NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 29, 2025
Corrected date: February 10, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during the recertification survey from 03/12/2025 to 03/19/2025, the facility did not ensure that comprehensive care plans were developed. This was evident for 3 residents (Resident #28, #79, and #93) out of 26 sampled residents. Specifically, a diuretic care plan was not developed for Resident #28, a [MEDICAL TREATMENT] care plan was not developed for Resident #79, and a hospice care plan was not developed for Resident # 93. The findings are: The facility policy titled Comprehensive Care Planning with effective date 1/26/2023 and last review date 10/16/2023 documented the facility utilizes an interdisciplinary team to provide an individualized comprehensive resident assessment and care planning process in order to maximize and maintain every resident's functional potential and quality of life. It also documented the interdisciplinary team is responsible for the overall supervision, training, consultation, and evaluation of the individual resident's care plan. 1) Resident # 28 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3. 0 ((MDS) dated [DATE] documented Resident # 28 was moderately cognitive impairment, had [DIAGNOSES REDACTED]. Medical Doctor Order started on 7/5/2024 and last renewed 3/1/2025 documented Resident #28 was ordered to receive 1 tablet of medication [MEDICATION NAME] 50mg tablet by oral route daily for essential hypertension. Comprehensive Care Plan related to Cardiac Status was initiated on 7/5/ 2024. The cardiac care plan had no focus, no goals, and no interventions entered. There was no documented evidence that a comprehensive care plan related to the diuretic use was developed and implemented in the medical record of Resident # 28. On 03/18/2025 at 03:16 PM, Registered Nurse #3 was interviewed and stated, they developed, reviewed, and updated the comprehensive care plans at least every 3 months for the residents on the floor. Registered Nurse #3 also stated the electronic medical record system gave them an alert when the care plans were due for review. Registered Nurse #3 reviewed Resident #28's medical record and was unable to locate a comprehensive care plan that was developed for Resident #28 about cardiac care or to take the diuretic medication [MEDICATION NAME]. Registered Nurse #28 stated there should be a comprehensive care plan to address Resident #28's need for cardiac care and/or taking the diuretic. 2) Resident # 79 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3. 0 ((MDS) dated [DATE] documented Resident # 79 was cognitively intact and received [MEDICAL TREATMENT] care. Medical Doctor Order started on 1/23/2025 and last renewed 2/20/2025 documented Resident #79 was ordered to receive [MEDICAL TREATMENT] 3 times a week on Tuesday, Thursday, and Saturday. Comprehensive Care Plan related to [MEDICAL TREATMENT] was initiated on 9/20/ 2024. The [MEDICAL TREATMENT] care plan had no interventions entered. There was no documented evidence that a comprehensive care plan related to [MEDICAL TREATMENT] was developed and implemented in the medical record of Resident # 79. On 03/18/2025 at 03:07 PM, Registered Nurse # 4 was interviewed and stated Resident #79 was on [MEDICAL TREATMENT] 3 times a week and they developed the [MEDICAL TREATMENT] care plan for Resident #79 on 9/20/ 2024. Registered Nurse # 4 reviewed the [MEDICAL TREATMENT] care plan for Resident # 79. Registered Nurse # 4 stated no interventions were entered into the [MEDICAL TREATMENT] care plan. Registered Nurse # 4 also stated the [MEDICAL TREATMENT] care plan was not considered developed as it missed the interventions. 3) Resident # 93 had [DIAGNOSES REDACTED]. The Significant Minimum Data Set 3. 0 ((MDS) dated [DATE] documented Resident # 93 was severely cognitive impairment and received Hospice care. Medical Doctor Order started on 1/31/2025 documented Resident #93 received Hospice care. There was no documented evidence that a comprehensive care plan related to Hospice care was developed and implemented for Resident # 93 in their medical record. On 03/18/2025 at 03:00 PM, Registered Nurse # 4 was interviewed and stated Resident #93 was on Hospice care since (MONTH) 2025. Registered Nurse # 4 also stated they did not develop a care plan related to Hospice for residents at the facility. Registered Nurse # 4 further stated they communicated with other staff for Hospice care through the progress notes. On 03/18/2025 at 03:24 PM, Director of Nursing was interviewed and stated the day shift registered nurses on the unit were responsible to develop, review, and update the comprehensive care plan at least every 3 months. Director of Nursing also stated every physician order [REDACTED]. Director of Nursing stated a comprehensive care plan is required for Hospice care. Director of Nursing also stated the care plans were not considered developed if the care plan missed goals or interventions. 10 NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedMarch 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Facility will notify the department of health and will conduct a fire watch when/if the fire alarm is impaired for more than 4 hours at any given time.03/01/2025 2. The facility's Fire Safety and Alarm Impairment Policy has been revised to ensure full compliance with NFPA 101: 9. 6. 1. 6 and NYCRR regulations. Updates include: Mandatory notification to the Department of Health for any fire alarm impairment [MEDICATION NAME] over 4 hours. Immediate implementation of a fire watch whenever the fire alarm system is offline, regardless of the duration. Documentation of fire watch rounds, including times and assigned staff, to be maintained for regulatory review. All involved staff members have been in-serviced. 03/01/25 3. The Maintenance Director will conduct weekly audits for the next 90 days to verify compliance with fire alarm impairment protocols and fire watch implementation. Any non-compliance will be immediately addressed. 03/01/25 4. Maintenance Director will be responsible for making Environmental rounds quarterly and reporting findings to Assistant Administrator to review at QA to ensure compliance for one year. 03/01/25 5. Responsible party: Director of Maintenance and Assistant Administrator 03/01/25 |