Chautauqua Nursing and Rehabilitation Center
September 15, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.80(a)(1)(2)(4)(e)(f):INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility?s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 15, 2017
Corrected date: November 13, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 9/15/17, the facility did not establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Two (Resident #96, Resident #210) of five residents observed for infection control practices during activities of daily living (ADL's) had issues with the lack of proper hand hygiene, the lack of proper disinfecting of a shared shower chair and the lack of proper disposal of contaminated linens. The findings are: 1. Resident #96 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Observation on 9/13/17 at approximately 10:15 AM revealed that resident was being transferred from bed to a shower chair. The resident was incontinent of urine. CNA #1 removed the resident's wet brief and placed it on the end of the bed (without a barrier). CNA #1 cleansed the resident's groin and peri area with a wet washcloth. CNA #1 placed the soiled washcloth on the brief. CNA #1 then rolled up the wet brief with the soiled washcloth and placed it on the over the bed table. There was no barrier between the table and the soiled brief and washcloth. While wearing the same gloves to provide incontinence care CNA #1 attached the resident's sling to the Hoyer (a mechanical lifting device) lift and used the remote control. CNA #1 did not change her gloves and her hands were not washed after providing incontinence care. Interview on 9/13/17 at approximately 10:30 AM with CNA #1 she stated that she should have put a barrier on the over the bed table before putting the wet brief and soiled washcloth on it. CNA #1 also stated she should have washed her hands after providing incontinence care. Interview on 9/13/17 at approximately 10:35 AM with Registered Nurse (RN #1) Unit Manager revealed that she expected her staff to place a barrier on the bed or put the soiled items in a garbage bag and that she expected her staff to wash their hands after providing incontinence care. Interview on 9/15/17 at approximately 7:30 AM with the Director of Nursing (DON) revealed that their process during incontinence care is that staff is to place a barrier at the end of bed to place the soiled linens. The DON also stated she expected her staff not to place soiled linens on an over the bed table. She also expected her staff to wash their hands after providing incontinence care. Review of the facility policy and procedure (P&P) entitled Incontinent Care dated 1/1/15 revealed that staff should remove brief and clothing and placed on a soiled barrier pad at the foot of the bed. The P&P also stated that to remove gloves and wash hands after completing incontinence care. 2. Observation on 9/13/17 at approximately 6:55 AM revealed Resident #210 was seated in a shower chair and being assisted by CNA #5. CNA #5 placed the resident over the toilet while seated in the shower chair. Continued observation revealed the resident remained seated over the toilet until approximately 8:00 AM. When CNA #5 removed the resident from over the toilet; observed was a large amount of liquid brownish black stool which covered the entire bottom of the toilet and had splattered the sides of the toilet bowl. Continued observation revealed CNA #5 transported the resident to one of the Ground Floor Shower Suites at approximately 8:05 AM and showered the resident seated on the shower chair. At approximately 8:20 AM the resident, was still seated in the shower chair and was placed over the toilet in shower room after her shower. The resident passed a small amount of liquid brown stool, which was also visible on the toilet seat and CNA #5 used three washcloths to cleanse the resident and placed the fecal soiled washcloths on a barrier. Continued observation revealed CNA #5 began dressing the resident and the resident again requested to go to the bathroom at approximately 8:40 AM. CNA #5 again cleansed the resident and discarded an additional three fecal soiled and blood tinged washcloths and used towel on a barrier. At approximately 8:53 AM, CNA #5 gathered the soiled linens still wearing the gloves used during personal care; opened the shower suite door; walked down a hallway to a Storage Room which had three bins for linens. There was no sink in this Storage Room. CNA #5 opened the bundle of linens and sorted the personal laundry from the soiled washcloths, removed the soiled gloves and walked back into the shower room and washed her hands for five seconds. CNA #5 transported the resident to the dining room at approximately 9:09 AM and the soiled shower chair was not cleaned. In addition, an immediate inspection of the Ground Floor Unit revealed the unit has two soiled rooms which are equipped with a sink. Additional observation on 9/13/17 at approximately 10:30 AM revealed CNA #5 cleaned the shower chair with bleach wipes. Observation revealed when CNA #5 was finished cleaning the chair, the underside ledge (which functionally allows for the placement of a bowl/receptacle for stool) had a copious amount of brown debris on the two ledges. When CNA #5 was cleaning the shower chair, the Housekeeping Director and a general housekeeper entered the shower room and asked who requested decontamination of the shower room. The two workers (Housekeeping Director and the housekeeper) generally cleaned the shower stall, tub area and floors; they did not clean or inspect the shower chair. When the cleaning staff were in the hall, the surveyor took the Housekeeping Director back in the shower suite to inspect the shower chair. The Housekeeping Director stated, the shower chair was not in a clean condition for use for another resident and further stated that it is the responsible of the CNA's to clean the shower chair. During an additional observation of the shower chair on 9/13/17 at approximately 10:55 AM with the Registered Nurse (RN#5) Unit Manager present the shower chair still had copious amounts of brown debris under the ledges. The RN #5 Unit Manager stated that the equipment was not decontaminated properly and that it is the responsibility of the CNA's to clean the shower chairs. RN #5 also stated the resident was taken off [DIAGNOSES REDACTED] (Clostridium difficile - bacterial infection in the stool that may cause diarrhea) precautions on 9/11/17 and she was not aware the resident was having loose stool again. During an interview on 9/13/17 at 11:01 AM, CNA #5 stated it is the responsibility of the CNA's to clean the shower chairs and they are also cleaned by the housekeeping staff on the third shift daily. CNA #5 stated she did not clean the shower chair immediately after use because there were no bleach wipes on the floor and she had to get them delivered. During an interview on 9/15/17 at approximately 9:30 AM, the RN Infection Control Nurse stated that staff are expected to follow universal precautions when providing resident care and that unit staff separate personal linens from institutional linens for washing purposes. The RN Infection Control Nurse was not aware that the Ground Floor Unit utilized two Storage Rooms not equipped with sinks to discard and house soiled linen receptacles. Review of the facility's entitled Policy on Universal/Standard Precautions dated 1/1/15 revealed that Universal/Standard precautions are used all times based on the principal that blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes of all residents are considered potentially infectious and include the use of hand hygiene, and the care of the environment, textiles and laundry. 415.19(a)(1)(b)(4)(c)

Plan of Correction: ApprovedOctober 12, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Corrective action for residents found to be affected by the deficient practice:
Housekeeping immediately sanitized Resident #96's room and its contents. Resident was then monitored for infection for seven (7) days. No infectious process or adverse effects were noted.
C.N.A. #1 was in-serviced on proper procedure for universal precautions
Resident #210 shower chair was thoroughly cleaned immediately by Housekeeping. No issues were identified with any other shower chairs. C.N.A. #1 was in-serviced on proper cleaning of shower chair after each resident use on 9/13/17.Resident was discharged on [DATE].
C.N.A. #5 was in-serviced on proper hand washing techniques and infection control procedures for incontinence to provide a barrier for all soiled items on 9/13/17.
Completed: 9/13/2017
Responsibility: Director of Nursing
II. Identification and corrective action for resident having the potential be affected by the same deficient practice:
All shower chairs in the building were immediately thoroughly cleaned by housekeeping. All C.N.A's will be in-serviced on hand washing techniques, universal precautions and shower chair sanitation
Completion: 11/13/2017
Responsibility: Director of Nursing
III. Systemic changes to ensure that the deficient practice does not recur:
Re-education of all staff on proper hand washing techniques, universal precautions and shower chair sanitation
Shower chairs will be audited monthly for cleanliness for 12 months, biannually thereafter
Hand washing techniques will be audited on five (5) C.N.A.'s (1 from each unit)each month for 12 months, then biannually thereafter.
Completion: 11/13/2017
Responsibility: Director of Nursing
IV. Quality Assurance Performance Program to ensure deficient practice does not recur:
To prevent the deficient practice from recurring, all audit results will be incorporated and reported during the QAPI Program to determine the effectiveness of the education and in-service program regarding infection control.
Completion: 11/13/2017
Responsibility: Director of Nursing

FF10 483.45(a)(b)(1):PHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH

REGULATION: (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-- (1) Provides consultation on all aspects of the provision of pharmacy services in the facility;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 15, 2017
Corrected date: November 13, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint Investigation (Complaint # NY 267) conducted during the Standard Survey completed on 9/15/17, the facility did not provide pharmaceutical services, including procedures that assure accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident. One (Resident #209) of ten residents reviewed for pharmaceutical services had issues with the transcription, and the administration of physician ordered medications. Specifically, there was a transcription error for an antibiotic ordered for the treatment of [REDACTED]. The finding is: 1. Resident # 209 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 5/5/17 revealed that the resident was cognitively intact. The MDS documented that the resident required extensive staff assistance for toilet use, was frequently incontinent of bladder and was treated for [REDACTED]. Review of the medical record revealed the resident was treated on 4/27/17 with oral antibiotics, 5/27/17 with oral antibiotics and 6/22/17 with oral antibiotics for UTI's identified through urine cultures and prolonged urinary symptoms. Review of a Nurse Practitioner (NP) progress note dated 6/26/17 revealed the resident was seen for the medical management of dysuria (painful urination) and UTI. Staff reported complaints of burning and frequency with foul smelling concentrated urine. The resident was treated on 5/30/17 with Macrodantin (antibiotic) and Cipro (antibiotic) for a UTI. The resident again is complaining of burning with urination, frequency and urgency. A urine culture on 6/20/17 revealed 500,00 units (normal 0-few) E. Coli (Escherichia coli- bacteria found in stool) and Macrodantin was ordered. The assessment plan revealed the resident has current signs and symptoms of UTI and is on Macrodantin 100 milligrams (mg) four times a day for seven days and the resident's dysuria is chronic. Treatment plans included to continue pyridium (urinary analgesic) and for staff to monitor the resident for her chronic and intermittent UTI's, encourage adequate fluid intake, continue Keflex (antibiotic) 250 mg every evening, Cranberry (used for prevention and treatment of [REDACTED]. The resident was seen by urology for consultation on 4/18/17 and had a planned urology appointment on 8/1/17. Review of a Nursing Progress Note dated 7/11/17 at 2:08 PM revealed the resident was seen by the NP for fatigue and lack of appetite on that day. The NP provided orders for a straight catheterization (tube placed into the bladder to collect urine) Urine Culture and Sensitivity (C&S), vital signs every four hours for 24 hours and Complete Blood Count (CBC)/Basic Metabolic Profile (BMP) in the morning. Review of a NP Progress Note 7/12/17 revealed the resident was seen for medical management of cardiac problems (A-Fib, Atherosclerotic Heart disease, Trans Ischemic Attacks (TIA-temporary loss of blood flow to the brain), hypertension, [DIAGNOSES REDACTED]), UTI's and congestive heart failure. A family member reported that the resident is tired and is not acting like herself. Staff reported that the resident has not had complaints of burning, frequency and they have not noticed any foul-smelling urine. The NP documented that a urine C&S was ordered via straight catheterization and will treat the resident as indicated. Review of a Urine Culture report revealed the sample was obtained on 7/12/17 and the results were faxed/sent to the facility on [DATE] at 2:00 PM. The NP reviewed the report on 7/17/17 which revealed E. Coli 200,00 col/ml and Strep Alpha 200,00 col/ml. A handwritten notation on the report documented, Rocephin (antibiotic) 1 gm (gram) IM (intramuscularly) may mix with 2.1 cc (measure of volume) 1% (percent) lidocaine (used to treat pain from some procedures) every twelve hours for seven days. Review of the nursing Progress Notes dated 7/13/17 through 7/17/17 revealed the following: - 7/13/17 at 5:28 PM revealed the resident did not eat or drink and at 10:04 PM revealed the resident was found on the floor without injuries while toileting herself. - 7/14/17 only pertained to an evaluation for the fall and did not contain any clinical information about the resident on that day. - There is no nursing documentation for 7/15 & 7/16/17 as well. - 7/17/17 at 4:05 PM a nursing Progress Note indicates the resident was alert with confusion, appetite good, denies any complaints of pain. Review of the physician's orders [REDACTED]. During an interview on 9/14/17 at approximately 3:12 PM, the Registered Nurse (RN) Unit Manager (UM) (#3) stated that Unit 2 A has two RN Unit Managers and both were sitting at the nurses' desk. Each RN thought the NP was talking to other thus the order for the Rocephin was not transcribed on 7/17/17. The RN #3 Unit Manager stated that the RN Unit Managers and LPNs (Licensed Practical Nurses) enter all provider orders in the electronic medical record. RN #3 UM stated that laboratory (labs) results are placed in the provider's folder for review. Once the provider reviews the labs, they hand the laboratory slip with the orders to the nurse. RN # 3 UM stated she did not recall seeing the order. The RN # 3 UM stated that she found the lab slip with the Rocephin order in the medical record on 7/19/17; after she was alerted that the resident was having shortness of breath. The RN #3 UM notified the NP and obtained orders for the Rocephin stat. The Rocephin is a stock medication in the facility and easily obtainable. Review of a Licensed Practical Nurse (LPN #1) nursing Progress Note dated 7/19/17 at 11:51 AM revealed the resident was dizzy and her blood pressure (B/P) was 140/108 (normal approximately 120/80), heart rate (HR) - 86 (normal 60 to 100 beats a minute), respirations - 22 (about 10 - 15 breaths per minute), temperature - 9.1 (normal 97.7-99.5 F). Vital signs were repeated with the head of the bed elevated and were documented as B/P 140/90, HR - 86-103, respirations - 24, pulse oxygenation (PO2)- 84 % (normal 95 percent to 100 percent) on room air. The RN was notified and PRN (as needed) O2 (oxygen) was administered with good effect, BP 138/88, HR 78, Respirations 18, and O2 SAT (PO2)- 92%. Review of a RN Nursing Progress Note dated 7/19/17 at 2:51 PM revealed the NP was notified and an order was received for Rocephin 1 gram IM every 12 hours for seven days, dose administered now. Review of a physician's orders [REDACTED]. - 7/19/17 at 2:44 PM, revealed an order for [REDACTED]. - 7/19/17 at 2:47 PM, revealed an order for [REDACTED]. - 7/19/17 at 2:49 PM, revealed an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. During an interview on 9/14/17 at approximately 2:45 PM, LPN #1 stated that she saw the resident on 7/17/17 and noted that she was alert with some confusion and next saw the resident on 7/19/17. LPN #1 stated that the resident reported to the CNA that she felt dizzy, so she took the resident's vital signs which revealed a low oxygen saturation (O2), she gave the resident some O2, and reported her findings to the RN. LPN #1 stated the resident was afebrile (without fever) and verified that she gave the resident a STAT (now) dose of Rocephin in the afternoon. Review of a LPN #2 nursing Progress Note dated 7/19/17 at 9:52 PM revealed the resident was very short of breath, pulse oxygenation (PO2) was between 66-74%, oxygen at 2 L (liters) was applied and the PO2 saturation improved to 82%, the nurse increased the oxygen to 4 L and the PO2 saturation improved to 92%. The Supervisor and medical on-call was notified. Review of a nursing Progress Note dated 7/19/17 at 11:54 PM revealed the family was updated and came to the facility. The family requested the resident be transferred to the hospital; the paperwork was prepared and resident was sent out at 9:45 PM to the emergency department. During an interview on 9/14/17 at approximately 3:24 PM, LPN #2 stated that she recalled the resident wasn't breathing well and after taking care of the resident she called the Supervisor and medical provider. LPN #2 stated that she believed she saw the resident after dinner. After LPN #2 reviewed the medical record she stated that she administered the resident's 9:00 PM medications and the IM Rocephin. LPN #2 stated the resident was sent out to the hospital not long after that encounter. During an interview on 9/14/17 at approximately 9:40 AM with the NP and attending Physician, the NP stated that on 7/12/17 she saw the resident for her medical problems, including a UTI. The NP stated the resident had a significant history of UTI's and was followed by a urologist. The NP recalled she ordered increased fluids, on that date the resident's white blood count was 6.8 (normal 4,500-10,000 white blood cells per microliter (mcL). Therefore, even if something cultured out in the urine, at that point she probably wouldn't have treated it. The attending Physician added that he probably would not have ordered an antibiotic unless the resident was showing signs of other problems. The NP stated that the Rocephin order did not get transcribed on 7/17/17 because each RN Unit Manager thought the other one was entering the order. At this facility, the nurses enter the orders in the electronic medical record. The NP recalled on 7/19/17 RN #3 Unit Manager informed her that the Rocephin was not ordered on [DATE]; she could not recall the provision of any other specific clinical information. During an additional interview on 9/15/17 at approximately 12:13 PM, the NP stated that she did not have an issue with the resident receiving the Rocephin at 9:00 PM on 7/19/17 rather than 12:00 AM on 7/20/17 because she wanted the resident to get the antibiotic medication on board since she missed doses from transcription error. During an interview on 9/14/17 at approximately 11:29 AM, the Director of Nursing (DON) stated most of the orders in the facility are verbal and the nurses enter them in the electronic medical record. In this case, there were two RN Unit Managers and each one thought the other was placing the order in the record. Regarding the 9:00 PM 7/19/17 Rocephin administration, the RN DON stated that the (MONTH) MAR indicated [REDACTED]. Based on the orders in the record, the next dose of Rocephin after the initial STAT dose was to be on 7/20/17 at 12:00 AM. Review of the facility's policy entitled Physician Verbal/Telephone Orders dated 1/1/15 revealed that verbal/telephone orders are received by a Licensed/Registered Nurse and entered exactly as stated by the physician. Review of the hospital Emergency Department record revealed on 7/19/17 the resident arrived in respiratory distress. The physician notes determined that the resident had acute respiratory distress with altered mental status due to sepsis and the resident was admitted to the Medical Intensive Care Unit. 415.18 (a)

Plan of Correction: ApprovedOctober 12, 2017

I. Corrective action for resident found to have been affected by the deficient practice:
The Nurse Practitioner was immediately questioned to verify if any other verbal orders were initiated throughout the building. No other verbal orders had been initiated.

Medical Director and Administrator met with the Nurse Practitioner to review the process of verbal orders on 9/11/17.
Resident #209 was discharged from the facility on 7/19/17.
The RN Unit Managers were both in-serviced and counseled on accurate acquiring, receiving, dispensing and administering of all drugs and biologicals on 7/19/17.
An audit was completed on all medical records to ensure a medical transcription error did not occur
Completion: 7/31/2017
Responsibility: Director of Nursing
II. Identification and corrective action for residents having the potential to be affected by the same deficient practice:
Verbal order policy will be reviewed and revised as necessary. All nurses and practitioners will be in-serviced on Verbal Order Policy.
Review medication transcription error policy with all nurses and revise as necessary.
Completion: 11/13/2017
Responsibility: Director of Nursing
III. Systemic changes to ensure that the deficient practice does not recur:
To prevent the deficient practice from recurring, the facility will establish a program to maintain all licensed personnel competencies on the ability to accept and transcribe orders accurately.
The facility will also audit a sample of five medical records from each unit per month for 12 months, then biannually thereafter to ensure a medical transcription error did not occur. This audit will compare orders dictated by the practitioner from the medical progress note to the orders that were transcribed in the Practitioners Orders.
Completion: 11/13/2017
Responsibility: Director of Nursing
IV. Quality Assurance Performance Improvement Program to ensure deficient practice does not recur:
All revisions to the verbal orders policy and medication transcription error policy will be brought before the QAPI Committee for approval
All audits will be reported during each QAPI meeting to determine the effectiveness of the process of giving and receiving practitioner orders.
Completion: 11/13/2017
Responsibility: Director of Nursing

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 15, 2017
Corrected date: November 13, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 9/15/17, the facility did ensure that services provided or arranged by the facility as outlined by the comprehensive care plan were provided by qualified persons in accordance with each resident's plan of care. One (Resident #189) of two residents observed for implementation of care for resident's with behaviors had an issue involving staff not utilizing two staff members for bed mobility and toileting as per the resident's plan of care. The finding is: 1. Resident #189 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/7/17 revealed the resident is severely cognitively impaired, is sometimes understood, and rarely/never understands. The resident requires extensive assistance of two or more persons for bed mobility and for toilet use. In addition, the MDS documented the resident is frequently incontinent of urine and always incontinent of bowel. Review of the undated Certified Nurse Aide (CNA) Care Guide (used by the CNA to provide care) included Bed Mobility: extensive assistance; Two + (plus) person physical assist; Toilet Use: extensive assistance; Two + person physical assist. In addition, the CNA Care Guide noted the resident can be combative. Review of the Physical Therapy (PT) Therapist Progress & Discharge Summary dated 7/13/17 included, PT recommends the following levels of assistance upon discharge to long term care: Bed Mobility: Extensive (EXT) assist x (times) two (persons). Review of the Occupational Therapy (OT) Therapist Progress & Discharge Summary dated 7/17/17 included, Nursing recs (recommendations) on unit are as follows: Total/Toileting: Total x two. Review of the undated Care Plan Activity Report included, has history (hx) of physical aggression towards staff and is physical at times during routine care. Review of CNA Documentation History Detail dated 8/15/17 through 9/15/17 it was documented approximately 50 instances of behaviors that included, resists care, repetitive physical movements, kicking/ hitting, pinching / scratching/ spitting, and yelling/ screaming. During an observation of morning care performed by CNA #3 and observed by the Registered Nurse (RN) MDS Coordinator on 9/13/17 at approximately 9:35 AM, the resident was supine (lying flat on back) in bed when CNA #3 untabbed the resident's brief, the resident was incontinent of a moderate amount of soft stool. CNA #3 proceeded to raise right the resident's buttock off the bed, rolled the resident slightly on to her left side, and washed the residents right hip and buttock. CNA #3 then stated, I'm going to roll you onto your side so I can clean you up. When interviewed by the Surveyor regarding the Bed Mobility section of the CNA Care Guide, CNA #3 stated, the two assist is just for boosting the resident up in the bed, I normally do her alone except for the boost. Request for two-person physical assist was made by the Surveyor on 9/13/17 at approximately 9:49 AM. Interview with the Director of Rehab on 9/13/17 at approximately 10:16 AM revealed bed mobility included rolling and boosting in bed. The Director of Rehab also stated that recommendations are made with the residents and staff safety in mind taking into consideration a residents' behaviors with hands on care. Interview with the RN MDS Coordinator on 9/14/17 at approximately 10:02 AM revealed, Bed mobility is everything from assisting with legs in and out of bed, boosting, side to side, if butt (buttocks) in/on the bed, it's bed mobility. If the Care Plan says two assists, then staff needs to use two assist. Interview with the Director of Nursing (DON) on 9/14/17 at approximately 1:51 PM revealed, the Care Plan needs to be followed, once therapy makes a recommendation it needs to be followed and we can't use less assistance than what's on the Care Plan. 415.11(c)(3)(ii)

Plan of Correction: ApprovedOctober 12, 2017

I. Corrective action for resident found to have been affected by the deficient practice:
C.N.A. #3 was in-serviced on bed mobility on 9/13/2017.
Resident #189 Care Guide was reviewed and revised to ensure clear and understandable instructions regarding all tasks included in bed mobility on 9/15/17.
Completion: 9/15/2017
Responsibility: Director of Rehabilitation
II. Identification and corrective action for residents having the potential to be affected by the same deficient practice:
All C.N.A.'s, Licensed Nursing and Therapy will be in-serviced on bed mobility.
All Resident care guides were reviewed and revised by 9/30/2017 to ensure instructions clearly reflect and display the assistance for each task included in bed mobility.
Completion: 11/13/2017
Responsibility: Director of Rehabilitation
III. The systemic changes to ensure that the deficient practice does not recur:
To ensure the deficient practice does not recur, the facility has an audit tool that will review a sample of care plans of all residents to ensure that they reflect appropriate bed mobility instructions.
A random audit will be completed by Therapy on 25 residents (5 residents from each of 5 units) quarterly for 12 months, then biannually thereafter. This audit will be completed on all 3 shifts (10 on 1st shift; 10 on 2nd shift; and 5 on 3rd shift).
A bed mobility audit by Therapy on bed mobility tasks will be completed monthly for all new admissions for 12 months and then biannually thereafter.
In-service will be held for all C.N.A.'s to review bed mobility and the use and understanding of the bed mobility instructions in the medical record.
Completion: 11/13/17
Responsibility: Director of Rehabilitation
IV. Quality Assurance Performance Improvement Program to ensure deficient practice does not recur:
The identified bed mobility and resident care guide issues will be incorporated into the QAPI program to ensure that the deficient practices do not recur. Results of these audits will be reported quarterly to review the effectiveness of its audit.
Completion: 11/13/17
Responsibility: Director of Rehabilitation

Standard Life Safety Code Citations

K307 NFPA 101:GAS AND VACUUM PIPED SYSTEMS - MAINTENANCE PR

REGULATION: Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 15, 2017
Corrected date: November 13, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed on 9/15/17, the facility's gas and vacuum systems lacked periodic inspection. This affected one (Unit 2A) of five resident units. The finding is: 1. Observation on Unit 2A on 9/12/17 from approximately 9:00 AM until 9:30 AM revealed the resident rooms in this unit were equipped with piped-in oxygen through a medical gas and vacuum system. Review of the facility's maintenance records for (YEAR) and (YEAR) revealed no evidence that the piped-in oxygen system had been periodically inspected or tested during that time. Interview with the Plant Operations Director on 9/13/17 at approximately 9:30 AM revealed the piped-in oxygen system has never been inspected or tested , but he contacted an outside contractor approximately three weeks ago to inquire about having the system inspected. Review of a written estimate from an outside contractor for vacuum and air compressor service revealed it was dated 8/23/17. Additional interview with the Plant Operations Director on 9/14/17 at approximately 3:10 PM revealed the piped-in oxygen system is approximately 12 or [AGE] years old and a risk assessment has not been performed on the system. Further interview revealed the outside contractor's estimate was approved, but a date for service has not yet been scheduled. According to the 2012 edition of the National Fire Protection Association (NFPA) 99, Health Care Facilities Code, a periodic testing procedure for Category 3 gas and vacuum systems and related alarm systems shall be implemented. It also states that a maintenance program shall be established for the following: (1) Relief valves in accordance with applicable codes or manufacturer's recommendations (2) Drive gas supply system in accordance with manufacturer's recommendations (3) Vacuum source equipment and accessories in accordance with manufacturer's recommendations (4) Vacuum piping system and the secondary equipment attached to vacuum station inlets to ensure the continued good performance of the entire vacuum system (5) Scavenging systems to ensure performance Additionally, NFPA 99 states that an audible and visual alarm indicator(s) shall be periodically tested to determine that it is functioning properly and the records of the test shall be maintained until the next test is performed. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 4.1, 4.1.3, 4.2, 4.3 2012 NFPA 99: 5.3, 5.3.1, 5.3.1.1, 5.3.13.4

Plan of Correction: ApprovedOctober 11, 2017

I. Corrective action for resident found to have been affected by the deficient practice:
The periodic inspection of the piped in O2 (oxygen) system has been scheduled to be completed on 10/5/17 and 10/6/17.
Completion: 10/6/2017
Responsibility: Director of Plant Operation
II. Action taken to identify other potential issues:
Maintenance of piped in oxygen system scheduled to be completed on 10/6/2017.
Annual service and inspection of the system will be completed by a certified service company and corrections completed as necessary.
A Systems Risk Assessment was completed using NFPA 99 guidelines for O2 piped-in system. Category 3 was determined for the piped-in O2 Risk Assessment.
Completion: 11/13/2017
Responsibility: Director of Plant Operation
III. Systemic changes to ensure that the deficient practice does not recur:
Maintenance program will be established for annual inspection of piped in O2 (oxygen) system. Audible and visual alarms will be tested at this time.
After each annual inspection, Director of Plant Operation will report to the QAPI Committee of all findings and all deficiencies that the outside contractor may have found during their inspection.
A Risk Assessment will be completed annually and all risk assessments will be reported to the QAPI Committee.
Completion: 11/13/2017
Responsibility: Director of Plant Operation

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 15, 2017
Corrected date: October 13, 2017

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 9/15/17, a fire department connection was not visible and accessible. The fire department connection is the connection through which the fire department can pump supplemental water into the sprinkler system, standpipe, or other system furnishing water for fire extinguishment to supplement existing water supplies. This affected one of one exterior fire department connection to the automatic sprinkler system that serves three (Ground Floor, First Floor, Second Floor) of three resident use floors. The finding is: 1. Observation on 9/13/17 at approximately 3:25 PM revealed a garden was located in front of and obstructing the sprinkler system's fire department connection, located on the exterior of the building. Further observation revealed this garden covered an area approximately 15 feet long by 15 feet wide and the tallest plants were approximately five and a half to six feet tall. Additional observation at this time revealed no part of the fire department connection was visible from the closest street, which was approximately 15 to 20 feet away. Interview with the Plant Operations Director at the time of the observation revealed this garden is called the Monarch Way Station and it was planted last spring. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.5, 19.3.5.1, 9.7.1.1, 9.7.5 2011 NFPA 25: 3.3.8, 13.7, 13.7.1, 13.7.4

Plan of Correction: ApprovedOctober 5, 2017

I. Corrective action for resident found to have been affected by the deficient practice:
A sign identifying the fire department connection location was placed where visible from the closest street.
Completion Date: 10/6/2017
Responsibility: Director of Plant Operation
II. Action taken to identify other potential issues:
On 9/15/17, the exterior of the building was checked for all other fire department connections to ensure they are fully visible from the closest street.
Completion Date: 9/15/2017
Responsibility: Director of Plant Operation
III. Systemic changes to ensure that the deficient practice does not recur:
Monthly audits of all fire department connections to ensure all are visible from the closest street and have proper signage indicating their location that is visible from the closest street. This audit will be conducted monthly for 6 months then biannually.
Completion Date: 10/13/2017
Responsibility: Director of Plant Operation
IV. Quality Assurance Performance Improvement Program to ensure deficient practice does not recur:
The identified issues will be incorporated into the QAPI program to ensure that the deficient practices do not recur. Results of monthly audits will be reported to QAPI quarterly.