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Cbl Federal Inspection 12 06 07 · -~ ... PRINTED: 12/19/2007 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORMAPPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMS NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPUERICUA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OFCORRECTION IDENTIFICATION NUMBER: COMPLETED A.BUILDING B. W1NG --,­ _ 095015 12106/2007 NAME OF PROVIDER OR SUPPUER STREET ADDRESS, CITY, STATE, ZIP CODE 1380 SOUTHERN AYE SE CAROLYN BOONE LEWIS HEALTH CARE CENTER WASHINGTON, DC 20032 PROVIDER'S PLAN OF CORRECTION (X5) (X4) 10 SUMMARY STATEMENT OF DEFICIENCIES 10 (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS­ COMPlETION PREFIX DATE TAG OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCy) FOOD INITIAL COMMENTS FOOD An annual recertification survey was conducted "December 3 through 6, 2007. The following deficiencies were based on record review, observations, and interviews with the facility staff. The sample included 27 residents based on a census of 177 residents on the first day of survey Disclaimer and five (5) supplemental residents. Preparation or execution of this Plan of Correction ("POC") F221 483. ~~~~) PHYSICAL RE~INTS F 221 does not constitute an admission SS=D or assent by the provider to the The resident has the right to beftee.from any truth, accuracy or veracity ofthe physical restraints imposed for purposes of facts alleged or conclusions set discipline or convenience, and not required to treat forth in the Statement of the resident's medical symptoms. Deficiencies ("SOD"). The POC is prepared and executed solely because it is required under the law. This REQUIREMENT is not met as evidenced by: By this response, Carolyn Boone Based on observations, record review and staff Lewis Health Care Center interviews for a sample of 27 residents, one (1) of acknowledges receipt of the SOD four (4) residents identified with restraints, it was determined that the clinical record lacked evidence and alleges that it is in compliance. that a vest restraint was the least restrictive device Accordingly, this POC is submitted for Resident #2. as written allegation ofcompliance effective December 28, 2007. The findings include: During the review of the clinical record, physician's orders signed and dated November 16, 2007 with an original order date.of May 15, 2007, indicated 'Vest Posey jacket to protect pt. (patient) release every two (2) hours for mobility and circulation in bedlwheelchair." Resident #2 has a history of falls. On December 3, 2007 at approximately 9:30 AM, Resident #2 was observed sitting in the day room in a wheelchair in a Vest Posey jacket with the Velcro fasteners in the back, the straps attached AB07tT~~Y _DIRECTOR'~ OR P'~VlDERlSUPPLIER REPRESENTATIVE'S SIGNATURE. • TITLE (X6) DATE ~(!zfJW1( 1J/J.!.trJ . a.'-""rt""-fh""""Ail,-,-"/""",,t2t.u..::'i11"l4<1'''''"'tl2~{(J ~~....L...:._ \Ily deficiencystatement endingwith an asterisk(") denotesa deficiencywhich the institutionmay be excusedfrom correcting providingit is determinedthat other ;afeguards provide sullicient protectionto the patients.(see instructions.) Except for nursing homes. the findingsstated above are disclosable90 days following the date of ;urveywhetheror not a plan of correction is provided. For nursinghomes. the above findings and plans of correctionare disdosable 14 days following the datethese locumems are made avail86llfto1tie faCIlitY. If aetiCienCies are Cite<I. an approved pliinOfrorrectiOh iSrequiSiIe to cOntinued programpartiCipiiliOh. 'ORM CMS-2567(02-99) PreviousVersionsObsolete . Event 10:898Z11 Faciflty 10:HCI If continuation sheet Page 1 of 41 PRINTED: 12/19/2007 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING -- - --­ ---- ------ ----- ------- ----- ------ B_ WING _ 095015 12/06/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1380 SOUTHERN AVE SE CAROLYN BOONE LEWIS HEALTH CARE CENTER WASHINGTON, DC 20032 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) ID II PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS­ COMPLETION DATE TAG OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) F 000 INITIAL COMMENTS F 000 An annual recertification survey was conducted December 3 through 6, 2007. The following deficiencies were based on record review, observations, and interviews with the facility staff. The sample included 27 residents based on a census of 177 residents on the first day of survey and five (5) supplemental residents. F 221 483.13(a) PHYSICAL RESTRAINTS F 221 F 221 483.13(8) SS=D PHYSICAL RESTRAINTS The resident has the right to be free from any physical restraints imposed for purposes of 1. Unit Manager referred resident #2 for discipline or convenience, and not required to treat rehab screen on 12-07-07. Rehab the resident's medical symptoms. recommended a selfrelease seat belt which is the least restrictive. Seat belt i was placed on residents' wheelchair on 12-14-07. This REQUIREMENT is not met as evidenced by: Based on observations, record review and staff 2. All other residents identified with interviews for a sample of 27 residents, one (1) of restraints has been assessed for the four (4) residents identified with restraints, it was least restrictive device and referred determined that the clinical record lacked evidence to rehab for screens as needed. that a vest restraint was the least restrictive device for Resident #2. 3. Licensed staff were in-serviced on 12-07-07 on the use ofrestraints The findings include: by Unit Manager and the referral process for rehab During the review of the clinical record, physician's screens. orders signed and dated November 16, 2007 with an original order date of May 15, 2007, indicated 4. Random audits will be conducted to "Vest Posey jacket to protect pt. (patient) release ensure the process is being followed every two (2) hours for mobility and circulation in and monitored in quarterly CQI. - 12-28-0'1 bed/wheelchair." Resident #2 has a history of falls. On December 3, 2007 at approximately 9:30 AM, Resident #2 was observed sitting in the day room in a wheelchair in a Vest Posey jacket with the Velcro fasteners in the back, the straps attached LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE ~/lfhJ1 ffltUo FORM CMS-2567(02.99) Previous Versions Obsolete Event ID: 898Z11 Facility ID: HCI If continuation sheet Page 4-of44 PRINTED: 12116/2007 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OM8 NO. 0938-0391 STATEMENT OFOI!F!CIENCIES (X,) PRDVIDERISUPPLlEFVCLlA 1X2) MULTIPLI: CONSTRUCTION (X3)DATE SURVI!Y AND PLAN OFCORRI!CilON ID5N1IFIC.rION NUMBER: COMPLETEO A.BUIWING B~WiR"G_- _ 095015 12106/2007 NAMeOF PROVIDBR OR SUPPLIER STRE:ET ADDRess. CITY, STATIo, ZIP coca 1380SOUTHERN AVE SE CAROLYN BOONE LEWIS HEALTH CARE CENTER WASHINGTON, DC 2.0032 (X4) 10 SUMMARY STATC/JIENT OF oeFICIENCIES 10 PROVIDEAS PLAN OF CORRECTION 1)(51 PR~I'TX (IOACH OEFICIENCV MUSTBE P~CEDED BY FULL REGULATORY PFlEI'IX (EACHCORRI<CTIVE ACTION SHOULDBECROSS­ COMPLETION TAG OR LSCIDENTIFYING INFORMATION) TAG REFERENceoTO Tl'4E API"AOpFlIA'r~ DeFICIENCY) DATE F 221 Continued From page 1 F 221 to the jacket were wrapped around the lower rims of the wheelchair. The resident was pulling an the vest in an attempt to remove it saying that he/she was hot. On December 3. 2007 at approximately 5:15 PM, the resident was observed in his/her wheelchair in the hallway across from the first floor nurse's station. He/she was pUlling the vest up in an attempt to remove it; the vest was observed anchored at the resident's necK beneath his/her chin. Review ofthe clinical recard revealed a consent form for vest restraint use signed and dated by the resident's responsible party on May 15, 2007. The resident's care plan for restraint use for safety was updated on October 24, 2007. A"Rehabilitation Screening" form in the record signed and dated October 29,2007 by the physical therapis! indicated, "Pt. using·Posey Vest which [he/she) is able to remove on occasion allowing nursing to prevent a fall. ...[She/he] is on the least restrictive device at this time." The record lacked evidence that other devices and/or interventions had been tried, On December 5,2007 at approximately 12:30 PM, a face-to-face interview was conducted with Employee #12; The employee stated, "This type of vest is the most restrictive; that type of restraint is not frequently used at the present time." During observation, the resident was unable to remove the restraint on both attempts. The record was reviewed on December 3, 2007. F 246 483.15(e)(1) ACCOMMODATION OF NEEDS F 246 FORM CMS-Z5B7(02-BBJ PreYloue VersionsObsole\o cysntI0:BeaZ'1 F.cility 10; ~CI If contlnuatlon sheet Page 2 of 41 From:MDS 202+574+0192 01/07/2008 15:27 1809 P.003/015 PRINTED: 1211912007 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED -- M~OICAID --_....... ..-... OMB NO. ",,"n """1 STATEMENT OF DEFICIENCIES (X1) PROVlDERlSUPPUERlCLlA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PlAN OF CORREC1l0N IDENTIFICATION NUMBER: COMPlETED A. BUIlDING B. W1NG ----:=_:.. 096015 12106/2007 NAMEOF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1380 SOUTHERN AVE SE CAROLYN BOONE LEWIS HEALTH CARE CENTER WASHINGTON, DC 20032 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTlON (XS) PREFIX . (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECllVE ACTION SHOULD BE CROSS­ COMPlEl'1OH TAG OR LSC IDEN11FYING INFORMATlON) TAG REFERENCED TO THE APPROPRlA~ DEFICIENCy) DAlE F 246 Continued From page 2 F 246 F 246 483.15(e) (1) SS=D ACCOMMODATION OF NEEDS ~ A resident has the right to reside and receive services in the facility with reasonable 1.
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