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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 19, 2020
Corrected date: January 8, 2021
Citation Details Based on record review and interview during the abbreviated survey (NY 590) the facility did not ensure sufficient nurse staffing to provide nursing care to all residents in accordance with resident care plans on 1 of 5 Units (Unit 7) including Residents #4, 9, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28. Specifically, there was not a nurse assigned to administer medication on the day shift on 11/1/2020 on Unit 7C, resulting in Residents #4, 9, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28 not receiving medications as ordered. Findings include: The staffing sheet documented: - licensed practical nurse (LPN) #13 was the night nurse (11 PM on 10/31/2020 to 7 AM on 11/1/2020) for Unit 7C. - On 11/1/2020, the day shift nurse (7 AM to 3 PM) was documented to be Assistant Director of Nursing (ADON) #14 and the form documented ADON #14 started the shift at 1 PM. Review of the 11/2020 Medication Administration Records (MAR) revealed Residents #4, 9, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, 26, 27, and 28 did not receive all medications ordered on the day shift on 11/1/2020. Refer to F760 - Residents are Free of Significant Medication Errors On 11/9/2020 at 12:18 PM, the Director of Nursing (DON) stated there was an agency licensed practical nurse (LPN) who worked from 11 PM on 10/31/2020 to 7 AM on 11/1/2020 on Unit 7. The DON stated she thought the agency LPN stayed into the day shift on 11/1/2020 and administered morning medications to the residents on 7C and then when the agency LPN left, the ADON took over for her. On 11/9/2020 at 1:27 PM, Staffing Coordinator #8 stated in an interview, on the morning of 11/1/2020, the agency LPN (LPN #13) from Unit 7C came to her, gave her the keys, and stated she was leaving. There was no relief nurse so Staffing Coordinator #8 told her she could not leave but she left anyway. LPN #13 told her she did not pass medications and Staffing Coordinator #8 notified the DON, ADON and the registered nurse Supervisor (RNS) in the building. The DON and ADON agreed to come in. Later on, in the shift, LPN #10 came to her (she was working on another unit) and took the medication keys for 7C so that she could administer the tube feedings that were not done earlier in the shift. On 11/9/2020 at 2:05 PM, ADON #14 stated in an interview, on 11/1/2020, he was called at around 10:30 AM to 11 AM, he thought by the DON, and was asked to come in. He came in around 1 PM to 1:30 PM and there was a nurse on 7C administering tube feedings. He did not know if she passed any medications or if medications were not given. He stated when he took over, he started passing medications that were due at 2 PM and later. On 11/9/2020 at 3:02 PM, the DON was re-interviewed and stated she did not look into the medication passes on 11/1/2020 because ADON #14 told her all medications were passed and there were no issues. She stated on that day, she tried to call RNs who were not scheduled and asked them to work and the Staffing Coordinator tried to cover the shift with LPNs, and they had no success. She stated she did not have the RNS pass medications on the day shift on 7C on 11/1/2020 as there was only one RNS for the building who could not be pulled to pass medications. 10NYCRR 415.13(a)(1)(i-iii) | Plan of Correction: ApprovedDecember 3, 2020 This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Van Duyn Center for Rehabilitation and Nursing agrees with the allegations and citations listed on the statement of deficiencies. Van Duyn Center for Rehabilitation and Nursing maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Van Duyn Center for Rehabilitation and Nursing written credible allegation of compliance. By submitting this plan of correction Van Duyn Center for Rehabilitation and Nursing does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position. Van Duyn Center for Rehabilitation and Nursing reserves all rights to raise all possible contentions and defenses in any civil or criminal or administrative claim, action or proceeding. Nothing contained in this plan of correction should be considered as a waiver of any potential acceptable peer review, quality assurance or self-critical examination privileges which Van Duyn Center for Rehabilitation and Nursing does not waive, and reserves the right to assert in any administrative, civil or criminal claim, action or proceedings offers its responses, credible allegations of compliance, and plan of correction as part of its ongoing efforts to provide quality care to residents. F-725 Sufficient Staff What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents #4, 9, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 26, 27 and 28 were assessed by the RN with no negative outcome as a result of no nurse assigned to medication administration. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the same practice. Unit staffing is confirmed each shift by the scheduling department/RN supervisors. The Director of Nursing is notified immediately of any unit that does not have a nurse assigned to medication administration so a nurse can be assigned. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? The process for verifying sufficient nursing staff was modified. The scheduling staff and the RN supervisors have been re-educated regarding the need to verify that there is a nurse present for medication administration on each unit each shift. Education includes the procedure to be followed for notifying the Director of Nursing of any unit without an assigned nurse. The Director of Nursing will assign nurses from other departments. to administer medications. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? Reports of missed treatments will be run daily and appropriate corrective action will be taken and documented as indicated. Results of the daily audits will be analyzed and trends will be identified and reported at the Quality Assurance/Performance Improvement Committee. Correction Date: January 8, 2021 Overseen by: Director of Nursing |