Forest Hills Care Center
December 29, 2017 Certification/complaint Survey

Standard Health Citations

FF11 483.12(a)(1):FREE FROM ABUSE AND NEGLECT

REGULATION: §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Scope: Isolated
Severity: Actual harm has occurred
Citation date: December 29, 2017
Corrected date: March 2, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during re-certification and complaint survey, the facility failed to ensure the resident's right to be free from neglect. This deficient practice resulted in harm to the resident. Specifically, The Comprehensive Care Plan (CCP) for the resident 10/24/17, stated that the resident requires two persons, and the use of an assistive device (Hoyer Lift), to transfer from bed to wheel chair. A Certified Nurse Assistant (CNA) willfully neglected to implement the CCP. The CNA attempted to transfer the resident by herself, and without the use of the Hoyer Lift. This negligence resulted in the resident falling during the transfer and sustaining a [MEDICAL CONDITION] hip. This was evident for one (1) out of three (3) residents reviewed for abuse out of the total sample of 18 residents. The Finding is: Complaint #NY 927 The Facility's Policy & Procedure (P&P) on Abuse, Neglect & Mistreatment of [REDACTED]. The P&P states its purpose is to ensure the safety of all residents by protecting them from abuse, neglect, and mistreatment. The policy states that each resident has the right to be free from abuse, mistreatment, neglect exploitation, & misappropriation of property. No one may subject residents to abuse including but not limited to facility staff, other residents including consultants, volunteers, staff or other agencies servicing the resident, family members or legal guardians, friends or other individuals. It also states that the facility maintains systems to prevent instances of abuse, neglect or mistreatment of [REDACTED]. Under the definitions of abuse, in the neglect category, it is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to attain or maintain their highest practicable level of physical, mental and psychosocial well being. Resident #20 is [AGE] years old and was originally admitted to the facility on [DATE]. The resident's most recent re-admission was 12/14/17. Diagnosis: [REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident's cognition is severely impaired and the resident is total dependent of two persons for physical assistance/transfers. All resident care needs must be anticipated since her cognitive ability is severely impaired as a result of her Alzheimer's/Dementia status and she has physical Limited Range of Motion. The Nurses Admitting Record of 04/13/15 documented the resident as wheelchair bound. The Comprehensive Care Plan(CCP) dated 10/24/17 included interventions required for this resident during transfers including the use of a mechanical (Hoyer) Lift for transfers to be done by two persons. Occupational/Physical Therapy Screening Form dated 10/16/17 -10/31/17, specifies, Transfer Status: Hoyer Lift with 2 persons assist. Monthly physician's orders [REDACTED]. The Resident's CNA Documentation Record (CDR) guides the CNAs on tasks performed and is used to record the care provided to residents. Record review for (MONTH) (YEAR) and (MONTH) (YEAR), revealed CNA#1, documented by signing her initials on the CDR, that she transferred the resident with 2 persons and the Hoyer Lift, during her shift, 7:00 AM to 3:00PM daily, except for 12/8/17, the date of the incident, where she neglected to follow medical orders and care plan directives for transfers with mechanical device and two person assist. Facility Incident/Investigation Report dated 12/8/17 and completed on 12/11/17 by an RN, revealed the CNA admitted to transferring without following resident transfer orders and did not ask for assistance from other staff members. X-rays were ordered on [DATE] and revealed the resident sustained [REDACTED]. The resident required a hospital admission on 12/9/17. It reveals the CNA was counselled and suspended indefinitely. On 12/26/17 at 9:30AM an interview with the resident's spouse was conducted. He stated he was not present when the incident happened on morning of 12/08/17 and was informed by staff. He said the Certified Nurse Aide (CNA) admitted she made a mistake by transferring without Hoyer Lift or assistance and said that the wheel chair brake had given way, the resident was assisted to the floor by aide, an evaluation was done and it was determined by x-ray, she had a fracture in the right hip and was sent to the hospital on [DATE]. He stated he advocated for the CNA to stay caring for his spouse since the resident has Alzheimer's and the CNA is familiar with her and the CNA had never done anything to harm the resident before. He said he felt the facility's disciplinee and in-service was sufficient and was happy she could return to care for his spouse. He commented that the CNA made a mistake on that day and accidents happen but her overall performance with his spouse is great and he insisted she stay. The facility took his request into consideration and allowed her to return. On 12/26/17 An interview with the Certified Nurse Aide(CNA#1) was conducted. The CNA stated, I made a stupid choice. I don't know why I did not get assistance or use Hoyer Lift. CNA stated she always cared for the resident and always asked for assistance for two persons transfer with Hoyer Lift but on 12/08/17, she took it upon herself to have her stand and transfer from bed to chair. The CNA stated she checked the wheel chair, secured the wheel chair brake but it gave way on the right side during transfer. She assisted the resident to slide to the floor, notifying the nurse immediately. The resident was evaluated by the nurse and later sent to the hospital after x-rays were done. The CNA stated she received 5-day suspension and was in-serviced again on all topics and allowed to return to work after the residents' spouse requested it. The incident occurred at approximately 6:45am during shift change with sufficient staff on the Unit on all shifts. Records reveals the staffing numbers per shift were as follows: 7-3pm shift: RN-1, LPN-2, CNA-5 3-11pm RN-1, CNA-4, 11pm-7AM LPN-1 and CNA-2. On 12/26/17 A brief interview with Director of Nursing Services(DNS) was conducted. The DNS stated the CNA was suspended after not following resident care plan for transfer. She was re-instructed and the spouse requested the CNA remain performing resident care since her overall health depended on it. On 12/28/17 at 10:52 AM an interview with the Rehabilitation Director (RD)was conducted. The RD stated the resident was a Hoyer Lift, two-person transfer, prior to the fall. She stated the resident was on a standing program in rehab, but the resident could not pivot. The resident had a fall on 12/08/17 when transferred by the CNA and was sent to the hospital on [DATE]. Resident was re-assessed by Physical Therapy/Occupational Therapy OT/PT after her return 12/14/17. Reported that now resident is on a skilled Physical Therapy/Occupational Therapy program: goal was to safely move in bed without pain. The goal was attained on 12/29/17. New Goals are for wheel chair positioning and return to a standing program. The Resident was on a Geri reclining chair until pain resolved, now is on a standard wheel chair since she attained that goal. Resident is Non-weight bearing on right leg, and has a bending ortho consult. Residents Pain Management therapy/short wave diathermy last day was 12/29/17, and re-evaluate for standing program. Resident has improved. She no longer requires two persons to assist in bed mobility. She is now moving in bed with the assistance of one person. Two person Hoyer Lift for transfers will remain. On 12/29/17 at 11:22 AM a second interview with the Director of Nursing(DNS) was conducted. The DNS stated she investigated the incident immediately and that all records demonstrated that the CNA was in-serviced prior to accident/incident. The DNS stated the CNA was in-serviced on all topics again after the 12/8/17 incident. The DNS has worked in the facility for [AGE] years. She stated that when she reported to work on 12/8/17 she was informed about the incident. The DNS immediately interviewed the CNA who said, I made a big mistake, saying the CNA was crying when she spoke to her. The DNS said that many residents voiced they liked the quality of her work and care and that she was a person without any previous incident. She also stated that the CNA could return to the facility after the residents' spouse advocated for her to continue working with resident but would have been terminated otherwise. A review of the Employee File/Records for the CNA revealed in-services and attendance sheets were identified for the following dates and topics: Abuse/Neglect/Mistreatment:01/05/17 & 6/30/17, Accountability: 4/17, Falls Precautions, Safety and Transfers: 5/8/17, Dementia/Behavior problems and pain: 6/21/17, Nail care: 7/17, Elopement, Toileting: 11/17, Active Shooter/bomb threats: 12/12/17. The facility provided all paperwork required, including criminal background check and certifications without prior history of any disciplinary actions or abuse. On 12/29/17 at 11:37 AM an Interview with Registered Nurse Supervisor (RNS #1) for the day shift was conducted. RNS#1 stated an accident/incident(A/I) report was completed by the out by the night supervisor, the resident was lifted off the floor with Hoyer Lift and put to bed, assessed by RNS #2, who notified the MD and orders for x-rays were obtained. RNS #1 was able to describe how A/I are reported by staff according to policy and procedures. Morning report is used as re-education and reminders to staff to follow all plan of care and used to address questions and concerns staff may have. The RNS #1 described her role on the unit and her function in ensuring staff follow plan of care including how she provides daily reminders and re-enforcements. Risk Management and In-services are also done by the Assistant Director of Nursing or the Director of Nursing. RNS #1 commented that it was a lack of judgement on the CNA's part when she chose to transfer without assistance or the Hoyer Lift device. 415.4(b)(1)(i)

Plan of Correction: ApprovedJanuary 30, 2018

Directed P(NAME) Done by GNYHCFA

F 600:
I. Immediate Correction:
Resident #20
1. The CNA responsible for the occurrence was suspended for failure to follow the resident#20 documented plan of care for transfer via Hoyer lift with 2 persons resulting in injury.
2. The resident was reassessed by Rehab services for transfer and mobility status. The Resident CCP and Cnaar was reviewed and updated to reflect current status.
3. The DNS held a conference call with the family and the family verbalized satisfaction with facility corrective actions.
4. The resident is currently pain free and is assessed for pain daily.
5. The CNA was re-inserviced Abuse/Neglect/Mistreatment, Accountability, Fall Precautions and Safety Transfers.
6. A Competency on Hoyer lift transfer was repeated for involved CNA.
7. The assigned CNA will be on probationary supervision documented on supervisory log daily by RNS x 3 months
8. All CNAs participated in Inservice on Hoyer Lift Transfers
9. On 1/18/18 the facility contracted the services of GNYHCFA to develop and implement the directed plan of correction and directed inservice.

10. On 1/123/18 the GNYHCFA consultants convened the facility QA Committee to assess the causative factors that may have contributed to the deficiencies cited, to identify and correct causative factors, identify routine triggers to alert facility of any evolving issues and develop audit tools to monitor facility compliance with the plan of correction.

Completion Date 1/25/18
II. Identification of Others
1. The facility respectfully states that all residents transferred via Hoyer lift were potentially affected by CNA?s failure to follow the Policy/Procedure for transferring residents.
2. On 1/23/18 the DNS obtained a list of all residents that are transferred via Hoyer lift. This list was utilized by the DNS to review all Physician orders, CCP and CNAAR instructions for accuracy including resident out of bed (OOB) schedules. Any issues were immediately corrected
Completion Date 2/02/18
III. Systemic Changes
1The DNS, Medical Director, Administrator in conjunction with GNYHCFA reviewed the facility Policy/Procedures for Abuse Prevention and found same to be compliant. The P/P will be reinserviced to all nursing staff by GNYHCFA Consultants.
The lesson plan will focus on:
? Ensuring staff knowledge on abuse including neglect as failure to provide goods and services to ensure residents attain/maintain their highest level of well-being.
? Discussion regarding importance of following resident specific plan of care.
? Review of definitions of Abuse
? Review/discuss the 7 elements of Abuse Prevention.
2. The DNS in conjunction with GNYHCFA Consultants reviewed the facility P/P for resident transfers using Mechanical Lifts and found same to be compliant. This P/P will be re-inserviced to all CNAs by the GNYHCFA Consultants.
The Lesson Plan will focus on:
? All residents are assessed by Rehab services to determine transfer ability and needs on Admission/Readmission, quarterly, upon significant change and as requested.
? The RNS documents individual transfer status on the CCP and Cnaar.
? The CNA conducts resident transfer as specified on CNAAR.
? The CNA will inform Unit Charge Nurse of any change or inability to carry out transfer as needed.
? All lesson plans and sign in sheets will be on file for validation.
Completion Date 02/13/18
IV. Quality Assurance
1. The RNS in conjunction with Rehab will complete a Hoyer lift competency for all CNAs initially, annually and as needed.
2. The GNYHCFA Consultants developed an audit tool to monitor staff compliance with Hoyer lift transfers which will be compared against the Physician order, MDS, CCP, CNAAR including include random CNA Interview s and Observations. This audit will be done by RNS for 4 residents weekly x 4 weeks followed by 4 residents monthly x 12 months.
3) The GNYHCFA Consultants developed a staff interview audit to monitor staff knowledge and compliance with Abuse Prevention. This audit will be conducted by SW for 4 staff members? weekly x 4 followed by 4 staff members monthly x 12 months.
Any issues will be followed up at IDT Morning Meeting and reported to QA Committee for follow up as needed.
Completion Date 2/26/18
V. Person Responsible for this F-Tag
1. Director of Nursing
2. Director of Rehab



FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Actual harm has occurred
Citation date: December 29, 2017
Corrected date: March 2, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a re-certification and complaint survey the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents Specifically, 1) The Comprehensive Care Plan (CCP) for Resident #20 documented that the resident requires two persons, and the use of an assistive device (Hoyer Lift), to transfer from bed to wheel chair. A Certified Nurse Assistant (CNA) willfully neglected to implement the CCP. The CNA attempted to transfer the resident by herself, and without the use of the Hoyer Lift. This negligence resulted in the accident with the resident falling during the transfer and sustaining a [MEDICAL CONDITION] hip. 2) Facility staff did not provide adequate supervision for a resident assessed at high risk for falls. Resident #78 had seven falls over a 4 month period. After the noted falls facility staff did not provide adequate interventions, and monitoring to prevent falls for the resident who attempted to transfer several times without assistance. This was evident for two out of three residents reviewed for supervision and prevention of accidents out of a total sample of 18 residents. The Findings are: 1) The Facility's Policy titled Transfer of Resident with a revision date of 11/01/2016 documents that it is the policy of the facility to conduct all transfers in accordance with the physician's orders [REDACTED]. The policy notes That a two person transfer requires 2 people. Hoyer Lift transfers always require 2 people. The procedure instructs that wheel chairs should be checked for safety and locked before beginning transfer. Resident #20 is [AGE] year-old with original admitted as 01/22/15 and most recent re-admission date of [DATE]. Diagnosis: [REDACTED]. All of the resident care needs must be anticipated since her cognitive ability is severely impaired because of her Alzheimer's/dementia status and her limited range of motion. The initial Nurse's Admission assessment dated [DATE] documented the resident as ambulating by wheelchair with assistance of one person. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the residents' cognition is severely impaired, and the resident is total dependent of two persons for physical assistance/transfers. The Comprehensive Care Plan(CCP) dated 10/24/17 included interventions required for this resident during transfers including the use of a mechanical Hoyer Lift for transfers to be done by two persons. Occupational/Physical Therapy Screening Form dated 10/16/17 -10/31/17 documented the resident's transfer status: Hoyer Lift with 2 persons assist. Monthly physician's orders [REDACTED]. The Resident's CNA Documentation Record (CDR) guides the CNAs on tasks performed and is used to record the care provided to residents. Record review for (MONTH) (YEAR) and (MONTH) (YEAR), revealed CNA#1, documented by signing her initials on the CDR, that she transferred the resident with 2 persons and the Hoyer Lift, during her shift, 7:00 AM to 3:00PM daily, except for 12/8/17, the date of the incident, where she neglected to follow medical orders and care plan directives for transfers with mechanical device and two person assist. Facility Incident/Investigation Report dated 12/8/17 and completed on 12/11/17 by RN, revealed the CNA admitted to transferring without following resident transfer orders and did not ask for assistance from other staff members. X-rays were ordered on [DATE] and revealed the resident sustained [REDACTED]. The resident required a hospital admission on 12/9/17. It reveals the CNA was counselled and suspended indefinitely. On 12/26/17 at 9:30 AM an interview with the spouse of Resident #20 was conducted. He statedthat he was not present when the incident happened on morning of 12/08/17 and was informed by staff. He said the Certified Nurse Aide (CNA) admitted she made a mistake by transferring without Hoyer Lift and that the wheel chair brake had given way, the resident was assisted to the floor by aide, an evaluation was done and it was determined by x-ray, she had a fracture in the right hip and was sent to the hospital on [DATE]. He stated he advocated for the CNA to stay caring for his spouse since the resident has Alzheimer's and the CNA is familiar with her and the CNA had never done anything to harm the resident before. He said he felt the facility's disciplinee and in-service was sufficient and was happy she could return to care for her. He commented that CNA made a mistake on that day and accidents happen but her overall performance with his spouse is great and he insisted she stay. The facility took his request into consideration and allowed her to return. On 12/26/17 An interview with the Certified Nurse Aide(CNA#1) was conducted. The CNA stated, I made a stupid choice. I don't know why I did not get assistance or use Hoyer Lift. CNA stated she always cared for the resident and always asked for assistance for two persons transfer with Hoyer Lift but on 12/08/17, she took it upon herself to have her stand and transfer from bed to chair. The CNA stated she checked the wheel chair, secured the wheel chair brake but it gave way on the right side during transfer. She assisted the resident to slide to the floor, notifying the nurse immediately. The resident was evaluated by the nurse and later sent to the hospital after x-rays were done. The CNA stated she received 5-day suspension and was in-serviced again on all topics and allowed to return to work after the residents' spouse requested it. The incident occurred at approximately 6:45am during shift change with sufficient staff on the Unit on all shifts. Records reveals the staffing numbers per shift were as follows: 7-3pm shift: RN-1, LPN-2, CNA-5 3-11pm RN-1, CNA-4, 11pm-7AM LPN-1 and CNA-2. On 12/26/17 A brief interview with Director of Nursing Services (DNS) was conducted. The DNS stated the CNA was suspended after not following resident care plan for transfer. She was re-instructed and the spouse requested the CNA remain performing resident care since her overall health depended on it. On 12/28/17 at 10:52 AM an interview with the Rehabilitation Director (RD)was conducted. The RD stated the resident was a Hoyer Lift, two-person transfer, prior to the fall. She stated the resident was on a standing program in rehab, but the resident could not pivot. The resident had a fall on 12/08/17 when transferred by the CNA and was sent to the hospital on [DATE]. Resident was re-assessed by Physical Therapy/Occupational Therapy OT/PT after her return 12/14/17. Reported that now resident is on a skilled Physical Therapy/Occupational Therapy program: goal was to safely move in bed without pain. The goal was attained on 12/29/17. New Goals are for wheel chair positioning and return to a standing program. The Resident was on a geri reclining chair until pain resolved, now is on a standard wheel chair since she attained that goal. Resident is Non-weight bearing on right leg, and has a bending ortho consult. Residents Pain Management therapy/short wave diathermy last day was 12/29/17, and re-evaluate for standing program. Resident has improved. She no longer requires two persons to assist in bed mobility. She is now moving in bed with the assistance of one person. Two person Hoyer Lift for transfers will remain. On 12/29/17 at 11:22 AM an interview with the Director of Nursing (DNS) was conducted. The DNS stated she investigation the incident immediately and that all records demonstrated that the CNA was in-serviced prior to accident/incident. The DNS stated the CNA was in-serviced on all topics again after the 12/8/17 incident. The DNS has worked in the facility for [AGE] years. She stated that when she reported to work on 12/8/17 she was informed about the incident. The DNS immediately interviewed the CNA who said, I made a big mistake, saying the CNA was crying when she spoke to her. The DNS said that many residents voiced they liked the quality of her work and care and that she was a person without any previous incident. She also stated that the CNA could return to the facility after the residents' spouse advocated for her to continue working with resident but would have been terminated otherwise. A review of the Employee File/Records for the CNA revealed in-services and attendance sheets were identified for the following dates and topics: Abuse/Neglect/Mistreatment:01/05/17 & 6/30/17, Accountability: 4/17, Falls Precautions, Safety and Transfers: 5/8/17, Dementia/Behavior problems and pain: 6/21/17, Nail care: 7/17, Elopement, Toileting: 11/17, Active Shooter/bomb threats: 12/12/17. The facility provided all paperwork required, including criminal background check and certifications without prior history of any disciplinary actions or abuse. On 12/29/17 at 11:37 AM an Interview with Registered Nurse Supervisor (RNS #1) for the day shift was conducted. RNS#1 stated an accident/incident(A/I) report was completed by the out by the night supervisor, the resident was lifted off the floor with Hoyer Lift and put to bed, assessed by RNS #2, who notified the MD and orders for x-rays were obtained. RNS #1 was able to describe how A/I are reported by staff according to policy and procedures. Morning report is used as re-education and reminders to staff to follow all plan of care and used to address questions and concerns staff may have. The RNS #1 described her role on the unit and her function in ensuring staff follow plan of care including how she provides daily reminders and re-enforcements. Risk Management and In-services are also done by the Assistant Director of Nursing or the Director of Nursing. RNS #1 commented that it was a lack of judgement on the CNA's part when she chose to transfer without assistance or the Hoyer Lift device.
2) The facility's policy on falls which was last revised on 07/2017 documented that the purpose of the policy is to provide a system whereby resident's falls are reported, their causes identified when possible and timely interventions are established to reduce the probability of repeated incidents. The care plan will be reviewed and updated upon each fall. It further states that if a frequent, or multiple faller is identified, the resident is placed on the frequent fall list and falling start program. The policy also documents that this resident should be assessed for resident's needs and determine the cause of behavior, for example: rule out pain, infection and to check for need to use the bathroom. Resident # 78 a [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. On 12/27/2017 at 11:45 AM resident was observed in his room seated in his geri-chair,well- groomed. The Comprehensive Care Plan dated 8/22/17 identified that the resident was at risk for falls secondary to poor balance and cognitive impairment with non-compliant behavior. The Care Plan has chair and bed alarms as interventions. No specific frequency for monitoring noted. The CCP also identified that the resident required assistance for toileting, however there was no toilteing schedule included in the plan. the CCP documented resident requires total assist of two(2) person with use of Hoyer lift, should have call bell within reach, observe balance and safety awareness during transfer and observe any changes in transfer ability .There was no documented evidenced either in the nurses notes or CCP on the monitoring done on the resident to prevent or abate further falls. The medical records documented that the resident had a total of 7 (seven ) falls from (MONTH) (YEAR) through (MONTH) 23, (YEAR). The first fall was noted in the Nurse's progress notes dated 08/19/2017 at 6:25 AM, documented that the resident was found on the floor by the CNA ( certified nursing assistant ). No injuries noted. The resident was brought back to bed with 2 persons assist. The note further documented that the resident was asked what happened, and responded that he lost his balance as he was trying to put on his pants. No new interventions were put into place after this fall. In early (MONTH) the resident was transferred from the rehab unit located on the first floor to the long term care unit on the second floor. The second fall was noted in the Nurse's progress notes dated 09/19/2017 at 7:30 PM. The CNA found the resident sitting on the floor in front of his wheelchair with a skin abrasion to the chin. The CNA alerted the Registered Nurse on duty (RN). The resident was transferred back to bed with 3 persons assist. The physician was notified. X-rays of the lumbar spine, bilateral hip, and pelvis area were ordered. The [MEDICAL CONDITION] was cleansed with nss ( normal saline solution ), and [MEDICATION NAME] ointment. Resident was referred to rehabilitation unit. X-rays were negative. The third fall was documented in the Nurse's progress notes dated 09/24/2017 at 10:15 AM. The resident was found on the floor in his room with no visible injuries. The nurses notes further documented significant decline in functional mobility requiring 2 persons transfers and inability to ambulate at this time. Resident was referred back to rehabilitation unit for evaluation. He was placed on skilled physical therapy to restore prior functional level and improve safety awareness. The MDS 3.0 ( minimum data set ) categorized as a Significant Change assessment was dated 09/27/2017. It identified the resident with a BIMS (brief interview for mental status) score of 6, indicating cognitive impairment. The resident was assessed as having the ability to usually understand and could be understood when when communicating. He was assessed as requiring extensive assist assistance of 2 plus person for transfers. The resident was assessed as continent of bowel and bladder, no toileting program was in place at this time. The resident required 2 plus persons for toileting. No walking activity noted on this assessment. The resident was assessed as not steady when trying to get on and off the toilet. The resident used a wheelchair for ambulation. There were no behaviors noted in the assessment. The fourth fall was documented in the Nurses progress notes dated 09/25/2017 at 6:30 PM. The resident was found sitting on the floor in front of his wheelchair by the sink in his room. Resident stated that he was talking with someone, and lost his balance. No visible injuries were noted. The care plan was updated to include floor mattress, bed alarm 2 1 /2 side rails and monitoring. No specific intervals or frequency for monitoring were noted. The fifth fall was documented in the Nurses progress notes dated 11/04/2017 at 1:10 PM. The resident was found on the floor on the second floor unit. The porter called charge nurse after he heard someone calling for help, and the noise of the bed alarm. No visible injuries noted. The sixth fall was documented in the Nurses progress notes dated 11/24/2017 at 6:50 PM. The resident was again found on the floor in front of his bed. No visible injuries were noted and was transferred back to bed with 3 persons assist. The seventh fall was documented in the Nurses progress notes dated 12/23/2017 at 9:20 PM. The staff responded to the bed alarm and found the resident on the floor. The resident was noted with redness on his right knee. The resident was transferred to bed with use of Hoyer Lift and 2 persons assist. The physician was notified. X-rays were taken with negative results. The Comprehensive Care Plans documented resident on total assist of two(2) with use of Hoyer Lift, call bell with in reach, observe balance and safety awareness during transfer and observe any changes in transfer ability. There was no documented evidenced either in the nurses notes or CCP on the monitoring done on the resident to prevent further falls. On 12/29/2017 at 11:30 AM the Assistant Director of Nursing (ADN ) was interviewed and stated resident during the early part of the year was able to ambulate and despite of instructions, he persist to do what he wants. Th DNS stated that when the resident was on the first floor, he was more closely supervised. When asked why, she responded it was because the unit was smaller, and the nursing staff was able to observe and see him when he goes to the bathroom. The DNS did not indicate that the resident was on a toilteting schedule when he resided on the first floor. The DNS stated that when the resident went to the second floor he continued to go to the bathroom when he wanted and self-ambulate. He was referred to the psychiatrist and rehabilitation. The DNS stated that the referral to the psychiatrist was made because most of this is behavioral. When the surveyor asked what has been done to address the behavior, she stated, I think that is what has not been added, and done. The monitoring and supervision which should include toileting. On 12/29/2017 at 1:46 PM CNA#2 was interviewed. She stated that the resident was able to walk by himself and go to the bathroom. She described the resident as very hyper. CNA#2 also stated that the resident started getting weaker. She said that one time she brought him to the bathroom, but he was shaky. She said that she reported this to the nurse several times, and even asked if a commode would be good for the resident. CNA#2 stated that she was off and when she came back she heard he fell down again. The CCP was not reviewed and revised to identify the resident's noted changes, such as increased weakness during toileting, shakiness as reported by CNA. Resident not able to follow instructions in regards calling for assistance by using call bell. The CCP did include interventions to anticipate resident's increase need for assistance particularly toileting. The CNA stated that she thought the resident would benefit from the use of a commode. There is no evidence that this intervention was discussed by the IDT. There was no increase in the monitoring and supervision for this resident to prevent falls. 415.12(h)(1)

Plan of Correction: ApprovedJanuary 30, 2018

Directed P(NAME) Done BY GNYHCFA
.Forest Hills Care Center
Directed P(NAME) F 689
I. Immediate Corrective Action:
Resident # 20
1) The resident was reassessed by Rehab services for transfer and mobility status. The Resident CCP and Cnaar was reviewed and updated to reflect current status.
2) The DNS held a conference call with the family and the family verbalized satisfaction for facility corrective actions.
3) The resident is currently pain free and is assessed for pain daily.
4) The CNA that did not follow the resident?s plan of care for mechanical lift transfer was suspended.
5) The assigned CNA was reeducated including a Mechanical Lift Competency.
6) The assigned CNA will be on probationary supervision documented on supervisory log daily by licensed nurse x 3 months
7) All CNAs participated in Inservice on Hoyer Lift Transfers
Resident # 78
1) The facility respectfully states that Resident passed away on 1/10/18.
2) The RNS responsible for updating Residents plan of care for fall prevention is no longer employed at the facility.
3) The DNS conducted an Inservice for all CCP Team members responsible for reviewing and revising care plan to prevent falls and implement interventions for specific monitoring and toileting needs.
4) On 1/18/18 the facility contracted the services of GNYHCFA to develop and implement the directed plan of correction and directed inservice.
4) On 1/23/18 the GNYHCFA consultants convened the facility QA Committee to assess the causative factors that may have contributed to the deficiencies cited, to identify and correct causative factors, identify routine triggers to alert facility of any evolving issues and develop audit tools to monitor facility compliance with the plan of correction.
Completion Date 1/25/18
.
II. Identification of Others:
1) The facility respectfully states that all residents were potentially affected.
2) The DNS in conjunction with the newly developed Safety Committee reviewed all Accident/Incident reports x 6 months to determine if any other residents were not assessed and Care planned for toileting and specific monitoring interventions to prevent falls. Any identified issues were immediately corrected.
Completion Date 2/02/18

III. Systemic Changes:
1) The DNS in conjunction with the GNYHCFA Consultants reviewed and revised the facility P/P for Fall Prevention. This P/P will be inserviced to all nursing staff and IDT team by GNYHCFA Consultants. The lesson plan will focus on:
? All residents will have a Fall Risk assessment completed by RN on Admission/Readmission, upon significant change, after each fall and quarterly.
? RN will initiate and implement Fall Prevention care plan for all residents at risk for falls.
? RN will document all interventions and assistive devices for fall prevention on CNAAR including hourly monitoring as needed.
? The CNA will sign for all resident interventions and assistive devices. CNA will report to Charge Nurse any instance where individual plan of care cannot be completed.
? The Charge nurse on each unit will conduct unit rounds at the start of each shift, before the end of shift as well as monitoring residents at meal times, and when residents are being transferred in and out of bed to ensure assistive devices and monitoring are implemented to prevent accidents.
? The RNS will conduct rounds on assigned unit on each shift. In conjunction with the charge nurse the RNS will complete and sign the Unit Safety Rounds Checklist to ensure interventions to prevent accidents are implemented.
? IDT Team members will review and add to fall prevention CCP incorporating identified risks, ADL needs including toileting, assistive devices as indicated and residents? customary routines.
? Fall Prevention Care plan will be reviewed and updated after each fall, quarterly and as needed.
2)The DNS, Administrator and Medical Director in conjunction with GNYHCFA Consultants developed a Safety Committee to ensure all falls are reviewed timely and individual residents fall prevention CCP are reviewed and revised as needed. This P/P will be inserviced by the GNYHCFA Consultants to all nursing and IDT team members by GNYHCFA. The lesson plan will include
? Facility Safety Committee will be compromised of DNS, Administrator, RN Risk Manager, SW, Rehab Director, licensed nurse and CNA.
? Facility Safety Committee will meet daily following IDT Morning Meeting (. All falls will be reviewed for root cause(s) with update to CCP and CNARR by Safety Committee.
? The Safety Committee will review any environmental needs and/or assistive device needed to prevent accidents.
? RNS will communicate and document any updated interventions and assistive devices to Unit staff following Safety Committee meeting via the Unit Inservice Form.
? The Safety Committee will monitor the ?Falling Star Program? to ensure residents that need an enhanced identifier due to frequent falls are identified and individual resident care plans are implemented and revised as needed.
? The Safety Committee will ensure list of residents on ?Falling Star Program is up to date revising as needed.
? Safety Committee will report all, trends.data and QAPI activities monthly at QA Meeting.
All lesson plans and sign in sheets will be kept on file for validation.
Completion Date 2/13/18
IV Quality Assurance:
1) The GNYHCFA Consultants developed an audit tool to monitor the facility?s compliance with ensuring each resident receives adequate supervision, monitoring and assistive devices to prevent accidents. Audit will be completed by RNS weekly for 4 randomly selected residents identified as high risk for falls including residents who are transferred using mechanical lifts weekly x 1 month followed by 4 residents monthly x 12 months.
2) The GNYHCFA Consultants developed an audit tool to monitor the facility?s compliance with conducting unit Safety rounds each shift to ensure interventions implemented to prevent accidents. This audit will be conducted by the RN Risk Manager weekly for each unit x 12 months.
All findings will be discussed at Safety Committee and reported to QA for follow as indicated.
Completion Date 2/26/18

V. Persons responsible for this Ftag : Administrator, DNS , Risk Manager, Rehab Director

Standard Life Safety Code Citations

ARRANGEMENT WITH OTHER FACILITIES

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] *[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 29, 2017
Corrected date: February 22, 2018

Citation Details

Based on documentation review and staff interview, the facility failed to ensure that the development of arrangements with other facilities was met. Specifically, review of the facility's transfer agreements with a non Long Term Care facility revealed a dated contract from 2009. This was noted during review of the facility's Emergency Preparedness plan. The finding is: On 12/28/2017 between the hours of 8am and 3:00pm during the Emergency Preparedness survey, the following was noted: Upon review of the facility's Emergency Preparedness documentation, it was revealed that the transfer agreement with a non Long Term Care facility was dated 2009. In an interview with the Administrator at approximately 2pm, he stated he can communicate with the school about the evacuation agreement.

Plan of Correction: ApprovedFebruary 2, 2018

E025
Plan of Correction for affected areas
No residents were identified in the Statement of Deficiencies.
Administration will contact the school identified in the transfer agreement and will update the transfer agreement with the identified non-LTC facility. The transfer agreement will be reviewed and updated annually or at any change.
Plan of Correction to identify other areas potentially affected
All residents have been identified as potentially being affected by this practice.
The Administrator of the(NAME)Hills Care Center reviewed all transfer agreements and M.O.A.?s and verified all agreements were updated within the last 12 months.
Plan of Correction for system measures to prevent reoccurrence
The Administrator of the(NAME)Hills Care Center will review and update all transfer agreements and M.O.A.?s in the facility Emergency Preparedness Manually annually or at any change.

Plan of Correction for monitoring corrective actions
The facility will develop an audit tool to monitor compliance with all transfer agreements and M.O.A.s being updated annually.
The Administrator will report on any updates to the Emergency Preparedness Manual and the annual review to the QAPI Committee on a quarterly basis for evaluation and follow-up.
Responsible party for this tag:
Administrator

K307 NFPA 101:MULTIPLE OCCUPANCIES - CONSTRUCTION TYPE

REGULATION: Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: December 29, 2017
Corrected date: February 22, 2018

Citation Details

The following waiver(s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver(s) to be continued. K133, SS=B The roof of a non-conforming building abuts an outer wall of the facility at the second floor level. There is no evidence that the required two-hour fire resistant rating is maintained. 711.2 (a) (1)

Plan of Correction: ApprovedFebruary 2, 2018

The facility respectfully wishes to continue this waiver. No changes have been made since the initial granting of this waiver.
Thank You

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 29, 2017
Corrected date: February 22, 2018

Citation Details

Based on documentation review and staff interview, the facility failed to ensure that policies and procedures for volunteers during a time of emergency were established. Reference is made to the facility's evacuation manual lacking a policy. The finding is: On 12/28/2017 between the hours of 8am and 3:00pm during the recertification survey, the following was noted: During a review of the facility's emergency preparedness manual, it was revealed that there were no policies or procedures in place to address the use of volunteers. This includes the process and role for integration of health care professionals to address surge needs during an emergency. In an interview on 12/28/2017 at approximately 2pm with the Administrator, he stated he can create a policy to address the issue.

Plan of Correction: ApprovedFebruary 2, 2018

E024
Plan of Correction for affected areas
No residents were identified in the Statement of Deficiencies.
The Administration and Ridgefield Associates will develop and provide a policy and procedure for the use of volunteers and the process and role for integration of health care professionals to address surge needs during an emergency. The policy will meet all applicable codes, rules, and regulations.
Plan of Correction to identify other areas potentially affected
All residents have been identified as potentially being affected by this practice.
The Administrator of the(NAME)Hills Care Center will incorporate the Volunteer policy and procedure in the facilities Emergency Preparedness Manual.
The Inservice Educator or designee will provide in-service training on the new Volunteer Policy and Procedure to all staff and volunteers. The policy and procedure will be reviewed and updated annually or at any policy change.
Plan of Correction for system measures to prevent re-occurrence
The Administrator of the(NAME)Hills Care Center will review and update all policies and procedures in the facility Emergency Preparedness Manually annually or with any policy change, including any policy or procedural changes to the Volunteer policy.
The Inservice Educator will provide additional education, as needed, on the new Volunteer Policy. Training on the Volunteer Policy will be included in all staff and volunteer orientation and will be reviewed during drills, with all policy changes and on an as needed basis.

Plan of Correction for monitoring corrective actions
The Administrator will report on any updates to the Emergency Preparedness Manual and the annual review to the QAPI Committee on a quarterly basis for evaluation and follow-up.
Responsible party for this tag:
Administrator

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 29, 2017
Corrected date: February 22, 2018

Citation Details

Based on documentation review and staff interview, the facility failed to ensure that the facility had policies and procedures for the provision of care, if evacuating to a non-health care facility under a waiver declared by the Secretary. The finding is: On 12/28/2017 between the hours of 8am and 3:00pm during the Emergency Preparedness survey, the following was noted: Upon review of the facility's Emergency Preparedness documentation, it was revealed that the facility did not have a policy or procedure for the provision of care, if the facility needed to evacuate to an alternate care site under a waiver declared by the Secretary. Specifically, the facility's evacuation plan indicated it would evacuate to a local school, but did not have any procedures on how this would be achieved. In an interview with the Administrator at approximately 2pm, he stated he can create a policy if the facility needs to evacuate to a non-health care facility.

Plan of Correction: ApprovedFebruary 2, 2018

E026
Plan of Correction for affected areas
No residents were identified in the Statement of Deficiencies.
Administration will develop and provide a policy and procedure for the provision of care, if the facility needed to evacuate to an alternate care site under a waiver declared by the secretary. The policy and procedure will including plans on the procedures to relocate to an alternate care site. The policy will meet all applicable codes, rules, and regulations.
Plan of Correction to identify other areas potentially affected
All residents have been identified as potentially being affected by this practice.
The Administrator of the(NAME)Hills Care Center will incorporate the new 1135 waiver policy and procedure into the facilities Emergency Preparedness Manual.
The Inservice Educator or designee will provide in-service training to all staff based on the 1135 waiver policy and procedure.
Plan of Correction for system measures to prevent re-occurrence
The Administrator of the(NAME)Hills Care Center will review and update all policies and procedures in the facility Emergency Preparedness Manually annually or at any policy change, including protocols related to 1135 waivers.
The Inservice Educator will provide additional education, as needed, on the new 1135 Waiver Policy. Training on the 1135 Waiver Policy will be included in all staff and volunteer orientation and will be reviewed during drills, with all policy changes and on an as needed basis.
Plan of Correction for monitoring corrective actions
The Administrator will report on any updates to the Emergency Preparedness Manual, including those related to 1135 waivers and the annual review to the QAPI Committee on a quarterly basis for evaluation and follow-up.
Responsible Party for this tag:
Administrator