REGULATION: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 18, 2020
Corrected date: April 10, 2020

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the abbreviated survey (NY 712), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #2) reviewed for quality of care. Specifically, Resident #2 had a change in condition that was not addressed timely. The resident was unable to take multiple medications, was unable to eat or drink, and medical was not notified timely. The resident was not re-assessed when clinical condition did not improve and orders for STAT (immediate) x-ray and labs were not implemented timely. Findings include: The 11/24/2015 Specimen Collection policy documented the charge nurse receiving the order will complete the required lab requisition. The Nurse Manager/Charge Nurse will obtain the ordered specimen or assign to the certified nurse aide (CNA) for collection to be completed within the shift, as able. If the ordered specimen was unable to be obtained that shift, it would be written on the 24-hour report to ensure the specimen was obtained on the next shift. The 6/2018 Change in Resident Condition Policy, documents the Nurse Supervisor or Charge Nurse will notify the resident's attending physician or on-call physician of a significant change in the resident's physical/emotional/mental condition, a need to alter the resident's medical treatment significantly, and refusals of treatment or medications. The registered nurse will complete an assessment of the resident and any changes in the resident's condition will be reported to the physician. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The 12/1/2019 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance with activities of daily living (ADLs), and required a mechanically altered diet. The 11/27/2019 comprehensive care plan (CCP) documented the resident was dependent on staff for eating. The CCP was updated on 11/29/2019 and documented the resident required pureed foods with honey-thick liquids. The 12/22/2019 at 3:30 PM, licensed practical nurse (LPN) #4's progress note documented the resident was lethargic and unable to eat or take medications. The resident responded to voice and touch, then went back to sleep. Medications were not provided during the shift and the registered nurse Supervisor (RNS) was made aware and assessed the resident. The plan was to monitor the resident and vital signs were: temperature 97.5 Fahrenheit (F), pulse 107 beats per minute, respirations 18 breaths per minute, blood pressure 133/95, and oxygen saturation level was 95% on room air. The 12/22/2019 at 1:36 PM, RNS #5's progress note documented she was called to assess the resident. The note contained no documentation that an assessment was completed, the reason for the assessment, findings or recommendations. The 12/22/2019 LPN #9's progress note for the evening shift documented the resident was lethargic, unable to take medications, and unable to eat dinner safely. There was no documentation the RNS or medical was notified. The 12/2019 Medication Administration Record [REDACTED] - On 12/22/19, the resident was not administered 16 medications scheduled for 8:00 AM - 12:00 PM, including [MEDICATION NAME] (muscle relaxant) 30 milligrams (mg), [MEDICATION NAME] ([MEDICAL CONDITION] medication) 500 mg, and [MEDICATION NAME] ([MEDICAL CONDITION] medication) 64.8 mg. - On 12/22/19, the resident was not administered the 12:00 PM and 4:00 PM doses of [MEDICATION NAME] 30 mg. - On 12/22/19, the resident was not administered the 7 PM to 10 PM dose of [MEDICATION NAME] 500 mg. - On 12/22/19, the resident was not administered the 8:00 PM dose of [MEDICATION NAME] 30 mg. The 12/23/2019 at 6:38 AM, LPN #6's progress note documented the resident was lethargic and weak, was not easily aroused physically or verbally, and woke up long enough to take a portion of the morning medications before falling back asleep. The condition was as reported by prior shift and the RNS was aware. The 12/23/2019 at 6:50 AM, RNS #7's progress note documented staff reported the resident had been lethargic and hard to arouse and not usual self. Medical was called for a change in condition and orders were given for STAT (immediate) CBC (complete blood count), BMP (basic metabolic panel), urinalysis and culture, and a chest X-ray. The resident's vital signs were: temperature 97.5 F, oxygen saturation level was 91% on room air, blood pressure was 117/72, respirations were 22 breaths per minute, and pulse was 127 beats per minute. The 12/23/19 at 6:50 AM, physician orders [REDACTED]. A STAT chest X-ray was also ordered. The 12/2019 MAR indicated [REDACTED]. The 12/23/2019 nurse practitioner (NP) #3's progress note (untimed) documented the resident was lethargic, had been lethargic for at least 24 hours, and was unable to eat or take medications. STAT labs and a chest X-ray were ordered at 6:00 AM and as of 1:00 PM, they had not yet been done. The resident was sent to the hospital to be evaluated. The 12/24/2019 hospital History and Physical documented the resident was admitted with acute [MEDICAL CONDITION] (change in mental status) possibly due to post-ictal state (after a [MEDICAL CONDITION]),[MEDICAL CONDITION] (severe infection), and severe dehydration. The resident's problem list included possible aspiration (foreign substance in the lungs) causing an infection, severe dehydration causing high sodium levels and metabolic acidosis (blood becoming more acidic), and low [MEDICATION NAME] and [MEDICATION NAME] levels. During an interview on 1/21/20 at 6:17 PM, LPN #4 stated if a resident had a change in condition, she would ask the CNAs what the resident's baseline was, take vitals, and call the RNS. She remembered calling the RNS for the resident due to a change of condition; the resident's baseline was happy, smiling, responsive and the resident went downhill on 12/22/19. The day that she reported the change in condition, the resident was not sent to the hospital. She reported to the RNS that the resident was unable to take medications that day. The RNS agreed that the resident was unsafe to take medications, she was going to call the resident's group home to find out the resident's baseline. When she finished her shift at 3:00 PM, she called the RNS again and the RNS had not had time to call the group home and the plan was still pending. During an interview on 1/21/2020 at 11:03 AM, RNS #5 stated if a resident had a change in condition, the LPN should obtain vitals and contact the RNS, and she would assess and contact medical if needed. If a resident missed medications due to lethargy, medical should be notified to determine if the route of the medications could be changed or if the resident needed an evaluation. She could not recall when the resident became ill. She reviewed the medical record during the interview, and stated she never completed her nursing progress note, did not document her assessment, and did not know if she contacted medical. During an interview on 1/27/19 at 3:19 PM, LPN #9 stated the resident was lethargic once when she took care of him and she did not administer ordered medications. She reviewed her progress note from 12/22/2019 and stated she did not document that she notified the RNS of the resident's condition and did not recall doing so. During an interview on 1/21/2020 at 1:40 PM, LPN #6 stated when she received report on 12/22/2019, she heard the resident was lethargic on the prior shift (evening) and it had been going on since the day shift. She stated on the 24-hour report that day, the day shift nurse wrote lethargic in capital letters and in large print next to the resident's name. She was told by the previous shift that the RNS had been contacted and the RNS saw the resident and knew the resident had not been taking any medications. On her shift, (11:00 PM to 7 AM), the RNS assessed the resident and she did not know the outcome after the RNS's assessment. During an interview on 1/21/2020 at 1:32 PM, RNS #7 stated if a resident had a change in condition, she would do an assessment and call medical. If STAT labs and x-rays were ordered, they would be completed on the shift after she left for the day. She did not remember the resident, but if her note was written at 6:50 AM then that was around the time that she saw the resident. She stated if the resident had a change in condition on the night shift she should have been notified at the beginning of her shift and not at the end of her shift at 6:50 AM. During an interview on 1/28/19 at 1:39 PM, RN #8 stated she vaguely remembered the resident and the change in condition. She was not covering the resident's unit that day and must have been asked to enter orders. She did not make a call to the x-ray or lab companies. Her process would be to notify the unit clerk of those orders so they could call. The unit clerk who worked at that time was no longer employed by the facility. Since she was not stationed on the unit the whole day, she would not have followed up on STAT lab or X-rays. During an interview on 1/21/20 at 11:41 AM, NP #3 stated 12/22/2019 was a Sunday so the on-call provider would have been responsible for any changes in condition that day and the staff would not have called her. When she came into the facility on [DATE], she received report that the resident was lethargic, and orders were in for labs and a chest x-ray. She was called to see the resident in early afternoon, the labs and x-ray had not been completed, and she was told at that time the resident had not been able to eat or take medications. Because she did not have the diagnostic test results, she did not know what to treat so she made the decision to send the resident to the hospital. During an interview on 1/28/19 at 2:18 PM, LPN Unit Manager #12 stated she recalled the day the resident was lethargic. She had received report that the resident was going to receive STAT labs. She checked back around 10:00 AM for the results and found out they were not done. NP #3 let her know that the resident had a change in condition, his labs and X-ray had not been initiated, and the NP assessed the resident. The RN from the resident's group home came in and noticed that the resident was different. When STAT orders were placed, staff had to call and get a reference number and print a requisition, which was done by whoever put the order in. If the secretary was there, who usually worked 8:00 AM - 4:00 PM, she would call. She was unaware that the resident had missed his medications. If a resident was missing medications, the RNS or RN Unit Manager would have to be called for an assessment. During an interview on 1/28/20 at 10:27 AM, RN Unit Manager #11 stated that STAT labs would be drawn, and x-rays taken within 2 to 4 hours of being ordered. If ordered as STAT, then the lab specimen went to a local hospital for processing. She stated the unit clerk, LPN Assistant Unit Manager, or she would call the lab and x-ray company when STAT orders were entered and get a requisition number. If a night shift RNS entered an order she would call on her own just to make sure. The resident's baseline was alert and smiling; if the resident was unable to wake up and take medications that would be a change in condition. If STAT orders were put in at 6:50 AM and had not resulted by 12:45 PM, she would call the lab and X-ray companies to see what was going on. 10NYCRR 415.12

Plan of Correction: ApprovedMarch 5, 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. F684 483.25 Quality of Care What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #2 was transferred to the hospital for further evaluation and treatment. He is no longer a resident of the facility. RN supervisor #5 was counseled regarding the need to document assessment of a resident with a change in clinical condition and the need to notify the medical provider. LPN #9 was counseled regarding the need to report all changes in resident clinical condition to the RN unit manager/supervisor. 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 facility residents have the potential to be affected by the same alleged deficient practice. The RN unit manager/supervisor will review the medical records of each resident to ensure any current change in resident clinical condition has appropriate and timely follow-up documented. All identified issues will be addressed immediately. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? All licensed nursing staff will be re-educated on the need to report, assess, notify medical and document on all changes in resident clinical condition and to monitor the status of STAT diagnostic tests to ensure timely care and treatment. The unit clerks will be re-educated regarding the process to be followed for monitoring STAT diagnostic tests. Nursing staff on each unit will complete and submit a Significant Medical Event form daily. The Assistant Director of Nursing will review the identified resident?ÇÖs medical record to ensure that appropriate assessments, notification, medical follow-up and ordered diagnostic tests are completed and documented on a timely basis. Any identified issues will be reported to the Director of Nursing immediately. 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? The Director of Nursing will monitor changes in resident condition and will notify the QAPI committee monthly of any issues related to the timely identification, reporting, assessment and follow up on changes in resident clinical condition. Correction Date: April 10, 202 Overseen by: Director of Nursing