oversight

Nursing Homes: Proposal To Enhance Oversight of Poorly Performing Homes Has Merit

Published by the Government Accountability Office on 1999-06-30.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                  United States General Accounting Office

GAO               Report to the Special Committee on
                  Aging, U.S. Senate



June 1999
                  NURSING HOMES
                  Proposal to Enhance
                  Oversight of Poorly
                  Performing Homes Has
                  Merit




GAO/HEHS-99-157
      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      Health, Education, and
      Human Services Division

      B-283084

      June 30, 1999

      The Honorable Charles E. Grassley
      Chairman
      The Honorable John B. Breaux
      Ranking Minority Member
      Special Committee on Aging
      United States Senate

      A persistent concern about the quality of care in our nation’s nursing
      homes is the number of homes that are cited for serious and repeat
      deficiencies. The federal government, in partnership with states, is
      responsible for ensuring that the 1.6 million elderly and disabled
      Americans in nursing homes receive adequate quality of care. However, as
      we previously reported, 1 in 4 of the nation’s nursing homes have serious
      deficiencies that harm residents or place them at risk of death or serious
      injury. Although most homes correct these deficiencies, 40 percent of
      these homes with serious deficiencies were cited for repeat deficiencies.1

      The Health Care Financing Administration (HCFA), the primary federal
      entity responsible for overseeing the quality of nursing home care, has
      announced initiatives intended to strengthen enforcement for homes that
      are found to have repeatedly harmed residents. This includes an initiative
      to expand the definition of homes classified as “poor performers.” In
      response, nursing homes raised concerns that some deficiencies that were
      cited as involving harm to residents were actually trivial in nature—the
      result of “overzealous” surveyors—and that HCFA’s initiative would result
      in an increased and unwarranted regulatory burden. You asked that we
      examine whether deficiencies reporting actual harm to residents represent
      serious problems and the implications of HCFA’s proposed action.

      To assess the seriousness of deficiencies that state surveyors cited as
      actual harm, we reviewed a random sample of 107 homes’ annual and
      complaint surveys that included deficiencies of actual harm to one or
      more residents—classified in HCFA’s regulatory framework as “G-level”
      deficiencies. These 107 surveys, selected from 10 large states based on
      data from fiscal year 1998, contained a total of 201 isolated actual harm
      deficiencies.2 Our information about the potential impact of HCFA’s

      1
       Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards
      (GAO/HEHS-99-46, Mar. 18, 1999).
      2
       These states represented the state within each of HCFA’s 10 regions with the most certified nursing
      home beds: California, Colorado, Florida, Illinois, Massachusetts, Missouri, New York, Pennsylvania,
      Texas, and Washington. These states represent 46 percent of all nursing home beds nationwide.



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                   B-283084




                   proposed action comes from an analysis of HCFA’s nationwide database of
                   survey results, the On-Line Survey, Certification, and Reporting (OSCAR)
                   system as of April 1999. We conducted our work between March and
                   June 1999 in accordance with generally accepted government auditing
                   standards. Appendix I contains a more detailed explanation of our scope
                   and methodology.


                   HCFA’s proposed expansion of the poor-performer criteria to include
Results in Brief   homes with repeated isolated actual harm deficiencies would substantially
                   increase the number of homes that would be subject to immediate
                   sanctions without a grace period to correct deficiencies. If this revised
                   definition had been in effect for the most recent 15-month period ending
                   April 1999, we estimate that the number of homes meeting HCFA’s
                   poor-performer criteria for imposing immediate sanctions would have
                   increased from about 1 percent to nearly 15 percent of homes nationwide.3


                   Nearly all of the deficiencies we examined represented serious care issues
                   resulting in harm to residents. Of the 107 surveys with G-level deficiencies
                   in our sample, 98 percent (all but 2) documented that actual harm had
                   occurred to one or more residents. Survey reports depict recurring
                   examples of actual harm such as pressure sores, broken bones, severe
                   weight loss, burns, and death. Another 8 of the 107 surveys with G-level
                   deficiencies had a deficiency that did not clearly document harm, but
                   other G- or higher-level deficiencies on the same survey resulted in harm
                   to residents.

                   Two-thirds of these 107 nursing homes had repeated violations—OSCAR
                   data showed they were also cited for isolated actual harm (G-level) or
                   higher deficiencies in a prior or subsequent survey. Therefore, they would
                   be subject to immediate sanction if HCFA’s revised poor performer
                   definition had been adopted, whereas the current definition allows an
                   opportunity to correct deficiencies without sanctions. Most of the repeat
                   violators (56 percent) were cited for the same deficiency, and 34 percent
                   were cited for closely related deficiencies. These findings suggest that
                   HCFA’s enhanced enforcement of homes found to repeat these serious care
                   problems has merit.




                   3
                    Our analysis is based on the number of homes meeting HCFA’s minimum federal criteria. States have
                   the option to establish criteria that are more stringent than the federal criteria.



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             Over the past year, joint efforts by the administration and Congress have
Background   resulted in a series of initiatives intended to improve the quality of care in
             our nation’s nursing homes. Since July 1998, the President and HCFA, which
             administers Medicare and Medicaid, have announced major changes in
             nursing home oversight and enforcement.4 One of the most controversial
             proposed changes relates to the revised definition of homes that would be
             categorized as “poorly performing” and subject to immediate sanctions
             without a grace period to take corrective action.

             States determine whether to refer a nursing home to HCFA for possible
             sanction on the basis of HCFA’s scope and severity grid, which classifies
             nursing home deficiencies by their scope—the number of residents
             potentially or actually affected—and severity—the potential for more than
             minimal harm, actual harm, or actual or potential for death or serious
             injury (“immediate jeopardy”). This grid places the deficiency in one of
             12 categories, labeled “A” through “L.” The most serious category (L) is
             for a widespread deficiency that causes actual or potential for death or
             serious injury to residents; the least serious category (A) is for an isolated
             deficiency that resulted in no actual harm and has potential only for
             minimal harm. (See table 1.) Homes with deficiencies that do not exceed
             the C level are considered in “substantial compliance” and, as such, to be
             providing an acceptable level of care.




             4
             See Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but Will Require Continued
             Commitment (GAO/T-HEHS-99-155, June 30, 1999).



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                                         B-283084




Table 1: HCFA’s Scope and Severity Grid for Medicare and Medicaid Compliance Deficiencies
                                                      Scope                                                         Sanctiona
Severity category            Isolated               Pattern                 Widespread              Required                Optional
Actual or potential for      J                      K                       L                       Group 3                 Group 1 or 2
death/serious injuryb
Other actual harm            G                      H                       I                       Group 2                 Group 1c
Potential for more than      D                      E                       F                       Group 1 for             Group 2 for
minimal harm                                                                                        categories D and        categories D and
                                                                                                    E; group 2 for          E; group 1 for
                                                                                                    category F              category F
Potential for minimal harm   A                      B                       C                       None                    None
(substantial compliance)
                                         a
                                          Group 1 sanctions are directed plan of correction, directed in-service training, and/or state
                                         monitoring. Group 2 sanctions are denial of payment for new admissions or all individuals and/or
                                         civil monetary penalties of $50 to $3,000 per day of noncompliance. Group 3 sanctions are
                                         temporary management, termination, and/or civil monetary penalties of $3,050 to $10,000 per day
                                         of noncompliance.
                                         b
                                             This category is referred to in regulations as “immediate jeopardy.”
                                         c
                                             Sanctions for this category also include the option for a temporary manager.



                                         The federal government has the authority to impose sanctions if homes are
                                         found not to meet these standards, including fines, denying payment for
                                         new or all residents with Medicare or Medicaid, or ultimately terminating
                                         the home from participation in Medicare and Medicaid. The scope and
                                         severity of a deficiency determine the types of applicable enforcement
                                         sanctions, which may be required or optional. Under their shared
                                         responsibility for Medicare-certified nursing homes, state agencies identify
                                         and categorize deficiencies and make referrals for proposed sanctions to
                                         HCFA. Under HCFA’s current policies, most homes are given a grace period,
                                         usually 30 to 60 days, to correct deficiencies. States do not refer homes to
                                         HCFA for sanctions unless the homes fail to correct their deficiencies
                                         within the grace period. Exceptions are provided for homes with
                                         deficiencies at the highest level of severity (J, K, or L) and for homes that
                                         meet HCFA’s definition of a “poorly performing facility”—a special
                                         category of homes with repeated serious deficiencies. HCFA policies call for
                                         states to refer these homes immediately for sanction. HCFA does provide a
                                         15-day notice period before the sanction takes effect. If a home comes into
                                         compliance within that time, the sanction is waived.5


                                         5
                                          Only civil monetary penalties can be assessed retroactively even if a home corrects the problem. For
                                         homes found to have a deficiency at the highest severity level (J, K, or L), HCFA may put a sanction
                                         into effect after a 2-day notice period.



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                             In July 1998, we recommended that HCFA eliminate the grace period for
                             homes cited for repeated serious violations and impose sanctions
                             promptly. HCFA modified its policy accordingly by altering its definition of
                             a poorly performing facility to include homes with repeated actual harm
                             (levels G, H, or I) or worse deficiencies. It initially included only homes
                             with repeated actual harm deficiencies that were a pattern or widespread
                             in scope (levels H or I) or worse. HCFA postponed until later in 1999
                             including homes with consecutive G- or higher-level deficiencies because
                             it recognized the significant increase in the number of homes that would
                             be affected and the associated additional costs it would have entailed.
                             Thus, HCFA’s current practice is that any home that had been cited with a
                             deficiency for pattern of actual harm to several residents (H-level) or
                             worse in two consecutive annual surveys or any intervening revisit or
                             complaint investigation would be considered a poorly performing facility
                             and referred immediately for sanction. Nursing homes given this
                             designation are automatically denied an opportunity to correct
                             deficiencies before sanctions are applied. Some homes, however, claim
                             that such deficiencies are not of sufficient magnitude to warrant
                             immediate sanction and increased scrutiny.


                             HCFA’s proposed expansion of the definition of a poorly performing facility
Including Homes With         would greatly increase the number of homes that are immediately referred
Repeated G-Level             to HCFA for sanction without a grace period to correct deficiencies.
Deficiencies Would           Expansion of the federal criteria to include G-level deficiencies could
                             create a significant increase in the number of homes denied a grace period
Significantly Increase       to correct deficiencies before sanctions are imposed. Applying the various
the Number Classified        criteria to recent OSCAR data,
as Poor Performers       •   146 homes (1.0 percent) would have been sanctioned immediately, based
                             on the former poor-performer criteria;
                         •   137 (1.0 percent) would have been sanctioned immediately, based on the
                             current revised criteria (H-level or higher); and
                         •   2,275 (15.2 percent) would have been sanctioned immediately, based on
                             the proposed expanded criteria (G-level or higher).6

                             Some states are concerned that this sharp increase in the number of
                             homes facing immediate sanction will also increase the number of
                             deficiencies that nursing homes contest through the informal dispute
                             resolution process between states and nursing homes. States have several

                             6
                              Over 600 homes had a combination of a G-level and an H-level or higher deficiency in their current,
                             prior, or intervening surveys.



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                                             B-283084




                                             mechanisms available to them, including supervisory review of a
                                             surveyor’s deficiency citations and the informal dispute resolution
                                             process, that they believe result in few if any unsupported actual harm
                                             deficiencies. Furthermore, nursing homes can formally appeal sanctions
                                             resulting from deficiency citations to the Department of Health and
                                             Human Services’ (HHS) Departmental Appeals Board.


                                             Nearly all of the 107 surveys of nursing homes with G-level deficiencies we
Nearly All Surveys                           reviewed— 98 percent (all but 2 surveys)—documented actual harm that
Documented Actual                            had occurred to one or more residents. Survey reports depicted repeated
Harm to Residents                            examples of actual harm, including pressure sores, broken bones, severe
                                             weight loss, burns, and death. The five most commonly cited deficiencies
                                             involved

                                         •   failure to prevent or treat pressure sores (23 percent);
                                         •   failure to prevent accidents (14 percent);
                                         •   failure to ensure adequate nutrition (8 percent);
                                         •   failure to provide acceptable quality of care (6 percent); and
                                         •   failure to prevent mistreatment, neglect, or abuse (4 percent).

                                             Quality-of-life deficiencies, such as preserving residents’ dignity and
                                             self-determination, accommodating residents’ needs, or providing needed
                                             social services, were cited in only 9 cases (4 percent). Another 8 of the 107
                                             surveys contained a G-level deficiency for which we did not find adequate
                                             documentation to show that a resident had been harmed. However, in
                                             each of these eight surveys, the home also had another G- or higher-level
                                             deficiency that documented harm to the resident.

                                             In many instances, “isolated” deficiencies actually affected multiple
                                             residents. HCFA defines isolated deficiencies as affecting a single or a few
                                             residents. While most deficiencies affected only 1 or 2 residents, our
                                             sample also included several deficiencies that harmed as many as 10 to 16
                                             residents (see table 2).

Table 2: Residents Affected by G-Level
Deficiencies
                                             Number of
                                             residents affected   1    2    3     4     5    6     7    8    10   13    14   16
                                             Number of
                                             deficiencies we
                                             reviewed             91   50   31   11     5    3     3    2     2    1     1    1




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                            B-283084




                            Appendix II provides summary statistics on the 201 deficiencies we
                            reviewed, and appendix III contains a brief abstract of each deficiency.


                            Additional OSCAR data revealed that about two-thirds of our sampled
Most Sampled Homes          homes (71 of 107) had another G-level or higher deficiency in either a prior
Have Serious and            or subsequent survey—often the same, or closely related, deficiency.
Repeated Deficiencies       Specifically, of the 71 repeat violators,

                        •   40 homes (56 percent) were cited for the same deficiency (the same
                            federal deficiency code, known as an “F-tag”),
                        •   24 (34 percent) were in the same category of deficiencies (such as quality
                            of care or dietary services), and
                        •   7 (10 percent) were cited in different categories.

                            These results are consistent with our March 1999 report that found that
                            each year more than 25 percent of the nation’s nursing homes had
                            deficiencies that caused actual harm to residents or put them at risk of
                            death or serious injury. Although most homes eventually returned to
                            compliance, many did not maintain this status. About 40 percent were
                            cited for deficiencies at the same or higher level of severity in subsequent
                            surveys. We found that HCFA’s enforcement mechanisms did not deter such
                            “yo-yo” patterns of compliance. HCFA’s proposal to enhance enforcement
                            of homes with repeated serious deficiencies that resulted in harm to one
                            or more residents is intended to better deter this pattern of repeated
                            noncompliance.


                            Despite state and federal efforts to improve the quality of care in the
Concluding                  nation’s nursing homes, many homes continue to be cited for deficiencies
Observations                that cause significant harm to residents. In the 107 surveys we reviewed,
                            nearly all deficiencies documented serious harm to one or more residents,
                            including pressure sores, broken bones, severe weight loss, and burns.
                            Survey data show that these are not isolated incidents—two-thirds of these
                            homes were cited for deficiencies at the same or a higher level of severity
                            in prior or subsequent surveys. The controversy with HCFA’s proposal to
                            expand the criteria for defining poor performers and impose sanctions on
                            homes with serious and repeat violations centers on the industry’s
                            contention that state surveyors are at times overzealous in their findings.
                            Some states are also concerned that this initiative could result in more
                            actual harm deficiencies being contested through the informal dispute
                            resolution process and subsequent sanctions being appealed to the HHS



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                  Departmental Appeals Board, and that the proposal would also result in
                  increased enforcement activity for the states and HCFA. However, our
                  analysis indicates that increased scrutiny of homes with repeated serious
                  deficiencies has merit. And for those few cases in which harm to a resident
                  is uncertain, mechanisms are in place for homes to request
                  reconsideration of the initial surveyor’s deficiency citations.


                  We provided a draft of this report to HCFA officials for comment. The
Agency Comments   Deputy Director for the Center for Medicaid and State Operations
                  generally concurred with our findings.


                  We will send copies of this report to the Honorable Nancy-Ann Min
                  DeParle, Administrator of HCFA, and to others who request them.

                  If we can be of further assistance or if you have any questions, please call
                  me at (202) 512-7118 or John Dicken, Assistant Director, at (202) 512-7043.
                  Gloria Eldridge, Terry Saiki, and Peter Schmidt prepared this report; Mary
                  Ann Curran and Kathleen Kendrick provided additional clinical review of
                  the documented deficiencies; and Evan Stoll conducted the analysis of the
                  OSCAR data.




                  William J. Scanlon
                  Director, Health Financing and
                    Public Health Issues




                  Page 8                           GAO/HEHS-99-157 Poorly Performing Nursing Homes
Page 9   GAO/HEHS-99-157 Poorly Performing Nursing Homes
Contents



Letter                                                                                             1


Appendix I                                                                                        12

Scope and
Methodology
Appendix II                                                                                       14

Federal Standards
Cited in Analysis of
Isolated Actual Harm
Deficiencies
Appendix III                                                                                      18

Abstracts of 201
Sampled G-Level
Deficiencies
Tables                 Table 1: HCFA’s Scope and Severity Grid for Medicare and                    4
                         Medicaid Compliance Deficiencies
                       Table 2: Residents Affected by G-Level Deficiencies                         6
                       Table I.1: Number of G-Level Deficiencies per Survey                       12
                       Table II.1: Description and Frequency of Federal Standards Cited           14
                         in GAO Sample of Isolated Actual Harm, G-Level, Deficiencies




                       Abbreviations

                       HCFA       Health Care Financing Administration
                       HHS        Department of Health and Human Services
                       OSCAR      On-Line Survey, Certification, and Reporting


                       Page 10                        GAO/HEHS-99-157 Poorly Performing Nursing Homes
Page 11   GAO/HEHS-99-157 Poorly Performing Nursing Homes
Appendix I

Scope and Methodology


                                   To determine the extent to which isolated actual harm deficiencies clearly
                                   documented actual harm to residents, we analyzed a random sample of
                                   survey reports from 10 states. First, we identified the state in each of
                                   HCFA’s 10 regions with the most certified nursing home beds—California,
                                   Colorado, Florida, Illinois, Massachusetts, Missouri, New York,
                                   Pennsylvania, Texas, and Washington. Next, we obtained and extracted all
                                   surveys (standard and complaint) from these 10 states that included at
                                   least one G-level deficiency from HCFA’s On-Line Survey, Certification, and
                                   Reporting (OSCAR) system. We selected 110 surveys from this group for our
                                   analysis. The sample was not drawn to be representative for each state but
                                   rather for the 10 states as a whole.

                                   After preliminary review, we excluded 3 of the 110 surveys because G-level
                                   deficiencies had been reduced to lower-level deficiencies by supervisory
                                   review or informal dispute resolution, although these changes were not
                                   reflected in HCFA’s data system. None of the three had higher-level
                                   deficiencies; thus, they contained no documented actual harm or
                                   immediate jeopardy.

                                   We reviewed the remaining 107 survey reports to determine

                               •   the number of G-level deficiencies,
                               •   the highest-level deficiency cited in each survey,
                               •   the specific deficiency code cited,
                               •   the number of residents affected, and
                               •   whether the narrative clearly documented actual harm to one or more
                                   residents.

                                   The 107 surveys contained a total of 201 G-level deficiencies. Surveys
                                   averaged almost two G-level deficiencies per survey, but some ranged as
                                   high as 7 or 10 such deficiencies per survey (see table I.1 for the
                                   distribution).

Table I.1: Number of G-Level
Deficiencies per Survey                                                                                        Total
                                   Number of G-level deficiencies     1     2    3     4    5     6    7    10 201
                                   Number of surveys in our sample   61    24   10     7    1     2    1     1 107

                                   Where survey reports did not clearly document actual harm to one or
                                   more residents, we had registered nurses from our team conduct a
                                   secondary review. We determined actual harm was documented in all but
                                   10 cases. For 8 of these 10, there were other G-level or higher deficiencies



                                   Page 12                           GAO/HEHS-99-157 Poorly Performing Nursing Homes
Appendix I
Scope and Methodology




in the survey that documented actual harm to one or more residents. In
only two instances did we find isolated examples of G-level deficiencies
that did not clearly document actual harm to residents.

To determine the extent to which our sampled homes had prior or
subsequent surveys with G-level or higher deficiencies, we extracted all
standard and complaint survey results for these homes from OSCAR. We
then compared the sampled survey with deficiencies cited in prior surveys
(limited to the previous standard survey, or about 1 year earlier) and
subsequent surveys.

To determine the impact of HCFA’s proposed expansion of the poorly
performing facility criteria, we extracted all standard and complaint
surveys using April 1999 OSCAR data. Next, we created a data set of current
(later than October 1997), prior, and complaint surveys. We then applied
the former criteria, current criteria, and proposed criteria for poorly
performing facilities to the data set we constructed.

We conducted our work between March and June 1999 in accordance with
generally accepted government auditing standards.




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Appendix II

Federal Standards Cited in Analysis of
Isolated Actual Harm Deficiencies

                                        The following table provides the federal standards, known as “F-tags,”
                                        that were used by HCFA and the states to document federal deficiencies for
                                        the surveys we sampled. These standards are arrayed within broader
                                        categories, such as resident rights, quality of care, and quality of life. The
                                        table includes a brief description of each standard as well as how
                                        frequently the standard was cited in our random sample of 201 G-level
                                        deficiencies in 107 nursing homes.

                                        The most frequently cited category was quality of care, which represented
                                        three-fourths of all documented G-level deficiencies in our sample. The
                                        three most frequently cited standards, relating to failure to prevent
                                        pressure sores, failure to prevent accidents, and inadequate nutrition,
                                        were quality-of-care deficiencies.

Table II.1: Description and Frequency
of Federal Standards Cited in GAO       Federal standard                                                               Frequency of
Sample of Isolated Actual Harm,         (F-tag) cited as a                                                        G-level deficiency
G-Level, Deficiencies                   deficiencya             Description                                          in GAO sample
                                        Resident rights (3.0 percent)
                                        157                     Facility must promptly notify resident’s family
                                                                and physician of any accidents or significant
                                                                change in status.                                                 5
                                        164                     Residents have the right to personal privacy
                                                                and confidentiality.                                              5
                                        Resident behavior and facility practices (11.0 percent)
                                        221                     Residents have the right to be free from
                                                                unnecessary chemical or physical restraints.                      2
                                        223                     Residents have the right to be free from
                                                                verbal, sexual, physical, and mental abuse,
                                                                corporal punishment, and involuntary
                                                                seclusion.                                                        4
                                        224                     Facility must develop and implement written
                                                                policies and procedures that prohibit the
                                                                mistreatment, neglect, and abuse of residents.                    9
                                        225                     Facility must not employ individuals found
                                                                guilty of mistreatment, abuse, or neglect;
                                                                must investigate all allegations of
                                                                mistreatment, neglect, or abuse; and must
                                                                report results of all investigations to proper
                                                                authorities.                                                      7
                                        Quality of life (4.5 percent)
                                        241                     Facility must provide care in a manner that
                                                                maintains or enhances each resident’s dignity.                    1
                                        242                     Residents have the right to self-determination
                                                                and participation.                                                3
                                                                                                                         (continued)




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Appendix II
Federal Standards Cited in Analysis of
Isolated Actual Harm Deficiencies




Federal standard                                                               Frequency of
(F-tag) cited as a                                                        G-level deficiency
deficiencya           Description                                            in GAO sample
246                   Facility must provide reasonable
                      accommodation of individual needs and
                      preferences.                                                        1
250                   Facility must provide medically related social
                      services to attain or maintain the highest
                      practicable well-being of each resident.                            4
Resident assessment (3.0 percent)
272                   Facility must make a comprehensive
                      assessment of each resident’s needs.                                1
276                   Facility must examine each resident and
                      review resident assessments no less than
                      every 3 months.                                                     1
279                   Facility must develop a comprehensive care
                      plan for each resident.                                             1
281                   Facility must provide services that meet
                      professional standards of quality.                                  3
Quality of care (75.1 percent)
309                   Facility must provide the necessary care and
                      services for each resident to attain or maintain
                      the highest practicable well-being.                                12
310                   A resident’s abilities in the activities of daily
                      living must not diminish unless clinical
                      conditions make it unavoidable.                                     5
311                   Facility must provide appropriate treatment
                      and services to maintain or improve residents’
                      abilities in the activities of daily living.                        2
312                   Residents who are unable to perform
                      activities of daily living must receive
                      necessary services to maintain good nutrition,
                      grooming, and hygiene.                                              7
314                   Facility must ensure residents entering facility
                      without pressure sores do not develop sores
                      and that residents with sores receive
                      necessary treatment to promote healing,
                      prevent infection, and prevent new sores.                          47
316                   Incontinent residents must receive treatment
                      and services to prevent urinary tract
                      infections and restore as much normal
                      function as possible.                                               5
317                   Residents who enter the facility without a
                      limited range of motion must not experience a
                      decline, unless clinical conditions make it
                      unavoidable.                                                        2
318                   Residents with a limited range of motion must
                      receive appropriate treatment to increase
                      range of motion or prevent further decline.                         5
                                                                                 (continued)


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Appendix II
Federal Standards Cited in Analysis of
Isolated Actual Harm Deficiencies




Federal standard                                                             Frequency of
(F-tag) cited as a                                                      G-level deficiency
deficiencya           Description                                          in GAO sample
319                   Residents who display mental or
                      psychosocial problems must receive
                      appropriate treatment and services to correct
                      assessed problems.                                                4
321                   Residents who have been able to eat alone or
                      with assistance must not be fed by
                      nasogastric tubes, unless clinical conditions
                      make it unavoidable.                                              1
322                   Residents who are tube fed must receive
                      appropriate treatment to prevent aspiration,
                      vomiting, and other complications; if possible,
                      restore normal eating skills.                                     1
323                   Facility must ensure resident environment is
                      as free of accident hazards as is possible.                       3
324                   Facility must ensure each resident receives
                      adequate supervision and assistance devices
                      to prevent accidents.                                            29
325                   Facility must ensure each resident maintains
                      acceptable parameters of nutritional status,
                      such as body weight.                                             17
328                   Facility must ensure residents receive
                      necessary treatment and specialized services.                     1
329                   Residents have the right to be free from
                      unnecessary drugs.                                                4
330                   Residents must not be given antipsychotic
                      drugs unless needed to treat a specific
                      condition diagnosed and documented in the
                      clinical record.                                                  1
333                   Facility must ensure residents are free of any
                      significant medication errors.                                    2
353                   Facility must have sufficient nursing staff to
                      provide services to attain or maintain the
                      highest practicable well-being for each
                      resident.                                                         3
Dietary services (0.5 percent)
365                   Facility must ensure residents receive food
                      prepared in a form that meets each resident’s
                      individual needs.                                                 1
Physician services (0.5 percent)
389                   Facility must provide or arrange for the
                      provision of physician services 24 hours a
                      day.                                                              1
                                                                               (continued)




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Appendix II
Federal Standards Cited in Analysis of
Isolated Actual Harm Deficiencies




Federal standard                                                              Frequency of
(F-tag) cited as a                                                       G-level deficiency
deficiencya              Description                                        in GAO sample
Dental services (0.5 percent)
411                      Facility must provide or obtain from outside
                         sources, routine and emergency dental
                         services to meet the needs of each resident.                    1
Pharmacy services (0.5 percent)
429                      Pharmacists must report any irregularities to
                         the attending physician and the director of
                         nursing.                                                        1
Infection control (0.5 percent)
441                      Facility must establish and maintain an
                         infection control program to provide a safe,
                         sanitary, and comfortable environment.                          1
Physicial environment (0.5 percent)
456                      Facility must maintain all essential
                         mechanical, electrical, and patient care
                         equipment in a safe operating condition.                        1
Administration (0.5 percent)
492                      Facility must operate in compliance with
                         federal, state, and local laws, and with
                         accepted professional standards.                                1

a
“F-tag” refers to HCFA’s code for federal deficiency citations.




Page 17                                    GAO/HEHS-99-157 Poorly Performing Nursing Homes
Appendix III

Abstracts of 201 Sampled G-Level
Deficiencies


          Most                No. of                                                                Was
Survey    severe           residents                                                                documented
numbera   rating   F-tag    affected     Deficiency abstract                                        harm done? Category
1         G         314           2      The nursing home did not ensure that residents with        Y           Quality of care
                                         pressure sores were assessed in a timely manner
                                         and received treatment and services to promote
                                         healing. The nursing home failed to identify and
                                         treat a resident’s pressure sore and to provide
                                         planned treatment for a pressure sore for another
                                         resident.
2         G         324           1      The nursing home failed to ensure that devices             Y           Quality of care
                                         designed to prevent accidents were available to
                                         residents and to ensure that residents received
                                         adequate supervision. A resident with a history of
                                         falls was under physician’s orders to have a lap tray
                                         as a restraint when sitting in a chair, unless under
                                         supervision. During one activity, the resident did not
                                         have a lap tray in place, and the supervisor left the
                                         room. The resident slipped out of her chair, twisted
                                         her leg, and fractured her hip.
3         G         328           1      Nursing home staff failed to provide foot care to one      Y           Quality of care
                                         resident, resulting in an undetected and untreated
                                         infected sore on the resident’s right foot.
4a        G         314           3      The nursing home did not intervene to prevent rapid        Y           Quality of care
                                         development of pressure sores in three residents.
                                         One was hospitalized with infected pressure sores.
4b        G         324           1      The nursing home failed to provide adequate                Y           Quality of care
                                         supervision to prevent one resident from falling and
                                         suffering a broken hip. An aide tried to transfer the
                                         resident alone, contrary to the resident’s plan of
                                         care, which called for two people to assist in
                                         transferring the resident.
5         G         314           3      The nursing home did not ensure that three                 Y           Quality of care
                                         residents with pressure sores were assessed in a
                                         timely manner and received treatment and services
                                         to promote healing and prevent the development of
                                         new sores. All three developed pressure sores while
                                         in the home, and the sores worsened. In two cases,
                                         a dietitian did not assess the residents for nutritional
                                         status for at least 1-1/2 years. In one case, a
                                         registered dietitian assessed the resident, but the
                                         dietitian’s recommendations were not acted upon.
6a        G         314           1      The nursing home failed to ensure that residents           Y           Quality of care
                                         admitted without pressure sores did not develop
                                         them. Following a fall, a resident became frightened
                                         of walking and stayed in bed most of the day. Within
                                         a month of the fall, she developed a pressure sore
                                         on her left heel. The home had not ordered a
                                         pressure-reducing mattress or heel protectors to
                                         prevent skin breakdown.
                                                                                                                   (continued)



                                       Page 18                                 GAO/HEHS-99-157 Poorly Performing Nursing Homes
                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                              Was
Survey    severe           residents                                                              documented
numbera   rating   F-tag    affected     Deficiency abstract                                      harm done? Category
6b        G         324           1      The nursing home failed to ensure that a resident        Y           Quality of care
                                         received adequate supervision and assistive
                                         devices to prevent accidents. The resident was
                                         sitting on the edge of her bed while a nurse’s aide
                                         put on her shoes. She suddenly bent over and
                                         struck her nose on the side rail. Her nose was
                                         swollen and bleeding, and X rays showed a
                                         possible fracture of her nasal bone. Although
                                         medical records showed she had a history of
                                         involuntary head motion and lip biting, there was no
                                         system in place to prevent injury when she exhibited
                                         involuntary movements of the head.
7         H         316           4      The nursing home lacked a program to prevent             Y           Quality of care
                                         bladder incontinence and to restore functional
                                         continence. This failure contributed to the decline in
                                         continence of two residents; for two other
                                         incontinent residents there was no evidence of
                                         intervention to restore normal continence. The
                                         director of nursing confirmed that the home did not
                                         have such a program, although 50 residents were
                                         occasionally or frequently incontinent. None of these
                                         50 residents were on an individually written bladder
                                         training program.
8a        G         311           3      The nursing home failed to ensure that three             Y           Quality of care
                                         residents with swallowing difficulties were fed
                                         appropriately according to their plans of care.
                                         Surveyors observed the three residents being fed
                                         inappropriate foods and drinks. In one case, a
                                         resident was fed while in the wrong position. One of
                                         the three residents had previously been hospitalized
                                         twice as a result of choking on a meal.
8b        G         314           7      The nursing home failed to ensure that seven             Y           Quality of care
                                         residents who required considerable assistance in
                                         the activities of daily living received necessary care
                                         to prevent development of pressure sores. The
                                         surveyor observed that the residents had not been
                                         repositioned every 2 hours as required in their plans
                                         of care. In some cases, the documented interval
                                         was as long as 4 hours. In one case, the resident
                                         had a deep, open pressure sore. No actual harm
                                         was documented for the other 6 residents, although
                                         several had a history of pressure sores.
                                                                                                                 (continued)




                                       Page 19                               GAO/HEHS-99-157 Poorly Performing Nursing Homes
                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                                Was
Survey    severe           residents                                                                documented
numbera   rating   F-tag    affected     Deficiency abstract                                        harm done? Category
9         G         324           5      The nursing home failed to provide adequate                Y           Quality of care
                                         supervision to three residents of the Alzheimer’s unit
                                         who were at risk for falls. Each of the three residents
                                         had fallen repeatedly. A fourth resident was
                                         improperly restrained when the one nurse’s aide
                                         assigned to the unit had to leave the resident’s room
                                         in order to provide care to a resident in another
                                         room. A fifth resident, also left unsupervised
                                         because of the staff shortage, physically abused
                                         another resident. Both the nurse’s aide and a family
                                         member stated that there was usually only one
                                         nurse’s aide on this unit during the evening shift,
                                         although the nursing home’s policies call for two to
                                         be present.
10a       G         310           3      Residents who needed physical therapy were not             Y           Quality of care
                                         provided the interventions designed in their care
                                         plans to prevent a decline in walking. One resident,
                                         who had made “significant progress,” was
                                         subsequently discharged from physical therapy to
                                         the restorative nursing program for daily walking.
                                         There was no evidence that this restorative service
                                         was provided, and 2 months later nursing
                                         documentation indicated that the resident was
                                         unable to walk “even with assistance.”
10b       G         324           2      A resident sustained hip fractures, a sprained wrist,      Y           Quality of care
                                         and numerous abrasions from six documented falls
                                         since her admission 4 months earlier. The nursing
                                         home failed to reassess her and implement
                                         preventive measures to ensure her safety. She was
                                         cognitively impaired, and four of her falls were a
                                         result of her attempting to use the toilet herself. In
                                         addition, the surveyor found a resident with brain
                                         damage to have long jagged nails even though an
                                         earlier investigation by the home determined that his
                                         nails were to be kept “clipped.” Five months
                                         earlier, the resident’s long nails caused him to
                                         lacerate his penis, requiring transfer to a hospital for
                                         12 sutures.
11a       I         157           2      The nursing home failed to ensure that the                 Y           Resident rights
                                         physicians of two residents experiencing serious
                                         respiratory difficulties were informed of their
                                         patients’ deteriorating conditions. Both residents
                                         subsequently died.
                                                                                                                   (continued)




                                       Page 20                                 GAO/HEHS-99-157 Poorly Performing Nursing Homes
                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                               Was
Survey    severe           residents                                                               documented
numbera   rating   F-tag    affected     Deficiency abstract                                       harm done? Category
11b       I         250           2      The nursing home failed to provide appropriate            Y           Quality of life
                                         interventions to two verbally and physically abusive
                                         residents to manage their behavioral symptoms, as
                                         specified in their plans of care. This deficiency was
                                         originally cited during an earlier complaint survey.
                                         The nursing home submitted a plan of correction to
                                         the state, indicating that it would reevaluate these
                                         residents and notify their physicians of the
                                         behaviors for further intervention. However, the
                                         home had not implemented the plan at the time of
                                         this survey over 2 months later. Both residents were
                                         abusive to staff. The nursing home’s documentation
                                         noted that the residents’ behaviors had continued
                                         over many months without the home reassessing
                                         the need for different interventions, including
                                         medication.
11c       I         309           1      The nursing home failed to provide appropriate care       Y           Quality of care
                                         to a resident with increasing respiratory distress for
                                         2 days. When the nursing home sent the resident to
                                         a dialysis clinic for scheduled dialysis, the dialysis
                                         facility determined that the resident was too sick to
                                         undergo dialysis and sent the resident to a hospital.
                                         The hospital diagnosed pneumonia, and the
                                         resident subsequently died.
12        G         312           4      Nursing home staff failed to provide prompt               Y           Quality of care
                                         incontinence care to four totally dependent
                                         residents, leaving them in their body wastes for
                                         between 1 and 3 hours. In one case, staff failed to
                                         cleanse a resident even when other care was being
                                         provided.
13        D         N/A         N/A      A state supervisor reduced two isolated actual harm       N/A         N/A
                                         deficiencies to a lower severity level of a pattern for
                                         potential for more than minimal harm. Therefore, this
                                         case was dropped from our sample.
14a       G         224           2      The nursing home failed to ensure that two residents      Y           Resident
                                         were free from verbal abuse. In the first instance, an                behavior and
                                         employee verbally intimidated a resident after                        facility
                                         accusing her of failing to return an inhaler. The                     practices
                                         resident said that she was terrified and complained
                                         to an ombudsman. The resident was still afraid and
                                         uneasy at the time of the survey a few days later. In
                                         the second instance, a resident had been
                                         repeatedly told that he had to wait for incontinence
                                         care despite repeated requests for assistance. The
                                         resident had a moderate pressure sore.
                                                                                                                   (continued)




                                       Page 21                                GAO/HEHS-99-157 Poorly Performing Nursing Homes
                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                                Was
Survey    severe           residents                                                                documented
numbera   rating   F-tag    affected     Deficiency abstract                                        harm done? Category
14b       G         242           3      The nursing home failed to honor personal choices          Y           Quality of life
                                         for three residents. Two residents stated that they
                                         would prefer to get up earlier to do activities, but the
                                         staff was not getting them up when requested. The
                                         surveyor observed one such case. In the third case,
                                         an oxygen-dependent resident with chronic
                                         obstructive pulmonary disease was not permitted to
                                         get his shower at his preferred time, which was just
                                         after he had used his inhaler to reduce shortness of
                                         breath. The one time he had been showered, he
                                         was not showered at his preferred time, and he was
                                         extremely short of breath afterwards. He declined
                                         subsequent offers of showers at his nonpreferred
                                         time and he was told that he could not receive a
                                         shower at another time. Also, the home refused to
                                         permit the resident to bring his wheelchair into the
                                         home, alleging lack of space. Because he was
                                         unable to carry portable oxygen equipment and
                                         unable to walk, he was unable to leave his room.
14c       G         310           3      The nursing home had not provided programs to              Y           Quality of care
                                         enable residents who could walk independently to
                                         do so. As a result, two residents became unable to
                                         walk independently, and a third became able to
                                         walk only 15 feet.
14d       G         324          10      The nursing home failed to ensure that residents           Y           Quality of care
                                         received adequate supervision and assistance to
                                         prevent accidents. One resident in the Alzheimer’s
                                         unit fell 16 times in the 2-month period prior to the
                                         survey, sustaining numerous injuries that included a
                                         broken wrist. Except for one intervention during the
                                         resident’s first month at the home, the resident’s
                                         plan of care was not revised to prevent further falls.
                                         The 10-patient Alzheimer’s unit was understaffed
                                         and therefore could not prevent falls and other
                                         accidents or answer residents’ call lights promptly.
14e       G         325           2      For two residents, the nursing home failed to              Y           Quality of care
                                         provide adequate assistance, appetizing food, and
                                         appropriately timed snacks and supplements to
                                         enable them to maintain nutritional status. As a
                                         result, both residents experienced significant
                                         unplanned weight loss over the months before the
                                         survey.
                                                                                                                    (continued)




                                       Page 22                                 GAO/HEHS-99-157 Poorly Performing Nursing Homes
                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                              Was
Survey    severe           residents                                                              documented
numbera   rating   F-tag    affected     Deficiency abstract                                      harm done? Category
14f       G         329           1      A resident was on a hypnotic medication when             N           Quality of care
                                         readmitted from the hospital. The nursing home
                                         began to decrease this medication and
                                         discontinued it on January 20. The home’s
                                         documentation indicated that the resident began to
                                         be anxious on the day the medication was
                                         discontinued, even to the point of abusing other
                                         residents. On January 22, the home’s staff obtained
                                         a physician’s order for an antianxiety medication for
                                         the resident. The surveyor cited the home for not
                                         documenting that the discontinuation of the
                                         hypnotic medication might have been a reason for
                                         the resident’s behavior. The surveyor also stated
                                         that the home’s documentation did not indicate that
                                         the staff had tried any interventions (other than
                                         medication) to alleviate the resident’s agitation.
                                         Further, the surveyor noted that the home placed
                                         the resident on an antianxiety medication without
                                         showing the need for such medication.
15        G         324          14      The nursing home failed to provide supervision and       Y           Quality of care
                                         assistance to prevent accidents for 14 residents. Six
                                         residents hit other residents, two left the building
                                         without the staff’s knowledge, and eight were found
                                         on the floor of their rooms from falls of unknown
                                         origin. Four residents sustained multiple falls, and
                                         one other resident sustained a broken hip.
16        G         309           1      The nursing home failed to provide a totally             Y           Quality of care
                                         dependent resident with the care and assessment
                                         he needed. He suffered a fracture of his right leg, as
                                         well as other leg injuries, but was not sent to the
                                         hospital for treatment for about 13 hours. The home
                                         failed to follow the care plan or the physician’s
                                         orders and did not perform a full body assessment
                                         when an injury was suspected.
                                                                                                                 (continued)




                                       Page 23                               GAO/HEHS-99-157 Poorly Performing Nursing Homes
                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                             Was
Survey    severe           residents                                                             documented
numbera   rating   F-tag    affected     Deficiency abstract                                     harm done? Category
17a       G         314           2      The nursing home failed to ensure that residents        Y            Quality of care
                                         with pressure sores received appropriate treatment
                                         and services to promote healing and prevent
                                         infection and that new residents without pressure
                                         sores did not develop them. One resident with
                                         multiple pressure sores was not properly monitored
                                         and did not receive treatment in accordance with
                                         physician orders. Although dressings were ordered
                                         for both heels, the surveyor observed that the right
                                         heel did not have a dressing and that the dressing
                                         on the left heel was stuck to the pressure sore.
                                         Another resident was admitted in August 1997
                                         without pressure sores but was identified as being
                                         at high risk for pressure sores. By October, the
                                         resident was noted to have developed a moderate
                                         pressure sore on her sacral area. In mid-November,
                                         the resident was transferred to an acute care
                                         hospital with a high fever and loss of consciousness
                                         resulting from a systemic infection caused by the
                                         infected pressure sore.
17b       G         324           1      The nursing home failed to ensure that a resident       Y            Quality of care
                                         received adequate supervision to prevent
                                         accidents. A resident was diagnosed with a seizure
                                         disorder that placed her at a high risk for falls.
                                         However, the nursing home failed to provide the
                                         supervision she required during toileting as a result
                                         of this risk. In one instance, she had fallen after
                                         being left on the toilet and suffered a laceration on
                                         her right eyebrow. The resident stated that she had
                                         a seizure but that nursing home staff had not
                                         witnessed it.
                                                                                                                 (continued)




                                       Page 24                               GAO/HEHS-99-157 Poorly Performing Nursing Homes
                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                               Was
Survey    severe           residents                                                               documented
numbera   rating   F-tag    affected     Deficiency abstract                                       harm done? Category
17c       G         325           4      The nursing home failed to ensure that residents          Y           Quality of care
                                         were properly nourished (as reflected by
                                         appropriate body weight and protein levels). One
                                         resident experienced a 60-pound weight loss—22
                                         percent of her weight—in a 6-month period. She
                                         was on a 1,500-calorie reduction diet (a very
                                         low-calorie diet). The resident’s laboratory test
                                         indicated that she had a very low protein level as a
                                         result of this diet, which increased the risk of her
                                         developing pressure sores. At the time of the
                                         survey, the resident had a pressure sore. Another
                                         resident with a history of skin breakdown had a
                                         breakdown of the left buttock area at the time of the
                                         survey. This resident’s nutritional notes indicated a
                                         loss of protein due to weight loss and poor oral
                                         intake, which decreased her resistance to infection
                                         and contributed to other complications. A third
                                         resident with kidney failure lost 13.3 pounds in 2
                                         weeks. The home failed to provide a sack lunch or
                                         make other provisions to ensure that the resident
                                         received adequate nutrition while she was away
                                         from the home receiving dialysis for 7 hours three
                                         times each week.
18a       G         314           1      The nursing home failed to provide devices for            Y           Quality of care
                                         pressure relief, consistent and accurate skin
                                         assessment, and treatments as ordered for one
                                         resident. These failures contributed to the resident’s
                                         developing a pressure sore on one heel.
18b       G         324           3      The nursing home failed to ensure that bed rails          Y           Quality of care
                                         were in good operating condition and used safely.
                                         As a result, two residents fell out of bed after having
                                         the bed rail collapse while they were leaning on it.
                                         One sustained injuries requiring emergency room
                                         treatment. In addition, a surveyor observed a
                                         resident smoking unsupervised in the smoking room
                                         with an oxygen bottle on the back of his wheelchair.
                                         The home failed to ensure that smoking residents
                                         were supervised and that combustibles were not
                                         present. These failures created the risk of fire or
                                         explosion.
                                                                                                                  (continued)




                                       Page 25                                GAO/HEHS-99-157 Poorly Performing Nursing Homes
                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                              Was
Survey    severe           residents                                                              documented
numbera   rating   F-tag    affected     Deficiency abstract                                      harm done? Category
19        G         314           2      The nursing home failed to ensure that residents         Y            Quality of care
                                         with pressure sores received appropriate treatment
                                         and services to promote healing and prevent
                                         infection. One resident’s pressure sores
                                         deteriorated to the point that they became infected
                                         with extensive drainage. Although the physician was
                                         aware of these symptoms, additional evaluation or
                                         treatment was not ordered. Interviews with family
                                         and staff indicated that the resident was not turned
                                         in bed on a consistent basis and that the home was
                                         not aggressive in its approach and treatment.
                                         Another resident was found to have similar
                                         problems with pressure sore care.
20a       G         250           2      For two residents, a nursing home failed to follow       Y            Quality of life
                                         the plan of care and provide regular social service
                                         contact. One terminally ill resident would sit in a
                                         wheelchair in a room or lie in bed all day facing the
                                         wall, without facial expression. The plan of care
                                         called for 1 to 12 monthly visits by the home’s social
                                         worker to provide support and monitor this resident,
                                         but no visits were documented. The clinical record
                                         for another resident documented that the resident
                                         had increased restlessness and anxiety exhibited
                                         by 42 episodes of repetitive calling out, anxiety,
                                         agitation, and altercations with other residents in a
                                         3-month period. This resident’s plan of care called
                                         for social service staff to visit twice weekly, but
                                         social service staff said they thought they were to
                                         visit twice monthly. No visits were documented for
                                         more than 1 month.
20b       G         312           1      The nursing home staff did not provide nail care to a    N            Quality of care
                                         resident who was totally dependent on staff for his
                                         care. This resident was observed lying in bed with
                                         long fingernails with dark material underneath them.
                                         Two days later, the resident was observed with
                                         dried brown matter underneath the nails and on the
                                         outside of the nails. Licensed staff said the resident
                                         was very weak due to a terminal diagnosis and was
                                         unable to do his own nail care. (Lacking further
                                         documentation regarding the home’s practices in
                                         performing other personal grooming of this resident,
                                         such as bathing, we could not determine whether
                                         this example constitutes actual harm.)
                                                                                                                   (continued)




                                       Page 26                                GAO/HEHS-99-157 Poorly Performing Nursing Homes
                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                             Was
Survey    severe           residents                                                             documented
numbera   rating   F-tag    affected     Deficiency abstract                                     harm done? Category
20c       G         314           3      A nursing home failed to provide necessary              Y            Quality of care
                                         treatment and services to promote healing, prevent
                                         infection, and prevent new pressure sores from
                                         developing. An initial wound assessment for one
                                         resident revealed two areas of severe pressure
                                         sores. More than 2 days passed, however, before a
                                         medicated ointment was ordered. Two other
                                         residents did not receive pressure-relief devices or
                                         sufficient repositioning to facilitate healing and
                                         prevent worsening of their sores.
20d       G         325           2      The nursing home failed to ensure the proper            Y            Quality of care
                                         nutritional status of two residents. Over a 10-day
                                         period, one resident lost 7 percent of her body
                                         weight, placing her 5 pounds below her minimum
                                         weight goal and 16 pounds below the lowest ideal
                                         body weight. Her medical record contained no
                                         information to explain this weight loss. Although her
                                         care plan called for her to be weighed weekly, there
                                         was no record of her weight during one 2-week
                                         period. Although a second resident lost 5 percent of
                                         his/her weight in one month, the home failed to seek
                                         nutritional intervention.
21a       H         312           3      Three incontinent residents were not given the          Y            Quality of care
                                         services necessary to maintain good personal
                                         hygiene. They were not promptly given incontinence
                                         care after episodes of incontinence and were not
                                         completely cleansed when given care. One resident
                                         was given incontinence briefs that were too small
                                         and developed multiple open areas on the left hip.
21b       H         314           3      The nursing home did not provide three residents        Y            Quality of care
                                         with adequate care to prevent and heal pressure
                                         sores. All three developed pressure sores. Despite
                                         this, the need for pressure-relieving devices was not
                                         addressed in their care plans.
22        G         309           1      A resident was burned by a heating pad left on          Y            Quality of care
                                         his/her back for 9 hours and 15 minutes. A nurse’s
                                         aide had placed the pad on the resident’s back,
                                         even though professional staff was required to do
                                         this. The physician’s order had not specified the
                                         duration of treatment, although instructions for the
                                         heating pad warned that a physician should
                                         prescribe the temperature setting and duration of
                                         the treatment. The staff had not requested
                                         clarification of this order.
                                                                                                                 (continued)




                                       Page 27                               GAO/HEHS-99-157 Poorly Performing Nursing Homes
                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                            Was
Survey    severe           residents                                                            documented
numbera   rating   F-tag    affected     Deficiency abstract                                    harm done? Category
23        H         314           4      The nursing home did not ensure that all residents     Y             Quality of care
                                         with pressure sores were assessed in a timely
                                         manner and received treatment and services to
                                         promote healing and prevent the development of
                                         new sores. Four residents had a total of five
                                         pressure sores, all of which developed while the
                                         residents lived in the home.
24        G         314           2      The nursing home failed to ensure that residents       Y             Quality of care
                                         without pressure sores did not develop them and
                                         that residents with pressure sores received
                                         appropriate treatment and services to promote
                                         healing. Pressure sores developed on residents
                                         because of wet bed linens, failure to assess
                                         residents to prevent skin breakdown, and failure to
                                         provide treatment after there was skin breakdown.
25        G         250           1      A resident demonstrated increasingly abusive           Y             Quality of life
                                         verbal behavior for about 1 month. The nursing
                                         home did not initiate any psychosocial intervention
                                         until after the resident physically abused and hurt
                                         her roommate. The roommate was found with a
                                         swollen right breast and a bruise on her chest and
                                         alleged that the resident had struck her.
26        G         365           2      The nursing home failed to ensure that two residents   Y             Dietary
                                         received special diets as ordered by their physician                 services
                                         because of swallowing problems. One resident
                                         choked on a piece of ham and had to be
                                         hospitalized.
27        G         324           3      The nursing home failed to ensure that three           Y             Quality of care
                                         residents received adequate supervision and
                                         assistive devices to prevent accidents. One man fell
                                         seven times before his situation was reevaluated.
                                         His final fall resulted in 12 sutures.
28a       G         224           1      The nursing home failed to notify a physician of a     Y             Resident
                                         resident’s worsening condition. The resident had a                   behavior and
                                         severe pressure sore with drainage and a strong                      facility
                                         odor as well as yellow, irritated open areas with                    practices
                                         yellow/green drainage on his scrotum and penis. He
                                         was admitted to a hospital.
                                                                                                                  (continued)




                                       Page 28                               GAO/HEHS-99-157 Poorly Performing Nursing Homes
                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                             Was
Survey    severe           residents                                                             documented
numbera   rating   F-tag    affected     Deficiency abstract                                     harm done? Category
28b       G         314           1      The nursing home failed to ensure a resident            Y            Quality of care
                                         received appropriate treatment of his infected
                                         pressure sores. The resident had a severe pressure
                                         sore with tunneling and drainage with a strong odor
                                         as well as yellow, irritated open areas with
                                         yellow/green drainage on his scrotum and penis. He
                                         was admitted to a hospital. Hospital personnel
                                         described him as dry and dehydrated on
                                         admission, with a large wound with odorous
                                         drainage on the left hip, necrosis on the back of his
                                         scrotum, thick purulent drainage from around his
                                         catheter, and feces caked on the soles of his feet.
                                         One hospital staff person described his condition as
                                         a “picture of neglect.”
29        G         314           1      The nursing home failed to ensure that a resident       Y            Quality of care
                                         received appropriate treatment to prevent and heal
                                         a pressure sore. He had a developing pressure sore
                                         on his right heel, which was not treated because
                                         nursing home staff were not aware of it until
                                         informed by the surveyor.
30        E         N/A         N/A      This home was determined to have no isolated            N/A          N/A
                                         actual harm deficiencies (G-level deficiencies) after
                                         it contested the state surveyor’s findings.
31        G         324           1      The nursing home failed to ensure that its residents    Y            Quality of care
                                         received adequate supervision to prevent
                                         accidents. While being turned in bed by a nursing
                                         assistant, a resident sustained a laceration above
                                         the left eye requiring sutures. According to the
                                         resident’s care plan, two people were required to
                                         turn the resident safely.
32        G         323           1      The nursing home failed to maintain an environment      Y            Quality of care
                                         as free from accident hazards as possible by failing
                                         to ensure that heating units in residents’ rooms did
                                         not present a burn risk to residents. One resident
                                         burned his hand. The surveyor found that the
                                         heating units in 59 rooms had hot surfaces that were
                                         a burn hazard. In addition, wheelchairs for five
                                         residents had nonworking brakes.
33        G         324           2      The nursing home failed to provide adequate             Y            Quality of care
                                         supervision to prevent accidents to two residents
                                         who sustained falls. One resident sustained a scalp
                                         injury requiring sutures, and the other fell numerous
                                         times.
                                                                                                                 (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                               Was
Survey    severe           residents                                                               documented
numbera   rating   F-tag    affected     Deficiency abstract                                       harm done? Category
34a       G         314           2      The home failed to monitor a chronic pressure sore,       Y           Quality of care
                                         follow its own procedures on pressure sore care,
                                         document the status of sores, and plan approaches
                                         and intervention for treatment for two residents. For
                                         one resident, the surveyor found that a pressure
                                         sore determined by the home to be healed had
                                         reopened and was not reported; the status of
                                         another resident’s pressure sore was not
                                         documented for a 3-week period, during which time
                                         it grew worse.
34b       G         325           2      The nursing home failed to intervene in a timely          Y           Quality of care
                                         manner to prevent the substantial weight loss of two
                                         residents. Both residents’ weight fell well below their
                                         ideal body weight.
34c       G         411           2      The nursing home failed to obtain needed dental           Y           Dental services
                                         care for two residents. Both residents had bad
                                         teeth, and one had a very painful lower jaw.
35        G         323           1      The nursing home failed to ensure that it was free        Y           Quality of care
                                         from accident hazards by not properly positioning
                                         beds away from electric baseboard heater units,
                                         failing to maintain heater guards in good repair, and
                                         failing to monitor the temperature settings of the
                                         units to prevent excessive heat. As a result, one
                                         resident sustained second degree burns, and other
                                         residents were put at risk of burns.
36        G         225           3      The nursing home failed to investigate and notify         Y           Resident
                                         responsible parties and agencies of sexual assault                    behavior and
                                         on female residents. A male resident was                              facility
                                         responsible for five assaults on three nonconsenting                  practices
                                         residents. The program director was aware of the
                                         first three incidents but did not notify any of the
                                         families, responsible parties, or authorities. The
                                         home failed to follow its own policy on reporting
                                         sexual abuse.
37        G         319           1      The nursing home failed to obtain needed                  Y           Quality of care
                                         psychiatric services for a resident who exhibited
                                         aggressive, violent, and bizarre behavior. The
                                         resident jumped or fell out of a third-floor window
                                         and died from his injuries.
38        G         281           1      A resident with diagnoses including diabetes,             Y           Resident
                                         hypertension, and Alzheimer’s disease complained                      assessment
                                         of not feeling well and had a blood sugar level of
                                         215. (Normal blood sugar ranges from 70 to 110.)
                                         There was no follow-up assessment or
                                         documentation of vital signs being taken until the
                                         resident had declined further. Emergency care was
                                         provided incorrectly by the nurse. The resident was
                                         transferred to a hospital, where he died.
                                                                                                                  (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                               Was
Survey    severe           residents                                                               documented
numbera   rating   F-tag    affected     Deficiency abstract                                       harm done? Category
39a       G         312           2      The nursing home did not provide two residents            Y           Quality of care
                                         who needed oral and personal care with timely
                                         assistance. One resident with a feeding tube did not
                                         receive proper mouth care. As a result, she choked
                                         and gagged on her mouth secretions and had to be
                                         suctioned. The next day she was whimpering and
                                         had rapid shallow respiration and a temperature of
                                         103 degrees. The second resident did not receive
                                         incontinence care for 1-1/2 hours even though she
                                         was calling for help.
39b       G         353          10      The nursing home did not have sufficient staff to         Y           Nursing
                                         provide timely and necessary care and supervision                     services
                                         of residents. Five residents complained that they
                                         had to wait long periods for their call lights to be
                                         answered. When they were answered, the staff
                                         member would come into the room, turn off the call
                                         light, leave, and not return. One resident’s call light
                                         was not answered for nearly 4 hours one night,
                                         resulting in a delay in her receiving needed pain
                                         medication. Also, one resident wandered into rooms
                                         of other residents without staff supervision or notice.
                                         Another resident did not receive antibiotic
                                         medication for an eye infection as ordered.
40        J         225           1      The nursing home administrator was not notified           N           Resident
                                         until the next morning of an unusual and untimely                     behavior and
                                         death of a resident that occurred on Monday,                          facility
                                         February 16, at approximately 7:55 p.m. Interviews                    practices
                                         of administration and staff revealed confusion as to
                                         how this incident occurred. The surveyor noted at
                                         the completion of the survey on Thursday, February
                                         19, that the home also did not notify appropriate
                                         authorities as required. This deficiency relates to
                                         investigating and reporting incidents of potential
                                         abuse or neglect of residents. However, HCFA’s
                                         requirement is that a nursing home has 5 working
                                         days to complete its investigation and to notify the
                                         appropriate authorities. The fifth working day would
                                         have been Monday, February 23.
41        G         224           1      The nursing home failed to implement written              Y           Resident
                                         policies and procedures prohibiting mistreatment,                     behavior and
                                         neglect, and abuse of residents. One resident                         facility
                                         required total assistance in being transferred from                   practices
                                         the bed to the chair. A physical therapist assessed
                                         the resident for transfer assistance and determined
                                         that the resident needed a mechanical lift for all
                                         transfers. When a nurse’s aide attempted to
                                         manually lift the resident, the resident’s leg became
                                         caught between the bed rail and the bed, resulting
                                         in multiple leg fractures.
                                                                                                                  (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                              Was
Survey    severe           residents                                                              documented
numbera   rating   F-tag    affected     Deficiency abstract                                      harm done? Category
42a       H         314           2      The nursing home failed to ensure that residents         Y            Quality of care
                                         who entered the home without pressure sores did
                                         not develop them and that residents with pressure
                                         sores received appropriate treatment and services
                                         to promote healing and to prevent infection. One
                                         new resident had no history of pressure sores and
                                         had no sores upon admission. Three months later,
                                         nursing notes showed that the resident had a
                                         severe pressure sore on his/her right heel. The
                                         notes also described unsuccessful attempts to
                                         contact a physician. Not until 7 days after the sore’s
                                         initial discovery did the physician give orders for
                                         treatment to begin. Another resident was assessed
                                         with multiple pressure sores within 8 days of
                                         admission. Although this resident’s care plan
                                         indicated that he was at risk for skin breakdown,
                                         there were no preventive measures, other than
                                         keeping him clean and dry, until after the second
                                         and third sores developed.
42b       H         319           1      The nursing home failed to ensure that residents         Y            Quality of care
                                         displaying mental adjustment difficulties received
                                         appropriate treatment for these problems. One
                                         resident was admitted with multiple complications,
                                         including chronic anxiety that was being treated
                                         with antianxiety medication. Over the next 19
                                         months, she experienced nutritional decline, skin
                                         breakdown, and multiple indicators of depression.
                                         The clinical record failed to document treatment of
                                         her depression until her health had become
                                         severely compromised, as indicated by a weight
                                         loss of 42-1/2 pounds, multiple pressure sores, and
                                         a decline in both physical and social functioning.
43        G         314           7      The nursing home failed to ensure that three             Y            Quality of care
                                         residents who were observed to have pressure
                                         sores received timely assessment and treatment as
                                         ordered by the physician. The home also failed to
                                         ensure that five dependent residents who were
                                         observed for incontinent care and skin conditions
                                         were provided pressure-relieving pads on their
                                         beds.
44        D         N/A         N/A      Two isolated actual harm deficiencies were deleted,      N/A          N/A
                                         and another deficiency was reduced from actual
                                         harm to potential for more than minimal harm after
                                         the nursing home disputed the state surveyor’s
                                         findings. Therefore, this home had no isolated
                                         actual harm deficiencies on this survey.
                                                                                                                  (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                                Was
Survey    severe           residents                                                                documented
numbera   rating   F-tag    affected     Deficiency abstract                                        harm done? Category
45a       H         164           3      A surveyor observed over 22 different residents            Y           Resident rights
                                         during a survey of a nursing home and found 3
                                         residents who were not ensured rights to personal
                                         privacy. One female resident was observed going to
                                         and returning from a shower in a shower-chair
                                         which “allowed for exposure of the resident’s naked
                                         buttocks.” While being placed on a bedpan,
                                         another female resident was exposed because
                                         bedcovers were thrown back and curtains were not
                                         drawn to provide privacy to the resident. A third
                                         resident was observed sitting on the toilet in the
                                         bathroom with both the bathroom and bedroom
                                         doors open. A nursing assistant working in the
                                         resident’s room at the time had neglected to close
                                         the doors.
45b       H         225           3      The nursing home failed to record and report               Y           Resident
                                         injuries that warranted notification to the state                      behavior and
                                         agency. One resident, documented as being at high                      facility
                                         risk for falls, sustained an unwitnessed fall and was                  practices
                                         found bleeding from her nose and with laceration on
                                         her forehead. Further evaluation at the hospital
                                         revealed the resident had also sustained a fractured
                                         neck. Another resident’s care plan documented
                                         prior falls and indicated she was at risk for falls. She
                                         was found lying on the floor of her room bleeding
                                         from two lacerations on the right side of her
                                         forehead. The unwitnessed fall required her to be
                                         taken to a hospital, where she received sutures. A
                                         third resident alleged abuse by a staff member
                                         resulting in a bruise on her nose. None of the three
                                         incidents were documented in the home’s incident
                                         log or reported to the state agency, as required.
45c       H         241           6      The nursing home failed to provide care in a manner        Y           Quality of life
                                         that maintained each resident’s dignity. A nursing
                                         assistant shampooed a resident’s hair by holding
                                         the sprayer directly over her head and allowing the
                                         shampoo and water to pour down over her eyes,
                                         nose, and mouth. The assistant then proceeded to
                                         vigorously scrub the resident while the resident
                                         cried audibly. Despite the resident’s distress, the
                                         assistant offered no reassurance or comfort. Also,
                                         five residents were observed in hospital gowns so
                                         worn and so thin that they failed to provide sufficient
                                         coverage to maintain resident dignity; that is,
                                         breasts were visible through the thin material.
                                                                                                                    (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                              Was
Survey    severe           residents                                                              documented
numbera   rating   F-tag    affected     Deficiency abstract                                      harm done? Category
45d       H         314           2      The nursing home failed to provide necessary             Y           Quality of care
                                         treatment for pressure sores in a timely and
                                         consistent manner: assessment was not timely,
                                         preventive measures were not taken, and
                                         monitoring and treatment were not initiated as
                                         needed. One resident was admitted with reddened
                                         heels, but no skin breaks. The home did not
                                         immediately initiate measures to protect the
                                         resident’s heels. Three months later, the resident
                                         developed advanced pressure sores that required
                                         surgery. Another resident with a history of pressure
                                         sores did not receive timely treatment of a severe
                                         pressure sore.
46        G         314           2      A nursing home resident was discovered in bed            Y           Quality of care
                                         surrounded by a foul-smelling, ammonia-like odor.
                                         When the charge nurse pulled back the resident’s
                                         covers, the incontinence pad was observed to be
                                         completely saturated with urine. The resident was
                                         soiled with feces and had developed three
                                         moderate pressure sores. A skin assessment 5 days
                                         earlier had revealed that the resident’s skin was
                                         intact with no breakdown. There were no orders to
                                         treat the pressure sores. Also, another resident was
                                         not properly treated for pressure sores.
47        G         325           1      The nursing home failed to implement                     Y           Quality of care
                                         recommended dietary interventions that were
                                         recommended by the home’s dietitian for one
                                         resident with continuing unplanned weight loss.
48        H         311           4      The nursing home failed to provide four residents        Y           Quality of care
                                         with restorative swallowing programs ordered by a
                                         therapist to prevent them from aspirating food into
                                         their lungs. This resulted in two of the residents
                                         requiring emergency hospitalization for aspiration
                                         pneumonia.
49a       I         246           1      The nursing home did not accommodate the needs           Y           Quality of life
                                         of one resident with severe respiratory problems.
                                         There was a strong, pungent odor of urine in the
                                         room (because of her incontinent roommate) that
                                         the resident complained brought on her “asthma”
                                         attacks. The resident had been hospitalized
                                         numerous times for her respiratory condition. On the
                                         second day of the survey, this problem was
                                         discussed with the home’s social services staff. As
                                         of the fourth day of the survey, the staff had neither
                                         discussed this problem with the resident nor made
                                         an attempt to accommodate her respiratory care
                                         needs.
                                                                                                                  (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                              Was
Survey    severe           residents                                                              documented
numbera   rating   F-tag    affected     Deficiency abstract                                      harm done? Category
49b       I         250           1      The nursing home did not provide psychosocial            Y           Quality of life
                                         services for a resident who complained of problems
                                         with her roommate. The resident alleged that the
                                         roommate invaded her privacy and would leave
                                         dirty incontinence pads in the bathroom. The
                                         resident had complained to the nursing home social
                                         worker and administrator with no success. She was
                                         told that she would have to move out of the room,
                                         which she did not want to do because she had lived
                                         there for almost 2 years. The resident said that she
                                         was “upset all the time” over this problem.
                                         Interviews with the social worker confirmed this
                                         problem. The nursing home did not provide any
                                         type of counseling for the two roommates.
49c       I         325           1      The nursing home did not ensure that a resident          Y           Quality of care
                                         maintained acceptable nutritional status. The
                                         resident lost more than 6 percent of her body weight
                                         in less than 2 months. A dietary review
                                         recommended supplementary feedings for added
                                         nourishment. However, 2 weeks later, the home was
                                         not providing these supplements.
49d       I         242           2      The nursing home did not allow the resident the          N           Quality of life
                                         right to choose activities and schedules consistent
                                         with his interests and make choices about aspects
                                         of his life in the home that were significant to the
                                         resident. A family member of a resident complained
                                         that the resident was no longer allowed to eat in the
                                         main dining room because he needed assistance
                                         with eating. Instead, the resident was told he would
                                         have to eat in one of the small dining rooms on the
                                         units. The family member explained that the resident
                                         enjoyed music and the main dining room had a
                                         piano player on certain days of the week. In
                                         addition, residents in the main dining room were
                                         offered soup, while residents who ate on the units
                                         were not offered soup. The surveyor noted that the
                                         soup was kept in the kitchen and if residents who
                                         ate in the unit wanted it, the nursing home staff
                                         would have to call the kitchen to get the soup for the
                                         resident.
50        G         309           1      A resident was admitted to the nursing home with         N           Quality of care
                                         diagnoses including chronic schizophrenia and
                                         diabetes. She often refused medications,
                                         treatments, and weight checks. She also fired her
                                         physician and refused to see another physician.
                                         During her stay, the home did not always notify her
                                         physician of her refusals. In addition, the home did
                                         not always notify her physician, as ordered, if her
                                         blood sugar level was below 60. No adverse
                                         outcome to the resident was noted in the
                                         documentation.
                                                                                                                  (continued)


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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                               Was
Survey    severe           residents                                                               documented
numbera   rating   F-tag    affected     Deficiency abstract                                       harm done? Category
51a       G         309           3      Three residents experienced injuries from falls. One      Y           Quality of care
                                         was identified to be at risk for falls and had a care
                                         plan developed to prevent them. Clinical
                                         documentation did not show that the care plan was
                                         implemented before she experienced a fall and
                                         fractured her hip. Another resident did not have a
                                         care plan to prevent falls, even though she suffered
                                         a fractured wrist a week earlier from a fall.
51b       G         324           3      Upon admission, a resident was assessed by the            Y           Quality of care
                                         nursing home to be at minimal risk for falls. Her care
                                         plan reflected interventions such as bed and chair
                                         monitor alarms. There was no evidence that the
                                         home had assessed or identified the need for
                                         supervision in order to prevent accidents. Two
                                         weeks after her admission, she was found lying on
                                         the floor with her wheelchair behind her. It was later
                                         learned that she had fractured her leg. Another
                                         resident dislocated her shoulder as a result of a fall.
                                         However, at the time of admission, there was no
                                         evidence that a risk assessment for falls had been
                                         done.
52a       G         316           3      A resident who was continent upon admission               Y           Quality of care
                                         deteriorated to being consistently incontinent. He
                                         complained to the surveyor of being unable to make
                                         it to the toilet in time because he could not remove
                                         the diaper that the nursing home staff had put on
                                         him. There was no evidence that the staff had
                                         evaluated his decline or had implemented
                                         interventions to prevent or address this decline. His
                                         current care plan stated that the nursing home staff
                                         was to “provide incontinence care after each
                                         incontinence episode.” Two other residents had
                                         similar problems with continence care: one resident
                                         remained continent only if a 2-hour toileting
                                         schedule was maintained, and another was not
                                         assisted in the bathroom despite her declining
                                         status. Instead, the only intervention provided by the
                                         nursing home was to clean this resident after each
                                         episode.
                                                                                                                  (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                               Was
Survey    severe           residents                                                               documented
numbera   rating   F-tag    affected     Deficiency abstract                                       harm done? Category
52b       G         325           2      Within 1 month after readmission, a resident lost         Y           Quality of care
                                         14-1/2 pounds, 9 percent of his body weight. There
                                         was no evidence to indicate that this weight loss
                                         had been evaluated or that interventions had been
                                         attempted. For another resident, who was being
                                         tube fed, the dietitian recommended increasing the
                                         caloric and fluid intake. Six days later, the physician
                                         ordered a product with more calories in it for
                                         feeding and instructed the home’s staff to flush the
                                         feeding tube as recommended by the dietitian.
                                         However, a week after this order was given, no
                                         changes had been made to the resident’s feeding
                                         or flushes. The nursing staff stated that they were
                                         waiting for the necessary product, which was on
                                         order. The dietitian had not been notified that the
                                         product was unavailable. An evaluation of
                                         alternative methods to provide additional nutrients
                                         and fluid had not been conducted.
52c       G         492           1      A resident was admitted to the nursing home and           N           Administration
                                         provided therapies that were covered by Medicare
                                         and other insurance for about 2 months. The home
                                         determined after 2 months that the resident would
                                         not improve with continued therapies and therefore
                                         stopped them. The home notified the resident’s
                                         family that the therapies were discontinued. Less
                                         than 3 weeks after the therapies were discontinued,
                                         the resident’s family requested that the home
                                         resume them and send the bill to the fiscal
                                         intermediary (Medicare’s contractor) to see if it
                                         would approve payment of the therapies. The home
                                         failed to send the bill to the fiscal intermediary.
                                         Instead, the home inappropriately charged the
                                         resident and the family. The documentation is not
                                         clear about whether therapies were continued
                                         during this period. It also does not state whether
                                         there was any adverse effect to the resident.
                                                                                                                  (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                               Was
Survey    severe           residents                                                               documented
numbera   rating   F-tag    affected     Deficiency abstract                                       harm done? Category
53a       K         224           1      A resident suffering from anxiety, a depressive           Y           Resident
                                         disorder, and an obstructive pulmonary disease had                    behavior and
                                         a history of agitation. He also experienced episodes                  facility
                                         of anxiety because of shortness of breath and                         practices
                                         abdominal discomfort. The physician had ordered
                                         medication to be given every 4 hours as needed for
                                         the abdominal discomfort. The resident asked a
                                         nurse for this medication and was told he could not
                                         have it, and was provided no explanation. The
                                         resident became agitated and hit the nurse. The
                                         nurse, when questioned by the surveyor about why
                                         the resident could not have the medicine, replied
                                         that the home’s policy was to give “those kinds of
                                         medication during the evening shift.” The resident
                                         asked for the medicine on a shift other than the
                                         evening shift and was inappropriately denied.
53b       K         314           1      The nursing home failed to ensure that residents          Y           Quality of care
                                         received necessary care and treatment to promote
                                         healing of pressure sores and to prevent new sores
                                         from developing. An assessment of one resident
                                         revealed clear skin and no pressure sores in
                                         January 1998. Treatment records showed healed
                                         pressure sores in February and March and a
                                         moderate pressure sore in April that healed in May.
                                         The resident developed another moderate sore in
                                         June, which deteriorated to a severe sore within 2
                                         weeks. This resident’s plan of care did not address
                                         this pressure sore until it had deteriorated to a
                                         severe sore.
53c       K         322           1      The nursing home failed to ensure that tube-fed           Y           Quality of care
                                         residents received treatment and services to
                                         prevent vomiting. Physician’s orders for a new
                                         tube-fed resident called for a maximum flow rate of
                                         70 cc’s per hour. The following day, in direct conflict
                                         with the physician’s orders, her flow was increased
                                         to 90 cc’s per hour. In subsequent episodes, the
                                         resident experienced repeated vomiting and
                                         eventually required hospitalization.
                                                                                                                  (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                             Was
Survey    severe           residents                                                             documented
numbera   rating   F-tag    affected     Deficiency abstract                                     harm done? Category
53d       K         389           3      The nursing home failed to ensure that physician        Y            Physician
                                         services were available to residents. One resident                   services
                                         received a new prescription to treat his gastric
                                         upset caused by his history of gastrointestinal
                                         bleeding, but the new medication was not covered
                                         under Medicaid. Attempts to contact the physician
                                         were unsuccessful for 4 days, during which time the
                                         resident did not receive necessary medication to
                                         address his history of gastrointestinal bleeding. The
                                         staff repeatedly attempted to call a physician to
                                         report another resident who had a decreased level
                                         of consciousness, was not swallowing, and had fluid
                                         in both lungs. Almost 3 hours later, the physician
                                         responded and ordered tests. Three hours later, the
                                         staff again attempted to contact this physician
                                         because the resident’s oxygen status had
                                         decreased. Over an hour later, the physician called
                                         back and the resident was transferred to an acute
                                         care hospital with congestive heart failure. The
                                         nursing home staff made six attempts to contact the
                                         attending physician and two attempts to contact the
                                         medical director to report a third resident with
                                         severe vomiting. The record shows neither the
                                         physician nor the medical director ever returned the
                                         calls. Staff indicated that it was a common
                                         occurrence for physicians not to return calls from
                                         the home.
54a       G         314           1      The nursing home failed to ensure that a resident       Y            Quality of care
                                         who entered the home without pressure sores did
                                         not develop them or received appropriate treatment
                                         and services to promote healing. One month after
                                         admission, a resident with no previous pressure
                                         sores developed a blackened area on the right heel.
                                         Several months later, the sore had not healed, and
                                         another moderate sore was discovered on the
                                         resident’s left heel. Despite some interventions to
                                         treat the sores, the right heel deteriorated to a
                                         severe sore with a small area of bone clearly visible
                                         in the wound.
                                                                                                                 (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                               Was
Survey    severe           residents                                                               documented
numbera   rating   F-tag    affected     Deficiency abstract                                       harm done? Category
54b       G         324           2      The nursing home failed to ensure that residents          Y           Quality of care
                                         received adequate supervision and assistive
                                         devices to prevent accidents. One resident with an
                                         “extremely high” risk of falls continued to climb out
                                         of bed and out of chairs despite past falls and
                                         injuries. In one instance, he was found lying on his
                                         back with the side rail on his face and a gash on his
                                         cheek. Another cognitively impaired resident was
                                         admitted with no history of falls or of needing
                                         restraints. Following admission, the resident had a
                                         series of eight falls within 2 months, some resulting
                                         in injuries. The home failed to provide adequate
                                         interventions to prevent accidents for both residents.
55        G         314           1      A cognitively impaired resident developed a               Y           Quality of care
                                         pressure sore on his coccyx while in the nursing
                                         home. The resident was also incontinent of bowel
                                         and bladder. The nursing home’s staff did not
                                         consistently cover the opened pressure sore with a
                                         dressing to protect the sore from feces and urine,
                                         thereby not promoting the healing of the sore.
56a       G         314           4      The nursing home failed to ensure that residents          Y           Quality of care
                                         without pressure sores did not develop sores. One
                                         resident developed a severe pressure sore with a
                                         thick yellow covering. Another resident’s care plan
                                         did not identify the need for preventive foot care,
                                         nor were any measures taken to prevent pressure
                                         sores. The resident developed a sore on the heel
                                         that was covered with a thick, black tissue. At least
                                         two other residents did not receive the treatment
                                         and services necessary to prevent new sores from
                                         developing.
56b       G         318           2      A physician’s order required that a resident wear a       Y           Quality of care
                                         hand splint for 4 hours during each nursing shift to
                                         decrease the risk of further deterioration of range of
                                         motion of the hand. Observers during all 3 days of
                                         the survey concurred that the nursing home staff did
                                         not apply the splint as ordered. The same resident
                                         also was assessed to be lacking in range of motion
                                         in both knees. The resident was required by
                                         physician’s order to be seated in a recliner to relieve
                                         a pressure sore and to wear a restrictive device on
                                         both legs. During each day of the survey, the
                                         resident was observed to have never left the bed.
                                         The device remained stored in the seat of the
                                         recliner. Another resident was observed with mitts
                                         on both hands. The home’s staff did not remove the
                                         mitts every 2 hours for 10 minutes as documented in
                                         the resident’s care plan. Instead, the surveyors
                                         stated that the resident wore the mitts during all
                                         days of the survey.
                                                                                                                  (continued)



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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                               Was
Survey    severe           residents                                                               documented
numbera   rating   F-tag    affected     Deficiency abstract                                       harm done? Category
57a       G         318           1      The nursing home failed to ensure that a resident         Y            Quality of care
                                         with limited range of motion received appropriate
                                         treatment and services in order to prevent further
                                         deterioration. A baseline mobility assessment for
                                         one resident indicated minimal to moderate
                                         reduction in range of motion in the hips, knees,
                                         elbows, wrists, fingers, shoulders, and ankles. Three
                                         months later, during the survey, a reassessment
                                         found that the fingers, shoulders, and one knee had
                                         declined to severe loss of range of motion. The
                                         nursing home staff failed to identify these problems
                                         and failed to develop a plan of care to address
                                         them.
57b       G         329           3      The nursing home failed to ensure that the drug           Y            Quality of care
                                         regimens of its residents were free of unnecessary
                                         drugs. Residents were given combinations of drugs
                                         including narcotics, hypnotics, sedatives,
                                         psychotropic, antidepressants, antipsychotics, and
                                         tranquilizers, with insufficient evaluation of the need
                                         for medication, the response of residents to the
                                         medication, or the effectiveness of the medication.
                                         One resident developed permanent, serious side
                                         effects from the medication.
58        G         316           2      The surveyors noted that the nursing home                 N            Quality of care
                                         improperly handled the catheter bags and tubing of
                                         two residents with urinary tract infections. The
                                         surveyors stated that the home’s improper handling
                                         of the catheters and tubing (allowing the catheter
                                         bag to be raised above a resident’s bladder and
                                         allowing the tubing to drag on the floor) created a
                                         risk of contamination of the catheter and, therefore,
                                         did not promote healing of the residents’ infections.
                                         However, the home stated that its catheter bags
                                         have an antireflux valve that prevents the backflow
                                         of urine into the resident’s bladder when the
                                         catheter bag is raised above the resident’s bladder.
                                         In addition, the catheter system that the home had
                                         is a sealed system so that there can be no
                                         contamination from dragging the tubing on the floor.
59        G         314           2      The nursing home failed to ensure that residents          Y            Quality of care
                                         with pressure sores were repositioned every 2 hours
                                         to promote healing and to prevent new sores from
                                         developing. One totally dependent resident was
                                         observed sitting in a wheelchair for over 3 hours
                                         without being repositioned. Additionally, the medical
                                         record indicated that the resident had a sore on her
                                         coccyx due to pressure from sitting in the
                                         wheelchair. Another totally dependent resident was
                                         observed lying flat in bed for more than 5 hours
                                         without repositioning. The resident’s medical record
                                         indicated that the resident had a pressure sore.
                                                                                                                   (continued)


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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                              Was
Survey    severe           residents                                                              documented
numbera   rating   F-tag    affected     Deficiency abstract                                      harm done? Category
60        G         314           7      For seven residents with pressure sores, the nursing     Y            Quality of care
                                         home failed to (1) provide proper care after
                                         incontinence, (2) report and document changes in
                                         skin condition, (3) follow physicians’ orders in
                                         making dressing changes to pressure sores, (4)
                                         follow care plans regarding reporting changes in
                                         pressure sores, (5) use clean cloths to cleanse
                                         open areas on the skin, (6) reposition residents at
                                         least every 2 hours, and (7) keep dressings clean,
                                         dry, intact, and completely covering pressure sores.
                                         Moreover, the home failed to review and revise the
                                         care plan for one resident regarding her worsening
                                         condition relating to her pressure sores, and to
                                         apply protective boots as ordered for another
                                         resident.
61        H         441           2      The nursing home did not ensure that measures            N            Infection
                                         were taken to prevent the spread of infection for two                 control
                                         residents. A surveyor observed a nurse’s aide
                                         continuing to wear the same gloves while cleaning a
                                         resident of stool, dressing the resident, transferring
                                         the resident to a chair, and combing the resident’s
                                         hair. The aide did not wash her hands after
                                         removing the gloves. The home did not ensure that
                                         another resident’s catheter was positioned correctly
                                         to aid in the flow of urine. The resident had a
                                         diagnosis of a urinary tract infection. Documentation
                                         does not support actual harm occurred to either
                                         resident. However, it does support potential for
                                         harm. Additionally, most catheter systems are
                                         closed systems and have an anti-reflux valve that
                                         prevents the risk of infection because of the back
                                         flow of urine. The documentation does not indicate
                                         the type of catheter system used and whether it had
                                         an anti-reflux valve.
62        G         333           1      The nursing home failed to ensure that residents         Y            Quality of care
                                         were free from significant medication errors. The
                                         staff failed to administer an antipsychotic drug to
                                         one resident diagnosed with chronic schizophrenia
                                         for 19-1/2 days. A psychiatrist’s notes indicated an
                                         increase in the resident’s irritability and agitation,
                                         also resulting in increased episodes of aggressive
                                         and loud verbalizations.
                                                                                                                  (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                                Was
Survey    severe           residents                                                                documented
numbera   rating   F-tag    affected     Deficiency abstract                                        harm done? Category
63        G         312           8      Residents in a nursing home who were unable to             Y           Quality of care
                                         perform activities of daily living did not receive
                                         proper care and services. Residents unable to leave
                                         their beds did not receive proper turning and
                                         repositioning, which left a purple bruise on one
                                         elbow and an old long yellow bruise on the upper
                                         chest of one resident. Incontinent residents were left
                                         in urine-soaked and feces-stained linens, which
                                         caused skin breakdown and rashes in at least one
                                         resident. Residents who were unable to groom
                                         themselves were not bathed; had long, jagged, dirty
                                         fingernails; dirty teeth; and dirty clothes.
64a       G         221           5      The nursing home failed to properly implement              Y           Resident
                                         therapeutic interventions for five residents. One                      behavior and
                                         resident was given hand mitts in order to prevent                      facility
                                         her from scratching herself. However, she was                          practices
                                         observed to be improperly wearing these hand mitts
                                         at meal times, which hindered her ability to eat. In
                                         another instance, the home used a self-releasing
                                         belt on a resident in a wheelchair without trying
                                         other alternatives. Two other residents were similarly
                                         not evaluated for the appropriateness of a
                                         self-release belt. A fifth resident had a physician’s
                                         order for a specific type of chair to be used when
                                         the resident was out of bed. The occupational
                                         therapist at the nursing home stated that the
                                         resident slid out of this chair when she required
                                         toileting. The nursing staff never assessed whether
                                         the resident’s toileting program was adequate.
                                         Instead, they tied the resident in her chair with a
                                         sheet so she would not slide out of it.
64b       G         309           5      A resident had an increase in episodes of choking          Y           Quality of care
                                         and coughing when eating. In response to this, the
                                         resident’s physician ordered a swallowing
                                         evaluation. This evaluation was completed and the
                                         therapist recommended that the resident be placed
                                         on thickened liquids to prevent the risk of aspiration
                                         pneumonia. Due to the resident’s daughter’s past
                                         refusal to accept this treatment, the nursing home
                                         did not immediately implement it, pending
                                         discussion with the daughter. The surveyor noted
                                         that the home’s administrator stated that staff had
                                         discussed this with the resident’s daughter.
                                         However, the administrator could not produce
                                         evidence that this had been done. The resident was
                                         ultimately admitted to the hospital with probable
                                         aspiration pneumonia 10 days after the treatment
                                         had been recommended. The nursing home also
                                         failed to follow the plan of care for several residents.
                                                                                                                   (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                              Was
Survey    severe           residents                                                              documented
numbera   rating   F-tag    affected     Deficiency abstract                                      harm done? Category
64c       G         324           1      The nursing home did not reevaluate the                  Y            Quality of care
                                         appropriateness of certain devices used to prevent
                                         a resident from sustaining further injury. The home
                                         used two padded side rails and an electric eye
                                         sensor on the bed of a resident who was at risk of
                                         falling out of bed. While these devices were in use,
                                         the resident sustained numerous falls resulting in
                                         lacerations. Documentation revealed that the
                                         resident would climb over the padded side rails to
                                         get out of bed. Although the sensor was supposed
                                         to sound when the resident tried to get out of bed, it
                                         did not sound on seven separate occasions.
65        G         353          13      The nursing home did not have sufficient staff to        Y            Nursing
                                         provide nursing services to assist residents to attain                services
                                         or maintain the highest practicable physical, mental,
                                         and psychosocial well-being. The home failed to
                                         monitor residents on a feeding program to assess
                                         amounts of food eaten and eating habits, and at
                                         least one resident lost weight. The resident lost nine
                                         pounds in one month (a significant weight loss is
                                         five pounds in one month). The home also failed to
                                         properly groom four residents and to provide
                                         assistance with activities of daily living for totally
                                         dependent residents on a timely basis.
66a       G         309           2      The nursing home did not provide or arrange timely       Y            Quality of care
                                         diagnostic evaluations that were required to
                                         manage the conditions for two residents. A resident
                                         had difficulty swallowing solid food and thickened
                                         liquids. The nursing home’s documentation
                                         indicated that the resident ate a small amount of
                                         food and that the resident was dehydrated. A
                                         gastroenterologist examined the resident and
                                         recommended that a feeding tube be inserted into
                                         the resident to meet his nutritional and hydration
                                         needs. The nursing home staff did not notify the
                                         resident’s physician of the gastroenterologist’s
                                         recommendation. Another resident had severe
                                         choking episodes while drinking liquids at breakfast
                                         and lunch. Although a speech therapist
                                         recommended an X ray be taken the next day to
                                         determine whether the resident had a swallowing
                                         problem, the X ray had not been done by the time of
                                         the survey 2 weeks later because of equipment
                                         malfunction. There was no documentation to
                                         indicate that the physician was made aware that a
                                         delay in service had occurred for this resident.
                                                                                                                  (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                               Was
Survey    severe           residents                                                               documented
numbera   rating   F-tag    affected     Deficiency abstract                                       harm done? Category
66b       G         314           2      The nursing home failed to ensure that residents          Y           Quality of care
                                         admitted without pressure sores did not develop
                                         them. A resident who was at high risk for pressure
                                         sores required turning and repositioning every 2
                                         hours as noted in both the care plan and the
                                         physician’s order. The resident developed several
                                         pressure sores in different locations. There were
                                         numerous blanks and omissions on the record
                                         showing how frequently a resident is turned in bed
                                         during a 2-month period. Another resident with a
                                         history of resolved pressure sores had a current
                                         physician’s order for heel protectors. The heel
                                         protectors were not available in the resident’s room,
                                         and staff interviews revealed an inability to recall
                                         how long the heel booties were unavailable.
                                         Additional staff interviews revealed that the home
                                         lacked a system for staff to ensure that each
                                         resident’s special needs, such as the need for heel
                                         booties to be available and utilized, are met.
67        G         325           2      The nursing home failed to ensure that residents          Y           Quality of care
                                         maintained acceptable parameters of nutritional
                                         status, such as body weight. One totally dependent
                                         resident lost 11.7 percent of her body weight in the
                                         first 18 days following admission. The staff failed to
                                         follow dietitian and physician’s orders on the level of
                                         nutrition this resident was to receive. Another
                                         resident lost 4.2 percent of her body weight in 10
                                         days (weight loss of 2 percent in one week is
                                         considered severe). Her severe weight loss was
                                         noted only after the surveyors found that she
                                         consumed only 20 to 50 percent of her meals, and
                                         they requested that she be weighed.
68        G         325           1      One resident experienced a severe weight loss of          Y           Quality of care
                                         20 pounds in 1 month. Staff did not inform the
                                         dietitian of the resident’s poor intake and did not
                                         feed the resident enough calories, even though the
                                         dietitian’s notes stated “Tolerates foods well.” The
                                         home also failed to inform the physician of the
                                         resident’s poor food intake and to develop a care
                                         plan to address the issue.
69a       G         224           1      The nursing home failed to ensure that residents          Y           Resident
                                         were not neglected. One resident was left on a                        behavior and
                                         bedpan throughout the 8-hour night shift until the                    facility
                                         resident was discovered on the bedpan in the                          practices
                                         morning by the day shift.
                                                                                                                  (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                             Was
Survey    severe           residents                                                             documented
numbera   rating   F-tag    affected     Deficiency abstract                                     harm done? Category
69b       G         314           1      The nursing home failed to ensure that residents did    Y             Quality of care
                                         not develop pressure sores while in the home. One
                                         resident was left on a bedpan overnight and
                                         developed pressure areas on both buttocks,
                                         consistent with the upper edge of the bedpan. This
                                         area subsequently deteriorated to a deeper wound
                                         and was reclassified by the home as a severe
                                         pressure sore.
70a       G         223           1      The nursing home failed to protect a resident from      Y             Resident
                                         sexual abuse. During interviews with nursing home                     behavior and
                                         staff, a surveyor learned that a resident had                         facility
                                         reported that a male employee had raped her and                       practices
                                         hit her in the face. The home’s staff did not believe
                                         the resident even though they admitted during
                                         interviews with the surveyor that the resident’s face
                                         was swollen. Therefore, they did not immediately
                                         investigate the incident, and the male employee
                                         continued to work and take care of some of the
                                         home’s other female residents. The home’s staff
                                         also did not document that the resident’s face was
                                         swollen. Two days later, the resident told her
                                         granddaughter about the abuse, and the
                                         granddaughter reported it to the nursing home. At
                                         that time, the home conducted an investigation.
70b       G         224           1      The nursing home failed to implement written            Y             Resident
                                         policies and procedures that prohibit mistreatment,                   behavior and
                                         neglect, and abuse of residents. The home did not                     facility
                                         implement policies and procedures when                                practices
                                         investigating an allegation of physical and sexual
                                         abuse by a staff member (incident above).
70c       G         225           1      The nursing home failed to report to the State Nurse    Y             Resident
                                         Aide Registry an individual who had a conviction of                   behavior and
                                         assault and battery of his sister. The home was                       facility
                                         aware of this conviction. This aide was involved in                   practices
                                         the physical and sexual abuse of the resident
                                         mentioned in 70a.
70d       G         272           1      The nursing home failed to develop a                    Y             Resident
                                         comprehensive plan of care to meet residents’                         assessment
                                         needs. One newly admitted resident was identified
                                         as at high risk for pressure sores; however, a
                                         comprehensive care plan for the prevention of
                                         pressure sores was not developed for this resident.
                                         The resident developed moderately severe pressure
                                         sores on both heels, which progressed to a severe
                                         stage within 4 weeks.
70e       G         314           1      The nursing home failed to ensure residents             Y             Quality of care
                                         admitted without pressure sores did not develop
                                         any. A resident developed moderately severe
                                         pressure sores on both heels, which progressed to
                                         a severe stage within 4 weeks.
                                                                                                                  (continued)


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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                             Was
Survey    severe           residents                                                             documented
numbera   rating   F-tag    affected     Deficiency abstract                                     harm done? Category
70f       G         316           1      The nursing home failed to provide treatment and        Y            Quality of care
                                         services to restore as much normal bladder function
                                         as possible. The home’s staff failed to carry out
                                         physician’s orders to provide bladder training for
                                         one resident. Training would have promoted healing
                                         of pressure sores on the resident’s buttocks.
71a       G         314           6      The home failed to provide necessary care to            Y            Quality of care
                                         prevent or promote healing of pressure sores for six
                                         residents with pressure sores by (1) not
                                         repositioning the residents every 2 hours as called
                                         for by the plan of care, (2) not using
                                         pressure-relieving devices, (3) not applying
                                         protective skin barriers, and (4) not providing
                                         complete care after incontinence. New pressure
                                         sores were noted for several of these residents.
71b       G         324           1      The home failed to investigate, address, and modify     Y            Quality of care
                                         the plan of care to prevent injury to one resident’s
                                         knee and ankle, which were found to be seriously
                                         bruised and scabbed over.
71c       G         325           2      The nursing home failed to maintain adequate            Y            Quality of care
                                         nutritional levels for two residents by not (1)
                                         identifying parameters for weight gain for one
                                         resident and weight loss for the other, (2) including
                                         in the dietary assessment specific factors related to
                                         accurate monitoring of food intake, and (3)
                                         addressing the impact of tube feeding formula on
                                         one resident’s blood sugar level. One resident’s
                                         nutritional status as measured by lab results was
                                         subnormal despite a small weight gain, and the
                                         second resident had lost weight steadily and was
                                         below ideal body weight.
                                                                                                                 (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                               Was
Survey    severe           residents                                                               documented
numbera   rating   F-tag    affected     Deficiency abstract                                       harm done? Category
72        G         225           1      The nursing home failed to fully investigate and          Y           Resident
                                         report possible abuse or neglect to the facility                      behavior and
                                         administrator. A nurse and a nurse’s aide escorted                    facility
                                         a resident to the whirlpool room for a bath. The                      practices
                                         nurse returned to the station and the nurse’s aide
                                         was left to bathe the resident. The nurse stated that
                                         she twice heard an attempt to open the door to the
                                         whirlpool room. She started to go back to the room,
                                         but the noise stopped. Later, the nurse’s aide
                                         leaned his head out of the door and requested a
                                         diaper for the resident. The nurse stated she got the
                                         diaper and when she arrived at the room, she saw
                                         the nurse’s aide dabbing the resident’s ear with a
                                         towel. The nurse noted that the resident’s ear
                                         appeared to be freshly swollen and discolored with
                                         two small open areas. On the following day, the
                                         resident was seen by a nurse practitioner, who
                                         documented that the resident had a contusion with
                                         a laceration to the ear and skull with swelling and
                                         infected tissue. The director of nursing spoke to the
                                         nurse’s aide about this incident and requested a
                                         written statement from the nurse. However, the
                                         director of nursing stated that she failed to obtain
                                         the statement from the nurse and to notify the
                                         home’s administrator of the alleged abuse.
73        G         324           2      The nursing home failed to provide one resident           Y           Quality of care
                                         with adequate visual supervision and failed to
                                         provide one resident with adequate supervision to
                                         prevent falls. The second resident was found on the
                                         landing of an interior stairwell, having fallen down 10
                                         steps and sustaining a bruise and a facial
                                         laceration, which required sutures.
74        G         324           1      The nursing home failed to put into place a care          Y           Quality of care
                                         plan to address a resident’s pattern of falls. After
                                         being discharged from physical therapy, the
                                         resident had numerous falls over more than a
                                         2-month period. One fall resulted in a fractured hip.
                                                                                                                  (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                             Was
Survey    severe           residents                                                             documented
numbera   rating   F-tag    affected     Deficiency abstract                                     harm done? Category
75        G         314           1      The nursing home failed to ensure that residents        Y            Quality of care
                                         admitted without pressure sores did not develop
                                         sores. A resident was assessed by the home to be
                                         at high risk for developing pressure sores. Nursing
                                         documentation revealed the measure implemented
                                         to prevent skin breakdown was to turn and
                                         reposition the resident. However, documentation
                                         and interviews with nursing staff revealed this
                                         intervention was ineffective because of the
                                         resident’s resistance and noncompliance with
                                         repositioning. No additional preventive measures
                                         were implemented, and the resident developed two
                                         blisters on the coccyx area 3 weeks later. It was not
                                         until approximately 1 week after this that additional
                                         measures such as cushions or bed overlays were
                                         put in place. At that time, nursing documented that
                                         the sore had worsened. Also, there was no
                                         assessment of the resident’s change in nutritional
                                         requirements as a result of the skin breakdown until
                                         after the area had severely worsened. At that time,
                                         the dietitian assessed the resident’s nutritional
                                         needs, determined the resident was not receiving
                                         adequate protein to promote healing, and
                                         recommended a supplement. There was no
                                         evidence of follow-up to this recommendation.
                                         Nursing documented that the pressure sore
                                         continued to deteriorate, including exhibiting
                                         tunneling and copious drainage.
76a       G         309           1      A physician’s orders for one resident called for        Y            Quality of care
                                         thickened liquids, and a speech therapist’s notes
                                         confirmed the resident was on thickened liquids for
                                         maximum safety. The surveyor observed the
                                         medication nurse giving the resident unthickened
                                         apple juice. The resident started coughing and
                                         choking when given the liquid. The nurse raised the
                                         head of the resident’s bed and started oxygen.
76b       G         324           4      The nursing home failed to ensure that residents        Y            Quality of care
                                         received adequate supervision to prevent
                                         accidents. One resident was observed with a
                                         bloody gauze above her left eye. Her record
                                         showed multiple falls and injuries, with ineffective
                                         intervention by the home’s staff. Three
                                         residents—one had limited range of motion of her
                                         fingers and a diagnosis of manic depression, the
                                         second was observed to be confused and
                                         disoriented at times and had a history of numerous
                                         falls, and the third was blind—were smoking
                                         unsupervised outside the home.
                                                                                                                 (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                              Was
Survey    severe           residents                                                              documented
numbera   rating   F-tag    affected     Deficiency abstract                                      harm done? Category
77        G         324           2      The nursing home failed to provide adequate              Y           Quality of care
                                         supervision to prevent accidents for two residents,
                                         both sustained falls with resulting injuries, and one
                                         exited the home in his wheelchair. The resident was
                                         found overturned in his wheelchair in a nearby alley.
                                         This resident had left the nursing home twice 5 days
                                         earlier.
78a       G         314           1      The nursing home failed to ensure residents with         Y           Quality of care
                                         pressure sores received appropriate treatment and
                                         services to promote healing and prevent infection.
                                         One resident who developed two moderately severe
                                         pressure sores on the coccyx was not repositioned
                                         regularly and did not receive a therapeutic mattress
                                         to promote healing of the sore.
78b       G         316           3      The nursing home failed to provide incontinence          Y           Quality of care
                                         training to restore as much normal function as
                                         possible. For three residents, the home did not
                                         determine the cause of residents’ incontinence or
                                         evaluate them for bladder retraining.
79a       G         314           3      Three residents were found to have developed             Y           Quality of care
                                         pressure sores, and all were having severe
                                         nutritional problems. The residents’ problems were
                                         not addressed in the care plans, nor were the
                                         residents identified to be at risk for developing
                                         pressure sores in consideration of the changes in
                                         nutritional status.
79b       G         325           4      The nursing home failed to ensure residents              Y           Quality of care
                                         maintained acceptable parameters of nutritional
                                         status. Several residents experienced severe weight
                                         loss, but the home did not intervene with aggressive
                                         nutritional and other interventions to prevent further
                                         decline.
80        H         325           3      The nursing home failed to weigh residents weekly        Y           Quality of care
                                         as ordered, to accurately document nutritional
                                         intakes, to document that supplements or snacks
                                         were offered, and failed to provide diets as ordered.
                                         Further, the home failed to have a system in place to
                                         notify the dietitian of relevant changes in condition,
                                         including abnormal lab results, and failed to follow
                                         dietary recommendations or responded very late to
                                         them. As a result, three residents experienced
                                         significant weight loss in a 3-month period. In
                                         addition, one of these residents had an abnormally
                                         low test for blood protein levels and had developed
                                         pressure sores.
                                                                                                                 (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                                Was
Survey    severe           residents                                                                documented
numbera   rating   F-tag    affected     Deficiency abstract                                        harm done? Category
81        I         314           2      The nursing home failed to prevent pressure sores          Y           Quality of care
                                         from developing and to properly treat pressure
                                         areas for two of three sampled residents with
                                         pressure areas. For one resident, the home failed to
                                         carry out preventive measures in the plan of care,
                                         resulting in development of a moderately severe
                                         pressure sore. Despite this pressure sore, the
                                         surveyor observed on three occasions that the
                                         preventive measures in the plan of care were not
                                         carried out for this resident. In addition, the resident
                                         had another open area that was not documented in
                                         the chart on 7/6. However, on 7/9, there was
                                         documentation of this sore in the chart dated 7/4.
82        G         157           1      The nursing home failed to notify the physician of a       Y           Resident rights
                                         significant change in one resident’s physical
                                         condition. The resident was noted to have reddened
                                         eyes with yellow drainage present. The physician
                                         was notified, and an antibiotic was ordered. One
                                         week later, documentation indicated eyes were still
                                         red with a large amount of pus. The resident’s eyes
                                         were still draining 10 days after the antibiotic
                                         treatment was started, yet the physician was not
                                         notified.
83        G         314           1      The nursing home failed to ensure that residents           Y           Quality of care
                                         who entered the home without pressure sores did
                                         not develop any and residents with pressure sores
                                         received appropriate treatment and services to
                                         promote healing and prevent infection. One resident
                                         developed a severe pressure sore on his right ankle
                                         while in the home. His care plan called for a foam
                                         pad and sheepskin for pressure relief. In four
                                         observations during the survey, he did not have the
                                         sheepskin in place. In two of these observations, he
                                         did not have the foam in place, and his sore rested
                                         directly on the bed. Weekly reports showed the
                                         depth of the wound increased from .25 cm to .50
                                         cm during the week of the survey.
84a       G         309           1      The nursing home failed to provide appropriate care        Y           Quality of care
                                         to a resident experiencing severe pain. The
                                         resident, as documented in the nurse’s notes, was
                                         experiencing consistent severe right leg and hip
                                         pain. However, the home did not have the resident
                                         reevaluated for the pain for 8 days, causing
                                         unnecessary physical and mental distress. Several
                                         times the resident was found “screaming out in pain
                                         with positioning” and “unable to bear weight.”
                                                                                                                   (continued)




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                                       Deficiencies




          Most                No. of                                                                Was
Survey    severe           residents                                                                documented
numbera   rating   F-tag    affected     Deficiency abstract                                        harm done? Category
84b       G         317           2      The nursing home failed to identify existing               Y           Quality of care
                                         reduction in range of motion in one resident or
                                         measure the range of motion in another resident to
                                         be able to evaluate whether range of motion had
                                         declined. One resident’s left wrist was flexed at a
                                         90-degree angle and dangled from a splint while
                                         the resident was in his wheelchair. The resident
                                         interacted with many staff and therapy personnel
                                         throughout all days of the survey; however, no one
                                         noted the improper positioning of the residents’ left
                                         wrist and hand. Another resident was noted to have
                                         reduced range of motion of her extremities upon
                                         admission, and the resident was at high risk for
                                         decreased range of motion because of neurological
                                         deficits related to a severe head injury. No
                                         assessment, however, indicated which specific
                                         joints were affected, nor were any of the affected
                                         joints measured.
85        G         242           1      The nursing home failed to give one resident the           Y           Quality of life
                                         right to make decisions about a significant aspect of
                                         her life in the home. Fearful of falling out of bed, the
                                         resident requested side rails on both sides of her
                                         bed. Family members also requested side rails for
                                         her protection. Four days later, while attempting to
                                         get out of bed, the resident fell, suffering multiple
                                         fractures. Side rails had not been installed as
                                         requested.
86a       G         224           1      The nursing home did not prevent the neglect of            Y           Resident
                                         one resident, who was left unsupervised in the                         behavior and
                                         bathroom and fell, sustaining a broken shoulder.                       facility
                                         The home also failed to promptly obtain an X ray                       practices
                                         when signs of the injury appeared.
86b       G         324           2      The nursing home did not provide adequate                  Y           Quality of care
                                         supervision to one resident to prevent accidents, as
                                         a result of which she fell in the bathroom, sustaining
                                         a broken shoulder. The home also failed to provide
                                         one resident with adequate supervision to prevent
                                         the resident from leaving the home while
                                         unsupervised. Several times, she was found on
                                         busy highways as much as 3 miles from the home.
                                         On several occasions, staff did not know resident
                                         was gone until informed by outside people,
                                         although resident had been documented as being
                                         in the home at 15-minute checks.
86c       G         325           1      The nursing home failed to ensure that one resident        Y           Quality of care
                                         maintained acceptable nutritional status. It failed to
                                         follow dietitian’s recommendations and physician’s
                                         orders regarding the resident’s weight loss and
                                         pressure areas, resulting in continuous weight loss
                                         and pressure sores.
                                                                                                                    (continued)


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                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                             Was
Survey    severe           residents                                                             documented
numbera   rating   F-tag    affected     Deficiency abstract                                     harm done? Category
87a       G         281           1      The nursing home failed to provide services that        Y            Resident
                                         met professional standards of quality. One resident                  assessment
                                         with metastatic bone cancer suffered “horrible or
                                         excruciating” pain on a daily basis. Staff did not
                                         perform adequate pain assessment or provide
                                         medication to control the pain.
87b       G         312           8      The nursing home failed to ensure residents             Y            Quality of care
                                         received necessary services to maintain good
                                         nutrition, grooming, and personal and oral hygiene.
                                         Surveyors cited multiple instances of poor hygiene,
                                         such as a resident with copious secretions from a
                                         tube in the trachea on a bib and running down the
                                         side of her neck, disheveled and dirty hair, and a
                                         strong smell of urine. Another resident identified as
                                         needing assistance for meals received assistance
                                         with only one bite of cereal and a sip of nutritional
                                         supplement before staff removed the rest of her
                                         uneaten meal.
87c       G         314           2      The nursing home failed to ensure residents who         Y            Quality of care
                                         entered the home without pressure sores did not
                                         develop any and residents with pressure sores
                                         received appropriate treatment and services to
                                         promote healing and prevent new sores. After
                                         readmission from repair of a hip fracture, one
                                         resident was assessed as being at high risk for skin
                                         breakdown. Within 5 months, she developed severe
                                         pressure sores on her coccyx and right heel.
                                         Another resident with a moderately severe to severe
                                         pressure sore on his sacrum was observed lying flat
                                         on his back for extended periods.
87d       G         323           1      The nursing home failed to ensure the environment       Y            Quality of care
                                         was as free of accident hazards as possible. One
                                         resident with Alzheimer’s disease wandered almost
                                         constantly around the home. She had a history of
                                         falls, including one when she attempted to sit in a
                                         chair that rolled away under her because its wheels
                                         were left unlocked and another when she tripped
                                         over a piece of equipment left in the hall. Surveyors
                                         cited several other hazards, such as exposed
                                         medications, in the area of the wandering resident.
87e       G         324           2      The nursing home failed to ensure residents             Y            Quality of care
                                         received adequate supervision to prevent
                                         accidents. One resident with Alzheimer’s disease
                                         and a history of wandering was found by police
                                         walking in circles in a nearby street. Another
                                         resident was observed unsupervised, wandering
                                         throughout the home in her wheelchair. Her record
                                         showed a history of falls and minor injuries.
                                                                                                                 (continued)




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                                       Deficiencies




          Most                No. of                                                                Was
Survey    severe           residents                                                                documented
numbera   rating   F-tag    affected     Deficiency abstract                                        harm done? Category
87f       G         333           1      The nursing home failed to ensure residents were           Y           Quality of care
                                         free from significant medication errors. Staff failed to
                                         follow physician’s orders for one diabetic resident.
                                         She became unresponsive and was transferred to
                                         the emergency room.
87g       G         353          16      The nursing home failed to ensure sufficient staffing      Y           Quality of care
                                         to meet residents’ needs. Surveyors cited a number
                                         of examples of insufficient staffing. One resident did
                                         not receive pain medication as requested. The
                                         surveyor observed this resident calling out for pain
                                         medication, and observed that the resident’s call
                                         bell was out of reach. The resident stated he had
                                         pain in his side and that he had asked several staff
                                         for pain medication, but no one had provided any.
                                         In addition, one resident with a moderately severe to
                                         severe pressure sore was not repositioned to relieve
                                         pressure on the sore, at least one resident did not
                                         receive walking therapy, call bells were not
                                         answered for 45 to 50 minutes, several residents
                                         exhibited poor hygiene, and wandering residents
                                         were not properly supervised.
88a       G         224           1      The nursing home failed to implement written               Y           Resident
                                         policies and procedures that prohibited                                behavior and
                                         mistreatment, neglect, and abuse of residents.                         facility
                                         Following an enema, one resident was left on a                         practices
                                         bedpan for 18 hours. The resident usually had
                                         results within 1 to 5 minutes and was to be assisted
                                         to the bathroom or placed on the bedpan and then
                                         cleansed after its use. Although the home had
                                         policies and procedures in place, staff failed to
                                         implement and follow these policies.
88b       G         309           1      A resident who had been left on a bedpan for 18            Y           Quality of care
                                         hours following an enema treatment developed two
                                         pressure sores as a result of the incident. While the
                                         resident was at risk for pressure sores, they did not
                                         exist prior to the incident. The incident resulted in
                                         two moderately severe pressure sores and both
                                         continued to deteriorate over the next 6 weeks.
88c       G         324           1      The nursing home failed to ensure residents                Y           Quality of care
                                         received adequate supervision and assistive
                                         devices to prevent accidents. One resident was
                                         found repeatedly on the floor after falling and
                                         sustained a fracture of the pelvis during one fall.
                                         Occupational therapy recommended the use of a
                                         bed alarm when in bed at all times. There was no
                                         evidence that the recommendation had been acted
                                         upon for at least 5 days after readmission to the
                                         home following a hospitalization for the fractured
                                         pelvis.
                                                                                                                   (continued)



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                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                               Was
Survey    severe           residents                                                               documented
numbera   rating   F-tag    affected     Deficiency abstract                                       harm done? Category
89a       K         157           1      A resident, who was not able to make any                  N           Resident rights
                                         decisions, was admitted to the nursing home with
                                         multiple pressure sores. The sores continued to
                                         worsen to a severe stage with greenish black tissue
                                         and a foul odor. The nursing home did not inform
                                         the resident’s legal guardian that the resident’s
                                         condition was deteriorating. The resident was
                                         discharged to the hospital and subsequently died.
                                         The documentation does not indicate whether the
                                         resident’s physician was notified so that appropriate
                                         interventions could have been taken.
89b       K         310           2      The nursing home failed to ensure that two residents      Y           Quality of care
                                         were provided adaptive equipment and assistance
                                         to maintain function in eating, walking, and
                                         transferring. One resident with severe Parkensonian
                                         tremor was not provided with assistance in eating or
                                         assessed for assistive devices. As a result, the
                                         resident lost 9 pounds in 3 months. A second
                                         resident able to walk independently was not
                                         provided with rehabilitative services after a fall, and
                                         as a result lost the ability to walk independently.
89c       K         312           3      The nursing home failed to ensure that three              Y           Quality of care
                                         dependent residents received the assistance
                                         necessary and called for in their plans of care to
                                         maintain adequate nutritional status. Significant
                                         weight loss was documented for one resident.
89d       K         314           5      The nursing home failed to ensure that three              Y           Quality of care
                                         residents received adequate incontinence care and
                                         were repositioned every two hours to avoid
                                         development of pressure sores. Two of these
                                         residents developed pressure sores, and the third
                                         was at high risk of them. One resident with pressure
                                         sores did not receive a high-calorie, high-protein
                                         diet to promote healing as called for in the plan of
                                         care.
89e       K         325           4      The nursing home failed to ensure that three              Y           Quality of care
                                         residents received adequate nutrition by failing to
                                         assist them in eating, or by using poor feeding
                                         technique. All three residents had unplanned weight
                                         loss. For one resident on tube feeding, the home
                                         failed to order a nutritional assessment until after a
                                         6-pound weight loss in 13 days. When the
                                         assessment documented that the resident was
                                         receiving less than one-half of his/her nutritional
                                         needs, the home failed to contact the physician on
                                         call for the resident’s attending physician, who was
                                         on vacation.
                                                                                                                  (continued)




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                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                           Was
Survey    severe           residents                                                           documented
numbera   rating   F-tag    affected     Deficiency abstract                                   harm done? Category
90        G         325           1      A resident lost 15 percent of body weight over a      Y             Quality of care
                                         6-month period, yet no attempts were made by staff
                                         to assist or encourage this dependent resident to
                                         eat during the mealtimes witnessed by the surveyor.
                                         The resident required total assistance to eat, yet
                                         one evening she was not seated with those
                                         requiring assistance to eat, and she ate nothing.
                                         The following morning, she received no assistance
                                         and ate none of her breakfast.
91a       G         223           1      The nursing home failed to ensure one resident was    Y             Resident
                                         free from abuse. A nursing home employee verbally                   behavior and
                                         abused an alert, oriented resident over a long                      facility
                                         period of time. The resident was frightened and                     practices
                                         apprehensive of this employee. The nursing home
                                         was aware of this problem but continued to permit
                                         the employee to enter the resident’s room on a
                                         regular basis to care for the resident’s totally
                                         dependent, noncommunicative roommate. After this
                                         survey, the employee was discharged. (Note: This
                                         complaint investigation occurred 6 months after the
                                         original incident.)
91b       G         309           1      An alert, oriented resident was verbally abused by    Y             Quality of care
                                         and forced to stand by a nursing home employee,
                                         causing the resident intense pain. Resident was
                                         upset and afraid of employee. (Note: employee
                                         involved was the same as in F223 citation—different
                                         resident.)
                                                                                                                (continued)




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                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                                Was
Survey    severe           residents                                                                documented
numbera   rating   F-tag    affected     Deficiency abstract                                        harm done? Category
92        G         314           2      The nursing home failed to ensure that residents           Y           Quality of care
                                         received necessary care and treatment to promote
                                         healing and prevent new sores from developing. A
                                         resident who had been declining in activities of daily
                                         living skills for more than a month developed a small
                                         open area. Prior to the development of this open
                                         area, there was no evidence of any assessment of
                                         this resident to identify her as potentially at risk for
                                         skin breakdown. The resident’s care plan did not
                                         show interventions for pressure-relieving devices in
                                         bed as per the home’s policy. Another resident was
                                         identified as having a moderately severe pressure
                                         sore on her hip. A surgical consultation prescribed
                                         a “flexicare bed if possible, otherwise an air
                                         mattress.” The air mattress was not provided for
                                         seven days. The resident was using an “egg crate”
                                         mattress prior to the development of the pressure
                                         sore and up until the time the air mattress was
                                         received. There was no evidence the resident was
                                         reassessed for the appropriateness of the continued
                                         use of the egg crate mattress, nor was there
                                         evidence that any alternative interventions were
                                         planned for a pressure-relieving device until the
                                         prescribed air mattress was received from the
                                         supplier.
93        G         314           1      The nursing home did not ensure that one resident          Y           Quality of care
                                         received necessary treatment and services to
                                         prevent and heal pressure sores. This resident
                                         developed moderately severe pressure sores while
                                         in the home. Despite this, a surveyor observed on
                                         two consecutive days that the resident was not
                                         being turned in bed every 2 hours as required in the
                                         plan of care.
94        G         314           1      The nursing home failed to properly assess and             Y           Quality of care
                                         treat a resident’s pressure sore. As a result, the
                                         resident’s pressure sore increased in size. One
                                         resident was readmitted with diagnoses including
                                         dementia and a fractured right leg. On the day of
                                         readmission, a nurse’s note stated that there was a
                                         “3.0 cm by 2.0 cm black area below the 5th toe.”
                                         There was no evidence, however, that a physician
                                         was notified of the pressure sore and therefore no
                                         treatment was ordered; this was later confirmed by
                                         the physician. Further, staff did not institute any
                                         monitoring to evaluate the progress of the pressure
                                         sore. Several weeks later, the sore had grown and
                                         deteriorated to a severe stage.
                                                                                                                   (continued)




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                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                              Was
Survey    severe           residents                                                              documented
numbera   rating   F-tag    affected     Deficiency abstract                                      harm done? Category
95        G         321           1      The nursing home failed to provide prompt dental         Y           Quality of care
                                         care to a resident who refused to eat because of a
                                         poor dental condition, and inserted a nasogastric
                                         tube for feeding. Before this problem arose, the
                                         resident was documented as eating well and having
                                         a good appetite. The resident had to have a feeding
                                         tube inserted to obtain nutrition.
96a       H         223           1      The nursing home failed to ensure residents were         Y           Resident
                                         free from abuse. One resident required extensive                     behavior and
                                         assistance and experienced excruciating pain daily                   facility
                                         due to multiple conditions. She alleged that one                     practices
                                         evening when she asked a staff member to move
                                         her about 2 inches, he threw her over to the side
                                         rail, and when she made a fist, he left her
                                         uncovered.
96b       H         224           1      The nursing home failed to implement written             Y           Resident
                                         policies and procedures that prohibited abuse of                     behavior and
                                         residents. A resident said she informed the                          facility
                                         medication nurse of abuse. The record showed no                      practices
                                         evidence that the medication nurse had informed
                                         the director of nursing or nursing home
                                         administrator as required by the home’s policies
                                         and procedures. Twenty-four hours after being
                                         informed of the abuse incident by the survey team,
                                         the home had not begun an investigation of the
                                         abuse or other procedures as required by its policy
                                         relating to abuse.
96c       H         225           3      The nursing home failed to ensure that three             Y           Resident
                                         allegations of abuse were investigated and reported                  behavior and
                                         to the appropriate authorities within 5 workdays after               facility
                                         the incident, as required by HCFA. In one case, the                  practices
                                         home had not reported to authorities the alleged
                                         abuse of a resident by an employee until 7 days
                                         after the incident. Additionally, the employee
                                         continued to work at the home. In a second case,
                                         the home had not reported to authorities the alleged
                                         abuse of a resident who was hospitalized and
                                         diagnosed with a dislocated shoulder for more than
                                         6 months after the incident. Furthermore, the home
                                         could not produce evidence that it had investigated
                                         this incident. In a third case of alleged
                                         resident-to-resident abuse, the home could not
                                         provide evidence that an investigation was
                                         conducted for almost 1 year after the incident.
                                                                                                                 (continued)




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                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                                 Was
Survey    severe           residents                                                                 documented
numbera   rating   F-tag    affected     Deficiency abstract                                         harm done? Category
96d       H         279           2      The nursing home failed to develop comprehensive            Y           Resident
                                         care plans for two residents. A resident received an                    assessment
                                         abrasion on her leg while being put to bed.
                                         Although the wound deteriorated, the home did not
                                         develop a care plan to address the wound, and 2
                                         months later, a physician determined that poor
                                         circulation to the leg might require surgery,
                                         including amputation. Another resident developed
                                         two moderately severe pressure sores within 12
                                         days of admission. Despite a history of pressure
                                         sores and a diagnosis of poor circulation, the home
                                         did not develop a comprehensive care plan to
                                         prevent new pressure sores from developing.
96e       H         281           3      The nursing home failed to provide nursing services         Y           Resident
                                         that meet professional standards of quality. Nursing                    assessment
                                         staff failed to (1) identify signs and symptoms of
                                         infection for two residents (resulting in the
                                         amputation of a finger and possibly a leg), (2)
                                         initiate neurological assessment of a resident with a
                                         potential head injury, and (3) follow physician’s
                                         orders for blood pressure monitoring for a resident
                                         who was potentially hemorrhaging.
96f       H         310           2      The nursing home failed to ensure that residents’           Y           Quality of care
                                         abilities in activities of daily living did not diminish,
                                         unless this was unavoidable. Two residents went
                                         from being continent of bowel and bladder to
                                         incontinent within 3 months. Health records showed
                                         that neither received assessment or treatment to
                                         promote normal function.
96g       H         314           2      The nursing home failed to ensure that residents            Y           Quality of care
                                         who entered the home without pressure sores did
                                         not develop them and that residents with pressure
                                         sores received appropriate treatment and services
                                         to promote healing and prevent infection. A resident
                                         with a history of pressure sores (but none on
                                         admission) developed a moderately severe
                                         pressure sore on each heel within 12 days of
                                         admission. Within 19 days of a readmission 2
                                         months later, the resident developed a moderately
                                         severe pressure sore on the coccyx. Another
                                         resident was admitted with a sore on her right heel,
                                         which healed. Staff failed to monitor the area as
                                         required by the home’s policy, resulting in a
                                         moderately severe sore recurring in the same area.
96h       H         329           1      The nursing home failed to ensure that residents’           Y           Quality of care
                                         drug regimens were free from unnecessary drugs.
                                         Within a 3-month period, one resident developed
                                         severe side effects from a series of antipsychotic
                                         medications.
                                                                                                                    (continued)



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                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                               Was
Survey    severe           residents                                                               documented
numbera   rating   F-tag    affected     Deficiency abstract                                       harm done? Category
96i       H         429           1      The nursing home failed to report the deterioration       Y           Pharmacy
                                         of a resident to the attending physician and the                      services
                                         director of nursing. Also, the pharmacist consultant
                                         did not monitor and report the deterioration of a
                                         patient experiencing severe side effects from a
                                         drug, despite warnings in drug literature that certain
                                         medications should be discontinued if such side
                                         effects occurred. (Same case as F329.)
96j       H         456           1      The nursing home failed to maintain all essential         Y           Physical
                                         mechanical patient care equipment in a safe                           environment
                                         operating condition. One resident was struck in the
                                         chest by a malfunctioning piece of equipment used
                                         to transfer the resident from a wheelchair into bed,
                                         causing chest pain and requiring observation and
                                         an X ray. The equipment had malfunctioned earlier,
                                         and records showed that no repairs were done.
97        G         225           2      The nursing home failed to report possible abuse or       Y           Resident
                                         neglect to state officials and investigate possible                   behavior and
                                         neglect. One resident was found on the floor next to                  facility
                                         her bed with a superficial laceration to the upper lip                practices
                                         and a nosebleed. The home’s investigation found
                                         that (1) the family had reported a defective side rail,
                                         which had not been fixed, and (2) the resident was
                                         told she could only go to the bathroom once an
                                         hour; at the time of the accident she was attempting
                                         to go to the bathroom. Another resident fell out of a
                                         wheelchair and sustained a skin tear to the right
                                         forearm. The resident’s plan of care called for a seat
                                         belt while in the wheelchair, but the nursing
                                         assistant could not find a soft belt restraint, so the
                                         resident was not wearing a belt. These instances of
                                         possible neglect and abuse were not reported to
                                         state officials as required.
98a       H         157           2      The nursing home failed to notify the residents’          Y           Resident rights
                                         physicians and/or family members in a timely
                                         manner of significant changes in medical condition.
                                         One resident exhibited changes in behavior,
                                         including slurred and garbled speech, a lack of
                                         verbalization, and a noninjury fall. When symptoms
                                         continued for 8 days, a physician was notified. The
                                         physician indicated a temporary reduction in blood
                                         supply to brain. The physician was not notified in a
                                         timely manner to initiate treatment. Another resident
                                         experienced repeated clogging of her feeding tube,
                                         which at one point staff were unable to unclog. The
                                         physician and family were not notified for 6 days.
                                         This resident also developed moderately severe
                                         pressure sores on two toes, but 18 days later there
                                         was still no evidence the physician and family had
                                         been notified.
                                                                                                                  (continued)



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                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                              Was
Survey    severe           residents                                                              documented
numbera   rating   F-tag    affected     Deficiency abstract                                      harm done? Category
98b       H         223           1      A nurse’s aide verbally abused one resident. The         Y            Resident
                                         resident reported the incident to a nurse, who failed                 behavior and
                                         to report the allegation to the administrator. No                     facility
                                         investigation was done. Records showed that 2                         practices
                                         months earlier the nurse’s aide was counseled for
                                         using abusive language in the presence of
                                         residents and family members.
98c       H         314           1      The nursing home failed to ensure that one resident      Y            Quality of care
                                         without pressure sores did not develop sores, and
                                         when sores did develop, failed to ensure that the
                                         resident received treatment and services to promote
                                         healing. A resident developed multiple, moderately
                                         severe pressure sores on her buttock and coccyx
                                         over a 3-month period. The resident’s plan of care
                                         did not address the turning assistance or frequency
                                         needed to provide pressure relief.
98d       H         330           1      The nursing home failed to ensure that residents         Y            Quality of care
                                         were free from unneeded antipsychotic drugs. Soon
                                         after admission, a 96-year-old resident with
                                         Alzheimer’s disease became agitated, periodically
                                         resisted care, and sometimes threatened other
                                         residents. The resident was then given Haldol twice
                                         daily. He became lethargic and unresponsive as a
                                         result of the Haldol. The home did not attempt other
                                         interventions before using Haldol.
99a       G         157           1      The nursing home first documented that a resident        N            Resident rights
                                         had open blisters on his thigh 1 day before a
                                         surveyor noticed the blisters. The surveyor
                                         determined that the nursing home’s staff had not
                                         notified the physician or the resident’s family of the
                                         blisters and asked the home’s staff to contact them.
                                         The documentation does not note the extent and
                                         severity of the blisters. Therefore, it is not evident
                                         that a 1-day delay was unacceptable.
99b       G         314           3      The nursing home failed to provide regular               Y            Quality of care
                                         repositioning and other care needed by three
                                         residents at high risk for skin breakdown. Two of the
                                         three developed pressure sores.
100a      G         314           1      The nursing home failed to ensure that residents         Y            Quality of care
                                         with pressure sores received appropriate treatment
                                         and to provide services to promote healing and
                                         prevent new sores from developing. One resident
                                         was admitted with a moderately severe pressure
                                         sore on the coccyx. Within 2 weeks, the resident
                                         had developed three new pressure sores and the
                                         moderately severe sore had progressed to a severe
                                         stage. Recommendation by the dietitian to increase
                                         the resident’s protein intake to promote healing was
                                         not implemented for over 2 months.
                                                                                                                  (continued)



                                       Page 61                                GAO/HEHS-99-157 Poorly Performing Nursing Homes
                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                             Was
Survey    severe           residents                                                             documented
numbera   rating   F-tag    affected     Deficiency abstract                                     harm done? Category
100b      G         318           1      The nursing home failed to ensure that a resident       Y            Quality of care
                                         with a limited range of motion received appropriate
                                         treatment and services to prevent a further
                                         decrease in range of motion. One resident was
                                         admitted with a reduction in range of motion to both
                                         hands and one arm. Surveyors observed that the
                                         resident’s range of motion in both the arm and the
                                         legs had decreased since admittance.
101a      G         314           3      Based on review of 3 of 28 clinical records, staff      Y            Quality of care
                                         interviews, and observation, the surveyor
                                         documented that the home failed to identify new
                                         pressure sores in a timely manner and failed to
                                         implement preventive measures for existing
                                         pressure sores. In one case, nursing documentation
                                         noted that the resident had developed a pressure
                                         sore on the left posterior thigh that was not found
                                         until it had deteriorated to a severe stage.
101b      G         317           1      A resident was documented as having freely mobile       Y            Quality of care
                                         upper and lower extremities before experiencing a
                                         decline in the mobility of the lower extremities. A
                                         physical therapy evaluation recommended that a
                                         knee separator be worn between the knees at all
                                         times and that the resident be provided
                                         range-of-motion therapy, with repositioning, prior to
                                         the application of the knee separator. Within a
                                         month and a half, another physical therapy
                                         screening was performed because of a decreased
                                         range of motion in the resident’s upper extremities,
                                         which revealed upper extremity range-of-motion
                                         deficiencies that could be improved with repetitive
                                         exercises. Recommendations were to refer the
                                         resident to the restorative nursing program for
                                         upper extremity range of motion and that passive
                                         range-of-motion exercises be done during every
                                         nursing shift. Documentation was lacking to support
                                         that any range-of-motion exercise was provided to
                                         this resident. On three separate occasions, with the
                                         resident in different positions, the surveyor found
                                         the knee separator not in use. A review of the
                                         resident’s care plan showed that prevention of the
                                         reduction in range of motion was not addressed.
101c      G         324           4      Based on 4 of 28 clinical records reviewed and          Y            Quality of care
                                         observations, the nursing home failed to provide
                                         adequate supervision and/or preventive measures
                                         for residents at high risk for falls. In one case, a
                                         resident was found on the floor on 11 occasions
                                         over a 4-month period, having experienced
                                         unwitnessed falls while walking. Another resident
                                         experienced 16 falls over a 9-month period; 13 were
                                         unwitnessed and 2 resulted in fractures.
                                                                                                                 (continued)



                                       Page 62                               GAO/HEHS-99-157 Poorly Performing Nursing Homes
                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                               Was
Survey    severe           residents                                                               documented
numbera   rating   F-tag    affected     Deficiency abstract                                       harm done? Category
102a      K         276           3      The nursing home failed to reassess in a timely           Y           Resident
                                         manner three residents for risk of falls and one of                   assessment
                                         the three for nutritional needs, and failed to develop
                                         interventions to deal with the three residents’
                                         changing needs. All three residents had repeated
                                         falls with injuries, and one of the three also
                                         experienced significant weight loss over a 3-month
                                         period; no reassessment or intervention was
                                         performed to deal with these problems.
102b      K         310           3      The nursing home failed to ensure that three              Y           Quality of care
                                         residents’ ability to walk did not decline unless the
                                         residents’ clinical conditions made this unavoidable.
                                         Although all three residents had goals for daily
                                         walking with assistance in their plans of care, none
                                         were being walked. Two of these residents had
                                         experienced declines in their ability to walk.
102c      K         318           5      The nursing home failed to provide appropriate            Y           Quality of care
                                         range-of-motion treatment and services to five
                                         residents, as called for by physicians’ orders and/or
                                         plans of care. Two of these residents experienced
                                         documented declines in their functional range of
                                         motion.
102d      K         324           2      The nursing home failed to provide adequate               Y           Quality of care
                                         supervision for two residents to prevent falls. One
                                         resident fell five times in 2 months, sustaining
                                         several injuries, including fractures to the wrist. The
                                         other fell 13 times over a 7-month period, sustaining
                                         several injuries, one of which required
                                         hospitalization.
103       G         309           1      The nursing home failed to obtain prompt treatment        Y           Quality of care
                                         for a resident following a fall that resulted in an
                                         injury. The resident was not treated and was in pain
                                         for 21 hours because the home failed to obtain
                                         prompt treatment for a fractured hip.
104       G         324           1      The nursing home failed to ensure the health and          Y           Quality of care
                                         safety of a resident by not providing adequate
                                         supervision. A clinical record review revealed that a
                                         resident fell down an open stairwell and sustained
                                         injuries that required emergency transport to the
                                         hospital.
                                                                                                                  (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                             Was
Survey    severe           residents                                                             documented
numbera   rating   F-tag    affected     Deficiency abstract                                     harm done? Category
105a      G         314           4      The nursing home failed to ensure that residents        Y             Quality of care
                                         with pressure sores received appropriate treatment
                                         and to provide services to promote healing and
                                         prevent new sores from developing. One resident
                                         was discovered with a severe pressure sore on her
                                         left heel—indicating that skin areas were not being
                                         checked regularly and that services were not
                                         provided to prevent this area from breaking down.
                                         Another resident was found with a moderately
                                         severe pressure sore on his coccyx—the sore had
                                         been misidentified as an abrasion and was not
                                         properly treated. Two other residents did not
                                         receive proper care to promote healing of their
                                         pressure sores.
105b      G         324           1      The nursing home failed to ensure that residents        Y             Quality of care
                                         received adequate supervision and assistive
                                         devices to prevent accidents. One resident was
                                         observed straddled across his bed with his legs
                                         across the arms of his wheelchair. He had hit his
                                         head on the side rail and was calling for help. Staff
                                         were noted walking by his room without coming to
                                         his aid until the presence of the surveyors was
                                         noted. Despite the resident’s history of falls and
                                         injuries, the home did not assess or evaluate the
                                         circumstances of his falls or take preventive
                                         measures.
105c      G         325           2      The nursing home failed to ensure that residents        Y             Quality of care
                                         maintained acceptable parameters of nutritional
                                         status, such as body weight. One resident lost 16
                                         percent of her body weight in less than 3 months
                                         (considered a severe loss), particularly significant
                                         because the resident also had a newly discovered
                                         severe pressure sore. Another morbidly obese
                                         resident was admitted to recover from knee surgery.
                                         Although the resident needed guidance in nutrition,
                                         she was never referred to or seen by a dietitian
                                         during her 25-day stay.
                                                                                                                  (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                               Was
Survey    severe           residents                                                               documented
numbera   rating   F-tag    affected     Deficiency abstract                                       harm done? Category
106a      G         314           1      The nursing home failed to ensure that residents          Y           Quality of care
                                         with pressure sores received appropriate treatment
                                         and services to promote healing. A resident’s initial
                                         assessment indicated that the resident was
                                         dependent on staff for all care needs. A pressure
                                         area on the buttock was present on admission. A
                                         month later, nursing documentation noted that the
                                         resident had an “open area” on the left buttock. A
                                         pressure sore risk assessment had not been done
                                         at that time. Observation 2 months after admission
                                         revealed that the resident had two moderately
                                         severe pressure sores on the left buttock. The
                                         nurse, who was present during the observation,
                                         stated that she was unaware of the existence of the
                                         resident’s pressure sores. An interview with the
                                         director of nursing noted that the licensed staff had
                                         not notified the physician or provided treatment for
                                         the resident’s pressure sore.
106b      G         324           2      The nursing home failed to provide supervision,           Y           Quality of care
                                         assistive devices, or other interventions for residents
                                         who had experienced frequent falls. Based on
                                         medical records review and staff interviews, the
                                         home did not provide adequate care for two
                                         residents. This resulted in multiple skin tears and
                                         bruises for one resident and a fall resulting in a
                                         fractured left clavicle for another resident.
107       G         319           1      The nursing home did not comply with physician’s          Y           Quality of care
                                         orders for a psychiatric evaluation for a male
                                         resident despite at least six sexual incidents over a
                                         6-month period. At least two female residents were
                                         unwillingly exposed to the genitalia of this resident.
108a      K         314           3      The nursing home failed to provide three residents        Y           Quality of care
                                         with necessary services and devices to prevent and
                                         heal pressure sores. All three residents developed
                                         severe pressure sores, yet the home did not provide
                                         any pressure-relieving devices to promote healing
                                         of the sores. One resident’s sore was so deep that
                                         bone was exposed.
108b      K         319           1      The nursing home failed to ensure that a resident         Y           Quality of care
                                         displaying aggressive behavior toward other
                                         residents received appropriate services and
                                         treatment to prevent this aggression. This resident
                                         struck seven other residents. The home failed to
                                         develop effective behavioral interventions to deal
                                         with this resident’s aggressiveness.
                                                                                                                  (continued)




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                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                             Was
Survey    severe           residents                                                             documented
numbera   rating   F-tag    affected     Deficiency abstract                                     harm done? Category
109       G         325           2      The nursing home failed to ensure that two residents    Y            Quality of care
                                         with diagnosed protein energy malnutrition received
                                         appropriate nutrition as recommended by a
                                         registered dietitian. Nursing staff were unaware of
                                         these recommendations. A doctor’s order was
                                         required for one resident’s diet to be changed
                                         because the resident had a feeding tube inserted
                                         into the stomach. The dietitian reported that the
                                         resident was not receiving the amount of protein
                                         that she required and recommended that the
                                         nursing home staff notify the physician. This was not
                                         done.
110a      G         221           6      The nursing home failed to ensure that six residents    Y            Resident
                                         were free from unnecessary use of restraints. One                    behavior and
                                         resident had falls from the bed when side rails were                 facility
                                         used and sustained bruises. After these incidents,                   practices
                                         the home did not address the risk of raised side
                                         rails and attempt to use other measures for this
                                         resident. The resident again fell from the bed (and
                                         sustained a hip fracture) when side rails were
                                         elevated.
110b      G         318           2      The nursing home failed to ensure that residents        Y            Quality of care
                                         with a limited range of motion received appropriate
                                         treatment and services to increase their range of
                                         motion and/or prevent further decline. Clinical
                                         records indicated that one resident had limited
                                         range of motion of her right elbow and wrist.
                                         Interventions listed in the current plan of care
                                         included using hand and elbow splints according to
                                         schedule and passive range-of-motion exercises
                                         seven times a week to prevent further decline. The
                                         resident was observed without the splinting device
                                         in place per the plan of care. The resident had
                                         experienced further decline in range of motion
                                         during a 6-month period the previous year. Another
                                         resident’s physical therapy screening noted that the
                                         resident required a splint to support her right ankle
                                         while walking. The physician’s order and resident’s
                                         care plan indicated that the splint was to be worn
                                         when out of bed. Observations on two separate
                                         days noted that the resident did not have a splint on
                                         when out of bed. The nurse was unaware that the
                                         splint was missing until the surveyor informed her.
                                         The splint could not be located in the resident’s
                                         room and was replaced by the physical therapy
                                         department.
                                                                                                                 (continued)




                                       Page 66                               GAO/HEHS-99-157 Poorly Performing Nursing Homes
                                       Appendix III
                                       Abstracts of 201 Sampled G-Level
                                       Deficiencies




          Most                No. of                                                                Was
Survey    severe           residents                                                                documented
numbera   rating   F-tag    affected     Deficiency abstract                                        harm done? Category
110c      G         324           3      The nursing home failed to provide adequate                Y           Quality of care
                                         supervision and assistive devices to prevent
                                         accidents. A resident had a history of falling while
                                         on her way to the bathroom, and the home’s
                                         planned preventive interventions included
                                         encouraging the resident to use the call bell for
                                         assistance. The resident was observed seated in
                                         her room unattended with the call bell out of reach.
                                         In addition, the resident received a psychoactive
                                         medication. The resident fell, but there was no
                                         assessment in the medical record of whether the
                                         resident’s psychoactive medication contributed to
                                         the fall. During a separate incident, the resident fell,
                                         receiving a laceration to the forehead that required
                                         sutures. Another resident, who had a history of
                                         falling from bed, had an intervention that a low bed
                                         be used when available. This was also included in
                                         the plan of care. There was no documentation to
                                         support follow-through with this recommendation.
                                         The resident had four additional falls from bed
                                         during a 2-1/2-month period. It was not until after
                                         the 2-1/2-month period that the lack of a low bed
                                         was addressed, and the resident’s mattress was
                                         placed on the floor at that time. A third resident, who
                                         had a history of falls while going to and from the
                                         bathroom, had a care plan directing that staff were
                                         to provide assistance to the resident while
                                         transferring and walking. The resident was
                                         observed on 2 separate days walking from the
                                         bathroom without assistance or supervision.
                                         Additionally, four residents interviewed during the
                                         survey complained of staff leaving them in the
                                         bathroom and not returning promptly (up to 20
                                         minutes). Observations of the noon meal in the main
                                         dining room noted that 26 residents were eating
                                         lunch with no nursing staff supervision for 10
                                         minutes. One of these residents was receiving
                                         continuous oxygen.
                                                                                                                   (continued)




                                       Page 67                                 GAO/HEHS-99-157 Poorly Performing Nursing Homes
                                        Appendix III
                                        Abstracts of 201 Sampled G-Level
                                        Deficiencies




           Most                No. of                                                                      Was
Survey     severe           residents                                                                      documented
numbera    rating   F-tag    affected      Deficiency abstract                                             harm done? Category
110d       G         329           1       A nursing home had no documentation to justify the              Y                Quality of care
                                           use of a long-acting psychoactive drug for a
                                           resident’s anxiety without attempting to use a
                                           short-acting drug first. Also, the home gave the
                                           resident a sleep-inducing drug for 3 months,
                                           although the home did not address possible causes
                                           of sleeplessness. The resident had two falls, one
                                           resulting in a laceration requiring sutures, and the
                                           medication regimen was not evaluated for possible
                                           causal contribution.

                                        a
                                         Some homes had multiple G-level deficiencies. These are reflected by the letters following the
                                        survey number.




(101861)                                Page 68                                    GAO/HEHS-99-157 Poorly Performing Nursing Homes
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