Buffalo Center for Rehabilitation and Nursing
February 22, 2018 Complaint Survey

Standard Health Citations

FF11 483.45(g)(h)(1)(2):LABEL/STORE DRUGS AND BIOLOGICALS

REGULATION: §483.45(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. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(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. §483.45(h)(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: February 22, 2018
Corrected date: April 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Abbreviated survey (Complaint #NY 660) completed on 2/22/18, the facility did not ensure that all drugs and biologicals were locked in compartments permitting only authorized personnel to have access. One (Third Floor/lounge area) of four medication rooms observed for safe medication storage was not secure. The medication room door did not self-close, latch or lock. The findings are: 1. Observation of the Third Floor lounge on 1/31/18 at 8:45 AM revealed the room had two solid core doors without automatic self-closers attached. The door on the left was an unlocked closet containing coats and personal belongings and the unlatched, unlocked door on the right was a medication room and contained a small counter with cabinets, an unlocked refrigerator and two metal cabinets mounted to the wall. Six residents were observed sitting in the lounge and non-medical staff were entering the closet next to the medication room. Observation of the Third Floor medication room, located in the lounge area, on 1/31/18 revealed the following: - 9:23 AM - The door was unlatched and unlocked and residents remained sitting in the lounge area and were independently moving around in wheelchairs. - 10:38 AM - The door was unlatched and unlocked and six residents were in the lounge area, including one resident ambulating independently with his walker. - 11:15 AM - The door was open with nursing staff present. As a nurse exited the medication room, she closed the door by swinging it closed with one hand. The door closed, but remained unlatched and unlocked. The nurse did not check the door to verify it was secured and walked away. Four residents and a Certified Nurse Aide (CNA) were in the lounge area. - 3:05 PM - The medication room door was latched and locked. Observation on 1/31/18 at 3:35 PM revealed a Licensed Practical Nurse (LPN #1 entered the unlatched and unlocked Third Floor medication room. The LPN stated she needed to retrieve her coat which was sitting on top of the refrigerator. Further observation with the Third Floor Unit Registered Nurse (RN #1) Unit Manager (UM) revealed a blue plastic bin was located on top of the counter and contained the following medication blister packs (carded plastic packaging used to dispense individual doses of medication) - 30 tablets of Levetiracetam ([MEDICAL CONDITION] medication) 50 milligrams (mg) - 28 tablets of [MEDICATION NAME] (nonsteroidal anti-[MEDICAL CONDITION] medication) 500 mg - 19 tablets of Potassium (K+- supplement) 20 milliequivalents (mEq) - 19 tablets of [MEDICATION NAME] (medication to decrease blood pressure) 25 mg - 24 tablets of [MEDICATION NAME] (antidepressant) 150 mg - 150 tablets of [MEDICATION NAME] (medication to treat [MEDICAL CONDITION] and nerve pain) 100 mg Observation of the unlocked refrigerator in the medication room revealed the following medications: [REDACTED] - six insulin vials in transparent plastic bags - one half full 16 ounce (oz.) bottle of liquid [MEDICATION NAME] (antibiotic) - one vial each of injectable pneumococcal and influenza vaccine - one opened box of [MEDICATION NAME] suppositories The cabinets above the counter in the medication room contained bottles of over-the-counter medications including Tylenol, Aspirin, multivitamins, and stool softeners. Upon exiting the medication room with the RN (#1) UM, the medication room door did not latch or lock. The RN UM stated, Oh it gets stuck, I'll have someone look at it. Observation on 2/1/18 at 8:30 AM revealed the Third Floor medication room door in was latched and locked. Interview with the RN UM on 2/1/18 at 9:00 AM revealed the medication room door on the Third Floor in the lounge area had been fixed by maintenance. 415.18(e)(1)

Plan of Correction: ApprovedMarch 21, 2018

The Medication room door on the 3rd floor was repaired by Maintenance on 1/31/18.
3rd floor medication nurses and unit managers were counseled by the DON on 2/1/18 regarding the need to ensure proper appropriate medication storage and the need to report any issues immediately.
All residents have the potential to be affected.
All medication room doors were checked by Maintenance on 1/31/18 with no further issues noted.
Medication storage policy was reviewed by the DON with no revisions required.
All licensed nursing staff will be re-educated by the RN Educator/designee regarding safe medication storage; education will include the need to immediately report any issues to Maintenance .
Weekly audits will be conducted by the Unit Managers x 8 weeks to ensure that all medication rooms are appropriately secured .
Results of the audits will be forwarded to the QAPI Committee for review and input.
Responsibility : DON

FF11 483.25:QUALITY OF CARE

REGULATION: § 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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 22, 2018
Corrected date: April 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during an Abbreviated Survey (Complaint #NY 733) completed on 2/22/18, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, one (Resident #1) of 3 residents reviewed for quality of care lacked arranging a follow up appointment with the surgeon to have sutures removed. Additionally, a peripherally inserted central catheter line (PICC line- a catheter that is inserted through the vein and advanced until the tip enters the central venous system) was removed by an unqualified Registered Nurse and did not follow facility protocols. The findings are: Review of the facility policy and procedure entitled Central Venous Access Devices: Removal dated 12/2014 revealed this procedure can be performed by licensed nurses according to state law and facility policy. The policy documented the nurse must be aware of the catheter length prior to removal. Every effort is made to obtain catheter length prior to removal, if unable to obtain length a specific order must be obtained to remove the catheter. Measure catheter length and assess catheter tip after removal to ensure entire catheter was removed. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS - a resident assessment tool) dated 5/6/17 documented the resident was cognitively intact, usually understands and was understood. The hospital Physician Discharge Order Form dated 4/29/17 documented the resident was to receive [MEDICATION NAME] (an antibiotic) 2 grams (gm) intravenous (IV) every 8 hours until 6/6/17. Further review revealed a follow up appointment was to be scheduled with the resident's orthopedic surgeon between 5/5/17 through 5/10/17. Review of a hospital PICC Data Collection form dated 4/27/17 documented the catheter size was 4 French single lumen with a total length of 40 centimeters (cm). Review of the nursing Progress Notes from 5/3/17 through 5/20/17 documented the following: -5/3/17, right arm PICC line intact no signs or symptoms (S&S) of infection, left knee stitches intact, resident removed ace wrap. -5/8/17, left leg [MEDICAL CONDITION] continues, stitches intact left knee, no signs and symptoms of infection. -5/17/17, IV antibiotic (ABT) continues via PICC line no adverse effects noted stitches intact. Left lower extremity [MEDICAL CONDITION] continues. -5/19/17, no adverse effects to IV ABT, no S&S of infection noted to right upper arm, no S&S of infection to surgical site, left leg, continue to monitor. -5/20/17, IV ABT continues no adverse effects staples intact. An Order Summary Report dated 4/29/17 through 5/25/17 included orders dated 4/30/17 to call the surgeon between (MONTH) 5 th and (MONTH) 10 th to schedule suture removal, an order dated 5/19/17 for [MEDICATION NAME] 2 grams every day for an infection for 38 days with an end date of 6/26/17, and an order dated 5/24/17 to remove the PICC line. A nursing Progress Note dated 5/24/17 by RN #1 documented the PICC line is removed from resident's right upper extremity. Resident has no s/s of distress and tolerates well. Vitals are within normal limits. During an interview on 2/2/18 at 8:40 AM, the Director of Nursing stated she could not locate any documentation in the medical record the resident's sutures were removed from the resident's left knee or if a follow up appointment to remove the sutures was made as ordered by the physician. During an interview on 2/2/18 at 9:00 AM, the Registered Nurse Unit Manager (RN # 1) stated she could not recall if the resident's stiches were removed or ever assessing the resident's surgical site. RN #1 stated that she removed the residents PICC line but could not recall if she knew the length of the catheter. RN #1 stated she was not PICC line certified and had not had any formal training. The only training, she had received on the care and removal of a PICC line was from one of the physicians at the facility, and the training consisted of a demonstration of removing a PICC line. During an interview on 2/2/18 at 10:10 AM, the In- Service Coordinator (RN#2)stated a Nurse Practitioner (NP) at the facility had done an informal in-service about six months ago on how to remove PICC lines. RN#2 was unable to provide documented evidence for the training, what was covered or who attended. The In-Service Coordinator was not aware if the facility provided any mandatory or routine training for PICC line care and removal. During an interview on 2/2/18 1:10 PM, the DON stated most of their nurses come from the hospital so they have the experience with PICC lines. They are not certified, but well versed in PICC line care. The facility does not require proof of training upon hire regarding PICC line care and removal. During a confidential telephone interview on 2/6/18 at 12:00 PM, a family member of the resident stated, the resident was discharged from the facility on 5/25/17, readmitted to the hospital on [DATE] for suture removal, reinsertion of the PICC line and antibiotic therapy. The resident remained in the hospital from 5/26/17- 5/30/17. During a telephone on 2/2/18 at 1:10 PM, the receptionist at the orthopedic surgeon's office stated, the resident was seen in the emergency roiagnom on [DATE] for suture removal, was admitted to the hospital for PICC line reinsertion and antibiotic therapy until 5/30/17. During a telephone interview on 2/6/18 at 1:46 PM, the resident's physician at the facility stated he could not recall if the resident had the sutures removed; That was a long time ago and I see so many patients. The resident was to see his physician in the community for a follow up appointment in early (MONTH) and he was unsure if the resident ever went for the appointment. I would have taken the sutures out if I knew they were still in but no one told me. That's not good that they were in that long. During a telephone interview on 2/7/18 at 2:36 PM, the DON stated the Unit Clerks are responsible for making follow up appointments for new admissions if it is documented in the discharge summary within two to three days after admission. If the follow up information is on the Medication Administration Record [REDACTED]. During a telephone interview on 2/7/18 at 1:00 PM, RN #1 Unit Manager stated that she had worked at a former hospital for 14 1/2 years. She did not receive any training while employed at the hospital on the care or removal of a PICC line. The training she had received at the facility was from a former physician assistant (PA) consisting of a demonstration of a removal of a PICC line on a former resident. Since her time employed at the facility she has remove approximately three or four PICC lines. When asked to explain how she removed resident's PICC line she stated, I went into his room with a central line kit, took his vitals, and [MEDICATION NAME] him. While in a supine position (lying with the face up) I had him take slow shallow breaths while pulling out the line. I applied a pressure dressing after and another nurse took his vital signs. When asked how she pulled out the PICC line, she stated, It depends on how the line is in, I go in the direction of the arm. When asked if she did anything with the catheter after removal she stated, No I didn't have to do anything with it, it didn't have to go for culture. Review of an email received on 2/6/18 from the New York State Education Department Office of Professions revealed the following guidance: a RN may insert or remove a PICC line if the facility has a protocol for insertion and removal, the RN has completed a course that covers the insertion and removal of a PICC line; including proper technique; factors that preclude removal and handling unexpected outcomes. Additionally, the RN has completed a series of successful demonstrations on the insertion and/or removal of PICC lines under direct supervision and is assessed annually as to continued competence. 415.12

Plan of Correction: ApprovedMarch 21, 2018

Resident # 1 was discharged to home on 5/25/17. The physician reviewed resident #1's record with no further issues noted.
The RN Unit Manager who was responsible for care of resident # 1 was counseled by the DON on 2/1/18. This counseling included the need to follow up on arrangement of resident appointments and the policy/protocol for removal of PICC lines .
All residents have the potential to be affected .
Resident PICC lines will not be removed by facility RNS unless the RN is PICC line certified .
The Unit managers along with unit secretaries will review the last 30 days of resident admissions to ensure that all resident follow up appointments are scheduled as ordered . Any issues noted will be immediately addressed.
All licensed nursing staff and Unit secretaries will be educated by the DON/designee regarding the need for timely scheduling of resident appointments.
Facility policies for PICC Line care/ removal and scheduling of appointments were reviewed by the DON; revision of PICC line policies will include the need for only PICC line certified RNS to remove PICC lines.
All RNS will be educated by the DON regarding the removal of PICC lines and the revised policy; residents needing PICC line removal will be sent to the hospital for removal unless there is a PICC line certified RN to remove.
5 Weekly resident appointment audits will be performed by the day shift RN supervisor for a period of 10 weeks. These audits will ensure that all newly admitted residents have follow up appointments scheduled by the unit secretaries as ordered. Any issues noted will be immediately addressed .
The DON will audit PICC lines weekly to ensure that PICC line removal is handled only via PICC line certified nurses or that resident is sent to hospital when PICC line removal is needed .
All audits will be forwarded to the QAPI Committee for review and input .
Responsibility : DON



FF11 483.20(f)(5); 483.70(i)(1)-(5):RESIDENT RECORDS - IDENTIFIABLE INFORMATION

REGULATION: §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 22, 2018
Corrected date: April 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Abbreviated survey (Complaints #NY 476, NY 733) completed on 2/22/18, the facility did not maintain clinical records on each resident in accordance with acceptable professional standards and practices that are complete; accurately documented; and readily accessible. One (Resident #1) of five residents' medical records reviewed for accuracy and completion had issues involving an incorrect date of birth documented throughout the medical record and incomplete and/or inaccurate documentation of the administration of an intravenous antibiotic on the Medication Administration Record [REDACTED] The findings are: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/6/17 revealed the resident is cognitively intact, is understood and usually understands. a.) Review of an ePACES Eligibility Response Details Report (to determine Medicaid eligibility) dated 4/28/17 revealed the resident's date of birth is 8/10/1978. Review of the Complete Medical Record from the hospital dated 4/23/17 to 4/29/17 revealed all of the documents were stamped with the resident's date of birth (DOB) as 8/10/1978. Review of the facility Admission Record sheet with a print date of 2/1/2018 and the Medical Administration Records (MARs) dated 4/2017 and 5/2017 revealed the resident's DOB was documented as 8/10/1987. Review of the following facility documents revealed the resident's date of birth was erroneously documented as 8/10/87: - Order Recap Report dated 4/29/17 to 5/25/17 - The History and Physical, completed by the physician, dated 5/1/17 - Nurse Practitioner (NP) Progress Notes dated 5/7/17 and 5/10/17 - Discharge Instruction Form dated 5/24/17 During a confidential interview on 2/6/18 at 12:00 PM, a family member of the resident stated they noticed that the resident's date of birth was incorrect on the Discharge Instruction Form when the resident returned home. Interview with the Finance Coordinator on 2/7/18 at 2:44 PM revealed the finance department receives residents' information from the admissions department prior to admission. Once a resident is admitted , all resident's personal identification information is reverified with the resident or representative to include billing and insurance information as well as the resident's date of birth. Telephone interview with the Admissions Coordinator on 2/9/18 at 2:00 PM revealed residents' preadmission information is obtained from the screener and the hospital face sheet and all information is verified by the ePACES report including the resident's DOB. If the resident doesn't have Medicare, the information is verified by the hospital face sheet. Review of preadmission screening information revealed the resident's Admission Record (face sheet) with a print date of 2/12/18 documented that the resident's DOB (date of birth) is 8/10/1978. Further review of the preadmission information revealed the Emergency Department Downtime Form, the hospital Medication Reconciliation Form, and the hospital Social Work Initial Admission Assessment documented that the resident's date of birth is 8/10/1978. b.) Review of an Order Summary Report for the period 4/29/17 to 5/25/17 revealed a physician's orders [REDACTED]. Review of the MAR indicated [REDACTED]. Addition review of the MAR indicated [REDACTED] - 5/5/17 at 12:00 AM - 5/8/17 at 8:00 AM - 5/9/17 at 12:00 AM - 5/13/17 at 4:00 PM - 5/14/17 at 12:00 AM - 5/19/17 at 8:00 PM During an interview on 2/2/17 at 1:00 PM after review of the resident's Progress Notes and MAR, the Director of Nursing (DON) stated she could not determine if the [MEDICATION NAME] was administered to the resident on the above dates. 415.22(a)(1,2)

Plan of Correction: ApprovedMarch 16, 2018

Resident # 1 was discharged from the facility on 5/25/17 .
Admissions Director will be counseled by the DON regarding the need to double check resident information entered on admission for accuracy.
The RNS responsible for administration of IV medication for resident # 1 will be counseled by the DON regarding the need for accurate and complete documentation .
All residents have the potential to be affected.
A check of all current resident DOBs will be conducted by the Admissions & HMO Coordinator/designee by 4/12/18 to ensure accuracy of inputted information. Any issues noted will be immediately addressed .
All residents receiving IV ABTS will be reviewed by the Administrative nursing staff to ensure accurate and complete documentation. Any issues noted will be immediately addressed.
Documentation policies were reviewed by the DON with no revisions required.
All staff responsible for inputting resident admission information will be educated by the DON regarding accuracy of transcription. A secondary check by HMO Coordinator/ designee will be conducted for all new residents within 72 hours of admission.
A facility IV binder will be instituted ; this binder will include MARS/ TARS for all residents receiving IV medications; RNS will be required to initial administration of IV medications and flushes in the binder. The Unit managers/ supervisors will be responsible to keep this binder updated as new admissions/ changing orders occur. In addition, there will be a whiteboard located in the Supervisor office for quick reference of residents receiving IVs.
All facility RNS will be educated regarding the new IV protocols by the DON .

Weekly IV Medication documentation audits of all residents receiving IVs will be conducted by the DON for 12 weeks. These audits will ensure that all IV medication administered is accurately and thoroughly documented. Any issues noted will be immediately addressed .
The Assistant Administrator will audit all new admission records for a period of 10 weeks to ensure that resident information is accurately entered into the resident record. Any issues noted will be immediately addressed .
The results of the audits will be forwarded to the QAPI Committee for review and input.
Responsibility : DON