Richmond Center for Rehabilitation and Specialty Healthcare
June 9, 2017 Certification 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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: August 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review conducted on a Complaint investigation during a Recertification survey the facility did not ensure that the MDS assessments accurately reflected the resident's status. Specifically, the comprehensive assessments did not reflect the resident's left neck mass. This was evident for 1 of 26 residents reviewed for comprehensive assessment in Stage 2. (Resident #191). Complaint # NY 342 The findings are: Resident # 191 is a [AGE] year old was re-admitted to the facility on [DATE] and a second readmission on 4/18/17 with [DIAGNOSES REDACTED]. On 6/5/17 at 1:05 PM, resident was observed lying in bed with head of the bed elevated, greeted surveyor appropriately. Large, red, pink mass noted in the left-side neck area. Resident stated that the mass had been there for some time and denied pain at the site. Resident stated that it [MEDICAL CONDITION], that treatment is done every week and the mass is getting smaller. On 06/07/2017 at 3:33PM, the resident was observed in the day room participating in a Music activity being conducted by facility staff. Resident smiled when greeted. Mass visible in neck area, skin intact, reddish, pink in color. Resident denied pain. The Annual Minimum Data Set ((MDS) dated [DATE] documented intact cognition and extensive assistance of one person for activities of daily living. There was no documented evidence that the left neck mass was documented on the MDS assessment. A review of the Annual MDS assessments completed on 2/15/16 and 1/14/17 and the Quarterly assessments completed on 5/13/16, 6/19/16, 9/18/16 and 11/23/16 revealed no documentation of a left neck mass. The admission record documented a [DIAGNOSES REDACTED]. The documented onset date was dated 3/28/17. The record further documented the [DIAGNOSES REDACTED]. The Nursing Quarterly Evaluations dated 2/15/16 through 5/5/17 were reviewed and documented: skin intact-no skin alterations. There was no documented evidence that the left neck mass was documented on the MDS assessments. On 6/09/2017 at 1:47 PM, an interview was conducted with the RN/NM (Registered Nurse/ Nurse Manager). The RN stated that she is responsible for reviewing the monthly nursing evaluation forms completed by the licensed nurses and had not noticed that the skin condition section was not coded accurately. The residents' left neck mass should have been documented as other with an explanation written in since the resident's condition was not listed on the template. The RN further stated that she reviewed the unit consultation book and was unable to locate the surgical consult that was ordered for follow-up after the CT scan had been performed in (MONTH) (YEAR). On 06/09/2017 at 12:55 PM, the RN/MDS Coordinator was interviewed and stated that when completing the assessments, she physically observes the resident, reviews the medical record including orders and physicians visits. Each section of the MDS is then completed and based on the active [DIAGNOSES REDACTED]. The RN further stated that she does not review MDS for accuracy and when her signature indicates that the MDS has been completed. The RN also stated she should have discussed the neck mass with the physician so the [DIAGNOSES REDACTED]. On 6/09/2017 at 2:33 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the left neck mass was identified in (YEAR) and a CT scan and x-rays were done. The DON stated that the mass was thought to be benign, the physician signed off on the report and did not make further recommendations. The Physician must have felt that no further work-up was necessary. The mass should have been captured on the nursing evaluation. The nurses are expected to be more familiar with their residents so that situations like this can be avoided. In addition, she added that there have been a number of changes in medical coverage at the facility and ultimately the Medical Director would have been responsible for ensuring that proper follow-up was done. The DON further stated that communication should have occurred between the physician and the MDS assessor when they observed that this information was not in the physicians documentation so the resident's condition could be captured on the MDS. Concerns had been previously identified with MDS accuracy. The MDS assessors and MD's are now required to attend morning meeting so that they can be more aware of what is happening with all the residents. A review of the facility policy MDS 3.0 documents the requirements are that (1) the assessment accurately reflects the resident's status, (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shift. 415.11 (b)

Plan of Correction: ApprovedJuly 17, 2017

DIRECTED PLAN OF CARE
What corrective action will be accomplished for those residents found to have been affected by the deficient practice?

For Resident#191 the MDS Assessor re-assessed him and correction was made to accurately reflect resident?s left neck mass.
Corrected MDS was resubmitted.
The MDS Coordinator was educated related to conducting a thorough assessment and coding instructions as stated in the policy and procedure titled MDS 3.0.

How will you 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 the deficient practice.
A full house audit of comprehensive MDS for the last 3 months was conducted to determine if the MDS accurately reflect their current Status.
Any findings will be addressed.

What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The policy and procedure titled MDS 3.0 was reviewed by the IDCPT
MDS Staff was educated on the policy/procedure that assessments accurately reflect the resident status, the registered nurse coordinates each assessment with the appropriate participation of health professional and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.
Nurse Management was educated on the MDS 3.0 policy/procedure and how to review the MDS that it reflects the resident status.
Education was provided to the nursing staff on the Implementation of a systematic approach to measure the growth of a mass throughout the progress of the disease, and was included in the policy Change in a Resident Condition or Status.
The MDS Coordinator and Unit Managers, were educated that prior to Care Plan meeting will evaluate on a quarterly basis, resident at bedside to ensure accurate documentation and coding in relationship to any areas found on assessment are captured and care plan any concerns needing medical attention and it was not a policy revision.

`How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction?
An Audit tool was created for the MDS Regional RN/Designee to conduct monthly audits 10% x3 months of Comprehensive MDS data specific to Section to ensure the MDS assessments accurately reflect the resident status.
Outcome will be provided to Monthly QA committee for review and follow up as needed.
Responsible Party:
DON/Designee


FF10 483.12(b)(1)-(3), 483.95(c)(1)-(3):DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES

REGULATION: 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on- (c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: August 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview conducted during a Complaint investigation during a Recertification survey, the facility did not develop and operationalize policies and procedures (P&P) for screening, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. Specifically, the facility did not have policies and procedures in place to ensure that an injury of unknown origin was thoroughly investigated. This was evident for 1 of 3 residents reviewed for Abuse. (Resident #436). Complaint # NY 342 Resident #436 is a [AGE] year old admitted to facility 10/13/15 with [DIAGNOSES REDACTED]. On 06/05/2017 at 1:59 PM, the resident was observed reclining in a geri-chair in the dayroom. The resident was calm, and was noted to be watching the television. The resident was appropriately dressed and groomed, smiled and attempted to wave when greeted. Contractures of the resident's upper and lower extremities were observed. On 06/07/2017 at 11:27 AM, the resident was observed in a geri-chair in the dayroom watching television. Resident was alert, calm and displayed no signs of distress or discomfort. The resident stated that he had a history of [REDACTED]. A review of the Quarterly Minimum (MDS) data set [DATE] documents severe cognitive impairment, makes self understood and able to understand others and requires the assistance of two persons to complete Activities of Daily Living. A review of the Accident/Incident Report completed on 1/20/17 documented that at 5:30 PM the resident was observed with L eye discoloration. The report documented that the resident was not able to state how the injury occurred and stated I don't know what happened. The report also documented that the Nurse Practitioner was notified and directed that a cold compress be applied to the left eye. Further review of the Accident/Injury Report revealed that the question was person involved seen by a physician? was unchecked and additional questions pertaining to place, date and time seen were also unanswered. Attached to the Accident/Injury Report were statements from the RN Supervisor, Licensed Nurse, and Certified Nurse's Aide who worked the 3 PM-11 PM shift on 1/20/17. The facility investigation did not 1. Include statements from staff persons from the preceding shifts to determine when the injury occurred 2. Identify the injury as of unknown origin 3. Accurately document the residents ability to explain the injury 4. Document the location and type of injury 5. Include documentation of a resident examination conducted by a physician or nurse practitioner. The facility did not ensure that policy and procedures were in place to ensure that an injury of unknown origin was thoroughly investigated. On 06/06/2017 at 3:45 PM, Certified Nursing Assistant (CNA) #1 was interviewed and stated that he noticed reddish discoloration of the resident's eye when he took his assignment on 1/20/17 3 PM-11 PM shift which he reported to the nurse immediately. He stated that the injury did not look like a new injury and looked like it might have occurred that day or night. He also stated that the resident is confused sometimes and not always able to provide information. He could not recall if he had cared for the resident on the previous shift. On 06/07/2017 at 12:46 PM, an interview was conducted with CNA #2 who worked the 7 AM -3 PM shift on 1/20/17 who stated that the resident had a black eye. She stated she noticed it right away because it was black and blue and purple. She further stated that she reported her observation to the licensed nurses on duty and was told that the issue had already been reported because it occurred on the previous shift. She stated that she did ask the resident about the injury but the resident was not able to tell how it had happened. On 06/07/2017 at 3:34 PM, an interview was conducted with Licensed Practical Nurse (LPN) #4 who stated that she worked on 1/20/17 on the 3 PM-11 PM tour and functioned as the middle nurse which means that she took care of orders, treatments and dealt with issues on both units on the 3rd Floor. She stated that CNA #1 reported that the resident had black and blue discoloration on her eye. She stated that she went into the residents room and observed the resident laying in bed with black and blue discoloration on the left eye. She stated that the resident was not able to explain what happened to the eye. She further stated that she reported it to the supervisor. On 06/08/2017 at 9:40 AM, a telephone interview was conducted with Registered Nurse #1 who was the Supervisor on 1/20/17 on the 3 PM to 11 PM shift. She stated that she was called by LPN #4 who told her that there was some bruising on the left eye. She further stated that she went to the resident and noticed bruising, light bluish discoloration on the left eye. She also stated that the resident was not seen by a physician but she notified the Nurse Practitioner (NP). She stated that the resident may have been seen by the NP the following day as residents have to be seen before the Accident/Injury report is signed off on. On 06/08/2017 at 11:42 AM, an interview was conducted with the Nurse Practitioner who stated that she provided off-hour coverage on that day. After review of the resident's medical record she stated that she had received a call describing a small bruise to the left eye with no drainage or skin opening. She stated that she asked the supervisor if they knew how the injury occurred which they did not. She further stated that she told staff to apply a cold compress and continue to monitor. The NP stated that she did not do an examination of the resident as the attending physician sees the resident on the day after the incident unless the injury occurred to a resident on her assigned floor in which case she would be required to examine the resident. She further stated that the practice is that nurses initiate the incident report and the regular physician will sign it. On 06/08/2017 at 1:23 PM, an interview was conducted with the Medical Director who stated that she had only been at the facility for the past 2 weeks and was still familiarizing herself with the ways things are done at this site. She stated that all residents should be seen by the physician following an incident and believes this may also occur on the day following the incident. On 06/09/2017 at 2:13 PM, an interview was conducted with the Director of Nursing (DNS) who stated that on off-hours the covering physician does not examine the residents and the physician who covers the floor will see the resident, usually the day after the incident. This physician would then write a note and complete the incident report. She also stated that in conducting investigations if abuse is suspected the staff involved is sent home, and statements would be obtained from staff working on that shift. She further stated that alert residents would be interviewed to determine if they had similar complaints and if the resident is not alert the medical record would be reviewed. In the case of an unknown injury she stated that staff from the preceding shifts would be interviewed and statements would only be obtained if resident did not have a prior documented history of behaviors that may have contributed to the injury. She also stated that the staff know the resident so she felt that the injury may have been caused by the resident given her medical condition and history. On 06/09/2017 at 2:07 PM, an interview was conducted with the Administrator who stated that when a concern is identified, the allegation is investigated. He stated that statements are obtained from each staff member on that shift, the involved resident, and the resident's roommates and an assessment is provided. He also stated that statements are obtained from the previous shift and then we evaluate all the statements. If a staff is identified as being involved in the allegation they are suspended pending the outcome of the investigation. He further stated that a physician always has to sign off on an accident/incident report and then the DNS signs off on them. A review of the facility policy Abuse/Behavior did not document how injuries of unknown origin should be managed by the facility. 415.4 (b)

Plan of Correction: ApprovedJuly 17, 2017

DIRECTED PLAN OF CARE
What corrective action will be accomplished for those residents found to have been affected by the deficient practice?

-The Resident#436 affected was re-assessed by NP for left eye bruise/ discoloration which was resolved on 1/27/17
-A thorough investigation was conducted:
- accurately identified resident?s ability to explain injury by interviewing the resident as well as include his cognitive status and BIMS score in the investigation summary. BIMS: 9
-Statements were obtained from staff on preceding shifts.
Based on physician assessment and review the discoloration is a side effect of Interferon Beta 1A solution therapy for Dx. of MS which is noted to cause easy bruising. Resident also suffers from muscle spasms that can impact the injury.
Care plan was updated to reflect such.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All incidents and accidents in the past 30 days were reviewed to determine if injuries of unknown origin were thoroughly investigated and that affected residents were assessed by the MD/NP.
No other findings were identified

What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Policy Abuse/Behavior was reviewed and revised to guide the staff on how to thoroughly investigate injuries of unknown origin, and provide thorough information to rule out suspected abuse, mistreatment, neglect and exploitation.
Additional Corporate Policies and Procedures, Accident and Incidents and Conducting an Investigation was reviewed and adopted by the Facility.
Education was provided to all nursing staff, Nursing Leadership, Administrator, Physicians and Medical Director on the processes and documentation requirements necessary to thoroughly investigate, treat and review potential abuse, mistreatment, neglect and exploitation of a resident as addressed in these polices.
Education provided to license nursing staff on incident and accident investigation as to describe their responsibility related to the completion, statements, and investigation of an injury of unknown source
Reinforcement of the Implementation of a Rapid Response call with Regional Staff any time a there is an injury of unknown source and the ruling out of a potential for abuse.
Reinforcement of the use of the Incident/Accident checklist guiding the complete and thorough process of incident/accident investigations.

The ADON Keeps a log of all incident/accidents including injuries of known and unknown origin for tracking and to ensure that all of above steps are taken.


`How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction?

An Audit tool was created for DON/Designee to review all incidents/Accidents with injury of known and unknown origin for comprehensive investigation and completion.
Outcome will be provided to Monthly QA committee for review and follow-up as needed.
The Regional Director of Clinical Services will conduct an audit of 20% all resident investigations of suspected abuse with injuries of unknown origin on a monthly basis x 3 month to ensure that incidents involving an injury of unknown origin was thoroughly investigated
Outcome will be provided to Monthly QA committee on a monthly basis for review and follow-up as needed.
Responsible party: Regional Clinical Director

FF10 483.60(i)(1)-(3):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: August 8, 2017

Citation Details

Based on observation and staff interviews, during the recertification survey, the facility did not ensure that food was stored in accordance with professional standards for food safety. Specifically, during the lunch tray line, the temperature reading for the cold sandwiches was 45 degrees Fahrenheit (F), above the required temperature of 41 degrees and below . Also, unlabeled resident food was observed in the unit pantry refrigerators. This was evident for the Kitchen and 2 out of 9 resident units (Unit 3B and Unit 4). The findings are: 1) On 6/7/17 at 11:20 AM, a lunch tray line observation was conducted, and the following was observed: The cold food temperature readings for the tuna and turkey and cheese sandwiches were 45 degrees Fahrenheit (F). The Policy for Food Storage- Cold dated 10/16 documented: Note: The Food Services Director/Cooks will ensure that all perishable foods are maintained at temperature of 41 degrees F or below except during necessary periods of preparation and service. Immediately after the observation an interview was conducted with the FSD (Food Service Director). The FSD stated that cold food items, such as sandwiches, should be stored at 41 degrees. The FSD stated that the food service workers make the sandwiches and place them in the refrigerator afterwards. The FSD continued to state that he does not want to place the sandwiches in the freezer because the residents would complain that the bread was frozen. The FSD further stated that when he checked the sandwiches this morning, the temperature ranges were between 41 to 43 degrees. The temperature rose because they were in middle of the tray line service. 2) An observation of the Unit 3B pantry refrigerator was conducted on 6/5/17 at 10:09 AM and the following observed: A brown paper bag containing Chinese food, a clear bag containing rice and chicken, and a yellow bag containing frozen waffles were not dated and labeled. The refrigerator log was dated and initialed on 6/5/17. 3) An observation of the Unit 4 pantry refrigerator was conducted on 6/5/17 at 10:31 AM and the following observed: A brown plastic bag containing a stryofoam box of chicken fingers and french fries was not dated and labeled. An interview was conducted with the Food Service Director on 6/9/17 at 2:30 PM. The FSD stated that the food service workers were not taking temperatures of the sandwiches during the trayline, and they only take temperatures of the tuna salad, egg salad or sliced meats in the refrigerator. The nursing staff are responsible for labeling food brought in from outside and stored in the unit pantry refrigerators. Food service staff also check the pantry refrigerators for temperature and to ensure food is dated and labeled, and they inform the nurse if any food has been stored for more than 48 hours. 415.14(h)

Plan of Correction: ApprovedJuly 17, 2017

DIRECTED PLAN OF CARE
What corrective action will be accomplished for those residents found to have been affected by the deficient practice?

The sandwiches with temperature above 41 degrees were removed from the tray line.
The undated foods from the pantries on units 3B and 4 were immediately removed.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
The director of food services checked all refrigerated sandwiches to ensure they maintained a temperature under 41 or below and were all found to be in that range.
All other pantry refrigerators on all units were inspected to ensure there was no undated food. None were found.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The policy for food temperature and log was reviewed and revised. The food temperature log was revised to include recording temperatures of cold food items. A QA audit tool was devised to ensure cold food temperatures are recorded and monitored during tray line.
Food Service Director provided education to Food service staff in regards to recording and monitoring temperature of all food items on serving line to include cold food items
The policy for storage of food in pantry refrigerator was revised to ensure charge nurse per shift check and monitor that all pantry refrigerator items are labeled and dated. A QA audit tool has been created to ensure that all pantry refrigerators contain only food with proper labeling and dating.

In service will be given to all nursing and dietary staff on the importance of keeping only labeled and appropriately dated foods in the pantry refrigerators
`How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction?
The FSD or designee will audit tray line temperatures weekly x 4weeks then monthly x 6mths to ensure cold food items are maintained at safe temperatures throughout service.
Director of Dietary or designee will audit all pantry refrigerators weekly x4 weeks then monthly x 6mths to ensure all items are labeled and dated.
The administrator/FSD will review finding of the audits weekly to ensure compliance and take action wherever necessary.
Any issues will be immediately addressed and corrected.
Results of the audits will be forwarded to the QA committee monthly for review and input
Responsible party: Food service director/ administrator

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: June 9, 2017
Corrected date: August 8, 2017

Citation Details

Based on observation and staff interview during the Recertification survey, the facility did not ensure that the environment was free of accident hazards. Specifically, a portion of the hand rail outside of the 2nd floor dining room was observed missing, exposing a portion of metal. This was evident during Environmental Observations. (2nd Floor) The finding is: On 6/08/2017 at 10:40 AM, the hand rail in the hallway outside of the 2 A & 2 B dining room was observed with a missing terminal portion and exposed metal. The hand rail between the dining room and room 262 was observed in disrepair. On 6/09/2017 at 8:44 AM, an observation was conducted of the 3rd floor dining area bathroom. The handrail to the right side, behind the toilet seat observed with a sharp exposed metal plate. An interview was conducted with the Director of Maintenance on 6/09/2017 at 2:56 PM. The Director stated that no one had reported any issues with the metal plate behind the toilet and that the sharp plate would be covered to prevent resident injury. 415.12(h)(l)

Plan of Correction: ApprovedJuly 17, 2017

DIRECTED PLAN OF CARE

What corrective action will be accomplished for those residents found to have been affected by the deficient practice?

The handrail in the hallway outside the 2A-B dining room was repaired.
The handrail between room 262 and the dining room was repaired.
The handrail in the dining room toilet behind the toilet seat was repaired and secured so that there was no exposed sharp metal
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
An inspection was made of all hand rails in hallways and bathrooms to ensure there were no hazardous conditions. None were found.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
All maintenance personnel will be in serviced on the importance of monitoring conditions of handrails on a regular basis.
All staff were educated to call and report to Maintenance any hazardous conditions including but not limited to broken or loose hand rail as well as write it on the maintenance work order book on each unit for repairs.

`How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction?
A QA tool was created for the Director of Maintenance to monitor the conditions of handrails in the facility.
The tool will be used weekly for one month then monthly X3 months.
The QA committee will review results monthly to ensure compliance and intervention where necessary
The administrator/DOM will review findings weekly for 1 month and then monthly thereafter to ensure compliance and intervention where necessary.
Responsible party: Administrator

FF10 483.10(i)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: August 8, 2017

Citation Details

Based on observations, record review and staff interview during the recertification survey, the facility did not ensure that housekeeping and maintenance services were provided to maintain a clean and orderly interior. Specifically, there were multiple resident rooms and common areas with dirty, streaked walls, floors, baseboards and resident furniture in disrepair. This was evident for environmental observations conducted on the 2nd, 3rd and 4th floors (Units 2 A, 2 B, 3 A & 3 B and 4 B). The findings are: On 6/05/2017 at 2:46 PM on unit 2 A, environmental observations were conducted and the following concerns were identified: Multiple plastered, unpainted surfaces throughout the unit hallway, Floor baseboards were heavily soiled and streaked with paint. The framed picture in the hallway was stained and the glass dirty. The plastic cover plate covering the medical gas shut off valve was cracked and with a hole. The floor in front of the elevators were soiled with a brown substance On 6/06/2017 at 11:00 AM, during an interview with a resident in room 406 a dried red substance was observed on the floor under bed A. Follow up observations on unit 2 A were conducted on 6/07/2017 at 8:07 AM. The following were noted: The corners and inner aspects of the nurses station were in disrepair Multiple nightstand drawer pulls were missing or in disrepair, including but not limited to rm (room) 225 & rm 227. The radiator near stairway C dirty and rusty. Observations of the dining rooms on units 2 A and 2 B were conducted on 6/7/17 at 8:30 AM. There were mismatched chairs, holes in the walls, baseboards heavily soiled and the electrical outlet cover near the entrance to the 2 B dining area was pushed in. The walls and baseboards in the 2 B dining room were dirty, stained and the floor heavily soiled. Holes and unpainted area were observed on the wall. The light fixture was dusty and in disrepair and the garbage can was splattered with a brown substance. Further observations included: The 2 B nurses station was cracked and missing a portion along the edge. Multiple resident room number panels on the walls outside the rooms, were in disrepair. The chair in the nurses station was ripped with the foam exposed. Observation were conducted on 6/07/2017 at 1:19 PM on unit 3 A. The following were observed: In room 337, the bathroom walls and hand rails were streaked and dirty. The wall outside of room 343 underneath the baseboard was streaked with a dried substance. During a resident (#247) interview conducted on 6/08/2017 at 10:00 AM, the resident's wheel chair was observed in disrepair. The wheels were worn, frayed and dirty. During the interview the resident stated that the wheelchair was hard to push and that she thought that's how wheelchairs are supposed to be. On 6/08/2017 at 12:09 PM, an unpainted portion of the wall in the 3 B dining room was observed with holes. Observations were conducted on 6/09/2017 at 8:35 AM to 9:22 AM on 3 B, and the following observed: A metal panel on the front surface of the public bathroom, on the lobby level was observed peeling away from the door with a sharp edge. A portion of the baseboard in rm 308 was missing An indented hole in the wall in rm 320 A stained ceiling tile above the toilet in the bathroom in rm 315, the bottom portion of the electrical outlet was exposed underneath and the radiator was rusted There were multiple dirty nightstands throughout the unit and paint spattered and heavily soiled baseboards, peeling wallpaper boarder outside rm 317 and multiple portions of the panels were missing from the nursing station. Observations were conducted on 6/09/2017 at 9:06 AM to 9:22 AM on 3 A: A portion of the baseboard was missing in the alcove in front of the clean utility room, cabinets were stained, dirty and a portion of the counter was missing in the clean utility room. Additionally, missing wall paper boarders, mismatched paint and dirty walls were noted in front of the elevators on the 3rd floor Observations were conducted on 6/05/2017 through 6/09/2017 on the 2nd floor: The radiator located at the Stair C door, next to room 224, the vent between the porter's closet were dirty, rusty and dusty. The chrome around the x-ray visualization machine in the dining room was broken and in disrepair. The right side molding at the entrance to the dining room was in disrepair The smoke cart with five drawers containing smoking material and blood pressure items was dirty, dusty and stained with a brown substance and cigarette burns The accordion room divider between the 2 A & 2 B dining room was in disrepair, heavily soiled with dried food and liquid stains and heavy dust In room 203 B, the alcove in front of the resident's bed was dirty, dusty and soiled with brown liquid stains over the wall area and counter. On 6/09/2017 at 8:03 AM, brown drip stains were observed on the inner surfaces of both doors in the clean utility room. The front panels of the cabinets inside the room were dirty and the signs attached to the cabinets were also dirty with the plastic pockets peeling An interview was conducted with the Director of Housekeeping on 6/07/2017 at 11:21 AM. The Director stated that the housekeepers are responsible for cleaning resident rooms, walls, dining rooms, vents and radiators weekly. If there is a problem, the housekeepers must report the problem to him and had not received any reported problems. The Director also stated that he would ensure a thorough cleaning of the facility, with emphasis on the second floor, getting extra staff to stay overnight to help with the cleaning. An interview was conducted on 6/07/2017 at 4:54 PM with the Director of Recreation. The Director stated that it is the recreation departments responsibility to maintain the cleanliness of the cigarette cart weekly and to restock it with cigarettes every Monday. The Director further stated that she reported the condition of the cart to the Administrator who stated he would purchase a new one. Interviews were conducted on 6/9/2017 at 11:10 am with the housekeepers on 2 A and 2 B. The housekeepers stated that they are assigned twenty-three rooms each, and are expected to thoroughly sweep, dust, clean spills, take out the garbage, clean the hallways, dining rooms, clean the dining room tables and chairs on their shifts. An interview was conducted with the unit housekeeper on 6/09/2017 at 12:30 PM who stated that he was responsible for cleaning all of the surfaces in the clean utility room, resident rooms, floors and cabinets. An interview was conducted with the unit LPN (Licensed Practical Nurse) on 6/09/2017 12:35 PM. The LPN stated that if something needs repair, there is a box in the wall kiosk where we can document needed repairs. There is a check box for a residents room and a space for a description of the issue, whether it is a mechanical issue related to wheelchairs, beds or in the hallways. An interview was conducted with the facility maintenance worker on 6/09/2017 at 3:00 PM. The worker stated he responds to the units to make repairs based on requests generated from the kiosk unless the staff tells him what is needed verbally. After addressing repairs from the kiosk, he will make rounds which entail walking around the unit and making the identified repairs. The Maintenance Director was interviewed on 6/09/2017 at 3:13 PM. The Director stated that when needed, repair requests are generated through the electronic kiosk and that he make rounds on the units daily. If he see something in need of repair, he delegates the repair to his staff and walks the floors to make sure that there are no needed repairs in the common areas. The Director slao stated that he doesn't go into resident rooms, but relies on the maintenance and nursing staff to input the information into the kiosk. An interview was conducted with the Director of Housekeeping on 6/09/2017 at 3:25 PM. The Director stated that he holds his staff to a high standard and that what was identified by the SA (State Agency) was unacceptable. I make rounds of the common areas daily and resident rooms as needed. I will address all of the concerns immediately. 415.5(h)(2)

Plan of Correction: ApprovedJuly 17, 2017

DIRECTED PLAN OF CARE

What corrective action will be accomplished for those residents found to have been affected by the deficient practice?

The multiple plastered, unpainted, pealing wallpaper, unmatched paint and holes in the walls were replaced, repaired and/or painted in the following areas, including, but not limited to:
2A ? hallways
2B ? dining room
3B ? dining room
317 ? Border and paint outside room
320 ? Hole in the wall
3A ? front of clean utility room
3A ? front of elevators
406- The floor under the bed was thoroughly cleaned and substance removed
The baseboard was replaced and installed in the following areas including, but not limited to:
2A ? unit hallways
2A ? dining room
2B ? dining room
343 ? outside the room
308 ? Missing portion
3A ? alcove in front of clean utility room
The following soiled and dirty areas were thoroughly cleaned including, but not limited to:
2A ? floor in front of the elevators
2B ? dining room
2 ? Radiator close to door C
2 ? Vent next to room 224
2 ? Accordion dividers in dining room
203 ? Alcove
2 ? Doors in clean utility room
2 ? Framed picture in hallway
2 ? Light fixture was replaced with new clean one
2 ? Dining room garbage and areas
337 ? Bathroom walls and rails
2A ? the plastic cover plate covering the medical gas cut off was replaced
2B ? a new outlet cover was installed for broken one near dining room entrance
2B ? light fixture was replaced with new one
2A and 2B ? dining room chairs were rearranged from units to match
2A ? the right side molding at entrance to the dining room was repaired
2nd floor ? a survey was done of the room number panels. Those that were in disrepair were temporarily fixed and new one were ordered
2B ? nurses? station chair was replaced
2nd floor ? the front sides of the cabinets? doors in the clean utility room were cleaned and repainted. Plastic pockets were replaced.
255, 227 ? nightstand draw pulls were replaced
315 ? The stained tile above room was replaced. The radiator cover was removed and painted. Exposed outlet was covered
The dirty smoking cart was replaced with the new one
Resident 247 ? wheelchair was replaced with appropriate new one
Lobby ? the metal panel on the front surface of the public bathroom was repaired
2A ? the nurses? station will be replaced
2B ? the nurses station will be replaced
3B ? The nurse?s station will be replaced
3A ? the clean utility room counter top will be replaced

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
The Director of Maintenance and staff made extensive and thorough rounds of all areas including, but not limited to: resident rooms, all hallways, dining rooms, bathroom, utility and medication equipment rooms and public areas
All issues identified were promptly addressed, repaired and/or replaced.
The Director of Housekeeping and supervisory housekeeping staff made extensive and thorough rounds of all areas including, but not limited to: resident rooms, all hallways, dining rooms, bathrooms, utility and medication rooms, floors and public areas.
All issues identified were promptly addressed and cleaned thoroughly
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The facility initiated a comprehensive maintenance plan. The plan includes, but is not limited to:
a) Repairing and/or replacing all issues identified
b) Reviewing all issues, systems, policy and procedures identified to ensure compliance going forward
c) Reviewing and initiating changes as necessary in systems of repairing any maintenance issues including repair of areas and equipment
All staff will be in-serviced on facility?s policy and procedures of reporting any and all maintenance issues and systems to do so.
The facility initiated a comprehensive housekeeping plan. The plan includes, but is not limited to:
a) Cleaning all areas and issues identified
b) Reviewing all issues and systems identified to ensure compliance going forward
c) Reviewing and initiating changes as necessary to systems of reporting, monitoring issues and policy and procedures.
All staff will be in-serviced on facility?s revised policies and procedures regarding the reporting of any and all housekeeping and maintenance issues including but not limited to:
Housekeeping: Unclean and soiled areas in rooms, hallways and dining rooms.
Maintenance: any and all broken and repair issues including but not limited to:
Walls, in rooms, floors, ceilings, ventilation systems, and all public areas, and the repair and replacement of equipment and hazardous conditions
Maintenance Staff were re-educated on what their duties are. The Maintenance Director was educated to conduct environmental rounds weekly and identify any concerns using the new Maintenance environmental tools and addressing any issues in a timely manner.
Housekeeping staff were re-educated on what their duties are. The Director of Housekeeping was educated to conduct environmental rounds weekly and identify any concerns using the new housekeeping environmental tool to ensure a clean environment in compliance with infection control guidelines.
`How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction?
Comprehensive quality assurance forms have been created to assist and ensure compliance. Forms will be completed by the maintenance department on a weekly basis for one month and monthly thereafter.
The quality assurance committee will review monthly to ensure compliance and take action where necessary.
The Administrator and/or the Director of Maintenance will review findings weekly to ensure compliance and take action where necessary.
Comprehensive quality assurance forms have been created to assist and ensure compliance. Forms will be completed by the Housekeeping department on weekly basis for one month and monthly thereafter.
The quality assurance committee will review monthly to ensure compliance and take action where necessary
The Administrator and/or the Director of Housekeeping will review findings weekly to ensure compliance and take action where necessary
Responsible party: Administrator
`

FF10 483.12(a)(3)(4)(c)(1)-(4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: 483.12(a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: August 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview conducted during a Complaint investigation during a Recertification survey, the facility did not ensure that potential violations involving mistreatment, neglect, or abuse including injuries of unknown source were thoroughly investigated. This was evident for 1 of 3 residents reviewed for Abuse. (Resident #436). Complaint # NY 342 The findings are: Resident #436 is a [AGE] year old admitted to facility 10/13/15 with [DIAGNOSES REDACTED]. On 06/05/2017 at 1:59 PM, the resident was observed reclining in a geri-chair in the dayroom. The resident was calm, and was noted to be watching the television. The resident was appropriately dressed and groomed, smiled and attempted to wave when greeted. Contractures of the resident's upper and lower extremities were observed. On 06/07/2017 at 11:27 AM, the resident was observed in a geri-chair in the dayroom watching television. Resident was alert, calm and displayed no signs of distress or discomfort. The resident stated that he had a history of [REDACTED]. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented severe cognitive impairment, makes self understood and able to understand others and requires the assistance of two persons for activities of daily living. A review of the Accident/Incident Report completed on 1/20/17 documented that at 5:30 PM the resident was observed with L eye discoloration. The report documented that the resident was not able to state how the injury occurred and stated I don't know what happened. The report also documented that the Nurse Practitioner was notified and directed that a cold compress be applied to the left eye. Further review of the Accident/Injury Report revealed that the question was person involved seen by a physician? was unchecked and additional questions pertaining to place, date and time seen were also unanswered. Attached to the Accident/Injury Report were statements from the RN Supervisor, Licensed Nurse, and Certified Nurse's Aide who worked the 3 PM-11 PM shift on 1/20/17. The facility investigation did not 1. Include statements from staff persons from the preceding shifts to determine when the injury occurred 2. Identify the injury as of unknown origin 3. Accurately document the residents ability to explain the injury 4. Document the location and type of injury 5. Include documentation of a resident examination conducted by a physician or nurse practitioner. The facility did not ensure that an injury of unknown origin was thoroughly investigated. On 06/06/2017 at 3:45 PM, Certified Nursing Assistant (CNA) #1 was interviewed and stated that he noticed reddish discoloration of the resident's eye when he took his assignment on 1/20/17 3 PM-11 PM shift which he reported to the nurse immediately. He stated that the injury did not look like a new injury and looked like it might have occurred that day or night. He also stated that the resident is confused sometimes and not always able to provide information. He could not recall if he had cared for the resident on the previous shift. On 06/07/2017 at 12:46 PM, an interview was conducted with CNA #2 who worked the 7 AM -3 PM shift on 1/20/17 who stated that the resident had a black eye. She stated she noticed it right away because it was black and blue and purple. She further stated that she reported her observation to the licensed nurses on duty and was told that the issue had already been reported because it occurred on the previous shift. She stated that she did ask the resident about the injury but the resident was not able to tell how it had happened. On 06/07/2017 at 3:34 PM, an interview was conducted with Licensed Practical Nurse (LPN) #4 who stated that she worked on 1/20/17 on the 3 PM-11 PM tour and functioned as the middle nurse which means that she took care of orders, treatments and dealt with issues on both units on the 3rd Floor. She stated that CNA #1 reported that the resident had black and blue discoloration on her eye. She stated that she went into the residents room and observed the resident laying in bed with black and blue discoloration on the left eye. She stated that the resident was not able to explain what happened to the eye. She further stated that she reported it to the supervisor. On 06/08/2017 at 9:40 AM, a telephone interview was conducted with Registered Nurse #1 who was the Supervisor on 1/20/17 on the 3 PM to 11 PM shift. She stated that she was called by LPN #4 who told her that there was some bruising on the left eye. She further stated that she went to the resident and noticed bruising, light bluish discoloration on the left eye. She also stated that the resident was not seen by a physician but she notified the Nurse Practitioner (NP). She stated that the resident may have been seen by the NP the following day as residents have to be seen before the Accident/Injury report is signed off on. On 06/08/2017 at 11:42 AM, an interview was conducted with the Nurse Practitioner who stated that she provided off-hour coverage on that day. After review of the resident's medical record she stated that she had received a call describing a small bruise to the left eye with no drainage or skin opening. She stated that she asked the supervisor if they knew how the injury occurred which they did not. She further stated that she told staff to apply a cold compress and continue to monitor. The NP stated that she did not do an examination of the resident, because the attending physician is supposed to examine the resident on the day after the incident. She stated that she would only examine the resident if they are assigned to her floor. She further stated that the practice in this facility is that nurses initiate the incident report and the regular physician signs it. On 06/08/2017 at 1:23 PM, an interview was conducted with the Medical Director who stated that she had only been at the facility for the past 2 weeks and was still familiarizing herself with the ways things are done. She stated that all residents should be seen by the physician following an incident and believes this may also occur on the day following the incident. On 06/09/2017 at 2:13 PM, an interview was conducted with the Director of Nursing (DNS) who stated that on off-hours the covering physician does not examine the residents and the physician who covers the floor will see the resident, usually the day after the incident. This physician would then write a note and complete the incident report. She also stated that in conducting investigations if abuse is suspected the staff involved is sent home, and statements would be obtained from staff working on that shift. She further stated that alert residents would be interviewed to determine if they had similar complaints and if the resident is not alert the medical record would be reviewed. In the case of an unknown injury she stated that staff from the preceding shifts would be interviewed and statements would only be obtained if resident did not have a prior documented history of behaviors that may have contributed to the injury. She also stated that the staff know the resident so she felt that the injury may have been caused by the resident given her medical condition and history. On 06/09/2017 at 2:07 PM, an interview was conducted with the Administrator who stated that when a concern is identified, the allegation is investigated. He stated that statements are obtained from each staff member on that shift, the involved resident, and the resident's roommates and an assessment is provided. He also stated that statements are obtained from the previous shift and then we evaluate all the statements. If a staff is identified as being involved in the allegation they are suspended pending the outcome of the investigation. He further stated that a physician always has to sign off on an accident/incident report and then the DNS signs off on them. A review of the facility policy Abuse/Behavior did not document how injuries of unknown origin should be managed by the facility. 415.4 (b)(1)(ii)

Plan of Correction: ApprovedJuly 17, 2017

DIRECTED PLAN OF CARE
What corrective action will be accomplished for those residents found to have been affected by the deficient practice?

-The Resident#436 was re-assessed by NP for left eye bruise/ discoloration which was resolved on 1/27/17
-A thorough investigation was conducted:
- accurately identified resident?s ability to explain injury by interviewing the resident as well as include his cognitive status and BIMS score in the investigation summary. BIMS: 9
-Statements were obtained from staff on preceding shifts.
Based on physician assessment and review the discoloration is a side effect of Interferon Beta 1A solution therapy for Dx. of MS which is noted to cause easy bruising. Resident also suffers from muscle spasms that can impact the injury.
Care plan was updated to reflect such.
-
Resident #436, Assigned licensed nurse involved in investigation was educated in how to thoroughly perform investigations of incidents and suspected abuse.
Resident #436 attending was educated regarding timely assessment of the patient post any unknown origin injury
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
-All incidents and accidents in the past 30 days were reviewed to determine if injuries of unknown origin were thoroughly investigated and completed, ruling out abuse, neglect and mistreatment, and that affected residents were assessed by the MD/NP. No other findings were identified

What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
- The Policy Abuse/Behavior was reviewed and revised to guide the staff on how to thoroughly investigate injuries of unknown origin, and provide thorough information to rule out suspected abuse, mistreatment, neglect and exploitation.
Additional Corporate Policies and Procedures, Accident and Incidents and Conducting an Investigation was reviewed and adopted by the Facility.
Education was provided to all nursing staff, Nursing Leadership, Administrator, Physicians and Medical Director on the processes and documentation requirements necessary to thoroughly investigate, treat and review potential abuse, mistreatment, neglect and exploitation of a resident as addressed in these polices.
Education provided to license nursing staff on incident and accident investigation as to describe their responsibility related to the completion, statements, and investigation of an injury of unknown source
Reinforcement of the Implementation of a Rapid Response call with Regional Staff any time a there is an injury of unknown source and the ruling out of a potential for abuse.
Reinforcement of the use of the Incident/Accident checklist guiding the complete and thorough process of incident/accident investigations by unit managers in a timely manner.
The ADON maintains a log of all incident/accidents including injuries of known and unknown origin for tracking and to ensure that all of above steps are taken.

- Any incident/accident involving an injury will be referred to MD/NP promptly for physical evaluation as required
-
`How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction?
An Audit tool was created to review all
incidents/Accidents with injury of known and unknown origin for comprehensive investigation and completion.
Outcome will be provided to Monthly QA committee for review and follow-up as needed.
Responsible party: DON


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: Isolated
Severity: Actual harm has occurred
Citation date: June 9, 2017
Corrected date: August 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review conducted on a Complaint investigation during a Recertification survey, the facility did not ensure that the unit physician reviewed and followed up on the residents entire plan of care and identified the development of a Stage [MEDICAL CONDITION] tumor. This was evident for 1 of 27 samples residents. (Resident #191). Complaint # NY 342 The findings are: On 2/2/17 at 1:56 PM, a complaint was called into the Department of Health hotline alleging that the resident had a baseball sized tumor rapidly growing on the left side of the neck. The complainant stated that nothing was being done and the resident had not been seen by the physician. Resident # 191 is a [AGE] year old was re-admitted to the facility on [DATE] and 4/18/17 with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented intact cognition and extensive assistance of one person for activities of daily living. On 6/5/17 at 1:05 PM, resident was observed lying in bed with head of the bed elevated, greeted surveyor appropriately. Large, red, pink mass noted in the left-side neck area. Resident stated that the mass had been there for some time and denied pain at the site. Resident stated that it [MEDICAL CONDITION], that treatment is done every week and the mass is getting smaller. 06/07/2017 at 3:33PM, the resident was observed in the day room participating in a Music activity being conducted by facility staff. Resident smiled when greeted. Mass visible in neck area, skin intact, reddish, pink in color. Resident denied pain. The physician progress notes [REDACTED]. The progress note further documented that an x-ray and an ultrasound of the neck was requested. The LPN (Licensed Practical Nurse) progress note dated 9/27/15 at 12:00 AM, documented swelling to the left side of the neck, seen by MD (Medical Doctor), X-ray of the neck, Ultrasound of the neck, Duplex Ultrasound and Carotid Left Side of Neck. The LPN (Licensed Practical Nurse) progress note day 3/3 dated 9/28/15 at 10:44 PM, documented: swelling to left side of neck. Awaiting result of ultrasound. The Carotid Doppler Ultrasonography Report dated 9/28/15 for evaluation of the carotid arteries, documented an incidental finding of a solid mass adjacent to the left mandible (jaw) measuring 3.6 x 3.0 cm (centimeters) of unknown etiology (cause). The physician progress notes [REDACTED]. The progress note further documented that a surgical consultation was requested for further evaluation of the mass. The Physicians Progress Note dated 11/17/15 documented the resident was seen by general surgery for [REDACTED]. An appointment scheduled on 11/20/15 for follow up with general surgery after the CAT Scan result. The Radiology Report dated 12/1/15 documented for CT (Computed Tomography) scan of the soft tissue of the neck was completed w/o (without) contrast (due to poor IV access) to rule out the presence of a mass. The report further documented there was a large 5.8 cm x 3.5 cm left-sided neck mass. The lesion was well-defined with smooth margins, with posterior displacement of the sternomastoid, with anterior, medial and inferior displacement of the submandibular gland. No necrotic adenopathy was identified. The documented impression: Probable large anterior cervical nodal mass. A primary neoplasm is considered less likely. The Physician order dated 12/31/15 documented: Surgical Consult-left side neck mass. There was no documented evidence in the medical record that the surgical consult was completed. There was no documentation that the referral for consultation was followed up on by the physician. The Physician H&P's (History and Physicals) dated 3/9/16 to 10/19/16 documented the residents was neck supple and the skin intact. The Physician H&P dated 6/29/16 documented: neck supple and left neck mass stable. The Physician H&P dated 11/16/16 documented: large mass to left side of neck, hard and non tender, does not disturb swallowing or eating. Plan: Neck mass-not new-patient to follow up with general surgery. The Order Listing Report documented ENT consult to evaluate mass to left neck that is slowly growing one time only for mass to left neck for 14 days dated 12/14/16-12/28/16. There was no documented evidence that the facility referred the resident for further evaluation after the diagnostic work up completed in (MONTH) (YEAR). The Soft Tissue-Neck CT Scan report for dated 1/19/17 documented a large necrotic left-sided level two neck mass measuring 6.0 x 6.8 x 6.3 cm. The mass is situated just below the left parotid gland. Impression: 1. Large left-sided level two necrotic mass/lymph node measuring up to 6.8 cm. Suggestive of [MEDICATION NAME] spread. 2. Prominence of left palatine tonsil which may represent primary site of neoplasm. Direct visualization/ENT evaluation is recommended. The [MEDICAL CONDITION] Oncology Consultation dated 3/13/17 documented: [AGE] year old with Stage [MEDICAL CONDITION] of left tonsil with large neck nodes and is not a candidate for definitive Chemo ([MEDICAL CONDITION])/RT ([MEDICAL CONDITION] Therapy). Will have [MEDICAL CONDITION] first. if a good response, can be re-evaluated for possible palliative [MEDICAL CONDITION]. The Hematology Consultation dated 3/15/17 documented concern that the resident would not tolerate chemo/[MEDICAL CONDITION]. Impression: Advanced SCC (Squamous Cell [MEDICAL CONDITION]). Recommendation: Port Placement. The re-admission record documented a [DIAGNOSES REDACTED]. The documented onset date was dated 3/28/17. The record further documented the [DIAGNOSES REDACTED]. The Hospital H&P (History and Physical) evaluation dated 4/16/17 documented: Chief Complaint: Rash. History of present illness: [AGE] year old lives in (name of facility) recently diagnosed with [REDACTED]. (February) (YEAR) which was bx. (biopsy) + (positive) for Sq. Cell Ca. Pt (Patient) p/w (presents with) chief complaint of resh which started (MONTH) 8th. There was no documented evidence that the resident's left-sided neck mass was further evaluated and/or treatment ordered by the unit Physician after the diagnostic work up that was completed in (MONTH) (YEAR) prior to re-evaluation in (MONTH) (YEAR). Further, there was a documented increase in the size of the mass, development of necrotic tissue and a [DIAGNOSES REDACTED]. An interview was conducted with the Medical Director on 6/09/2017 at 11:10 AM. The Director stated that she has been working as the Medical Director for the past two weeks and had reviewed the CAT Scan report from (MONTH) (YEAR). Based on the written report which was suggestive of a metastatic process, the resident should have been referred for Hematology/Oncology follow-up and evaluation to determine the source of [MEDICAL CONDITION] in a more timely manner. She further stated that the resident should have been monitored on a monthly basis by the attending physician to ensure that the proper care and attention was provided. A review of the facility policy Physician Visits documents 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. 415.15 (b) (iii)

Plan of Correction: ApprovedJuly 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** DIRECTED PLAN OF CARE
What corrective action will be accomplished for those residents found to have been affected by the deficient practice?
Resident #191 current physician is aware of the resident entire plan of care

Resident#191 new physician had already identified the patient stg [MEDICAL CONDITION] to l. He is being treated under oncologist treatment with [MEDICAL CONDITION] that was started on 4/5/17 to address resident?s Left Neck Mass

A plan of care was created for resident # 191 [MEDICAL CONDITION] and [MEDICAL CONDITION].
The resident #191 old physician and previous nurse managers are no longer with the facility
Resident #191 new nurse manager was educated regarding resident plan of care and follow up steps.
A IDCP meeting had been held to review the plan of care, treatment and follow up steps with the resident
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A review of all residents? charts was conducted to determine if residents requiring visits by MD as well as scheduled monthly visits were done in a timely manner. In addition to ensure their physician are aware of their entire plan of care and F/U on identified concerns and consults and tests ordered
Any finding was addressed.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
-All physicians and NP were in serviced on the policy and procedure regarding ?Care Planning Process: Physician Role and F/U on identified concerns and consults and tests ordered
-Nurse Managers were in-serviced to review ?Physician Monthly Review? to ensure that residents Total Plan of Care was reviewed by MD as scheduled.

How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction?
An Audit tool was created to monitor physician visits in timely manner and to ensure that residents? total plan of care is being reviewed by MD and F/U on identified concerns and consults and tests ordered.
Unit Managers will audit residents? physician visits and compliance with plan of care on a monthly & ongoing basis and submit the findings to Monthly QA committee for review and correction as needed.
Responsible Party: DON



FF10 483.24, 483.25(k)(l):PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.

Scope: Isolated
Severity: Actual harm has occurred
Citation date: June 9, 2017
Corrected date: August 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, during a complaint investigation conducted during the recertification survey, the facility did not ensure that care and services were provided for a resident to attain or maintain the highest practicable physical well-being. Specifically, ongoing assessment, monitoring and medical-surgical follow-up of a mass on the left side of a resident's neck was not provided to the resident in a timely manner. The resident was eventually diagnosed with [REDACTED]. This was evident for 1 of 27 sampled residents reviewed for the provision of care and services. (Resident # 191) Complaint # NY 342 The findings are: On 2/2/17 at 1:56 PM, a complaint was called into the Department of Health hotline alleging that the resident had a baseball sized tumor rapidly growing on the left side of the neck. The complainant stated that nothing was being done and the resident had not been seen by the physician. Resident # 191 is a [AGE] year old was re-admitted to the facility on [DATE] and 4/18/17 with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented intact cognition and extensive assistance of one person for activities of daily living. On 6/5/17 at 1:05 PM, resident was observed lying in bed with head of the bed elevated, greeted surveyor appropriately. Large, red, pink mass noted in the left-side neck area. Resident stated that the mass had been there for some time and denied pain at the site. Resident stated that it [MEDICAL CONDITION], that treatment is done every week and the mass is getting smaller. 06/07/2017 at 3:33 PM, the resident was observed in the day room participating in a Music activity being conducted by facility staff. Resident smiled when greeted. Mass visible in neck area, skin intact, reddish, pink in color. Resident denied pain. The physician progress notes [REDACTED]. The progress note further documented that an x-ray and an ultrasound of the neck was requested. The Licensed Practical Nurse (LPN) progress note dated 9/27/15 at 12:00 AM, documented swelling to the left side of the neck, seen by MD (Medical Doctor), X-ray of the neck, Ultrasound of the neck, Duplex Ultrasound and Carotid Left Side of Neck. The Licensed Practical Nurse (LPN) progress note dated 9/28/15 at 10:44 PM, documented: swelling to left side of neck. Awaiting result of ultrasound. The Carotid Doppler Ultrasonography Report dated 9/28/15 for evaluation of the carotid arteries, documented an incidental finding of a solid mass adjacent to the left mandible (jaw) measuring 3.6 x 3.0 cm (centimeters) of unknown etiology (cause). The physician progress notes [REDACTED]. The progress note further documented that a surgical consultation was requested for further evaluation of the mass. The Physicians Progress Note dated 11/17/15 documented the resident was seen by general surgery for [REDACTED]. An appointment scheduled on 11/20/15 for follow up with general surgery after the CAT Scan result. The Radiology Report dated 12/1/15 documented for CT (Computed Tomography) scan of the soft tissue of the neck was completed w/o (without) contrast (due to poor IV access) to rule out the presence of a mass. The report further documented there was a large 5.8 cm x 3.5 cm left-sided neck mass. The lesion was well-defined with smooth margins, with posterior displacement of the sternomastoid, with anterior, medial and inferior displacement of the submandibular gland. No necrotic adenopathy was identified. The documented impression: Probable large anterior cervical nodal mass. A primary neoplasm is considered less likely. The Physician order [REDACTED]. There was no documented evidence in the medical record that the surgical consult was completed. There was no documentation that the referral for consultation was followed up on by the physician. The Nursing Quarterly Evaluation dated 2/15/16 through 1/14/17 were reviewed and documented: skin intact-no skin alterations. There was no documented evidence that the residents left-sided neck mass was assessed and monitored by the registered and licensed nurses from 2/15/16 through 5/5/17. The Physician H&P's (History and Physicals) dated 3/9/16 to 10/19/16 documented the resident's neck was supple and the skin intact. The Physician H&P dated 6/29/16 documented: neck supple and left neck mass stable. The Physician H&P dated 11/16/16 documented: large mass to left side of neck, hard and non tender, does not disturb swallowing or eating. Plan: Neck mass-not new-patient to follow up with general surgery. The medical record included a document titled Order Listing Report. This report documented that an Ear Nose and Throat consult to evaluate mass to left neck was ordered . The report further documented that the mass was slowly growing and this consult was for one time only for mass to left neck for 14 days. The time period was from 12/14/16-12/28/16. There was no documented evidence that the facility referred the resident for further evaluation after the diagnostic work up completed in (MONTH) (YEAR). The medical record documented that the resident was not referred for further evaluation of the left-sided neck mass until (MONTH) (YEAR). Further, there was a documented increase in the size of the mass, development of necrotic tissue and a [DIAGNOSES REDACTED]. The Soft Tissue-Neck CT Scan report dated 1/19/17 documented a large necrotic left-sided level two neck mass measuring 6.0 x 6.8 x 6.3 cm. The mass is situated just below the left parotid gland. Impression: 1. Large left-sided level two necrotic mass/lymph node measuring up to 6.8 cm. Suggestive of [MEDICATION NAME] spread. 2. Prominence of left palatine tonsil which may represent primary site of neoplasm. Direct visualization/ENT evaluation is recommended. The [MEDICAL CONDITION] Oncology Consultation dated 3/13/17 documented: [AGE] year old with Stage [MEDICAL CONDITION] of left tonsil with large neck nodes and is not a candidate for definitive Chemo ([MEDICAL CONDITION])/RT ([MEDICAL CONDITION] Therapy). Will have [MEDICAL CONDITION] first, if a good response can be re-evaluated for possible palliative [MEDICAL CONDITION]. The Hematology Consultation dated 3/15/17 documented concern that the resident would not tolerate chemo/[MEDICAL CONDITION]. Impression: Advanced SCC (Squamous Cell [MEDICAL CONDITION]). Recommendation: Port Placement. The re-admission record documented a [DIAGNOSES REDACTED]. The documented onset date was dated 3/28/17. The record further documented the [DIAGNOSES REDACTED]. Review of the physicians orders and medical record documented that the resident was transferred to the hospital on [DATE] for evaluation of a rash that developed after first [MEDICAL CONDITION] treatment. The Hospital H&P (History and Physical) evaluation dated 4/16/17 documented: Chief Complaint: Rash. History of present illness: [AGE] year old lives in (name of facility) recently diagnosed with [REDACTED]. (February) (YEAR) which was bx. (biopsy) + (positive) for Sq. Cell Ca. Pt (Patient) p/w (presents with) chief complaint of rash which started (MONTH) 8th. On 6/08/2017 at 1:54 PM, an interview was conducted with the Certified Nursing Assistant (CNA) # 6. The CNA stated that she has worked on the unit for the past two years and as far as she can recall the resident has had a neck mass. The CNA further stated that the resident was more active before starting [MEDICAL CONDITION] and would participate in unit activities. An interview was conducted with the Medical Director on 6/09/2017 at 11:10 AM. The Director stated that she has been working as the Medical Director for the past two weeks and had reviewed the CAT Scan report from (MONTH) (YEAR). Based on the written report which was suggestive of a metastatic process, the resident should have been referred for Hematology/Oncology follow-up and evaluation to determine the source of [MEDICAL CONDITION] in a more timely manner. She further stated that the resident should have been monitored on a monthly basis by the attending physician to ensure that the proper care and attention was provided. On 6/09/2017 at 1:47 PM, an interview was conducted with the Registered Nurse/ Nurse Manager (RN/NM ). The RN stated that she is responsible for reviewing the monthly nursing evaluation forms completed by the licensed nurses and had not noticed that the skin condition section was not coded accurately. The residents' left neck mass should have been documented as other with an explanation written in since the resident's condition was not listed on the template. The RN further stated that she reviewed the unit consultation book and was unable to locate the surgical consult that was ordered for follow-up after the CT scan had been performed in (MONTH) (YEAR). On 6/09/2017 at 2:33 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the left neck mass was identified in (YEAR) and a CT scan and x-rays were done. The DON stated that the mass was thought to be benign, the physician signed off on the report and did not make further recommendations. The Physician must have felt that no further work-up was necessary. The mass should have been captured on the nursing evaluation. The nurses are expected to be more familiar with their residents so that situations like this can be avoided. In addition, she added that there have been a number of changes in medical coverage at the facility and ultimately the Medical Director would have been responsible for ensuring that proper follow-up was done. The three physicians who were providing care for the resident during this period were no longer employed at the facility and unavailable for interview. 415.12

Plan of Correction: ApprovedJuly 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** DIRECTED PLAN OF CARE
What corrective action will be accomplished for those residents found to have been affected by the deficient practice?

Resident#191 new physician had already identified the patient stg [MEDICAL CONDITION] to l. He is being treated under oncologist treatment with [MEDICAL CONDITION] that was started on 4/5/17 to address resident?s Left Neck Mass
A plan of care was created for resident # 191 [MEDICAL CONDITION] and [MEDICAL CONDITION].
The resident #191 old physician and previous nurse managers are no longer with the facility
Resident #191 new nurse manager was educated regarding resident plan of care and follow up steps.
A IDCP meeting had been held to review the plan of care, treatment and follow up steps with the resident.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A full body assessment of all residents was done to identify any mass or growth.
A review of residents? charts was done to identify any current mass or growth that needs a comprehensive plan of care and medical-surgical follow up steps to ensure ongoing assessment and appropriate treatment interventions.
Any findings will be addressed

What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
Attending Physicians were educated regarding Facility policy and procedure for Resident ?Attending Physician Responsibilities?, and ?Care Planning Process: Physician Responsibility? and Facility policy for Resident ?Change in Condition?
Nursing staff were educated on Revised policy on ?Change in Resident?s Condition or Status? to include creating a list of residents with mass or growth and on-going assessment and monitoring of mass or growth and follow up steps including medical-surgical consults and will share the information with attending physician. Care plan will be updated accordingly.
Unit Managers will be responsible to create a list of residents with mass or any growth and to ensure a comprehensive plan of care is in place in regards to the treatment, on-going assessment and monitoring of mass or growth and follow up steps and will share the information with attending physician. Care plan will be updated accordingly.
`How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction?
An Audit Tool was created for Unit Managers to review all residents with mass or any growth Weekly to ensure a comprehensive plan of care is in place in regards to the treatment and follow up steps.
The result will be submitted to Monthly QA committee for review and follow-up as needed.
Responsible Party: DON

FF10 483.30(a)(1)(2):RESIDENTS' CARE SUPERVISED BY A PHYSICIAN

REGULATION: §483.30(a) Physician Supervision. The facility must ensure that-- (1) The medical care of each resident is supervised by a physician; and (2) Another physician supervises the medical care of residents when their attending physician is unavailable.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: August 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews conducted on a Complaint investigation during Recertification survey the facility did not ensure that another physician supervises the medical care of residents when their attending physician is unavailable. Specifically, the facility did not ensure that a resident with an injury or unknown injury was physically evaluated by a physician, or nurse practioner when the resident's attending physician was not available. This was evident for 1 out of 3 sampled residents for abuse out of 27 sampled residents reviewed. (Resident #436) This was evident for 1 of 27 sampled residents reviewed for Residents' Care Supervised by a phyisician. (Resident # 436). Complaint # NY 342 The findings are: Resident #436 is a [AGE] year old admitted to facility 10/13/15 with [DIAGNOSES REDACTED]. On 06/05/2017 at 1:59 PM, the resident was observed reclining in a geri-chair in the dayroom. The resident was calm, and was noted to be watching the television. The resident was appropriately dressed and groomed, smiled and attempted to wave when greeted. Contractures of the resident's upper and lower extremities were observed. On 06/07/2017 at 11:27 AM, the resident was observed in a geri-chair in the dayroom watching television. Resident was alert, calm and displayed no signs of distress or discomfort. The resident stated that he had a history of [REDACTED]. A review of the Quarterly Minimum Data Set ((MDS) dated [DATE] documents severe cognitive impairment, makes self understood and able to understand others and requires the assistance of two persons to complete Activities of Daily Living (ADL). A review of the Accident/Incident Report completed on 1/20/17 documented that at 5:30 PM the resident was observed with L eye discoloration. The report documented that the resident was not able to state how the injury occurred and stated I don't know what happened. The report also documented that the Nurse Practitioner was notified and directed that a cold compress be applied to the left eye. Further review of the Accident/Injury Report revealed that the question was person involved seen by a physician? was unchecked and additional questions pertaining to place, date and time seen were also unanswered. Review of the medical record revealed no evidence of a physical examination or referral for medical follow-up after the injury. There was no documented evidence that the resident had been seen and evaluated by a medical professional in a timely manner after sustaining an injury of unknown origin. On 06/06/2017 at 3:45 PM, Certified Nursing Assistant (CNA) #1 was interviewed and stated that he noticed reddish discoloration of the resident's eye when he took his assignment on 1/20/17 on the 3 PM-11 PM shift which he reported to the nurse immediately. He stated that the injury did not look like a new injury and looked like it might have occurred that day or night. He also stated that the resident is confused sometimes and not always able to provide information. He could not recall if he had cared for the resident on the previous shift. On 06/07/2017 at 12:46 PM, an interview was conducted with CNA #2 who worked the 7 AM -3 PM shift on 1/20/17 who stated that the resident had a black eye. She stated she noticed it right away because it was black and blue and purple. She further stated that she reported her observation to the licensed nurses on duty and was told that the issue had already been reported because it occurred on the previous shift. She stated that she did ask the resident about the injury but the resident was not able to tell how it had happened. On 06/07/2017 at 3:34 PM, an interview was conducted with Licensed Practical Nurse (LPN) #4 who stated that she worked on 1/20/17 on the 3 PM-11 PM tour and functioned as the middle nurse which means that she took care of orders, treatments, and deals with issues on both units on 3rd Floor. She stated that CNA #1 reported that the resident had black and blue discoloration on her eye. She stated that she went into the residents room and observed the resident lying in bed with black and blue discoloration on the left eye. She stated that the resident was not able to explain what happened to the eye. She further stated that she reported it to the supervisor. On 06/08/2017 at 9:40 AM, a telephone interview was conducted with Registered Nurse #1 who was the Supervisor on 1/20/17 on the 3 PM to 11 PM tour. She stated that she was called by LPN #4 who told her that there was some bruising on the left eye. She further stated that she went to the resident and noticed bruising, light bluish discoloration on the left eye. She also stated that the resident was not see by a physician but she notified the Nurse Practitioner (NP). She stated that the resident may have been seen by the NP the following day as residents have to be seen before the Accident/Injury report is signed off on. On 06/08/2017 at 11:42 AM, an interview was conducted with the Nurse Practitioner who stated that she provided off-hour coverage on that day. After review of the resident's medical record she stated that she had received a call describing a small bruise to the left eye with no drainage or skin opening. She stated that she asked the supervisor if they knew how the injury occurred which they did not. She further stated that she told staff to apply a cold compress and continue to monitor. The NP stated that she did not do an examination of the resident as the attending physician sees the resident on the day after the incident unless the injury occurred to a resident on her assigned floor in which case she would be required to examine the resident. She further stated that the nurses initiate the incident report and the regular physician will sign it. On 06/08/2017 at 1:23 PM, an interview was conducted with the Medical Director who stated that she had only been at the facility for the past 2 weeks and was still familiarizing herself with the ways things are done at this site. She stated that all residents should be seen by the physician following an incident and believes this may also occur on the day following the incident. She was not sure of whether there was hands off communication occurring between the covering physician and the attending and stated that at morning meeting that occurs each morning they can communicate changes in the status of any other resident. She also stated that she did not think meetings occurred on weekends only on weekday mornings and was unsure of the process on weekends. On 06/09/2017 at 2:33 PM, an interview was conducted with the Director of Nursing who stated that on off-hours the covering physician does not examine the residents and the physician who covers the floor will see the resident, usually the day after the incident and write a note. She also stated that if the incident occurs on the weekend the attending physician will see the resident on the following Monday. If the incident is considered an emergency, with an open wound or witnessed injury the resident would be seen and if the physician thinks it is necessary the resident would be sent to the hospital. She also stated that there is no hand-off communication between the physicians and that the information is placed on the 24 hour report where it is passed from nurse to nurse and shift to shift. The facility policy Physician Visits dated (MONTH) 2013 did not reference physician visits that occur in an emergency situation or during off-hours. 415.15 (b)(1)(i)(ii)

Plan of Correction: ApprovedJuly 17, 2017

DIRECTED PLAN OF CARE
What corrective action will be accomplished for those residents found to have been affected by the deficient practice?

Resident #436 Monthly Physician Review was conducted by NP on 6/28/17-
No significant change noted
Resident #436 physician was educated regarding the care of the resident with an injury or unknown injury to be evaluated physically by a physician
Resident #436 physician was educated regarding appropriate physician support and coverage during weekend and holidays as needed
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A house review of all residents? physician visits was conducted to ensure all residents have been seen by their physician post injury of known/unknown origin in a timely manner.
Any findings were addressed
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
Policy on ?Attending Physician Responsibility? was revised to address physical evaluation of a resident with known or unknown injury by a medical provider as required. The Revised policy was reviewed with all physicians/NPs
On-call PA was contracted for attendance in the facility on Weekends
- A new medical director was hired on 6/26/17
-The medical director is available to cover whenever the primary care physician is unavailable
How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction?
`How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction?
An Audit tool was created to monitor physician visits in a timely manner post injury of known/ unknown origin.
Unit Managers will audit residents? physician visits post injuries on a monthly & ongoing basis and submit the report to Monthly QA committee for review and correction as needed.
Responsible Party: DON