Health inspection·September 27, 2018

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure the portion sizes reflected in the menu spreadsheet were followed to ensure residents received adequate nutrition. This directly affected one (Resident #117) of one reviewed for dietary. The facility identified five Residents (#117, #69, #89, #20, #94) residing on the first floor who received a pureed diet. The facility census was 128. Findings include: Record review revealed Resident #117 was admitted to the facility on [DATE] with the following diagnoses; Alzheimer's disease, dementia, hypertension, anemia and major depressive disorder. Review of Resident #117's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident had long term and short term cognitive impairment and required extensive assistance with mobility, dressing, toileting, personal hygiene and eating. Review of Resident #117's weights revealed the resident has not had a significant weight loss in the past six months. Observation on 09/25/18 at 5:03 P.M. of the first floor serving tray line revealed [NAME] #36 made a pureed diet for Resident #117 using a six ounce (oz) scoop of ravioli, a three oz scoop of carrots and three oz scoop of bread. Interview with [NAME] #36 at the time of the observation verified Resident #117 received a six oz scoop of ravioli, a three oz scoop of carrots and three oz scoop of pureed bread. Review of Resident #117's meal ticket for dinner revealed the resident should have received a six oz of ravioli, four oz of carrots, and two oz of bread for dinner on 09/25/18. Review of the facility's diet spreadsheet revealed residents on dysphagia pureed diets should received six oz of ravioli, four oz of carrots, and two oz of bread for dinner on 09/25/18. The facility identified five Residents (#117, #69, #89, #20, #94) in the facility residing on the first floor that received a pureed diet. Review of the facility's meal service policy dated 02/2017 reported food will be prepared utilizing methods to assure appropriate nutritive value. The policy also indicated, Portion sizes are outlined on the production sheets and meal tickets. Page 1 of 3 366320 366320 09/27/2018 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of policy the facility failed to maintain proper documentation on a valid form of resident's advanced directives wishes for their code status. This affected one (Resident #420) of 32 residents reviewed for advanced directives. The resident census was 128. Findings include: Record review revealed Resident #240 was admitted to the facility on [DATE] with the following diagnoses; enterocolitis due to clostridium difficile, malignant neoplasm of head, face and neck, chronic obstructive pulmonary disease, dysphagia, dementia and anemia. Review of Resident #240's Minimum Data Sets (MDS) assessments revealed the resident did not have a current MDS completed due to her being newly admitted to the facility. Resident #240's discharge MDS from her prior stay at the nursing facility dated 08/21/18 revealed the resident was cognitively intact and required limited assistance with bed mobility, transfers, dressing and personal hygiene. Resident #240 also required supervision with eating and extensive assistance with toileting. Review of Resident #240's code status in the electronic chart on 09/24/18 revealed the resident was listed as a Do Not Resuscitate Comfort Care (DNRCC). Review of Resident #240's code status in the paper chart on 09/24/18 at 5:02 P.M. revealed a blank code status form to be sticking out of the chart. The chart also contained red stickers indicating the resident was a DNRCC. No other code status documentation signed by the resident or by a physician was found in the chart. Interview with Registered Nurse (RN) #201 on 09/24/18 at 5:05 P.M. verified the finding of Resident #240 having a blank code status form sticking out of the chart. RN #201 also confirmed Resident #240's chart contained red stickers indicating the resident's code status was a DNRCC but reported the chart did not contain any paperwork signed by the resident or a physician verifying the code status. Follow up interview with RN #201 on 09/24/18 at 5:17 P.M. revealed she could not find a signed code status form from the resident or the physician in the facility's medical records department. Follow up interview with RN #201 on 09/26/18 at 9:18 A.M. verified a DNR code status form signed by the resident and the physician was placed in the resident's chart on 09/24/18 after the surveyor identified there was not a signed DNR code status form in the chart. RN# 201 also reported she and another nurse obtained telephone verification for the resident's code status order on 09/24/18. RN #201 reported that prior to a resident being coded, she would check the hard chart for a DNR. RN #201 reported nursing staff verify a resident is a DNR code status on a signed DNR form prior to determining if a resident should be coded. RN #201 reported Resident #240 would have been a full code on 09/24/18 due to there being no signed record of a DNR or no DNR order in the chart. Interview with Licensed Practical Nurse (LPN) #135 on 09/26/18 at 2:10 P.M. revealed LPN #135 would determine a resident's code status by looking on her report sheet or in the resident's hard chart. LPN #135 reported she would verify resident to be a DNR by looking for a signed code status form in the advanced directives portion of the chart prior to determining if a resident is a DNR or a full 366320 Page 2 of 3 366320 09/27/2018 Shawneespring Health Care Center 10111 Simonson Road Harrison, OH 45030

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few code. LPN #135 reported if the signed DNR form could not be found, the resident would be a full code until a DNR was verified. Interview with RN #125 on 09/26/18 at 2:11 P.M. revealed RN #125 would determine a resident's code status by looking in the hard chart and on her report sheet. RN #125 reported if a person were to have a DNR code status, she would verify the code status with the signed DNR form in the advanced directives section of the chart. RN #125 stated the resident would be a full code if the signed DNR code status paper could not be found or verified. The facility's Advance Care Planning policy dated 12/2017 revealed The problems, goals and interventions are discussed and documented during the caring planning session and documented in the medical records of the resident. This includes the resident's preference for advance care planning and advanced directive. 366320 Page 3 of 3