) TAG cnoss-nersaeucen TO THE i care DEFICIENCY) 3 -N 904 Continued From page 24 904 1 containing care and services based on diag noses. and conditions impacting the resident outcomes. 2 The Quality Assurance and Improvement failed to ensure the implementation of a system to identify aaimiiar issuqs of interim care pian devfiopment and timely Respiratory evaluations, deveiop a system to corrected 1 identified issues and a method to 'monitorfor the effectiveness of irnpiernentation of systems changes and the need for further system changes to ensure the highs'-it quality health services are prizwide to all facility residents. 1 3. A review of Resident medical record was conducted on 5115111, at1.:4O pm. The Resident was admitted as a respite care for hospice care. The resident has a malignant melanoma secondary to lung cancer and a upper right fungating tumor of the mouth. Resident #6 was 1 admitted to the facility on 5113.02. The orders and the nurses' notas were reviewed. The 2 physician orders documented an order as "02 1 (Oxygen) via nit: (nasai cannula) 24 -Um (1241 i Liters per minute) pm (as needed). 3 The interim care plan identifies the need. far -T oxygen therapy as 2 via nit: at 2-4 per minute The nurse note, dated M3112. at 30:30 identifies Resident #6 was admitted under a facility dnctors care. The note documents the Bilateral Lung sounds are diminished with saturation at93% on room air. The nurse ducurnants "Meds (Medications) reviewed and faxed to MD (Medina! Doctor). An interview with a floor nurse was conducted after the record review, on 5/15111. at 1:40 pm. The nurse stated the 2 wouid be administered AH CA Form 3020-01303 STRTE FORM awemi 25 as as From: FROM Health Care Adm nistration 06/04/201213201 24 2012 #109 72538551034 I3 78 PRINTED: 05:'24n'201 2 FORM APPROVED TARPON STATEMENT OF DEFICJENGIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SLIPPIJEH (X1) IDENTIFICATEON NUMBER: B5819 POINT NURSING AND REHABILITATII (142) ULTIPLE CONSTRUCTION A. BUILDNG B. WING STREET ADDRESS. CITY. STATE. ZIP GODS 5115? PARK CLUB DRIVE SARASOTA. FL 34235 pro} om: suauev COMPLETED 05:1-srzon (K4) ID PREFIX TAG SUMMARY STATEMENT BF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY REGULATORY DR LSC INFORMATEGN) ID PREFIX mo Pnovroaas PLAN 0? connzohoir (EACH conneorlve ACTION sHooLo BE cnosenereaeflceo TO THE Aranprniara (X5) COMPLETE -DATE N904 I would need clarification because of the 2 at 2-4 liters." The RT stated "Need to "get more Continued. From page 25 between 24 Limre depending on the of the resident. When asked how the decision would be made, the nurse stated "Thiswould be by the 2 sah.lratione." The nurse than commented if the mturations were higher the resident wouid require less oxygen. The nurse was asked what parameter would be needed for a resident with a saturation of 90%. The nurse indicated that she would start at the lower dose of oxygen and go up according to the resident - response, but than stated" i see the order oouid probably use clarification." The Respiratory Therapist (RT) was interviewed, on GSM 5112, at 1:50 pm. The RT explained this was a new Resident and she had gone into the Resident room to evaluate the day before, but Resident #6 was requesting tolleting assist, and did not perform a Respiratory Evaluation. The RT explained 'the evaluation had. yet to be cornpleied. When asked about the expectation of the new admission respiratory evaluations. The RT commented she likes to get the eveiuatione as -soon as possible. The Ftespiraio-ry Therapisi commented normaliy she-would go in look, at the resident, and than reviews the orders. The RT reviewed the current orders and stated "These information from hospice too" regarding past needs and past history of respiratory treatments. The RT eta-ted can work. on this now." The facility failed to provide interim care plans containing care and services based on diagnoses '5 and impacting the resident outcomes. 1 The Quality Assurance and Performance improvement failed to ensure the impiermntatlon of a system to identify similar issues of interim care plan deveiopment and timely Respiratory N904 AHCA Form STATE FORM Bweoi 1 ii coniinualion sheet 26 of so O6/04/20i213:02 #109 From: 24 2012 14: 13/51'. 13: PRNTED: 0$i2zu2o12 A F.ORM.APPROVED Aqency for Heaith Care Administration STATEMENT 04' 0(1) MULTIPLE lxal DATE suavsv AND PLAN OF CORRECVTON ioelmrloxrlon NUMBER: W) COMPLETED A, BUILDING I 5 a. who 85819 1 05i'15I2012 NAME or PROWDER on SUPPLIER i STREET ADDRESS. CITY. STATE. ZIP cool: 2 . 515? PARK CLUB DFHVE. mnpou NURSING mo 1 SAMSWAF FL 34235 (X4, "3 soummv armament or i in PROVIDERS PULN OF oonaecnon 0:5, pfigpqx (EACH DEFICIENCY must as PRECEDED av sou. PR5-fix ooranacnvs ACTION SHOULD COMPLETE TAG REG-ULATDRY on EDENTIPHNIS TAG CROSS-REFEFIEHCED T0 THEAPPROPRIATE om: oerioiemm 964 Continued rom page 26 904 availuations. develop a system to corrected identified issues and a method to monitor for ihe effectiveness of irnplamentation of systems changes and tho need for timber system changes to ensure the highest quality health oarvioea are provide to ail facility residents 4. A review of the medical record for Resident #4 was conducted on The record raveals the Resident has a history of including. but not limited to; Chronic Obstructed Pulmonary Disease (COPD), Congestive Heart Failure (CHF). and urinary retention' A physician oiarification order dated 0tl.iO4I2G1'2 includes: - Adjust 02 up to to litors to 02 Sara so-94 via nic, Check 02 sates (ovary) shift and pm (as needed), if 02 sat goes below 38 administer 02 at 10 liter via non-breather until 02 oats 90%. The care plan was updated on refiecting this order. On at 10:45 the RT-documents Rasl'dont#4's heart rate at 101. Respiratory Rate 20. breath sounds "extremely diminished with little air movement with little air movement." The RT documents the "nurse aware of status and offered medication." The follow up RT notes are documentod on 04f26!12: At 12:05 pm- the RT documents the O2 saturation. is at 139%, on 10 Liters of 02 Heart Rate 1-02, Respiratory Rate 20. The 12:15 pm. saturation is at 91% on 10 Liters of O2, and HR 1-01 and Respiratory Rate 70. The RT did not document the Resident treatment and oxygen therapy was deiivered by the route of- the rebreather or nasal cannula as ordered by the physician. and as documented on the care plan. AHCA Form 3920-0001 STATE FORM swoon llooniinualioo sheet 27 of so #109 From: FROM <1'Hu>uMr 34 2012 1 1: 14/51'. 123: as/No. 75-mas.-31934 73 PRINTED: 05f24I2012 I FQRMAPPR-OVED for Health Gare-Admmisghon STATEMEW (x1 PROVIDERISUPFLIERICUA Mumpr om; DATE sunvsv AND PLAN OF NUMBER: Om EJOMPLETIED A. BUILEHNG via as:-r5r2o12 NAME our pnovroen on sumausn smear ADDRESS, crrv, STATE. ZIP co DE TARPON r-vomr AND REHAEILITATII my no i SUMMARY or oer-rcseir-ores ED run OF connection 95, {axon oerrcreucv war as msoeoro av (EACH ACTION SHOULD as me nesmronv on 1.80 IDENHFYENG INFORMATION) mg; CROSS-FIEFERENCED TO The APPROPRIATE DATE . DEFICJENCY) 904 Continued From page 2? 904 The facility faiied to prcwidie respiratory care and services as prescribed by the physician per a written physician ordiar and as outlined on the care man for Re-sideni#4. The administration had prdvided inservices for nursing staff in 11l201'i ragarding physician orders but failed 10 evaluate the ei-'fectivaness of the education provided. The administration faiied to determine the need for additional evaiuation and intervention to provide opiimai 'praciioes, resuiting in an incompiate Quality Assurance and Performance irnpravement intervention. 5, A review of the record for Resident 3 was odnducted on 0511512012 at 4:50 p.m. The record neveais the Resident was Originally admitted to the facility. on. 06:'U1f2011, with the diagnosis of, but not iirniied to: -Brain injury. Hypertension, Depressive Disorder and Convuisions. The" resident has a PEG tubeigastrostomy (Tu-be "Inserted into the stomach for nutritional and medication ardrninistration access). The resident receives Jewry 1.5 calorie give 240 mi via peg 6 times per day at 5:00 a.rn., - 9:00 1:00 pm, 5:00 pm, 9:00 pm. and 1:00 am. The Medication Administration Record (MAR) for May .2012' was reviewed with the Director of Nursing (DON), ai..4:65 pm, on 511 5x12. The A record documented 2 of the tube feedings (TF) 5 were heid (not administered) on Niay 82012. The held feedings were rhe 9:00 am. and the p.m. On one tube feeding at 1:00 pm. was noted as held. The DON. was asked about the mid feedings. The DON stated "We wouid have to look at the Residents record." The nurse notes, for AHCA Form 3020-0001 STATE FORM BWQD11 Iiconiinuafim sheet :28 C1 an 06/04/2012 13:02 #109 From: FRGH 24 2012 14l$T. 7333551934 F, 79 0324:2012 . FORM Health Care STATEMENT OF DEFICIENCIES AND WW OF CDRRECHON (X1) MIJLTIPLE consrnucnou lX3l DATE . BUILDING . 8 WW6 i B5819 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. STATE. ZIP CCIDE TARPON NURSING AND REHABILITATH lo SUMMARY swemewr or DEFICIEMCIES i lt) Paovloea-s mu Gr coaaecncm (X5, EAOH MUST as FRECEDED av FULL PREFIX (EACH -coanecrlve ACTION SHOULD BE . cosmerg mg. nseumronv on LSO 'mg caassmererreucsn ro rue APPROPRIATE hare DEFICIENCY) 904' Continued From page 25 904 050812012, were reviewed. The record reveals Resident #3 had a radiology diagr:nsti.c an 05/08/2012 (Lumbar Puncture). The entry damd. 0510812012, at 1:20 documented the resident had an episode of emesis (vomiting) after the procedure and another episode of emesls on. return to the facility, The nurse documents the physician was called for as needed phenergan orders (orders for an _antieme_tir:- nausea A 2:30 nurse entry documents "Resident had a large amaunt ai brownish ernesls around 1345 (1 :45 at bedside awaiting from the (doctors) orders. All his meals {medic-atlnn) and food were held per order i The Unit Manager was asked about the order. he Unit Manager stated she would look for the - order and commented the of the TF on . multiple occasions were a nursing judgment. At approximately 5:30 on 5115!'! 2. .9 M08 (Minimum Data Set) returned with the copied records and scaled "these are the orclers the nurse was referring is regarding the hold of medications and The MD3 Coordinator painted to a highlighted area on the - document entitled "Discharge instruction Summary lhe entry documents "After" 1530 (3:30 pm), pt (patient) may resume usual activlly." The facility was unable to provide physician notificafihn documentation after multiple episodes of emesis for Resident The facility failed to follow their incident policy, 5 failed to notify the of the potential oonsequence of the error, and failed to investigate the facility process inlagrity la prevent future incidents. The key stafi members failed to identify and repart appropriately quality deficiencies and potential AHCA Form 3020-0001 STNE FORM Bwerm aheal as or an #109 MAY 24 201.2 14:1 6/31'. 13: ac/Ho. 7333561034 1: ac. 0512412012 . . . APPR Aa_ency for Heaith Care Administration OVED STATEMENI or iaericieiici-as mm . A auimmc i 3. ii 353" nsiisizmz NAME cr PROVIDER on SUPPLIER smear ADDRESS. cmr. sums. cone mapon POINT uunsme mu . (K4, 5, sumwwr STATEMENT or DEFICIENGIES in man. or connect . (EACH DEFICIENCY MUST BE PRECEDED U1-L PREFIX (EACH CORRECTIVE ACTION suwgflas 1-Ac; nscuuvroav an LSC IDENTIFYENG INFORMATEONI m; GROSSJIEFERENCED TO THE we 904 Continued From page 29 904 I consequences of those deficiencies to the Assessment and Assurance Commitiee. The membars of the Quality Assessment and Assurance Committee and Administration faiied to examine incidents as quality indicators and identify issues associated with events and incidents to correct -quality deficiencies. 6. The submitted to the agency field office the process impierrienied aft-er 10131112, modified to address the transcribing hospital discharge medication orders and health care service delivery: The admission chart would be brought to the morning QM meeting and reviewed for accuracy. The review would now iriciude c=ompar.ing the 3008. to the Mediai Form. . the charge nurse was to sail! the Dietician in discuss the tube feeding orders. This does not address the needed in mon-iiaor in ensureiihat this has been erffaciive and when ongoing issues are identified how the system win he modified, how to identify nursing care cielivsry that is communicated to the physician for medicai orders and direction on the need for revision to nursing care delivery- lsclaied Class i Correction Date: 6/15J'i2 KHCP4 3029-0001 STATE FORM ii sheet so ciao ii (39. RICK SCOTT ELIZABETH DUDEK GOVERNOR Better Health Care for all Floridians SECRETARY May 24, 2012 Administrator Tarpon Point Nursing And Rehabilitation Center 5157 Park Club Drive Sarasota, FL 34235 Re: CCR #2012004256 Dear Administrator: On April 26, 2012-May 15, 2012, a complaint survey was conducted in your facility by representatives of this office. The purpose of this visit was to determine if your facility was in compliance with requirements for nursing homes participating in the Medicare and/or Medicaid programs. Your facility was found not in substantial compliance with the participation requirements. Enclosed are the provider's copies of Form CMS-2567 (Statement of Deficiencies and Plan of Correction) and State (3020) Form. These forms reference the deficiencies that were identified during the visit. You will not receive a copy of this letter and attachments in the mail; you will only receive this faxed report. A Plan of Correction (POC) for the deficiencies must be submitted to this Field Office 10 days after your facility receives the faxed Form CMS--2567. Failure to submit an acceptable POC within ten (10) days after receipt of the faxed statement of deficiencies may result in the imposition of remedies. You will be notified by telephone if your POC is found to be unacceptable. The correction date indicated by the facility shall be after the date of survey exit. Deficiencies shall be corrected no later than June 15, 2012. Your POC must contain the following: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; 0 How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; Headquarters 2727 Mahan Drive Tallahassee, FL 32308 Fort Myers Field Office 2295 Victoria Avenue, Room 340 Fort Myers, FL 33901 Phone (239) 335-1315; Fax (239) 338-2372 Tarpon Point Nursing And Rehabilitation Center May 24, 2012 Page 2 What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; and, How the corrective action(s) will be monitored to ensure the deficient practice will not recur, what quality assurance program will be put into place. Recommended Remedies: Please note that this letter does not constitute formal notice of imposition of alternative sanctions or termination of your provider agreement. Should the Centers for Medicare Medicaid Services determine that termination or any other sanction is warranted, we will provide you with a separate formal notification of that determination. Remedies will be recommended for imposition by CMS if your facility has failed to achieve substantial compliance by the revisit. Informal dispute resolution for the cited deficiencies will not delay the imposition of the enforcement actions recommended. A change in the seriousness of the noncompliance found may result in a change in the remedy recommended. When this occurs, you will be advised of any change in remedy. - A Civil Money Penalty in the amount effective May 15, 2012, the date when noncompliance was identified to exist. 0 A mandatory denial of payment for new admissions will be imposed August 15, 2012 if substantial compliance is not achieved by that time. 0 Termination of Medicare Agreement. We are recommending to the CMS Regional Office and/or State Medicaid Agency that your provider agreement be terminated on November 15, 2012 if substantial compliance is not achieved by that time. If, upon the subsequent revisit, your facility has not achieved substantial compliance, the CMS Regional Office or State Medicaid Agency will impose the other remedies indicated above, or a revised remedy, if appropriate. Informal Dispute Resolution: In accordance with ?488.33 1, you have one opportunity to question cited deficiencies through an informal dispute resolution process. To be given such an opportunity, you are required to send your written request, along with the specific deficiencies being disputed, and an explanation of why you are disputing those deficiencies, to: Attention: IDR Coordinator Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 9-A Tallahassee, Florida 32308 FAX (850) 414-6946 or Phone number: (850) 412-4301 The IDR request must be sent during the same 10 days you have for submitting a Plan of Correction Tarpon Point Nursing And Rehabilitation Center May 24, 2012 Page 3 for the cited deficiencies. An incomplete informal dispute resolution process will not delay the effective date of any enforcement action. The Quality Assurance Questionnaire has long been employed to obtain your feedback following survey activity. This form has been placed on the Agency's website at as a first step in providing a web-based interactive consumer satisfaction survey system. You may access the questionnaire through the link under Health Facilities and Providers on this page. Your feedback is encouraged and valued, as our goal is to ensure the professional and consistent application of the survey process. Thank you for the assistance provided to the surveyors. If you have questions, please contact this office at (239) 335-1315. Sincerely, Harold D. Williams Field Office Manager HDW/lsj Enclosure R6WB