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Scope: Pattern
Severity: Immediate jeopardy to resident health or safety
Citation date: March 9, 2022
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review during the Recertification Survey initiated on 3/1/2022 and completed on 3/9/2022, the facility failed to ensure each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of [REDACTED]. This was identified for one (Resident #220) of three residents reviewed for Behavioral health. Specifically, Resident #220 was admitted to the facility with a known history of illicit drug abuse. The admission psychosocial assessment dated [DATE] documented the resident was utilizing and selling illicit drugs in the previous nursing facility. The facility failed to develop and implement an effective comprehensive person-centered plan of care to address the substance abuse disorder. On 12/13/2021, Resident #220 was found unresponsive, was transferred to the hospital, and was diagnosed with [REDACTED]. No assessments or changes to the resident's plan of care were made upon their return from the hospital on 12/16/ 2021. Subsequently, Resident #220 was again found unresponsive on 3/2/2022, was transferred to the hospital for an overdose of Heroin and was diagnosed with [REDACTED]. This resulted in actual harm to Resident #220 with potential for serious harm for 64 residents with a history of drug abuse that is Immediate Jeopardy. The finding is: The facility policy on assessment process dated 12/2021 documented that all residents receive timely, accurate, and appropriate interdisciplinary assessment and care planning. The assessment and review should be completed upon return from the hospital, when there is a significant change that appears to be permanent, based on a comparison of the resident's pre and post hospital status. The facility Behavior Documentation Policy and Procedure dated 4/4/2008 and last revised in 3/2022 documented to monitor residents' behavior and document on a daily basis. Behavior documentation is done on a daily basis on the Certified Nursing Assistant (CNA) Accountability Record by the CNA. It is the responsibility of the caregiver to document the resident's behavior, the intervention utilized for that behavior, and the efficacy of the intervention used every shift. The facility Contraband policy and procedure dated 11/2021 documented in order to ensure a safe environment, all residents presenting to the facility will be subject to a search directed towards identifying contraband and preventing its entrance into the facility. The policy defined contraband as items of danger including illegal substances. The procedure documented that all residents who enter the facility will be subjected to search if any suspected, or any evidence of having contraband. If a resident is found to have controlled substances during their stay, the staff member who finds the controlled substances will bring this to the attention of the attending in charge and the nurse in charge. Visitors who bring contraband into the facility may be asked to leave and may be denied visiting privileges in the future. The resident involved may become subject to a repeat search with confiscation or checking of objects as described above. The facility did not have a documented Policy and Procedure for management of residents with [DIAGNOSES REDACTED]. Resident #220 was admitted with [DIAGNOSES REDACTED]. The MDS documented Resident #220 required limited assistance of one-person with locomotion in the resident's room. The locomotion off the unit did not occur in seven days of the MDS look back period. The MDS documented the resident was feeling depressed, or hopeless, and had disturbed sleep. The Quarterly MDS assessment dated [DATE] documented Resident #220 had a BIMS score of 15, indicating intact cognition. The MDS further documented Resident #220 required supervision without physical help from staff for locomotion on and off the unit. The resident was feeling depressed, or hopeless, and had disturbed sleep. The resident exhibited behavioral symptoms that were not directed towards others in four to six days in the last 7 day look back period of the MDS. Resident #220 was observed on 3/1/2022 at 10:29 AM seated in their wheelchair in the hallway and conversing with another resident. Resident #220 stated that there are no activities that meet their interests. Resident #220 stated that it was very boring at the facility, and they (Resident #220) had complained to the recreation staff. Resident #220 stated that nothing was done and they did not find the current activities appropriate for them (Resident #220). The psychosocial assessment dated [DATE] documented Resident #220 was at another skilled nursing facility for 2 years for back issues. Resident was discharged in (MONTH) 2021 from the other facility. Resident #220 was admitted to the current facility on 8/24/2021 for subacute rehabilitation and was discharged on ,[DATE]/ 2021. Resident #220 decided they (Resident #220) could not stay where they were discharged to and had several hospitalization s until admitted as a second admission to the facility on ,[DATE]/ 2021. The psychosocial assessment documented Resident #220 was kicked out of previous facility for using and selling heroin, [MEDICATION NAME], and cocaine. The psychosocial assessment documented that Resident #220's judgement was poor. Resident #220 was noted to be anxious, impulsive, easily agitated, and disregarded rules. The history of polysubstance abuse care plan dated 9/28/2021 documented that Resident #220 was kicked out of a previous skilled nursing facility for using and selling heroin, [MEDICATION NAME] and cocaine. Resident #220 knew what was done was wrong and will not do that in the current facility. The goal included that Resident #220 will not use or sell illegal substances. The interventions included to encourage participation in activities of interest, social work one to one visits for emotional support and counselling as needed, psychiatric consultation, and psychological services follow up as needed. There were no care plan updates from 9/21/2021 to 3/2/ 2022. The psychology consultation dated 10/14/2021 documented that Resident #220 had [DIAGNOSES REDACTED]. Resident #220 reported briefly receiving psychotherapy at a previous Skilled Nursing Facility. Resident #220 reported that they (Resident #220) were living with a friend but were unhappy with the arrangement because their friend was using drugs. The Psychologist documented the Resident #220 presents with a history of drug abuse and was homeless with limited social supports and significant health issues. Resident #220 agreed to speak with the Psychologist today but declined psychotherapy and was coping adequately. No psychotherapy was recommended at this time. The physician's orders [REDACTED].#220 having a peer-to-peer altercation. There was no documented evidence that a psychological evaluation was completed after the 12/2/2021 referral. The Situation Background Assessment Recommendation (SBAR) Communication Form dated 12/13/2021 documented Resident #220 had a change in condition with symptoms of altered mental status. The SBAR documented Resident #220 presented with altered level of consciousness, weakness, and shortness of breath. Around 9:00 PM, Resident #220 was observed sitting in the chair very lethargic with alteration in consciousness and was transferred to the hospital. The hospital record dated 1 | Plan of Correction: ApprovedApril 15, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F0740- 483. 40 Behavioral Health related to substance abuse, for Resident #220 with a history of Polysubstance abuse non-prescribed illicit and/or any non-administered legal drugs the following is implemented. AHPECF residents receive the necessary behavioral health care and services to attain or maintain the highest achievable physical, mental, and psychosocial well-being, in unity with the complete assessment and plans of care. No further resident was harmed by this issue. ELEMENT NUMBER ONE (#1) RESIDENT #220 The Corrective action accomplished by AHPECF for those residents found to have been affected by the practice are as follows for resident #220 are: 1. CCP updated by multidisciplinary team resident as a Polysubstance Abuser/High Alert Resident 2. Resident #220 was notified of the drug rehabilitation program attendance requirement prior to re-entering/re-admission to the facility 3. Upon readmission all visitation will also be supervised and packages searched for an illegal substances. 3A. Resident #220 returned and was immediately sent out again for attempting to hit another resident. 4. Upon readmission to the facility resident will be given a Contract/Agreement for a resident with a substance abuse history 5. Refusal to sign the contract or violation of this agreement will be witnessed by two social workers and documented in the residents chart, along with documentation in the care plan A) Ramifications/Violation of contract are as follows: B) First violation will result in counseling and random urine toxicology no less than once a week C) Second violation of the agreement will result in revocation of visitation and placed in the secure unit D) Third violation will result in discharge planning in accordance with facility policy and government regulations, based upon the danger to self and others in the facility ELEMENT NUMBER TWO (#2) IDENTIFYING OTHER RESIDENTS: NO other resident was harmed. Immediately the multidiscipline team checked all charts, and records, and created a High Alert List of residents who have a history of Polysubstance Abuse. 1. A High Alert List of residents with a history of polysubstance abuse is kept in an orange reference Binder on all units and at the Security/Ambulance Entrance and at the Security/Visitor Entrance of all residents with a history of Polysubstance Abuse. The admission department will update this list as needed. Once the resident has been placed on the High Alert list, Nursing staff documentation daily after observation of any change in the resident alter mental status, behavior, or change resident status. Nurses will notify the MD of any alert changes. [MEDICATION NAME] will then be used on residents if needed. Nursing monitoring documentation on audit tool of resident on High Alert list any change related to s/s of drug abuse will be completed daily. ELEMENT NUMBER 3 (#3) EDUCATION: Education began to educate and re-educate staff that the resident with a history of polysubstance abuse is kept on a High Alert List. This High Alert List will be kept, maintained, and updated by Admission Department. An Orange reference Binder titled Alert with an up-to-date HIGH ALERT LIST will be kept on all units and at the Security/Ambulance Entrance and at the Security/Visitor Entrance of all residents with a history of Polysubstance Abuse - Completed by Admission Department. Below is a list of measures/actions and systemic changes taken by AHPECF to identify other residents having the potential to be affected by this same issue: 2. Additional EDUCATION implemented by AHPECF are: A) Identifying Signs and Symptoms of Drug abuse B) Medical and Nursing departments re-educated on the use of [MEDICATION NAME] C) High Alert List (History of Polysubstance Abuse) ÔÇ£ Orange Binder D) Recognizing Drug Seeking Behaviors E) Education for Security Department consists of Residents Delivery Log and Residents Incident Report. 3. Additionally POLICIES created and/or revised implemented by AHPECF to are: A) Management of resident with a history of substance abuse B) Resident with Alcohol and other drug problems C) Contraband Other actions/measures and systemic changes taken by AHPECF to ensure this is addressed and does not recur are: 1. [MEDICATION NAME] kept in the Nursing Supervisors' Office is now placed in all units' emergency carts as well as the Nursing Supervisors' Office. Nursing and Medical staff were re-educated on how to use [MEDICATION NAME] Nasal. [MEDICATION NAME] was to be given and 911 called for a change in Loss of Consciousness for any High Alert Resident 2. Room Search documentation ÔÇ£ resident on High Alert list ÔÇ£ completed randomly by two staff from Nursing, Security, and/or Social Work. 3. New Care Plans were developed and placed in High Alert residents' charts 4. AHPECF developed Resident Substance Abuse Agreement/Contract -- created and given to all residents on the High Alert List. The Contracts that are 100% completed notifies residents of AHPECF stands on using Polysubstance altering alcohol and/or drug is not allowed. A resident who refuses to sign a contract or violator is notified of consequences - completed by SW. A resident who fails to comply will be given discharge planning in accordance with facility policy and government regulations, based upon the danger to self and others in the facility. A) First violation will result in counseling and random urine toxicology no less than once a week. B) Second violation will result in revocation of visitation and placed in a secure unit. C) Third violation will result in discharge planning in accordance with facility policy and government regulations, based upon the danger to self and others in the facility. 2. Social work and the facility created a comprehensive care plan that can be individualized and addresses residents with Polysubstance Abuse. 3. Policies were created and revised to ensure AHPECF procedures are addressing residents with Polysubstance Abuse. 4. The Education/In-service Department began and completed educating facility-wide staff on the list. All staff, every discipline, which includes nursing, SW, dietary, housekeeping, medical, environmental, rehab, recreation, security, HR, business office, Asian, and central supply, every employee in AHP educated. ELEMENT NUMBER FOUR (4) FACILITY PLAN TO MONITOR: To ensure the corrective actions are monitored and to ensure deficient practices will not recur, AHPECF has created several tools to check and monitor residents on the High Alert List. These tools/ audit measuring devices are completed by Nursing, Social Work, Security, and other disciplines as needed. Documentation is kept daily, monthly, and quarterly as needed. Below is a list of tools used to ensure deficient practices will not recur: 1. Nursing daily observation tool (Identify any change in resident's L(NAME)) 2. Room Search Tool - (Identify any suspicious objects found in the resident's room) 3. Security - Returning resident tool (Identify any change in resident's status after Out of Facility) 4. Contracts - (Identify any resident who refuses to sign a contract, will then initiate policy) Other corrective actions are monitored and to ensure deficient practices will not recur, AHPECF Quality Assurance Performance Improvement, (QAPI) department will randomly check each department to make sure procedures developed/tools/audits are being used correctly. QAPI will monitor this monthly, document findings, and bring them to monthly QAPI meetings. Non-compliance will be addressed by re-education and further disciplinary action to staff as needed. CONSULTING GROUP: Group Nash Healthcare, Instructors: GN, HP, and LG are 3/21/ 22. The exact dates and times of the Direct In-services and continued facility in-services will be documented in a letter on facility letterhead as discussed with DOH on 4/6/ 22. THE DATE OF CORRECTIVE ACTION IS: Date for Correction - 4/29/22 and the responsible party for the P(NAME) is: ELEMENT NUMBER FIVE (#5) RESPONSIBLE INDIVIDUALS FOR THIS CORRECTIVE ACTION ARE: The Administrative team, specifically Administrator, DON, and Medical Director |
Scope: Pattern
Severity: Immediate jeopardy to resident health or safety
Citation date: March 9, 2022
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews during the Recertification Survey initiated on 3/1/2022 and completed on 3/9/2022 the facility failed to ensure that the resident's environment was free of accident hazards for one (Resident #220) of 4 residents reviewed for accidents. Specifically, Resident #220 with a known history of Polysubstance abuse, was not supervised to prevent the availability of non-prescribed illicit drug usage within the facility. Resident #220 was readmitted to the facility on ,[DATE]/ 2021. A Psychosocial assessment dated [DATE] documented the resident was utilizing and selling illicit drugs in the previous nursing facility. The current facility did not develop care plan interventions to monitor and supervise the resident for substance abuse. On 12/13/2021 Resident #220 was found unresponsive and transferred to hospital for opioid drug overdose. The facility did not initiate an investigation after the 12/13/2021 incident. The hospital discharge recommendations were to provide supervised visits. The facility did not address and re-assess the interventions to monitor and prevent the resident from obtaining illicit drugs. Subsequently, on 3/2/2022 the resident was found unresponsive and sent to hospital with [DIAGNOSES REDACTED].#220) snorted heroin and passed out. Additionally, the facility did not have a system in place to identify and monitor residents with history of drug abuse. This resulted in actual harm to Resident #220 with potential for serious harm for 64 residents with history of drug abuse that is Immediate Jeopardy and Substandard Quality of Care. The finding is: The facility Contraband policy and procedure dated 11/2021 documented in order to ensure a safe environment, all residents presenting to the facility will be subject to a search directed towards identifying contraband and preventing its entrance into the facility. The policy defined contraband as items of danger including illegal substances. The procedure documented that all residents who enter the facility will be subjected to search if any suspected, or any evidence of having contraband. If a resident is found to have controlled substances during their stay, the staff member who finds the controlled substances will bring this to the attention of the attending in charge and the nurse in charge. Visitors who bring contraband into the facility may be asked to leave and may be denied visiting privileges in the future. The resident involved may become subject to a repeat search with confiscation or checking of objects as described above. The facility did not have a documented Policy and Procedure for management of residents with [DIAGNOSES REDACTED]. Resident #220 was admitted with [DIAGNOSES REDACTED]. The MDS documented Resident #220 required limited assistance of one-person with locomotion in the resident's room. The locomotion off the unit did not occur in seven days of the MDS look back period. The MDS documented the resident was feeling depressed, or hopeless, and had disturbed sleep. The Quarterly MDS assessment dated [DATE] documented Resident #220 had a BIMS score of 15, indicating intact cognition. The MDS further documented Resident #220 required supervision without physical help from staff for locomotion on and off the unit. The resident was feeling depressed, or hopeless, and had disturbed sleep. The resident exhibited behavioral symptoms that were not directed towards others in four to six days in the last 7 day look back period of the MDS. The psychosocial assessment dated [DATE] documented Resident #220 was at another skilled nursing facility for 2 years for their back issues and was kicked out of previous facility for using and selling heroin, [MEDICATION NAME] and cocaine. The psychosocial assessment documented that Resident #220's judgement was poor. Resident #220 was noted to be anxious, impulsive, easily agitated, and disregarded rules. The history of polysubstance abuse care plan dated 9/28/2021 documented that Resident #220 was kicked out of a previous skilled nursing facility for using and selling heroin, [MEDICATION NAME] and cocaine. Resident #220 knew what was done was wrong and will not do that in the current facility. The goal included that Resident #220 will not use or sell illegal substances. The interventions included to encourage participation in activities of interest, social work one to one visits for emotional support and counselling as needed, psychiatric consultation, and psychological services follow up as needed. The Nursing Progress Note from 9/23/2021 through 12/12/2021 were reviewed and indicated no documented behaviors related to consuming or selling illicit drugs. The Situation Background Assessment Recommendation (SBAR) Communication Form dated 12/13/2021 documented Resident #220 had a change in condition with symptoms of altered mental status. The SBAR documented Resident #220 presented with altered level of consciousness, weakness, and shortness of breath. Around 9:00 PM, Resident #220 was observed sitting in the chair very lethargic with alteration in consciousness and was transferred to the hospital. The hospital record dated 12/13/2021 documented that Resident #220 was admitted to the hospital for altered mental status with Acute Hypoxic [MEDICAL CONDITION] secondary to drug overdose (cocaine, opiate and benzodiazepine) with moderate improvement after [MEDICATION NAME] 2 milligram (mg) injection. As per Emergency Medical Service (EMS) the oxygen saturation rate for Resident #220 was 82% (normal 95% or above) on room air at the Skilled Nursing Facility and was Hypotensive (low blood pressure). The hospital discharge summary dated 12/15/2021 documented a note to the Skilled Nursing Facility: supervised visiting only. Resident #220 has been receiving drugs from outside visitors and subsequently overdosed. There was no documented evidence of an investigation to determine the root cause of Resident #220's opiate overdose nor where and how the resident received the drugs. The Nursing Admission/Readmission note dated 12/16/2021 documented that Resident #220 was admitted from the hospital at 7:40 PM. The resident was to only have supervised visitation. The Social Work note dated 12/16/2021 documented Resident #220 stated that a visitor brought the drugs to the building. Resident #220 stated that they took the visitor's phone number out of their phone and will not do it again. The Social Worker re-educated Resident #220 about not to smoke or vape in the facility. The history of polysubstance abuse care plan dated 9/28/2021 was not updated after the resident had returned from the hospital on [DATE] with a [DIAGNOSES REDACTED]. A document titled Resident Delivery Searches dated 12/2021 documented that when a delivery comes to the facility for any of the following residents, the deliveries are to be searched for contraband. The list of names included Resident # 220. The Physician readmission note dated 12/17/2021 documented Resident #220 had a past medical history of [REDACTED].#220 was admitted on [DATE] (to the hospital) for altered mental status with Acute Hypoxic [MEDICAL CONDITION] secondary to drug overdose (cocaine, opiate and benzodiazepine) with moderate improvement after [MEDICATION NAME] 2mg injection. The assessment and plan included to continue current medications, provide safe environment, adequate nutrition, and supportive care. Monitor fingerstick, GI follow up for hepatic mass and psychiatry follow up. The Physician did not acknowledge the recommendation from the hospital related to supervised visitation for Resident # 220. The Social Work note dated 1/4/2022 documented Resident #220 was moving from Unit 22 to Unit 46. Resident #220 was educated about not smoking or vaping in the facility. The Physician's note dated | Plan of Correction: ApprovedApril 15, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** To address the issue of F689- 483. 25, the Quality of Care: Free of Accident Hazards/Supervision/Devices for resident #220 with a history of Polysubstance abuse non-prescribed illicit and/or any non-administered legal drugs. The following actions were accomplished after Immediacy was placed on 3/3/22 during the Department of Health (DOH) recertification survey. A. Holly Patterson Extended Care Facility (AHPECF) promptly placed measures to address the immediacy. Interim Plan of Correction completed 3/3/22 lists explicit procedures initiated, developed, and implemented by AHPECF to address the issue of immediacy. On 3/7/22 AHPECF wrote a letter for removal of immediacy, this letter was accepted by the DOH on 3/7/22 and, the immediacy was removed on the same date of 3/7/ 22. On 3/21/22 the Official SOD was issued. Along with taking measures listed below to assure the safety of other residents in the care of the facility, AHPECF obtained consultant services to address the Statement of Deficiency (SOD). The consultants information was sent via secure file to the Department of Health, Division of Nursing Homes, on the evening of 3/21/ 22. ELEMENT NUMBER ONE (#1) RESIDENT# 220: For Resident #220 the measures listed below were implemented to immediately address F689- 483. 25, the Quality of Care: Free of Accident Hazards/Supervision/Device. No further resident was harmed by this issue 1. CCP updated by multidisciplinary team resident as a Polysubstance Abuser/High Alert Resident 2. Resident #220 was notified of the drug rehabilitation program attendance requirement prior to re-entering/re-admission to the facility 3. Upon readmission all visitation will also be supervised and packages searched for an illegal substance. 3A. Resident #220 returned and was immediately sent out again for attempting to hit another resident. 4. Upon readmission to the facility resident will be given a Contract/Agreement for a resident with a substance abuse history 5. Refusal to sign the contract or violation of this agreement will be witnessed by two social workers and documented in the residents chart, along with documentation in the care plan A) Ramifications/Violation of contract are as follows: B) First violation will result in counseling and random urine toxicology no less than once a week C) Second violation of the agreement will result in revocation of visitation and placed in the secure unit D) Third violation will result in discharge planning in accordance with facility policy and government regulations, based upon the danger to self and others in the facility ELEMENT NUMBER TWO (#2) IDENTIFYING OTHER RESIDENTS: These measures/corrective actions are accomplished by AHPECF for those residents found to have been affected by the practice. No other resident was harmed, below is a list of measures taken to identify any other possible residents: 1. Immediately the multidiscipline team checked all charts, records, and created a High Alert List of residents who have a history of Polysubstance Abuse 2. The education/in-service department began and completed educating facility-wide staff on the list. This education notified staff that a resident with a history of polysubstance abuse is kept on a High Alert List. This High Alert List will be kept, maintained, and updated by Admission Department. An orange reference Binder title with up-to-date HIGH ALERT LIST will be kept on all units and at the Security/Ambulance Entrance and at the Security/Visitor Entrance of all residents with a history of Polysubstance Abuse - Completed by the Admission Department. ELEMENT NUMBER THREE (#3) EDUCATION: Additional measures/actions and systemic changes taken by AHPECF to identify other residents having the potential to be affected by this same issue: 1. A High Alert List of residents with a history of polysubstance abuse is kept in an orange reference binder on all units and at the Security/Ambulance Entrance and at the Security/Visitor Entrance of all residents with a history of Polysubstance Abuse. The admission Department will update this list as needed. Once the resident has been placed on the High Alert list, nursing staff documentation daily after observation of any change in the resident alter mental status, behavior, or change in resident's status. Nurses will notify the MD of any alert changes. [MEDICATION NAME] will then be used on residents if needed. Nursing monitoring documentation on audit tool of resident on High Alert list any change related to s/s of drug abuse will be completed daily. 2. All staff, every discipline, which includes nursing, SW, dietary, housekeeping, medical, environmental, rehab, recreation, security, HR, business office, Asian, and central supply, every employee in AHP educated on identifying signs and symptoms of drug abuse on 3/3/22 3. Medical and Nursing department's re-education on the use of [MEDICATION NAME] Incident report began on 3/3/ 22. Other actions/measures and systemic changes taken by AHPECF to ensure this is addressed and does not recur are: 1. [MEDICATION NAME] kept in the Nursing Supervisors' Office is now placed in all unit's emergency carts as well as the Nursing Supervisors' Office. Nursing and Medical Staff were re-educated on how to use [MEDICATION NAME] Nasal. [MEDICATION NAME] was to be given and 911 called for a change in Loss of Consciousness for any High Alert Resident 2. Room Search documentation ÔÇ£ resident on High Alert list ÔÇ£ completed randomly by two staff from Nursing, Security, and/or Social Work. 3. New Care Plans were developed and placed in High Alert residents' charts. 4. AHPECF developed Resident Substance Abuse Agreement/Contract -- created and given to all residents on the High Alert List. The Contracts that are 100% completed notifies residents of AHPECF stands on using Polysubstance altering alcohol and/or drug is not allowed. A resident who refuses to sign a contract or violator is notified of consequences - completed by SW. A resident who fails to comply will be given discharge planning in accordance with facility policy and government regulations, based upon the danger to self and others in the facility. A) First violation will result in counseling and random urine toxicology no less than once a week. B) Second violation will result in revocation of visitation and placed in a secure unit. C) Third violation will result in discharge planning in accordance with facility policy and government regulations, based upon the danger to self and others in the facility. 1. Additional EDUCATION implemented by AHPECF are: A) Identifying Signs and Symptoms of Drug abuse B) Medical and Nursing department re-educated on the use of [MEDICATION NAME] C) High Alert List (History of Polysubstance Abuse) ÔÇ£ Orange Binder D) Recognizing Drug Seeking Behaviors E) Education for Security Department consists of Residents Delivery Log and Residents Incident Report. 2. Additionally POLICIES created and/or revised implemented by AHPECF to are: A) Management of resident with a history of substance abuse B) Resident with Alcohol and other drug problems C) Contraband ELEMENT NUMBER FOUR (#4) FACILITY'S PLAN TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: To ensure the corrective actions are monitored and to ensure deficient practices will not recur, AHPECF has created several tools to check and monitor residents on the High Alert List. These tools/ audit measuring devices are completed by Nursing, Social Work, Security, and other disciplines as needed. Documentation is kept daily, monthly, and quarterly as needed. Below is a list of tools used to ensure deficient practices will not recur: 1. Nursing daily observation tool (Identify any change in resident's L(NAME)) 2. Room Search Tool - (Identify any suspicious objects found in the resident's room) 3. Security - Returning resident tool (Identify any change in resident's status after Out of Facility) |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2022
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the Recertification Survey initiated on 3/1/2022 and completed on 3/9/2022, the facility did not ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This was identified on one of thirteen units reviewed for the Medication Storage task. Specifically, Resident #364 was administered [MEDICATION NAME] ([MEDICAL CONDITION]) 0. 5 milligrams (mg) without accurate reconciliation on the Control Substance Administration Record (Narcotic Sheet). The finding is: The facility's undated Medication Administration Policy and Procedure documented upon removal of the controlled substance from the container the nurse must record the date, hour, amount used, signiture and the amount of the controlled substance remaining on the Controlled Substances Administration Record form. The nurse. The Policy further documented the nurse administer the medication per the policy then documents the date and time on the Medication Administration Record. Resident #364 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The MDS documented the resident received Antianxiety medication for the seven days during the assessment look back period. During a Medication Storage observation on 3/7/2022 at 12:05 PM on nursing unit 31, the unit medication cart was observed, including the Narcotic medications in the cart. Resident #364's Controlled Substance Administration Record for [MEDICATION NAME] was reviewed. The Controlled Substance Administration Record documented that the last [MEDICATION NAME] tablet was administered on 3/6/2022 at 8:00 PM. The amount of the [MEDICATION NAME] medication remaining on the Controlled Substance Administration Record was documented to be 22 tablets. However, the [MEDICATION NAME] medication tablets remaining in the blister pack were 21 tablets. The Medication Administration Record [REDACTED]. The Licensed Practical Nurse (LPN) #3 was interviewed on 3/7/22 at 12:15 PM and stated they (LPN #3) had administered the medication to Resident #364 at 8:00 AM on 3/7/22 but did not sign the Controlled Substance Administration Record. LPN #3 stated when they (LPN #3) removed the tablet from the blister pack, they (LPN #3) should have signed the Control Substance Administration Record and after administering the medication they should have signed the MAR. The Registered Nurse (RN) #6, who was the Nurse Manager, was interviewed on 3/7/22 at 12:20 PM and stated that all the nurses are instructed to sign the Narcotic Sheet after removing the narcotic medication from the blister pack. RN #6 stated that LPN #3 should have signed the Controlled Substance Administration Record at the time the tablet was removed from the blister pack and should have signed the MAR indicated [REDACTED] The Director of Nursing Services (DNS) was interviewed on 3/9/2022 at 1:23 PM and stated when LPN#3 removed the medication from the blister pack LPN #3 should have signed the Control Substance Administration Record right away. After administering the medication to the resident, LPN #3 should have signed the MAR. 415. 18(b)(1)(2)(3) | Plan of Correction: ApprovedApril 7, 2022 F755- 493. 47(a)(b)(1)-(3) Pharmacy/Srcvs/Procedures/Pharmacist/ Records AHPECF provides pharmaceutical services, including following procedures that assure the accurate acquiring, receiving, dispensing, and administering of all resident's drugs and biologicals) needs are met. To correct the deficiency related to resident #364, staff LPN#3 gave control substance medication and did not sign the medication record after administering the medication. AHPECF immediately re-educated LPN#3 on signing directly after medication is given. Staff was also written up for a medication error. This was an isolated issue with one nurse and no resident was harmed from this error. AHPECF further undated Medication Administration Policy and Procedure documented upon removal of the controlled substance from the container the nurse must record the date, hour, amount used, signature and the amount of the controlled substance remaining on the Controlled Substances Administration Record form. The Policy further documented the nurse administers the medication per the policy then documents the date and time on the Medication Administration Record. The resident was not harmed nor was any other resident harmed by this issue. The Corrective action taken by AHPECF to insure other residents that could be affected by the practice are as follows: 1) The facility immediately intervened and assuring staff LPN #3 was instantly re-educated on the importance of signing for medication after dispensing/giving any resident his/her medication. 2) The facility then re-educated all LPNs and RNs on the need of signing directly after medication is given. 3) The facility additionally instituted disciplinary action to LPN #3 for this error. Below is a list of measures/actions and systemic changes taken by AHPECF to identify other residents having the potential to be affected by this same issue are safe: 1) The facility re-education of all nurses on all shifts. 2) The facility will ensure along with re-education, all nurses complete an annual medication pass which includes reviewing of the nurse signing immediately after medication is given to the resident 3) Facility updated the medication control drug policy indicated staff signing/documenting immediately after medication and narcotic administration. 4) Nurses are re-educated on checking MAR for missing signatures at the end of each shift. To ensure the corrective actions are monitored and to ensure these practices will not recur, AHPECF has taken the following steps: 1) Monthly random audits will be conducted by the Nursing Supervisor to insure all MARs and narcotic sheets are signed on every shift. 2) QAPI will conduct their own random documented survey. 3) QAPI will also keep this issue on the QAPI monthly agenda as needed. Date for Correction - 4/29/22 and responsible party for the P(NAME) is: The Director of Nursing (DON) |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 25, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 25, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 25, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 25, 2022
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and documentation review during the recertification survey, the facility was not provided with a conforming 2012 NFPA 99 - Health Care Facilities and 2011 NFPA 70 - National Electrical Code Conforming Type 1 Essential Electrical System (EES) in that Life Safety Branch wiring was not separated from Critical System Branch wiring. This was noted for Unit 22 of the A building that has a certified ventilator unit that utilizes life support equipment. The findings are: Based on record review during an offsite post survey revisit on [DATE], the facility was not provided with a 2012 NFPA 99 - Health Care Facilities and 2011NFPA 70 - National Electrical Code conforming Type 1 Essential Electrical System for resident on life support equiment. The facility could not provide an approved Time Limited Waiver from CMS to address this issue as indicated on their Electronic Plan Of Corrections. The facility was cited for the following during the [DATE] recertification survey: The findings are: During the Life Safety Code inspection on [DATE] to [DATE] between of 8:45am and 4:30pm, it was noted that resident rooms on Unit 22, that has residents requiring life support equipment, was not provided with a 2012 NFPA 99 - Health Care Facilities and 2011NFPA 70 - National Electrical Code conforming Type 1 Essential Electrical System. The Essential Electrical System contained loads from both the Life Safety Branch and the Critical System branch (CS). Examples include the following: 1) Emergency power panel EL-201 located in the ventilator unit, Unit 22, contained loads from both the Life Safety Branch (Emergency Lighting) and the Critical Branch (Nurse Call). 2) Emergency power panel EL-201A located in the ventilator unit, Unit 22, contained loads from both the Life Safety Branch (Oxygen Control Panel) and the Critical Branch (Room Receptacles). At the time of the survey, it was noted that the facility has 21 certified ventilator beds with a current census of 10 residents requiring life support equipment (electrically connected ventilators). In an interview on [DATE], at 10:45am, the Administrator stated that the facility had a time limited waiver for the installation of a Type 1 Essential Electrical System that expired and that an extension for the waiver was filed with the Bureau of Architectural and Engineering Review (BAER). The Administrator further stated that the work to complete the separation of the wiring and for a new generator hasn't commenced. A review of NYSDOH records revealed that the facility application for a time limited waiver to address this issue is pending approval. 2012 NFPA 101 2012 NFPA 99 NYCRR 711. 2(a) 10 NYCRR 415. 29 | Plan of Correction: ApprovedJune 6, 2022 K 915 ÔÇ£ Type 1 Essential Electrical System (EES) Plan of Correction: No residents have been adversely affected by this deficiency and it is not anticipated that any residents will be affected by this deficiency. Interim measures, detailed below, are in place to mitigate any associated risks. The Type 1 Essential Electrical System Project began on 4/25/22; the project is funded through the Statewide Transformation 1 Grant. The design for the electrical system is a Type 1 EES for the A Building Second Floor of the nursing home and is detailed in the construction documents. Detailed drawings and specifications to correct the deficiency were documented in the construction documents and awarded to qualified contractors to complete this project. A new time limited waiver was requested by BAER to be submitted in lieu of an extension of the existing waiver. This has been submitted by Nassau Health Care Corporation on 4/25/ 22. There will be weekly meetings held by our Construction Management Team, Gilbane, on status updates, logistics and scheduling of work. Status updates will be provided monthly to the QAPI Committee. Timeline for implementation of compliant essential electrical system: Selection of design professional: Status ÔÇ£ Complete, Completion Date: 3/9/22 Evaluation of Deficiency & Recommendation of Corrective Action Required: Status ÔÇ£ Complete, Completion Date: 3/9/22 Preparation of Contract Documents: Status ÔÇ£ Complete, Completion Date: 3/9/22 Obtaining Local Permits & Approvals: Status ÔÇ£ Complete, Completion Date: 5/31/22 Duration of Construction (including phasing): Status ÔÇ£ In Progress, Start Date: 4/25/22, Expected Completion Date: 4/28/23 Interim Measures: To mitigate risks associated with this deficiency; existing utility management policies and procedures remain in full effect and provide for the safety of the facility occupants. Testing of the building generator is conducted weekly and generator maintenance is provided quarterly until such time that the electrical upgrades are completed. Measure of Success: The Superintendent of Building Operations and Maintenance will perform a monthly audit for satisfactory completion of weekly generator testing and quarterly generator maintenance activities. Expected compliance rate: 100%. Audit start date: 6/2022, audit to continue until project completion. Audit results will be presented quarterly to the QAPI Committee. Title of Person Responsible: Vice President of Facilities |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 25, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: N/A
Severity: N/A
Citation date: May 25, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 25, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 25, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 25, 2022
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |