Saratoga Center for Rehab and Skilled Nursing Care
October 23, 2017 Complaint Survey

Standard Health Citations

FF10 483.20(g)-(j):ASSESSMENT ACCURACY/COORDINATION/CERTIFIED

REGULATION: (g) Accuracy of Assessments. The assessment must accurately reflect the resident?s status. (h) Coordination A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. (i) Certification (1) A registered nurse must sign and certify that the assessment is completed. (2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. (j) Penalty for Falsification (1) Under Medicare and Medicaid, an individual who willfully and knowingly- (i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or (ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment. (2) Clinical disagreement does not constitute a material and false statement.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 23, 2017
Corrected date: December 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews for an abbreviated survey (Case #'s NY 448 and NY 525), the facility did not ensure the assessment accurately reflected the residents' status for 6 (Resident #'s 18, 26, 48, 54, 55, 57 of 6 residents reviewed. Specifically: For Residents #'s 26 and 57, the facility did not ensure the Minimum Data Set (MDS) assessments for Swallowing/Nutritional Status (Section K) were accurate; For Resident #48, the MDS assessment for Medications (Section N) did not include the use of a diuretic (a fluid pill); For Residents #'s 18, 54, and 55, the MDS assessment for Unhealed Pressure Ulcers (Section M) did not document the resident had pressure ulcers. The lack of an accurate reflection of the resident's status has the potential to affect care planning. This is evidenced by: Resident #26: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had intact cognition. Section K, Question K0510 of the MDS dated [DATE], documented the resident had received [MEDICATION NAME]/IV feedings and enteral feedings within the seven days prior to the assessment date. During an interview on 9/6/17, the Director of Nursing (DON) stated there were no residents in the facility who were receiving [MEDICATION NAME]/IV feedings. During an interview on 9/6/17 at 10:45 am, the Director of Nutritional Services, a Registered Dietician (RD), was unable to state the difference between [MEDICATION NAME] and enteral feedings. The Director of Nutritional Services stated that there is an MDS reference manual she could use and did not recall if she referenced to it to complete the nutritional assessments for Residents #26 and 57. During an interview on 9/6/17 at 10:19 am, the MDS Coordinator stated that [MEDICATION NAME]/IV feedings are given though a vein. The MDS Coordinator stated, I don't think they've ever done them here. The MDS Coordinator stated the errors would create discrepancies in care planning and reimbursement and that he would need to correct both MDS assessments. The MDS Coordinator stated the Registered Dietician may not have understood the difference between [MEDICATION NAME]/IV nutrition and enteral feedings. During an interview on 9/6/17 at 10:45 am, the Director of Nutritional Services, a Registered Dietician (RD), was unable to state the difference between [MEDICATION NAME] and enteral feedings. The Director of Nutritional Services stated that there is an MDS reference manual she could use and did not recall if she referenced to it to complete the nutritional assessments for Residents #26. Resident #48 The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had moderate cognitive deficit. A physician's orders [REDACTED]. Section N, Question N0410, Medications Received, of the MDS dated [DATE], did not include the use of a diuretic. A physician's orders [REDACTED]. Section N, Question N0410, Medications Received, of the MDS dated [DATE], did not include use of a diuretic use. During an interview on 9/18/17 at 2:03 pm, the MDS Coordinator stated for completion of Section N in the MDS, the physician's orders [REDACTED]. The MDS nurse looks at the 7 days prior to the date of the MDS assessment to determine the medications used during that period. Then, the nurse enters that information in Question N0410, Medications Received. He stated reimbursement and care planning would be affected if a medication used during the 7 day timeframe was not documented. During an interview on 9/18/17 at 2:12 pm, the MDS nurse stated prior to electronic medical records, the MDS nurses reviewed the medication administration records and the physician orders [REDACTED]. She stated the medications are reviewed for a period of seven days prior to the MDS assessment. She stated answering the questions incorrectly would affect care planning. Resident #57: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had severe cognitive impairment. Section K, Question K0510, of the MDS dated [DATE], documented the resident had received [MEDICATION NAME]/IV feedings and enteral feedings within the seven days prior to the assessment date. During an interview on 9/6/17, the Director of Nursing (DON) stated there were no residents in the facility who were receiving [MEDICATION NAME]/IV feedings. During an interview on 9/6/17 at 10:19 am, the MDS Coordinator stated that [MEDICATION NAME]/IV feedings are given though a vein. The MDS Coordinator stated, I don't think they've ever done them here. The MDS Coordinator stated the errors would create discrepancies in care planning and reimbursement and that he would need to correct both MDS assessments. The MDS Coordinator stated the Registered Dietician may not have understood the difference between [MEDICATION NAME]/IV nutrition and enteral feedings. During an interview on 9/6/17 at 10:45 am, the Director of Nutritional Services, a Registered Dietician (RD), was unable to state the difference between [MEDICATION NAME] and enteral feedings. The Director of Nutritional Services stated that there is an MDS reference manual she could use and did not recall if she referenced to it to complete the nutritional assessments for Residents #57. 10 NYCRR 415.11(b)

Plan of Correction: ApprovedNovember 10, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident number 48 was discharged from the facility on 11/7/16. Resident number 54 was discharged from the facility on 10/18/17. Resident number 57 was discharged from the facility 10/6/17. Resident number 18 was discharged from the facility on 6/13/17. Resident number 26 is still in the facility, coding error of section K of the MDS has been corrected. Resident number 55 MDS has been reviewed and deemed accurate.
All residents have the potential to be affected by this deficient practice.
All MDS from the month of (MONTH) will be audited for accuracy of Sections K, M and N.
Any negative findings will be immediately corrected.
All MDS nurses will be provided with review of the list of medication categories
The wound RN will provide the MDS RN?s with weekly updated list of current wounds
Nutrition office employees who will be coding Section K have been educated on [MEDICATION NAME] and enteral therapy.
Audit random sample of 10 MDS weekly x4 weeks, then 20 monthly x2 months and report during the quarterly QA meeting.
QA committee will decide any continued audit.
Responsible Party: MDS Coordinator/Designee

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident?s medical record. (iv)In consultation with the resident and the resident?s representative (s)- (A) The resident?s goals for admission and desired outcomes. (B) The resident?s preference and potential for future discharge. Facilities must document whether the resident?s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 23, 2017
Corrected date: December 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during abbreviated surveys (Case #'s NY 497, NY 525, and #NY 994), the facility did not ensure it developed a comprehensive care plan (CCP) for each resident that described the services to be furnished to attain or maintain the resident's highest practicable physical well-being for three (Resident #'s 16, 48, and #50) of three residents reviewed. Specifically: For Resident #16, there was no CCP for the resident's [DIAGNOSES REDACTED].#'s 48 and 50, there was no CCP for a [MEDICAL CONDITION] disorder. This is evidenced by: The Policy and Procedure for Interdisciplinary/Comprehensive Care Plans revised 4/2016 documented, The comprehensive care plan shall be developed for each resident to meet all medical, nursing and mental and psychological needs that are identified in the comprehensive assessment. Resident #16: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderate cognitive deficit. A physician's orders [REDACTED]. The CCP did not include a care plan for [MEDICAL CONDITION] disorder. During an interview on 9/13/17 at 8:42 am, the Director of Nursing stated there should have been a care plan for the resident's [MEDICAL CONDITION] disorder. Resident #48: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderate cognitive deficit. A physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) did not contain a care plan for [MEDICAL CONDITION] disorder. During an interview on 8/29/2016 at 1:56 pm, the Director of Nursing stated she would expect there to be a care plan for [MEDICAL CONDITION] in place for residents on anticonvulsant medications. Resident #50: The resident was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderate cognitive impairment. A physician's orders [REDACTED]. A progress note dated 11/2/2017 at 6:55 pm, documented the resident had mild [MEDICAL CONDITION] activity [MEDICATION NAME] approximately 3 minutes that was witnessed by a Licensed Practical Nurse and the resident's daughter. The resident was sent to the hospital for evaluation. The Comprehensive Care Plan (CCP) did not include a care plan for [MEDICAL CONDITION] disorder and a CCP was not implemented following the resident's 11/2/2017 [MEDICAL CONDITION]. During an interview on 8/29/2016 at 1:56 pm, the Director of Nursing stated she would expect there to be a care plan for [MEDICAL CONDITION] in place for residents on anticonvulsant medications. 10 NYCRR 415.11(c)(1)

Plan of Correction: ApprovedNovember 10, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident number 16 discharged from the facility 6/26/17. Resident number 50 discharged from the facility on 11/22/16. Resident number 48 was discharged from the facility on 11/7/16.
All residents have the potential to be affected by this deficient practice
All resident care plans will be reviewed to reflect that there is a care plan for significant diagnosis, including but not limited to the following Diagnosis: [REDACTED].

Unit managers or RN designee will be educated to initiate care plans on admission, readmission or upon a newly identified significant diagnoses
All readmissions and newly identified significant [DIAGNOSES REDACTED].
Audits will be reported weekly x4, then monthly x2 and report during the quarterly QA meeting.
QA committee will decide any continued audit.
Responsible Party: MDS Coordinator/Designee

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Isolated
Severity: Actual harm has occurred
Citation date: October 23, 2017
Corrected date: December 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during an abbreviated survey (Case # NY 211) the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used without adequate monitoring; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued for one resident (Resident #42) of three residents reviewed. Specifically, for Resident #42, who received a blood thinner medication [MEDICATION NAME] ([MEDICATION NAME] - a blood thinner associated with an increased risk for bleeding) daily for [MEDICAL CONDITION] (irregular heartbeat that can lead to blood clots/stroke), the facility did not perform physician ordered weekly blood testing to monitor [MEDICATION NAME] for potential clinically significant adverse consequences for six consecutive weeks. The facility failed to notify the physician when the resident began to bleed rectally, and the resident was not sent to the hospital until more than 24 hours later. The resident was diagnosed with [REDACTED]. This is evidenced by: The Facility Policy and Procedure (P&P) for Anticoagulation Therapy dated 6/16/16, documented a therapeutic INR range must be maintained to prevent further complications. All residents who receive anticoagulant therapy must have the PT/INR results reported to the physician in a timely manner. When a PT/INR is scheduled, the licensed nurse will document it on the eMAR (electronic medication administration record). This will alert the Medication Nurse when the laboratory result is due and not to administer the medication (unless ordered) until the result is back. If the INR is out of range or there is no INR range, the MD needs to be notified before the next scheduled dose is given. The following key points were documented: Licensed Nurses administering [MEDICATION NAME] ([MEDICATION NAME]) on a day a PT/INR was scheduled, must know the results prior to administering the medication. If a result is not in as scheduled, it is the Licensed Nurse responsibility to notify the Supervisor immediately. If the MD does not return the call or fax back orders within 1 hour of [MEDICATION NAME] administration, the Supervisor must call again. If still no response, notify the Medical Director. Resident #42 The resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The resident also has a prosthetic heart valve. The Brief Interview for Mental Status (BIMS) was assessed as 8/15; moderate cognitive impairment on the Minimum Data Set ((MDS) dated [DATE]. Review of the Comprehensive Care Plan (CCP) for Anticoagulant Therapy dated 9/1/15 and last reviewed on 5/17/16, documented the resident was on [MEDICATION NAME] therapy and to continue with goal and interventions to monitor the resident for signs and symptoms of bleeding (rectal bleed), schedule laboratory tests as ordered, report any signs and symptoms of bleeding to the MD, and maintain PT/INR range as ordered by the MD. There were no further reviews/updates documented on the CCP after 5/17/16. The Initial Physician assessment dated [DATE], documented the resident was taking [MEDICATION NAME] 3 mg daily. Review of the physician orders [REDACTED]. The Physician order [REDACTED]. The Laboratory test result report for a PT/INR dated 2/20/17, documented the INR was 3.2 and included documentation that a therapeutic INR range for patients on stable oral [MEDICATION NAME] therapy was 2.0 - 3.0. The report documented the physician was notified and to hold the [MEDICATION NAME] and repeat the PT/INR on Thursday (2/23/17). The Physician order [REDACTED]. Review of the medical record for PT/INRs done after 2/20/17: There was no documentation in the medical record that the PT/INR test was repeated on 2/23/17 as ordered, however, the eMAR dated 2/23/17 documented that [MEDICATION NAME] 3 mg was given. There was no documentation that the physician was notified that the [MEDICATION NAME] was administered without a PT/INR result. On Monday 2/27/17, LPN #12 documented [MEDICATION NAME] PT/INR's are due by 6:00 pm on the second shift. There was no documentation in the medical record for a test result for a PT/INR dated 2/27/17, however, the eMAR dated 2/27/17 documented [MEDICATION NAME] 3 mg was given. There was no documentation that the physician was notified that the [MEDICATION NAME] was administered without a PT/INR result. There was no documentation in the medical record for PT/INR test results for Monday 3/6/17, 3/13/17, 3/20/17, 3/27/17, and 4/3/17, however, the eMAR documented the tests were done and that [MEDICATION NAME] 3 mg was given on each of the days noted. There was no documentation that the physician was notified that the [MEDICATION NAME] was administered without a PT/INR result. Review of the eMAR for (MONTH) (YEAR), documented the resident continued to receive [MEDICATION NAME] 3 mg from 4/4/17 - 4/8/17. The Nursing Progress Note written by LPN #13 dated 4/7/17 at 11:32 pm, documented the resident was having frank bleeding (obvious visible presence of blood) from the rectum and that the Supervisor was made aware. The note documented the resident has hemorrhoids, will continue to monitor. There was no documentation in the medical record that the resident was assessed by a qualified person and no documentation the physician/family was notified. The Nursing Progress Note written by RN #5 dated 4/8/17 at 11:53 pm, documented the resident had 3 episodes of rectal bleeding that was getting progressively worse. Resident is on [MEDICATION NAME]. The physician was notified and the resident was sent to the ER. The Hospital Emergency Department Nurse assessment dated [DATE] at 1:14 am, documented patient passing frank red blood from rectum. The Hospital Emergency Department Provider report dated 4/9/17 at 1:19 am, documented per nurse the patient was passing blood clots during triage. Review of the laboratory results documented the hemoglobin (carries oxygen from the lungs to the tissues) was 9.1 (normal range is 13.5 - 17.2), and the hematocrit (the percentage of red blood cells in the blood) was 30.4 (38.8 - 50). The physician ordered to monitor the hemoglobin and hematocrit closely; every 6 hours and to consult the gastrointestinal team for further recommendations. The Hospital Laboratory result for a PT/INR dated 4/9/17, documented the INR was >10.8 (therapeutic range is 2.0 - 3.0). Review of the Hospital History and Physical report dated 4/9/17, documented acute lower GI bleed with supratherapeutic INR and chronic use of [MEDICATION NAME] ([MEDICATION NAME]). INR is greater than 10.8. The patient received Vitamin K (reverses the effects of [MEDICATION NAME]) 5 mg in the ER. The digital rectal exam did not demonstrate any hemorrhoids. The Hemoccult (a test for hidden blood in the stool) is positive with bright red blood. The resident also needed a transfusion to reverse the effects of the [MEDICATION NAME]. The Hospital Transfusion Service Record dated 4/9/17 at 3:38 am, documented the resident received a unit of thawed plasma (a blood product used to treat conditions in which there are low blood clotting factors). During an interview on 8/28/17 at 3:21 pm, with LPN #10 regarding the PT/INR, he stated that prior to [MEDICATION NAME] administration, he checks the previous INR to make sure it's therapeutic. If there is no laboratory result available, he would notify the Supervisor. He stated, It would be terrible if the INR is 6 and he got [MEDICATION NAME]. During an interview on 8/28/17 at 3:40 pm, with RNS (Registered Nurse Supervisor) #1, he stated the PT/INR results get documented in the Nursing Progress Notes usually by the Nurse Manager, but he is doing it right now. All laboratory results get faxed to the Nursing Supervisor's office. Anything over an INR of 3 gets called to the MD to get a change in the [MEDICATION NAME]. The LPN's and RN's are aware of that. He stated he called the laboratory for the most current result and they sent 2/20/17. He knows there were more labs done after that because it was written in the progress notes INR 1.5, etc. Review of the Nursing Progress Notes dated (MONTH) (YEAR) - (MONTH) (YEAR) documented an INR of 3.6 on 2/10/17. There were no other documented INR results after 2/10/17. During an interview on 8/28/17 at 4:00 pm, with LPN #11, she stated that prior to [MEDICATION NAME] administration she checks the PT/INR. Sometimes the result is in the computer, in the progress notes. If the result is not there, she pulls the chart. Laboratory work is done on Monday; RNS #1 will enter the result. If the result of the INR is over 3, notify the Supervisor and then then MD gets notified. RNS #1 normally gets the results. During an interview on 8/28/17 at 4:32 pm, with the Director of Nursing (DON), Regarding the frank bleeding from the resident's rectum on 4/7/17 during the evening shift, she stated, I supervised the next day. I never got anything from the day shift about the bleed. I had my own report sheet on all 6 units. The only thing I heard about was the flu swab that was done on the resident. That would have been nice to know. Regarding the familiarity with the facility's anticoagulation P&P, she stated they draw labs every Monday. If the resident refused to have blood drawn, call the MD. Lab results go to the Supervisor via fax if they are normal. If the results are abnormal, the laboratory calls the Supervisor, and the Supervisor calls the MD. RNS #1 documents the result of the PT/INR in a nursing note. RNS #1 can also enter the result in the dropdown box in the computer system. Regarding no PT/INRs done after 2/20/17, she stated, On Monday, if they don't see a result, they should call the Supervisor. The lab should have been checked. There's a whiteboard on the unit that indicates who has a PT/INR. Labs are drawn first thing in the morning, before 7:00 am. The results come to the facility during the day shift. There was a Nurse Manager in charge of the resident's unit in (MONTH) (YEAR). During a phone interview on 10/12/17 at 10:38 am, with MD #2, regarding the PT/INR tests not being done as ordered, she stated she was aware of the order to repeat the INR; Not that it wasn't being done. She stated, I think that was a transition time; no RN Nurse Managers. The LPN's might have been managing the units. Regarding the management of the PT/INR results, she stated, I would order it, expect it to be carried out, and called with the results. She stated, If the nurse manager had a log, they would be able to keep track of the PT/INRs. Regarding the PT/INRs not being done after 2/20/17, she stated, There seems to be a serious error on their (Nursing) part. The unit manager needs to be responsible. They were lacking a charge nurse. That's when the error occurred. The LPN's are not geared to assess. Regarding the frank bleeding from the resident's rectum on 4/7/17, she stated, They should have notified me and it should have been documented. If I'm not notified, how will I know? During a phone interview on 10/12/17 at 2:01 pm, with the Medical Director, regarding the PT/INR of 3.2 on 2/20/17, he stated he would expect a call to be made to the MD. The MD will take action as to whether to hold or adjust the [MEDICATION NAME] and give an order for [REDACTED]. He would expect an assessment of the stability of the resident; vital signs, mental status. He stated, There needs to be a RN that would go and assess the resident and have the physician contacted to see what the next course of action is. This is what they are taught to do. During a phone interview on 10/17/17 at 2:59 pm, with LPN #13, she stated she works the 3-11 pm shift on unit B-3 and was familiar with the resident. In regards to being familiar with the facility's anticoagulation therapy P&P she stated, Then or now? Now, I would check the INR. In regards to checking the INR result back in April, she stated she believes that she was, however, she could not state where she would look for the result. The call was disconnected (reason unknown) and after a few minutes, LPN #13 called the surveyor back. LPN#13 was asked again if she was checking the INR result prior to administering [MEDICATION NAME]. She replied, INRs are done on Monday. If high hold it. She was asked where she finds the INR result. She replied, The PT/INR is done during the day. She was asked again where she knows to look for the result. She replied, It's usually taken care of during the day. She confirmed the [MEDICATION NAME] was usually given at 6:00 pm. She was asked again where she finds the INR result. She replied, A lab sheet, downstairs somewhere. Regarding the 4/7/17 documentation of the rectal bleeding, notifying the Supervisor, and the hemorrhoids, she stated, I saw hemorrhoids. She could not remember what happened and if the Supervisor saw the resident. It was documented on the eMAR for (MONTH) (YEAR) that [MEDICATION NAME] was administered by LPN #13 on all 4 days the PT/INR test was scheduled to be done; 3/6/17, 3/13/17, 3/20/17, and 3/27/17. 10 NYCRR 415.12(1)(1)

Plan of Correction: ApprovedNovember 21, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
Resident #42 has been discharged from the facility 4/8/17
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
All residents have the potential to be affected by this practice.
1. The facility conducted an audit on all residents on anti-coagulant therapy.
2. Audit tool will include
a. Medication Order
b. Lab if applicable (PT/INR)
c. Results if applicable
d. MD Notification if applicable
e. Signs and symptoms of bleeding.
f. Responsible party notification
3. Any negative finding will be immediately relayed to the attending MD for medical management and resident/resident representative for any changes in treatment.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
The facility consultant will review with the Clinical Team and Facility Administrator the following systemic measure to prevent recurrence as well as conduct the directed education to address the cited deficiency.
1. All licensed nurses will be educated on the revised anticoagulation policy and procedure.
2. Batch order was created to include order entry for anti-coagulant, and order for blood draw.
3. Anti coagulant policy has been reviewed and revised to include that all PT/INR result will be relayed to the MD or Medical Director.
4. The Staff Educator will conduct a facility wide in-service for all licensed nurse regarding the notification of change policy, including but not limited to signs and symptoms of GI bleed.
a. Immediate notification of signs and symptoms of bleeding while on anti-coagulant
i. Black tarry stool
ii. Frank rectal bleeding
iii. Excessive bruising to one or more part of the body
iv. Bleeding gums
v. Blood in the urine/ tea colored urine output
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Facility Consultant will assist the Administrator/QA Coordinator and the Director of Nursing to initiate a reasonable and attainable QAPI programs to discuss the results of the facility audit.
1. Unit Manager/designee will complete the anticoagulant audit tool weekly x 4, then monthly x 2 and reported to the QA quarterly meeting. The QA Committee will decide if future audits will continue based on the findings.
2. Audit tool will include
a. Medication Order
b. Lab if applicable (PT/INR)
c. Results if applicable
d. MD Notification if applicable
e. Signs and symptoms of bleeding.
f. Responsible party notification
The date for correction and the title of the person responsible for correction of each deficiency.
? Director of Nursing

FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 23, 2017
Corrected date: December 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case #'s NY 069 and NY 204), the facility did not ensure that the residents' environment remained as free of potential accident hazards for two (Resident #'s 8 & 46) of four residents reviewed. Specifically: For Resident #8, the facility did not ensure timely interventions were developed and implemented to prevent the resident from falling out of bed; For Resident #46, the facility did not ensure therapy recommendations were followed resulting in the resident's fall out of the wheelchair. This is evidenced by the following: Resident #8: The resident was re-admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment, was understood and could understand others. The MDS documented the resident required extensive assistance of two (2) staff members for bed mobility, transfer, dressing, toileting, and was not able to ambulate. The ADL #5 (care instructions) dated 3/21/2017, documented the resident had bilateral enabler bars on both sides of the bed. The Falls Risk assessment dated [DATE], included documentation by Registered Nurse (RN) #9 of the resident's risk for falls related to Parkinson's, use of Anti-Parkinson's medications, history of seizures, unsteady balance, unsteady gait, bowel and bladder incontinence, pain, and impaired mobility. A nurse progress note dated 3/24/2017 at 11:40 pm, written by LPN #17, documented the resident turned self-sideways in bed with legs off the bed. The resident was repositioned and a pillow under the sheet on the left side of the bed near the resident's feet due to the resident turning herself sideways in the bed with her feet off the bed. The Falls Comprehensive Care Plan (CCP) (last updated 3/21/2017), did not include documentation of specific interventions to prevent the resident from putting her feet off the left side of the bed. The ADL #5 (last updated 3/21/2017), did not document specific interventions to prevent the resident from putting her feet off the left side of the bed. A nurse progress note dated 3/26/2017 at 7:00 pm, written by LPN #17, documented the resident was found turned sideways in bed with feet on the floor. The resident was taken to the nurse's station for safety. The Falls CCP and ADL #5 (last updated 3/21/2017), did not include specific interventions to prevent the resident from putting her feet off the bed. The Accident & Incident (A & I) Report dated 3/28/2017 at 6:20 pm, documented the resident was found on the floor on the left side of her bed. The resident had no apparent injuries. The resident had positioning rails on the bed. The A & I documented the following additions for interventions: Rearrange the bed for left side to be on the wall, add bilateral floor mats, add bed alarm, and add bolsters. A nurse progress note dated 3/28/2017 at 6:47 pm, written by RN #9, documented the resident was found on the floor on the left side of the bed, an RN assessment was completed and no injuries were identified. The Falls CCP dated 3/28/2017, documented the resident was found on the floor at bedside with no apparent injuries. Interventions for a bed alarm and bilateral floor mats were added. A nurse progress note dated 3/29/2017, written by RN #1, documented the family was notified and in agreement with placing the left side of the bed against the wall, bilateral bolsters (long, thick pillow that is placed under other pillows for support) at middle of the bed, and a right-side enabler bar at the head of the bed. The physician was notified. The Falls CCP dated 3/29/2017, did not include the resident's bed placement against the wall on the left side or the bilateral floor mats change to the right sided only The ADL #5 dated 3/29/2017, documented the resident's bed was placed against the wall on the left side, a right floor mat, a bed alarm, and bolsters at the middle of the bed were added The Restraint CCP dated 3/29/2017, documented the resident had Tourette's Syndrome: that bilateral bolsters were added to the middle of the bed, and an enabler (positioning device) bar was at the right head of the bed. Physician #1's progress note signed 3/29/2017, did not include the resident's bed was placed against the wall on the left side. Interview on 8/22/2017 at 2:20 pm, Registered Nurse Supervisor (RNS)#1 stated that LPN #17 should have notified an RN that the resident was making independent transfer attempts out of bed. RNS #1 stated that he would not expect an LPN to initiate fall preventative interventions without an RN assessment. RNS #1 stated that an RN would have added the preventative fall interventions to the resident's ADL #5 and Falls CCP. RNS #1 also stated that the facility always has an RN available to assess a resident. Interview on 8/22/2017 at 2:45pm, the Director of Nursing (DON) stated that LPN #17 should have notified an RN for an assessment and a new fall assessment should have been completed. The DON stated that the resident's fall on 3/28/2017 could have been prevented if the LPN had notified an RN of the resident's transfer attempts. Interview on 8/23/2017 at 12:15 pm, LPN #18 stated that if a resident was attempting to get out of their bed she would have gotten the resident out of the bed. LPN #18 stated she would tell the LPN Charge Nurse or RN. She stated that if interventions were changed she would have updated the Certified Nurse Aide staff verbally and monitored the changes for efficiency every 15 to 30 minutes. Resident #46: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Falls CCP dated 6/22/2016, documented the resident had poor comprehension, poor communication, incontinence, deconditioning, confusion, history of falls, and unaware of safety needs. The resident specific interventions documented a bed alarm, tab alarm, consult Physical Therapy or Occupational Therapy as needed. The ADL #5 dated 6/23/2016, documented the interventions of a bed alarm, tab alarm, a chair sensor, a wander guard and use of a wheelchair with a cushion for locomotion. The ADL #5 dated 7/11/2016, documented the intervention for a wheelchair with a cushion was discontinued and a chair was added. The ADL #5 dated 8/11/2016, documented the resident's ambulation status was limited assist with wheeled walker and did not include the use of a wheelchair. The facility A & I dated 9/04/2016, at 5:50 pm documented the resident tipped backwards while in the wheelchair. The Falls CCP dated 9/04/2016, documented the resident had poor comprehension, poor communication, incontinence, deconditioning, confusion, and was unaware of safety needs. The CCP documented resident specific interventions for a bed alarm, tab alarm, consult Physical Therapy or Occupational Therapy as needed, and a wheelchair with rear anti tippers. A Rehabilitation Screening dated 9/07/2016, documented the resident should not be seated in a wheelchair as she was able to ambulate. The resident was able to sit in a regular chair. The Falls CCP dated 9/07/2016, did not include the therapy recommendation for the resident not to sit in the wheelchair. A nurse progress note dated 9/08/2016 at 6:23 pm, LPN #19 documented the resident had an alarm on in a straight back (regular) chair. A nurse progress note dated 9/08/2016 at 8:31 pm, LPN #19 documented the resident continued to get up from straight back chair and carry the safety alarm, while ambulating unsteadily. LPN #19 placed the resident in a wheelchair where she didn't need assistance with mobility. The resident self-propelled on the unit. A nurse progress note dated 9/8/2016, at 10:46 pm, written by LPN #19 documented the resident was placed in a straight chair with the alarm but moved the chair across the unit with her feet. The ADL #5 dated 9/12/2016, documented the safety interventions for a bed alarm and tab alarm while in chair. A progress note dated 9/13/2016, written byRN #7 documented the resident was re-issued a wheelchair with rear anti-tippers after a discussion with Rehabilitation. The ADL #5 dated 9/13/2016, documented safety interventions for a bed alarm and tab alarm while in the chair. The resident used a wheelchair with rear anti-tippers for locomotion. The facility A & I dated 9/21/2016, documented the resident was found on the floor after observed sleeping in the wheelchair. The resident had no injuries. A Rehabilitation Screening Request dated 9/21/2016, documented the resident's feet could not reach the floor with a cushion in the wheelchair. The resident utilized her feet to self-propel while in the wheelchair. A Physical Therapy note dated 9/26/2016, written by Physical therapist (PT) #1 documented the resident was issued a new hemi-height (specific type) wheelchair with anti-pressure cushion to allow her feet to reach the floor. Interview on 8/25/2017, at 11:05 am, LPN #10 stated that if a resident had a change she would call an RN for an assessment. Interview on 8/28/2017 at 9:30 am, PT #1 stated that nursing gave a wheelchair back to the resident because she kept standing up and down. She stated the wheelchair that nursing issued to the resident was not evaluated by therapy. She stated that therapy utilizes additional resident factors such as: weight, height, cognition, and safety awareness when they issue a wheelchair. The wheelchair that nursing gave the resident was too high and the resident slid forward when she was self-propelling the wheelchair. Additionally, PT #1 stated the resident was issued a hemi-height wheelchair after a therapy evaluation on 9/28/17. Interview on 8/29/2017, at 9:30 am, the Administrator stated she would expect a therapy evaluation within 24 hours of a request. 10NYCRR415.12 (h) (1)

Plan of Correction: ApprovedNovember 10, 2017

Resident number 8 was discharged from the facility on 4/1/17. Resident number 46 discharged from the facility 9/1/17.
All residents at high risk for falls have the potential to be affected by this deficient practice.
All current fall risk assessments will be reviewed to identify residents with moderate to high risk for falls
All residents with moderate to high risk for falls (fall risk assessment score 5 and above) will have an updated care plan and interventions if any fall has occurred.

Reviewed falls assessment form and scoring will be added for simple scoring
All admissions and readmissions and significant changes will be brought to daily clinical startup to ensure care plan for falls has been updated.
All residents with an actual fall will have a corresponding intervention reflected in their care plan.
Education provided to all staff regarding care plan updates and interventions
Will initiate transition to use PointClickCare for care plans in electronic health record.
All referrals to therapy will be reflected in the 24 hours report. When therapy receives a referral they will document a response within 24 hours.
All falls will be audited for fall risk assessment and care plan update.
Audit will be reported weekly x4, then monthly x2 and reported at quarterly QA.
The QA committee will decide any continued audit
Responsible Party: Assistant Administrator/Designee

NG TREATMENT/SERVICES - RESTORE EATING SKILLS

REGULATION: (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- (4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the residentís clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and (5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: 2017-10-23
Corrected date: 2017-12-01

Citation Details

Details not available

Plan of Correction: N/A

Plan of correction not approved or not required

FF10 483.10(g)(14):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)

REGULATION: (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 23, 2017
Corrected date: December 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during an abbreviated survey (Case NY 211), the facility did not immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status (a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for one (Resident #42) of three residents reviewed. Specifically, for Resident #42, who receives the blood thinner [MEDICATION NAME] daily, the facility did not ensure the physician was notified that laboratory tests ordered for weekly PT/INR (blood test for persons who take [MEDICATION NAME] ([MEDICATION NAME] -blood thinner)) were not done weekly from 2/23/17-4/3/17. On 4/7/17 at 11:32 pm, the resident's physician was not immediately consulted and the resident's representative was not notified when the the resident began to bleed rectally. The resident was sent to the hospital on [DATE] at 11:53 pm, a delay in treatment of [REDACTED]. This is evidenced by: Refer to F Tag 329 The Facility Policy and Procedure (P&P) for Anticoagulation Therapy dated 6/16/16 documented a therapeutic INR range must be maintained to prevent further complications. All residents who receive anticoagulant therapy must have the PT/INR results reported to the physician in a timely manner. When a PT/INR is scheduled, the licensed nurse will document it on the eMAR (electronic medication administration record). This will alert the Medication Nurse when the laboratory result is due and not to administer the medication (unless ordered) until the result is back. If the INR is out of range or there is no INR range, the MD needs to be notified before the next scheduled dose is given. The following key points were documented: Licensed Nurses administering [MEDICATION NAME] ([MEDICATION NAME]) on a day a PT/INR was scheduled, must know the results prior to administering the medication. If a result is not in as scheduled, it is the Licensed Nurse responsibility to notify the Supervisor immediately. If the MD does not return the call or fax back orders within 1 hour of [MEDICATION NAME] administration, the Supervisor must call again. If still no response, notify the Medical Director. The P&P for Notification of Changes dated 11/7/16 documented it is the policy of the facility to immediately consult with the resident's physician and notify the resident's legal representative upon significant change in status or condition (physical, mental, or psychosocial). Resident #42 The resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The resident also has a prosthetic heart valve. The Brief Interview for Mental Status (BIMS) was assessed as 8/15; moderate cognitive impairment on the Minimum Data Set ((MDS) dated [DATE]. Review of the Comprehensive Care Plan (CCP) for Anticoagulant Therapy dated 9/1/15 and last reviewed on 5/17/16, documented the resident was on [MEDICATION NAME] therapy and to continue with goal and interventions. The interventions were to monitor the resident for signs and symptoms of bleeding (rectal bleed), schedule laboratory tests as ordered, report any signs and symptoms of bleeding to the MD, and maintain PT/INR range as ordered by the MD. There were no further reviews/updates documented on the CCP after 5/17/16. The Initial Physician assessment dated [DATE], documented the resident was taking [MEDICATION NAME] 3 mg daily. Review of the physician orders [REDACTED]. The Physician order [REDACTED]. The Laboratory test result for a PT/INR dated 2/20/17, documented the INR was 3.2 and included documentation that a therapeutic INR range for patients on stable oral [MEDICATION NAME] therapy was 2.0 - 3.0. The physician was notified and the report documented to hold [MEDICATION NAME] and repeat the PT/INR on Thursday (2/23/17). The Physician order [REDACTED]. Review of the medical record for PT/INRs done after 2/20/17, documented: - There was no documentation in the medical record that the PT/INR test was repeated on 2/23/17 as ordered, however, it was documented on the eMAR dated 2/23/17 [MEDICATION NAME] 3 mg was given. There was no documentation that the physician was notified that the [MEDICATION NAME] was administered without a PT/INR result. - On Monday 2/27/17 LPN#12 documented [MEDICATION NAME] PT/INR's are due by 6:00 pm on the second shift. There was no documentation in the medical record for a test result for a PT/INR dated 2/27/17, however, it was documented on the eMAR dated 2/27/17 [MEDICATION NAME] 3 mg was given. There was no documentation that the physician was notified that the [MEDICATION NAME] was administered without a PT/INR result. - There was no documentation in the medical record for PT/INR test results for Monday 3/6/17, 3/13/17, 3/20/17, 3/27/17, and 4/3/17, however, it was documented on the eMAR the tests were done and it was documented [MEDICATION NAME] 3 mg was given on each of the days noted. There was no documentation that the physician was notified that the [MEDICATION NAME] was administered without a PT/INR result. - Review of the eMAR for (MONTH) (YEAR) documented the resident continued to receive [MEDICATION NAME] 3 mg from 4/4/17 - 4/8/17. The Nursing Progress Note written by LPN #13 dated 4/7/17 at 11:32 pm documented the resident was having frank bleeding (obvious visible presence of blood) from the rectum and the Supervisor was made aware. The resident has hemorrhoids, will continue to monitor. There was no documentation in the medical record that the resident was assessed by a qualified person and no documentation the physician/family was notified. The Nursing Progress Note written by RN#5 dated 4/8/17 at 11:53 pm, documented the resident had 3 episodes of rectal bleeding that was getting progressively worse. Resident is on [MEDICATION NAME]. The physician was notified and the resident was sent to the ER. The Hospital Emergency Department Nurse assessment dated [DATE] at 1:14 am, documented patient passing frank red blood from rectum. The Hospital Emergency Department Provider report dated 4/9/17 at 1:19 am documented per nurse the patient was passing blood clots during triage. The Hospital laboratory result for a PT/INR dated 4/9/17 documented the INR was >10.8 (therapeutic range is 2.0 - 3.0). Review of the Hospital History and Physical report dated 4/9/17, documented acute lower GI bleed with supratherapeutic INR and chronic use of [MEDICATION NAME] ([MEDICATION NAME]). INR is greater than 10.8. The patient received Vitamin K (reverses the effects of [MEDICATION NAME]) 5 mg in the ER. The digital rectal exam did not demonstrate any hemorrhoids. The Hemoccult (a test for hidden blood in the stool) is positive with bright red blood. The resident also needed a transfusion to reverse the effects of the [MEDICATION NAME]. The Hospital Transfusion Service Record dated 4/9/17 at 3:38 am documented the resident received a unit of thawed plasma (a blood product used to treat conditions in which there are low blood clotting factors). During an interview on 8/28/17 at 3:21 pm with LPN #10, regarding the PT/INR, he stated that prior to [MEDICATION NAME] administration, he checks the previous INR to make sure it's therapeutic. If there is no laboratory result available, he would notify the Supervisor. During an interview on 8/28/17 at 3:40 pm, RNS #1 stated the PT/INR results are usually documented by the Nurse Manager, in the Nursing Progress Notes, but he is doing it right now. All laboratory results are faxed to the Nursing Supervisor's office. Anything over an INR of 3 gets called to the MD to get a change in the (dosage of) [MEDICATION NAME]. The LPN's and RNS are aware of that. He stated he called the laboratory for the most current result and they sent 2/20/17. He knows there were more labs done after that because it was written in the progress notes INR 1.5, etc. Review of the Nursing Progress Notes dated (MONTH) (YEAR) - (MONTH) (YEAR) documented an INR of 3.6 on 2/10/17. There were no other documented INR results after 2/10/17. During an interview on 8/28/17 at 4:00 pm, with LPN #11 stated that prior to [MEDICATION NAME] administration she checks the PT/INR. Sometimes the result is in the computer, in the progress notes. If the result is not there, she pulls the chart. Laboratory work is done on Monday; RNS#1 will enter the result. If the result of the INR is over 3, notify the Supervisor and then then MD gets notified. RNS#1 normally gets the results. During an interview on 8/28/17 at 4:32 pm, with the Director of Nursing (DON), regarding the frank bleeding from the resident's rectum on 4/7/17 during the evening shift, the DON stated, I supervised the next day. I never got anything from the day shift about the bleed. I had my own report sheet on all 6 units. The only thing I heard about was the flu swab that was done on the resident. Regarding the familiarity with the facility's anticoagulation P&P, the DON stated they draw labs every Monday. If the resident refused to have blood drawn, they call the MD. Lab results go to the Supervisor via fax if they are normal. If the results are abnormal, the laboratory calls the Supervisor, and the Supervisor calls the MD. RNS #1 documents the result of the PT/INR in a nursing note. RNS #1 can also enter the result in the dropdown box in the computer system. Regarding PT/INRs that were not done after 2/20/17, the DON stated, On Monday, if they don't see a result, they should call the Supervisor. The lab should have been checked. There's a whiteboard on the unit that indicates who has a PT/INR. Labs are drawn first thing in the morning, before 7:00 am. The results come to the facility during the day shift. During a phone interview on 10/12/17 at 10:38 am, with MD #2, regarding the PT/INR tests not done as ordered, MD #2 stated she was aware of the order to repeat the INR; not that it wasn't being done. She stated, I think that was a transition time; no RN nurse managers. The LPN's might have been managing the units. Regarding the management of the PT/INR results, she stated, I would order it, expect it to be carried out, and called with the results. She stated, If the nurse manager had a log, they would be able to keep track of the PT/INRs. Regarding the PT/INRs not done after 2/20/17, she stated, There seems to be a serious error on their (Nursing) part. The unit manager needs to be responsible. They were lacking a charge nurse. That's when the error occurred. The LPN's are not geared to assess. Regarding the frank bleeding from the resident's rectum on 4/7/17, she stated, They should have notified me and it should have been documented. If I'm not notified, how will I know? During a phone interview on 10/12/17 at 2:01 pm, with the Medical Director, regarding the PT/INR of 3.2 on 2/20/17, he stated he would expect that the MD was called who would take action as to whether to hold or adjust the [MEDICATION NAME] and give an order for [REDACTED]. He would expect an assessment of the stability of the resident; vital signs, mental status. He stated, There needs to be a RN that would go and assess the resident and have the physician contacted to see what the next course of action is. This is what they are taught to do. During a phone interview on 10/17/17 at 2:59 pm, LPN #13 stated she works the 3-11 pm shift on Unit B-3 and was familiar with the resident. Regarding the LPN's familiarity with the facility's anticoagulation therapy P&P, she stated, Then or now? Now, I would check the INR. In regards to checking the INR result back in April, she stated she believes that she was, however, she could not state where she would look for the result. LPN #13 responded to whether or not she checked the INR result prior to administering [MEDICATION NAME] that INRs are done on Monday. If high hold it. When asked where the INR result could be found, she stated, The PT/INR is done during the day. When asked to clarify the location of the results she stated again that, It's usually taken care of during the day. She confirmed the [MEDICATION NAME] was usually given at 6:00 pm and when asked She again where she would find the INR result, she stated, A lab sheet, downstairs somewhere. Regarding documentation of rectal bleeding on 4/7/17, she stated, I saw hemorrhoids. She could not remember what happened and if the Supervisor saw the resident. The eMAR for (MONTH) (YEAR) documented that [MEDICATION NAME] was administered by LPN #13 on all 4 occasions the PT/INR test was scheduled to be done; 3/6/17, 3/13/17, 3/20/17, and 3/27/17. 10 NYCRR 415.3(e)(2)(ii)(b)

Plan of Correction: ApprovedNovember 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Res #42 ? dc 4/8/17 ? record review revealed discharge to the hospital

LPN educated and counseled regarding not following anti-coagulation policy.
RN will be given education/counseling regarding documentation and notification of MD and resident representative.
All resident on anti coagulant have the potential to be affected by this practice
An audit has been completed on all residents on anticoagulants. All residents in the 24 hr/72 report will be audited for notification for any change in condition as well as residents on anti coagulants.
Any negative findings will be immediately relayed to attending MD and or Medical Director and Resident?s representative
The Audit will include all residents on anti-coagulants.
Batch order was created to include order entry for anti-coagulant, and order for blood draw
Anti coagulant policy has been reviewed and revised to include all PT/INR result will be relayed to the MD, Physician Extender and/or Medical Director.
The Policy reflects:
a.Immediate notification of signs and symptoms of bleeding while on anti-coagulant
i. Black tarry stool
ii. Frank rectal bleeding
iii. Excessive bruising to one or more part of the body
iv. Bleeding gums
v. Blood in the urine/ tea colored urine output
Reviewed notification of change policy and will conduct a facility wide in-service to review with all licensed nurses.
Education will be provided to all licensed nurses regarding the new [MEDICATION NAME] template in point click care.
The DON/ designee will review and 24hr/ 72 report for any residents with change in conditions if the appropriate notification has been made.
Medication error policy review has been completed for all licensed nurses.
Weekly audit will be conducted for 20 % of the resident in the 24hr/ 72 hr report. X 4 weeks, then monthly x 2 month and report during the quarterly QA meeting
The weekly audit will include all resident in the 24/72 hrs. report on anticoagulant therapy.
QA Committee will decide any continued audit.
Responsible Party: Director of Nursing/Designee

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 23, 2017
Corrected date: December 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Base on record review and staff interviews during abbreviated surveys (Case #'s NY 994 and #NY 448), the facility did not ensure it provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one (Resident #50) of three residents (Resident #'s 50, 51, and 57) reviewed for pharmacy services. Specifically, Resident #50 did not receive three consecutive doses of Vimpat (an anti-seizure drug) over a two-day period. On the second day, Resident #50 had a seizure and was transferred to the hospital. This is evidenced by: Resident #50 The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had moderate cognitive impairment. A physician's order form dated 10/22/2016 ordered Vimpat 100 mg, one tablet by mouth twice a day for 5 days. The order was submitted to the pharmacy to dispense 10 tablets of Vimpat 100 mg. A physician's order form dated 10/22/2016 for Vimpat 100 mg, documented, Discontinue (D/C) 10/27/16 handwritten and un-initialed; however, there was no physician's order to D/C the Vimpat. The Medication Administration Record [REDACTED]. An Official New York State Prescription form dated 10/24/2016 was submitted to the pharmacy by the Medical Doctor (MD). The prescription was for Vimpat 100 mg, one tablet by mouth every 12 hours with 60 tablets to be dispensed. The electronic shipping manifest dated 10/26/2016, documented the Vimpat order for 60 tablets was accepted by the facility on 10/26/16 at 2:36 pm. The MAR indicated [REDACTED]. The Controlled Substance Record (CSR) documented that on 11/1/16, Vimpat 100 mg was signed out at 8:00 am, with a count of 50 tablets remaining. Two Licensed Practical Nurses (LPN) documented they wasted the dose. The MAR indicated [REDACTED] The MAR indicated [REDACTED]. A progress note dated 11/2/2016 documented at approximately 7:00 pm, the resident had mild seizure activity lasting about 3 minutes witnessed by staff LPN and visiting daughter. A Registered Nurse (RN) assessed the resident and notified the MD on call for an order to transfer the resident to the hospital. A physician's order form dated 11/2/2017, documented Transfer to emergency room . The Emergency Department (ED) assessment dated [DATE], documented the resident had a grand mal seizure according to her daughter. On reviewing the records, it may be possible that the patient has not been receiving her anti-seizure medication. The ED's review of medications on 11/2/2016, documented the resident's Vimpat had been discontinued. The ED Nurses Summary Report dated 11/2/2016, documented, the facility was contacted regarding medications at this time. It has been confirmed with the RN responsible for this patient at the facility that there are no anti-seizure medications on her med list currently, specifically lacosamide (Vimpat). However, when the patient was discharged from the hospital, (D/C date 10/22/2016) the MD's disposition summary specifically noted lacosamide 100 mg twice a day at 8:00 am and 8:00 pm. The ED Nurses Summary Report dated 11/2/2016, documented Vimpat 100 mg, by mouth, one time only, was administered to the resident at 9:53 pm. The ED Departure Summary dated 11/3/2016, documented the primary [DIAGNOSES REDACTED]. The secondary [DIAGNOSES REDACTED]. The resident was discharged [DATE] at 3:16 am, to the facility by ambulance. The Patient Visit Information sheet dated 11/3/2016, documented the ED MD sent the resident back to the facility with an order for [REDACTED]. A physician's order form from the facility dated 11/3/16, documented Vimpat 100 mg tablet, one tablet by mouth twice a day. The MAR indicated [REDACTED]. An Interim Renewal Note dated 11/4/2016, documented the resident was seen by MD #2 following her ED visit. The MD documented, The patient had seizure grand mal and was sent to emergency room . Resident was not getting seizure meds regularly. During an interview on 8/21/17 at 3:10 pm, MD #2 stated that missing 2-3 doses of Vimpat, especially since the resident was not on any other anti-seizure medications, could cause a seizure. It was negligent not to administer the Vimpat as ordered, since it was available and the resident did not refuse it. During a phone interview on 8/23/17 at 10:35 am, the Pharmacist stated the pharmacy never received an order to discontinue Vimpat, but did receive a STAT order (one that needed immediate attention) on 11/3/16 for Vimpat 100 mg by mouth daily-do not send. They filled a prescription for Vimpat, a 5 day supply, on 10/22/16, followed by a prescription for a 30 day supply on 10/26/16 that was filled on 10/27/16. The resident's only prescribed anti-seizure medication was Vimpat. If Vimpat use is discontinued, the dose should be tapered down for a week or more to minimize the potential for an increase in seizure activity. Due to the fact the resident was not on any other anti-seizure medications, stopping the medication abruptly could have potentially led to a risk for seizure activity. During an interview on 8/24/2017 at 1:41 pm, Licensed Practical Nurse #2 (LPN) stated she signed out a dose of Vimpat from the narcotic cabinet on 11/1/16, but when she saw D/C (discontinue) 10/27/2016 written on the Vimpat order, she wasted it with another LPN. She stated she knows she didn't drop it on the floor, because I would have signed out another dose. She stated the 10/28-10/31/2016 doses should not have been administered because it was discontinued. She stated whoever wrote that should have initialed it. You need an MD order to discontinue anything. She stated she should have contacted the supervisor, but didn't believe she did. During an interview on 8/24/17 at 2:13 pm, Registered Nurse Supervisor #1 (RNS) stated the 10/22/16 order for Vimpat should not have been discontinued, but renewed. The initial 5 day supply would have been phoned in by the MD, followed by a written prescription that would need to be faxed to the pharmacy to cover the verbal order. He then obtained a prescription for a 30 day supply of Vimpat and faxed that to the pharmacy. For an MD order to be generated with a medication change, it would need to be entered into the computer for an order to appear. The Vimpat should not have been discontinued, It was a routine medication. When the LPN saw the handwritten, unsigned order for Vimpat, she should have notified the Unit Manager. During an interview on 8/29/17 at 1:56 pm, the Director of Nursing stated whoever wrote D/C Vimpat 10/27/16, should have initialed it. She stated when the LPN saw the documentation discontinuing the Vimpat, she should have notified the supervisor before making the decision to discontinue it. During a phone interview on 9/8/17 at 10:45 am, the Medical Director stated Vimpat 100 mg twice a day was a typical starting dose. It was a low dose so it would lower the risk of seizures from stopping it abruptly. He stated the LPN should have questioned the D/C order. 10 NYCRR 415.18(a)

Plan of Correction: ApprovedNovember 22, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident # 57 discharged [DATE], #50 discharged [DATE]
Resident #51 medication has been audited and showed that all her orders are verified for accuracy and completeness.


All residents have the potential to be affected by this deficient practice. Facility currently uses the Order Entry in Pointclick Care as the current means of order entry. No other written orders being transcribed in the medical record.

All licensed nurses will be reeducated regarding order recap for any new orders.
Education will include completeness and accuracy of orders. All orders must include the following;
a. Order detail (Med name, dose, frequency, route), for none medication order must include the appropriate instruction or steps to be followed.
b. Order date (when the order was written), and/ or when the order is to be initiated.
c. Name of the prescriber and signature (if applicable).
d. If any of the above item is not specified/clear in the order then the order will be considered incomplete, therefore, requires clarification from MD/NP.
e. Consultant recommendations are not valid orders unless approved by the attending MD.

2. Order entry will be further reviewed for completeness and accuracy by the DON/designee daily. Any incomplete or unclear orders to be reviewed with attending MD/NP or Medical Director.
Unit Managers/designee will review 5 random MD/NP orders weekly for completeness and accuracy x 4 weeks, then monthly x 2 months. Results of audit will be presented during the quarterly QA meeting.
QA Committee will review and decide if continued audits are warranted.
Responsible Party: DON/Designee

FF10 483.30(b)(1)-(3):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDERS

REGULATION: (b) Physician Visits The physician must-- (1) Review the resident?s total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; (2) Write, sign, and date progress notes at each visit; and (3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 23, 2017
Corrected date: December 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and resident interviews during an abbreviated survey (Case #NY 525), the facility did not ensure the physician reviewed the resident's total program of care, including medications and treatments, at each visit for five residents (Resident #'s 33, 40, 51, 61, and #62) of 5 residents reviewed for physician visits. Specifically, for Residents #'s 33, 40, 51, 61, and #62, the physician documented physical examination findings, but had not examined the residents. This is evidenced by: The Policy and Procedure dated 7/2015, titled Physician Visits Policy and Procedure documented, The Attending Physician must perform relevant tasks at the time of each visit, including a review of the Resident's total program of care and appropriate documentation. Resident #33 The resident was admitted to the facility on [DATE], with a readmission date of [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact. The 30-60-90/Interim Renewal Note dated 9/19/17, written by Medical Doctor #1 (MD) documented physical examination findings that included lung sounds, heart sounds, and bowel sounds. During an interview on 9/27/17 at 12:09 pm. The resident stated he had talked with MD #1, but mostly when he comes to the unit, he's in the office doing paperwork. I hardly ever see him out on the floor. He stated the MD had seen him on two occasions for acute illness, but other than that, he had never done a hands on examination. Resident #40 The resident was admitted to the facility on [DATE], with a readmission date of [DATE]. His [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was cognitively intact. The 30-60-90/Interim Renewal Note dated 9/19/17, written by MD #1 documented physical examination findings that included lung sounds, heart sounds, and bowel sounds. During an interview on 9/27/17, the resident stated that MD #1 doesn't see him often. He stated when he does see him, it's for a few minutes and then he leaves. He stated the MD does not do a physical exam; doesn't listen to his heart, lungs, or abdomen. I guess he relies on the nurses for that information. Resident #51 The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact. During an observation on 9/26/2017 at 1:59 pm, MD #1 entered the resident's room and left the room at 2:00 pm without examining the resident. The 30-60-90/Interim Renewal Note dated 9/26/2017, written by MD #1 documented physical examination findings that included lung sounds, heart sounds, and bowel sounds. Resident #61 The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact. The 30-60-90/Interim Renewal Note dated 9/26/2017 and written by MD #1 documented physical examination findings that included lung sounds, heart sounds, and bowel sounds. During an interview on 9/27/2017 at 11:35 am, the resident stated when MD #1 came to see her on 9/26/17, he did not examine her at all. He just talked. Resident #62 The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was cognitively intact. During an observation on 9/26/2017 at 1:52 pm, MD #1 entered the resident's room. He spoke with her regarding concerns she voiced and then exited the room. He did not perform a physical examination. The 30-60-90/Interim Renewal Note dated 9/26/17, written by MD #1, documented physical examination findings that included lung sounds, heart sounds, and bowel sounds. During an interview on 9/26/17 at 3:14 pm, MD #1 stated to another surveyor, in the presence of this surveyor, I see every resident, even if it's only to say hello. During an interview on 9/27/17 at 1:34 pm, the Registered Nurse Unit Manager (RNUM) stated MD #2 did not always examine residents when he saw them. During an interview on 9/27/17 at 2:26 pm, LPN #7 stated when MD #1 makes rounds, he reviews labs, x-rays, etc. for the residents he'll be seeing. She stated he then discusses the residents with the nurse. Following that, he sees the residents. She stated he will look in the room and say, How are you doing? to the resident. She stated he rarely does a hands-on physical exam. During an interview on 10/10/17 at 9:14 am, the Administrator stated, Bottom line, the MD must assess the resident. No matter how minor, the MD has to assess hands-on to determine the problem and talk with the resident. She stated the MD must do a hands-on physical assessment every 60 days. She stated until this was brought to her attention by the surveyor, she was unaware MD #1 was documenting assessment findings on residents he did not examine. During an interview on 10/12/17 at 1:52 pm, the Medical Director stated he was very disturbed to learn MD #1 was documenting physical examinations on residents he was not examining. The dates of MD visits investigated, observations, and staff and resident interviews that substantiated the reports pertaining to MD #1's physician visits, were reviewed with the Medical Director. He stated as soon as the interview with the surveyor was completed, he was going to phone MD #1 to schedule an appointment with him. 10 NYCRR 415.15(b)(2)(iii)

Plan of Correction: ApprovedNovember 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. All cited active residents will be re-examined by an MD. Involved cited physician has been terminated from the facility. Medical Director has been notified.

1. All residents have the potential to affected by the deficient practice a staff member will be available to round with physician, NP, PA during scheduled visits.
2. Resident under the cited physician will be re-assigned to another service.
3. All resident will have an updated H&P

1. A medical board meeting has been scheduled to be lead by the Medical Director to discuss and review the facility policy on physician visits.
2. The Medical Director will complete an annual evaluation and review of the medical staff.

1. The Medical Director/ will do random audits of physician progress notes [REDACTED]. Results of the audit will be reviewed during the quarterly QA meeting.
2. QA Committee will review and decide if continued audits are warranted.

FF10 483.10(e)(1), 483.12(a)(2):RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS

REGULATION: §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). 42 CFR §483.12, 483.12(a)(2) 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 symptoms. (a) The facility must- (1) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident?s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 23, 2017
Corrected date: December 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation during abbreviated (Case #'s NY 701, NY 662), the facility did not ensure each resident received the least restrictive alternative physical restraint and did not ensure documentation of ongoing re-evaluation of the need for restraints for 2 (Resident #'s 43 and 56) of three (3) residents reviewed. Specifically: For Resident #43, the facility did not ensure a signed consent was on file, that quarterly assessments were completed for physical restraint use, and that the restraint was released as ordered by the physician; For Resident #56, the facility did not ensure the restraint was released as ordered by the physician. This is evidenced by: The Facility Restraints (Physical)(obstructing freedom of a person's bodily movement) Assessment Policy and Procedure dated 06/2015 documented: - Nursing to document the alternatives (other interventions tried before use of the use of the physical restraint) that were used and include the length of time used (the amount of time the restraint was in use). - Nursing to document resident's response to those alternatives and the effects. - Authorization for Use (permission for physical restraint to be applied and the medical reasons for use) form completed upon initiation of restraint, quarterly with Minimum Data Set (MDS) and as needed. - Resident (with a physical restraint in use) should be reviewed at least quarterly to determine if he/she is a candidate for restraint reduction or elimination The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI) Version 1.13 dated (MONTH) (YEAR) documented: Chairs that prevent rising include any type of chair with a locked lap board, that places the resident in a recumbent position that restricts rising. Resident #43: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment, sometimes understood and sometimes able to understand others. The resident required extensive assistance of one (1) staff member for bed mobility, transfer, ambulation, dressing, and toileting and had daily use of a physical restraint (device that restricts freedom of movement). The Facility Restraint Authorization Form (dated 2/25/2016, at 3:00 pm) documented the resident received the physical restraint of a Geri-chair with a tray for a history of falls and safety reasons. The form documentation included the health care proxy (HCP) provided verbal consent on 3/22/2016. The resident's medical record did not include Facility Restraint Authorization's dated after 3/22/2016. The Physical Restraint Evaluation Form dated 3/02/2017, documented symptoms for physical restraint use as: unsteady gait, agitated and aggressive behavior, forgetting ambulation devices, frequent falls, and attempts to self-transfer. Alternative interventions had been attempted and were unsuccessful. The restraint was effective as the resident had not fallen and the safety of the resident and others had been maintained. The HCP was notified. The Physical Restraint Comprehensive Care Plan (CCP) dated 3/02/2017, documented the resident required the use of Geri-chair with tray prn (as needed). The interventions of quarterly assessments for restraint use, to use the Geri-chair with tray table if the resident was aggressive, and to release the restraint every 2 hours for toileting, ambulation, repositioning, mealtimes, and activities. The Physical Restraint CCP documentation did not include specific interventions to be attempted prior to physical restraint application. A physician's orders [REDACTED]. The resident medical record dated 3/21/2017 -8/28/2017 did not consistently include the specific alternatives used, the specific length of time used, or the resident's response to specific alternatives and the effects on the resident. The CNA Restraint Documentation Form dated 5/1/2017 - 5/31/2017, did not include that the resident's Geri-chair with tray was consistently released every two hours. The resident's medical record dated 6/01/2017 - 6/30/2017, not include a Physical Restraint Quarterly assessment or documentation that the Geri-chair with tray was consistently released every two hours. The Physical Restraint Comprehensive Care Plan (CCP) dated 6/02/2017, documented the resident required the use of Geri-chair with tray prn with interventions for quarterly assessments for restraint use, for use of the Geri-chair with tray table if the resident was aggressive, and for the release of the restraint every 2 hours for toileting, ambulation, repositioning, mealtimes, and activities. The Physical Restraint CCP documentation did not include specific interventions to be attempted prior to physical restraint application. The MDS assessment dated [DATE], did not include the resident used a chair that prevented rising daily. The CNA Restraint Documentation Form dated 7/1/2017 - 7/4/2017, did not include the consistent release of the Geri-chair with tray every two hours from the resident. A nurse progress note dated 7/05/2017, written by Registered Nurse (RN) #8 documented the resident was agreeable to sleeping in his bed, and not in his chair. The eTAR dated 7/05/2017 - 7/31/2017, documented the Geri-chair with tray was released every two hours, each shift. Eight (8) nurse initial boxes were blank. The therapy progress note dated 7/06/2017, written by Physical Therapist (PT) #2 documented a different chair was evaluated for use but was found to have potential impact on the resident's transfer ability. The resident was to go back to bed for sleeping. The Kardex dated 7/27/2017, documented the resident had to go to bed and not sleep in the chair. A nurse progress note dated 7/28/2017, written by PT #3, documented the resident's seating was changed from the Geri-chair with tray to a Scoot Broda (tilting and reclining chair) on a trial basis due to complaints of discomfort and the resident's positioning ability in the Geri-chair. The Kardex 7/28/2017 documentation included a (Scoot) Broda Chair was used for locomotion (undated) and the Geri-chair for locomotion was crossed out (undated). The Care Card documentation did not include the restraint Geri-chair with tray was discontinued, on 7/28/2017. The Physical Restraint CCP documentation (last updated 6/02/2017), did not include documentation that the Geri chair was discontinued and a Scoot Broda chair was initiated, on 7/28/2017. The progress note dated 7/29/2017, written by Licensed Practical Nurse (LPN) #13 documented the resident continued to push forward in the Scoot Broda chair, which resulted in the chair tipping forward. The resident's seating was changed back to the Geri-chair and the tray was removed every two hours and for all meals. The Physical Restraint CCP (last updated 6/02/2017), did not document that the Scoot Broda chair was discontinued and a Geri-chair was resumed on 7/29/2017. The Kardex documented a recliner (chair) was used for locomotion (undated) and the Geri-chair and (Scoot) Broda chair for locomotion was crossed out (undated). The documentation did not reveal the Scoot Broda chair was discontinued and a Geri-chair was resumed on 7/29/2017 The nurse progress note dated 7/31/2017, written by PT#2, documented Physical Therapy changed the resident's out of bed seating to a (Scoot) Broda Chair again on a trial basis. The unit staff could tilt and reposition the chair for the resident's comfort. The Physical Restraint CCP (last updated 6/02/2017), documentation did not document the Geri-chair was discontinued and a Scoot Broda chair was resumed on 7/31/2017 and did not include specific instructions for positioning comfort while in the Scoot Broda chair. The Kardex documentation included a recliner (chair) was used for locomotion (undated) and the Geri-chair and (Scoot) Broda chair for locomotion were crossed out (undated). The Kardex documented use of a Geri-chair with tray restraint. The Kardex did not include staff could tilt and reposition the chair for the resident's comfort. The nurse progress note dated 7/31/2017, written by Registered Nurse Supervisor (RNS) #2, documented the resident had been trialing a new chair and tried to stand on the chair foot rests. The resident fell with no identified injuries. T he Falls CCP dated 7/31/2017, documented the resident had a fall with no injuries and that the resident used a Geri-chair with tray table as a safety device. There was no documentation for specific interventions to prevent the resident from standing on the foot rests of the Scoot Broda chair. The CNA Restraint Documentation Form dated 8/1/2017 - 8/3/2017, did not include that the Geri-chair with tray was consistently released every two hours from the resident. A physician order [REDACTED]. Release restraint every two (2) hours for ten (10) minutes for ADL's. The reason for use was safety and the end date was established as indefinite. The eTAR documented: 8/03/2017 - 8/28/17 - Release restraint every two (2) hours each day. 8/11/2017 for 11:00 pm - 6:00am - See the progress notes. The eTAR did not include documentation for other times the restraint was removed. Nurse progress notes dated from 8/11/2017, 11:00 pm - 7:00 am shift, LPN #14 documented the resident was in bed. During an observation of the resident on 8/28/2017, at 12:00 pm, the resident was resting in the central dayroom, sitting in his Geri-chair with the tray table in use. The resident had his eyes closed, and was calm. The resident did not display signs of agitation or aggression. Interview on 8/25/2017, at 11:05 am, LPN #10, stated that when the Geri-chair tray table was removed Resident #43 tried to stand or reaches out towards other resident's. LPN #10 stated that the CNA's document the release of the restraint or the LPN's initial on the eTAR for the restraint release. LPN #10 also stated that the resident does sleep in the chair. Interview on 8/28/2017 at 2:00 pm, the Director of Nursing (DON) stated that restraint use and elimination evaluations were expected to be reviewed quarterly. She stated she expects restraint documentation to be accurate. Interview on 8/29/2017 at 9:30 am, the Administrator stated she expected the facility staff to follow the Restraint Policy and Procedure and review restraint use quarterly. She would expect behavior monitoring to validate restraint use and accurate documentation of restraint release. Interview on 10/24/2017 at 2:23 pm, the DON stated that the facility copies of Resident #43's Kardex all had the last digit (of (YEAR)) of the year cut-off. The DON stated the writing looked like RN #8's, as she was re-writing the Kardex's during the month she was employed at the facility. Resident #56: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident to have severely impaired cognition, sometimes able to make self-understood and sometimes able to understand others. The resident required two staff extensive assist for bed mobility, transfer, dressing, and toileting. The resident required one staff extensive assist for feeding. The Physical Restraint (initial evaluation) dated 7/01/2017 documented the resident's behavior as agitated, aggressive, independent transfer attempts, sliding out of wheelchair, and attempts to get out of bed. The resident was verbally abusive, and pinched, struck at, and hit staff. A physician's orders [REDACTED]. The resident's medical record dated 7/01/2017 - 7/27/2017, did not include a schedule for the 2-hour release of the Geri-chair with tray restraint. The Restraint CCP dated 7/01/2017, documented the physical restraint of Geri-chair with tray was in use prn. The documentation included the medial symptoms of self-inflicted behavior, abuse, and violence. The Restraint CCP documented the interventions to release the restraint every 2 hours, evaluate the effectiveness of the restraint, including the interventions (i.e., modifying environment, toileting plan, and exercise). The Kardex dated 7/02/2017, documented the resident utilized a Geri-chair with tray restraint. The resident had aggressive behavior, was deaf (unable to hear), and blind in the left eye. A nurse progress note dated 7/02/2017, written by LPN #15 documented the resident out of bed in Barco lounger (Geri-chair) with tray per physician's orders [REDACTED]. The eTAR dated 7/02/2017, did not include documentation that the resident was in the Geri-chair with tray restraint, what alternative interventions were attempted before placing the resident in the restraint, and the length of time the resident was in the restraint. The documentation did not reveal the restraint was released every two hours as ordered by the physician. A progress note dated 7/11/2017, written by Occupational Therapist (OT) #1 documented the resident required extensive assist of 2 staff members to transfer from the Geri-chair to the toilet on the day shift. The Restraint Elimination assessment dated [DATE], documented the resident was a good candidate for restraint elimination. The resident's medical record did not include removal of the Geri-chair with tray. The MDS's dated 7/08/2017, 7/15/2017, and 7/27/2017 documented the resident used a restraint in a chair or out of bed daily. The documentation did not accurately identify the resident used a chair that prevented rising. Interview on 8/29/2017 at 2:30 pm, the DON stated that there was no documentation of interventions utilized prior to the restraint use for the resident and that the CCP did not document resident specific interventions to attempt prior to restraint utilization. She also stated that displayed specific resident behaviors should be documented prior to restraint application. Interview on 8/30/2017 at 10:55 am, LPN #16 thought that the medical record needed to have documentation the chair prevented the resident from rising to enter the restraint Geri-chair with tray as a chair restraint. Interview on 9/8/17 at 10:45 am, the Medical Director stated he expected monitoring of behaviors for use of restraints. 10NYCRR 415.4(a)

Plan of Correction: ApprovedNovember 21, 2017

Resident number 43 is still in the facility, restraint reduction has been completed, MD notified new order to discontinue geri-chair with tray table use. Resident number 56 has been discharged from the facility.
All residents have the potential to be affected by the deficient practice.

Facility wide evaluation/visual assessments for geri-chairs with tray and other restraints have been conducted (seatbelts, mitts, vest, etc). No other residents have been affected by the above-cited practice. Facility currently does not have any residents on restraints based on the visual assessment conducted on each unit. As well as the most recent MDS assessment/review.
Facility wide review for all employees regarding policy and restraint identification. Nursing staff education will include:
1. Releasing restraint as directed by Policy and Procedure
2. Assessment for restraint reduction
3. Documentation for restraint need
4. Notification to the MD and family
5. Consent for restraint use
6. Monthly assessment for restraint elimination assessment.
Audit for environmental check to visualize use of any geri-chair with trays as well as other restraint devices will be conducted weekly x4 weeks, then monthly x2 months and report during the quarterly QA meeting.
QA committee will decide any continued audit.
Responsible Party: Director Of Nursing/Designee

FF10 483.21(b)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 23, 2017
Corrected date: December 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during an abbreviated survey (Case # NY 211), the facility did not ensure that services provided or arranged by the facility, as outlined by the comprehensive care plan met professional standards of quality for one (Resident #42) of three residents reviewed. Specifically, for Resident #42, the facility did not follow physician orders [REDACTED]. This is evidenced by: Refer to F Tag 329 The Facility Policy and Procedure (P&P) for Anticoagulation Therapy dated 6/16/16 documented a therapeutic INR range must be maintained to prevent further complications. All residents who receive anticoagulant therapy must have the PT/INR results reported to the physician in a timely manner. When a PT/INR is scheduled, the licensed nurse will document it on the eMAR (electronic medication administration record). This will alert the Medication Nurse when the laboratory result is due and not to administer the medication (unless ordered) until the result is back. If the INR is out of range or there is no INR range, the MD needs to be notified before the next scheduled dose is given. The following key points were documented: Licensed Nurses administering [MEDICATION NAME] ([MEDICATION NAME]) on a day a PT/INR was scheduled, must know the results prior to administering the medication. If a result is not in as scheduled, it is the Licensed Nurse responsibility to notify the Supervisor immediately. If the MD does not return the call or fax back orders within 1 hour of [MEDICATION NAME] administration, the Supervisor must call again. If still no response, notify the Medical Director. Resident #42 The resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The resident also has a prosthetic heart valve. The Brief Interview for Mental Status (BIMS) was assessed as 8/15; moderate cognitive impairment on the Minimum Data Set ((MDS) dated [DATE]. Review of the Comprehensive Care Plan (CCP) for Anticoagulant Therapy dated 9/1/15 and last reviewed on 5/17/16, documented the resident was on [MEDICATION NAME] therapy and to continue with goal and interventions. The interventions were to monitor the resident for signs and symptoms of bleeding (rectal bleed), schedule laboratory tests as ordered, report any signs and symptoms of bleeding to the MD, and maintain PT/INR range as ordered by the MD. There were no further reviews/updates documented on the CCP after 5/17/16. Review of the physician orders [REDACTED]. The Physician order [REDACTED]. The Laboratory test result for a PT/INR dated 2/20/17, documented the INR was 3.2 and included documentation that a therapeutic INR range for patients on stable oral [MEDICATION NAME] therapy was 2.0 - 3.0. The report documented the physician was notified and to hold [MEDICATION NAME] and repeat the PT/INR on Thursday (2/23/17). The Physician order [REDACTED]. Review of the medical record for PT/INRs done after 2/20/17, documented: -There was no documentation in the medical record that the PT/INR test was repeated on 2/23/17 as ordered, however, it was documented on the eMAR dated 2/23/17 [MEDICATION NAME] 3 mg was given. There was no documentation that the physician was notified that the [MEDICATION NAME] was administered without a PT/INR result. - On Monday 2/27/17, LPN #12 documented [MEDICATION NAME] PT/INR's are due by 6:00 pm on the second shift. There was no documentation in the medical record for a test result for a PT/INR dated 2/27/17, however, it was documented on the eMAR dated 2/27/17 [MEDICATION NAME] 3 mg was given. There was no documentation that the physician was notified that the [MEDICATION NAME] was administered without a PT/INR result. - There was no documentation in the medical record for PT/INR test results for Monday 3/6/17, 3/13/17, 3/20/17, 3/27/17, and 4/3/17, however, it was documented on the eMAR the tests were done and it was documented [MEDICATION NAME] 3 mg was given on each of the days noted. There was no documentation that the physician was notified that the [MEDICATION NAME] was administered without a PT/INR result. -Review of the eMAR for (MONTH) (YEAR), documented the resident continued to receive [MEDICATION NAME] 3 mg on 4/4/17 - 4/8/17. The Nursing Progress Note written by LPN #13 dated 4/7/17 at 11:32 pm, documented the resident was having frank bleeding (obvious visible presence of blood) from the rectum and the Supervisor was made aware. The note documented the resident has hemorrhoids, will continue to monitor. There was no documentation in the medical record that the resident was assessed by a qualified person and no documentation the physician/family was notified. The Nursing Progress Note written by RN #5 dated 4/8/17 at 11:53 pm, documented the resident had 3 episodes of rectal bleeding that was getting progressively worse. Resident is on [MEDICATION NAME]. The physician was notified and the resident was sent to the ER. The Hospital Emergency Department Nurse assessment dated [DATE] at 1:14 am, documented patient passing frank red blood from rectum. The Hospital Emergency Department Provider report dated 4/9/17 at 1:19 am, documented per nurse the patient was passing blood clots during triage. The Hospital laboratory result for a PT/INR dated 4/9/17 documented the INR was >10.8 (therapeutic range is 2.0 - 3.0). Review of the Hospital History and Physical report dated 4/9/17 documented acute lower GI bleed with supratherapeutic INR and chronic use of [MEDICATION NAME] ([MEDICATION NAME]). INR is greater than 10.8. The patient received Vitamin K (reverses the effects of [MEDICATION NAME]) 5 mg in the ER. The digital rectal exam did not demonstrate any hemorrhoids. The Hemoccult (a test for hidden blood in the stool) is positive with bright red blood. The resident also needed a transfusion to reverse the effects of the [MEDICATION NAME]. The Hospital Transfusion Service Record dated 4/9/17 at 3:38 am, documented the resident received a unit of thawed plasma (a blood product used to treat conditions in which there are low blood clotting factors). During an interview on 8/28/17 at 4:32 pm, with the Director of Nursing (DON), regarding the frank bleeding from the resident's rectum on 4/7/17 during the evening shift, she stated, I supervised the next day. I never got anything from the day shift about the bleed. I had my own report sheet on all 6 units. The only thing I heard about was the flu swab that was done on the resident. Regarding the DON's familiarity with the facility's anticoagulation P&P, the DON stated they draw labs every Monday. If the resident refused to have blood drawn, call the MD. Lab results go to the Supervisor via fax if they are normal. If the results are abnormal, the laboratory calls the Supervisor, and the Supervisor calls the MD. RNS #1 documents the result of the PT/INR in a nursing note. RNS #1 can also enter the result in the dropdown box in the computer system. Regarding the PT/INRs that were not done after 2/20/17, she stated, On Monday, if they don't see a result, they should call the Supervisor. The lab should have been checked. There's a whiteboard on the unit that indicates who has a PT/INR. Labs are drawn first thing in the morning, before 7:00 am. The results come to the facility during the day shift. During a phone interview on 10/12/17 at 10:38 am with MD #2, regarding the PT/INR tests not being done as ordered, she stated she was aware of the order to repeat the INR; not that it wasn't being done. She stated, I think that was a transition time; no RN nurse managers. The LPN's might have been managing the units. Regarding the management of the PT/INR results, she stated, I would order it, expect it to be carried out, and called with the results. She stated, If the nurse manager had a log, they would be able to keep track of the PT/INRs. Regarding the PT/INRs not being done after 2/20/17, she stated, There seems to be a serious error on their (Nursing) part. The unit manager needs to be responsible. They were lacking a charge nurse. That's when the error occurred. The LPN's are not geared to assess. Regarding the frank bleeding from the resident's rectum on 4/7/17, she stated, They should have notified me and it should have been documented. If I'm not notified, how will I know? During a phone interview on 10/12/17 at 2:01 pm, with the Medical Director, regarding the PT/INR of 3.2 on 2/20/17, he stated he would expect a call to be made to the MD. The MD will take action as to whether to hold or adjust the [MEDICATION NAME] and give an order for [REDACTED]. He would expect an assessment of the stability of the resident; vital signs, mental status. He stated, There needs to be a RN that would go and assess the resident and have the physician contacted to see what the next course of action is. This is what they are taught to do. During a phone interview on 10/17/17 at 2:59 pm, with LPN #13, she stated she works the 3-11 pm shift on unit B-3 and was familiar with the resident. In regards to being familiar with the facility's anticoagulation therapy P&P she stated, Then or now? Now, I would check the INR. In regards to checking the INR result back in April, she stated she believes that she was, however, she could not state where she would look for the result. The call was disconnected (reason unknown) and after a few minutes, LPN #13 called the surveyor back. LPN#13 was asked again if she was checking the INR result prior to administering [MEDICATION NAME]. She replied, INRs are done on Monday. If high hold it. She was asked where she finds the INR result. She replied, The PT/INR is done during the day. She was asked again where she knows to look for the result. She replied, It's usually taken care of during the day. She confirmed the [MEDICATION NAME] was usually given at 6:00 pm. She was asked again where she finds the INR result. She replied, A lab sheet, downstairs somewhere. Regarding the 4/7/17 documentation of the rectal bleeding, notifying the Supervisor, and the hemorrhoids, she stated, I saw hemorrhoids. She could not remember what happened and if the Supervisor saw the resident. It was documented on the eMAR for (MONTH) (YEAR) that [MEDICATION NAME] was administered by LPN #13 on all 4 days the PT/INR test was scheduled to be done; 3/6/17, 3/13/17, 3/20/17, and 3/27/17. 10 NYCRR 415.12(1)(1)

Plan of Correction: ApprovedNovember 21, 2017

Resident number 42 was discharged from the facility on 4/8/17.
All residents have the potential to be affected by this practice.
The facility audited all resident on anti-coagulant therapy
Audit tool will include:
a. Medication Order
b. Lab if applicable (PT/INR)
c. Results if applicable
d. MD Notification if applicable
e. Signs and symptoms of bleeding.
Any negative findings will be immediately relayed to the attending MD and Resident representative.
Batch order was created to include order entry for anti-coag, and order for blood draw.
All licensed nurses will be re-educated on the revised anticoagulation policy and procedure.
Anti coagulant policy has been reviewed and revised to include that all PT/INR results will be relayed to the MD, Physician Extender and/or Medical Director. The policy will also include immediate notification to physician for signs and symptoms of:

i. Black tarry stool
ii. Frank rectal bleeding
iii. Excessive bruising to one or more part of the body
iv. Bleeding gums
v. Blood in the urine/ tea colored urine output
Bleeding while on anti-coagulant
Reviewed notification of change policy and will conduct a facility wide in-service to review with all licensed nurses; any changes in condition on 24/72 hour report will be relayed to attending physician, and/or physician extenders.
Unit Manager/Designee will complete the audit weekly x 4, then monthly x 2 and reported to the QA quarterly meeting. The QA Committee will decide if future audits will continue based on the findings.
Responsible Party: Director of Nursing/Designee

FF10 483.25(g)(2):SUFFICIENT FLUID TO MAINTAIN HYDRATION

REGULATION: (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident?s comprehensive assessment, the facility must ensure that a resident- (2) Is offered sufficient fluid intake to maintain proper hydration and health.

Scope: Isolated
Severity: Actual harm has occurred
Citation date: October 23, 2017
Corrected date: December 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during abbreviated surveys (Case #'s, NY 497 and NY 525), the facility did not ensure the facility provided each resident with sufficient fluid intake to maintain proper hydration and health for one (Resident #48) of 4 residents reviewed for nutrition and hydration. Specifically, for Resident #48, the facility did not ensure fluid intake was monitored to identify a decrease, and that the decrease was reported to the dietician, nursing or medical doctor (MD) from [DATE]- [DATE]. The facility did not ensure nurse practitioner's orders dated [DATE], for an increase in fluid intake was implemented after the resident was diagnosed with [REDACTED]. This resulted in severe dehydration requiring hospitalization . The resident expired in the hospital. This is evidenced by: Resident #48: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderate cognitive deficit. The Policy and Procedure (P&P) (undated) for Intake and Output documented purpose was to maintain an accurate record of the resident's fluid balance and identify residents at risk for dehydration. Several conditions were listed that may predispose a resident for dehydration including infections, decrease in intake, chronic [MEDICAL CONDITION], and the use of diuretics. The signs and symptoms for dehydration may include (but are not limited to), altered mental status, lethargy, weakness, dry skin and dry mouth. Laboratory (lab) results will demonstrate an increase in hematocrit (a test to determine the number of red blood cells in the blood), blood urea nitrogen (BUN- a test to determine kidney function,), and creatinine (another test to determine kidney function). A P&P for Laboratory Services dated (MONTH) (YEAR), documented that in the event a STAT (immediately) lab was ordered, the nursing supervisor would draw the lab onsite, complete the necessary paperwork and Maintenance/Transportation would deliver the lab specimen to the specified laboratory for testing. An P&P (undated) for Dietary Request Slip/Communication Policy documented that the dietary/communication books will be issued to Nursing, Therapy, Social Work, and the Wound Care Nurse. The slips should be used for changes related to the following, but not limited to: poor fluid intake, urinary tract infection, abnormal lab values, and change in conditions not noted above. A form titled Rehab Dietary Request last revised (MONTH) (YEAR), was available for staff communication with dietary regarding any changes. The Comprehensive Care Plan (CCP) for actual or potential alteration in nutritional status, last updated on [DATE], included the following interventions: Monitor/evaluate lab work as needed. Fluid intake study as assigned and as needed, feeding level-dependent, at least 2032 ml (milliliters) fluids served daily on tray, 8 ounces Ensure Plus (dietary supplement) three times a day with meals, and cranberry juice at breakfast due to a urinary tract infection (implemented [DATE]). Lab results dated [DATE], documented the following, with the normal range for each test in parentheses after the result; BUN 24 (,[DATE] mg/dl), Creatinine 1.36 (0XXX,[DATE].30 mg/dl), Glomerular Filtration Rate (GFR- a test that shows how well the kidneys are filtering the blood) 36, (normal is greater than 60), Sodium 139 (,[DATE]) meq/l, Chloride 105 (,[DATE] meq/l), Hemoglobin 9.1 (11XXX,[DATE].0 gm/dl), and Hematocrit 29.7% (34XXX,[DATE].0%). The initial Comprehensive Nutritional assessment dated [DATE], completed by Diet Technician (DT) #2, documented the resident's intake was poor. The resident was provided with 2032 ml of fluids per day, refused 50% of the daily amount, was at risk for inadequate intake, and to proceed with a plan of care for nutrition and hydration. The resident's feeding status was downgraded to dependent, and to encourage fluid intake. A review of the Meal Consumption Sheets, (completed by the Certified Nursing Assistants (CNAs) from [DATE]- [DATE], documented the resident consumed between 720 ml- 1080 ml in fluids daily. On [DATE] and [DATE], 600 ml and on [DATE], 630 ml were consumed by the resident. Beginning on [DATE], the resident's daily fluid intake significantly decreased as follows: [DATE]- 360 ml with sips at dinner, [DATE]- 360 ml, [DATE]- 840 ml, [DATE]- 780 ml, [DATE]- 540 ml, [DATE]- 420 ml, [DATE]- 540 ml, [DATE]- 500 ml. On [DATE], the resident was sent to the hospital at the family's request. The Nutrition assessment dated [DATE], completed by DT #1, documented the resident was at risk for dehydration related to multiple medication usage as evidenced by medication side effects. The medications were documented as: [MEDICATION NAME], Atenelol, [MEDICATION NAME], Celex, [MEDICATION NAME], Loratidine, [MEDICATION NAME], Irion, and Artificial Tears. The Intake Acceptance/Nutritional Problems section documented, supplement (Ensure 8 ounces three times a day with meals) acceptance was good, and fluid acceptance was approximately ,[DATE]%. The Assessment Summary documented, No issues Noted. Nursing has noted intake of solids at meals is poor, but resident drinks well. The Family Nurse Practitioner (FNP) note dated [DATE], documented the resident was seen due to the daughter's concern regarding generalized pain. The resident's skin and mouth were dry. The [DIAGNOSES REDACTED]. Tylenol as needed for pain, and an additional 250 ml of fluids every shift were ordered. The orders for Tylenol and the increase in fluids were written on the FNP's Interim Renewal Note. The order was not implemented. A progress note dated [DATE] at 10:58 pm, written by Licensed Practical Nurse (LPN) #5, documented the resident seemed to be a little lethargic this shift. A progress note dated [DATE] at 3:00 pm, written by LPN #4, documented the resident's daughter had expressed concern her mother might be dehydrated. The daughter also expressed concern about the resident's positioning in her chair, She seems to be leaning toward the right more often with her head tilted. The LPN documented the resident's Intake and Output (I&O) would be monitored for 72 hours. There was no I&O documented in the resident's record from [DATE]- [DATE]. A progress note dated [DATE] at 10:40 am, documented DT #1 spoke with the resident's daughter about her concerns regarding her mother's poor intake. She explained to the daughter the resident was eating approximately ,[DATE]% of meals per the meal consumption log and unit staff, and the resident was drinking 100% of her Ensure provided with meals. The daughter requested ice cream and pudding be added to lunch and supper trays and documented that would start at lunch time on the date of this note. DT #1 discussed the outcome of two recent Speech Therapy evaluations, with no new recommendations. She sent a referral to Occupational Therapy to request an assessment of the resident at meal times. A physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. A progress note dated [DATE] at 2:11 pm, written by LPN #6 documented the resident needed encouragement to engage in conversation, was not responding normally, needed encouragement to swallow drinks/food and that the Charge Nurse and Assistant Director of Nursing were aware. The Dietary Request form dated [DATE], and completed by LPN #6, documented, Please send pudding and ice cream as per family. An unsigned, undated note attached to the Dietary request form documented Resident already receives pudding with all meals as of [DATE] conversation with daughter and ice cream with lunch and supper- see nutrition progress note ,[DATE]. A Medical Doctor (MD) visit note dated [DATE], documented that MD #2 saw the resident for an urgent visit with new orders to discontinue [MEDICATION NAME] (a fluid pill), to watch for aspiration (inhaling food or fluids into the lungs), to continue total care, to obtain a urine culture and sensitivity (C&S), and a comprehensive metabolic panel (CMP-lab tests for blood levels that show electrolyte levels, kidney and liver function, etc.) to be done on [DATE]. A progress note dated [DATE] at 2:03 pm, written by LPN #6, documented the resident was less responsive than yesterday, that the resident's daughter requested the resident be sent to the hospital and that the MD and charge nurse were aware. The hospital Emergency Department (ED) physical examination dated [DATE] at 2:04 pm, documented that the patient appeared ill, dehydrated, was tilting head to the right with mouth wide open, eyes appeared sunken, and mucous membranes were profoundly dry. The hospital work up revealed severe dehydration with resulting uremia (indicates [MEDICAL CONDITION]) and acute on [MEDICAL CONDITION]. Hospital lab results dated [DATE], documented the following increases in lab results. (Labs for [DATE] are in parentheses for comparison): BUN 122 (24), Creatinine 3.65 (1.36), GFR 12 (36), Sodium 172 (139), Chloride 133 (105), Hemoglobin 11.6 gm/dl (9.1), and Hematocrit 38.1% (29.7%). During an interview on [DATE] at 10:03 am, the Registered Dietician (RD) stated the resident's intake was variable, fluid consumption poor and that it was unlikely the resident's dehydration occurred overnight. The RD stated indicators of dehydration could be dry lips, dry tongue, lethargy, and change in mental status. During an interview on [DATE] at 10:26 am, the FNP (Family Nurse Practitioner) stated she saw the resident on [DATE] and ordered an additional 250 ml of fluid every shift. The FNP stated she had expected staff to implement the additional fluid on the date ordered. She stated she ordered the extra fluid to improve the resident's hydration. She stated when she completes a visit, she provides a copy of her visit note to the charge nurse or unit manager to ensure they are aware if any follow-up was required. The FNP stated that if the staff had followed up with increasing the resident's fluids as ordered, that this may have been prevented. The FNP stated if she had been notified of changes in the resident's condition, she would have ordered further interventions such as lab work or an IV (for fluids). During an interview on [DATE] at 11:19 am, Diet Technician (DT) #1 stated changes in residents' medication, poor fluid intake, urinary tract infections, abnormal lab values, etc., were to be reported on the facility's Dietary Request Form. She stated she never received notification of the resident's decrease in fluid intake that occurred following her [DATE] Meal Consumption Sheet review. The DTs reviewed the Meal Consumption Sheets weekly, and based on the documentation, made food and fluid changes as indicated. She also stated the 24 hour Intake and Output (I&O), done for 72 hours by nursing, are not reported to the dietician or DTs. She stated I would have to seek it out. She stated if she had known the results of the admission I&O, she would have contacted the daughter to check the resident's preferences, make a Speech and Occupational Therapy referral, added fluids between meals, and notified the MD. She stated she would have expected nursing to report the change in the resident's fluid intake during the week of [DATE]-[DATE]. She stated the FNP's [DATE] order for an additional 250 ml every shift should have been started on [DATE]. If the nurses had documented the FNP's order to increase fluids in the nurses' notes, it would have appeared on the 24-hour report and the DT would have been aware. During an interview on [DATE] at 1:40 pm, the Director of Nursing (DON) stated the unit managers should be reviewing the residents' I&O sheets from admission and the meal consumption sheets and report decreased fluid intake to dietary, the MD, and family. She stated she was aware of the Dietary Request Form. She stated changes in condition, such as decreased fluid intake, medication changes, a urinary tract infection, or abnormal labs must be reported to the DT or RD. She stated the decrease in the resident's fluid intake for the week of [DATE]-[DATE] should have been reported to dietary by nursing. She stated the [DATE] order to increase fluids should have been implemented on [DATE]; the delay was unacceptable. During an interview on [DATE] at 11:29 am, MD #2 stated the fluid increase ordered by the FNP on [DATE] should have been started right then and there, not three days later. Regarding the resident's changes in condition during the week of [DATE]- [DATE], there should have been RN assessments with each change and MD notification. She stated if she had been updated on the resident's changes in condition, she would have been more aggressive with treatment, such as increase in fluids, labs, and clysis (the administration other than orally of any of several solutions to replace lost body fluid). She stated there was a communication problem. She stated there was no Registered Nurse Unit Manager for the resident's unit at that time and the LPNs were running the unit. She stated she saw the resident on [DATE] at the request of the resident's daughter. She stated she discontinued the resident's [MEDICATION NAME] and ordered a Comprehensive Metabolic Panel (CMP) to be done on [DATE] to rule out dehydration from [MEDICATION NAME] use and to check kidney function. When asked if she could have ordered the lab draw STAT (immediately) she stated she was unaware that could be done, and the nurses would schedule the lab for a routine draw. When the P&P for STAT lab draws was reviewed with her, she stated, I correct myself. I should have ordered the labs for the 28th, not the 31st. She stated the [DATE] labs from the hospital indicated acute dehydration. During an interview on [DATE] at 2:15 pm, with the Medical Director, the Meal Consumption sheets for fluid intake the week of [DATE]- [DATE] were reviewed. The fluid intake was significantly decreased from prior to [DATE]. The P&P for the Rehab Dietary Request form was reviewed with the Medical Director. The P&P was not followed, so Dietary was not notified of the changes in the resident's fluid intake. He stated the [DATE] order written by the FNP to increase fluids to 250 ml every shift should have been implemented on [DATE]. When nursing documentation was reviewed from [DATE]- [DATE], he stated there should have been an RN assessing the resident and the MD should have been notified. Discussed with the Medical Director that MD #2 was unaware she could order STAT labs, the Medical Director stated, There's not a facility in New York State that can't get STAT labs. The Medical Director stated a lot of things fell through the cracks; that there was the potential to prevent the resident from becoming as acutely ill as she did. 10 NYCRR 415.12(j)

Plan of Correction: ApprovedNovember 21, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Resident number 48 was discharged from the facility on 11/7/16.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
All residents have the potential to be affected by this deficient practice. The following corrective actions will be taken.
1. A potential for dehydration evaluation will be completed for all residents.
2. The Nutrition office will be notified of any residents with a score for high risk for the potential for dehydration evaluation and consume 50% or less for 5 out of 9 consecutive meals, using dietary communication slip.
3. An RN assessment will be completed and documented in the medical record for those resident with score for high risk for the potential for dehydration evaluation and consume 50% or less for 5 out of 9 consecutive meals.
4. RN assessment will include but not limited to the following;
a. altered mental status
b. lethargy
c. weakness
d. dry skin
e. dry mouth
f. poor skin turgor.
5. Licensed nurse will notify the MD and family of the changes in condition. Nursing staff will follow MD orders.
6. Care plan will be initiated and/or updated.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
The facility consultant will review with the Clinical Team and Facility Administrator the following systemic measure to prevent recurrence as well as conduct the directed education to address the cited deficiency.
1. All licensed nurses will be educated on how to complete the potential for dehydration evaluation form
2. All licensed nurses will be re-educated by the Staff Educator/designee to notify MD of changes in conditions such, decrease in appetite, refusal of fluids. Including monitoring and documenting of conditions not limited to the following;
a. Diarrhea
b. Vomiting
c. Fever
d. Poor food and fluid intake
e. Increased dose of diuretic
f. Abnormal lab results (i.e Hgb/Hct, BUN, Crea, Na, etc.)
3. The potential for dehydration evaluation will be completed for all admissions, readmissions, and significant change.
4. All high-risk residents that do not exhibit any signs and symptoms of dehydration via RN assessment and no new orders from the MD, will be monitored by the Dietary Technician/designee using the meal consumption sheet. Negative trend or findings will be reported during clinical meetings.
5. Unit Managers/designee will conduct review of the meal consumption sheet to identify negative trends. Trend will be reported daily during clinical meetings except weekends and holidays. Nutrition office will continue to review of the meal consumption sheets weekly.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Facility Consultant will assist the Administrator/QA Coordinator and the Director of Nursing to initiate a reasonable and attainable QAPI programs to discuss the results of the facility audit.
1. The DON/designee will conduct an audit on all admissions, readmissions and all residents reported in the 24hr./72hr. report with clinical symptoms of potential dehydration. Audits will include but not limited to the following;
a. Resident involved
b. Was the resident reported on the 24/ 72 report?
c. Potential for dehydration form completed?
d. Any signs and symptoms of dehydration? RN assessment completed?
e. MD and Family Notification
f. New interventions implemented.
2. Resident condition/s may include but not limited to the following;
a. Vomiting
b. Diarrhea
c. Poor fluid and food intake
d. Change in mental status
e. Abnormal labs (i.e Hgb/Hct, BUN, Crea, Na, etc.)
3. Audits will be reviewed and reported weekly x 4 weeks, then monthly x 2 months and reported during the quarterly QA report.
4. QA Committee will decide if continued audits are warranted.
The date for correction and the title of the person responsible for correction of each deficiency.
? Director of Nursing

FF10 483.25(b)(1):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES

REGULATION: NG TREATMENT/SERVICES - RESTORE EATING SKILLS

Scope: Isolated
Severity: Actual harm has occurred
Citation date: October 23, 2017
Corrected date: December 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation during an abbreviated survey (Case # NY 377), the facility did not ensure care was provided that prevented residents from developing pressure ulcers and that residents with pressure ulcers received the necessary treatments and services needed to promote healing and prevent infection for 2 (Resident #'s 60 and 18) of 4 residents reviewed for pressure ulcers. Specifically: For Resident #'s 60 and 18 the facility did not recognize and assess the resident's risk for developing pressure ulcers, did not develop or implement timely resident specific interventions to minimize the risk for the development or worsening of pressure ulcers or apply relevant policies and procedures to prevent and treat pressure ulcers in accordance with standards of practice, consistently notify physicians' of changes in skin integrity, follow physicians orders for treatments, interventions and recommendations for the treatment of [REDACTED]. Also, the facility did not ensure Comprehensive Care Plans and Care Cards (ADL #5s) (instructions for resident's care) included the physician ordered interventions/recommendations for staff to follow. This resulted in the development of avoidable pressure ulcers to Resident #60's and #18's left heels. This is evidenced by: The Wound Care Policy and Procedure (P&P) dated 3/2015, documented the following objectives; Identify residents at risk for ulcer development, Identify measures to prevent /minimize wound development, Residents would receive the necessary treatment and services to promote healing; and prevent infection; Identify the type of ulcer; to assess and document ulcers; to effectively treat and heal ulcers. When a pressure ulcer is identified the registered nurse (RN) will assess any pressure distribution devices, update the ADL #5 (instructions for resident's care form), update the Skin Risk assessment form, initiate an Actual Alteration in Skin Integrity care plan, obtain an order for [REDACTED]. Residents with decreased mobility, impaired circulation, incontinence, recent hospital stays, and the [DIAGNOSES REDACTED]. understand the cause of the ulcer. The purpose of the P&P is to develop a comprehensive care plan that reflects the risk factors identified to stabilize, reduce or remove underlying risk factors, and to monitor and address the impact of changes that increase a resident's risk. Risk assessments are to be done on admission and readmission, annually, quarterly per MDS schedule, with a significant change and PRN (e.g. pain, acute illness). Pressure redistribution equipment is provided per the risk factors. Impaired/decreased mobility was documented as a cofactor that places a resident at risk for pressure ulcer. The Pressure Ulcer Protocol Braden/Risk Assessment Policy and Procedure (P&P) (undated) documented an individual and comprehensive assessment is provided per current guidelines to promptly identify risk for pressure ulcer development utilizing the Braden Scale, and MDS (Minimum Data Set) 3.0. Pressure ulcers are staged using the National Pressure Ulcer Advisory Panel (NPUAP). The policy identified characteristics of Pressure Ulcer Stages 1 - 4, Suspected Deep Tissue Injury, Unstageable, and Kennedy Terminal Ulcer. Kennedy Terminal Ulcer was documented as a pressure ulcer that occurs at the end of life. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue. If slough (light colored stringy dead tissue) or eschar (dead tissue) obscures the wound base, this is an Unstageable Pressure Injury. Stage 4: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly muscle, tendon, ligament, cartilage, or bone. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Resident #60: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. During an observation on 9/26/2017 at 10:25 am, the resident was asleep in bed and a pair of blue foam booties were on a chair in the resident's room. The 30-60-90/Interim Renewal Note dated 6/14/2017, written by physician (MD #1) documented the resident did not have skin issues or pressure ulcers. The Nutrition assessment dated [DATE], documented the resident was consuming approximately 50-100% of meals and fluids, was non-ambulatory, skin was intact, and the resident did not have pressure ulcers. The Braden Scale for Predicting Pressure Sore Risk dated 6/23/2017, documented the resident was a moderate risk for developing pressure sores, was chair fast, had a severely limited or non-existent ability to walk, was unable to bear own weight and/or must be assisted into a chair or a wheelchair. The resident had very limited mobility, was able to make occasional slight changes in body or extremity position, and was unable to make frequent or significant changes in body or extremity position independently. The resident had problems with friction and shear, required moderate to maximum assistance in moving and that complete lifting without the resident sliding against the sheets was impossible. On 6/27/2017, the facility documented a change in the resident's transfer status. At 2:52 pm, the physical therapist (PT #2) documented the resident refused to stand up several times with assistance, refused to demonstrate that she could not stand unassisted and was changed to a Hoyer lift for transfers. The Nursing Progress note dated 7/6/2017 at 1:57 pm, documented the resident required the use of the Hoyer lift for transfer, and that the resident could self-propel in the wheelchair. The Weekly Wound Tracking Form dated 7/9/2017 written by RN Supervisor (RNS) #2, documented the initial identification of an unstageable pressure ulcer located on the resident's left heel that measured 4.5 cm x 7.5 cm. A treatment was not documented on the eTAR (electronic treatment administration) record. The resident's medical record did not include documentation that the resident's risk for the development of pressure sores was assessed following the identification of the pressure ulcer on 7/9/2017. The resident's risk was not assessed again until 9/15/2017. The eTAR dated (MONTH) (YEAR), documented a physician order [REDACTED]. A physician order [REDACTED]. The treatment order was documented on the eTAR from 7/20/2017 - 9/27/2017. There were no other treatment orders for the wound. The Comprehensive Care Plan (CCP) for At Risk for Breakdown, last updated on 5/18/2016, did not include the pressure ulcer on the left heel identified on 7/9/17. The CCP did not include any individualized interventions for the treatment of [REDACTED]. The ADL #5 updated on 7/17/2017 did not include interventions to prevent pressure ulcers on the resident's heels. The 30-60-90/Interim Renewal Note dated 7/11/2017, written by MD #1, documented the resident did not have skin issues and did not have pressure ulcers. The same findings were documented on the 30-day renewals dated 8/8/2017 and 9/12/2017. The PT Progress note dated 7/12/2017 at 3:54 pm, written by PT #1, documented the resident was seen for a left heel blister. Due to the location of the area noted, PT #1 recommended that the resident should not wear shoes at this time, as the resident was transferred with a Hoyer lift and did not need shoes to transfer. The recommendation that the resident should not wear shoes was not documented on the CCP or the ADL #5. The Weekly Wound Consult notes written by the Wound MD and Weekly Wound Tracking written by RNS (Registered Nurse Supervisor) #2; the Director of Nursing (DON); RNS #1; and RNS #3 from 7/9/17 - 9/13/17, documented inconsistencies regarding the left heel pressure ulcer staging and size. Recommendations from the Wound MD were not implemented: The wound consult dated 7/12/2017, documented the resident was a new patient, with an ischemic (local deficiency of blood supply ( stage 2 (partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red-pink wound bed without slough (soft, moist, dead tissue) pressure ulcer located on the left heel with visually estimated measurements of 3.5 x 3 cm. Exact measurements are periodically charted by nurses on the chart, mild pain, and necrotic (dead) tissue; covered with a dry scab. Recommendations were to offload the part, and foam booties; Recommendations for offloading and foam booties were also documented on the wound consults dated 8/9/2017, 8/16/2017, 9/6/2017, and 9/1320/17. The recommendations were not implemented until 9/13/17 (2 months after they were first recommended). The eTAR documented the heel booties were first implemented on 9/13/2017, to be worn while in bed at bedtime. The wound consult dated 7/26/2017, documented a 3 x 3 cm black scab with a scant amount of drainage that will be debrided when the scab loosened. The consult did not include the stage of the pressure ulcer. The Weekly Wound Tracking form dated 7/26/2017, documented the pressure ulcer was a stage 2 that measured 5.3 x 4 cm. The Wound Consult dated 8/2/2017, documented visually estimated measurements of 7 x 4.5 cm; exact measurements are periodically charted by nurses on the chart. The wound was staged as ? - covered with black dry scab. The Weekly Wound Tracking dated 8/2/2017, documented the pressure ulcer was unstageable and measured 4.5 x 7.0 cm. The Wound Consult dated 8/9/17, documented the wound measured 4.5 x 7.5 cm, was staged as ?, the wound was covered with necrotic tissue and would likely need debridement next week. The Weekly Wound Tracking form dated 8/9/2017, documented a SDTI (suspected deep tissue injury) that measured 4.5 x 7.5 cm, and documented a current treatment for [REDACTED]. (The eTAR documented the heel booties were not implemented until 9/13/17). The Wound Consult dated 8/21/2017, documented the wound measures 4 x 3 cm, and was not staged. The wound was documented as worse, with a necrotic base. Will need debridement next visit. The recommendation was for frequent position change as per protocol for pressure sore. The Weekly Wound Tracking dated 8/24/2017, documented the pressure ulcer was unstageable, measured 4 x 3 cm, had 20% necrosis in the wound bed, the visible tissue was improving, and was hospital acquired. (The medical record did not include documentation of a hospitalization ). The Wound Consult dated 9/13/2017, documented visually estimated measurements of 4 x 7 cm, that the wound was not stageable, and the depth questionable as the wound was covered with a black dry scab. The wound did not require debridement. The Weekly Wound Tracking dated 9/13/2017, documented the pressure ulcer was unstageable, measured 7 x 4 cm, and had 20% necrosis in the wound bed. The Physician order [REDACTED]. This intervention was not documented on the ADL #5. The Nursing Progress note dated 9/20/2017 at 12:56 pm, written by RN #5, documented the resident was seen and examined by the Wound MD. The left heel wound measures 4 cm x 6.5 cm, 100% necrotic hard wound bed, wear heel booties in and out of bed. This intervention was not implemented by Nursing until 9/27/2017. The Physician order [REDACTED]. Interview on 9/14/2017 at 3:00 pm, RNS #1 stated he documented hospital acquired on the Weekly Wound Tracking form dated 8/24/17, because he thought the resident went out to the hospital and came back with it and was not aware the pressure ulcer was first identified on 7/9/2017. RNS #1 stated wound tracking was not done from the 1st week of (MONTH) through 8/3/17. RNS #1 stated that the staging of pressure sores was inconsistent due to no formal training in the facility. The vascular surgeon/wound doctor rounds every Wednesday. Regarding turning and positioning RNS #1 stated that he has been telling CNAs to turn and position, because you can have the most sophisticated measures in the world, but if they don't off load, it's not going to work. Regarding addressing the resident's pressure ulcer on the CCP, he stated I have been trying to get as many pressure ulcer care plans done as possible. Wound tracking is done by the RN only. Interview on 9/26/2017 at 11:30 am, PT #1 stated she saw the resident on 7/12/2017 for a left heel blister. She recommended no shoes. The resident required a Hoyer lift for transfers at that time. A relief shoe was not needed, because the resident wasn't standing. She stated the recommendations need to be documented on the ADL care plan by Nursing. The ADL #5 did not include the intervention for no shoes. Interview on 9/26/2017 at 2:35 pm, MD #1 stated the Wound MD comes on Wednesdays, and his notes might come in a day or two later. The RN Manager will call him when the consult reports arrive, but could not state that the nurses call him for every consult. Regarding the recommendations for offloading and the foam booties first made by the Wound MD on 7/12/2017, but not implemented until 9/13/2017, MD #1 stated, There's a delay in carrying out what the wound care doctor recommended. MD #1 stated he would expect the interventions for the resident's heels to be on the ADL #5. MD #1 stated, They (Certified Nursing Assistants) are part of the care team. Regarding the treatment ordered for the left heel that was not implemented until 7/19/17, MD #1 stated, Obviously a 10-11-day delay. Regarding MD #1's documentation that there were no skin issues and no pressure ulcers on the 30-day Renewals dated 7/11/2017, 8/8/2017, and 9/12/2017, MD #1 stated, Maybe it's a mistake on my end. I'll have to update my notes on that. Interview on 9/26/2017 at 3:15 pm, the RN Nurse Manager (RNNM) #1 stated that she would have expected that the wound identified on 7/9/2017 would have been documented on the care plan, so that Nursing could see if they were meeting their goals. The wound consult report is faxed to the facility, and the physician reviews it. The nurse that sees the report should be notifying the physician. The nurse will get an order for [REDACTED]. Interview on 9/27/2017 at 2:18 pm, the Wound MD stated sometimes a nurse from the facility would go with him on wound rounds. He stated, Sometimes RNS #1 would come on the rounds, sometimes some would come that knew nothing about wound care, and sometimes I would go through the whole building and no one would be with me. This was discussed with the Administrator. In regard to speaking with the nurses about the recommendations, he stated, I would tell the nurse to offload, and use foam booties. Regarding the intervention for the foam booties that was not implemented until 9/13/2017, he stated, That obviously needs to be corrected. Regarding the inconsistencies in wound staging (unstageable, stage 2, suspected deep tissue issue) of the left heel wound on the Weekly Wound Tracking forms, he stated, People who don't have any experience are putting things down on the report. Regarding the expectation for when the resident was to wear foam booties, he stated, When the resident is in bed. Regarding the expectation for Nursing after recommendations for the resident were made, he stated, The foam booties I expect to be carried out by Nursing. They don't need to wait for the doctor. Regarding the visually estimated measurements on his consult reports, he stated, Nursing wasn't measuring. Resident #18: The resident was re-admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had moderately cognitive impairment, was understood and able to understand others. The resident required extensive assistance of two staff members for bed mobility, and extensive assistance of one staff member for toileting, hygiene, and dressing. The resident was at risk for developing pressure ulcers and did not have a pressure ulcer. An ultrasound to bilateral lower extremities dated 12/2/2016, documented the resident had normal blood flow from the common femoral veins to the popliteal (leg) veins and that the calf veins were clear. The Nursing Re-Admitting Form dated 12/08/2016, documented the resident did not have pressure ulcers. The facility Braden Scale for Predicting Pressure Sore Risk instructions documented to complete the Braden Scale on admission for four (4) weeks and then quarterly thereafter. The Admission Braden Scale dated 12/8/2016, documented the resident was at risk for skin breakdown. The resident had very limited mobility, made occasional slight changes in body or extremity position, and was unable to make frequent or significant changes independently. A physician order [REDACTED]. The eTAR dated 12/01/2016 - 12/31/2016, did not include the physician order [REDACTED]. A CCP titled Actual Skin Breakdown dated 12/08/2016, documented the resident had a low Braden scale, impaired mobility, incontinence, impaired nutrition, and impaired cognition. An intervention documented to apply skin prep to bilateral heels. The resident's medical record did not include a Braden Scale for week #2 of the resident's re-admission (12/15/2016). A nurse progress note dated 12/20/16, written by LPN #2, documented the resident was having increased difficulty with transfers and was unable to ambulate. The resident's Braden Scale dated 12/21/2016, documented the resident was at risk for skin breakdown. The resident's medical record did not include a Braden Scale for week #4 of re-admission (12/29/2016) A Nurse Progress Note dated 1/8/2017, written by RNUM #2, documented the resident had an opened left heel blister. The Weekly Wound Tracking Form, written by RNUM #2, dated 1/08/2017, documented the resident had a Stage 2, left heel wound from a popped blister. The wound measured 6 cm (l) x 5 cm (w), had scant, serous drainage and was treated with [MEDICATION NAME] (foam dressing) (standing order). A Nurse Progress Note dated 1/11/2017 at 4:45 am, written by RN #1, documented the resident had a superficial, left heel open area with serosanguinous (slightly yellow or pink, thin) drainage. A Nurse Progress Note dated 1/11/2017 at 1:52 pm, written by LPN #2, documented that Physician #1 noted an odor of the left heel and recommended oral antibiotics for 7 days, a dressing order change, no shoe on that foot, a blue offloading bootie and a pressure reducing mattress to off load pressure to the heels. The Care Card dated 8/9/17, with multiple revisions including revisions on 1/11 and 1/12/2017, did not include instructions for the resident to wear the physician ordered blue offloading bootie. A nurse progress note dated 1/12/2017, written by LPN #4, documented a foul odor was present during a dressing change. The Braden Scale for Predicting Pressure Sore Risk dated 1/18/2017 documented the resident was at risk for developing pressure sores. The Wound Physician Consult dated 1/18/2017, documented a chronic Stage 2 pressure ulcer of the left heel with black eschar (thick, dead tissue) that measured 3 cm x 2 cm. The Weekly Wound Tracking Form, written by LPN #2 dated 1/19/2017, documented an unchanged, Stage 2, pressure ulcer to the right (physician documented pressure ulcer left heel) heel that decreased in size and had a depth of 0.2 cm. The Weekly Wound Tracking dated 1/25/2017, written by LPN #2 documented the stage 2 pressure ulcer to the right heel was improving and that the wound increased in size. The Wound Physician Consult dated 02/01/2017, documented the resident had a worsening, unstageable, pressure ulcer to the left heel with a complicating factor of [MEDICAL CONDITION] (PAD) (narrowing of the arteries). Recommendation for a referral to the wound care clinic. The Weekly Wound Tracking Form, written by LPN #2, dated 2/01/2017, documented the resident had an unchanged, unstageable, pressure ulcer to the left heel. The pressure ulcer had an increase in width, a decrease in length, a moderate amount of odorous seroanguinous drainage, inflammation, and had a necrotic (dead tissue) center. An infection was suspected. A Nurse Progress Note dated 2/01/2017 at 11:02 am, written by LPN #2 documented the resident was seen by the Wound Physician. The left heel had declined by increasing in size, had yellow drainage and a strong new odor. A Nurse Progress Note dated 2/01/2017 at 1:36 pm, written by LPN #2, documented Physician #1 assessed the left heel and ordered a new oral antibiotic due to the increased drainage and odor and a left foot x-ray to rule out osteo[DIAGNOSES REDACTED] (infection of the bone). The X-Ray of the left foot report dated 2/01/2017, documented highly suggestive of an [MEDICAL CONDITION] change of osteo[DIAGNOSES REDACTED] with concomitant (associated) [MEDICAL CONDITION] (skin infection). A Nurse Progress Note dated 2/04/2017 at 8:02 am, written by LPN #4, documented an extremely foul odor was noted during dressing change. A Nurse Progress Note dated 2/04/2017 at 12:08 pm, written by LPN #5, documented the resident continued Keflex (oral antibiotics), the back of heel to both sides of ankle bone appeared dark in color and open with serosanguinous drainage noted. The note did not include physician or RNS notification of the change in condition. A Nurse Progress Note dated 2/06/2017, written by LPN #2, documented the Wound Physician recommended a left heel wound culture. A Nurse Progress Note dated 2/06/2017 at 11:00 pm, written by LPN #9, documented an odor coming from the foot. The Wound Physician Consult dated 02/08/17, documented the resident had an unstageable, pressure ulcer to the left heel. The resident had equal pedal (feet) pulses bilaterally, no [MEDICAL CONDITION] of bilateral lower limbs, and no varicosities (varicose veins). The resident had osteo[DIAGNOSES REDACTED] to be confirmed by Magnetic Resonance Imaging (MRI) (a test for pictures of inside the body) and would be treated at the Wound Care Center. The Weekly Wound Tracking dated 2/08/2017, written by LPN #2, documented the resident's heel pressure ulcer was unchanged, was unstageable, had decreased in length, increased in width, was inflamed, had an odor and an infection was suspected. A Nurse Progress Note dated 2/09/2017, written by LPN #2, documented preliminary wound culture results for moderate amounts of two separate bacteria's. The facility physician was notified. The note did not document that the Wound Physician was notified of the culture results. A Wound Physician Consult dated 02/14/2017, documented the resident had a worsening, unstageable, pressure ulcer to the left heel. The resident had equal pedal pulses bilaterally, no [MEDICAL CONDITION] of bilateral lower limbs, and no varicosities. The whole heel was necrotic and gangrenous (death of tissue caused by a lack of blood supply) with a need for urgent hospitalization . The resident may need amputation (removal of a limb). The resident was hospitalized [DATE] - 2/23/2017, for a non-healing left heel wound. A hospital nursing note dated 2/14/2017 at 2:40 pm, documented the resident had a non-healing ulcer to the left heel with black eschar (thick, dead tissue), red wound edges, and a foul smell. The wound measured 8.5 cm x 6.7 cm. The resident refused the surgical consult recommendation dated 2/14/2017, for a [MEDICAL CONDITION] (left leg). The Hospital Discharge Summary dated 2/21/2017, documented a [DIAGNOSES REDACTED]. The Nursing Re-Admitting Form dated 02/23/2017, documented the resident had a necrotic pressure ulcer to the left heel. A physician order [REDACTED]. The CCP dated 2/23/2017, titled Actual Skin Breakdown and Care Card did not include the use of foam booties to bilateral ankles while in bed and to off load heels. The Weekly Wound Tracking Form dated 3/01/2017, written by LPN #2, documented the pressure ulcer measured 9.5 cm (l) x 6 cm (w) x 0.5 cm (d), with black necrotic edges. A physician's orders [REDACTED]. Interview on 8/29/2017, at 1:56 pm, the DON stated re-admission orders [REDACTED]. She stated that prior to the EMR, physician orders [REDACTED]. Interview on 9/6/17 at 9:15 am, the DON (became DON on 7/26/2017, was previously RNUM #2 ) stated that when a wound is discovered she would expect an RN assessment, MD notification, off loading of pressure to that area, update of the care card and care plan with interventions. She stated that on 1/8/17 when she assessed the left heel wound, she should have initiated skin prep to heels, off loaded the pressure to the heel, update the care card and care plan, and notify the MD and the family. She also stated that she expected weekly wound tracking to be complete and thorough, with no blanks. Interview on 9/6/17, at 9:50 am, LPN #2 stated that she would have expected that when the wound was discovered, she would have expected application of skin prep, pressure reducing mattress, pressure off loading of the heel, and the care plan and care card to have been updated. Interview on 9/6/2017, at 10:27 am, the DON stated that she now was able to see that the EMR carry over of physician orders [REDACTED]. She stated there was no current system in place to ensure accuracy of transcription of physician orders [REDACTED]. Interview on 9/28/17 at 9:42 am, the Wound Physician stated he expected nursing staff to implement pressure reducing interventions upon wound identification, update the care plan, update the care card, and notify the facility physician. He stated that he expected to be notified of any wound related test results when the facility received the results. He also stated, he expected the nursing staff to implement any wound care recommendations the same day the recommendations were made. 10NYCRR415.12(c)(1)

Plan of Correction: ApprovedNovember 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
1. Resident # 18 was discharged on [DATE].
2. Resident# 60, the order for heel booties was verified, booties were provided and applied to the resident as prescribed
3. CNA assigned educated regarding application of booties as scheduled, ADL 5 card updated.
4. Care plan is updated as of current date.
5. MD was notified and updated on left heel status.
6. Left heel skin breakdown continues to show improvement based on weekly evaluation.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
All residents have the potential to be affected by this deficient practice.
1. Facility wide skin sweep/check has been completed.
2. Any new identified skin changes and breakdown from the skin sweep was immediately communicated with the attending MD/ Medical Director and treatment to be initiated immediately if applicable.
3. Braden scale will be completed for all resident. Any residents with a score of moderate to high risk will be addressed care plan for risk of skin breakdown.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
The facility consultant will review with the Clinical Team and Facility Administrator the following systemic measure to prevent recurrence as well as conduct the directed education to address the cited deficiency.
1. Policy on wound care was reviewed and updated.
2. Facility wide education for all nursing staff (RN, LPN, CAN) will be conducted by the Staff Educator/designee regarding the changes in the Wound Care Policy. Education will include but not limited to the following
a. Changes in the policy
b. Identification of new skin issues including immediate notification as well as initiating new intervention/s.
c. Preventative measures to prevent development of skin breakdown for at risk residents. (i.e special mattresses, off-loading device, supplementation)
3. Braden scale will be done on admission, readmission, quarterly, significant changes and if a new skin issue has been discovered.
4. A new wound team (AmeriWound) has been contracted by the facility will be conducting weekly wound rounds to include nursing, dietary, rehab and wound MD. The Wound Team/ Wound RN will also conduct basic training to include wound staging for accuracy of assessments and the importance of following the plans for prevention.
5. Facility has created a new position for bath aids responsible for once a week to observe skin and complete a weekly skin check sheet for all residents and will report directly to the licensed nurse. The RN will assess any identified skin changes.
6. Wound MD and wound RN is responsible to update weekly wound evaluations and will notify the licensed staff on the unit of any changes in treatment.
7. Wound binder has been instituted on each nursing unit by the wound RN including a dermal tracker sheet for all active wounds being evaluated.
8. Newly discovered skin areas are documented on the 24-hour report.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Facility Consultant will assist the Administrator/QA Coordinator and the Director of Nursing to initiate a reasonable and attainable QAPI programs to discuss the results of the facility audit.
1. The facility will conduct an audit on all readmissions and all residents with newly identified skin issue.
2. Audit will include the following;
a. Completion of Braden Scale
b. Orders for new wound treatment in place
c. Care plan in place
d. MD and responsible party notification
3. Audits will be conducted weekly x 4 weeks, then monthly x 2 months and reported during the quarterly QA report.
4. QA Committee will decide if continued audits are warranted.
The date for correction and the title of the person responsible for correction of each d
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