Teresian House Nursing Home Co Inc
July 10, 2018 Complaint Survey

Standard Health Citations

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 10, 2018
Corrected date: September 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during an abbreviated survey (Case #NY 366) the facility did not ensure the comprehensive person-centered care plan was implemented for 1 (Resident #2) of 3 residents to meet the resident's medical and nursing needs identified in the comprehensive assessment. Specifically, Resident #2 was put to bed without non skid socks care planned for safety. The resident was found on the floor next to her bed. This was evidenced by: Resident #2: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident had moderately impaired cognition and was able to make herself understood and could understand others. The Comprehensive Care Plan dated 3/30/17, for ADL self care deficit documented the resident's bedtime routine included putting non skid socks on. The Resident Nursing Instructions (directs care) dated 4/1/16, documented Safety-nonskid socks at bedtime. Bedtime routine-after putting nonskid socks on and put to bed by 7:30 PM. The nursing progress note dated 5/22/18 at 1:44 am, documented the resident was observed sitting on the floor next to her bed. The Incident & Accident Report dated 5/22/18 at 1:20 am, documented the Certified Nursing Assistant (CNA) entered the room and the resident was observed sitting on the floor next to the bed. It documented the care plan was not followed. CNA #1's statement dated 5/22/18, documented that Resident #2's non skid socks were not applied before putting the resident to bed. During an interview on 6/4/18 at 3:30 PM, CNA #1 stated that on 5/22/18 she put the resident to bed and did not put the resident's nonskid socks on at bedtime. The resident was care planned for nonskid socks. During an interview on 6/4/18 at 4:00 PM, the Director of Nursing stated CNA #1 was educated regarding following the careplan. 10NYCRR415.4(b)(1)(i)

Plan of Correction: ApprovedAugust 14, 2018

Develop/Implement Comprehensive Care Plan
Resident #2
Element I
Corrective Action for effected resident:
Interdisciplinary team met to discuss residents plan of care upon return from acute care setting 5/23/2018. Care plan was reviewed and revised including input from resident who identified dislike of non-skid socks while in bed. Team therefore agreed to removed non-skid socks from plan of care and initiated ghost alarm while in bed.
Element II
Identify other residents:
House wide review of all residents care planned for non-skid socks at bed time. Input from residents and direct care staff to determine those in agreement and effectiveness of continued use. Changes made as identified.
Element III
Systemic Change
Reviewed and revised facility policy Care Plan Procedure to reflect information gathered from geriatric aide (CNA) regarding residents care and appropriateness of current interventions. House wide re-education completed during unit based staff meetings.
Element IV
Quality Assurance
Interdisciplinary meetings are held quarterly, annually and with significant change. Resident care plan reviews and revisions will be conducted during this scheduled time to ensure the appropriateness of current interventions.
Audits will be conducted weekly on all residents that have completed their quarterly, annually or significant change review.
Results will be reported to the quality assurance committee monthly x2 months and thereafter at a frequency to be determined by the quality assurance committee.

Responsible individual:
Director of Nursing or designee

FF11 483.25(l):DIALYSIS

REGULATION: §483.25(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: July 10, 2018
Corrected date: September 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during an abbreviated survey (Case #NY 75) the facility did not ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of 5 residents reviewed. Specifically, after Resident #1 refused [MEDICAL TREATMENT] on 5/26/18, the facility did not collaborate with the [MEDICAL TREATMENT] Center for a substitute [MEDICAL TREATMENT] date for the resident, or with the local hospital. Subsequently, Resident #1 was admitted to the hospital on [DATE] for worsening blood-urea-nitrogen and creatinine due to missing [MEDICAL TREATMENT] on 5/26/18. This was evidenced by: Resident #1: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment, could make herself understood and understood others. The Policy & Procedure titled Care and Management of a Resident on [MEDICAL TREATMENT] dated 8/8/2014, documented that it was the facility's policy to maintain communication with the [MEDICAL TREATMENT] unit by telephone and the communication book. The Comprehensive Care Plan (CCP) titled The resident needs [MEDICAL TREATMENT] related to [MEDICAL CONDITION] documented the resident received [MEDICAL TREATMENT] three times each week on Tuesday, Thursday, and Saturday. The Registered Nurse Supervisor (RNS) Report dated 5/26/18, documented Resident #1 had fallen and complained of not feeling well. The nursing progress note dated 5/26/18 at 1:38 pm, signed by the RNS documented the resident was found on the floor in her bathroom at 9:08 am. She was sitting with her legs flexed and was leaning against the wall, and the resident reported she tried to use the toilet but her legs gave out. The resident reported she did not feel well. No injuries were noted, and the physician and family made aware by the unit nurse. The [MEDICAL TREATMENT] Center progress note dated 5/26/18 at 2:09 pm, documented the resident did not come for [MEDICAL TREATMENT] that day, and the nursing home (NH) nurse was notified. The NH nurse stated the resident fell that morning and complained that her knees were weak, and the was refusing to get out of bed. The [MEDICAL TREATMENT] Center told the NH nurse to watch the resident's fluid and foods high in potassium, and if the resident became symptomatic the NH could send her to the emergency department for further evaluation. A nurse progress note dated 5/27/18 at 2:31 pm, documented the resident complained of not feeling well and wanted to go to the hospital. The 24-Hour Condition Sheet, Unit Report dated 5/28/18, documented on the day shift the resident was being monitored after a fall. She complained of feeling shaky, and the RNS was aware. A nurse progress notes dated 5/29/18 at 9:57 am, documented the resident had some shaking that morning. Staff reported that the resident was weak and unable to stand. The resident had been scheduled to receive [MEDICAL TREATMENT] Saturday 5/26/18, but the [MEDICAL TREATMENT] Center canceled. The Nurse Practitioner was notified and the resident was to be sent to the hospital for lethargy and altered mental status. The 24-Hour Condition Sheet, Unit Report dated 5/29/18, documented the resident had weakness and shakiness noted on the day shift and was unable to stand or feed herself. The Nurse Practitioner ordered to send the resident to the hospital for evaluation due to lethargy and change in mental status. The RNS Report dated 5/29/18, documented the resident was transferred to hospital at 9:55 am for evaluation. The hospital History and Physical (H&P) dated 5/29/18, documented the following laboratory results: Blood Urea Nitrogen (BUN) 87 (an important indication of kidney function; normal value: 7-18), Creatinine 8.2 (another measure of kidney function; normal value: 0.60-1.30) and Potassium 6.2 (normal value 3.5-5.1 the H&P's Assessment and Plan documented the likely scenario for the resident's weakness was an accumulation of a new medication ([MEDICATION NAME]) and the worsening of the resident's BUN and creatinine secondary to the resident missing [MEDICAL TREATMENT] on 5/26/18. For the resident's end stage [MEDICAL CONDITION], the resident was receiving [MEDICAL TREATMENT] with hopes that the potassium level comes into a better range. For the resident's high potassium level, the resident is on [MEDICAL TREATMENT] and the cardiac rhythm will be monitored. The resident was admitted to the hospital and it was expected that her [DIAGNOSES REDACTED]. The hospital Transfer Discharge Summary dated 5/30/18, documented the resident was seen by Nephrology who recommended [MEDICAL TREATMENT] be performed on the day of admission to the nursing home due to her high blood potassium level and because the resident missed [MEDICAL TREATMENT] on 5/26/18. During an interview on 6/1/18 at 9:45 am, the Director of Nursing (DON) stated that, if the nurse did not speak to the physician about the resident missing a [MEDICAL TREATMENT] session, she should have called him back and gotten orders for the resident. During an interview on 6/1/18 at 2:15 pm, the Registered Nurse Manager (RNM) stated she was told on the morning of 5/29/18, that the resident refused to go to [MEDICAL TREATMENT] on 5/26/18. The RNM stated LPN #1's statement documented Resident #1 refused [MEDICAL TREATMENT]. LPN #1 had stated the resident fell a little after 9:00 am and the [MEDICAL TREATMENT] Center called the facility. LPN #1 told them the resident was not going to [MEDICAL TREATMENT] and asked if there was availability for another day, and the [MEDICAL TREATMENT] Center said there was no availability, and the RNM was not sure if LPN #1 called the physician. The RNM was not aware of a protocol to follow for missed [MEDICAL TREATMENT] treatments. During an interview on 6/1/18 at 2:45 pm, the Nurse Practitioner (NP) stated he was not aware the resident did not receive a scheduled [MEDICAL TREATMENT]. The nurse should have called the physisicn on the day the resident missed [MEDICAL TREATMENT] and ask for instructions on what to do and what to monitor the resident for. During an interview on 6/4/18 at 11:40 am, the physician stated he remembered the phone message regarding the resident's fall and that she did not want to be sent to [MEDICAL TREATMENT] on 5/26/18. He did not return the call to the nursing home because he thought the facility would have followed a [MEDICAL TREATMENT] protocol. The nurses should have made arrangements with the [MEDICAL TREATMENT] Center for the resident to receive [MEDICAL TREATMENT] the next day, or arranged for hospital [MEDICAL TREATMENT] if the [MEDICAL TREATMENT] center was not open. The Nursing Supervisor should have been notified and made sure other [MEDICAL TREATMENT] arrangements were made. During an interview on 6/4/18 at 1:30 pm, the Registered Nurse Staff Educator (RNSE) stated that changes in the resident's condition should have been communicated to the RNS, and the nurses should have called the physician when the resident was complaining of symptoms after missing a [MEDICAL TREATMENT] session; or the resident should have been sent to the emergency room . The RNSE stated she had been the educator for approximately 1 year and had not provided [MEDICAL TREATMENT] education to the staff in that time. During an interview on 6/4/18 at 3:50 pm, the RNM stated the [MEDICAL TREATMENT] Center had no other appointments available on 5/26/18 after the resident refused [MEDICAL TREATMENT]. LPN #1 should have called the physician for instructions. She also stated monitoring of residents that miss a [MEDICAL TREATMENT] treatment would need to be addressed, and the facility's P&P for [MEDICAL TREATMENT] needed to be revised. During an interview on 6/4/18 at 1:05 pm, LPN #1 stated that on the morning of 5/26/18, the resident had a fall in her room. The resident said she was not hurt, but she felt weak and was not going to [MEDICAL TREATMENT]. When LPN #1 was still with the resident, the [MEDICAL TREATMENT] Center called and she told them the resident was not coming. LPN #1 asked the [MEDICAL TREATMENT] nurse for another appointment and was told there were no openings, and the [MEDICAL TREATMENT] Center would call if an opening came available. LPN #1 stated she left a message for the physician about the resident's refusal to go to [MEDICAL TREATMENT], but she did not recall if she documented that anywhere. During an interview on 6/4/18 at 1:50 pm, RNS #2 stated the resident refused [MEDICAL TREATMENT] treatment on 5/26/18, because she did not feel well. She tried to convince the resident to go to [MEDICAL TREATMENT], but the resident refused. On 5/27/18 RNS #1 was told that [MEDICAL TREATMENT] would call if they had an opening. On Monday the resident said she was feeling weak, her vital signs were taken and the resident was assessed, and the LPN was told to check with the [MEDICAL TREATMENT] Center again to see if they could get an early appointment for the resident. During an interview on 6/4/18 at 4:00 pm, the DON stated she was not notified that the resident had missed [MEDICAL TREATMENT] on 5/26/18. The nurses should have spoken to the physician about the resident missing [MEDICAL TREATMENT], and if the nurse did not receive a call back from the physician, the nurse should have made additional calls to the physician for instructions. 10 NYCRR 415.12

Plan of Correction: ApprovedAugust 14, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** [MEDICAL TREATMENT]
Elememt I
Resident Effected
Resident #1 was transferred to acute care setting 5/29/18 following RN assessment for complaints of shakiness, lethargy and inability to stand requiring increased assistance with ADL's. On day of admission resident was dialyzed. Resident was readmitted to facility on 5/30/18 at baseline functioning. Collaborative meeting with resident, family, interdisciplinary team and [MEDICAL TREATMENT] staff to formulate plan to prevent future occurrence. Encourage resident to openly express feelings surrounding medical condition. Determine when possible residents reason for desire to cancel. Provide education on potential problems that may arise with canceled/delayed treatments.
Element II
Identify other potential residents
House wide review identifies one other resident receiving [MEDICAL TREATMENT]. Facility policy [MEDICAL TREATMENT] was reviewed and revised. Standing order added for both residents to include notifying physician and [MEDICAL TREATMENT] center of canceled appointment. Reschedule with [MEDICAL TREATMENT] center for next available opening, document communication with changes in resident record report to RN and MD immediately.
Element III
Systemic change
Reviewed and revised facility policy [MEDICAL TREATMENT] to include steps to be taken in event of canceled [MEDICAL TREATMENT] appointment. Educate resident on potential outcomes of canceling appointment including possible need to transfer to emergency department for [MEDICAL TREATMENT] treatment and admission. Encourage resident to express feelings/concerns. Involve family as needed. Education of nursing staff to include revisions to policy and early reporting of change in condition of resident with canceled [MEDICAL TREATMENT] appointment. Update RN nurse manager/RN house supervisor and MD, document communication with changes in resident record. Report to oncoming licensed staff to ensure that further monitoring of change in resident condition will be ongoing.
Element IV
Quality Assurance

Weekly review of [MEDICAL TREATMENT] residents notes to determine if scheduled appointments were missed and appropriate actions taken x4 weeks. Further reporting at monthly quality assurance committee meeting x2 months and thereafter at the frequency determined by the committee by the quality assurance committee.
Responsible individual:
Director of Nursing or designee