Nursing Homes: Proposal To Enhance Oversight of Poorly Performing Homes
Has Merit (Letter Report, 06/30/1999, GAO/HEHS-99-157).

GAO has previously reported that one in four of the nation's nursing
homes has deficiencies so serious that they have harmed residents or
placed them at serious risk of death or injury. (See GAO/HEHS-99-46,
Mar. 1999.) Forty percent of the homes with serious deficiencies were
cited for repeat deficiencies. The Health Care Financing Administration
(HCFA), which oversees the quality of nursing home care, has announced
plans to beef up enforcement at homes found to have repeatedly harmed
residents. This includes expanding the definition of homes classified as
"poor performers."  HCFA's proposal to include homes with repeated
isolated actual harm deficiencies would significantly increase the
number of homes that would be subject to immediate sanctions without a
grace period to correct the problems. If this revised definition had
been in effect as of April 1999, GAO estimates that the number of
nursing homes meeting HCFA's poor-performer criteria would have risen
from about one percent to nearly 15 percent of facilities nationwide.
Two-thirds of the poor-performing nursing homes GAO surveyed had
repeated violations. As a result, they would have been subject to
immediate sanction under HCFA's revised poor performer definition. The
current definition allows them an opportunity to correct the problems
without sanctions. Most of the repeat violators were cited for the same
deficiency, and about one-third were cited for closely related problems.
These findings suggest that HCFA's enhanced enforcement of homes found
to repeat these serious care problems has merit.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-99-157
     TITLE:  Nursing Homes: Proposal To Enhance Oversight of Poorly
	     Performing Homes Has Merit
      DATE:  06/30/1999
   SUBJECT:  Elder care
	     Nursing homes
	     Surveys
	     Sanctions
	     Elderly persons
	     Safety standards
	     Patient care services
	     Noncompliance
	     Federal/state relations
	     Negligence
IDENTIFIER:  HCFA Online Survey, Certification, and Reporting System
	     Medicaid Program
	     Medicare Program

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    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 GAO    United States 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 1Nursing Homes: Additional Steps Needed
    to Strengthen Enforcement of Federal Quality Standards (GAO/HEHS-
    99-46, Mar. 18, 1999). 2These 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.
    Page 1                                      GAO/HEHS-99-157 Poorly
    Performing Nursing Homes 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. Results in Brief    HCFA's proposed expansion of the
    poor-performer criteria to include 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. 3Our 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. Page 2
    GAO/HEHS-99-157 Poorly Performing Nursing Homes B-283084
    Background    Over the past year, joint efforts by the
    administration and Congress have 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. 4See Nursing Homes: HCFA
    Initiatives to Improve Care Are Under Way but Will Require
    Continued Commitment (GAO/T-HEHS-99-155, June 30, 1999). Page 3
    GAO/HEHS-99-157 Poorly Performing Nursing Homes 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) aGroup 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. bThis category is referred to in regulations as
    "immediate jeopardy." cSanctions 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 5Only 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. Page 4
    GAO/HEHS-99-157 Poorly Performing Nursing Homes B-283084 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. Including Homes With HCFA's
    proposed expansion of the definition of a poorly performing
    facility Repeated G-Level                would greatly increase
    the number of homes that are immediately referred to HCFA for
    sanction without a grace period to correct deficiencies.
    Deficiencies Would              Expansion of the federal criteria
    to include G-level deficiencies could Significantly Increase
    create a significant increase in the number of homes denied a
    grace period 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 6Over 600 homes had
    a combination of a G-level and an H-level or higher deficiency in
    their current, prior, or intervening surveys. Page 5
    GAO/HEHS-99-157 Poorly Performing Nursing Homes 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 Surveys                          Nearly
    all of the 107 surveys of nursing homes with G-level deficiencies
    we Documented Actual                           reviewed- 98
    percent (all but 2 surveys)-documented actual harm that 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
    Page 6                                  GAO/HEHS-99-157 Poorly
    Performing Nursing Homes B-283084 Appendix II provides summary
    statistics on the 201 deficiencies we reviewed, and appendix III
    contains a brief abstract of each deficiency. Most Sampled Homes
    Additional OSCAR data revealed that about two-thirds of our
    sampled Have Serious and               homes (71 of 107) had
    another G-level or higher deficiency in either a prior 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. Concluding                     Despite
    state and federal efforts to improve the quality of care in the
    Observations                   nation's nursing homes, many homes
    continue to be cited for deficiencies 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 Page 7                               GAO/HEHS-
    99-157 Poorly Performing Nursing Homes B-283084 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. Agency Comments    We provided a draft of
    this report to HCFA officials for comment. The 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. Page 13
    GAO/HEHS-99-157 Poorly Performing Nursing Homes 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) Page 14                                  GAO/HEHS-
    99-157 Poorly Performing Nursing Homes 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)
    Page 15                                   GAO/HEHS-99-157 Poorly
    Performing Nursing Homes 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) Page 16                                   GAO/HEHS-
    99-157 Poorly Performing Nursing Homes 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)
    Page 29                                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 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) Page 30
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    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) Page 31
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    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) Page 32                                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 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) Page 33
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    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) Page 34
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    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) Page 35
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    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) Page 36
    GAO/HEHS-99-157 Poorly Performing Nursing Homes Appendix III
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    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) Page 37
    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 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) Page 38
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    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) Page 39                                 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 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) Page 40
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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 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) Page 41                                 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
    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) Page 42
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    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) Page 43                                  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 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) Page 44
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    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) Page 45
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    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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    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
    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)
    Page 47                                 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 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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    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
    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) Page 49                                GAO/HEHS-99-157
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    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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    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) Page 51
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    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) Page 52
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    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) Page 53
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    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) Page 54
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    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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    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) Page 56                                 GAO/HEHS-99-
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    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) Page 57
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    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) Page 58                                 GAO/HEHS-99-
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    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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    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) Page 60
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    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
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    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-
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    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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    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) Page 64
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    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) Page 65
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    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. aSome homes had
    multiple G-level deficiencies. These are reflected by the letters
    following the survey number. (101861)
    Page 68                                    GAO/HEHS-99-157 Poorly
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