Federal Health Survey - Washington, D.C.

DE?ARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 06/09/2011FORM APPROVED

OMB NO 0938-0391STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIAAND PLAN OF CORRECTION IDENTIFICATION NUMBER:

095038 05/09/2011NAME OF PROVIDER OR SUPPLIER

METHODIST HOME

(X3) DATE SURVEYCOMPLETED

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING _

STREET ADDRESS, CITY, STATE, ZIP CODE

4901 CONNECTICUT AVENUE, NW

WASHINGTON, DC 20008

(X4) 10PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY

OR LSC IDENTIFYING INFORMATION)

10PREFIX

TAG

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)

(X5)COMPLETION

OATE

5/9/11

5/~1

5/15/11

F 000 INITIAL COMMENTS

An annual Quality Indicator Survey [QIS](recertification survey) was conducted on May 4through May 9, 2011. The following deficiencieswere based on observations, staff interviews,resident interviews and record review. The totalsample was 22 residents.

F 241 483.15(a) DIGNITY AND RESPECT OFSS=D INDIVIDUALITY

The facility must promote care for residents in amanner and in an environment that maintains orenhances each resident's dignity and respect in fullrecognition of his or her individuality.

This REQUIREMENT is not met as evidenced by:

Based on observations and staff interview for two(2) residents, it was determined that facility stafffailed to promote dignity during dining as evidencedby the observation of two(2) residents that sat idleas others dined in their presence. Residents # 34and 37.

The findings include:

During dining observations of the breakfast meal onMay 5, 2011 and May 6, 2011, it was determinedthat facility staff failed to promote Residents #34and 37 ' s dignity by allowing the residents to sit idlewhile others dined.

The observation of the breakfast meal on May 5,2011 at 8:30 AM revealed Residents #34 and 37shared a table in the dining room on the first floorHealth Services Care unit. Facility staff beganserving individual meals at 8:34 AM. The meals

F 000 THIS PLAN OF CORRECTION IS SUBMITTED FORPURPOSES OF REGULATORY COMPLIANCE ANDAS PART OF THE METHODIST HOME'SONGOING EFFORTS TO CONTINUOUSLYMAINTAIN THE HIGH QUALITY OF CARE ANDSERVICES PROVIDED, AS SUCH IT DOES NOTCONSTITUTE AN ADMISSION OF THE FACTS ORCONCLUSIONS FOR ANY PURPOSEWHATSOEVER,

F 241

1. The deficient practice was corrected foraffected residents by bringing them intothe dining room only as staff wereavailable to provide the feedingassistance required.

2. Other residents who may requirefeeding assistance will be identifiedthrough discussions at Monthly NutritionAlert Committee meetings, review ofMonthly Nursing Assessments and CNAdocumentation, update of the quarterlyMDS, and care plan reviews. Onceidentified, these residents will bebrought into the dining room only as staffare available to provide the feedingassistance required.

3. Nursing and Dining Services policies willbe revised to address how residentswho require feeding assistance are to beidentified and served in the dining roomsin order to maintain their dignity. Staffwill be in-serviced on implementation ofthis policy.

4. Policy implementation and compliancewill be monitored through the quarterlyQuality Assurance/Quality ImprovementCommittee, beginning with secondquarter reports (July, 2011) Datacollection will begin 5/15/11.

5/15/11

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

c::;;:;-£;(lIITLE (X6\ DATE

1Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that othersafeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the dateof 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 thesedocuments are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation

FORM CMS-2S67(02-99) Previous Versions Obsolete Event ID: W1XU11 Facility ID: METHODIST If continuation sheet Page 1 of 9

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES


OMS NO 0938-0391STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

05/09/2011NAME OF PROVIDER OR SUPPLIER

METHODIST HOME

(X1) PROVIDERISUPPLIER/CLIAIDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYCOMPLETED

A BUILDING

B. WING _095038




(X4) IDPREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR

LSC IDENTIFYING INFORMATION)


CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

IDPREFIX

TAG

(X5)COMPLETION

DATE

F 241 Continued From page 1 F 241were presented to residents that were seated and/orsubsequently entered the dining area and had norequirements for feeding assistance. Residents #34and 37 sat at their table as others were served and I

dined in their presence. At 9:15 AM [greater than 40minutes later], facility staff presented meals toResidents #34 and 37, each of whom was providedwith total assistance for meal consumption.

A second observation of the first floor breakfast mealwas conducted on May 6, 2011 at 8:30 AM.Residents #34 and 37 were observed seatedtogether. Facility staff began serving individual mealsat 8:44 AM. At 9:07 AM, after the residents thatrequired no feeding assistance had been served,Resident #34 was presented with his/her meal andassistance for meal consumption. Resident #37received his/her meal and assistance at 9:18 AM.

Facility staff failed to promote dignity during diningfor Residents #34 and 37, who required feedingassistance. The residents waited to eat until afterresidents that had no requirements for feedingassistance had been served. The findings werediscussed during an interview with Employee #2 onMay 9,2011 at 10:30 AM.

F 279 483.20(d), 483.20(k)(1) DEVELOPSS=D COMPREHENSIVE CARE PLANS

F 279

A facility must use the results of the assessment todevelop, review and revise the resident'scomprehensive plan of care.

The facility must develop a comprehensive care planfor each resident that includes measurableobjectives and timetables to meet a resident's

FORM CMS-2S67(02-99) Previous Versions Obsolete

• l

Event ID: W1XU11 Facility ID: METHODIST If continuation sheet Page 2 of 9

· t DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES


OMB NO 0938-0391(X2) MULTIPLE CONSTRUCTION

A. BUILDING


STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

METHODIST HOME


B. WING _095038 05/09/2011




(X4) 10PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR I


(X5)COMPLETION

DATE

10PREFIX

TAG


CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

F 279 Continued From page 2medical, nursing, and mental and psychosocialneeds that are identified in the comprehensiveassessment.

F 279! 1. There was no opportunity to correct thedeficient finding identified during thesurvey, as the resident's dental visitoccurred more than 30 days prior. Theresident experienced no negative 5/9/11outcome as a result of this deficientfinding.

2. Orders for residents having toothextractions will be reviewedimmediately upon return to the facilityby the Nursing Supervisor. An interimcare plan will be developed within 24hours to include new orders received.New treatment orders will also continue

! to be added to the Treatment 5/11/11Administration Record (TAR).

3. The nursing policy on resident careplanning will be updated to specificallyinclude development of interim care

I plans for any physician orders receivedstatus post surgical procedures,

I including dental extractions. All RN

iSupervisors, Charge Nurses, and theMDS Coordinator will be in-serviced onthis policy update and on componentsto be included in the interim care plan. 5/11/11

, 4. Policy implementation and compliancewill be monitored through the quarterlyQuality Assurance/QualityImprovement Committee, beginningwith second quarter reports (July,2011 ). Data collection will begin 5/11/115/15/11.

I

The care plan must describe the services that are tobe furnished to attain or maintain the resident'shighest practicable physical, mental, andpsychosocial well-being as required under §483.25;and any services that would otherwise be requiredunder §483.25 but are not provided due to theresident's exercise of rights under §483.1 0, including I

the right to refuse treatment under §483.1 0(b)(4). i


Based on clinical record reviews and staffinterviews for one (1) of 30 sampled residents, it wasdetermined that facility staff failed to develop a careplan with goals and approaches for mouth carestatus post teeth extraction and denture care forResident #47.


The Physician's Orders dated April 7, 2011 directed,Brush denture upper & (and) lower teeth cc (with)Clinpro 1:1 Sodium fluoride anti-cavity toothpaste q I(every) AM (morning) - cavity prevention. i

Resident's husband/will provide toothpaste. Thephysician also directed on April 7, 2011, "Cleandenture daily and use adhesive sparingly."

A review of the clinical record revealed that theaforementioned orders/directives were written after Ia dental consultation on April 7, 2011

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:W1XU11 Facility 10: METHODIST If continuation sheet Page 3 of 9



OMB NO 0938-0391STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(X1) PROVIDERISUPPLIER/CLIAIDENTIFICATION NUMBER


A. BUILDING I(X3) DATE SURVEY

COMPLETED

I095038


METHODIST HOME

B. WING _05/09/2011




(X4) IDPREFIX

TAG



(X5)COMPLETION

DATE

IDPREFIX

TAG



F 279 Continued From page 3during which the resident had six (6) teethextracted.

Review of the care plans on the clinical recordrevealed that the record lacked a care planwith goals and approaches for mouth care statuspost extraction and denture care for the resident.

A face-to-face interview was conducted withEmployee #5 at approximately 12:31 PM on May 9,2011. After reviewing the record/care plans, theemployee acknowledged that the record lacked acare plan with goals and approaches for mouth carestatus post teeth extraction and denture care for theresident. The record was reviewed on May 6,2011.

F 371 483.35(i) FOOD PROCURE,SS=B STORE/PREPARE/SERVE - SANITARY

The facility must -(1) Procure food from sources approved orconsidered satisfactory by Federal, State or localauthorities; and(2) Store, prepare, distribute and serve food undersanitary conditions


Based on an observation that was made during atour of the main kitchen on May 3, 2011 at 3:30 PM,it was determined that the facility staff failed toprepare and serve food under sanitary conditions asevidenced by seven (7) of seven (7) soiled shelves.

F 279

Deficiency States observationMade during tour on May 3, 2011 at 3:30 P.M.Surveyors Did Not begin Annual Survey until3: 12 PM on May 4, 2011

F 371Seven out of seven shelves containing spices wereobserved soiled.

1. Corrective Action for residents affected bydeficient practice:

The spices were removed from the shelves and allshelves were cleaned and sanitized. 5/4/11

2. Methods to identify other residents at risk fordeficient practice:

All other shelves and counters in the department werechecked to ensure there were no further occurrencesfor unsanitary conditions. 5/4111

3. Systemic changes to ensure deficient practices donot occur:

Director will purchase stainless steel racks or a cabinetto store spices in to ensure debris from spices does notsettle on shelves. All Cooks re-trained on daily cleaningassignments. 7/1/11

FORM CMS-2S67(02-99) Previous Versions Obsolete EventlD: W1XU11 If continuation sheet Page 4 of 9Facility ID: METHODIST


,KII\lI t:u: Ub/UOfILUllFORM APPROVED


(X1) PROVIDERISUPPLlERfCLlAIDENTIFICATION NUMBER:


A BUILDING


095038


METHODIST HOME

B WING _05/09/2011




(X4) 10PREFIX

TAG



(XS)COMPLETION

OA.TE

10PREFIX

TAG

PROVIDER'S PLAN OF CORRECTION(EACH CORFF. TIVE ACTION SHOULD BE

CROSS-REFEr ·JCEDTO THE APPROPRIATEDEFICIENCY)

F 371 Continued From page 4 F 371 4. Performance Monitoring to ensure solutions aresustained:

Monthly sanitation audits conducted by managementand to ensure compliance. 6/15/11 I

Ongoing


On May 3, 2011 at 330 PM seven (7) of seven (7)shelves containing spices were observed soiled.

This observation was made in the presence ofEmployees #6 and #7 who acknowledged thesefindings during the tour.

F 372 483.35(i)(3) DISPOSE GARBAGE & REFUSESS=B PROPERLY

The facility must dispose of garbage and refuseproperly.


Based on an observation made during a tour of themain kitchen on May 3, 2011 at 3:30 PM, it wasdetermined that the facility failed to dispose ofgarbage and refuse properly as evidenced by two(2) of two (2) trash receptacles that were observedcontaining garbage.

The findings include

On May 3, 2011 at 3:30 PM, two (2) of two (2) trashreceptacles were observed containing garbage(food waste).

This observation was made in the presence ofEmployee #6 and #7 who acknowledged thesefindings during the tour.

F 428 483.60(c) DRUG REGIMEN REVIEW, REPORTSS=D IRREGULAR, ACT ON

Deficiency States observationMade during tour on May 3, 2011 at 3:30 P.M.Surveyors Did Not begin Annual Survey until3:12 PM on May 4, 2011

2 of 2 trash receptacles were observed containingF 372

garbage (food waste).

1. Corrective Action for residents affected bydeficient practice:

The sandwich wrapped in plastic wrap was removedfrom the trash receptacle in the dish room anddiscarded without the plastic wrap into the garbagedisposal. Bread ends were removed from the trashreceptacle in the kitchen and discarded into the garbagedisposal.

II

5/4/11

2. Methods to identify other residents at risk fordeficient practice:

All other trash receptacles were inspected throughoutthe department to ensure there was no food wasteevident.

5/4/11

3. Systemic changes to ensure deficient practices donot occur:

Provide separate food waste containers at work stationsand have staff discard food waste into the garbagedisposals in the dish room throughout the shift. Ail staffre-trained on proper disposal of food waste,

4. Performance Monitoring to ensure solutions aresustained:

Dietary Management will monitor trash receptaclesdaily.

6/15/11Ongoing

5/4/11Ongoing

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:W1XU11 If continuation sheet Page 5 of 9Facility 10: METHODIST

DEPARTMENT OF HEALTH AND HUMAN SERVICES. I CENTERS FOR MEDICARE & MEDICAID SERVICES




095038


METHODIST HOME


05/09/2011

(X4) 10PREFIX

TAG



(X5)COMPLETION

DATE


A. BUILDING

B. WING _




F 428 Continued From page 5

The drug regimen of each resident must be reviewedat least once a month by a licensed pharmacist.

The pharmacist must report any irregularities to theattending physician, and the director of nursing, andthese reports must be acted upon.


Based on record review and staff interview, it wasdetermined that the physician failed to act upon apharmacy communication associated with aMedication Regimen Review. Resident #51.


A review of the clinical record for Resident #51revealed a communication dated April 5, 2011documented by the consultant pharmacist, entitled.. Note to Attending Physician ...

The note to the physician read as follows: u Thispatient has been receiving the PPI [Proton-PumpInhibitor] Pantoprazole, for an extended period. Dueto the associated risks of long term therapy of PPI ' s(i.e. hypomagnesia, fractures, pneumonia, c-diffetc.), recommend re-evaluate continued use at thistime. Recommend consider a taper and/or ranitidineor prn antacids, if clinically appropriate .:'

A review of the most current physician's orders

10PREFIX

TAG



5/9/11

5/11/11

5/20/11

5/20/11

FORM CMS-2S67(02-99) Previous Versions Obsolete Event 10: W1 XU11

F 428 1. There was no opportunity to correct thedeficient finding identified during thesurvey, as the Pharmacy reviewoccurred more than 30 days prior. Theresident experienced no negativeoutcome as a result of this deficientfinding.Monthly chart audits will be expandedto include determination of physiciansignatures on each MedicationRegimen Review submitted by theConsultant Pharmacist. If not signed,the chart will be flagged for thephysician's review during the nextweek's visit.Medical Staff policies will be updated toinclude the physician's responsibilitiesto review and sign monthly MedicationRegimen reports. Physicians will benotified in writing of this policy updateas well as receive copies of the policy.Policy implementation and compliancewill be monitored through the quarterlyQuality Assurance/QualityImprovement Committee, beginningwith second quarter reports (July,2011). Data collection will begin5/20/11.

2.

3.

4.

Facility 10: METHODIST If continuation sheet Page 6 of 9

,DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 06/09/2011FORMAPPROVED




095038 05/09/2011NAME OF PROVIDER OR SUPPLIER

METHODIST HOME


A. BUILDING

B. WING _




(X4) IDPREFIX

TAG


LSC IDENTIFYING INFORMATION) I

(X5)COMPLETION

DATE

F 428 Continued From page 6signed March 10, 2011, directed the administrationof Pantoprazole sodium 40mg by mouth daily forgastro-esophageal reflux [Gerd]. A review of theMedication Administration Records [MARs] for Apriland May 2011 revealed Pantoprazole wasadministered in accordance with the physician'sorders.

A concurrent review of the medical record lackedevidence that the physician acted on the pharmacy ,communication. There was no evidence that he/shewas aware of the communication or that he/shedisagreed with the recommendations. The findingswere reviewed and acknowledged during aface-to-face interview with Employee #2 on May 9,2011 at 11:00 AM.

F 514 483.75(1)(1) RESSS=B RECORDS-COMPLETE/ACCURATE/ACCESSISLE

The facility must maintain clinical records on eachresident in accordance with accepted professionalstandards and practices that are complete;accurately documented; readily accessible; andsystematically organized.

The clinical record must contain sufficient information, to identify the resident; a record of the resident's !

assessments; the plan of care and services provided;the results of any preadmission screening conductedby the State; and progress notes.


Based on record review and staff interview for

IDPREFIX

TAG

PROVIDER'S PLAN OF CORRECTION

I

(EACH CORRECTIVE ACTION SHOULD BEI CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

F 428'

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W1XU11 If continuation sheet Page 7 of 9Facility ID: METHODIST

DEPARTMENT OF HEALTH AND HUMAN SERVICES, ' CENTERS FOR MEDICARE & MEDICAID SERVICES



(X1) PROVIDERlSUPPLIERlCLIAIDENTIFICATION NUMBER:

095038


METHODIST HOME


A. BUILDING


B. WING _05/0912011




(X4) IDPREFIX

TAG

(X5)COMPLETION

DATE



IDPREFIX

TAG



F 514 Continued From page 7one (1) of 22 sampled residents it was determinedthat facility staff failed to provide accuratedocumentation of the resident's physical therapyexercises in the resident's clinical record. Resident#14.

A review of the nurses' notes in the resident'sclinical record revealed the following documentationdated April 21, 2011 at 10:00PM; "Late entry forApril 20, 2011, ... resident fell during PM care,CNA [Certified Nursing Assistant) was puttinghim/her to bed, resident c/o [complained of) his/her® leg was giving away. CNA unable to supporthis/her weight, eased him/her to the floor. "

A review of prior documentation dated January 7,2011 at 2:00PM revealed the followingdocumentation, "Staff reported to writer at 7:25AM[that) while transferring resident from bed with two[2) staff assist with standing lift ... staff loweredresident to the floor. "

The Fall Care Plan of April 21, 2011, revealed thatthe resident was referred to the Rehabilitation(Rehab) Department for screening for transfer withstanding lift. The last documentation on the careplan regarding the evaluation was dated April 25,2011. Review of the resident's clinical recordfailed to reveal any evidence of the resident'sevaluation by the Rehab Department.

A face-to-face interview was conducted withEmployee #5 at approximately 3:45PM on May 9,2011. The employee was queried regarding theresults of the Rehab evaluation. He/sheresponded, 'We cannot find the notes for April

I. T here was no opportunity to correct the deficientfiuding identified during the survey. The screen wascompleted but yet to be filed. Since the director ofrehab was away on vacation, other staff could notfind it. The screen was completed on 4122/11 after'communication from the nurse. The status thenwas awaiting family's consent to begin therapy,The resident experienced no negative ontcome asa result of the deficient finding. 4/22/11

2. Screens post fall will be completed within 48 hoursof notification to therapy staff. A copy of screen trackinglog will be placed on each floor nursing station. Thescreens shall be filed within 48 hours. Regional managerldesignee will carry ont the functions in the absence of thedirector of rehab. Original log is placed in the gymand as a measure to have effective communication;copy of the log will now be placed on each floor alongwith the documentation. IDT communication regardingthe follow up on falls will be carried out every Wednesdayduring stand up meeting. 6/1/11

Monthly audit will be performed by director- of rehablooking for appropriate and timely filing of all documentsand followed up by quarterly audits by the corpor-ate offla;;ship rehab. 6/1/11

Policy implementation and compliance will be monitoredthrough the quarterly Quality assurance/qualityimprovement, beginning with second quarter" reports(July 2011). Data collection from June I" 2011 onwards. 7/21/11

FORM CMS-2S67(02-99) Previous Versions Obsolete Event ID:W1XU11 Facility ID: METHODIST If continuation sheet Page 8 of 9


OMS NO 0938-0391DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES


STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION



A. BUILDING

B. WING _095038 05/09/2011NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


WASHINGTON, DC 20008METHODIST HOME





IDPREFIX

TAG

(X5)COMPLETION

DATE

(X4) IDPREFIX

TAG

F 514 Continued From page 82011. I called the therapist and he/she is checkingfor the notes in the department. "

F 514

A face-to-face interview was also held withEmployee #8 at approximately 4:00PM on May 9,2011. He/she stated, "The manager is away and Iam filling in. I will check the information that he/sheleft me and I will call him/her to get the information ifI cannot find it in the department." Employee #8later stated," I spoke to the manager and I looked atan e-mail from him/her. The resident was seen afew times. Initially, he/she refused to be screened.He/she has now agreed but we are awaitingpermission from his/her son/daughter. Theson/daughter has been called and a message wasleft but he/she has not responded." Theemployee acknowledged that the informationregarding the attempts to screen the resident andthe resident's refusal to be screened should havebeen documented in the resident's record." Therecord was reviewed on April 6, 2011.

If continuation sheet Page 9 of 9FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:W1XU11 Facility 10 METHODIST

Federal Health Survey - Washington, D.C.

Documents