NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 16, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (NY 900), the facility did not ensure that a resident with urinary and bowel incontinence received appropriate treatment and services to prevent urinary tract infections. This was evident for 1 out of 3 residents (Resident #1) reviewed for incontinence. Specifically, Resident #1 who was always incontinent of bladder and bowel functions and dependent on direct care staff for cares was diagnosed with [REDACTED]. 2024. Review of Resident #1's certified nurse accountability reports for (MONTH) 2024, (MONTH) 2024, (MONTH) 2024, (MONTH) 2024, and (MONTH) 2024 revealed numerous occasions where there was no documented evidence of direct care staff providing bladder and bowel incontinence care. The Findings are: The undated Facility Incontinence policy documented residents who are incontinent of urine, feces, or both are kept dry, clean and comfortable while maintaining their dignity. Disposable diapers and pads are used throughout the long-term care facility for residents who are incontinent of urine, feces, or both. Residents are washed and changed when wet or soiled. Residents with incontinence problem are checked for toileting and changing at least every four hours. The plan for incontinence care is written in the resident's care plan. Resident #1 initially admitted to the facility on [DATE] and last readmitted on [DATE] had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (an assessment tool for health status) dated 9/10/2024 documented the resident had severe cognitive impairment. The resident had impairment to both upper and lower extremities on both sides. The resident was dependent for eating, toileting, bed mobility and transfers. The resident was always incontinent of bladder and bowel. Review of an incontinence care plan initiated 6/15/2024 and last updated 11/4/2024, documented Resident #1 had a catheter which was discontinued on 6/14/ 2024. Resident #1 is now incontinent of bladder and bowel. The goal was the resident would be free of urinary tract infection x 90 days. Interventions listed included apply barrier ointment after cares, clean peri-area from front to back, provided incontinence care every 2 to 4 hours and as needed, monitor for signs and symptoms of urinary tract infection, and observe skin for integrity changes with incontinence cares and notify the physician of changes. Review of Resident #1's urinalysis lab reports dated 5/7/2024 and 9/9/2024 revealed they were diagnosed with [REDACTED]. Review of Resident #1's certified nurse assistant accountability report for (MONTH) 2024 revealed that direct care staff did not document that they provided bladder incontinence care on 9 occasions and bowel incontinence care on 5 occasions. Review of Resident #1's certified nurse accountability report for (MONTH) 2024 revealed that direct care staff did not document that they provided bladder incontinence care on 19 occasions and bowel incontinence care on 21 occasions. Review of Resident #1's certified nurse accountability report for (MONTH) 2024 revealed that direct care staff did not document that they provided bladder incontinence care on 67 occasions and bowel incontinence care on 35 occasions. Review of Resident #1's certified nurse accountability report for (MONTH) 2024 revealed that direct care staff did not document that they provided bladder incontinence care on 94 occasions and bowel incontinence care on 46 occasions. Review of Resident #1's certified nurse accountability report for (MONTH) 2024 revealed that direct care staff did not document that they provided bladder incontinence care on 43 occasions and bowel incontinence care on 15 occasions. During interview on 11/14/2024 at 2:16 PM, Registered Nurse #1 stated that with the certified nurse assistant accountability documentation they can see what was done and what is overdue. Registered Nurse #1 stated they have not seen any trends with missing signatures in the certified nurse assistant documentation. Registered Nurse #1 stated they remind their staff daily between 2 PM or 2:30 PM to complete their documentation before the shift is over. Registered Nurse #1 stated since they do not work the evening shift, they will speak to the nurses directly and they would inform the supervisor so they can address it the issue with the night shift staff. Registered Nurse #1 stated the residents are supposed to be checked and changed every 2 to 4 hours and that residents who are more frequently incontinent may be checked every 2-3 hours. During an interview on 11/14/2024 at 5:16 PM, the Director of Nursing stated if not documented symbol in indicated in the check box on a certified nurse accountability, it could be a charting omission, or it could indicate the task was not completed. The Director of Nursing stated it is the responsibility of the unit managers to monitor the certified nurse assistant documentation errors. The Director of Nursing stated the unit managers can monitor for documentation errors on their I-pad. The I-pad also helps them to check and see what is going on in the unit. The Director of Nursing stated the unit managers dashboard in the electronic medical record shows when residents tasks are due or if medications are due, so that they can follow up with their staff to ensure their staff is doing what they are supposed to do. 10 NYCRR 415. 12(d)(1) | Plan of Correction: ApprovedJanuary 14, 2025 Plan for affected Resident: Resident #1 is being changed every 2-3 hours. Resident is on a UTI prevention protocol. Resident currently has no UTI. Incontinent care documentation is being done following incontinent care for bowel and bladder. Resident currently does not have a foley catheter. Plan to identify other potentially affected residents: Nurse Managers to do daily audits of CNA documentation for incontinent care bowel and bladder of each resident on their unit. Nurse Manager/Supervisor to run report an hour before the end of each shift to ensure that the charting has been done or is in progress for all incontinent residents. Plan for system changes and measures to prevent occurrences: The facility will take the following measure to ensure that the problem doe not reoccur: The incontinent policy was reviewed and updated. Nursing Educator to re-educate CNA's and LPN's on peri care, Urinary tract infections and the incontinent policy. All incontinent residents are to be placed on a toileting schedule or changing schedule every 2-4 hours and PRN. Nurse Manager/Supervisor/designee to check that incontinent care is rendered to all incontinent residents on each unit per protocol every 2-4 hours. Nurse Manager/Supervisor to run report an hour before the end of each shift to ensure that the documentation has been done or is in progress after care is rendered for all incontinent residents. Residents readmitted with new foley catheter will be assessed by the RN for appropriateness of the foley and follow up with NP/MD for clinical necessity or foley will be removed if not indicated. Plan for Monitoring Corrective action: Nurse Manager/designee to do weekly audits on 10% of the residents per unit and patient resident observation to ensure that incontinent care is being provided timely and documentation is being done when incontinent care is provided. Findings will be reported to the QAPI committee monthly times three(3) and quarterly times two (2) |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 16, 2024
Corrected date: N/A
Citation Details Based on record review and interviews during an abbreviated survey (NY 900, NY 530) the facility did not ensure a facility-wide assessment documented what resources are necessary to care for its residents competently during day-to-day operations including nights and weekends. The assessment did not include a review of individual staff assignments and systems for coordination and continuity of care for residents within and across the staff assignments. Findings include: The Facility Assessment provided was last completed on 8/16/2024 and last reviewed by the quality assurance and improvement committee on 9/18/ 2023. The staffing plan documented a table describing the number of staff available to meet residents' needs, which listed the position of staff by title, as well as the number of full time employees that hold these positions. On 11/12/2024 the facility wide assessment was reviewed and revealed the assessment did not include the staffing plan, the requirements of number of staff allotted for each unit or per shift. During an interview on 11/14/2024 at 5:45 PM the Administrator stated they have been working in the facility since mid-August 2024. The Administrator stated the staffing has greatly improved since they started in the facility, which has helped a lot with the issues being faced. The Administrator was informed by the surveyor that the staffing requirements for the units was not listed in the facility assessment, and they stated completing the facility assessment was a little new to them. The Administrator was asked to update the assessment with the missing information and resend the Assessment. 10 NYCRR 415. 26 | Plan of Correction: ApprovedDecember 30, 2024 The facility assessment was updated to include an updated staffing plan, the requirements of number of staff allotted for each unit or per shift. Plan for system changes and measures to prevent recurrence: The facility assessments staffing plan will be reviewed on a quarterly basis to review what changes need to be made to the staffing plan. Any updates/changes and initiatives will be reviewed. Additional input will be requested from the team to see what other suggestions and ideas they might have. Plan for monitoring corrective action: Facility assessment will be reviewed on a quarterly basis and any changes/updates will be discussed at the QA meeting |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 16, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (NY 900, NY 503), the facility did not ensure the residents environment remained free of accident hazards as is possible and that each resident received adequate supervision to prevent accidents for 2 out of 3 (Residents #2, #3) residents reviewed for accidents. Specifically, (1) Resident #2 who had history of falls and required moderate assistance for transfers had falls from their wheelchair on 8/3/2024, 8/8/2024, 8/30/2024, 9/14/2024, 9/29/2024 with no injuries; (2) Resident #3 had unwitnessed falls on 8/7/2023, 11/14/2023, 1/5/2024 and 1/10/2024 with minor injuries. There was no documented evidence that new interventions were implemented to prevent further falls and care plans were not updated on each occurrence for both Residents #2 and # 3. The findings are: The Facility Fall Risk Assessment and Fall Prevention policy dated (MONTH) 2003 and last revised (MONTH) 30, (YEAR), documented all residents will be free of falls and free of injuries associated with falls. The facility will implement common sense interventions to aide in the prevention of falls, implement a plan of care based upon the resident risk category and assess all residents for falls at least on admission, re-admission, quarterly, when conditions deteriorate and upon fall. 1) Resident #2 initially admitted to the facility on [DATE] and last readmitted on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum (MDS) data set [DATE] documented the resident had moderate cognitive impairment. The resident required supervision for eating and bed mobility, dependent for toileting and required moderate assistance with transfers. Review of a falls care plan initiated 7/25/2024 and last reviewed 10/10/2024 documented the resident is at risk for falls due to a history of falls, poor safety awareness and impulsiveness. Interventions listed included: 8/31/2024- fall risk assessment quarterly, well it and clean/dry environment, provide assist with activities of daily living as needed, non-skid socks, keep in view of staff as much as practical, 9/29/2024-remind to stay in wheelchair and ask for assistance, 10/10/2024-keep in a supervised area with supervision in place, 10/13/2024-velcro release seat belt in wheelchair and 11/12/2024-wheelchair pad alarm. Review of an accident/incident report on 8/3/2024 at 2:30 PM revealed Resident #2 had an unwitnessed fall in the dayroom, wheelchair alarm sounded. The certified nurse assistant in the dayroom was assisting another resident when Resident #2 fell . Resident had x-rays done of the pelvis and bilateral hips to rule out fracture, results negative. There were no documented interventions implemented to prevent further falls. Review of an accident/incident report on 8/8/2024 at 7:30 AM revealed Resident #2 was found on their knees in the television room, attempted to climb out of the recliner chair, approximately 5 feet away from their wheelchair. There were no documented interventions implemented to prevent further falls. Review of an accident/incident report on 8/30/2024 at 4 PM revealed Resident #2 was found on the floor in the television room in front of their wheelchair. There were no documented interventions implemented to prevent further falls. Review of an accident/incident report on 9/14/2024 at 1:50 PM revealed Resident #2 was found sitting on the floor in front of their wheelchair. There were no documented interventions implemented to prevent further falls. Review of an accident/incident report on 9/29/2024 at 1:35 PM revealed Resident #2 stood up quickly from their wheelchair and lost their balance and fell , sustained an abrasion to the right knee. The resident then got up from the floor before they could be assessed by the Registered Nurse. Resident #2 was reminded to ask for assistance. There were no documented interventions implemented to prevent further falls. 2) Resident #3 admitted to the facility 5/28/2023 with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 10/1/2023 documented the resident was cognitively intact. The resident required a walker or a wheelchair for locomotion, set up assistance with meals and was independent with toileting, bed mobility and transfers. Review of a risk for falls care plan initiated on 5/28/2023 and last reviewed on 1/24/2024 documented interventions such as anti-skid socks, clean/dry environment, fall risk assessment quarterly, monitor for adverse effects of medication, if awake during the night offer: toileting, snacks, ambulation, maintain a well-lit environment, call bell within reach, provide assistance with activities of daily living as needed and safety re-education as needed. Review of an accident/incident report dated 8/7/2023 at 1:35 AM revealed Resident #3 stated they were trying to get up and transfer to their wheelchair to go to the bathroom and they missed the side of the bed and fell . The resident was found on their right side on the right side of the bed, no injuries were noted. There were no documented interventions implemented for fall prevention. Review of an accident/incident report dated 11/14/2023 at 4:45 PM revealed Resident #3 was found on the floor in their room next to the bed. Resident #3 stated they tried to get out of bed on their own and did not ask for help. Resident #3 sustained a minor injury, skin tear to their right forearm, which was treated and wrapped. Resident #3 did not complain of pain or discomfort at the time and bilateral hip x-rays were completed with negative results. There were no documented interventions implemented for fall prevention. Review of an accident/incident report dated 1/5/2024 at 2:15 PM revealed Resident #3 was ambulating in their room and appeared to slip and fall. The resident was found sitting upright on the floor near their wheelchair with their oxygen nasal cannula in place and attached to wheelchair. The oxygen tubing was around the wheelchair. Resident #3 hit the top of their head and was noted to have a tender area with a 1. 5 cm bump offered ice. The resident complained of pain to the right arm. Review of an accident/incident report dated 1/10/2024 documented at 5:45 AM revealed Resident #3 was found on the floor and was unable to state what occurred. The resident was confused at times. The resident was found sitting on the floor wearing their oxygen nasal cannula. Resident #3 sustained minor injury, a hematoma to the middle of their forehead an ice pack was applied, and they were sent to the emergency room for evaluation. During an interview on 11/14/2024 at 5:16 PM, the Director of Nursing stated they have an at risk meeting every Thursday with the interdisciplinary team, rehabilitation, and unit managers to discuss falls. The Director of Nursing stated in the meetings they talk about safety interventions in place and how effective and what the next steps should be. The Director of Nursing stated they have been having these risk meetings for almost a year. The Director of Nursing stated Resident #3 was alert, but they had poor safety awareness. The Director of Nursing stated they still tried with the resident to maintain their safety, but because of Resident #3's cognitive status, the resident is able to make their own decision and move about and go where they want. The Director of Nursing stated they feel Resident #3 has some confusion. The Director of Nursing stated Resident #2 is very impulsive, the resident has a safety belt in place on their wheelchair, which so far seems to be working. The Director of Nursing stated they want their residents in the facility to be safe. The Director of Nursing did not provide new interventions that were put in place for Resident # 3. During an interview on 11/14/2024 at 5:45 PM, the Administrator stated they have been in the facility since mid-August of 2024. The Administrator stated they have quarterly quality assurance and performance improvement meet | Plan of Correction: ApprovedJanuary 29, 2025 Plan for affected Resident: Resident #2 continues wheelchair pad alarm and remains in supervised area for safety. All fall interventions will be documented on updated care plan at the time of fall and reviewed at the risk meeting weekly. Resident has not had any recent falls. Resident #3 is no longer at the facility. Plan to identify other potentially affected residents: All admissions and readmission fall risk assessments will be reviewed upon admission and each quarter to ensure the appropriate interventions are in place to aid in the prevention of falls based upon the resident risk category. Resident charts were audited from (MONTH) 1st2024 to current for residents that are at risk for falls to ensure that appropriate interventions are in place. Plan for system changes and measures to prevent recurrence: The fall policy was reviewed and updated. The facility will take the following measures to ensure the problem does not reoccur: Nurse educator/ designee will re- educate all licensed nursing staff on Fall Risk assessment and Fall Prevention. All CNAs will be in-serviced on fall prevention by Staff Educator/designee. All new admissions/readmissions and any incident or accident that took place the day before will be reviewed at the morning IDT meeting to ensure that interventions are in place and properly documented. All new admission & re-admission resident charts will be audited weekly by ADON/Designee. Additionally, those residents who are at risk of falls will be in a supervised area for safety. Daily Environmental rounds will be conducted by nurse managers/supervisor and nurse educator to ensure the unit is free from accident hazards as is possible. Nursing staff will rotate supervised areas to ensure adequate supervision is being provided for residents that are at risk, as documented on the CNA assignment. Plan for monitoring corrective action: The facility plans to monitor its performance to make sure that solutions are substantiated by doing weekly audits that will be conducted by the nurse managers/designee to ensure all residents discussed at the at-risk meeting/ admission and readmission have fall interventions with date in place. Findings will be reported to the QAPI committee monthly times three (3) and quarterly times two (2) there after. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 16, 2024
Corrected date: N/A
Citation Details Based on record review and interviews during an abbreviated survey (NY 900, NY 503), the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 12 out of 39 residents reviewed for identification bands. Specifically, during an observation on 11/12/2024 there were 12 residents on the Apple unit observed without identification bands in place. The findings are: The facility Medication Administration policy dated 12/2016 and last revised 10/2023 documented that prior to administration of medication, the nurse must verify the resident's identification by checking the resident's identification band with the patient's name and medical record number. During observation conducted on 11/12/2024 at 3 PM on the Apple unit, there were 12 out of 39 residents noted without identification bands in place. During an interview on 11/12/2024 at 11:10 AM, Licensed Practical Nurse #1 stated most of the residents they administered medications to today on the apple unit did not have an identification band in place. Licensed Practical Nurse #1 stated to identify the residents with no identification they had to ask other staff members or look at the picture in the electronic medical record system to identify the residents during the medication pass. During interview on 11/14/2024 at 2:16 PM, Registered Nurse #1 who works on the Apple unit stated whenever they find residents on their unit with no identification bands, they inform the unit secretary, and they provide a new identification band for the residents. Registered Nurse #1 stated they will conduct their own audit on the unit for identification bands and have the secretary print out new ones for the residents that need them. Registered Nurse #1 stated they try to check the identification bands for the residents on their unit at least once a week and replaces the bands for the residents who need it. The residents on the Apple unit often remove their identification bands. During an interview on 11/14/2024 at 5:16 PM, the Director of Nursing stated all residents should have an identification band in place. They stated they do have an issue on the Dementia (Apple) unit because the residents remove their identification bands. The Director of Nursing stated the residents on the Apple unit should be checked every shift to ensure they have their identification bands in place. The Director of Nursing sated they will follow up with Registered Nurse #1 about checking the resident's identification bands frequently to ensure they are in place. 10 NYCRR 415. 12 | Plan of Correction: ApprovedDecember 30, 2024 Plan for Affected Resident: All 12 Residents affected were given new wrist bands. Plan to identify other potentially affected residents: All residents wrist bands were checked on each unit. All residents had wristbands in place. Plan for system changes and measures to prevent occurrence: The facility medication administration policy was reviewed. The policy was updated. All nursing staff were educated with emphasis on verification of residents by checking the residents name and medical record number on their wrist bands. If a resident does not have a wristband, they can verify via EMAR picture and continue their medication administration. The LPN is to create a wristband for any resident without a wristband by the end of the shift. All LPNs including nurse 1, were re-educated on the facility medication administration policy with emphasis on resident identification bands. Plan for monitoring correction action: Weekly audits will occur for one month on 15 residents per unit by the ADON/ Unit Mangers/Designee to ensure that all residents are wearing an identification band. After one month the wristbands will be audited biweekly for an additional two months. After two additional months wristband audits will be conducted monthly. All results will be reported at the quarterly quality measure meeting. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 16, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (NY 900, NY 503) the facility did not ensure medications were administered in accordance with the prescriber's order or in accordance with professional standards for 3 out of 3 residents (Resident #1, Resident #2, Resident #3) reviewed for medication administration. Specifically, (1) Resident #1 had an order for [REDACTED]. 2024. There was no documented evidence that the physician was made aware of the medication being administered late. (2) Resident #2 had an order for [REDACTED]. 2024. There was no documented evidence that the physician was made aware of the medication being administered late. (3) Resident #3 had an order for [REDACTED]. 2024. The Medication Administration Record [REDACTED] 2024. Further review of the Medication Administration Record [REDACTED] 2024. There was no documented evidence that the physician being made aware of Resident #3's refusals of the medications or not being administered the medications. The Findings are: The Facility Medication Administration policy dated 12/16 and last revised 10/23 documented it is the policy of the facility that all medications will be administered in a safe and systematic way. The nurse will document in the resident's electronic medical record after the medication is administered by signing the electronic medical record. The nurse should double check and ensure all medications were administered to the resident as per the physician order, with no missing signatures. Upon completion of the medication pass, the nurse should review the administration dashboard to ensure there is no missing documentation. 1)Resident #1 initially admitted to the facility on [DATE] and last readmitted on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 9/10/2024 documented the resident had severe cognitive impairment. Review of a [MEDICAL CONDITION] disorder care plan initiated 5/6/2024 documented the resident had a history of [REDACTED]. Resident was on [MEDICATION NAME] and the goal was the resident's [MEDICAL CONDITION] would be controlled by medication x 90 days. Interventions listed included administer anticonvulsant medications as ordered by physician and document and monitor all [MEDICAL CONDITION] activity. Review of the physician's orders [REDACTED]. Review of Resident #1's medication administration detail report revealed on 10/30/24 the [MEDICATION NAME] Sprinkles 9 PM dose was administered at 11:24 PM. During an interview on 11/14/2024 at 4:08 PM Licensed Practical Nurse #3 stated they know what medication Resident #1 gets, but they do not remember what time they signed it out for on 10/30/ 2024. Stated they did not notify the physician that Resident #1 had received their [MEDICATION NAME] medication late. Review of a physician's orders [REDACTED]. Review of Resident#1's medication administration detailed report for (MONTH) 2024 revealed, the resident's [MEDICATION NAME] Sprinkles were not administered within the regulated timeframe as follows: -11/7/2024-6 AM dose was administered at 1:25 PM -11/7/2024-12 PM dose was administered at 1:25 PM -11/11/2024-6 am dose given at 8:01 AM -11/12/2024-12 PM dose administered at 2:16 PM During an interview on 11/14/2024 a 1:40 PM Licensed Practical Nurse #4 stated if a medication is given outside of the hour before or hour after the medication due time, then the physician should be made aware. Licensed Practical Nurse #4 stated they would also have to write progress note about the medication being given late. Licensed Practical Nurse #4 stated they made an error in the documentation on 11/7/2024 for Resident #1's 6 AM and 12 PM doses of [MEDICATION NAME] and that they gave the [MEDICATION NAME] to Resident #1 on time. During an interview on 11/14/2024 at 1:55 PM Licensed Practical Nurse #1 stated if a medication is given late then they have to inform the physician and also write a progress note. Licensed Practical Nurse #1 stated Resident #1's 6 AM dose of [MEDICATION NAME] on 11/11/2024 was signed in error by them and the 12 PM dose is administered on their time. Stated they gave Resident #1 their [MEDICATION NAME] on time at 12 PM on 11/12/2024, but they signed off on the medication record late. There was no documented evidence of the physician being made aware of Resident #1 receiving their [MEDICATION NAME] sprinkles medication late on 11/7/2024, 11/11/2024 or 11/12/ 2024. 2)Resident #2 initially admitted to the facility on [DATE] and last readmitted on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 10/21/2024 documented the resident had moderate cognitive impairment. The resident required supervision for eating and bed mobility, dependent for toileting and required moderate assistance with transfers. Review of a [MEDICAL CONDITION] care plan initiated 7/25/2024 and last reviewed 10/28/2024 documented the resident will maintain highest level of functional mobility. Interventions listed included administer medication as per physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of Resident #2's Medication Administration Record [REDACTED]. Review of Resident #2's detailed medication administration report revealed on 8/30/2024 their 10:30 AM dose of [MEDICATION NAME]-[MEDICATION NAME] was administered at 12:05 PM. Further review of the detailed administration report revealed [MEDICATION NAME]-[MEDICATION NAME] was administered as follows: 10:30 AM dose on 9/4/2024 administered at 12:13 PM, 10:30 AM dose on 9/6/2024 administered at 1:25 PM, 6:30 PM dose on 9/6/2024 administered on 8:48 PM and 6:30 PM dose on 9/17/2024 at 9:15 PM. During an interview on 11/14/2024 at 4:30 PM Licensed Practical Nurse #6 stated they do not remember giving Resident #2 their 6:30 PM dose of [MEDICATION NAME]-[MEDICATION NAME] late on 9/17/ 2024. Stated they would inform the physician if they gave the medication late and they try to sign off for their medication administration as they go, but if they are short staffed then they may sign off for the administration late, if helping the certified nurse assistants with cares. During an interview on 11/14/2024 at 4:48 PM Licensed Practical Nurse #4 stated they are administering medications at the designated time, but they are not able sign immediately at times because it can be very busy. Stated they did not notify the physician that they administered Resident #2's 10 :30 AM | Plan of Correction: ApprovedJanuary 29, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F760- Plan for affected Residents: Residents #1 & #2 will have their medication given within the regulated time frame. Resident #3 MD/NP will be made aware when the resident refuses medication. Resident #1 [MEDICATION NAME] and [MEDICATION NAME] levels were drawn, and the levels were in normal limits with no adverse effects. Plan to identify other potentially affected residents: Each Nurse Manager will do a weekly audit on 10 residents on their unit to ensure the medication is being administered timely. In addition, the Nurse Manager will conduct weekly chart audits on medication administration documentation to ensure that MD was made aware if a resident refused medication. Plan for system changes and measures to prevent occurrences: The policy was reviewed. Nurse Educator/ADON will re-educate LPN/RNs on medication administration policy highlighting, medication administration time. MD/NP to be notified when a resident refuses medication and this should be documented in the progress note as well as the medication administration record. Weekly medication administration competency will be done on 10% of the licensed nurses by Nurse educator/designee. Plan for Monitoring Corrective action: Nurse managers will conduct weekly audits on 10 % of the residents on their unit to ensure that medications are given at the time prescriber ordered or in accordance with professional standards. Additionally, weekly chart audits will be done by each nurse manager on 10 % of residents on their unit to ensure that for those residents that refused medication the NP/MD was notified, and its documented in the medical record. The facility plans to monitors its performance to ensure solutions are sustained by nurse educator/designee conducting weekly medication administration competency on 10% of the licensed nurses. Findings will be reported to the QAPI committee monthly times three (3) and quarterly times two (2). |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 16, 2024
Corrected date: N/A
Citation Details Based on record review and interviews during an abbreviated survey (NY 900, NY 503), the facility did not ensure sufficient nursing staffing to attain or maintain the well-being of each resident for 39 residents on Unit A as determined by the facility nursing coverage plan as necessary to meet the needs of the residents. The findings are: The Facility Nursing Coverage Plan policy dated 8/3/2021 documented the purpose was to outline a staffing plan that shall be used to determine the personnel recommended for each shift as defined for each unit's core coverage and as necessary to provide the scope of services required to meet resident care. The Facility Assessment provided by the facility was last revised on 8/16/ 2024. The last review by the Quality Assurance and Improvement Committee was on 9/18/ 2023. The staffing plan documented a table describing the number of staff available to meet residents' needs, which listed the position of staff by title, as well as the number of full-time employees that hold those positions. The Facility Assessment on 11/12/2024 revealed the assessment did not include the staffing plan, the number of staff required/allotted for each unit or per shift. Review of an undated facility document titled Putnam Ridge Staffing Guidelines documented 5 Certified Nursing Assistants for the Day shift for Unit A, 4 Certified Nurse Nursing Assistants for the Evening shift on unit A, and 2 Certified Nurse Nursing Assistants for the night shift on unit A 7 days/week. The document also noted that these are guidelines for ideal staffing at maximum PAR (Provider Average Ratio) levels. Review of the staffing schedules for the A unit for (MONTH) 2024 revealed that staffing was below 4 Certified Nursing Assistants on the day shift and 2 Certified Nursing Assistants on the night shift: 3 Certified Nursing Assistants worked on the day shift on 5/7/2024, 5/11/2024, 5/12/2024, 5/15/2024, 5/20/2024, 5/21/2024, 5/28/2024, 5/30/2024 and 5/31/2024 and 1 Certified Nursing Assistants was scheduled for the night shift on 5/20/ 2024. Review of the staffing schedule for the A unit for (MONTH) 2024 revealed that staffing was below 4 on the day shift and below 3 on the evening shift: 3 Certified Nursing Assistants worked on the day shift on 6/2/2024, 6/15/2024, 6/16/2024, 6/18/2024, 6/22/2024, 6/23/2024 and 6/30/2024, 2 Certified Nursing Assistants worked on the evening shift on 6/2/2024, 6/29/2024 and 6/30/2024 and 1 Certified Nursing Assistants worked on the night shift on 6/7/2024, 6/11/2024, 6/22/2024, 6/23/2024, 6/28/2024 and 6/29/ 2024. Review of the staffing schedules for the A unit for (MONTH) 2024 revealed staffing was below 4 Certified Nursing Assistants on the day shift and 3 Certified Nursing Assistants on the evening shift and 2 Certified Nursing Assistants on the night shift: 3 Certified Nursing Assistants worked on the day shift on 7/1/2024, 7/11/2024, 7/14/2024, 7/17/2024, 7/20/2024, 7/21/2024, 7/24/2024, 7/25/2024 and 2 Certified Nursing Assistants worked on the day shift on 7/28/2024, 2 Certified Nursing Assistants worked on the evening shift on 7/5/2024 and 1 Certified Nursing Assistants worked on the night shift on 7/28/2024 During an Interview conducted on 11/12/2024 at 1:05 PM, the Director of Nursing stated that the staffing requirements for the Certified Nursing Assistants on the A unit are 4 to 5 during the day shift, 3 to 4 during the evening shift, and 2 during the night shift. During an interview on 11/12/2024 at 11:20 AM, Certified Nursing Assistant #3 stated they have been working in the facility for 1 year and they do not have adequate staffing all the time. Certified Nursing Assistant #3 stated instead of 4 Certified Nursing Assistants, most days they have 3 Certified Nursing Assistants because when they have 4 scheduled, one is usually pulled to cover another unit. Certified Nursing Assistant #3 stated they have discussed this issue with the administration that they need more staff, and nothing has been done about it. Certified Nursing Assistant #3 stated sometimes staff is moved from a unit mid-way through an assignment or shift to complete an entire new assignment on a different unit. Certified Nursing Assistant #3 stated administration does not call the agency for staff and that there have been many times when agency staff report to the facility and are told they were not needed when they were short staffed. During an interview on 11/12/2024 at 11:36 AM, Certified Nursing Assistant #5 stated that staffing could be better on most days. They stated they have 9 residents who require total care assigned to them today. Certified Nursing Assistant #5 stated on the weekends the staffing is rough on the day shift where there can be only 3 Certified Nursing Assistants scheduled. Certified Nursing Assistant #5 stated there have been times when there were only 2 Certified Nursing Assistants scheduled to the unit on the day shift on the weekend and the staffing in the facility is not good. Certified Nursing Assistant #5 stated they speak with Administration about staffing all the time and nothing ever changes, they are told that new hires are coming, and no one ever comes. Certified Nursing Assistant #5 stated the facility was using agency staff, but they got rid of a lot of them. During an interview on 11/12/2024 at 11:50 AM, Certified Nursing Assistant #6 stated there are usually 4 Certified Nursing Assistants on the unit, 2 on each side. Certified Nursing Assistant#6 stated there are 41 residents on the unit and with 4 Certified Nursing Assistants each person has 10 assigned residents and all the residents on the unit need total care. Certified Nursing Assistant #6 stated they have a unit assistant to help with making the residents beds. Certified Nursing Assistant #6 stated if they are short staffed with only 3 Certified Nursing Assistants, they have to provide cares to 13 residents who need total care and that is tough. Certified Nursing Assistant #6 stated that if 4 Certified Nursing Assistants are assigned to the unit on the day shift, they will each have 10 residents and they can give good care to the residents. Certified Nursing Assistant #6 stated sometimes on the weekend there are only 2 Certified Nursing Assistants, and it is tough. Certified Nursing Assistant #6 stated they have told Administration about short staffing, and administration do try to call staff, but they cannot find anyone to cover the shifts. During an interview on 11/12/2024 at 1:05 PM, the Director of Nursing, they stated staffing for the Certified Nursing Assistants in the facility is as follows: Day shift: on all units- 4-5 Certified Nursing Assistants, 5 is the goal, usually they have 4, but they are working to get to the 5 Certified Nursing Assistants at all times; Evening shift: on all units 3-4 Certified Nursing Assistants; Night shift: on the B unit there are 3 Certified Nursing Assistants and 2 Certified Nursing Assistants on the other 3 units (A, C and D). The Director of Nursing stated they do use agency staff to a minimum and they are trying to hire more staff for the facility. The Director of Nursing stated they will use any measure to make the staffing better. Staffing is a big problem, but they are working very hard to address it. During an interview on 11/14/2024 at 5:16 PM, the Director of Nursing stated they are now hiring more staff and the staffing levels are getting to where they need to be. The progress can be seen in the scheduling within the last month compared to 6 months ago. The Director of Nursing stated when they came to the facility 2 years ago, they were using mostly agency staff, but they have hired on more facility staff, and they do not use agency staff as much anymore. During an interview on 11/14/2024 at 5:45 PM, the Administrator stated the staffing has greatly improved since they started in the facility, which has helped a lot with the issues they face. During a telephone interview on 12/16/2024 at 2:05 PM, the Staffing Coordinator/Nursing recruiter stated they have been working in the facility since (MONTH) of 2024. The Staffing Coordinator/Nursing Recruiter stated there is a PAR (P | Plan of Correction: ApprovedJanuary 14, 2025 The Staffing Coordinator/designees will schedule sufficient staffing on all units and all shifts. The facility assessment was reviewed and updated to show current staffing resources. Plan for Monitoring Corrective Action: The facility has implemented a bi-weekly staffing meeting, to go over new hires, retention, recruitment, incentives and all other related staffing issues. The finial staffing schedule will be reviewed on a weekly basis by staffing coordinator/DON and findings presented to the bi-weekly staffing meeting. The facility will seek additional contracts from staffing agencies as a staffing contingency plan. We will increase the frequency of our orientation to facilitate a quicker onboarding process thereby increasing our staffing resources. Our facility assessment will be reviewed and updated annually or as needed to show current staffing resources All findings from the bi-weekly staffing meeting will be monitored by the QAPI monthly x 6 by the staffing coordinator/designee. |