Eddy Village Green
August 17, 2016 Certification/complaint Survey

Standard Health Citations

FF09 483.60(b), (d), (e):DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

REGULATION: The facility must employ or obtain the services of a licensed pharmacist who establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2016
Corrected date: October 7, 2016

Citation Details

Based on observations and interviews during a recertification survey, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically: the facility did not ensure that medication was dispensed from a labeled bottle. This is evidenced by: Finding #1 During a medication pass observation at 10:30 am Licensed Practical Nurse #3 dispensed a pill into a medication cup for Resident #158, stating, this is her aspirin. After dispensing the medication the bottle was given to the surveyor for review. The bottle was a plain white medication bottle. There was no medication name on the bottle or a visible expiration date on the bottle. When the surveyor asked LPN #3 what was in the bottle, LPN #3 took the bottle back, discarded the dispensed medication and the unlabeled bottle and returned with a new marked bottle for administration. During an interview on 8/11/16 at 10:35 am LPN #3 stated that she should not have dispensed medication from the unmarked bottle. During an interview on 8/16/16 at 1:30 pm RNM #2 stated that medications could not be given if they were not labeled and that they should have been discarded. During an interview on 8/16/16 at 2:30 pm the Director of Nursing stated that no medication should be given from an unmarked bottle and the medication in the unmarked bottle should have been discarded. 10NYCRR 415.18(d)

Plan of Correction: ApprovedSeptember 9, 2016

Between 8/20 and 8/22 all medication cabinets were inspected by the Director of Nursing, and no other unlabeled bottles were found.
Education to all Licensed Nurses regarding safe labeling of medications. Responsible Party: Director of Nursing, 10/7/2016
Audits of Medication cabinets will be completed monthly in all houses for three months and reported to the QAPI committee with a compliance goal of 100%. If 100% compliance is not achieved, re-education and monthly auditing will continue for the houses below 100%.
Responsible Party: Director of Nursing

FF09 483.35(i):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2016
Corrected date: October 7, 2016

Citation Details

Based on observation, manufacturer ' s directions review, and staff interview during a recertification survey, it was determined that the facility did not adhere to generally accepted food sanitation practices. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Chapter 1 Subpart 14 State Sanitary Code, the community standard for food service establishments operating in New York State both state that chemicals used in sanitizing (to kill bacteria) food equipment are to be at the correct concentration. Specifically: in 2 of 9 houses checked, the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was not as required by the manufacturer. This is evidenced as follows. The kitchen in House 5 was inspected on 08/11/2016 at 9:37 and again on 08/15/2016 at 9:45 am. Equipment washing and sanitizing was taking place in the 3-compartment sink. The concentration of QAC used in the sanitizing rinse sink, the third sink, was found to be less than 150 parts per million (ppm) when measured at 75 degrees Fahrenheit (F). The kitchen in House 2 was inspected on 08/11/2016 at 1:10 pm. Equipment washing and sanitizing was taking place in the 3-compartment sink. The concentration of QAC used in the sanitizing rinse sink, the third sink, was found to be 500 ppm when measured at 75 F. Record review of the manufacturer 's label directions on the QAC concentrate stated the concentration is to be between 150 ppm and 400 ppm when the solution is between 65 F and 75 F. The Regional Hospitality Manger stated in an interview conducted on 08/15/2016 at 11:55 am that sometimes the staff add water to sanitizer if the sink drains a little and that staff need to be re-educated on mixing the sanitizing solution. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.112

Plan of Correction: ApprovedSeptember 9, 2016

Water fill line marked on all sinks, new measuring cups being deployed for measuring the amount of sanitizer. New standard work instructions being developed and training provided to all Shabazim (C.N.A.'s) in houses.
Responsible Party: Director of Dining Services
Completion Date: (MONTH) 7, (YEAR)
Each house will be audited weekly for four weeks - compliance target is 100% of houses will have sanitizing concentration between 150 and 400 ppm. Any house that does not achieve 100% compliance will receive re-education, and if necessary corrective action, and will be audited weekly until compliance is achieved.
Once 100% compliance is achieved, this will be a quarterly QAPI audit for the next twelve months.
Responsible Party: Director of Dining Services

FF09 483.65:INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2016
Corrected date: October 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not ensure it maintained an Infection Control Program designed to help prevent the development and transmission of disease and infection for 5 ( # 109, 134, 144, 162, 174) of 17 resident's reviewed. Specifically: resident's 109, 134, and 162 did not receive [DIAGNOSES REDACTED] testing when they were admitted to the facility; for resident #144 there was no documented evidence that the step 1 Purified Protein Derivative (PPD) ( a test to determine the presence of [DIAGNOSES REDACTED] (TB)) reading had been completed on the date and time ordered and no documentation of the results of the the PPD was found., For Resident # 174 the ordered reading of the step 1 PPD was done before the mandatory 48 to 72 hrs after the step 1 PPD was administered. This is evidenced by: The facility's [DIAGNOSES REDACTED] Guidelines (policy to prevent the transmission of TB) dated (MONTH) 2012 documents if the Mantoux is not given during the admission process, the Charge Nurse/ Unit Manager must notify the Infection Control Practitioner, the Director of Nursing or designee. The facility's policy and procedure for [DIAGNOSES REDACTED] (TB) administration of Mantoux Test dated (MONTH) 2013 documents all new residents will be administered a 2-step Mantoux test upon admission if they have a previous history of a negative reaction to the PPD (a skin test to determine negative or positive reaction for past exposure to [DIAGNOSES REDACTED]). All residents who have a positive results will have a follow up chest x-ray done per the physicians (MD) order. It further documents to document the administration and to read the results 48 hours to 72 hours after the administration of the Mantoux serum and to document the results using millimeters (mm) of induration. (size of reaction). It further documents if the induration is more than 10 mm, do not repeat but notify the Medical Staff and Infection Control Practitioner. The Re-test Step-2 ( second part of the PPD testing id to be done within two weeks following the Step 1 procedure. If their is a refusal of the admission PPD, or tests are positive, notify the MD for chest x-ray orders. Resident # 109 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Elder's Immunization record documented the resident had a Flu and Pneumonia vaccine. There was no record of [DIAGNOSES REDACTED] testing. A physician order [REDACTED]. The Medication Administration Records for (MONTH) were reviewed and there was no record of a PPD being administered to the resident. Nursing noted for (MONTH) were reviewed and there was no documentation a PPD was done. During interview on 8/16/16 at 10:49 the Registered Nurse Manager (RNM) stated there was no PPD done for this Elder. She stated that standing orders are for PPD on admission so you don't have to get a specific order for the Elder. She said she looked at the MAR and there was no PPD. The RNM stated that they thought if an Elder transferred from a nursing home to a nursing home in a closed system they did not have to do a PPD. Resident # 144 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set of 8/8/16 assessed that the Elder was rarely understood, sometimes understands, and was severely cognitively impaired. A physician order [REDACTED]. The Elder's Immunization record documented the resident had refused the Flu and Pneumonia vaccine. A review of the MAR documented that a step 1 PPD had been given on 8/2/16. The MAR documented a reading of the PPD was to be done on 8/4/16. There was no documented evidence for the results of the reading of the [DIAGNOSES REDACTED] testing in the MAR, nursing progress notes, treatment record (TAR) or the immunization record. During interview on 8/15/16 at 12:20 PM the RNM stated that the Licensed Practical Nurse (LPN) administered the PPD as order and appropriately documented the site and administration. She stated that the RN has to do the reading of the results 48 to 72 hours after the PPD was done for the Elder. She stated that standing orders for PPD are to be done with admission unless the resident has a history of a positive PPD and then an X-ray is needed to rule out presence of [DIAGNOSES REDACTED]. She stated she was the person that was suppose to do the reading and stated she had done the reading and that the results had been negative. She was unable to provide any documented evidence that the reading had been done. The RNM was unable to state the date or time the reading of the PPD was done. Resident # 174 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set of 8/8/16 assessed that the Elder was understood and understands. It further documents the residents score for Brief Interview for Mental Status (BIMS) is 5/15. A physician order [REDACTED]. A physician order [REDACTED]. The Elder's Immunization record documented the resident had refused the Flu and Pneumonia vaccine. A review of the MAR documented that a Step 1 PPD had been given on 12/31/16 at 11:33 PM. The MAR documented a reading of the PPD was to be done on 1/3/16. A review of the MAR documented the Step 1 PPD was read on 1/2/16 at 6:14 PM. A nursing progress note dated 12/31/15 at 7:14 PM documented the elder refused placement of the PPD. A nursing progress note dated 1/01/16 at 01:16 AM documented the elder allowed placement of the PPD at 11:20 PM. During interview on 8/15/16 at 12:30 PM the RNM stated that the evening RN administered the Step 1 PPD as order on 12/31/15 at 11:23 PM after the Elder was reproached after refusing the PPD earlier. She stated that the RN has to do the reading of the PPD induration 48 to 72 hours after the PPD was administered to the Elder. She stated that standing orders instructions for PPD are to be done on admission unless the resident has a history of a positive PPD and then an X-ray is needed to rule out presence of [DIAGNOSES REDACTED]. She further stated this elder needed a Step 1 and Step 2 PPD. She stated another Registered Nurse (RN) on the evening shift was the person that did the reading and stated that she had done the reading and that the results had been negative. After the RNM reviewed the MAR she stated the PPD was read earlier than the mandatory 48 hours to 72 hours that is the mandatory time stated in the facility's TB policy. She stated that this could cause a false reading and would not be a reliable reading unless it was followed up with a another reading after a complete 48 hours to 72 hours had pasted. There was no further documented evidence of the Step 1 PPD repeat reading in the MAR, TAR, progress noted or immunization records after the first reading.

Plan of Correction: ApprovedSeptember 9, 2016

All admissions for the previous year have been reviewed for compliance, 94 admissions reviewed, 19 deceased , 56 compliant, 19 noncompliant. Those who did not meet current regulatory requirements were given one or two-step ppd, per current guidelines.
Responsible Party: Director of Nursing
Completion Date: (MONTH) 25, (YEAR)
Re-writing policy for ppd and creating a standard work instruction on how to create Ppd orders for administration and reading in Point Click Care.
Responsible Party: Assistant Director of Nursing
Completion Date: (MONTH) 13, (YEAR)
Re-Educate all licensed nursing staff to the Ppd policy
Responsible Party: Assistant Director of Nursing
Completion Date: (MONTH) 7, (YEAR)
Audit 100% of admissions for compliance within 30 days of admission, report to QAPI committee monthly for the next 3 months. Compliance goal 100%, if less than 100%, will continue to review 100% of admissions monthly until compliance is 100%.
Responsible Party: Assistant Director of Nursing

FF09 483.10(e), 483.75(l)(4):PERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS

REGULATION: The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. 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. Except as provided in paragraph (e)(3) of this section, the resident may approve or refuse the release of personal and clinical records to any individual outside the facility. The resident's right to refuse release of personal and clinical records does not apply when the resident is transferred to another health care institution; or record release is required by law. The facility must keep confidential all information contained in the resident's records, regardless of the form or storage methods, except when release is required by transfer to another healthcare institution; law; third party payment contract; or the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2016
Corrected date: October 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interviews during a recertification survey, the facility did not ensure that the resident has the right to personal privacy and confidentiality of his or her personal and clinical records. 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. Specifically: the facility did not ensure that a resident's change in medical condition was not discussed in front of another resident. This is evidenced by: Finding #1 During a medication pass administration on 8/11/16 at approximately 9:00 am Registered Nurse (RN) #1 was in room [ROOM NUMBER] with Resident #12 dispensing his medication when she answered a cell phone call. RN #1 discussed a decline in Resident #14's condition and the treatments administered up to that time with the person on the phone. The nurse did not excuse herself from Resident #12's room for this conversation. During an interview on 8/11/16 at 9:20 am RN #1 stated that she should not have discussed Resident #14 in front of Resident #12, that she should have stepped out of the room. During an interview on 8/11/16 at approximately 3:00 pm the Director of Nursing stated that the nurse should not have discussed Resident #14's medical condition in front of Resident #14. 10NYCRR 413.3(d)(1)(ii)

Plan of Correction: ApprovedSeptember 22, 2016

RN Counseling related to patient privacy and the importance of confidentiality.
Responsibility: Director of Nursing, 9/10/2016
Education/Self Learning Module on patient confidentiality for all licensed nurses.
Responsibility: Director of Nursing, 10/7/2016
Immediately after the inservice, a post-test will be administered, goal will be 90% or above for each student - re-reduction will be provided to anyone scoring below 90%. A random self-test will be distributed to 10 random licensed nursing staff 30 days after training with a goal of 90% of staff scoring 90% or higher. Anyone scoring below 90% will receive re-education. If target not met, monthly testing will continue until 90% at or above 90% is achieved. Results will be reported to the QAPI committee. Leadership Rounding in public areas to monitor for any incidents of disclosure of PHI will occur quarterly on an ongoing basis and be reported to the QAPI committee. Responsible Party: Administrator/Director of Nursing

FF09 483.75(l)(1):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2016
Corrected date: October 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during a recertification survey, the facility did not ensure that it maintained clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized for two Residents (#s 125, 158) of twenty-nine residents reviewed. Specifically: for Resident # 158 the facility did not ensure that the Medication Administration Record (MAR) accurately documented the instructions for giving [MEDICATION NAME] (a medication for dementia). For Resident# 125 there was lack of consistent documentation of the reason an as needed (PRN) pain medication was given. This is evidenced by: Resident #158 The resident was admitted to the nursing home on 2/11/11 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident usually understood and was usually understood by others. During a Medication Pass Administration on 10/11/16 at 10:30 am, LPN #3 dispensed an [MEDICATION NAME] 5 mg tablet into a medicine cup from a blister pack that documented [MEDICATION NAME] 5 mg give 1 tablet daily at bedtime along with 9 other medications to administer to the resident during the morning medication pass. The surveyor stopped LPN #3 and asked her to re-read the [MEDICATION NAME] order (documented give one tablet daily at bedtime) and blister pack. LPN #3 removed the [MEDICATION NAME] from the cup and left a note for the RN about the discrepancy between the administration time on the MAR and the instructions for administration. A Physician order [REDACTED]. A Physician order [REDACTED]. MAR for (MONTH) and (MONTH) of (YEAR) documented [MEDICATION NAME] tablet 5 mg give one tablet by mouth at bed time. The medication was scheduled to be administered at 9:00 am. There were signatures in the 9:00 am administration time daily from 7/1 - 8/10/16. During an interview on 8/11/16 at 10:35 am the Licensed Practical Nurse (LPN) #3 stated that she was not aware that the instruction said to give at bedtime and obviously did not look at it. Additionally LPN #3 stated that she looked at the medication dose and time but did not always look at the instructions for administration. During an interview on 8/16/16 at 1:30 pm the Registered Nurse Manager (RNM) #2 stated that on 5/6/16 the NP wrote and order to change the administration time for the [MEDICATION NAME] and that she changed the time in the computer but not the instructions. Additionally RNM #2 stated that she would like to think that someone would have gotten clarification on the order. During an interview on 8/16/16 at 2:30 pm the Director of Nursing (DON) stated that staff should have questioned the order and brought it to someone's attention so it could have been corrected. Resident # 125 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS of 7/22/16 assessed that the resident usually understands, was usually understood and had severe cognitive impairment. It further documented the resident had occasional moderate pain. The Comprehensive Care Plan for alteration in comfort dated 5/27/13 had interventions that included: monitor and document episodes of pain outside the timed pain medication administration; see pain management standard of care. The Pain Management Standard of Care documented: determine pain characteristics; medications as ordered and monitor for side effects and effectiveness; utilize pain rating scale. The facilities Pain Management Protocol dated 4/2011 documented under Procedure: # 5 collect data for pain location and intensity prior to each intervention (drug and non drug) and within 4-5 hours after. The facilities Pain Rating Scale dated 4/2011 documented: it is the policy of Eddy SNF's (Skilled Nursing Facilities) to utilize the Pain Rating Scale to determine a resident's level of pain. A physician order [REDACTED]. The Medication Administration Record (MAR) for (MONTH) (YEAR) documented the PRN [MEDICATION NAME] given 5 times. Two of the times there was documentation of where the pain was, three times there was not. All times documented effectiveness but no further descriptors or scale. The Medication Administration Record (MAR) for (MONTH) (YEAR) documented the PRN [MEDICATION NAME] given 5 times. One of the times there was documentation of where the pain was, three times there was not. Four times documented effectiveness but no further descriptors or scale. One of the times used the pain scale for before and after the medication. The Medication Administration Record (MAR) for (MONTH) (YEAR) documented the PRN [MEDICATION NAME] given 11 times. On four occasions a pain scale was used prior to prn pain medication administration. Two of the times the pain scale was used also had documentation where the pain was, two did not. Four of the times there was no documentation where the pain was. All times documented effectiveness but no further descriptors or scale was documented. During interview on 8/16/16 at 10:27 am the LPN who has given the PRN pain medication to the resident stated the Elder usually calls and asks for the PRN pain medication. The LPN asks her on the pain scale what the pain is and where. The LPN stated she documents the pain scale for the PRN. She stated the computer gives a screen with the scale. She looked at this Elder's MAR and said it did not have the pain scale programmed. She stated she did not perform the pain scale after but would document effective. During interview on 8/1`6/16 at 10:35 am the RNM stated the nurse should determine if an Elder is in pain, should use a scale. If the Elder is not verbal use other measures. The RNM stated she would document that. The RNM stated they don't do a scale after , just document effective or not effective, that is the way the computer is set up. 10NYCRR 415.22(a)(1-4)

Plan of Correction: ApprovedSeptember 22, 2016

The Frequency Code in Point Click Care was corrected. Please note the Administration time was consistent with the order.
Responsible Party: RN Nurse Manager
Completion Date: (MONTH) 11, (YEAR)
The eMAR of all residents in houses 19,21,22 and 24, (where the RN who made the error is assigned)will be reviewed for consistency between the administration time and the frequency code. A sample of 2 eMARs per house will be audited in all other houses - if an error is found, 100% of eMARS in that house will be audited.
Responsible Party: Director of Nursing
Completion Date: 9/16/2016
Re-education will be provided to all licensed nurses regarding order entry in Point Click Care.
Responsible Party: Director of Nursing
Completion Date: 10/7/2016
A random sample of 32 residents per quarter will be audited for eMAR accuracy for the next six months. Any errors will trigger a full audit of a house. Re-education and corrective action will be utilized as necessary.
Responsible Party: Director of Nursing
Regarding Resident 125, the opportunity for immediate correction is passed.
Education will be provided to all Licensed staff on the Pain management standard of care, use of the pain scale, and documentation expectations regarding location of pain, initial pain level, and effectiveness including follow up pain level as it relates to all PRN medications.
Responsible Party: Director of Nursing
Completion Date: (MONTH) 7, (YEAR)
An audit of PRN Pain medication will be completed for adherence to the standard of care including completeness of documentation for pain location and effectiveness. Five residents per week who received prn pain medication will be audited for eight weeks. Results will be communicated to staff, follow up education and corrective action will be utilized as needed. Results will be reported to the QAPI committee monthly. Further auditing will be focused on houses/residents/or nurses who are not showing compliance with the protocol.
Responsible Party: Director Nursing