CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 000 INITIAL COMMENTS F 000 F 157 SS=H Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately. 483.10(b)(11) NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in 483.12(a). The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in 483.15(e)(2); or a change in resident rights under Federal or State law or F 157 LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. Event : Y62411 Facility : 0876 If continuation sheet Page 1 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 157 Continued From page 1 F 157 regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member. This REQUIREMENT is not met as evidenced by: Based on observation, record review and interview, the facility failed to ensure the physician was immediately consulted upon deterioration of a recurrent Stage II pressure ulcer resulting in a delay in treatment for 1 (Resident #1) of 3 (Residents #1, #3 and #20) case mix residents with pressure ulcers. The failed resulted in a pattern of harm for Resident #1 whose pressure ulcer deteriorated and had the potential to cause more than minimal harm for 4 residents with pressure ulcers, as identified on a list provided by the Administrator on 3/19/11. The facility further failed to ensure the family was notified of the deterioration of a recurrent Stage II pressure ulcer for 1 (Resident #1) of 3 (Residents #1, #3 and #20) case mix residents with pressure ulcers and failed to ensure the family was notified of a psychological evaluation for 1 of 1 (Resident #17) case mix resident with an order for a psychological evaluation. This failed practice had the potential to affect 4 residents who had pressure ulcers and 1 resident with an order for a psychological evaluation, according to a list provided by the Administrator on 3/19/11. The findings are: 1. The Policy and Procedure for Pressure Ulcer and Skin Conditions, Care and Prevention of documented, "...Notification of the Physician is Event : Y62411 Facility : 0876 If continuation sheet Page 2 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 157 Continued From page 2 F 157 required when a new pressure ulcer is identified as well as when treatment is not effective..." 2. The Resident Informational Handbook, part of the admission packet, documented, "...Notice of Rights and Services...The facility must consult with you and notify your physician and interested family member of any significant change in your condition or treatment..." 3. Resident #1 had diagnoses of Congestive Heart Failure, Decubitus Ulcer and Coronary Artery Disease. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/18/11 documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent on two-plus persons for activities of daily living, was of incontinent of bowel and bladder, received as needed pain medication and was at risk of developing a pressure ulcer. a. The resident's March 2011 Physician orders documented, "...3/8/11 D/C [Discontinue] previous coccyx [wound] care orders. Clean [with] wc [wound cleaner]. Apply Xenaderm T [three times a day] [and] PRN [as needed] until resolved..." The Physician orders were signed by the Physician on 3/16/11. b. On 3/16/11:00 at 8:55 a.m., a body audit was performed by Registered Nurse (RN) #3; the resident had 3 small pinpoint stage II open areas all in an approximate 1 centimeter (cm) diameter area on his coccyx. They were pink in color and had no drainage. c. On 3/17/11 at 2:30 p.m., a wound treatment to the resident's coccyx was observed. Registered Event : Y62411 Facility : 0876 If continuation sheet Page 3 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 157 Continued From page 3 F 157 Nurse (RN) #3 stated, "Oh it's much worse today than yesterday." The RN took a plastic measure guide out of her pocket and measured the wound. The area measured 3 cm by 1 cm. The stage II open wound had serous sanguineous drainage present. d. On 3/18/11 at 9:05 a.m., RN #3 was asked, "Did you notify the physician yesterday of the increase in size of the resident's wound?" She stated, "No. If we were to change the order I would have talked to him, but at this time we are going to continue with the Xenaderm. Try to stick with Xenaderm couple more days probably until Monday." The RN was asked, "Did you notify his family of the change in the wound?" She stated, "No ma'am, but his son comes everyday. Again, the family would get notified if there was a new treatment order. " e. On 3/18/11 at 11:10 a.m., RN #3 was asked, "Has the doctor seen the resident's wound?" She stated, "No, he has not looked at his [resident's] bottom." The RN was asked, "Is the Doctor aware that the resident has a wound?" She stated, "Oh yeah." The RN was asked, "Can you show documentation where the physician is aware of the wound?" She stated, "I don't know that we have any, other than his signature on the order for the treatment. At the most, it would be a 6 day period before they [the doctor or the nurse practitioner] would sign off the order. If it's anything really serious he would be made aware. A phone call would be documented in the nurses' Event : Y62411 Facility : 0876 If continuation sheet Page 4 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 157 Continued From page 4 F 157 notes. In terms of sores that have developed here I can't think of anything serious enough for immediate notification. We rarely get anything greater than a Stage II." f. A Physician progress note dated 3/18/11 documented, "Called to see patient by staff secondary to progression of wound on sacrum from stage one to stage II. Now has curvilinear ulceration on [right] side ~ [approximately] 2-3 inches long. Will treat [with] duoderm..." 4. Resident #17 had diagnoses of Cerebrovascular Accident, Depression, Chorea Gravis, Dementia, Colon Cancer and Alcoholism. The Annual MDS with an ARD of 12/28/10 documented the resident was moderately impaired in cognitive skills for daily decision making, had no behaviors and was independent in activities of daily living. a. A Physician order dated 3/16/11 documented, "Psyc [psychiatric] eval [evaluation]. Send copy of nurses notes to appt.[ appointment]..." b. The plan of care reviewed 12/29/10 documented, "3/16/11 Psyc eval ordered." F 164 SS=E c. As of 3/18/11 at 5:25 p.m., there was no documentation in the Nurses' Notes or in the Social Service Progress Notes that the resident's family had been notified regarding the order for a psychiatric evaluation. 483.10(e), 483.75(l)(4) PERSONAL PRIVACY/CONFENTIALITY OF RECORDS The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. F 164 Event : Y62411 Facility : 0876 If continuation sheet Page 5 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 164 Continued From page 5 F 164 Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. Except as provided in paragraph (e)(3) of this section, the resident may approve or refuse the release of personal and clinical records to any individual outside the facility. The resident's right to refuse release of personal and clinical records does not apply when the resident is transferred to another health care institution; or record release is required by law. The facility must keep confidential all information contained in the resident's records, regardless of the form or storage methods, except when release is required by transfer to another healthcare institution; law; third party payment contract; or the resident. This REQUIREMENT is not met as evidenced by: Based on observation, record review and interview, the facility failed to ensure clothing or draping was provided to prevent unnecessary exposure of body parts during incontinent care for 1 (Resident #1) of 5 (Residents #1, #2, #4, #5 and #8) case mix residents who were incontinent and Medication Administration Records (MAR's) were not left open and unattended for 2 (Residents #3 and #16) of 16 (Residents #1 through #16) case mix residents who received medications. The failed practice had the potential Event : Y62411 Facility : 0876 If continuation sheet Page 6 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 164 Continued From page 6 F 164 to affect all 72 residents in the facility who received medications and 24 residents who were dependent for incontinent care, according to a list provided by the Administrator on 3/19/11. The findings are: 1. Resident #1 had diagnoses of Dementia with Behaviors, Osteoarthritis, Coronary Artery Disease and Chronic Atrial Fibrillation. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/18/11 documented the resident was severely impaired in cognitive skills for daily decision making per staff assessment per staff assessment for mental status, was totally dependent on the physical assistance of two-plus persons for activities of daily living and was incontinent of bowel and bladder. a. On 3/18/11 at 9:15 a.m., Licensed Practical Nurse (LPN) #6 and Certified Nursing Assistant (CNA) #3 provided incontinent care for the resident. The resident was rolled to his side, his back and buttock areas were exposed. The resident was then positioned on his back and the hospital gown was removed by LPN #6, leaving the resident's genital area exposed to the 6 people in the room during the procedure. The resident stated on two different occasions, "Cover me up." b. On 3/19/11 at 10:10 a.m., LPN #6 was asked, "How were you trained to promote privacy during incontinent care?" She stated, "Pull privacy curtains, tell the resident what you are going to do." The LPN was asked, "Should a resident be left exposed during incontinent care?" She stated, "No." Event : Y62411 Facility : 0876 If continuation sheet Page 7 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 164 Continued From page 7 F 164 2. On 3/16/11 at 12:03 p.m., Resident #3's Medication Administration Record (MAR) was open, on the medication cart, with confidential information in full view. The medication cart was sitting in the hallway and there was no LPN in view. F 241 SS=E 3. On 3/16/11 at 12:37 p.m., Resident #16's MAR was open, on the medication cart, to confidential information. The medication cart was sitting in the hallway and there was no LPN in view. 483.15(a) DIGNITY AND RESPECT OF INDIVUALITY The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. F 241 This REQUIREMENT is not met as evidenced by: Based on observation, record review and interview, the facility failed: to ensure staff knocked or announced themselves before entering for 1 (Resident #2) of 9 (Residents #1 through #9) case mix residents; to ensure staff did not did not position themselves above a resident to provide assistance with eating for 1 (Resident #2) of 2 (Residents #2 and #4) case mix residents who required assistance with eating at the feeding assistance table on the fifth floor; to ensure catheter privacy bags were provided when in public view for 2 (Residents #27 and #28) of 6 (Residents #2, #3, #14, #20, #27 and #28) Event : Y62411 Facility : 0876 If continuation sheet Page 8 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 241 Continued From page 8 F 241 case mix residents with an indwelling urinary catheter; and to ensure staff did not ignore a request at meal time for 1 (Resident #29) of 8 (Residents #3, #8, #9, #13, #14, #15, #19 and #20) case mix residents on the sixth floor. The failed practice had the potential to affect all 72 residents who resided in the facility, according to the Resident Census and Conditions of Residents dated 3/14/11; 5 residents who ate at the feeding assistance table on the fifth floor, according to a list provided by the Administrator on 3/19/11; 11 residents with indwelling urinary catheters, according to a list provided by the Administrator on 3/19/11 and 38 residents who ate in the dining room on the sixth floor, according to initial round on 3/14/11. The findings are: 1. Resident #2 had diagnoses of Anxiety and Depression. The Significant Change Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/13/11 documented the resident had severely impaired cognitive skills for daily decision making per staff assessment for mental status and required limited assistance of one person for eating. a. On 3/15/11 at 12:54 p.m., the resident sat in a wheelchair at the assisted dining table. Certified Nursing Assistant (CNA) #2 stood over the resident and offered him fluids and food. The resident declined to open his mouth. CNA #3 stood over the resident to offer food. CNA #3 talked to the other CNAs at the table for residents who required feeding assistance, about personal issues and did not involve the resident in the conversation. Event : Y62411 Facility : 0876 If continuation sheet Page 9 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 241 Continued From page 9 F 241 On 3/17/11 at 4:35 p.m., when asked if staff should stand over a resident when assisting at a meal and talk to other staff, Registered Nurse (RN) #4 stated, "Never." b. On 3/14/11 at 4:15 p.m., Registered Nurse (RN) #2 entered the resident's room, without knocking or announcing herself prior to entrance. On 3/16/11 at 3:37 p.m., Certified Nursing Assistant (CNA) #1 did not knock before entering the resident's room. 2. Resident #27 was admitted to the facility on 3/7/11 and had a diagnosis of Urine Retention. a. On 3/14/11 at 3:34 p.m., Registered Nurse (RN) #3 stated the resident was alert and oriented, used a wheelchair for mobility and had a Foley catheter. At this time, the resident was in bed; catheter tubing was observed connect to a urine collection bag. There as yellow urine in the collection bag. b. On 3/14/11 at 5:35 p.m., the resident was in a wheelchair in the dining room. An indwelling urinary catheter bag was visible underneath the wheelchair. The urine collection bag was not in a privacy bag. 3. Resident #28 had a diagnosis of Urinary Retention. a. On 3/14/11 at 3:34 p.m. RN #2 stated the resident was alert, oriented times one, was mobile per wheelchair and had an indwelling catheter. At this time, the resident was lying in bed. Yellow urine was noted in the resident's Event : Y62411 Facility : 0876 If continuation sheet Page 10 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 241 Continued From page 10 F 241 urine collection bag. b. On 3/15/11 at 10:20 a.m., the resident was in a wheelchair, in the hallway, near the nurses' station. A urinary catheter bag was under the wheelchair, with no privacy bag. 4. Resident #29 had diagnoses of Parkinson's Disease and Dementia with Behavior Disturbance. The Annual MDS with an ARD of 3/2/11 documented the resident had a score of 12 (moderately impaired) per brief interview for mental status (BIMS) and required setup help for eating. a. On 3/14/11 at 3:42 p.m., RN #1 stated the resident had the behavior of agitation. b. On 3/15/11 at 12:25 p.m., the resident was sitting in the dining room at a table by himself. Licensed Practical Nurse (LPN) #7 was holding a medicine cup with a pill in it and a glass of water. The LPN administered the medication to Resident #8, who was sitting at another table in the dining room. After Resident #8 took the medication, the LPN picked up the used water glass and returned to the medication cart. While returning to the cart, the LPN walked past Resident #29, who asked LPN #7 for a coffee cup as she walked past him. The LPN did not look at the resident or acknowledge him in any way and continued past him to her cart where she discarded the used glass into the trash receptacle on the medicine cart. c. On 3/15/11 at 12:26 p.m., LPN #7 was asked what the resident had asked for. The LPN stated, "He wanted a coffee cup." The LPN was asked why she did not stop for the resident's request. Event : Y62411 Facility : 0876 If continuation sheet Page 11 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 241 Continued From page 11 F 241 She stated, "Well, I had pills in my hand and we didn't have coffee cups." F 246 483.15(e)(1) REASONABLE ACCOMMODATION SS=E OF NEEDS/PREFERENCES A resident has the right to reside and receive services in the facility with reasonable accommodations of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered. F 246 This REQUIREMENT is not met as evidenced by: Based on observation, record review and interview, the facility failed to ensure a resident's need for socialization was accommodated, as evidenced by failure to ensure 1 (Resident #7) of 3 (Residents #3, #7, and #8) case mix residents on isolation was not confined to his room unnecessarily; failed to ensure a table was provided in resident rooms for use during meals for 2 of 2 (Residents #2 and #9) case mix residents who ate their meals in their room on the fifth floor; and failed to ensure a bed was of a length to accommodate a height in excess of 6-feet for 1 (Resident #3) of 2 (Residents #3 and #9) case mix residents who were greater than 6-feet tall. This failed practice had the potential to affect 11 residents who ate the evening meal in the room on fifth floor and 11 residents who were greater than 6-feet tall, according to a list provided by the Assistant Director of Nursing (ADON) on 3/16/11. The findings are: 1. Resident #7 had a diagnosis of Urinary Tract Infection (UTI). The Quarterly Minimum Data Set Event : Y62411 Facility : 0876 If continuation sheet Page 12 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 246 Continued From page 12 F 246 (MDS) with an Assessment Reference Date (ARD) of 2/23/11 documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 (13-15 indicates cognitively intact), was always continent of bowel and bladder and was independent with toilet use. a. A physician's order dated 3/4/11 documented, "Bactrim DS [double strength] i [one] PO [orally] B [two times a day] X [times] 14 days and then [recheck] UA [urinalysis]". b. The plan of care dated 2/24/11 documented an update dated 3/4/11 for, "MRSA [Methicillin-resistant Staphylococcus aureus] Bladder Inf. [infection]. Give Bactrim per order... Contact Isolation..." c. Nurse Notes dated 3/4/11 documented, "Resident had UA come back with Methicillin-resistant staphyloccus aureus in urine... Place in isolation until urine [negative]. Resident was informed why he had to be put in isolation very receptive and cooperative with situation." d. Nurse Notes dated 3/10/11 at 8:15 p.m. documented, "...Remains in contact isolation. Reports he 'is bored'. Does have TV in room, but not interested much in watching TV..." e. Nurse Notes dated 3/11/11 at 10:15 a.m. documented, "...Remains in contact isolation. Has left room twice 'just to get out for awhile.' Found in B hall. Escorted back to room." f. Nurse Notes dated 3/11/11 at 9:00 p.m. documented, "...Remains in contact isolation, but cont. [continues] to come out of room and into Event : Y62411 Facility : 0876 If continuation sheet Page 13 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 246 Continued From page 13 F 246 hallway..." g. On 3/14/11 at 4:10 p.m., Registered Nurse (RN) #2 stated, "Positive MRSA in urine. Eats in room now due to isolation. He didn't like it when I told him he had to eat in his room, but I explained about MRSA and he's okay with it." RN #2, when asked if the resident was continent or incontinent of bowel and bladder, stated, "Continent." h. On 3/15/11 at 8:52 a.m., Resident #7 stated, "I like to go out to the dining room and they don't walk with me around the block like they used to. I have to stay in my room now due to the infection. That kinda bothers me." i. On 3/15/11 at 11:23 a.m., the resident was asked what he would do if he was allowed to come out of his room. Resident #7 stated, "Wheel around the hall and look out the window." When asked if there was any problem with being in the room, Resident #7 stated, "Boredom. Don't watch TV except for the news. They preach about washing hands. I can go to the bathroom by myself." The resident denied any problems with incontinence or dribbling of urine and stated, "Don't need help with any of that. Come back and visit. I've got lots of time." j. On 3/15/11 at 11:42 a.m., Licensed Practical Nurse (LPN) #5 was asked why the resident was on isolation and what they did for isolation. LPN #5 stated, "MRSA in the urine. Keep him away from others, make him stay in his room. He's continent. I don't know if he washed his hands. I spoke with resident about isolation, MRSA and handwashing. He doesn't like it. He's social, roams around. Has been on isolation about 7 days." The resident had been on isolation for 11 Event : Y62411 Facility : 0876 If continuation sheet Page 14 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 246 Continued From page 14 F 246 days at this time. k. On 3/15/11 at 11:44 a.m., when asked what she does for the isolation resident, the Activity Director stated, "I don't do anything specific. He doesn't like structured activities. He didn't attend when not on isolation. He roams around the hall and visits with the fellows. He does watch TV in his room and I visit at times." l. On 3/15/11 at 11:55 a.m., when asked about the resident being on isolation, the Director of Nurses (DON) stated, "I wasn't aware he was on isolation." When asked about a continent resident that could wash their hands, the DON stated, "No isolation needed. Need to educate staff about not causing undue psychological stress." 2. Resident #2 had diagnoses of Debility, Anxiety and Depression. The Significant Change Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/13/11 documented the resident had severely impaired cognitive skills for daily decision making per staff assessment for mental status and required assistance with eating. a. The Plan of Care dated 2/1/11 documented, "Assisted with meals in assisted dining area." b. On 3/15/11 at 6:10 p.m., Certified Nursing Assistant (CNA) #4 brought the resident's meal tray into the resident's room. The resident was in bed. There was no overbed table in the resident's room. The CNA stated, "His [resident's] table's gone." CNA #4 asked the resident if he was hungry and the resident nodded to indicate, "Yes." The CNA sat the meal tray on the heat/air Event : Y62411 Facility : 0876 If continuation sheet Page 15 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 246 Continued From page 15 F 246 unit shelving under the window and stated, "The table was here last night. Don't know where it went." The CNA assisted the resident to eat by handing him food from the tray approximately 3-feet away. The CNA stated, "Usually I set it up in front of him and he'll feed himself." c. On 3/16/11 at 3:15 p.m., there was no overbed table in the resident's room. At 3:20 p.m., CNA #4 stated, "I will be getting the resident up for supper because there is no overbed table in the room." 3. Resident #3 had diagnoses of Replacement of Hip Joint and Dislocation of Hip. The Significant Change MDS with an ARD of 3/8/11 documented the resident had a score of 15 (cognitively intact) per brief interview for mental status (BIMS), had pain almost constantly that had made it hard to sleep at night and limited day-to-day activities, was 76-inches tall (6-feet and 4-inches tall) and was readmitted to the facility on 3/4/11 from an acute care hospital. a. An Admission Evaluation And Interim Care Plan dated 3/14/11 documented the resident had "Failed hip arthroplasty" on 3/1/11 and 3/9/11. The reason for admission was documented as, "S/P [status post] dislocation Rt [right] hip." The form documented the resident needed assistance with bed mobility, had an abduction splint and had a pain pill daily with the worst pain reported at a level 8 on scale of 0-10 (5-10 excruciating pain). b. The Physician's orders dated 3/14/11 documented, "MSIR [Morphine Sulfate] 15 mg [milligrams] Q [every] 4 HRS [hours]; and Tylenol 325 mg 2 tabs (total dose = 650 mg) Q 6 hours for pain." Event : Y62411 Facility : 0876 If continuation sheet Page 16 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 246 Continued From page 16 F 246 As of 3/15/11 at 11:00 a.m., the resident's March 2011 Medication Record documented the resident had received the morphine dose five times since his readmission on 3/14/11 and had received the Tylenol three times. c. On 3/15/11 at 6:00 p.m., the resident was in bed. The head of the bed was up approximately 30 degrees and the resident was wearing an abduction splint. The resident's feet were flat on the bed footboard. The resident was asked his height and he stated, "Six-foot four." The resident was asked if his bed was too short. He stated, "Yes ma'am, I'm almost crying now. It compacts my joints and everything." The resident was asked if anyone had asked about his bed or if he had told anyone about his bed. He stated, "No, I didn't think there was anything they could do." d. On 3/15/11 at 6:50 p.m., Registered Nurse (RN) #2 was asked if anyone had talked with the resident about his bed. She stated, "No one talked with him about his bed." The RN was asked if anyone had assessed his size and the bed he was in, especially after his last two hip dislocations. She stated, "Not that I know of." 4. Resident #9 had diagnoses of Chronic Obstructive Pulmonary Disease, Diabetes Mellitus and Muscle Weakness. The Quarterly MDS with an ARD of 2/15/11 documented the resident had a score of 14 per BIMS (cognitively intact) and required setup help for eating. a. On 3/16/11 at 3:28 p.m., the resident did not have an overbed table in his room. b. On 3/16/11 at 3:35 p.m., the resident did not Event : Y62411 Facility : 0876 If continuation sheet Page 17 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 246 Continued From page 17 F 246 F 281 SS=H have an overbed table in his room. He was lying on top of his bed, talking with the surveyor. CNA #5 came into the resident's room to pass an afternoon snack to the resident. The CNA placed the resident's Orange Sherbet cup on his bed, on top of the linens. The resident picked the sherbet up from his bed to eat it. 483.20(k)(3)(i) SERVICES PROVED MEET PROFESSIONAL STANDARDS The services provided or arranged by the facility must meet professional standards of quality. F 281 This REQUIREMENT is not met as evidenced by: Based on observation, record review and interview, the facility failed to ensure Physician orders for wound care treatments were not written by nurses without consulting the Physician to obtain the order for 1 (Resident #1) of 3 (Residents #1, #3 and #20) case mix residents with pressure ulcers. The failed practice resulted in a pattern of harm for Resident #1, whose pressure ulcer deteriorated, and had the potential to cause more than minimal harm for 4 residents with pressure ulcers, as identified on a list provided by the Administrator on 3/19/11. The facility failed to ensure Physician Orders were checked for accuracy and clarified by licensed staff on a monthly basis for 3 (Residents #1, #6 and #7) of 9 (Residents #1 through #9) case mix residents who had physician orders. The failed practices had the potential to cause more than minimal harm for all 72 residents in the facility with Physician orders, according to the Resident Census and Conditions of Residents form dated 3/14/11 Event : Y62411 Facility : 0876 If continuation sheet Page 18 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 281 Continued From page 18 F 281 The findings are: 1. The Arkansas State Board of Nursing Rules located at http://www.arsbn.arkansas.gov/lawsrules/pages/ rules.aspx documented, "...The Practice of Professional Nursing: The performance for compensation of any acts involving the observation, care, and counsel of the ill, injured, or infirm; the maintenance of health or prevention of illness of others; the supervision and teaching of other personnel; the delegation of certain nursing practices to other personnel as set forth in rules established by the board; or the administration of medications and treatments as prescribed by practitioners authorized to prescribe and treat according to state law where such acts require substantial specialized judgment and skill based on knowledge and application of the principles of biological, physical, and social sciences..." 2. Resident #1 had diagnoses of Congestive Heart Failure, Decubitus Ulcer, Dementia with Behaviors, Hypertension, Osteoarthritis, Coronary Artery Disease and Chronic Atrial Fibrillation. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/18/11 documented the resident was severely impaired in cognitive skills for daily decision making per staff assessment for mental status, was totally dependent on two-plus persons for activities of daily living, was always incontinent of bowel and bladder, received as needed pain medication, was at risk of developing a pressure ulcer and received oxygen therapy. The Plan of Care dated 3/3/11 had no documentation regarding a Foley catheter. Event : Y62411 Facility : 0876 If continuation sheet Page 19 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 281 Continued From page 19 F 281 a. The facility failed to ensure Physician orders for wound care treatments were not written by nurses without consulting the Physician to obtain the order: 1) A Nurses Note dated 1/10/11 documented, "Open area [times] 2 to coccyx area both approximately 1 cm [centimeter] diameter. Bloody drainage noted. N.O.[ new order] for Duoderm." The resident's January 2011 Treatment Administration Record (TAR) documented on 1/10/11, "Duoderm coccyx area Q [every] three days." 2) A Nurses Note dated 1/22/11 documented, "Duoderm to buttock [changed]. Area dark pink in color with no open area noted." 3) The resident's February 2011 TAR documented, "Coccyx Duoderm resolved 2/8/11." 4) The March 2011 TAR documented by Nurses' initials that a treatment of DuoDerm to the coccyx every 3 days was done on 3/4/11 and 3/7/11. 5) The Physician order dated 3/8/11 documented, "dc [Discontinue] previous coccyx wound care orders. Clean with WC [wound cleaner] apply Xenaderm tid [three times a day] and prn [as needed] until resolved..." The Physicians' orders were signed by the Physician on 3/16/11. The March 2011 TAR documented the treatment was changed on 3/8/11 to clean area on coccyx with wound cleaner. Apply Xenaderm three times a day (T) until resolved; this treatment was done from 3/8/11 through 3/18/11. Event : Y62411 Facility : 0876 If continuation sheet Page 20 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 281 Continued From page 20 F 281 6) The Quality Assurance Skin Book provided by Registered Nurse (RN) #5 documented: Date: 2/21/11 area: Coccyx 4 [by] 3 cm Stage I Treatment: Duoderm Date: 2/23/11 area: coccyx 1/4 [by] 1/4 Stage I Treatment: Duoderm Date: 3/2/11 area: coccyx 1.5 [by] 1.5 [by] [less than] 0.1 Stage II Treatment: Duoderm Date: 3/8/11 area: coccyx 2.0 [by] 1.0 [by] 0 Stage II Treatment: Xenaderm started Date: 3/16/11 area: coccyx 1.0 [by] 1.0 [by] [less than] 0.1 Stage II Treatment: Xenaderm 7) On 3/16/11 at 8:55 a.m., a body audit was performed by Registered Nurse (RN) #3; the resident had three small pinpoint stage II open areas in an approximately 1 cm diameter area on his coccyx. The open areas were pink in color and had no drainage. 8) On 3/17/11 at 2:30 p.m., a wound treatment to the coccyx was observed. RN #3 stated, "Oh, it's much worse today than yesterday." The RN took a plastic measure guide out of her pocket and measured the wound by touching the plastic measure guide to the wound. The area measured 3 cm [by] 1 cm. The stage II area had serous sanguineous drainage. The Quality Assurance Skin Book provided by Registered Nurse (RN) #5 documented, date: 3/17/11 3 cm [by] 1 cm Stage II bloody drainage. Event : Y62411 Facility : 0876 If continuation sheet Page 21 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 281 Continued From page 21 F 281 9) On 3/18/11 at 9:05 a.m., RN #3 was asked, "What is your procedure when you identify a wound or when a wound is worsening?" The RN stated, "Our doctor has given us the latitude to write our own orders if the area is not improving we normally change the treatment. We also have a wound consultant that comes once a month." RN #3 was asked, "Did you notify the Physician yesterday of the increase in size of the resident's wound?" She stated, "No, If we were to change the order I would have talked to him, but at this time we are going to continue with the Xenaderm. Try to stick with Xenaderm couple more days, probably until Monday." 10) On 3/18/11 at 10:15 a.m., in reference to obtaining orders for wound treatments RN #3 stated, "We explained to the doctor and showed him the algorithm for wound treatments that we use and he said that's fine. Also, the wound consultant would make recommendations." 11) On 3/18/11 at 11:10 a.m., RN #3 was asked, "Has the doctor seen the resident's wound?" She stated, "No he has not looked at his bottom." The RN was asked, "Is the Doctor aware that the resident has a wound?" She stated, "Oh yeah." The RN was asked, "Can you show documentation where the Physician is aware of the wound?" She stated, "I don't know that we have any, other than his signature on the order for the treatment. At the most it would be a six day period before they [the doctor or the nurse practitioner] would sign off the order. If anything really serious, he [Physician] would be made aware. A phone call would be documented in the Event : Y62411 Facility : 0876 If continuation sheet Page 22 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 281 Continued From page 22 F 281 Nurses' notes. In terms of sores that have developed here, I can't think of anything serious enough for immediate notification. We rarely get anything greater than a Stage II." 12) A Physician progress note dated 3/18/11 documented, "Called to see patient by staff secondary to progression of wound on sacrum from stage one to stage II. Now has curvilinear ulceration on [right] side ~ [approximately]2-3 inches long. Will treat [with] duoderm..." 13) On 3/18/11 at 12:20 p.m., when asked about the resident being treated with Xenaderm RN #3 stated, "Xenaderm is not on the Algorithm but it's been a long time treatment for pressure ulcers here. He [Physician] is aware and has signed off on all the orders." On 3/19/11 at 10:30 a.m., the Director of Nursing (DON) stated, "The nurses follow the algorithm for wound care approved by the doctor." The surveyor stated, "Xenaderm is not on the algorithm." The DON stated, "Yes [correct]." The DON was asked if the nurses could write an order without the Physician's approval. She did not answer the question. She was also questioned if this was part of the Arkansas State Board of Nursing practice; she did not answer the question. b. The facility failed to ensure Physician Orders were checked for accuracy and clarified by licensed staff on a monthly basis: 1) The Admission Physician orders documented the resident was readmitted to the facility on 2/21/11. As of 3/19/11 at 11:35 a.m., there was Event : Y62411 Facility : 0876 If continuation sheet Page 23 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 281 Continued From page 23 F 281 no admission orders for the resident's Foley catheter or oxygen. 2) The resident's March 2011 Physician orders contained no documentation of an order for oxygen or a Foley catheter. The March 2011 Treatment Administration Record (TAR) documented by Nurses' initials that oxygen was administered to the resident from 3/4/11 through 3/16/11. 3) On 3/14/11 at 3:50 p.m., the resident was receiving oxygen at 2 liters per nasal cannula (2L/NC) and had a Foley catheter with amber urine noted in the drainage bag. On 3/15/11 at 8:40 a.m., 10:29 a.m., 11:50 a.m. and 5:10 p.m., the resident was receiving oxygen at 2 liters per nasal cannula and had a Foley catheter. On 3/16/11 at 8:55 a.m., the resident was in bed receiving oxygen at 2 liters per nasal cannula. The resident's Foley catheter was draining dark amber urine. On 3/17/11 at 8:20 a.m., the resident was in bed receiving oxygen at 2 liters per minute via nasal cannula. The resident had a Foley catheter draining urine to a collection bag. On 3/18/11 at 10:10 a.m., Registered Nurse (RN) #3 stated that the person that worked with the resident's Physician orders had been off on extended leave and orders had been dropped off. 3. Resident #6 had a diagnosis of Cancer of the Lung with Metastasis. The Quarterly MDS with an Event : Y62411 Facility : 0876 If continuation sheet Page 24 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 281 Continued From page 24 F 281 ARD of 12/23/10 documented the resident scored 13 (cognitively intact) per brief interview for mental status (BIMS), required supervision with assistance of one person for activities of daily living and was continent of bowel and bladder. a. A physician order dated 10/1/09 documented the resident was to receive a Saline Updraft, 3 milliliters (ml) via nebulizer over 15 minutes, four times daily (qid) while awake. b. The Assessment for Self - Administration of Medications dated 10/29/09 documented, approval granted to self-administer: yes [checked]. At the top of the page [Nebulizer] was handwritten in. c. As of 3/15/11 at 9:42 a.m., the resident's March 2011 Physician's orders contained no documentation of an order for self-administration of updraft treatments. d. On 3/14/11 at 3:47 p.m., during the 4:00 p.m. medication pass, Licensed Practical Nurse (LPN) #1 entered the resident's room with the saline for the resident's updraft. The resident stated, "I'll do it before supper." The LPN placed the vial of saline on the table with the updraft machine and left the resident's room. e. As of 3/14/11, there was no current physician order on the March 2011 Physician Orders sheet for the resident to self-administer the updraft treatments f. On 3/18/11 at 10:10 a.m., Registered Nurse (RN) #3 stated that the person that worked with the resident's Physician orders had been off on extended leave and orders had been dropped off. Event : Y62411 Facility : 0876 If continuation sheet Page 25 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 281 Continued From page 25 F 281 4. Resident #7 had diagnoses of Chronic Airway Obstruction, Lesion of the Lung and Ischemic Heart Disease. The Quarterly MDS with an ARD of 2/23/11 documented the resident had a score of 13 (cognitively intact) per BIMS and did not receive oxygen. The Plan of Care dated 2/24/11 contained no documentation of the resident requiring oxygen. a. The resident's March 2011 Physician orders signed by the physician (with no signature date) documented, "Oxygen change O2 [oxygen] tubing weekly on Thurs [Thursday]" on the typed form. The March 2011 Physician's orders did not document an order for oxygen administration. The order sheet did not document the amount of oxygen to administer, how to administer the oxygen or if the oxygen was to be administered continuous or as needed. b. The resident's March 2011 TAR documented, "O2 2 L/Min [liters per minute] via N/C [nasal canula] for O2 sats [saturation] less than 90%. Check 2 sats per shift." Oxygen saturation levels were documented on the TAR on 3/15/11 for the 7:00 a.m. to 3:00 p.m. shift as 96% and on 3/16/11 for the 7:00 a.m. to 3:00 p.m. shift as 94%. c. On 3/14/11 at 4:10 p.m., an oxygen concentrator was in the off position in the resident's room. The tubing was bagged and dated 3/10/11. d. On 3/15/11 at 8:52 a.m. and on 3/16/11 at 8:55 a.m., the resident had oxygen on per nasal cannula at 2 liters per minute. Event : Y62411 Facility : 0876 If continuation sheet Page 26 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 281 Continued From page 26 F 281 F 282 SS=E e. On 3/18/11 at 10:10 a.m., RN #3 was questioned about the resident having no current oxygen order. The RN looked at the resident's clinical record and found no order on the March 2011 Physician orders or on the February 2011 Physician orders. An oxygen order was printed on the January 2011 Physician orders. The RN stated, "Our person who does this has been off on extended leave. The orders have gotten dropped off." 483.20(k)(3)(ii) SERVICES BY QUALIFIED PERSONS/PER CARE PLAN The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care. F 282 This REQUIREMENT is not met as evidenced by: Based on observation, record review and interview, the facility failed to ensure supplements were provided as per the Physician's plan of care for 2 (Residents #2 and #10) of 6 (Residents #1, #2, #4, #9, #10 and #14) case mix residents who received supplements and failed to ensure a therapeutic diet was provided as per the Physician plan of care for 1 (Resident #24) of 6 (Residents #1, #2, #5, #7, #8 and #9) case mix residents with a therapeutic diet. This failed practice had the potential to affect 22 residents who received Physician ordered supplements, according to a list provided by the Administrator on 3/19/11 and 44 residents with a Physician ordered therapeutic diet, according to the diet list provided by the Dietary Director on 3/14/11. The findings are: Event : Y62411 Facility : 0876 If continuation sheet Page 27 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 282 Continued From page 27 F 282 1. Resident #2 had diagnoses of Anxiety and Depression. The Significant Change Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/13/11 documented the resident had severely impaired cognitive skills for daily decision making per staff assessment for mental status and required limited assistance of one person for eating. a. A Physician order dated 12/27/10 documented, "Health shakes T [three times a day]." b. The Plan of Care dated 2/1/11 documented, "Assisted with meals in assisted dining area." c. On 3/15/11, the resident's lunch tray card documented, "Healthshake [at] meals." d. On 3/15/11 at 12:50 p.m., the resident was served fluids of 8-ounces of tea and 8-ounces of 2% milk. Certified Nursing Assistant (CNA) #2 offered the resident a drink and some potatoes. There was no health shake on the resident's tray. No health shake was offered before the resident left the dining area. e. On 3/17/11 at 4:35 p.m., when asked if the resident received health shakes at meals Certified Nurse Assistant (CNA) #1 stated, "Yes, he loves health shakes." 2. Resident #10 had a Physician order dated 2/22/11 for Resource 2.0 60 ml [milliliters] po [by mouth] tid [three times a day] with med [medication]pass. On 3/14/11 at 3:33 p.m., during the 4:00 p.m. Event : Y62411 Facility : 0876 If continuation sheet Page 28 of 105
CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) PROVER'S PLAN OF CORRECTION F 282 Continued From page 28 F 282 medication pass, Licensed Practical Nurse (LPN) #1 administered the resident's medication with 60 ml of Resource 2.0 while the resident was in their bed. The LPN gave the resident a sip of the Resource 2.0 and said, "Get your med down?" The LPN did not encourage the resident to take the rest of the Resource 2.0. The LPN took the Resource 2.0, with 3/4 of it left, and threw it away in the trash. 3. Resident #24 had diagnoses of Hypertension and Respiratory Distress. The Quarterly MDS with an ARD of 2/3/11 documented the resident had a score of 11 (moderately impaired) per brief interview for mental status. a. A Physician's order dated 8/10/09 documented a regular mechanical, no seeds diet. F 309 SS=E b. On 3/14/11, at the dinner meal, the resident was served lettuce, two tomato slices that contained seeds, spicy baked fries (with skins) and 2 sugar cookies. 483.25 PROVE CARE/SERVICES FOR HIGHEST WELL BEING Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. F 309 This REQUIREMENT is not met as evidenced by: Based on observation, record review and interview, the facility failed to ensure pain Event : Y62411 Facility : 0876 If continuation sheet Page 29 of 105