Eastchester Rehabilitation and Health Care Center
May 26, 2017 Certification Survey

Standard Health Citations

FF10 483.10(a)(1):DIGNITY AND RESPECT OF INDIVIDUALITY

REGULATION: (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident?s individuality. The facility must protect and promote the rights of the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 26, 2017
Corrected date: July 24, 2017

Citation Details

Based on observation and interview, the facility did not ensure that residents were fed in a manner to enhance their dignity. Specifically, residents were fed while staff were standing over them. This was evident for 1 of 5 resident floors (4th floor). The finding is: On 5/24/17 from 12:39 PM to 12:55 PM, the 4th floor lunch was observed. Five staff members, consisting of 4 Certified Nursing Assistants (CNAs) and 1 Licensed Practical Nurse (LPN #2), were observed feeding residents while standing over them. One of the CNAs finished feeding one resident while standing and then began feeding another resident while standing. The Registered Nurse (RN) was observed trying to encourage a resident to eat by attempting to feed the resident while standing over them. On 5/24/17 at 3:18 PM, LPN#2 was interviewed and stated that she should be seated while feeding residents in order to be face to face with them. She stated that being seated enables staff to be at eye level so they can speak to the resident and see inside the resident's mouth. She further stated that she was standing because there were no stools left, and there were only 4 stools in the dining room. On 5/24/17 at 3:22 PM, the RN Unit Manager #1 was interviewed and stated that staff should be seated while feeding so that the resident can be made comfortable, making the meal more enjoyable. She further stated that with the number of staff present today, there were not enough stools available, but she normally encourages her staff to sit while feeding. The RN also stated that she was trying to encourage the resident to eat, and if the resident started accepting the food, she would have obtained a chair to sit in. On 5/25/17 at 1:10 PM, CNA #1 was interviewed and stated staff should sit and feed the residents, but yesterday there were not enough chairs in the dining room. She further stated that normally there are only 4 CNAs on the floor, but yesterday there were more people feeding. On 5/25/17 at 1:17 PM, CNA #2 was interviewed and stated that she is a rehab aide, but she comes to the floors during meals to assist with feeding. She further stated that she should sit while feeding so that she can make eye contact and interact with the resident. She stated that being seated also makes it easier to wipe the residents face as needed and have a better view of the resident so that any concerns, such as choking, can be identified. 415.5(a)

Plan of Correction: ApprovedJune 19, 2017

1. Immediate corrective action
a) LPN#2, CNA#1, and CNA#2 were counseled on dignity and respect of individuality as it pertains to assisting residents with feeding.
b) The food service director audited the building to ensure there are enough stools, any units missing stools will be made full.
c) This audit was completed by (MONTH) 31, (YEAR).
2. Identification of other residents:
a. All residents who require assistance while eating have the potential to be affected. A review of all units throughout the facility was conducted and no other issues were identified.
b. This was completed by (MONTH) 31, (YEAR).
3. Systemic Changes:
a) The Administrator/ DNS/Designee will ensure there are chairs available for the staff in the dining room for staff to sit during mealtimes.
b) The nursing staff was inserviced on dignity and respect of individuality as it pertains to assistance with eating to ensure that all residents who require assistance in eating are fed in a manner that enhances their dignity. Lesson plan and attendance sheets will be kept on record for validation
c) This audit will be completed by (MONTH) 30, (YEAR).
4. Quality Assurance
a) An audit tool was created to monitor meals to ensure dignity and respect of individuality for residents who require assistance with eating. The Administrator/ Director of Nursing/Designee will audit on a weekly basis x 4 weeks, than monthly x 3, and quarterly thereafter. Audits with negative findings will have immediate corrective action
b) Audit results will be presented to the QI/QM committee quarterly for review to ensure compliance.
c) The Administrator/ Designee will be responsible to for the compliance of this issue by (MONTH) 24, (YEAR) and ongoing.

FF10 483.45(b)(2)(3)(g)(h):DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

REGULATION: The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-- (2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. 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. (h) Storage of Drugs and Biologicals. (1) 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. (2) 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: May 26, 2017
Corrected date: July 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews during the Recertification survey, the facility did not ensure that all drugs were labeled in accordance with currently accepted professional principles, including the expiration date when applicable. This was identified during the Medication Storage Task review on the 4th floor. Specifically, There was a vial of Humalog that was opened and dated but had expired past the 28 days. This was evident for 1 of 5 of medication storage units inspected. The finding is: During an observation on [DATE] at 7:45AM on the 4th floor, in the medication refrigerator contained 1 vial of Humalog labeled ,[DATE] and the date of the survey was ,[DATE], 36 days had passed since the vial has been opened. On [DATE] immediately after observing the expired vial, the Licensed Practical Nurse (LPN) was interviewed and the LPN stated I believe Humalog can be discarded 42 days after being opened. The LPN further stated that there should be a list of all medications and only nursing has the list and it is only for the regular nursing staff. Then he stated was a regular staff member of the facility. On [DATE] at 2:06 PM the Registered Nurse Manager (RN) on the 4th floor was interviewed and the RN stated that all opened insulin needs to be discarded after 28 days. There is no official list in the nursing Department. Also, any nurse can reorder the medication so it is the responsibility of any nurse that sees the vial has expired to discard after the 28 days and re-order the new insulin. The manufacturer of Humalog Insulin documents that recommended use of (opened) Humalog vials and the Humalog KwikPen insulin must be dated when opened and discarded after 28 days, even of the vials still contain the medicine. 415.18 (d)

Plan of Correction: ApprovedJune 19, 2017

I. Immediate corrective action
a) There was no resident identified to be affected by this deficient practice.
b) The LPN on the 4th floor was counseled on proper labeling and storage of drugs and biologicals specifically that Humalog must be discarded 28 days after being opened.
c) This was completed by (MONTH) 26, (YEAR).
II. Identification of other residents
a) The facility respectfully acknowledges that residents could be affected by this issue especially if receiving Humalog.
b) An audit of all units throughout the facility was conducted to identify any opened medication past 28 days and no other expired medication was identified.
c) This was completed by (MONTH) 29, (YEAR).
III. Systemic changes
a) The Policy and Procedure on Storage of Opened Multidose Vials? was reviewed and revised by the DNS and the Administrator.
b) The facility inserviced all nurses on proper labeling and storage of drugs and biologicals with an emphasis on Humalog being discarded after 28 days from opening.
c) This will be completed by (MONTH) 30, (YEAR).
IV. Quality Assurance
a. An audit tool was created by the DNS to monitor all refrigerated medication for compliance with proper labeling, storage of drugs and date started to calculate medication?s date to be discarded. The Director of Nursing/designee will audit all medication weekly x 4 weeks, then monthly for 3 months and quarterly thereafter.
b. Any negative findings will be reported to the Administrator for immediate corrective action.
c. Audit results will be presented to the QI/QM committee quarterly for review to ensure compliance and follow up as indicated. The outcome of this audit will be quantified and reported to the QI/QM Committee by the DNS.
d. The DNS will be responsible for the compliance of this issue by (MONTH) 24, (YEAR)
and ongoing.

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: May 26, 2017
Corrected date: July 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility did not ensure that the facility prepared food under sanitary conditions. Specifically, Dietary and Kitchen staff were observed during multiple observations preparing food while not properly wearing hair restraints such as hair and beard nets. The findings are: 1) On 05/24/2017 at 11:26 AM during the observational tour of the facility's kitchen Dietary staff were observed not properly wearing hair restraints or beard nets while preparing food. Dietary #8 was observed preparing had hair on his chin about 1/2 inch long, without a beard net, preparing coleslaw. During that same time the Cook who was chopping vegetables for soup was observed with a beard approximately ½ inch of hair on his chin. The Cook did not have on a beard net. The Assistant Food Supervisor (AFS) was observed assisting with the tray line - handling cold items. The AFS was wearing a hairnet. However it was not properly covering her hair as hair from both sides were sticking out from the hairnet. Dietary Aide #6 was observed preparing eggs for sandwiches. She was wearing a hairnet. However, the hairnet did not properly cover her hair, as her hair was sticking out from the sides of the hairnet. 2) On 05/25/2017 at 10:19 AM during a second observational tour of the facility's kitchen the Cook was observed preparing vegetables and did not have a beard net covering his beard. On 05/26/2017 at 9:30AM an interview was conducted with the Food Service Manager (FSM). FSM stated that men should have clean-shaven moustache and the female Dietary Aides (DA) must have their hair fully covered as soon as they enter the kitchen. FSM further stated that Staff must wear the hairnet at the hairline to secure loose hair. FSM stated that a Staff In-service training regarding the use of hair restraints/hairnets is done once a month. FSM added that if any Dietary Aide is not in compliance, the Dietary Aide will be disciplined. A copy of the policy and procedure for the use of hairnet/beard net was provided. Assistant Food Supervisor (AFS) was not interviewed since AFS was off on 5/26/2017 On 05/26/2017 at 11:09 AM The Cook was interviewed and said he forgot to wear the beard net during entrance and on the second day. He worked at the facility for [AGE] years now. The facility policy documents that men must be clean shaven. A small trimmed mustache is permitted . Hair must be pulled away from face and secured. Hairnets must be worn to secure all loose hair. 415.14(h)

Plan of Correction: ApprovedJune 19, 2017

I. Immediate corrective action
a) Dietary aide #8, Cook, and Dietary aide #6 were counseled on preparing food in a sanitary and professional manner, specifically on the importance of wearing hair restraints.
II. Identification of other residents
a) All residents have the potential to be affected by this deficient practice.
b) The Food Service Director and the Administrator developed an audit to assure that staff was wearing hair restraints while in the kitchen area. This audit and immediately conducted and no other issues were identified.
c) This audit was completed by (MONTH) 31, (YEAR).
III. Systemic changes
a) The Policy and Procedure on Uniform/ Personal Hygiene was reviewed and found to be compliant. The Dietary and Food Service staff were all inserviced on preparing food in a sanitary and professional manner specifically on wearing proper hair/beard restraints/nets. This was completed on (MONTH) 26, (YEAR).
b) Lesson plan and attendance logs will be kept on record for validation
c) Signs were posted at all entrances to the kitchen regarding ?hair nets must be worn past this point? holders with hair nets were also put up at all entrances to the kitchen. This was completed by (MONTH) 31, (YEAR)
IV. Quality assurance
a) An audit tool was created to monitor the use of hair and beard nets in the kitchen to ensure that food in the kitchen in prepared in a sanitary and professional manner. Food Service director /designee will audit weekly x 4 weeks, then monthly for 3 months, and quarterly thereafter.
b) Any negative findings will be reported to the Administrator for immediate corrective action.
c) Audit results will be presented to the QI/QM committee quarterly for review to ensure compliance and follow up as indicated. The outcome of this audit will be quantified and reported to the QI/QM Committee by the Food Service Director.
d) The Food Service Director will be responsible for the compliance of this issue
by (MONTH) 24, (YEAR) and ongoing.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 26, 2017
Corrected date: July 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews and record review the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were provided to meet the needs of each resident. Specifically, Resident #24 did not receive her scheduled medication for two days because the medication was not in stock. The procedure for dispensing medication to the facility was not followed, resulting in dispensed medication not being received by the facility from the pharmacy in a timely manner. As a result, the facility did not have medication available. This was evident for one (1) resident out of 6 residents reviewed for Unnecessary Medication out of a sample of 31 residents. (Resident # 24). The finding is: Resident # 24 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 05/22/17 at 9:45 AM resident # 24 informed the SA that she is still waiting to receive her medication since yesterday Sunday (05/21/17). She stated that she is been told repeated that this past weekend that pharmacy has not delivered it because they are located in New Jersey. She stated that the nurses also have told her that pharmacy will deliver it on the next delivery but it never came. The resident stated that this medication helps her with her hand spasms and pain. The physician order dated 05/50/17 documented medications including, carbamazepine (Tegretol) 200 milligrams twice a day 9:00 am and 5:00 pm for muscle spasms Review of the Medication Administration Record [REDACTED]. Reason: 05/21/17 9:00 am pharmacy called. to dispense on next run. On 05/21/17 at 5:00 pm not administered. Awaiting delivery. PMD (primary medical doctor) aware. On 05/22/17 at 9:00 am not administered. Awaiting delivery PMD aware. Review of the MAR for 05/22/17 timed at 11:45 am documented Carbamezepine 200 mg by mouth was administered. Review of Nursing Progress notes from 05/19/17 - 05/21/17 found no documented evidence that medication was unavailable. Review of the nurse progress note dated 05/22/17 documented, did not get her medication for [DIAGNOSES REDACTED] .resident in no acute distress .no complaint of pain .wants her medication before going to therapy . On 05/22/17 at 11:40 am the SA observed a ten (10) day supply of carbamazepine 200 mg by mouth given twice a day was delivered and received by the unit nurse manager who then signed the packing slip. On 05/22/17 at 11:45 am the resident received her medication. RN #1 was interviewed on 05/22/17 at 10:30 AM. RN #1 is the Nurse Manager for the 1st floor. RN #1 stated that she was just informed this morning that an issue of medication for this resident had occurred over the weekend. She stated that she spoke to the medical doctor and called the pharmacy to request a stat (immediate) delivery of this medication. She stated that she was told by the pharmacy that a delivery for this medication had been made on (MONTH) 5th. RN #1 stated that she looked in on the resident who expressed that she needed her medication before going to therapy today. RN #1 stated that the resident did not tell her that she was in any pain. RN #1 further stated that the nurses are to report medication issues to the supervisor and that the doctor should be made aware. She stated that this is not a typical pain medication and therefore no pain scale is used. She stated that the resident is asked daily if she is in pain and that it is documented in the daily notes. She stated that medications are to be reordered at least three days prior to the resident running out. Nurses can call or use the computer to reorder. She stated that it is important that nurses report when medications are unavailable, and other pharmacy issues. She stated failure to do so has the potential to affect scheduled medication administration times and treatment schedules. LPN #2 (Licensed Practical Nurse) was Interviewed on 05/23/17 at 9:30 AM. LPN#2 was on duty on Friday 05/19/17 during the day shift. LPN #2 stated that she called the pharmacy during the afternoon on 05/19/17 to reorder the Carbamezepine because the resident had only three pills remaining. The Pharmacy informed her that a thirty (30) day supply was sent on (MONTH) 5, (YEAR). The Pharmacy staff told her that they would get back to her because they would have to be reimbursed. LPN #2 stated that when issues of medication arise, or when there is a pharmacy issue she is to notify her supervisor. She stated that she did not do this. LPN #2 stated that she did not report this to the oncoming shift. She stated that the resident had enough medication for Friday 05/19/17 and Saturday 05/20/17. LPN #3 was interviewed on 05/23/17 at 11:15 AM. LPN #3 was on duty during the day shift on Saturday 05/20/17. LPN #3 stated that medications are to be reordered five to seven days before the resident is out of medication. She stated that she called the pharmacy, but not about this medication. She stated that she recalls the there were enough medications in the blister pack. LPN #4 was interviewed on 05/24/17 at 9:42 AM. LPN #4 was on duty during the evening shift on Saturday 05/20/17. LPN #4 stated that she called the pharmacy about the need for the above medication and was told that a delivery would be made in the evening. LPN #4 did not report to the supervisor that the resident had run out of the Carbamezepine. LPN #5 was Interviewed on 05/24/17 at 11:15 AM. LPN #5 was on duty during the day shift on Sunday 05/21/17. LPN #5 stated that the pharmacy did not deliver the medication Carbamezepine. LPN #5 stated that she was told to expect a delivery and none was made. She stated that she called the pharmacy in the afternoon and was told that the facility would be billed and that a delivery would be made in the evening. She stated that she informed the resident that her medication would be delivered in the afternoon. She stated that the resident was ok and did not complain of being in pain. She denied that the resident rang the call bell frequently to request her medication. She stated that she checked in frequently to reassure her that her medication would be delivered. The LPN stated that she did not report this issue to her supervisor, or the physician. She stated that she informed the nursing staff on the incoming evening shift to expect the delivery of the Carbamezepine. LPN #6 was Interviewed on 05/24/17 at 3:35 PM. LPN #6 was on duty during the evening shift on Sunday 05/21/17. LPN #6 stated that she was informed by the day shift nurse that the resident did not receive her 9:00 AM medication Carbamezepine and to expect a pharmacy delivery in the evening. She stated that she checked in with the resident often because she was worried that the resident did not receive her medication. She stated that the resident looked uncomfortable and that the resident told her that she was having tingling and spasms and might have been in pain. She stated that she called the pharmacy and was told that a midnight delivery would be made. LPN #6 stated that she did not follow up with her supervisor and that the doctor was not notified. She stated that she informed the oncoming night shift to expect a delivery of the residents medication. Interview with the medical doctor on 05/23/17 at 1:50 pm and stated that he is the treating physician since the residents admission. He stated that the resident has a disease that manifests itself with spasms which affect her entire body particular her bladder, her hands and her spinal cord. I have seen her a few times to listen to her lungs, take her pulse and ask her, how are you doing?. She has not mentioned that she has pain. I have not asked her if she is experiencing pain. I expect patients to tell me if they are having pain. I did not associate her having pain with her spasms and was not mentioned to me. I was not previously made aware that she did not get her medication all day Sunday and part of Monday. I was made aware of this today by the nurse manager. I visited her today Monday afternoon, once she received her medication and she told her hands felt tingly,. I expect that when a problem with medication come up that I am made so that I can reorder something else. Interview on 05/24/17 at 12:30 pm with the pharmacy customer service personnel stated that she refills MEDICATION ORDERS FOR [REDACTED]. The first order was requested and received on 04/07/17 with delivery made on 04/08/17 for 30 days. On 05/03/17 60 pills (30 day supply) was delivered as a request was placed by phone for the same medication. When asked for proof of delivery none was available. She stated that no receipt is available for proof of this delivery / transaction. She stated that outside vendor called wellness express is contracted out to make deliveries. She stated that a call was received on 05/05/17 by a nurse saying that the medication was not available. We re-sent a 30 day supply. When asked for proof of this delivery none was available. She stated that the driver is to scan the bar code on the packing slip. She stated that the driver carries a small device that scans the bar code and that this may have not been done by the driver. She stated that a ten day supply was sent on Monday 05/22/17. Proof of this delivery was provided. On 05/24/17 at 12:30 pm the pharmacy customer service agent was interviewed. She was stated that she refills MEDICATION ORDERS FOR [REDACTED]. The first order was requested and received on 04/07/17 with delivery made on 04/08/17 for 30 days. On 05/03/17 60 pills (30 day supply) was delivered as a request was placed by phone for the same medication. When asked for proof of delivery none was available. She stated that no receipt is available for proof of this delivery / transaction. She stated that outside vendor is contracted out to make deliveries. She stated that a call was received on 05/05/17 by a nurse saying that the medication was not available. We re-sent a 30 day supply. When asked for proof of this delivery none was available. She stated that the driver is to scan the bar code on the packing slip. She stated that the driver carries a small device that scans the bar code and that this may have not been done by the driver. She stated that a ten day supply was sent on Monday 05/22/17. Proof of this deilvery was provided. On 05/24/17 at 12:50 PM the QA person for Specialty Pharmacy was interviewed. It was stated that a outside vendor picks up meds, from pharmacy located in New Jersey and delivers them. The delivery person carries a device that scans the bar code on the packing slip. The devices are important because this is data that is collected and imported into the pharmacy system for proof of delivery. We have had this problem before with the devices in the past and we contact the vendor company to address the problem. The pharmacy contract states that the facility has a designated window of time of 24 hours to report delivery discrepancies and the pharmacy will resend those meds at no cost to the facility. The issue seems to be that the driver is not scanning delivery receipts. It is up to pharmacy to review this information and determine of we want to continue to do business with the vendor. This seems to be an ongoing problem with the driver and has been known to us. It is up to pharmacy as to how they want to handle this. The delivery person is to scan the receipt that is attached to the med bag and signed by the receiving nurse. Interview with the Director of Nurse on 05/24/17 at 3:10 pm stated that her staff are to report any medication issues to the nurse managers especially if they are being told by pharmacy if a delivery has already been made. The nurses are to order once a resident has a least a three day supply left. They have been inservices on how to do this on sigma. The doctor is to be made aware immediately if a resident is not getting there prescribed medication. This way the doctor can do something else or order something else. Also the nurse are to be monitoring and documenting the status of the resident in the meanwhile. Reporting and communicating to oncoming shifts is important and keeps everyone aware of what to anticipate. Review of the facility policy for unavailable medications' documented, it is the policy that each individual receive the necessary medication as ordered by the Primary Medical Doctor (PMD) .when medications are not available, the PMD will be notified who will adjust medication regime accordingly .nurse must notify supervisor nurse must notify Pharmacy nurse document in the progress note that the medication is unavailable and that the PMD is notified .the supervisor is responsible for contacting the pharmacy if any problems regarding delivery .the nurse must document on 24 hour report sheet . Review of Specialty Pharmacy contract dated (MONTH) (YEAR) documented, .Provide products in a prompt and timely manner .collaborate with the facility to coordinate pharmacy documentation processes . 415.18(a) .

Plan of Correction: ApprovedJune 19, 2017

I. Immediate corrective action:
a) Resident # 24 was evaluated and assessed for pain by the RN and Physician on (MONTH) 24, (YEAR). No changes were made to the residents? medication regimen at this time.
b) All nurses were inserviced on proper procedure for unavailable medications, proper notification of Nursing Supervisors for unavailable medications, proper endorsement of medications requested for re-fill.
c) Lesson Plan and attendance will be maintained for validation.
II. Identification of other residents
a) The facility respectfully acknowledges that all residents could be affected by this issues.
b) The DNS/ADNS reviewed all residents who receive pain medication to assure that the medication was available and that pain assessments were done.
c) This will be completed by (MONTH) 23, (YEAR)
III. Systemic Changes was reviewed and revised by the administrator and DNS
a) The Policy and Procedure for ?Unavailable Medication? was reviewed and revised by the administrator and DNS
b) The unit nurses will log all re-ordered medications, all communication with the pharmacy, all notification to Nurse Manager/ Supervisor for follow-up and review.
c) This will be completed by (MONTH) 30, (YEAR)
IV. Quality Assurance
a) The log will be reviewed every shift by the Nurse Manager/ Supervisor on an ongoing basis.
b) Any negative finding will be reported to the DNS for immediate correction.
c) Audit results will be presented to the QI/QM committee quarterly for review to ensure compliance and follow up as indicated. The outcome of this audit will be quantified and reported to the QI/QM Committee by the DNS.
d) The DNS will be responsible for the compliance of this issue by (MONTH) 24, (YEAR) and ongoing.

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: May 26, 2017
Corrected date: July 24, 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 that necessary care and services were provided to maintain the residents highest practical physical mental and psychological well being. Specifically, resident # 24 was not assessed for pain when her medication became unavailable. This was evident for one (1) resident out of 2 reviewed for Pain Management. (Resident # 24). The finding is: Resident # 24 was admitted on [DATE]. The medical record documented the following diagnoses; included, disease of the spinal cord; muscle spasms; general muscle weakness and neuro[DIAGNOSES REDACTED] optica ( inflammation and demyelination optic nerve and spinal cord, also known as NMO), chronic pain. On 05/22/17 at 9:45 am resident # 24 informed the SA (State Surveyor) that she had been waiting waiting to receive her [MEDICATION NAME] medication since Sunday (05/21/17). She stated that she had repeatedly been told that the pharmacy has not delivered the medication because they are located out of state. She stated that the nurses also have told her that pharmacy will deliver it on the next delivery but it never came. The resident stated that this medication helps her with her hand spasms and pain. The resident stated that she also receives [MEDICATION NAME] for her spasms, but that the carbamezapine which is the [MEDICATION NAME] medication provides her with the greatest relief from pain and discomfort due to the spasms in her hand, back and feet. She stated that she has been on this medication since her discharge from the hospital, approximately three (3) months. The resident was observed sitting in her wheelchair, beside her bed with tightened facial muscles and grimacing. Her hands were in front of her and appeared rigid, partially closed hands appeared stiff and fingers slightly curled. The resident was presenting with fast jerky hand movements as she spoke. She stated that when she does not get this medication she feels an increase in pain and tingling to her hands, feet and back. She stated that her hands begin to feel tingling, her hands curl, and become rigid and then has uncoordinated or jerky hand movements. She stated that when she does not get her medication she feels pain and increase tingling of her hands. She stated that she finds it hard to open her hands and feels discomfort and pain. She stated that she finds it hard to brush her teeth, and comb her hair. She stated that she does not want to create a problem but that she needs to have this medication before therapy as this allows her to participate in her treatments which require strength and endurance. Review of the Minimum Data Set ((MDS) dated [DATE] documented clear speech, understood, understand, brief interview of mental status score of 15 out of 15, who requires extensive staff assist for activities of daily living needs. Pain assessment interview documented pain frequency occasionally, verbal indicator mild. Should the Staff assessment for pain be conducted, no. Review of the Comprehensive Care Plan (CCP) for Pain, dated 04/10/17 documented, avoid activities that aggravate or exacerbate pain, resident on pain medication, updated 05/22/17 to include: re-assessed the resident for pain due to missing one day of [MEDICATION NAME]. Review of the Nursing Progress Notes dated 05/21/17 and 05/22/17 documented, no pain. On 05/23/17 at 11:35 am the resident was observed during physical therapy. The resident was observed on a stationary bike using her upper body arms hands legs and feet. Her facial muscles were relaxed and she was smiling. The resident was later interviewed and stated that she received her medication close to 12:00 PM on 05/22/17. She stated that she was not able to go to therapy on this day because her muscles were rigid, hands were curled, her pain level felt like ten (10). The resident stated that on Sunday 05/21/17 kept on ringing the bell to ask about her medication and was repeatedly told by the nurses that pharmacy had not delivered it. She stated that she was not asked if she was in pain and she told the staff that she was. She stated that when she gets her medication her pain level decreases to one (1) or two (2). She stated that she did not go to therapy on Monday 05/22/17 because this requires strength and endurance on her part to use some kind of clay with her hands to treat the spasms she get to her fingers. She stated that this treatment helps with her hand stiffness and helps her to open her hands. She stated that her condition is a form of [MEDICAL CONDITION] and inflammation in her spine. She stated that she was getting spasms to her hands and fingers about fifteen (15) times a day which would last about ten (10) to fifteen (15) seconds. She stated that the spasms include pain. The spasms come on a a tingling sensation. The medication has made me feel so much better and given my quality of life, a reduction in tightness and curling of my hands and toes. As soon as I received the medication I feel better, my muscle are more relaxed. On Sunday 05/21/17 I kept ringing the call bell and was told the medication would be here by 9:00 am then told by 4 or 5 PM then the shift changed. Then I was told that it would be here by midnight. Meanwhile my pain is eight or nine and I feel my muscle tighten and I am in tears. She stated that she told the staff that she was in pain and needed her medication. On Monday 05/22/17 I told the nurse that I wanted to go home. She stated that the therapist came to on Monday to bring her to therapy and I told her that I could not go because I was in pain and that I did not get my medication on Sunday and on Monday as scheduled. She stated that she finally received her medication on Monday 05/22/17 close to 12:00 PM. She stated that she is not asked about pain and that the doctor came in to see her on Monday in the afternoon after she got her medication. He listened to my chest, my blood pressure and asked how I was doing. I told him that the tingling in my hands was subsiding and that I felt cramps to my hands. He did not ask about pain and I offered none. His visits are only a few seconds long. Review of the Medical assessment dated [DATE] documented, no arthralgia, myalagia. .general body spasms .responding to [MEDICATION NAME]. Review of Physician interim note dated 05/22/17 documented, .history of body spasms .who apparently did not receive carbamezepine yesterday. Patiient claims she had minor cramps to her fingers last night .no severe spasms. The physician orders for medication date 05/50/17 documented the following: [MEDICATION NAME] 200 milligrams twice a day at 9:00 AM and 5:00 PM for muscle spasms Review of the Medication Administration Record [REDACTED]. Reason: 05/21/17 9:00 am pharmacy called. to dispense on next run. On 05/21/17 at 5:00 PM not administered. Awaiting delivery. PMD (primary medical doctor) aware. On 05/22/17 at 9:00 am not administered. Awaiting delivery PMD aware. The Medication Administration Record [REDACTED]. Review of Nursing Progress notes from 05/19/17 - 05/21/17 found no documented evidence that medication was unavailable. There was no documented evidence of ongoing assessment due to the resident not receiving her medication as it related specifically to her condition and [DIAGNOSES REDACTED]. LPN #2 (Licensed Practical Nurse) was Interviewed on 05/23/17 at 9:30 AM. LPN#2 was on duty on Friday 05/19/17during the day shift. LPN #2 stated that she called the pharmacy during the afternoon on 05/19/17 to reorder the Carbamezepine because the resident had only three pills remaining. The Pharmacy informed her that a thirty (30) day supply was sent on (MONTH) 5, (YEAR). The Pharmacy staff told her that they would get back to her because they would have to be reimbursed. LPN #2 stated that when issues of medication arise, or when there is a pharmacy issue she is to notify her supervisor. She stated that she did not do this. LPN #2 stated that she did not report this to the oncoming shift. She stated that the resident had enough medication for Friday 05/19/17 and Saturday 05/20/17. LPN #3 was interviewed on 05/23/17 at 11:15 AM. LPN #3 was on duty during the day shift on Saturday 05/20/17. LPN #3 stated that medications are to be reordered five to seven days before the resident is out of medication. She stated that she called the pharmacy, but not about this medication. She stated that she recalls the there were enough medications in the blister pack. LPN #4 was interviewed on 05/24/17 at 9:42 AM. LPN #4 was on duty during the evening shift on Saturday 05/20/17. LPN #4 stated that she called the pharmacy about the need for the above medication and was told that a delivery would be made in the evening. LPN #4 did not report to the supervisor that the resident had run out of the carbamezapine. LPN #5 was Interviewed on 05/24/17 at 11:15 AM. LPN #5 was on duty during the day shift on Sunday 05/21/17. LPN #5 stated that the pharmacy did not deliver the medication carbamazapine. LPN #5 stated that she was told to expect a delivery and none was made. She stated that she called the pharmacy in the afternoon and was told that the facility would be billed and that a delivery would be made in the evening. She stated that she informed the resident that her medication would be delivered in the afternoon. She stated that the resident was ok and did not complain of being in pain. She denied that the resident rang the call bell frequently to request her medication. She stated that she checked in frequently to reassure her that her medication would be delivered. The LPN stated that she did not report this issue to her supervisor, or the physician. She stated that she informed the nursing staff on the incoming evening shift to expect the delivery of the carbamezapine. LPN #6 was Interviewed on 05/24/17 at 3:35 PM. LPN #6 was on duty during the evening shift on Sunday 05/21/17. LPN #6 stated that she was informed by the day shift nurse that the resident did not receive her 9:00 AM medication carbamezapine and to expect a pharmacy delivery in the evening. She stated that she checked in with the resident often because she was worried that the resident did not receive her medication. She stated that the resident looked uncomfortable and that the resident told her that she was having tingling and spasms and might have been in pain. She stated that she called the pharmacy and was told that a midnight delivery would be made. LPN #6 stated that she did not follow up with her supervisor and that the doctor was not notified. She stated that she informed the oncoming night shift to expect a delivery of the residents medication. RN #1 was interviewed on 05/22/17 at 10:30 AM. RN #1 is the Nurse Manager for the 1st floor. RN #1 stated that she was just informed this morning that an issue of medication for this resident had occurred over the weekend. She stated that she spoke to the medical doctor and called the pharmacy to request a stat (immediate) delivery of this medication. She stated that she was told by the pharmacy that a delivery for this medication had been made on (MONTH) 5th. RN #1 stated that she looked in on the resident who expressed that she needed her medication before going to therapy today. RN #1 stated that the resident did not tell her that she was in any pain. RN #1 further stated that the nurses are to report medication issues to the supervisor and that the doctor should be made aware. She stated that this is not a typical pain medication and therefore no pain scale is used. She stated that the resident is asked daily if she is in pain and that it is documented in the daily notes. She stated that medications are to be reordered at least three days prior to the resident running out. Nurses can call or use the computer to reorder. She stated that it is important that nurses report when medications are unavailable, and other pharmacy issues. She stated failure to do so has the potential to affect scheduled medication administration times and treatment schedules. The nurse progress note dated 05/22/17 and timed at 5:51 PM documented: that the writer of the note met with the resident at 9:00 AM to discuss medications. Resident verbalized that she did not receive [MEDICATION NAME] on 5/21/17. The writer documented that the resident was not in any acute distress and did not complaint of any pain. The note also documented the receipt of the carbaamazepine On 05/22/17 at 11:40 AM the SA observed a ten (10) day supply of [MEDICATION NAME] 200 mg by mouth given twice a day was delivered and received by the unit nurse manager who then signed the packing slip. On 05/22/17 at 11:45 am the resident received her medication. The Occupational Therapy note dated 05/22/17 and timed at 2:39 PM documented that tthe OT went to see the resident at 9:00 AM and observed the resident agitatied. The resident reported that she had not received her medication since Sunday and notified nurse manager. The OT wrote that they saw the resident again at 11:30 AM no treatment was provided. The OT wrote that they visited with the resident again at 1:30 PM, the resident reported that she was feeling better. Bedside therapy was provided. Interview with the Occupational therapist (OT) on 05/24/17 at 10:25 am stated that the resident has [MEDICATION NAME] [DIAGNOSES REDACTED] which is an infection in the spine and this decreases her coordination. She stated that she went to pick up the resident on Monday 05/22/17 between 9: 00 and 9: 30 am and observed the resident sitting in her wheelchair in her room and appeared agitated. She noticed that her hands were rigid and slightly closed and uncoordinated finger and hand movements. I asked her what was wrong and she said that she did not receive her medications for her spasms on Sunday and when I saw her she had not received her medications at this time. She looked upset and very uncomfortable. She stated that she was in pain. The OT stated that she went to the nurse manager and asked why her med's were not given and she told her she would get back to me. The resident refused therapy at this time because she was in pain. I informed the nurse manager that therapy could not take place at this time because the resident was in pain. She said she returned at 11:30 am to see the resident and the resident had not received her medication yet. She was very upset and stated that she wanted to go home. The resident stated that she was in pain and uncomfortable. She was having uncoordinated movements of the fingers still with rigidity. She observed her getting her medication at 11:45 am when the nurse came in. She said sheI returned at 1:30 PM and she looked much better, her hands were less rigid and she was calmer and not as upset. She was no longer having uncoordinated movements. She said she chose not to perform any rigid exercise because she had just gotten her medication and some of our exercises include use of stationary bike while standing, a pulley, progressive exercise that require a lot of strength. She said she used her professional judgment and chose to perform therapeutic exercise at bedside. The resident was agreeable to this and stated that she had tingling in her hands. No rigidity is involved at bedside I did light therapeutic exercise. She was given 2 pound weight versus 4 pound weights which she normally uses. She did a 30 minute session. She said she reported this to her supervisor and documented in her notes. The Physical Therapist note dated 5/22/17 documented that the resident was seen at the bedside for physical therapy. The resident reported having muscle spasms in arms and legs and difficulty to participate with funcitional mobility especially abmulation. Resident performed assisted active range of motion in both lower extremities and positioning along with safety education and pacing and energy conservation techniques. Interview with Physical therapist (PT) on 05/24/17 at 11:30 am and stated that he went to see the resident at 3:00 PM on 05/22/17 and she told him that she was not feeling well. The PT said he saw her in the morning and she was not her usual self. When she is on the unit we do progressive exercise and use 3 pound weights. She was not in good condition this day to do exercise. She would need 100 % focus and on Monday she was not able to concentrate. Not having her medications affected her treatment and her ability to focus on her therapy. Interview at 9:20 am on 05/24/17 with the assigned day shift Certified Nurse Aide (CNA) on duty on 05/21/17 and on 05/22/17 stated that on 05/21/17 she went to perform morning (am) care. She stated that the resident needs extensive assistance and is transferred out of bed with one person into a wheelchair. She stated that the resident likes to get of of bed early as this is her routine and enjoys her therapy. The CNA stated that the resident told her she did not want to be touched and that she had not gotten her medication. The CNA stated that is was not the residents usual manner. She did not want me to touch her. She stated that this was unusual for her to refuse am care. She stated that later on during the day the resident allowed her to help her out of bed. She stated that on Monday 05/22/17 she cared for the resident and that she seemed fine. CNA #1 was interviewed on 05/22/17. CNA # was on duty during the evening shift. She stated that the resident was not crying or complaining and found nothing unusual about the resident. She stated that she provided PM care did not notice anything the matter with the resident. The MD (Medical Doctor) was interviewed on 05/23/17 at 1:50 PM. The MD stated that he is the treating physican since the resident's admission. He stated that the resident has a disease that manifests itself with spasms which affect her entire body particular her bladder, her hands and her spinal cord. The MD stated that he has seen her a few times to listen to her lungs, take her pulse and ask her, how are you doing?. The MD denied that the resident has complained of pain during his visits. However, the MD also stated that he has not asked her if she is experiencing pain. The MD stated that he expects patients to tell me if they are having pain. I did not associate her having pain with her spasms and was not mentioned to me. I was not previously made aware that she did not get her medication all day Sunday and part of Monday. I was made aware of this today by the nurse manager. I visited her today Monday afternoon, once she received her medication and she told her hands felt tingly,. I expect that when a problem with medication come up that I am made so that I can reorder something else. Interview at 9:20 am on 05/24/17 with the assigned day shift Certified Nurse Aide (CNA) on duty on 05/21/17 and on 05/22/17 stated that on 05/21/17 she went to perform morning (am) care. She stated that the resident needs extensive assistance and is transferred out of bed with one person into a wheelchair. She stated that the resident likes to get of of bed early as this is her routine and enjoys her therapy. The CNA stated that the resident told her she did not want to be touched and that she had not gotten her medication. The CNA stated that is was not the residents usual manner. She did not want me to touch her. She stated that this was unusual for her to refuse am care. She stated that later on during the day the resident allowed her to help her out of bed. She stated that on Monday 05/22/17 she cared for the resident and that she seemed fine Interview on 05/24/17 at 12:30 pm with the pharmacy customer service personnel stated that she refills MEDICATION ORDERS FOR [REDACTED]. The first order was requested and received on 04/07/17 with delivery made on 04/08/17 for 30 days. On 05/03/17 60 pills (30 day supply) was delivered as a request was placed by phone for the same medication. When asked for proof of delivery none was available. She stated that no receipt is available for proof of this delivery / transaction. She stated that outside vendor called wellness express is contracted out to make deliveries. She stated that a call was received on 05/05/17 by a nurse saying that the medication was not available. We re-sent a 30 day supply. When asked for proof of this delivery none was available. She stated that the driver is to scan the bar code on the packing slip. She stated that the driver carries a small device that scans the bar code and that this may have not been done by the driver. She stated that a ten day supply was sent on Monday 05/22/17. Proof of this deilvery was provided. . Interview with the Director of Nurse on 05/24/17 at 3:10 pm stated that her staff are to report any medication issues to the nurse managers especially if they are being told by pharmacy if a delivery has already been made. The nurses are to order once a resident has a least a three day supply left. They have been inservices on how to do this on sigma. The doctor is to be made aware immediately if a resident is not getting there prescribed medication. This way the doctor can do something else or order something else. Also the nurse are to be monitoring and documenting the status of the resident in the meanwhile. Reporting and communicating to oncoming shifts is important and keeps everyone aware of what to anticipate. Review of the facility policy for unavailable medications' documented, it is the policy that each individual receive thenecessary medication as ordered by the Primary Medical Doctor (PMD) .when medications are not available, the PMD will be notified who will adjust medication regime accordingly .nurse must notify supervisor nurse must notify Pharmacy nurse document in the progress note that the medication is unavailable and that the PMD is notified .the supervisor is responsible for contacting the pharmacy if any problems regarding delivery .the nurse must document on 24 hour report sheet . Review of Specialty Pharmacy contract dated (MONTH) (YEAR) documented, .Provide products in a prompt and timely manner .collaborate with the facility to coordinate pharmacy documentation processes . 415.12 .

Plan of Correction: ApprovedJune 19, 2017

I. Immediate corrective action:
a) Resident #24 was evaluated and assessed for pain by the RN and MD on (MONTH) 24, (YEAR). No changes were made to the residents? medication regimen at this time.
b) All nurses were inserviced on proper procedure for reporting unavailable medications to the Nursing Supervisor, Physician and the pharmacy. This will be completed by (MONTH) 23, (YEAR).
II. Identification of other residents
a) The facility respectfully acknowledges that all residents could be affected by this deficient practice.
b) The DNS/ADNS reviewed all residents who receive pain medication to assure that the medication was available and that the pain assessment was complete. All identified issues will be corrected.
c) This will be completed by (MONTH) 23, (YEAR).
III. Systemic Changes
a) The Policy and Procedure on ?Unavailable Medication? was reviewed and revised by the Administrator and DNS.
b) The facility revised the Nursing Admission Assessment in SigmaCare to include a more comprehensive pain assessment.
c) The facility revised the Physician's Admission History and Physical, monthly Progress note and episodic progress notes to include pain evaluation/ assessment.
d) The facility reviewed and updated the pain care plan.
e) This will be completed by (MONTH) 19, (YEAR).
IV. Quality Assurance
a) An audit tool was created by the DNS to monitor unavailable medication, completion of pain assessment and proper documentation. DNS /designee will audit weekly x 4 weeks, then monthly for 3 months and quarterly thereafter.
b) Any negative findings will be reported to the Administrator for immediate corrective action.
c) Audit results will be presented to the QI/QM committee quarterly for review to ensure compliance and follow up as indicated. The outcome of this audit will be quantified and reported to the QI/QM Committee by the DNS/designee.
d) The DNS will be responsible for the compliance of this issue by (MONTH) 24, (YEAR) and ongoing.

FF10 483.10(f)(1)-(3):SELF-DETERMINATION - RIGHT TO MAKE CHOICES

REGULATION: (f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. (f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. (f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 26, 2017
Corrected date: July 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and family interview, record review, and staff interviews, the facility did not ensure that a resident was allowed to interact with members of the community inside the facility at the time of her choosing. Specifically, a resident's spouse was told he had to leave during a visit due to the hour. This was evident for 1 of 3 residents reviewed for Choices (Resident #96). The finding is: The Policy and Procedure for Visiting Hours documented Visiting hours are 24 hours 7 days per week. The policy further documented that family members are encouraged to visit between the hours of 11 AM and 9 PM, and family members who wish for extended visiting hours will be advised to speak to the Social Worker or Administration to place a request. The Social Worker will notify the Interdisciplinary Team of any extended visiting hours and inform the front desk/receptionist. Resident #96 is a resident, admitted [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. On 5/22/17 at 9:55 AM, the resident was interviewed and stated that visiting hours end at 9:00 PM, but she was told by the Director of Nursing (DON) that 24 hour visiting was permitted as long as others are not disturbed. The resident further stated that one time her spouse was visiting, and the evening shift nurse, Licensed Practical Nurse (LPN) #1, told her spouse that he had to leave because it was after 9:00 PM. The resident stated that they did not argue with the nurse and her spouse left. They never reported the incident to anyone. On 5/25/17 at 1:26 PM, the resident's spouse was interviewed and stated that he was in the room sitting when LPN #1 told him that it was time to leave because it was after 9:00 PM. He stated that he was just sitting and not being loud or disruptive. He meant to speak to the social worker about it, but he has not spoken to them yet. He said he was not aware that he needed to be on any special list to visit at anytime. He stated he was confused because he sees other visitors coming in late. The facility Admission Packet documented: While our visitation hours are 24/7, our preferred visiting hours are from 9:00 AM to 8:00 PM. This is to ensure the privacy and comfort of each and every resident in our facility. All visitors must sign in and sign out in the visitors' log located at the reception desk in the lobby. This procedure is an essential part of ensuring the security of the building and the safety of all residents. If you or another family member are not able to visit during regular visiting hours, special accommodations can be made. Speak to your social worker for assistance. On 5/24/17 at 4:14 PM, A bulletin board where visiting hours were posted was observed by the front door of the facility. Visiting hours were 11 AM to 9 PM. The board noted to see social work about exceptions. On 5/24/17 at 11:06 AM, LPN #2 was interviewed and stated if visitors come after hours, the front desk has to inform the Registered Nurse (RN) Supervisor before letting them in. She further stated if family members are already visiting, they stay until they are ready to leave,and the facility staff does not throw anyone out. She stated she was not aware that the resident's husband was told to leave. On 5/24/17 at 11:11 AM and 11:27 AM, RN Unit Manager #1 was interviewed and stated visiting hours are anytime. There are people who need to come late. She stated visitors are not thrown out, and she has never heard of any issues with visitors not being able to stay late. The visiting hours are 11 AM to 9 PM, but people are allowed to come after 9 PM. She stated that visitors may also stay after 9 PM. On 5/24/17 at 3:50 PM, LPN #1 was interviewed and stated visiting hours end at 9pm, and visitors are reminded of the time upon entry into the facility. He further stated that at 9:00 PM, security does an overhead page to remind visitors of the time and to inform them that visiting hours are over. He also reminds visitors on the unit that it is time to leave and to please wrap up their visit. He stated it is the facility policy for visitors to leave at that time. On 5/24/17 at 4:16 PM, the Security Guard for the evening shift was interviewed and stated visiting Hours are 11am to 9 pm. At 9pm, he makes an announcement that visiting hours are over, and he requests that visitors make their way to the lobby. He further stated that after 9pm, he calls the nursing supervisor to get approval for all visitors. He stated there is a list of pre-approved visitors outside the posted visiting hours at the security desk that is provided by Social Work. The Security Guard stated that if the nursing supervisor did not know about the late visitor, the visitor could be turned away, but most of the time, they will let the visitor in for 10 minutes or so. On 5/26/17 at 8:45 AM, the DON was interviewed and stated visiting hours are 24/7, but we prefer people to visit in between 11 to 9 PM. We tell people to speak to social work and get on the list if they would like to visit outside the recommended hours. Staff are not instructed to make visitors leave who are not being disruptive or interfering with care. She stated that she can see how the list can be misleading when the visiting hours are 24/7, and residents should not be denied visitors because their name is not on the list. They will need to clarify the policy and procedure with staff. 415.5(b)(1-3)

Plan of Correction: ApprovedJune 23, 2017

I. Immediate corrective action:
a) Resident # 96 was spoken to by the social worker and clarified visiting hours with her.
b) LPN#1 was counseled on facilities policy regarding visiting hours.
c) This was completed by (MONTH) 31, (YEAR).
II. Identification of other residents
a. All residents have the potential to be affected to be affected by this deficient practice.
III. Systemic Changes
a) The Policy and Procedure on Visitation was reviewed and revised by the Administrator, DNS and the Director of Social Service to include 24 hour visitation per day and no longer having the security announcement at 9PM.
b) The bulletin board at the front of the facility and the welcome packet were revised in accordance to the facility policy to eliminate the occurrence of further confusion among residents, visitors and staff.
c) All staff will be inserviced on the facility?s policy pertaining to visiting hours. Lesson plan and attendance sheet will be kept on record for validation
d) A letter explaining the revised visiting hours policy will be sent to all family members.
e) The policy and procedure regarding visiting hours will be clarified during resident council meeting.
f) This will be completed by (MONTH) 24, (YEAR)
IV. Quality Assurance
a) An audit tool was created to monitor staff and residents knowledge of the facility?s visitation policy. The Director Social Services/Designee will audit 5 resident and 3 staff members weekly x 4 weeks, then monthly x 3 months, and quarterly thereafter.
b) Any negative findings will be reported to the Administrator for immediate corrective action.
c) The outcome of this audit will be reported to the QI/QM Committee by the Director of Social Service quarterly for review to ensure compliance and follow up as indicated.
d) The Director of Social Service will be responsible for the compliance of this issue by (MONTH) 24, (YEAR).

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 26, 2017
Corrected date: July 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility did not ensure that resident's plan of care and medical doctor's order was followed. Specifically, Resident #24 did not receive medications ordered by the physician for two days. As a result the resident's plan of care to address pain and discomfort was not followed. This was evident for one (1) resident out of a Sample of 31 residents reviewed for adherence to plans of care and physicians orders. The finding is: Resident # 24 was admitted on [DATE] with diagnosisthat included, disease of the spinal cord; muscle spasms; general muscle weakness and neuro[DIAGNOSES REDACTED] optica ( inflammation and demyelination optic nerve and spinal cord, also known as NMO), chronic pain. Review of the Comprehensive Care Plan (CCP) for Pain, dated 04/10/17 documented, avoid activities that aggravate or exacerbate pain, resident on pain medication, updated 05/22/17 to include: re-assessed the resident for pain due to missing one day of [MEDICATION NAME]. The physician order dated 05/50/17 documented medications including, [MEDICATION NAME] 200 milligrams twice a day 9:00 am and 5:00 pm for muscle spasms On 05/22/17 at 9:45 am resident # 24 informed the SA that she is still waiting to receive her medication [MEDICATION NAME] since yesterday Sunday (05/21/17). She stated that she is been told repeated that this past weekend that pharmacy has not delivered it because they are located in New Jersey. She stated that the nurses also have told her that pharmacy will deliver it on the next delivery but it never came. On 05/22/17 at 11:40 am the SA observed a ten (10) day supply of [MEDICATION NAME] 200 mg by mouth given twice a day was delivered and received by the unit nurse manager who then signed the packing slip. On 05/22/17 at 11:45 am the resident received her medication. Upon a second interview with the resident on 5/23/17 she informed the SA that she finally received her medication on Monday 05/22/17 close to 12:00 PM. She stated that she is not asked about pain and that the doctor came in to see her on Monday in the afternoon after she got her medication. He listened to my chest, my blood pressure and asked how I was doing. I told him that the tingling in my hands was subsiding and that I felt cramps to my hands. He did not ask about pain and I offered none. His visits are only a few seconds long. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. to dispense on next run. On 05/21/17 at 5:00 pm not administered. Awaiting delivery. PMD (primary medical doctor) aware. On 05/22/17 at 9:00 am not administered. Awaiting delivery PMD aware. The MAR for 05/22/17 timed at 11:45 am documented Carbamezepine 200 mg by mouth was administered. The Nursing Progress notes from 05/19/17 - 05/21/17 found no documented evidence that medication was unavailable. There was no documented evidence of ongoing assessment due to the resident not receiving her medication as it related specifically to her condition and [DIAGNOSES REDACTED]. The nurse progress note dated 05/22/17 documented, did not get her medication for [DIAGNOSES REDACTED] .resident in no acute distress .no complaint of pain .wants her medication before going to therapy . LPN #2 (Licensed Practical Nurse) was Interviewed on 05/23/17 at 9:30 AM. LPN#2 was on duty on Friday 05/19/17during the day shift. LPN #2 stated that she called the pharmacy during the afternoon on 05/19/17 to reorder the Carbamezepine because the resident had only three pills remaining. The Pharmacy informed her that a thirty (30) day supply was sent on (MONTH) 5, (YEAR). The Pharmacy staff told her that they would get back to her because they would have to be reimbursed. LPN #2 stated that when issues of medication arise, or when there is a pharmacy issue she is to notify her supervisor. She stated that she did not do this. LPN #2 stated that she did not report this to the oncoming shift. She stated that the resident had enough medication for Friday 05/19/17 and Saturday 05/20/17. LPN #3 was interviewed on 05/23/17 at 11:15 AM. LPN #3 was on duty during the day shift on Saturday 05/20/17. LPN #3 stated that medications are to be reordered five to seven days before the resident is out of medication. She stated that she called the pharmacy, but not about this medication. She stated that she recalls the there were enough medications in the blister pack. LPN #4 was interviewed on 05/24/17 at 9:42 AM. LPN #4 was on duty during the evening shift on Saturday 05/20/17. LPN #4 stated that she called the pharmacy about the need for the above medication and was told that a delivery would be made in the evening. LPN #4 did not report to the supervisor that the resident had run out of the carbamezapine. LPN #5 was Interviewed on 05/24/17 at 11:15 AM. LPN #5 was on duty during the day shift on Sunday 05/21/17. LPN #5 stated that the pharmacy did not deliver the medication carbamazapine. LPN #5 stated that she was told to expect a delivery and none was made. She stated that she called the pharmacy in the afternoon and was told that the facility would be billed and that a delivery would be made in the evening. She stated that she informed the resident that her medication would be delivered in the afternoon. She stated that the resident was ok and did not complain of being in pain. She denied that the resident rang the call bell frequently to request her medication. She stated that she checked in frequently to reassure her that her medication would be delivered. The LPN stated that she did not report this issue to her supervisor, or the physician. She stated that she informed the nursing staff on the incoming evening shift to expect the delivery of the carbamezapine. LPN #6 was Interviewed on 05/24/17 at 3:35 PM. LPN #6 was on duty during the evening shift on Sunday 05/21/17. LPN #6 stated that she was informed by the day shift nurse that the resident did not receive her 9:00 AM medication carbamezapine and to expect a pharmacy delivery in the evening. She stated that she checked in with the resident often because she was worried that the resident did not receive her medication. She stated that the resident looked uncomfortable and that the resident told her that she was having tingling and spasms and might have been in pain. She stated that she called the pharmacy and was told that a midnight delivery would be made. LPN #6 stated that she did not follow up with her supervisor and that the doctor was not notified. She stated that she informed the oncoming night shift to expect a delivery of the residents medication. RN #1 was interviewed on 05/22/17 at 10:30 AM. RN #1 is the Nurse Manager for the 1st floor. RN #1 stated that she was just informed this morning that an issue of medication for this resident had occurred over the weekend. She stated that she spoke to the medical doctor and called the pharmacy to request a stat (immediate) delivery of this medication. She stated that she was told by the pharmacy that a delivery for this medication had been made on (MONTH) 5th. RN #1 stated that she looked in on the resident who expressed that she needed her medication before going to therapy today. RN #1 stated that the resident did not tell her that she was in any pain. RN #1 further stated that the nurses are to report medication issues to the supervisor and that the doctor should be made aware. She stated that this is not a typical pain medication and therefore no pain scale is used. She stated that the resident is asked daily if she is in pain and that it is documented in the daily notes. She stated that medications are to be reordered at least three days prior to the resident running out. Nurses can call or use the computer to reorder. She stated that it is important that nurses report when medications are unavailable, and other pharmacy issues. She stated failure to do so has the potential to affect scheduled medication administration times and treatment schedules. On 05/24/17 at 12:30 pm the pharmacy customer service agent was interviewed. She was stated that she refills MEDICATION ORDERS FOR [REDACTED]. The first order was requested and received on 04/07/17 with delivery made on 04/08/17 for 30 days. On 05/03/17 60 pills (30 day supply) was delivered as a request was placed by phone for the same medication. When asked for proof of delivery none was available. She stated that no receipt is available for proof of this delivery / transaction. She stated that outside vendor called outside vendor is contracted out to make deliveries. She stated that a call was received on 05/05/17 by a nurse saying that the medication was not available. We re-sent a 30 day supply. When asked for proof of this delivery none was available. She stated that the driver is to scan the bar code on the packing slip. She stated that the driver carries a small device that scans the bar code and that this may have not been done by the driver. She stated that a ten day supply was sent on Monday 05/22/17. Proof of this deilvery was provided. Interview with the Director of Nurse on 05/24/17 at 3:10 pm stated that her staff are to report any medication issues to the nurse managers especially if they are being told by pharmacy if a delivery has already been made. The nurses are to order once a resident has a least a three day supply left. They have been inservices on how to do this on sigma. The doctor is to be made aware immediately if a resident is not getting there prescribed medication. This way the doctor can do something else or order something else. Also the nurse are to be monitoring and documenting the status of the resident in the meanwhile. Reporting and communicating to oncoming shifts is important and keeps everyone aware of what to anticipate. Review of the facility policy for unavailable medications' documented, it is the policy that each individual receive the necessary medication as ordered by the Primary Medical Doctor (PMD) .when medications are not available, the PMD will be notified who will adjust medication regime accordingly .nurse must notify supervisor nurse must notify Pharmacy nurse document in the progress note that the medication is unavailable and that the PMD is notified .the supervisor is responsible for contacting the pharmacy if any problems regarding delivery .the nurse must document on 24 hour report sheet . 415.11(c)(3)(ii) . .

Plan of Correction: ApprovedJune 19, 2017

I. Immediate corrective action
a) Resident # 24 was evaluated and assessed for pain by the RN and Physician on (MONTH) 24, . No changes were made to the residents? medication regimen at this time.
b) All nurses were inserviced on proper procedure for reporting unavailable medications to the Nursing Supervisors, Physician and the pharmacy. The care plan must be updated according to the circumstances.
c) Lesson plan and attendance will be maintained for validation
II. Identification of other residents
a) The facility respectfully acknowledges that all residents could be affected by this issues.
b) A random review of all residents with a pain care plan was conducted by the MDS coordinator/designee and no other residents were affected.
III. Systemic Changes
a) The Policy and Procedure on ?Comprehensive Care Planning? was reviewed and revised by the DNS and the MDS Coordinator.
b) The DNS and the MDS coordinator reviewed and revised the Pain Care Plan.
c) This will be completed by (MONTH) 16, (YEAR).
IV. Quality Assurance
a) The MDS Coordinator will audit pain care plans on an ongoing basis according to the resident?s care plan schedule if pain is part of their plan of care.
b) Any negative findings will be reported to the Administrator for immediate corrective action.
c) Audit results will be presented to the QI/QM committee quarterly for review to ensure compliance and follow up as indicated. The outcome of this audit will be quantified and reported to the QI/QM Committee by the MDS Coordinator.
d) The MDS Coordinator will be responsible for the compliance of this issue by
(MONTH) 24, (YEAR) and ongoing

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Receptacles Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking. 6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 26, 2017
Corrected date: July 24, 2017

Citation Details

Based on observations, staff interviews and record reviews conducted during the Life Safety Code Survey, it was determined that the facility did not properly maintain electrical receptacles. Specifically, receptacles connected to the essential electrical system (generator) were not consistently identified. This was observed on the 2nd and 3rd floors of the facility. The finding is: On 05/24/2017 and 05/25/2017, between the hours of 09:30 am to 02:30 pm, duplex electrical outlets on the 2nd and 3rd floor vent units were observed with standard cover plates that were white in color. Red cover plates on emergency outlets were noted throughout the facility on the 6th, 5th, 4th and 1st floors. In an interview on 05/24/17 at approximately 11:00 am, the Director of Engineering stated that all the electrical receptacles are on the generator and the outlets in the vent dependent rooms have a sticker indicating the function. The 2012 edition of NFPA 99, Health Care Facilities Code, requires the cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the life safety and critical branches shall have a distinctive color or marking so as to be readily identifiable. If color is used to identify these receptacles, the same color should be used throughout the facility. (10 NYCRR: 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99:6.5.2.2.4.2)

Plan of Correction: ApprovedJuly 18, 2017

I. Immediate corrective action
a) The facility immediately replaced the white cover plates with red cover plates on electrical outlets on the second and third floors.
b) This was completed on (MONTH) 26, (YEAR).
II. Identification of other residents
a) The Administrator and Maintenance Director conducted an audit of all units throughout the facility and no issues were identified.
b) This was completed on (MONTH) 26, (YEAR).
III. Systemic changes
a) The Maintenance, Housekeeping, Nursing and Respiratory staff on the second and third floors will be in-serviced on the proper placement and use of red cover plates to electrical outlets supplied from the life and safety and critical branches so they are readily identifiable.
b) This will be completed on (MONTH) 24, (YEAR).
IV. Quality Assurance
a) An audit tool was created by the Maintenance Director to monitor all electrical outlets throughout the facility in the next three months then quarterly. The outcome of this audit will be quantified and reported to the QI/QM Committee by the Maintenance Director.
b) Any negative findings will be reported to the Administrator for immediate corrective action.
c) Completion date: Ongoing

K307 NFPA 101:RAMPS AND OTHER EXITS

REGULATION: Ramps and Other Exits Ramps, exit passageways, fire and slide escapes, alternating tread devices, and areas of refuge are in accordance with the provisions 7.2.5 through 7.2.12. 18.2.2.6 to 18.2.2.10 or 19.2.2.6 to 19.2.2.10

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 26, 2017
Corrected date: July 24, 2017

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that handrails were provided on the exit ramp leading to the outside of the facility. This was observed in the basement area. The Finding is: On (MONTH) 25, (YEAR) between the hours of 10:00 am and 12:00 pm during the recertification survey, an exit ramp (change in elevation) was observed from the basement area to the public way and no handrail was observed in this area. In an interview with the Maintenance Director and the Administrator on (MONTH) 25, (YEAR) at approximately 02:15 pm, they stated that handrails will be provided. 2012 NFPA 101: 19.2.2.6 to 19.2.2.10 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJuly 18, 2017

I. Immediate corrective action
a) The facility immediately placed handrails at the exit ramp leading to the outside of the facility.
b) This was completed on (MONTH) 26, (YEAR).
II. Identification of other residents
a) The Administrator and Maintenance Director conducted an audit of the facility?s exit ramps that may require hand rails and none were identified.
b) This was completed on (MONTH) 26, (YEAR).
III. Systemic changes
a) The Maintenance Director will in-service all maintenance staff on importance and proper use of handrails for safety when exiting and entering the exit ramp in the outside of the facility particularly the basement area.
b) This will be completed on (MONTH) 24, (YEAR).
IV. Quality Assurance
a) An audit of exit ramps leading to the outside of the facility will be conducted monthly for the next 3 months then quarterly. The outcome of this audit will be quantified and reported to the QI/QM Committee by the Maintenance Director.
b) All issues found will be corrected immediately and reported to the Administrator.
b) Completed date: Ongoing