Morris Park Rehabilitation and Nursing Center
January 18, 2019 Certification Survey

Standard Health Citations

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: February 6, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the re-certification survey, the facility did not ensure infection control practices were maintained to provide a sanitary environment, and to help prevent the development and transmission of communicable diseases and infections. Specifically, universal precautions and hand hygiene practices were not followed by a Licensed Practical Nurse (LPN) during and after a midline dressing change observation. This was evident in 1 of 2 residents reviewed under the infection care area (Resident #177). The finding is. The facility policy and procedure titled, PICC-Mid-Line/Intravascular Peripheral Lines-IV Lines (Dated 3/2017) was reviewed and documented the following. .hand hygiene is performed either by washing hands with antiseptic soap and water or with alcohol-based hand rub . The facility policy and procedure titled, Hand Hygiene/Hand Care Policy (Dated 2/7/2017) was reviewed and documented the following. .Use alcohol-based hand rub or hand washing before, during, and after removing gloves, before aseptic or sterile procedures, upon entry and leaving resident's rooms . Resident #177 most recent admission was on 1/11/2019. Resident [DIAGNOSES REDACTED]. On 01/17/2019 from 10:16 AM to 10:32 AM, an LPN was observed performing a midline dressing change on resident #177. After the LPN washed her hands, she placed the unopened sterile midline cleaning kit on a visibly soiled bedside table without cleaning or placing a barrier on the bedside table. The bedside table was soiled with a dried up clear colored spot. She opened the cleaning kit, placed a surgical mask on, and donned a pair of sterile gloves without washing or sanitizing her hands. The LPN then placed a clean drape under the resident's left arm and removed the netting that was covering the midline area. She opened part of the wrapper and placed the [MEDICATION NAME] swab sticks still in its wrapper on top of the drape. The LPN proceeded to remove the old midline dressing and placed it on the bedside table next to the cleaning kit. The LPN removed her gloves and donned a new pair of sterile gloves without washing or sanitizing her hands in between. The LPN then cleaned the midline area with the [MEDICATION NAME] swab sticks and placed the clean dressing on it. The LPN then gathered all the used supplies with the drape that was placed under resident's left arm and placed it on the bedside table where the cleaning kit and old dressing was. She proceeded to remove her gloves and placed it on top of the bedside table. The LPN then left the resident room without washing or sanitizing her hands to retrieve another box of gloves. Once retrieved, she placed the box of gloves on top of the bedside table. The LPN then donned a new pair of gloves to collect and discard the used supplies in the trash. The LPN then removed the gloves and washed her hands. The LPN left the resident room without sanitizing the resident's bedside table. On 01/18/2019 at 10:37 AM, the LPN was interviewed and stated she should have been following the sterile technique which emphasizes hand washing when performing the midline dressing. She further stated the bedside table was supposed to be cleaned with a sanitizer wipe before and after use and draped before use. The LPN then stated she was supposed to wash her hands before, during and after performing the midline care. Specifically, after removing the old dressing, after removing gloves and before putting on new gloves, and then before putting on a new dressing. On 01/18/2019 at 10:45 AM, the Registered Nurse Manager (RNM) was interviewed and stated resident #177 is on universal precautions where hand washing is the main focus before and after resident contact. The RNM stated the nurse is supposed to wash hands before, during, and after midline care to prevent infection. On 01/18/2019 at 12:06 PM, the Director of Nursing (DON) was interviewed and stated a sterile technique was supposed to be used when performing midline care. She stated sterile technique emphasizes hand washing prior, during, and after midline dressing change. The LPN's are also supposed to place clean supplies on top of a clean surface. 415.19(b)(4)

Plan of Correction: ApprovedMarch 7, 2019

1. The midline access site of resident # 177 was assessed by MD on 1/17/19 and was found without evidence of infection. The Midline catheter for resident # 177 was discontinued and removed by MD on 1/18/19. The involved LPN was counseled by the DNS on 1/18/19 on her failure to maintain sterile field, use appropriate hand hygiene during midline dressing change and follow infection control practices to prevent transmission of communicable diseases and infection. COMPLETION DATE 1/22/19
2. The facility did not have any other residents with a midline catheter on 1/18/19. There have been no other residents in the facility with a midline catheter to date. COMPLETION DATE 2/4/19
3. The policy for PICC-Midline/Intravascular peripheral Lines-IV lines was reviewed on 2/4/19 by DNS and Medical Director and was found within compliance. The policy on Hand Hygiene was reviewed on 2/4/19 by DNS and Medical Director and was found within compliance. A staff education seminar on midline catheters and dressing change provided by StatLine Access was scheduled and completed on 1/29/19. An inservice and lesson plan reviewing F 880- including the details/errors made by the LPN within the SOD was created by DNS 2/1/19. Inservice for all licensed nurses was started on 2/2/19 and will be ongoing until all licensed nurses have been educated. COMPLETION DATE 2/13/19
4. A midline dressing change competency was created by DNS on 2/4/19. The ADNS/RN supervisor/designee will assess the competency of 1 licensed nurse on each unit (5 units) weekly x 4 weeks, then monthly x 3 months then quarterly thereafter. In the absence of a resident with a current midline catheter in place the competency assessments will be done on practice/ mock up midline site. The results of the competency assessments will be presented monthly at the QAPI meetings. COMPLETION DATE 2/13/19 & ongoing
5. Date of Correction and Person Responsible
All corrections were completed by Director of Nursing Services on 2/13/19.

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - OTHER

REGULATION: Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 10 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: January 30, 2019

Citation Details

2012 NFPA 99 6.1* Applicability. 6.1.1 This chapter shall apply to new health care facilities as specified in Section 1.3. 1999 NFPA 99 1999 NFPA 99 1.2 Specific requirements for wiring and installation on tial, designing safeguards to ensure continuity in these circuits, andequipment are covered in NFPA 70, National Electrical Code. 2011 NFPA 70 110.27 110.27 Guarding of Live Parts. (A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. (2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them. (3) By location on a suitable balcony, gallery, or platform elevated and arranged so as to exclude unqualified persons. (4) By elevation of 2.5 m (8 ft) or more above the floor or other working surface. (B) Prevent Physical Damage. In locations where electrical equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage. Based on observation and staff interview during the recertification survey, the facility did not ensure that electrical equipment was protected against accidental contact. This occurred on five out of seven floors of the building. The findings include: During the Life Safety Code portion of the recertification survey of 1/15/2019 between 9:00 am and 12:00 pm, unlocked electrical circuit panels were noted on resident room floors 1-5 of the facility. One of three electrical circuit panels located on each resident room floor was found to be unlocked, allowing access to residents or unauthorized personnel. During interviews concurrent with these findings, the administrator stated that the panels would be kept locked. 2012 NFPA 101 2012 NFPA 99 1999 NFPA 99 2011 NFPA 70 10 NYCRR 711.2 (a)

Plan of Correction: ApprovedJanuary 30, 2019

On 01/17/19 Facility Engineering staff locked the identified electrical panels identified during survey on all resident floors.
On 01/17/19 facility engineering staff concluded inspection of all floors for unlocked electrical panels. All panels on all floors are locked.
Facility Engineering and Environmental Services staff will be re-educated on the requirements that all electrical panels shall be locked at all times to prevent unauthorized access. All participants will understand the life safety issues identified during the facility?s survey and the importance of ensuring compliance with the identified life safety issues on a routine basis.
The Preventive Maintenance & Scheduling program will be followed reflecting the daily rounds to ensure all electrical panels are unlocked to prevent unauthorized access.
The Maintenance Director has been assigned the responsibility for monitoring the electrical panels and report the findings monthly to the Safety Committee for a period of one (1) year.
Building occupants health and safety has not been jeopardized by these findings.

K307 NFPA 101:ELECTRICAL SYSTEMS - OTHER

REGULATION: Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99)

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 18, 2019
Corrected date: January 30, 2019

Citation Details

2102 NFPA 101 19.5 Building Services. 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2011 NFPA 70 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel. Ground-fault circuit-interruption for personnel shall be provided as required in 210.8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location. (B) Other Than Dwelling Units. All 125-volt, singlephase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel. (1) Bathrooms (2) Kitchens (3) Rooftops (4) Outdoors Exception No. 1 to (3) and (4): Receptacles that are not readily accessible and are supplied by a branch circuit dedicated to electric snow-melting, deicing, or pipeline and vessel heating equipment shall be permitted to be installed in accordance with 426.28 or 427.22, as applicable. Exception No. 2 to (4): In industrial establishments only, where the conditions of maintenance and supervision ensure that only qualified personnel are involved, an assured equipment grounding conductor program as specified in 590.6(B)(2) shall be permitted for only those receptacle outlets used to supply equipment that would create a greater hazard if power is interrupted or having a design that is not compatible with GFCI protection. (5) Sinks - where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink. Exception No. 1 to (5): In industrial laboratories, receptacles used to supply equipment where removal of power would introduce a greater hazard shall be permitted to be installed without GFCI protection. Exception No. 2 to (5): For receptacles located in patient bed locations of general care or critical care areas of health care facilities other than those covered under 210.8(B)(1), GFCI protection shall not be required. (6) Indoor wet locations (7) Locker rooms with associated showering facilities (8) Garages, service bays, and similar areas where electrical diagnostic equipment, electrical hand tools, or portable lighting equipment are to be used Based on observation and staff interview during the recertification survey, the facility did not ensure that all electrical outlets within 6' of a water source are protected by ground fault circuit interrupters (GFCI). This occurred on 5 out of 7 floors of the facility. The findings include: During the Life Safety Code portion of the recertification survey on 1/15/2019 between 9:00 am and 12:00 pm, it was noted that in soiled utility rooms on resident room floors 5 through 1, the electrical receptacles located within 6' of sinks were are not of the GFCI type or connected to GFCI circuits, which are required to protect personnel from electrical shock. Upon interview at the time of the findings, the Administrator and Maintenance Director stated that the receptacles in the soiled utility rooms would be replaced. 2012 NFPA 101 2011 NFPA 70 10 NYCRR 711.2 (a)

Plan of Correction: ApprovedJanuary 30, 2019

On 1/17/19 Facility Engineering staff permanently replaced the identified electrical receptacles in the soiled utility rooms on all floors with GFCI electrical receptacles.
On 01/17/19 facility engineering staff concluded inspection of all ?wet areas? for electrical receptacles within 6 feet not protected by a GFCI. No other electrical receptacles were found within 6 feet of the ?wet area? that were not protected by a GFCI.
The Preventive Maintenance & Scheduling program will be followed reflecting the monthly inspection and testing of GFCI receptacles and will be documented in the Facilities Records & Logs.
The Maintenance Director has been assigned the responsibility for monitoring the GFCI receptacles and report the findings monthly to the Safety Committee for a period of one (1) year.
Building occupants health and safety has not been jeopardized by these findings.