The New Jewish Home, Manhattan
April 19, 2019 Complaint Survey

Standard Health Citations

FF11 483.25:QUALITY OF CARE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 8, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during an abbreviated survey (NY 439), the facility did not ensure that a resident receive the necessary care and treatment to maintain the highest practicable wellbeing. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, Resident #1 missed two scheduled appointments for Hematology/Oncology clinic for Platelet [MEDICAL CONDITION] on [DATE] and [DATE]. Secondly, Resident #1 was noted with low Blood Pressure (B/P) of ,[DATE] on [DATE] at 3:18 PM, and the Doctor was not made aware. On [DATE] at 2:50 AM, Resident #1 was observed unresponsive; Cardiopulmonary Resuscitation (CPR) was initiated and 911 called. Resident expired in the Hospital Emergency at 3:45 AM. The findings include: The Facility's Policy and Procedure titled Outside Appointment dated [DATE] states that upon determination by the Primary care physician that a specialist consultation/procedure is needed and is not offered by the facility, an appointment will be made to assure appropriate consultation/treatment. The Facility's Policy and Procedure tilted Notification of Change in Resident/Patient Condition or Status dated ,[DATE] states in the event of a change in a resident/patient's condition or status, the facility will promptly notify the resident/patient primary care physician, the family or designated representative. The policy further states that the nurse is responsible to notify the primary care physician when there is a need to alter the resident/patient's treatment plan significantly. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) was incomplete and had no documentation of Resident #1's Brief Interview of Mental Status (BIMS, used to determine attention, orientation and ability to recall information). The Hospital Discharge Instruction dated [DATE] documented that Resident #1 was scheduled for a follow-up appointment with Hematology/Oncology Doctor on [DATE] at 4:30 PM. Nurses' Notes dated from [DATE]-[DATE] reviewed and revealed no documentation that Resident #1 had a follow-up appointment on [DATE]. A Physician order [REDACTED]. A Nurse's Note dated [DATE] at 8:39 PM documented that Resident #1 was scheduled to have plasma infusion on Tuesday ([DATE]). A physician's orders [REDACTED]. Review of Resident #1's medical record, revealed no information as to why Resident #1 missed two clinic appointments for blood transfusion. A Nursing Note dated [DATE] at 3:18 PM documented that Resident #1's B/P was ,[DATE]. Record review revealed that the Doctor was not made aware and no interventions were implemented. A Nursing Note dated [DATE] at 2:50 AM documented that Resident #1 was lethargic, with vomiting, diarrhea, and B/P ,[DATE]. The Doctor was informed, and the Registered Nurse Supervisor (RNS) assessed Resident #1. The Doctor ordered to transfer Resident #1 to the Hospital. Resident #1 became unresponsive; CPR initiated and Code Blue was activated. Emergency Medical Service (EMS) arrived and took over the CPR. Resident #1 was transported off the unit at 3:08 AM. The Hematology/Oncology Specialist Chart Note dated [DATE] at 12:06 PM documented that Resident #1 missed the scheduled appointment on [DATE]. The Supervisor at the facility said that they had no information about Resident #1's appointment. The facility performed a Complete Blood Count and Platelets were still above 50k and Hemoglobin above 8. Transfusion appointment was rescheduled for Tuesday, [DATE], but Resident #1 did not come. The Supervisor said that it was the job of the wife to schedule Access a Ride and she (the wife) did not. The resident's relationship with wife was explained to the Supervisor. According to documentation, Social Worker and Patient Care Access from department (clinic) coordinated and arranged for Access a Ride. However, Resident was not outside the facility. The Hematology/Oncology Specialist recorded that she had explained to the nursing home the importance of Resident #1's appointment and transfusion. The Hematology/Oncology Specialist was interviewed on [DATE] at 11:33 AM and stated that Resident #1 did not come for his appointment on [DATE]. She called the facility and the Supervisor (does not remember name) told her that the facility was not informed of the appointment. She rescheduled the appointment for [DATE] and Resident #1 did not show up for the appointment. Again, she called the Nursing Supervisor and rescheduled the appointment for [DATE]. This appointment was moved to [DATE] because of a snowstorm. She stated that she was upset because she wanted Resident #1 to come for the blood transfusion; she called the facility the entire week and the resident did not show up. Resident #1 needed blood transfusion every week. The Primary Physician was interviewed on [DATE] at 2:11 PM and stated that she recalled that Resident #1 refused to go for the initial clinic appointment and the Clinic Doctor (Hematology/Oncology Specialist) was made aware of Resident #1's Platelets results. The Doctor rescheduled the appointment on [DATE]. Regarding Resident #1's low B/P of ,[DATE] on [DATE], the Physician stated that she does not recall anyone calling her about the low B/P. If she was made aware, interventions would have been implemented and evaluation documented. The Unit Clerk (UC) was interviewed on [DATE] at 4:37 PM and stated that she was responsible for arranging transportation for outside appointments. Resident #1's Face Sheet showed that the resident was private pay and had Medicare. The resident was responsible for paying out of pocket and arranging his own transportation. The unit Clerk pointed out that she made transportation arrangement for Resident #1's scheduled appointment on [DATE], but the resident missed the ride (Resident was transferred to the Hospital on [DATE] at 3:08 AM). The Assistant Director of Nursing (ADON) was interviewed on [DATE] at 11:28 AM and stated that she does not know why Resident #1 missed the initial appointment on [DATE]. There was a conversation between the Hematology/Oncology Specialist and the NP and the appointment was rescheduled on [DATE]. She said that the resident refused to go to the appointment on [DATE] and it was rescheduled for [DATE]. The appointment was moved to [DATE] because of a snowstorm. She pointed out that when a resident is admitted , and the resident has a follow-up appointment, the doctor is required to order the appointment; then the unit clerk will arrange for the transportation. 415.12

Plan of Correction: ApprovedApril 26, 2019

Plan for Affected Resident
? The affected resident was transferred to the hospital. 1/5/2018
Plan to identify potentially affected residents
? The Assistant Director of Nursing /Nursing Supervisors reviewed the medical records of all patients/residents scheduled for hematology/oncology clinic appointments in the past 30 days and determined that there we no additional potentially affected residents. 4/26/2019
? The Director of Nursing determined that all residents are potentially affected for a potential change in condition. 4/26/2019
Measures and Systems
? The Director of Clinical Resources reviewed the existing policy on scheduling outside appointments and revised it to include physician notification and documentation for any missed/refused outside appointments. 4/26/2019
? The Director of Clinical Resources/designee will re-educate all appropriate clinical staff on the revised policy. 6/1/2019
? The Director of Nursing and Medical Director reviewed the existing policy for Notification of a Change in Resident/Patient Condition Status and revised it to include specific clinical parameters for notification and escalation of a physician or nurse practitioner. 4/26/2019
? The Clinical Educator will provide education for all licensed nurses on the policy 6/1/2019
Plan for Follow-Up/Monitoring
? On a monthly basis, for the next three months the Director of Medicine/designee will audit all scheduled outside appointments that were either missed or refused to ensure that there was notification to the physician and documentation in the medical record. 6/1/2019
? On a monthly basis, for the next three months, the Director of Nursing/designee will audit 100% of patients with a change in condition to confirm adherence to the policy for Notification of a Change in Resident/Patient Condition Status 6/1/2019
? The results of these audits will be reported to the Administrator
? The Administrator will present the reports to the QAPI committee on a monthly basis.
? Based on the results of the audits the QAPI committee will recommend frequency of ongoing auditing.
?
Responsible for Compliance
? The Director of Nursing will be responsible for maintaining compliance.

FF11 483.20(f)(5); 483.70(i)(1)-(5):RESIDENT RECORDS - IDENTIFIABLE INFORMATION

REGULATION: §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 8, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during an abbreviated survey (NY 439), the facility did not ensure that a resident medical record contain an accurate representation of the resident treatment/or services. This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, Resident #1 missed two scheduled appointments for [MEDICAL CONDITION] and there was no documentation in Resident #1's medical record. The findings include; The Facility's Policy and Procedure tilted Notification of Resident/Patient Condition or Status dated 3/1997 states that Nurse/Social worker/ Physician are to Documents in the Integrated progress Notes the following: any changes in resident's medical condition or status, Information regarding the transfer to the Hospital for Emergency medical treatment and record of communications with resident, the family, and physician regarding mentioned items. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) was incomplete and had no documentation of Resident #1's Brief Interview of Mental Status (BIMS, used to determine attention, orientation and ability to recall information). The Hospital Discharge Instructions dated 12/26/2017 documented that Resident #1 was scheduled for a follow-up appointment with the Hematology/Oncology Doctor on 12/29/2017 at 4:30 PM. Nurses Notes dated from 12/26/2017-12/28/2018, revealed no documentation regarding Resident #1' follow-up appointment on 12/29/2017. Review of the physician's orders [REDACTED]. A Nurse's Note dated 12/29/2017 at 8:39 PM documented that Resident #1 was rescheduled to have plasma infusion on Tuesday (01/02/2018). A physician's orders [REDACTED].#1 to attend clinic appointment on Tuesday (01/02/2019) at 9:00 AM for Platelets transfusion. Review of the nursing and medical notes dated from 12/26/2017-01/03/2018, revealed no documentation as why Resident #1 missed his clinic appointments for blood [MEDICAL CONDITION]. In addition, no interventions were documented. A follow-up interview was conducted with the UM on 04/08/2019 at 3:24 PM. He stated that he had a conversation with Resident #1 when he refused to go for the appointments, but unfortunately, he did not document. A follow-up interviewed was conducted with the ADON on 04/08/2019`at 2:18 PM. She stated that the doctor and the nurse did not document in Resident #1's medical record and that they should have documented. 415.12

Plan of Correction: ApprovedApril 26, 2019

Plan for Affected Resident
? The affected resident was transferred to the hospital. 1/5/2018
Plan to identify potentially affected residents
? The Assistant Director of Nursing /Nursing Supervisors reviewed the medical records of all patients/residents scheduled for hematology/oncology clinic appointments in the past 30 days and determined that there we no additional potentially affected residents. 4/26/2019
? The Director of Nursing determined that all residents are potentially affected for a potential change in condition. 4/26/2019
Measures and Systems
? The Director of Clinical Resources reviewed the existing policy on scheduling outside appointments and revised it to include physician notification and documentation for any missed/refused outside appointments. 4/26/2019
? The Director of Clinical Resources/designee will re-educate all appropriate clinical staff on the revised policy. 6/1/2019
? The Director of Nursing and Medical Director reviewed the existing policy for Notification of a Change in Resident/Patient Condition Status and revised it to include specific clinical parameters for notification and escalation of a physician or nurse practitioner. 4/26/2019
? The Clinical Educator will provide education for all licensed nurses on the policy 6/1/2019
Plan for Follow-Up/Monitoring
? On a monthly basis, for the next three months the Director of Medicine/designee will audit all scheduled outside appointments that were either missed or refused to ensure that there was notification to the physician and documentation in the medical record. 6/1/2019
? On a monthly basis, for the next three months, the Director of Nursing/designee will audit 100% of patients with a change in condition to confirm adherence to the policy for Notification of a Change in Resident/Patient Condition Status 6/1/2019
? The results of these audits will be reported to the Administrator
? The Administrator will present the reports to the QAPI committee on a monthly basis.
? Based on the results of the audits the QAPI committee will recommend frequency of ongoing auditing.
?
Responsible for Compliance
? The Director of Nursing will be responsible for maintaining compliance.