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(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

07/25/2017PRINTED:

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OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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DATECROSS-REFERENCED TO THE APPROPRIATE

MULBERRY, IN 46058

155600 05/12/2017

MULBERRY HEALTH & REHABILITATION CENTER

502 W JACKSON ST

00

F 0000

Bldg. 00

This visit was for a Recertification and

State Licensure Survey. This visit

included a State Residential Licensure

Survey.

Survey dates: May 7, 8, 9, 10, 11 and 12,

2017.

Facility number: 000470

Provider number: 155600

AIM number: 100289210

Census Bed Type:

SNF/NF: 106

SNF: 31

Residential: 5

Total: 142

Census Payor Type:

Medicare: 22

Medicaid: 92

Other: 23

Total: 137

These deficiencies reflect State Findings

cited in accordance with 410 IAC

16.2-3.1.

Quality Review was completed on

5/17/17.

F 0000 Mulberry Health & Retirement

Community respectfully requests

a desk review in lieu of an on site

follow up survey

FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determined that

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

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

_____________________________________________________________________________________________________Event ID: EYP111 Facility ID: 000470

TITLE

If continuation sheet of 31

(X6) DATE




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483.20(g)-(j)

ASSESSMENT

ACCURACY/COORDINATION/CERTIFIED

(g) Accuracy of Assessments. The

assessment must accurately reflect the

resident’s status.

(h) Coordination

A registered nurse must conduct or

coordinate each assessment with the

appropriate participation of health

professionals.

(i) Certification

(1) A registered nurse must sign and certify

that the assessment is completed.

(2) Each individual who completes a portion

of the assessment must sign and certify the

accuracy of that portion of the assessment.

(j) Penalty for Falsification

(1) Under Medicare and Medicaid, an

individual who willfully and knowingly-

(i) Certifies a material and false statement in

a resident assessment is subject to a civil

money penalty of not more than $1,000 for

each assessment; or

(ii) Causes another individual to certify a

material and false statement in a resident

F 0278

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FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EYP111 Facility ID: 000470 If continuation sheet of 31




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assessment is subject to a civil money

penalty or not more than $5,000 for each

assessment.

(2) Clinical disagreement does not constitute

a material and false statement.

Based on interview and record review,

the facility failed to provide

documentation regarding changes in

urinary continence status as entered on

the MDS (minimum data set) assessment

for 3 of 3 residents reviewed for urinary

incontinence (Residents 49, 43 and 150).

Findings include:

1. The record for Resident 49 was

reviewed on 5/09/17 at 3:26 p.m.

Diagnoses included, but were not limited

to, type 2 Diabetes Mellitus, heart failure,

diabetic neuropathy and Parkinson's

disease.

The admission MDS completed on

2/06/17 indicated the resident was always

continent of urine. The MDS completed

on 2/21/17 indicated the resident was

occasionally incontinent of urine.

The CAA (care area assessment)

worksheet dated 2/21/17, indicated

"...Resident requires assist with toileting.

Episodes of bladder incontinence. See

MDS and addle [activities of daily living]

documentation for this assessment...."

F 0278 No corrective action can be taken

for the residents identified because

the assessments have already

occurred. No resident was

negatively affected by the lack of

documentation on number of

incontinent episodes.

All residents have the potential to be

affected.

The facilities Electronic Medical

Records system has the capability of

requiring staff to enter the number

of incontinent episodes each shift.

This feature has been turned on for

all residents. The facilities Certified

Nursing Assistants will be in-serviced

on documenting incontinent

episodes.

The MDS department will monitor

the tracking of incontinent episodes

on an ongoing basis during the

assessment period. A CQI audit tool

will be completed by MDS for the

first 60 days to ensure all

comprehensive and quarterly

assessments reflect number of

incontinent episodes that occurred.

Director of Nursing will report to the

facilities Quality Assurance

committee on results of the audits,

and any actions necessary to ensure

06/11/2017 12:00:00AM





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During an interview on 5/12/17 at 1:56

p.m., the DON (Director of Nursing)

indicated the ADL documentation does

not show episodes of the resident's

incontinence and she indicated the score

for the urinary incontinence on the MDS

is obtained by verbal conversations with

the staff. The DON could not provide

written documentation on how many

episodes of incontinence the resident had

during the assessment period.

100% compliance.

483.25(d)(1)(2)(n)(1)-(3)

FREE OF ACCIDENT

HAZARDS/SUPERVISION/DEVICES

(d) Accidents.

The facility must ensure that -

(1) The resident environment remains as

free from accident hazards as is possible;

and

(2) Each resident receives adequate

supervision and assistance devices to

prevent accidents.

(n) - Bed Rails. The facility must attempt to

use appropriate alternatives prior to

installing a side or bed rail. If a bed or side

rail is used, the facility must ensure correct

installation, use, and maintenance of bed

rails, including but not limited to the following

elements.

(1) Assess the resident for risk of

entrapment from bed rails prior to

installation.

F 0323

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(2) Review the risks and benefits of bed rails

with the resident or resident representative

and obtain informed consent prior to

installation.

(3) Ensure that the bed’s dimensions are

appropriate for the resident’s size and

weight.

Based on observation, record review and

interview, the facility failed to provide

easy access to a call light for a resident

able to use a call light system for 1 of 3

residents reviewed for call light access.

(Resident 134).

Finding includes:

During resident observation on 5/8/17 at

10:33 a.m., the call light was observed

draped over the call system on the wall.

During this observation, there was a sign

taped to the bedside table that indicated

"...Stop, use call light...."

A review of the care plan initiated

12/17/14 indicated the resident was at

risk for falls and interventions included

"...Keep call light in easy reach...."

During an interview with CNA 1 on

5/8/17 at 10:42 a.m., she indicated the

resident does not use the call light, the

staff assist the Resident 134 with

dressing in the morning but then the

Resident does everything else on her

F 0323 The resident identified in the survey

is independent and chooses to drape

call light over the call system on the

wall. The facility will remove “keep

call light in easy reach” from the

care plan. Additionally the care plan

will reflect the resident’s choice to

drape the call light off the call

system on the wall.

No other residents have the

potential to be affected.

No further monitoring will be

required as the care plan will be

corrected.

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own. The resident is up and down on her

own throughout the day. Resident uses a

wanderguard.

During an interview with Resident 134

on 5/10/17 at 10:20 a.m., she was able to

point to the call light which was draped

over the call system on the wall when

asked where her call light was located.

During an interview with LPN 1 on

5/10/17 at 10:40 a.m., she indicated the

resident does not use a call light because

it confuses the resident.

3.1-45(2)

483.45(d)

DRUG REGIMEN IS FREE FROM

UNNECESSARY DRUGS

(d) Unnecessary Drugs-General. Each

resident’s drug regimen must be free from

unnecessary drugs. An unnecessary drug is

any drug when used--

(1) In excessive dose (including duplicate

drug therapy); or

(2) For excessive duration; or

(3) Without adequate monitoring; or

(4) Without adequate indications for its use;

F 0329

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or

(5) In the presence of adverse

consequences which indicate the dose

should be reduced or discontinued; or

(6) Any combinations of the reasons stated

in paragraphs (d)(1) through (5) of this

section.


the facility failed to monitor for specific

targeted behaviors for an antipsychotic

medication and failed to monitor for

adverse effects of a diabetic medication

for 2 of 5 residents reviewed for

unnecessary medications (Resident 174

and 8).

Findings include:

1. Resident 174's record was reviewed on

05/11/2017 at 1:31 p.m. Diagnoses

included, but were not limited to,

dysphagia, dysthymic disorder, aphasia

following Cerebrovascular disease and

dementia with behavioral disturbance.

Resident 174's medications included, but

were not limited to, Zyprexa (an

antipsychotic medication) 5 mg

(milligrams) give a half a tab every

morning and one tab every evening

related to dementia with behavioral

disturbance and Zoloft (an antidepressant

medication) 100 mg every day related to

dysthymic disorder.

F 0329 The residents identified in the

survey had current medication

regimen reviewed by Pharmacist

and attending physician to ensure

proper use of medications.


affected. Pharmacist has reviewed

all medication orders for each

resident to ensure accuracy and

necessity.

Licensed nursing staff will be

in-serviced on facility policy for

insulin dependent diabetic residents.

Facility Behavior management

committee will monitor routinely all

GDR’s and failed GDR’s for

supportive documentation.

Nursing management will audit

monthly GDR reports to ensure

supportive documentation for

targeted behaviors is in place. A CQI

audit tool will be completed

monthly for 90 days to ensure

compliance. Director of Nursing will

report to the facilities Quality

Assurance committee on results of

the audits, and any actions

necessary to ensure 100%

06/11/2017 12:00:00AM





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Resident 174's Medication

Administration Record (MAR) indicated

to observe for the following behaviors

and to specify: itching, picking at skin,

restlessness (agitation), hitting, increase

in complaints, biting, kicking, spitting,

cussing, racial slurs, elopement, stealing,

delusions, hallucinations, psychosis,

aggression and refusing care.

Resident 174's Admission Minimum

Data Set (MDS) assessment dated

12/31/2016, was marked as "none of the

above" which indicated the resident did

not have hallucinations or delusions.

A Physicians progress note from the

neurologist dated 1/11/2017, indicated

"...He was given diagnosis of Lewy Body

Dementia... although he has not had

hallucinations...."

An initial psychiatric evaluation dated

1/30/2017, was marked as "No" regarding

delusions, hallucinations, and suicidality

under the thought content section.

A "Note to Attending

Physician/Prescriber" from the

Pharmacist dated 1/5/2017, indicated

"...he may benefit from discontinuing his

Zyprexa 2.5 mg every am and 5 mg every

evening. Please consider reducing the

compliance. Additionally Nursing

management will audit blood sugars

that occur outside of parameters for

proper physician notification and

documentation. A CQI audit tool

will be completed weekly for the

first 30 days and monthly for the

next 90 days to ensure compliance.





100% compliance.





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evening dose to 2.5 mg for 14 days, then

discontinuing his morning dose, leaving

just the evening dose for 14 days, then

discontinuing the evening dose...." The

Physician responded with "agree" on

2/9/2017.

A Nursing Progress note dated 1/10/2017

at 2:35 p.m., indicated the resident

climbed out of his chair and crawled

around on the floor in front of his chair.

Precipitating factors were the resident

was sitting in the recliner in his room.

Resident was incontinent of bowel.

Non-pharmacological interventions were

staff assisted him up and provided peri

care, encouraged him to attend activities

and offered him a snack and fluids.

Outcome: no further episodes were noted.


at 9:58 p.m., indicated the motion sensor

started to go off and the resident was

found by the nurse crawling fast towards

the bathroom in his room. Precipitating

factors were the resident was sitting in

his recliner with the motion sensor in

place. Non-pharmacological

interventions were the resident was

assisted to his wheelchair by 2 staff

members, a skin assessment was

completed with no new areas noted,

assessed for pain, toileted, changed and

assisted to bed. Outcome: The resident





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rested in bed with the call light in reach.


at 9:37 p.m., indicated the resident was

wandering in the hallway self propelling

his wheelchair and tried to go into room

304. Precipitating factors were the

resident was sitting in his wheelchair in

the hallway after dinner.


the resident was redirected. Outcome:

The resident stayed by the nurses station.


at 8:05 a.m., indicated the resident was

trying to stand without help and stated he

can get up and walk by himself and asked

where "she was and why nobody looks."

Precipitating factors were the resident

was sitting in his wheelchair ready for

breakfast. Non-pharmacological

interventions were the resident was

provided one on one, talked with the

resident and answered questions about

why he was here. Outcome: The resident

was taken to breakfast.


at 9:09 a.m., indicated the resident was

wandering around the facility in his

wheelchair. Precipitating factors were the

resident was just at breakfast.


one on one and redirected back to the





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unit. Outcome: the resident continued to

wander.


at 9:05 p.m., indicated the resident was

standing up from a seated position in his

wheelchair several times this evening

shift and was noted to have confusion.

Precipitating factors were family

members just left and resident was in his

wheelchair . Non-pharmacological

interventions were one on one, toileted,

ambulated, gave resident liquids and his

harmonica to play. Outcome: The

resident continued to be restless until he

was assisted into bed.

Nursing Progress note dated 2/18/2017 at

1:21 p.m., indicated the resident was

wandering around the facility looking for

a way home . The resident was going out

the front door and would not let staff turn

him around. The resident wandered for a

few feet and then let staff bring him back

inside. Precipitating factors were the

resident wanted to go home.


one on one provided and explained he

was here to get stronger after a stoke and

his wife knows he was here and she

would be here later. Outcome: The

resident sat at the nurse's station and

stated he would sit there and wait for his

wife to come.





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No other behavioral notes were found in

Resident 174's record for the month of

February 2017.

A "Note to Attending

Physician/Prescriber" from the

Pharmacist dated 2/21/17, indicated

"...the behavioral health team feels as if

he may benefit from a return to his

original dose of Zyprexa 2.5 mg every

morning and 5 mg every evening due to

an increase in behaviors...." The

Physician responded that he agreed with

the increase on 2/27/2017.

A Physicians progress note from the

primary doctor dated 3/10/2017,

indicated "...increased Zyprexa due to

increased behaviors...."

Resident 174's quarterly MDS assessment

dated 3/11/2017, was marked as "none of

the above" which indicated the resident

did not have hallucinations or delusions.

Resident 174's Care Plan dated

12/13/2016, addressed the problem of the

potential for depression due to being in a

new environment and away from his

wife. Interventions included, but were not

limited to, "...Observe for non-verbal

signs and symptoms of depression...."





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A Care Plan dated 12/30/2017, addressed

the problem the resident had episodes of

intentional changes in position as

evidenced by climbing out of bed onto

the floor and crawling around, cannot

consistently or clearly express purpose,

will wander with increased anxiety which

stems from delusional episodes, believes

his wife is present and will search the

building due to he seeing her when she

was not actually there. Interventions

included, but were not limited to,

"...assess resident for pain and provide

care, be alert of behavior and pattern

changes after medication reductions or

changes, if resident appears tired assist

the resident to a comfortable environment

and observe for increased wandering due

to most often/likely related to

delusions...."

A Care Plan dated 2/15/2017, addressed

the problem of at risk for wandering due

to confusion and diagnosis of dementia.

Interventions included, but were not

limited to, "...Assist resident on walks or

allow to wander ad lib [as much and as

often as desired] in a safe/secure area and

divert attention when when resident

becomes insistent on leaving the

facility...."

During an interview on 05/12/2017 at

3:00 p.m., the Social Service Director





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indicated there were no more behavior

notes documented in the progress notes

and the behavior notes did not address

the resident's delusions.

A facility policy related to antipsychotic

medications was not provided by the time

of exit.

2. During an interview on 5/9/2017 at

11:27 a.m., Resident 8 indicated she had

a hypoglycemic (low blood sugar)

episode the previous morning.

The record for Resident 8 was reviewed

on 5/9/2017 at 2:33 p.m. Diagnoses

included, but were not limited to, a 3-part

fracture of the surgical neck of the right

humerus, Diabetes Mellitus,

hypertension, cataract, hyperlipidemia,

tremor, anemia, hypothyroidism, repeated

falls, and muscle weakness.

The resident's Medication Administration

Record dated May 2017, included, but

was not limited to, the following orders:

Humalog Solution 100 unit/mL (a

medication used to treat diabetes) inject 6

units subcutaneously one time a day

(8:00 a.m.) related to Diabetes Mellitus

due to an underlying condition with

unspecified complications. Order date:

3/31/2017.

Humalog Solution 100 unit/mL (a

medication used to treat diabetes) inject





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subcutaneously one time a day (12:00

p.m.) related to Diabetes Mellitus due to

an underlying condition with unspecified

complications. Order date: 3/31/2017.

Levemir Solution 100 unit/mL (a

medication used to treat diabetes) inject

10 units subcutaneously in the morning

(8:00 a.m.) related to Diabetes Mellitus

due to an underlying condition with

unspecified complications. Order date:

3/24/2017.

Levemir Solution 100 unit/mL (a

medication used to treat diabetes) inject 6

units subcutaneously at bedtime (8:00

p.m.) related to Diabetes Mellitus due to

an underlying condition with unspecified


Blood sugar checks in the a.m. and h.s.

(bedtime) two times a day related to

Diabetes Mellitus due to an underlying

condition with unspecified


The record for Resident 8 lacked

documentation of the hypoglycemic

episode on 5/8/17 including vital signs,

observations, interventions, and a blood

sugar. No documentation of vital signs,

observations and interventions were

noted from a hypoglycemic episode on

3/20/2017.


p.m., the DON (director of nursing)





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indicated a critical blood sugar level was

less than 60 mg/dL (milligrams of

glucose per deciliter of blood) and greater

than 400-500 mg/dL.


p.m., LPN 1 indicated that Resident 8 had

a low blood sugar episode while walking

with restorative on 5/8/2017 and that the

night shift nurse would have assessed the

resident and documented the blood sugar,

observations, interventions, and

outcomes in the progress notes of the

electronic medical record (EMR).

Additionally, the night shift nurse would

have communicated with the doctor the

low blood sugar. LPN 1 indicated the

EMR lacked documentation of the

hypoglycemic episode and there was no

record of the MD being notified in the

"Dr. Communication Book."


10:48 a.m., the DON indicated the nurses

should have followed facility policy and

documented the hypoglycemic episode

including findings, interventions and

observations in the clinical record.

During an interview on 5/11/2017 2:13

p.m., RN 1 indicated there was no

documentation of a progress note for a

critically low blood sugar in the resident's

record for 3/20/2017 and no





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communication record with the MD was

located in the "MD Communication

Book."

A facility policy titled "Hypoglycemia

(Insulin shock)" dated March 2003

received from LPN 1 on 5/10/2017 at

3:15 p.m. indicated Nursing Interventions

included: " ...4. Take Vital Signs 5.

Continue to monitor until symptoms have

cleared. 6. Document findings and

observations in medical record ..."

3.1-48(a)(3)

3.1-48(a)(4)

483.60(i)(1)-(3)

FOOD PROCURE,

STORE/PREPARE/SERVE - SANITARY

(i)(1) - Procure food from sources approved

or considered satisfactory by federal, state

or local authorities.

(i) This may include food items obtained

directly from local producers, subject to

applicable State and local laws or

regulations.

(ii) This provision does not prohibit or

prevent facilities from using produce grown

in facility gardens, subject to compliance

with applicable safe growing and

food-handling practices.

F 0371

SS=F

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(X4) ID

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(X5)

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(iii) This provision does not preclude

residents from consuming foods not

procured by the facility.

(i)(2) - Store, prepare, distribute and serve

food in accordance with professional

standards for food service safety.

(i)(3) Have a policy regarding use and

storage of foods brought to residents by

family and other visitors to ensure safe and

sanitary storage, handling, and

consumption.


interview, the facility failed to ensure

foods were labeled with a use by date and

opened foods were covered in 1 of 1

kitchen. This deficient practice had the

potential to affect 136 of 137 residents

receiving food from the kitchen.

Findings include :

During the initial tour of the kitchen on

5/7/17 at 3:05 p.m., the following were

observed:

1. 13 containers of bean salad were

observed in the reach-in refrigerator

uncovered and undated.

2. One jar of pickle relish was opened in

the reach-in refrigerator with no use by

date.

3. One jar of dill strips was opened in the

reach-in refrigerator with no use by date.

F 0371 Corrective action taken by the

Dietary staff at the time the items

were identified to not have a used

by date on them, even though they

were not expired, was to remove the

items from the reach in refrigerator.

The uncovered bean salads were to

be used for the staff meal that

evening and were distributed

accordingly. They had no potential

to affect any resident.

No resident had the potential to be

negatively affected by the alleged

deficient practice as none of the

items identified in the survey were

expired.

Dietary staff will be in serviced on

the facilities policy of dating all items

when they are opened. Dietician will

be responsible for monitoring

opened items in the kitchen to

ensure they are dated when

opened. A CQI audit tool will be

completed weekly for the first 30

days and monthly for the next 90

days to ensure compliance. Dietician

06/11/2017 12:00:00AM





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OMB NO. 0938-0391




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B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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TAG




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TAG



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(X5)

COMPLETION


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During an interview on 05/09/2017 2:26

p.m., the Dietary Manager indicated the

containers should have been covered and

dated as well as a use by date on the jars.

A current policy titled "Storage of Food

and Supplies" undated, obtained from the

Administrator on 5/10/17 at 11:02 a.m.,

indicated "...Prepared foods stored in the

refrigerator will be covered with paper,

plastic lids, plastic wrap or trays above

the stored items...."

A current policy titled "Shelf Life and

Labeling Procedure" undated, obtained

from the Administrator on 5/10/17 at

11:02 a.m., indicated "...2. Open food

items must have an "open" date and a

"use by" date...."

3.1-21(i)(3)

will report to the facilities Quality




compliance.

483.45(b)(2)(3)(g)(h)

DRUG RECORDS, LABEL/STORE DRUGS

& BIOLOGICALS

The facility must provide routine and

emergency drugs and biologicals to its

residents, or obtain them under an

F 0431

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agreement described in §483.70(g) of this

part. The facility may permit unlicensed

personnel to administer drugs if State law

permits, but only under the general

supervision of a licensed nurse.

(a) Procedures. A facility must provide

pharmaceutical services (including

procedures that assure the accurate

acquiring, receiving, dispensing, and

administering of all drugs and biologicals) to

meet the needs of each resident.

(b) Service Consultation. The facility must

employ or obtain the services of a licensed

pharmacist who--

(2) Establishes a system of records of

receipt and disposition of all controlled drugs

in sufficient detail to enable an accurate

reconciliation; and

(3) Determines that drug records are in

order and that an account of all controlled

drugs is maintained and periodically

reconciled.

(g) Labeling of Drugs and Biologicals.

Drugs and biologicals used in the facility

must be labeled in accordance with currently

accepted professional principles, and

include the appropriate accessory and

cautionary instructions, and the expiration

date when applicable.

(h) Storage of Drugs and Biologicals.

(1) In accordance with State and Federal

laws, the facility must store all drugs and

biologicals in locked compartments under

proper temperature controls, and permit only

authorized personnel to have access to the

keys.





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(2) The facility must provide separately

locked, permanently affixed compartments

for storage of controlled drugs listed in

Schedule II of the Comprehensive Drug

Abuse Prevention and Control Act of 1976

and other drugs subject to abuse, except

when the facility uses single unit package

drug distribution systems in which the

quantity stored is minimal and a missing

dose can be readily detected.

Based on observation, interview and

record review, the facility failed to

discard expired medications and failed to

refrigerate medications as indicated from

the Pharmacy in 4 of 7 medication carts

reviewed (Resident 25, 55, 87, 65, 63, 28,

150 and 86).

Findings include:

1. During medication storage review on

05/12/2017 at 1:40 p.m., the 200 Hall

medication cart for rooms 201-213 had

the following:

a. One vial of Lantus insulin (a diabetic

medication) for Resident 25 with a label

to "refrigerate until opened" was

unopened, not dated and in the

medication cart.

b. One vial of Cyanocabalam (Vitamin

B-12) for Resident 55 was opened and

used and was not labeled with an open

date.

c. One vial of Lantus insulin with a fill

date from the pharmacy of 1/21/17, for

F 0431 Corrective action taken for those

residents identified in the survey

was to destroy the medications

identified and order new ones from

the pharmacy.


affected. All medication carts have

been audited for expired or

non-dated medications.


in-serviced on facilities policy for

medication disposal.

Nursing management will audit all

medication carts for expired or

non-dated medications. A CQI audit

tool will be completed weekly for

the first 30 days and monthly for the






100% compliance.

06/11/2017 12:00:00AM





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(X3) DATE SURVEY

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Resident 87 with a label to "refrigerate

until opened" was unopened, not dated

and in the medication cart.


05/12/2017 at 1:40 p.m., the 200 Hall


the following:

a. One vial of Lantus insulin with a fill

date from the pharmacy of 2/21/2017, for



and in the medication cart.

b. One vial of Humalog insulin (a

diabetic medication) with a fill date from

the Pharmacy of 9/20/2016, for Resident

65 with a label to "refrigerate until

opened" was unopened, not dated and in

the medication cart.

c. One vial of Humalog insulin with a

fill date from the Pharmacy of 4/18/17,

for Resident 63 with a label to

"refrigerate until opened" was unopened,

not dated and in the medication cart

d. One vial of Levemir insulin with a fill

date from the Pharmacy of 4/20/17, for



and in the medication cart


p.m., LPN 3 indicated the insulin should

have been refrigerated until opened and

dated and the vial should have been





07/25/2017PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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labeled with an open date.


5/12/17 at 10:50 a.m., the 300 Hall


the following:

a. One-75 count bottle of [brand name]

Extra Strength Antacid (used to relieve

heartburn) for Resident 28 was opened

and dated 12/1/16 and had a

manufacture's expiration date of 02/11.


am, RN 1 indicated the medication found

in the 300 unit hallway medication cart

for rooms 317-325 was expired.


5/12/17 at 12:40 p.m., the 400 Hall

medication cart had the following:

a. One 25 count softgels of [brand name]

stool softener (used to relieve

constipation) for Resident 150 was

unopened and had a manufacture's

expiration date of 1/2017.

b. A vial of Even Care Glucose Control

Solution (a solution used to check if the

glucose meter and strips are working

correctly) was opened and dated with an

expiration date of 01/2017.

c. A bottle of Latanoprost Solution

0.005% (eye drops used to treat open

angle glaucoma) for Resident 86 was

opened, dated 3/30/17 and expired.





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12:48 p.m., LPN 2 indicated the

medication found in the 400 unit hallway

medication cart was expired.

A document titled "Medication

Expiration Dates" undated, received from

LPN 2 on 5/12/2017 at 12:45 p.m.,

indicated "...Latanoprost Solution

(Xalatan) should be refrigerated before

opening and once opened it should be

stored at room temperature for 6

weeks...Insulin may be kept at room

temperature before and after opened but

is only good for 30 days once it is stored

at room temperature...Insulin's expire 30

days after opening at room temperature,

30 days after opening refrigerated and

Lantus expires 28 days after opening...All

multi-dose vials should be dated and

initialed when opened by licensed staff.

Medications should be discarded

according to the date opened, expiration

date or according to the manufacturer

expiration date, whichever comes first...."

3.1-25(o)

483.70(i)(1)(5)

RES

RECORDS-COMPLETE/ACCURATE/ACCE

SSIBLE

F 0514

SS=D

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(i) Medical records.

(1) In accordance with accepted

professional standards and practices, the

facility must maintain medical records on

each resident that are-

(i) Complete;

(ii) Accurately documented;

(iii) Readily accessible; and

(iv) Systematically organized

(5) The medical record must contain-

(i) Sufficient information to identify the

resident;

(ii) A record of the resident’s assessments;

(iii) The comprehensive plan of care and

services provided;

(iv) The results of any preadmission

screening and resident review evaluations

and determinations conducted by the State;

(v) Physician’s, nurse’s, and other licensed

professional’s progress notes; and

(vi) Laboratory, radiology and other

diagnostic services reports as required

under §483.50.


the facility failed to document a

hypoglycemic (low blood sugar) episode

for 1 of 5 residents reviewed for

unnecessary medications (Resident 8).

Finding includes:

F 0514 No corrective action can be taken

for the resident identified as the

episode already occurred, and had

no negative outcome for the

resident.

All residents with a diabetes

diagnosis have the potential to be

06/11/2017 12:00:00AM





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a.m., Resident 8 indicated she had a

hypoglycemic episode the previous

morning.

The record for Resident 8 was reviewed

on 5/9/2017 at 2:33 p.m. Diagnoses

included, but were not limited to, a 3-part

fracture of the surgical neck of the right

humerus, Diabetes Mellitus,

hypertension, cataract, hyperlipidemia,

tremor, anemia, hypothyroidism, repeated

falls, and muscle weakness.

The record for Resident 8 lacked

documentation of the hypoglycemic

episode on 5/8/2017, including, but not

limited to, vital signs, observations,

interventions and a blood sugar.


p.m., LPN 1 indicated Resident 8 had a

low blood sugar when she came in on

5/8/2017 and the night shift nurse should

have checked the resident's blood sugar,

documented the results in the progress

note, and notified the doctor of the

episode. Doctors are notified using a

facsimile (fax) communication form and

a copy of the form is placed in the "Dr.

Communication Book." LPN 1 indicated

no progress note was found in the

electronic medical record (EMR) and no

affected.


in-serviced on facility policy for

insulin dependent diabetic residents.

Nursing management will audit

blood sugars that occur outside of

parameters for proper physician

notification and documentation. A

CQI audit tool will be completed

weekly for the first 30 days and

monthly for the next 90 days to

ensure compliance. Director of

Nursing will report to the facilities

Quality Assurance committee on

results of the audits, and any actions


compliance.





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communication was written to the

physician in the "Dr. Communication

Book."


10:48 a.m., the DON (director of nursing)

indicated the nurses should have

documented the hypoglycemic episode

including, but not limited to,

observations, vital signs, a blood sugar,

and interventions in resident 8's record.

A current facility policy titled

"Hypoglycemia (Insulin shock)" dated

March 2003, received from LPN 1 on

5/10/2017 at 3:15 p.m., indicated nursing

interventions included, but were not

limited to, " ...4. Take Vital Signs 5.

Continue to monitor until symptoms have

cleared. 6. Document findings and

observations in medical record...."

3.1-50(a)(2)

R 0000

Bldg. 00

This visit was for a State Residential

Licensure Survey. This visit included a

Recertification and State Licensure

R 0000 Mulberry Health & Retirement

Community respectfully requests

a desk review in lieu of an on site

State Form Event ID: EYP111 Facility ID: 000470 If continuation sheet of 31




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Survey.

Survey dates: May 7, 8, 9, 10, 11 and 12,

2017.

Facility number: 000470

Residential Census: 5

These State Residential Findings are

cited in accordance with 410 IAC 16.2-5.

Quality Review was completed 5/17/17.

follow up survey

410 IAC 16.2-5-5.1(f)

Food and Nutritional Services - Deficiency

(f) All food preparation and serving areas

(excluding areas in residents ' units) are

maintained in accordance with state and

local sanitation and safe food handling

standards, including 410 IAC 7-24.

R 0273

Bldg. 00


interview, the facility failed to ensure

foods were labeled with a use by date

and, opened foods were covered in 1 of 1

kitchen. This deficient practice had the

R 0273 Corrective action taken by the

Dietary staff at the time the items

were identified to not have a used

by date on them, even though they

were not expired, was to remove the

items from the reach in refrigerator.

06/11/2017 12:00:00AM





07/25/2017PRINTED:

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OMB NO. 0938-0391




A. BUILDING

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(X3) DATE SURVEY

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(X4) ID

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potential to affect 5 of 5 residents

receiving food from the kitchen.

Findings include :

During the initial tour of the kitchen on

5/7/17 at 3:05 p.m., the following were

observed:

1. 13 containers of bean salad were

observed in the reach-in refrigerator

uncovered and undated.

2. One jar of pickle relish was opened in

the reach-in refrigerator with no use by

date.

3. One jar of dill strips was opened in the

reach-in refrigerator with no use by date.

During an interview with the Dietary

Manager on 05/09/2017 2:26 p.m., she

indicated the containers should have been

covered and dated as well as a use by

date on the jars.

A current policy titled "Storage of Food

and Supplies" undated, obtained from the

Administrator on 5/10/17 at 11:02 a.m.,

indicated "...Prepared foods stored in the

refrigerator will be covered with paper,

plastic lids, plastic wrap or trays above

the stored items...."

A current policy titled "Shelf Life and

Labeling Procedure", undated, obtained

The uncovered bean salads were to

be used for the staff meal that

evening and were distributed

accordingly. They had no potential

to affect any resident.

No resident had the potential to be

negatively affected by the alleged

deficient practice as none of the

items identified in the survey were

expired.

Dietary staff will be in serviced on

the facilities policy of dating all items

when they are opened. Dietician will

be responsible for monitoring

opened items in the kitchen to

ensure they are dated when

opened. A CQI audit tool will be

completed weekly for the first 30

days and monthly for the next 90

days to ensure compliance. Dietician

will report to the facilities Quality




compliance.





07/25/2017PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

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from the Administrator on 5/10/17 at

11:02 a.m., indicated "...2. Open food

items must have an "open" date and a

"use by" date:..."

410 IAC 16.2-5-6(c)(4)

Pharmaceutical Services - Deficiency

(4) Over-the-counter medications,

prescription drugs, and biologicals used in

the facility must be labeled in accordance

with currently accepted professional

principles and include the appropriate

accessory and cautionary instructions and

the expiration date.

R 0300

Bldg. 00

Based on observation, interview and

record review the facility failed to ensure

expired medication was removed from a

medication cart. This affected 1 of 1

medication carts reviewed for expired

medications. (Resident 301).

Finding includes:

During a medication storage review with

RN 2 on 5/12/17 at 9:45 a.m., the

following was observed:

1. A bottle of Lantus Solution (an

antidiabetic) 100 units per milliter was

opened on 3/17/17. A physician's order

for Resident 301 dated 3/31/17 indicated

give Lantus 30 units subcutaneously one

R 0300 Corrective action taken for the

resident identified in the survey was

to destroy the medication identified

and order a new one from the

pharmacy.


affected. All medication carts have

been audited for expired or

non-dated medications.


in-serviced on facilities policy for

medication disposal.

Nursing management will audit all

medication carts for expired or

non-dated medications. A CQI audit

tool will be completed weekly for

the first 30 days and monthly for the


06/11/2017 12:00:00AM





07/25/2017PRINTED:

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OMB NO. 0938-0391




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time a day.


a.m., RN 2 indicated she knew insulin

products expired 28-30 days after

opening.

A current policy titled "Medications/Drug

Disposal/Expired" dated July, 2014,

obtained from the Director of Nursing on

5/12/17 at 12:00 p.m., indicated

"...Following manufacturing guidelines

for expired medication...."

A document titled " Medication

Expiration Dates" undated, obtained from

the Director of Nursing on 5/12/17 at

2:25 p.m., indicated "...Lantus-28 days

after opening...."





100% compliance.


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