Elderwood at Waverly
August 2, 2017 Certification/complaint Survey

Standard Health Citations

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 4, 2017
Corrected date: October 2, 2017

Citation Details

Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure a sanitary, orderly, and comfortable interior for 1 of 4 residential floors (second floor). Specifically, the second floor shower area walls were spackled and not painted. Findings include: On 8/1/2017 at 3:31 PM, a surveyor observed the walls in the second floor shower area were spackled/not painted, and two of the wall water pipe access panels were loose/falling. During record review on 8/2/2017, a surveyor observed: - schematic diagrams for the interior alterations for the facility's patient tub room issued 6/19/2015; and - multiple third party vendor estimates for different parts of the interior alteration for the patient tub rooms, dated between 12/6/2016 and 12/19/2016. During an interview on 8/2/2017 at 5:50 PM, the Administrator stated the originally planned tub renovation was delayed due to environmental issues found on the floors above. During an interview on 8/2/2017 at 5:50 PM, the Maintenance Lead stated the second floor shower area walls had been spackled and unpainted for at least 9 months. 10NYCRR 415.5(h)(1)

Plan of Correction: ApprovedSeptember 1, 2017

The walls were painted on second floor and access panels were secured on (MONTH) 7th, (YEAR). On (MONTH) 5th, (YEAR), we will begin the construction process for the Shower rooms. This will include removal of all ceramic tile, replacement of dry wall, and replacement of ceramic tile. The Director of Maintenance will be responsible for the monitoring of the project and the safety plan for residents as the construction is implemented. The Director of Maintenance will provide updates at the monthly QAPI meetings along with continued assessment of painting and maintenance of sanitary, orderly and comfortable interior for all residential /units/floors.

FF10 483.25(c)(2)(3):INCREASE/PREVENT DECREASE IN RANGE OF MOTION

REGULATION: (c) Mobility. (2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. (3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 4, 2017
Corrected date: September 4, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, the facility did not ensure 3 of 17 residents (Resident #7, 10, and 20) reviewed for range of motion (ROM) received the appropriate treatment and services to improve and/or to prevent a decrease in ROM. Specifically, Residents #7 and 20 were planned to have a hand devices and were observed throughout survey without them, and Resident #10's arm was not elevated on a pillow as planned. Findings include: 1) Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was moderately impairment. He exhibited no behavioral symptoms, did not reject care, and was totally dependent on staff for dressing, hygiene, and transfers. The occupational therapy (OT) discharge summary dated 12/29/2016, documented the resident required maximum assistance for daily care, and required monitoring of the right hand device for skin integrity and ROM (range of motion). The undated Kardex (care instructions), and the comprehensive care plan (CCP) initiated 5/22/2017, documented the resident had a right hand contracture (permanent shortening of a muscle or joint). Interventions included a right upper extremity hand ball or right resting hand splint. The instructions were to remove the splint for skin checks, hygiene, and as requested by resident. If the resident refused the splint, 2 rolled washcloths were to be placed in his hand to keep the thumb web space open. The splint was to be stored in top drawer of the nightstand. An OT evaluation dated 6/21/2017 documented the resident was planned to have a splint and if the resident refused to wear the resting hand splint a washcloth roll was to be placed in his hand. The certified nurse aide (CNA) documentation, dated 8/1/2017, showed at 12:03 PM the right hand splint was in use, and at 9:53 PM it was refused. There was no documentation that anyone was told of the resident's refusal. The resident was observed on 8/1/2017 without a hand splint or rolled washcloth in his hand at 12:40 PM, 3:15 PM, and at 7:00 PM while in bed. The CNA documentation, dated 8/2/2017, showed at 1:59 PM and 9:28 PM the right hand splint was in use. The resident was observed by the surveyor on 8/2/2017 without a hand splint or rolled washcloth in his hand at 9:20 AM, while in the dining room; and at 10:30 AM, 3:20 PM, and 5:35 PM while in bed. The CNA documentation, dated 8/3/2017, showed at 1:59 PM the right hand splint was in use, and at 9:26 PM it was refused. There was no documentation that anyone was told of the resident's refusal. The resident was observed by the surveyor on 8/3/2017, without a hand splint or rolled washcloth in his hand at 8:45 AM, while in the dining room; and at 11:15 AM, 11:50 AM, 1:30 PM, 4:00 PM, and 4:30 PM while in bed. The resident was observed on 8/4/2017 without a hand splint or rolled washcloth in his hand at 9:00 AM in the dining room. The resident's hand splint was observed multiple times each day from 8/1/2017 to 8/4/217 in the right top drawer of the resident's dresser. When interviewed on 8/4/2017 at 9:40 AM, occupational therapist (OT) #16 stated the resident should have the hand splint or washcloth on the hand and often refused it. If the splint or washcloths were not being used nursing should document and the resident should be referred to therapy for an assessment. She stated the splint or washcloths should be used or offered daily. During an interview with CNA #17 on 8/4/2017 at 9:50 AM, she stated the resident used a ball or washcloth in his right hand for a contracture. She stated she was unaware the resident had a splint or brace for the hand; she usually placed a washcloth in his hand every morning, and the resident was unable to open or close his hand. The CNA stated she provided care for the resident on 8/2, 8/3, and 8/4/2017, and did not see a hand splint in his room. The resident did not have a washcloth in his had at the time of interview and the CNA stated she was not sure how often he was to have it in his hand. When interviewed on 8/4/2017 at 10:05 AM, registered nurse (RN) Manager #18 stated CNAs referred to the Kardex for care instructions. If a splint or washcloth was on the Kardex or CCP, then it was to be used. She also stated the therapy department did monthly and random audits for devices. 2) Resident #20 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was severely impaired. She required extensive assistance with all activities of daily living (ADL's) and had impairments with her arms and hands. The occupational therapy (OT) discharge summary dated 4/7/2017 documented the resident was to use a right palm protector to maintain skin integrity related to [MEDICAL CONDITION] and prevent further contractures. The palm protector was to be removed during meals and for hand hygiene. The comprehensive care plan (CCP) dated 7/20/2017, documented the resident had a right hand contracture. Interventions included passive range of motion and a palm guard to be applied during wake hours and hour of sleep (HS) and was to be removed during meals. The certified nurse aide ( CNA) documentation report dated 8/1/2017 - 8/3/2017 documented the resident required assistance with a right hand palm guard to be applied during wake hours and hour of sleep (HS) and was to be removed during meals and skin checks. The documentation for the use showed: - On 8/1/2017 at 12:20 PM was checked for use and applied; and from 2:00 PM - 10:00 PM the palm guard was not applicable (N/A); - On 8/2/2017 at 10:12 AM was applied and checked for use; and - On 8/3/2017 on the 6:00 AM - 2:00 PM there was no documentation recorded. The resident was observed without a palm guard on : - On 8/1/2017 at 11:20 AM while in the hallway; - On 8/3/2017 from 2:00 PM to 2:23 PM in the hallway; and - On 8/4/2017 at 7:00 AM. The resident's hand splint was observed on 8/4/2017 in the resident's room, in the top drawer of the resident's dresser. During an interview with CNA #4 on 8/4/2017 at 7:13 AM, she stated she was Resident #20's primary CNA and the resident required total assistance with her ADLs and required a right palm guard to help prevent skin breakdown and contractures. She stated the resident refused at times and the refusal was documented on the CNA documentation report. She stated the resident was care planned to have the palm guard on at all times and it was to be removed before she ate and for skin checks. She stated the palm guard was located in her dresser drawer and she did have the palm guard in place on Tues. 8/1/2017. She stated the resident refused on 8/2/2017 and 8/4/2017. When interviewed on 8/4/2017 at 7:48 AM, licensed practical nurse (LPN) #6 stated CNAs referred to the Kardex and CCP for care instructions. Resident #20 required hand splints to be worn during the waking hours to prevent skin breakdown and further contractures. She stated the palm guard was to be remove right before she ate and when washing her hands. She stated the CNAs were responsible for notifying the nurse if the resident refused the palm guard and she was unaware of the resident's refusal. When interviewed on 8/4/2017 at 8:50 AM the occupational therapist (OT) #7 stated the resident had contractures to both hands, had a right palm guard, and was seen in (MONTH) (YEAR) for the left hand as she had left hand swelling. She stated the plan was to have the palm guard at all times except for meals or hand hygiene during the meal and replaced immediately after the meal to prevent pain and further contractures. She stated if the resident refused to wear the palm guard after 3 or 4 times, she expected to be notified and to re-evaluate and make the necessary changes to the plan of care. She stated she was not notified the resident was not using the palm guard. 3) Resident #10 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had severe cognitive impairment, did not exhibit any behavioral symptoms, did not reject care, and required extensive assistance for all activities of daily living (ADLs). The resident also had a ROM impairment on one upper extremity. The admission assessment dated [DATE] documented the resident had [MEDICAL CONDITION] (swelling) of the right hand and right sided paralysis. The comprehensive care plan (CCP) initiated 7/23/2017 documented the resident had limitations in ROM, was at risk for impaired skin integrity and had right hand [MEDICAL CONDITION]. Interventions included keeping the right hand elevated with a pillow at all times. The undated Kardex (care instructions), documented the resident was to have the right hand elevated with a pillow at all times. The certified nurse aide (CNA) ADL documentation for 8/1-8/2/2017, documented the resident had her hand elevated with a pillow for each shift. The following observations of the resident were made: - On 8/1/2017 at 4:48 PM, seated in a chair in her room, her right arm down at her right side, and no pillow; - On 8/1/2017 at 5:25 PM, in her wheelchair in the dining room, right arm in between upper leg and inside of wheelchair, and no pillow supporting her arm; - On 8/2/2017 at 4:23 PM, in her wheelchair with no pillow supporting her right arm; and - On 8/3/2017 at 3:45 PM, seated in a chair in her room, right arm down at her side, no pillow supporting her arm. When interviewed on 8/3/2017 at 3:45 PM, the resident, who had limited speech, was asked if she preferred to have the pillow under her arm, she replied yes. She demonstrated by using her left hand to lift her right hand, raising it up near the arm rest, and was unable to keep it on the armrest, as her arm fell back down to her side. She was asked if it was more comfortable for her to have it elevated, she stated yes. When asked if she ever refused or removed the pillow, she stated no. When asked if she usually had the pillow, she motioned with her hand indicating half and half, and agreed when asked if she meant sometimes. During an interview on 8/3/2017 at 4:25 PM, CNA #13 stated the resident was to have a pillow under her right arm at all times for comfort and positioning as she had no use of her right arm and it would hang down at her side without the pillow. During an interview with registered nurse (RN) Manager #12 on 8/4/2017 at 10:25 AM, she stated the resident was care planned for a pillow under her arm due to swelling. She stated she checked the resident that morning and she continued to have swelling. She stated a pillow should be under her right arm at all times. 10NYCRR 415.12(e)(2)

Plan of Correction: ApprovedSeptember 1, 2017

Resident #7 was evaluated by OT on 8/17/17. OT noted that the right hand splint was ill fitting and resident would benefit from an adjusted splint to prevent worsening contracture. He will continue to be seen by OT until goals are met. Resident #10 was discharged from the facility. Resident #20 was evaluated by OT on 8/21/17. OT noted that there was no change in range of motion and the current right palm protector remains the most appropriate treatment. All CNA's were re-educated on the use of all assistive devices. All residents with splint devices were reviewed to insure that the splint/device was on the care plan and Kardex and is being applied as scheduled. The CNA will document the application and or removal of the device in the Kardex and the Kardex documentation will be reviewed weekly by the Unit Manager. The DON and Director of Rehabilitation will audit splint/devices on a weekly basis for four weeks then monthly for two months at the monthly QAPI meeting to insure devices are in place as scheduled until 100% compliance is achieved.

FF10 483.10(h)(1)(3)(i); 483.70(i)(2):PERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS

REGULATION: 483.10 (h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (h)(3)The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. §483.70 (i) Medical records. (2) The facility must keep confidential all information contained in the resident?s records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 4, 2017
Corrected date: August 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' personal privacy and confidentiality was maintained for 3 of 12 residents (Residents #10, 12, and 24) and 4 additional residents (Residents 30, 31, 32, and 33). Specifically: - Resident #12 had a video camera placed in her room by the facility, consent was not obtained prior to installation, and she was not care planned for the video monitoring. - Residents #10 and 12 had video monitors that were visible to non-staff. - Residents #24, 30, 31, and 32 had video monitors at the nursing station and Resident #29 was allowed to sit in front of the monitors. - Resident #33 was visible on Resident #32's video monitor without consent and was not care planned to be monitored. - Resident #30 had a video monitor and there was no evidence of informed consent. Findings include: The facility's undated policy and procedure titled Photography, Audio Recording, Video Surveillance and Other Imaging of Residents, Visitors, and Workforce Members was requested and printed on 8/3/2017 and included: - Consent was defined as the resident's or resident's legal representative's written acknowledgement and/or agreement of the use and/or disclosure of protected health information for treatment, payment or health operations purposes or other reasons permitted by the HIPAA Privacy Rules. - Video and/or audio surveillance equipment may not be initiated by the facility in a private location without proper approval of the affected resident and/or responsible party. 1) Resident #10 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A determination of incapacity for medical decision-making, signed 7/21/2017, documented the resident had a relative acting as a surrogate for medical decision-making. A photo authorization form, which included use of video surveillance was noted declined by the resident's representative, and dated 7/21/2017. The comprehensive care plan (CCP) initiated 7/21/2017, documented the resident was at risk for falls related to alteration in mental status, history of falls, impaired gait, and incontinence. The interventions included gait belt while out of bed, call light in reach, do not leave alone in bathroom, and non-skid footwear. The CCP was updated on 8/2/2017 with an intervention of a video monitor in room for safety, provide privacy as needed. The resident's undated Kardex (care instructions) as viewed by the surveyor on 8/2/2017 at 9:02 AM, documented safety instructions including: do not leave alone in bathroom, gait belt when out of bed, high elopement risk, monitor whereabouts, non-skid footwear and non-skid socks. The Kardex did not include any information regarding the use of video monitoring. On 8/2/2017 from 9:10 AM, a small, nearly 3 inch video monitor was observed on the desk at the nursing station. The monitor was labeled with the resident's room number and displayed a view of the resident's bed. On 8/2/2017 at 9:51 AM, unit clerk #10 stated the camera had been there for a while so that the resident could be monitored for safety. She stated the resident sometimes liked to go to her room and close the door when there was too much activity on the unit; she liked the quiet, liked looking at her books, and coloring. She stated the camera helped staff keep an eye on her while she was in her room alone. A nursing progress note dated 8/2/217 at 12:44 PM, entered by registered nurse (RN) Manager #12 documented she spoke with the resident's sister and obtained verbal consent for a video camera to be in place in the resident's room for safety purposes. There was no documented evidence of consent for video monitoring from 7/21/2017 to 8/2/2017. The resident's undated Kardex printed on 8/3/2017, documented safety instructions included video monitor in room for safety, provide for privacy as needed. When interviewed on 8/3/2017 at 8:32 AM, certified nurse aide (CNA) #9 stated the video monitoring was initiated since the time around admission, was due to the resident's impaired cognition, confusion, and it was to watch her. He stated the monitor was located at the desk, anyone could see it, he turned the camera around when providing care, and faced it toward the bed when done. The CNA stated he was not aware of specific instructions or policy regarding use of the camera and privacy. During an interview with CNA #13 on 8/3/2017 at 4:25 PM, she stated the video monitoring was for safety. She stated the resident was on 1:1 monitoring for a while, even with the video monitoring, the camera was in the room, and after she fell asleep, the CNA would leave and turn on the camera. She stated the camera had been in use pretty much since the resident was admitted , and she confirmed it was in use prior to 8/2/2017. The CNA stated the resident was able to undress herself and had a commode in the room, per resident's preference. She stated there were no instructions for use of the camera or privacy and it was common sense to turn it off or turn it around when providing care. During an interview with RN Manager #12 on 8/4/2017 at 10:25 AM, she stated video cameras were used as a last resort intervention for safety monitoring due to frequent falls. Any supervising nurse can initiate one, prior consent was required, and the care plan would be updated. She stated CNAs were expected to review the Kardex each day so they would know the camera was in place. She had no prior knowledge of the camera being used in the resident's room, she did not know when the camera was initiated or who made the decision. She stated it should have been added to the care plan and Kardex prior to 8/2/2017, and verbal consent was obtained 8/2/2017. She also stated the video monitors should not be in view of non-staff. 2) Resident #30 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was intact; she required limited assistance of one person for transfer and ambulation; and she had one fall with injury (not major) during the last quarter. The resident's care card (care instructions), undated, documented the resident was alert and oriented to person, place, and time. She walked with limited assistance of 1 person and could ambulate 100 feet with her rolling walker. She required 1 person for transfers with a rolling walker and cueing to scoot to the edge of the chair, to push up from the arms of the chair, and to reach back for the chair before sitting. She was to have signs in the room to remind her to ask for help. For safety, she was to have a video monitor with privacy provided for care. A nursing note dated 5/14/2017 at 6:59 PM, documented the resident was reminded to ring for assistance and educated on the dangers of falling. The resident stated she wanted to do it herself and did not want to wait when she had to go. A nursing note dated 5/24/2017 at 7:13 PM, documented the resident fell and sustained a scalp laceration and steri-strips were applied. The physician's progress note dated 5/25/2017, documented the resident had a fall the previous day while trying to close the curtains. The resident sustained [REDACTED]. Nursing progress notes written daily from 5/24/2017 to 6/7/2017, did not document video monitoring was initiated. A care plan meeting progress note dated 7/5/2017 at 9:54 AM, contained no documentation regarding the use of video monitoring. A nursing note dated 7/19/2017 at 11:01 AM, documented the resident self transferred to the toilet with and without ringing for assistance and was noted to be very nervous. She was reminded and educated on the dangers of self transfers. During an observation on 8/3/2017 at 3:50 PM, another resident (Resident #29) was observed sitting behind the nursing station. Directly in front of the resident were 4 video monitors including Resident #30's. Resident #30's monitor was on and showed a view of her bed and recliner chair. Minutes later, Resident #30 could be seen on the video monitor in her wheel chair propelling herself in front of the bed to her night stand. She was observed for several minutes and then propelled herself to the other side of the bed where she could not be seen. During an observation and interview on 8/3/2017 at 4:05 PM in the resident's room, Resident #30 stated the video camera was placed because the staff did not trust her. She stated the sun was shining bright one day and she got up to pull the curtain closed and fell backwards. She stated she was told not to get up without assistance and frequently did not like to wait for help. She stated she liked her freedom (to transfer independently), she did not have a choice and she was told she had to have a camera in her room for safety. The comprehensive care plan (CCP), revised on 8/3/2017, documented the resident was at risk for falls and a video camera was initiated on 5/24/2017. During a record review on 8/4/2017 at 8:00 AM, there was no documented evidence the resident gave informed consent for the video monitoring or that the family was notified. During an interview on 8/4/2017 at 10:30 AM, the registered nurse (RN) #21 Manager stated cameras were used for residents that had frequent falls or did not call for assistance. Cameras were used as a last resort, they were turned away during care and consent was obtained from the resident or family prior to the camera being placed. She stated Resident #30 forgot to ring for assistance, self-transferred and had a fall. She stated with the camera in place, the resident used her call bell more often. The resident was capable of making decisions although some days her anxiety impaired her decision making. She stated she was not sure if the resident or her family were asked for consent and they usually asked both. She also stated Resident #29 should not have been behind the desk and that there was a portable phone for residents to use. 3) Resident #33 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was intact and he required extensive assistance for bed mobility, transfers, dressing, eating, and toilet use. He was independent with locomotion in his wheelchair. A photo/advertising release form was declined by the resident on 12/27/2012. During an observation on 8/3/2017 at 3:50 PM, another resident (Resident #29) was observed sitting behind the nursing station. Directly in front of the resident were 4 video monitors assigned to Residents #24, 30, 31, and 32 (Resident #33's roommate). Resident #32's monitor showed an empty bed and a curtain pulled blocking the view of Resident #33's side of the room. During an observation on 8/3/2017 at 4:30 PM, Resident #33 was seen on Resident #32's video monitor at the nursing station. Resident #33 was in his wheelchair next to his bed with his back toward the camera. He was moving his upper body back and forth towards the bed. During observation and interview in the resident's room on 8/3/2017 at 4:32 PM, the resident stated he was doing his exercises. He stated the camera in the room was for his roommate. He stated the roommate frequently got out of bed on his own, he was not supposed to, and sometimes staff would see him on the camera and come to the room to tell him to get back in bed. He stated he kept the curtain pulled and could not be seen on the camera. He also stated he got himself dressed in the morning and sat on the bed to dress. During an interview on 8/4/2017 at 10:30 AM, registered nurse (RN) #21 Manager stated cameras were used for residents that had frequent falls or did not ring for assistance. She stated the camera in Resident #33's room was for his roommate and only Resident #32's bed should be in view. 10NYCRR 415.3 (d)

Plan of Correction: ApprovedAugust 26, 2017

On 8/4/17 upon notification that resident #30 did not want the video monitor in her room, the video monitor was removed. Resident #30 was placed on hourly checks to insure safety. Residents #10, #12, #24 ,#31, #32, and #33 had the video monitors removed from their rooms and care plans were updated and reviewed by the interdisciplinary team to determine other safety interventions. All video monitors were removed from resident rooms effective 08/15/2017. The facility will no longer utilize video monitors as an intervention. These residents will be monitored for three months via our QAPI team for any safety issues by the Director of Nursing.

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: Potential to cause more than minimal harm
Citation date: August 4, 2017
Corrected date: September 4, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification and abbreviated surveys (NY 353), it was determined the facility did not ensure residents were provided with the necessary services to maintain optimal physical well-being for 2 of 17 residents (Residents #3 and 17) reviewed for quality of care. Specifically, Resident #17 had a wound that was not assessed by a qualified professional, the wound became infected and the resident was readmitted to the hospital. Resident #3 was not provided anti-pressure boots as planned. Findings include: 1) Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was intact and skin impairments included a deep tissue injury (DTI), an open lesion on the foot, and surgical wounds. The admission assessment form dated 4/4/2017 at 2:34 PM, documented the resident had a sealed dressing on the left inner thigh and left groin to be left in place until the weekly dressing change on 4/7/2017. The left lower leg had a dressing in place, it was to be removed on 4/5/2017 and a Wound VAC (negative pressure wound therapy) was to be applied. The note documented those wounds would be measured with the next dressing changes. Other skin impairments included: the resident's right heel had a 2.5 centimeter (cm) x 3.5 cm fluid filled sac that was white in color and the surrounding skin was dark red; the right foot, third toe was missing a toe nail. The physician's orders [REDACTED]. - applying the Wound VAC to the resident's left lower extremity after cleaning with normal saline on day shift every Monday, Wednesday, and Friday; - applying [MEDICATION NAME] Gel ( wound dressing) and cover with gauze to the resident's 3rd left toe twice a day. The comprehensive care plan (CCP) initiated 4/4/2017, documented the resident had surgical sites to the left inner thigh and left groin. There were no interventions specific to these sites. The resident's skin assessment notes dated 4/5/2017 at 6:28 PM, completed by registered nurse (RN) #19 Unit Manager, documented 2 surgical incisions on the front lower left leg that were being treated with the Wound VAC, a wound on the left toe being treated by [MEDICATION NAME], and a deep tissue injury on the right heel. The assessments included the type of wound, measurements, description, pain, and treatment plan. A physician's orders [REDACTED]. The instructions were to cleanse with normal saline, pat dry, and cover with [MEDICATION NAME] Border-Lite AG 4 x 8 weekly and as needed (PRN). Licensed practical nurse (LPN) #20's progress note dated 4/7/2017, documented the left upper thigh dressing and left groin dressing was changed as ordered. There were 25 staples intact to left thigh incision without redness or drainage. The resident's left groin incision had a small amount of brown colored drainage and some steri strips fell off when the dressing was removed. The site was moist and bright pink and the RN came in to assess. There was slough (dead tissue) noted in the wound bed and no odor. There was no documentation by the RN for the groin or thigh wounds on 4/7/2017. A nursing note dated 4/8/2017 at 5:30 PM, documented the resident's dressing to the inner left thigh was elevated, slight [MEDICAL CONDITION] was noted, and the resident was medicated for pain. The resident's skin assessment notes dated 4/10/2017 at 11:14 AM, completed by RN #19, documented surgical incisions on the front lower left leg that were being treated with the Wound VAC, a wound on the left toe being treated by [MEDICATION NAME], and a deep tissue injury on the right heel. The assessments included the type of wound, measurements, description, pain, and treatment plan. The resident's medical record did not document a skin assessment for the resident's left thigh and left groin surgical wounds. The nursing progress note dated 4/11/2017 at 4:58 PM, documented the resident was admitted to the hospital due to a non-healing left groin wound. The resident received intravenous (IV) antibiotics and was sent to the operating room for wound debridement. When interviewed on 8/3/2017 at 5:00 PM, RN #19 stated the LPNs did dressing changes and the RNs did the initial wound assessment and weekly assessments. She stated she did not remember Resident #17 and when asked to look at the resident's record on the computer, she stated she had no recollection of the resident. She stated if an LPN came to her to report a resident's wound looked infected, she would assess it and call the physician with her findings. When interviewed on 8/4/2017 at 8:25 AM, LPN #20 stated she remembered the resident well and she had many wounds. She stated the resident had a Wound VAC on her lower left extremity to treat 2 wounds. She stated the resident also had wounds on her left thigh and groin. She stated the dressing change to the thigh and groin wounds was weekly and she remembered the groin site being bright pink with some drainage when changed on 4/7/2017. She stated she went to RN #19 with her concerns and RN #19 said it was OK. She stated on 4/10/2017, RN #19 came in to measure and assess the wounds when she was changing the Wound VAC dressing. She stated the resident complained of discomfort and a foul smell at the left groin site. She said RN #19 did not assess the left groin, she told the resident she had an appointment the next day and the physician would look at it then. She stated the wounds treated by the Wound VAC looked good, it was the groin wound that was concerning. She stated the Director of Nursing (DON) asked her many questions regarding the situation and LPN #20 stated she felt bad and wondered if she should have done something different. When interviewed on 8/4/2017 at 8:45 AM, the DON stated she did not have an investigation for Resident #17. When asked specifically about the infected wound, she stated a friend of the resident's expressed concern and she looked into it. She stated she spoke to the 2 nurses caring for the resident and the Medical Director and had no concerns regarding the resident's care. She stated she did not document any of her conversations. When interviewed on 8/4/2017 at 9:30 AM, the resident's friend stated she was present during the resident's dressing change on 4/10/2017. She stated LPN #20 and RN #19 were in the room when the resident complained about discomfort and an odor at the groin site. She stated RN #19 told the resident she would see the vascular physician at the clinic the next day. When interviewed by phone on 8/4/2017 at 9:50 AM, the resident stated when LPN #20 changed the dressing to the groin on 4/7/2017 she thought it did not look good and had RN #19 look at it. She stated RN #19 glanced at the wound, said it was OK and left the room. The resident stated over the weekend she noticed discomfort and an odor from the wound, and on 4/10/2017 she told RN #19 and LPN #20. She stated RN #19 told her the physician would look at it the next day at her appointment. She stated when she went to her appointment the following day, she was admitted to the hospital for the infected wound. When interviewed on 8/4/2017 at 12:44 PM, RN #19 stated the wound should have been assessed by the RN Manager or another RN at the first dressing change. She stated there should have been an assessment of the thigh and groin wounds by a RN on 4/7/2017. She stated the assessment would be on a skin assessment form with measurements and a description of the wound. She did not remember if she assessed the thigh and groin wounds. She stated when she saw the resident for her wounds on 4/10/2017, the groin dressing was not due to be changed. She said the resident did not complain about the wound and she would have looked at the groin if the resident said something. When interviewed on 8/4/2017 at 1:10 PM, the Medical Director stated weekly reviews were done on residents that go to the hospital unexpectedly to see if the hospitalization was unavoidable or if anything could have been done different. He did not recall being notified before the resident went to the hospital or discussing the resident's case after she was sent to the hospital. 2) Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had severely impaired cognition, required extensive assistance with all activities of daily living (ADL's), was at risk for developing pressure ulcers and had pressure relieving devices in place for prevention. The 7/2017 certified nurse aide (CNA) care guide (care instructions) documented the resident was to have heel protectors. The CNA Documentation report for 8/2017 did not show the resident had anti-pressure boots, when they were to be provided, or when to be removed. The comprehensive care plan (CCP) was reviewed on 8/1/2017 and documented the resident was at risk for skin breakdown related to pressure ulcers. The goal was her skin would remain intact and interventions included blue boot heel protectors. The resident was observed in bed or in her reclining wheelchair not wearing anti-pressure boots and her heels lying directly on the bed or footrest on: - 8/1/2017 at 11:20 AM, 12:05 PM, 3:50 PM; - 8/2/2017 at 7:10 AM, 8:29 AM, 10:20 AM, 3:15 PM; - 8/3/2017 at 8:00 AM, 12:38 PM, 2:38 PM; and - 8/4/2017 at 7:00 AM. CNA #1 was interviewed on 8/4/2017 at 7:20 AM. She stated she was the resident's assigned CNA for the 7 AM - 3 PM shift and the resident required total assistance with all ADL's. She stated the resident had pressure prevention boots on at night and when in bed . She stated she documented the care provided on the kiosk. Licensed practical nurse (LPN) #6 was interviewed on 8/4/2017 at 7:48 AM. She stated the CNAs were responsible for ensuring anti-pressure boots were on the resident. She stated she expected the staff to provide the anti-pressure boots when the resident was in bed. She stated the resident was often anxious and rubbed her feet and heels on the mattress. 10NYCRR 415.12

Plan of Correction: ApprovedSeptember 1, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17 was discharged from the facility. Re-education to be completed with all registered nurses regarding policy: Pressure Ulcer/Skin Ulcer (assessment and monitoring program) which states, as part of the admission/readmission process a skin assessment will be documented by a Registered Nurse within 24 hours of admission. If the RN is unable to complete the Skin Assessment on the day of admission, due to pain, refusal, etc., the RN will obtain a physician's orders [REDACTED]. Skin Assessments, Admission/Re-admission, weekly and change in condition documentation will be completed by a RN and documented as a Skin Assessment in the residents electronic medical record upon completion of the assessment. The DON is responsible for monitoring this education and assessing the adherence to this policy monthly via the QAPI meeting. The monitoring by the DON will continue until goals have been met.
For Resident #3, the kardex (CNA documentation), was updated to state heel protectors on while in bed; remove when out of bed. All residents plans of care were reviewed to insure devices were care planned and had clear instructions regarding application and time. All CNA's were re-educated on the use of all devices. The resident devices to include; but not limited to, splints, heel protectors, U pillows, wedges, will be audited to insure proper placement by unit managers weekly for four weeks and then monthly for two months. The results will be reported at the monthly QAPI meeting for three months by the DON, or until 100% compliance is achieved.

Standard Life Safety Code Citations

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE COMPAR

REGULATION: Subdivision of Building Spaces - Smoke Compartments 2012 EXISTING Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier. 19.3.7.1, 19.3.7.2 Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 2, 2017
Corrected date: October 1, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure two smoke compartments, within a sleeping floor, with 30 or more resident beds for 1 of 6 units (South Unit). Specifically, the South Unit had 34 resident beds and it lacked the required number of smoke compartments. Findings include: During tour of the first floor on 8/2/2017 at 3:11 PM, a surveyor observed the South Unit had 34 resident beds and only one smoke compartment. During an interview on 8/2/2017 at 3:11 PM, the Director of Environmental Services stated a couple of years ago with the help of a consultant some cross-corridor doors were removed on first floor South Unit due to staff not being sure which were the smoke barrier doors. He was not aware two of the cross-corridor doors were part of the smoke barrier. He was aware resident units with 30 or more resident beds were required to have two smoke compartments. During an interview on 8/2/2017 at 5:59 PM, the Maintenance Lead stated the smoke barrier cross-corridor doors were removed before he was hired in (MONTH) 2014. 2012 NFPA 101 19.3.7.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 18, 2017

Smoke barrier doors will be installed on the South Unit to insure that there are two compartments for the 34 total residents on that nursing unit.(NAME)Judson, Director of Maintenance, is responsible for ensuring that the doors are installed appropriately per the LSC guidelines. The smoke barrier doors will be permanent and all audits completed will involve the confirmation that LSC standards for smoke barrier doors will be met and monitored monthly via the environmental audit. These audits will be completed for three months and reviewed at the monthly QAPI meeting noting 100% compliance achieved.