Houghton Rehabilitation & Nursing Center
May 1, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 1, 2017
Corrected date: June 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 5/1/17, the facility did not ensure that the resident environment remains as free of accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents. One (Resident #115) of five residents reviewed for accidents had issues that involved the lack of effective safety interventions following a fall. The finding is: 1. Resident #115 was admitted to the facility on [DATE] and has a [DIAGNOSES REDACTED]. Additionally, the resident had a fall since admission without injury and requires extensive assist of one staff member with transfers, ambulation and toileting needs. Review of the Care Plan with a revised date of 4/27/17 revealed the resident is at risk for falls related to a history of falls, dementia [DIAGNOSES REDACTED]. Additionally, the resident has limited physical mobility and a self - care deficit related to dementia and muscle weakness. Planned interventions include extensive assist of one person for transfers, ambulation and toileting. Review of the Kardex (guide used by staff to provide care) dated 4/27/17 revealed the resident required extensive assist of one person for transfers, ambulation and toileting with the use of a rolling walker (RW) and a gait belt (used around the resident's waist to transfer from one position to another or to safely ambulate). Encourage resident to wear appropriate foot wear when ambulating. Review of a PT Screen dated 4/7/17 revealed the resident had functional limitations of both lower extremities, and transfers with extensive assist of one person. The resident is not steady moving on and off the toilet, or moving from a seated to standing position and is only able to stabilize with staff assistance. Review of a nursing Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls; requires hands on assist to move from place to place, and has a decrease in muscle coordination. Review of an untitled Accident & Incident (A&I) Report dated 4/11/17 revealed the resident had a witnessed fall from her wheelchair in the dining room. The resident leaned to far forward and fell out of her wheelchair. Team recommendations were that the resident has a PT evaluation pending for reassessment of assistance. The Care Plan was reviewed by the team and there were no updates made. Review of a Fall Consult dated 4/13/17 completed by PT revealed the resident self -transferred, had no pain with Passive Range of Motion (PROM). The PT made no changes to the resident's Care Plan/ Care Guide (Kardex). Staff were to continue with current recommendations; extensive assist of one staff member with the use of a RW and a gait belt for transfers and ambulation, and extensive assist of one staff member for toileting. Review of a Progress Note dated 4/24/17 at 7:09 AM revealed the resident had a fall, no treatment was required and no injuries were noted. Review of an A&I Report dated 4/24/17 revealed the resident had an unwitnessed fall from the toilet. Description of the incident; Resident #115 was placed on the toilet by a Registered Nurse (RN) #1. RN #1 heard a noise in the hallway and exited the bathroom to investigate the noise in the hallway. RN #1 then heard Resident #115 vocalize from the bathroom. RN #1 re-entered the resident's bathroom to find the resident on the floor in front of the toilet. Review of the A&I Report and Care Plan attached to A&I revealed there were no recommendations. Review of a Fall Consult dated 4/24/17 completed by PT revealed the resident self -transferred and had no pain with PROM. The PT made no changes to the resident's Care Plan/ Care Guide. Staff were to continue with current recommendations; extensive assist of one staff member with the use of a RW and a gait belt for transfers and ambulation, and extensive assist of one staff member for toileting. Review of a nursing Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls; requires hands on assist to move from place to place, and has a decrease in muscle coordination. The resident exhibits loss of balance while standing, uses short shuffling steps, and exhibits jerking or instability when turning. During an interview on 4/27/17 at 12:14 PM, RN #2 was aware the resident had a fall on 4/24/17 but could not state what interventions were put into place after the fall. RN #2 stated the resident had a history of [REDACTED]. RN #2 stated that the team had not yet reviewed the 4/24/17 incident. During an observation on 4/27/17 at 12:17 PM a bed alarm was observed on the resident's bed. During an interview on 4/27/17 at 12:25 PM, Certified Nurse Aide (CNA) #1 stated that the resident has had a bed alarm for approximately six months because she is non-compliant with transfers and has a history of unresponsive episodes. CNA #1 stated she does not leave the resident alone in the bathroom as she is confused and non-compliant. During an interview on 4/27/17 at 12:27 PM, Licensed Practical Nurse (LPN) #1 stated the resident tries to get up unassisted and has fallen. During an interview on 4/27/17 at approximately 12:35 PM, the Director of Therapy stated ideally a resident who is confused with a history of falls and utilizes an alarm, should not be left alone while on the toilet. During an interview on 4/27/17 at 12:37 PM, the PT stated the team had not met to discuss the fall from 4/24/17 and that the resident requires extensive assist of one staff member for transfers, and ambulation. Additionally, the resident has fair sitting balance and requires extensive assist of one person for toileting. The PT further stated he was unaware the resident utilized an alarm, and should not have been left alone on the toilet. During an interview on 4/27/17 at 12:42 PM, the Occupational Therapist (OT) stated the resident should not have been left alone on the toilet. During an interview on 4/27/17 at 12:30 PM, the Director of Nursing (DON) stated the team had not yet reviewed the 4/24/17 incident. The DON stated that a confused resident with a history of falls, that utilizes an alarm and required extensive assist with transfers, ambulation and toileting should not be left unattended in the bathroom. During a telephone interview on 4/27/17 at 2:54 PM, RN #1 stated that he assisted Resident #115 into the bathroom in the early morning of 4/24/17. The resident was sitting at the edge of the bed and the bed alarm did not sound. RN #1 stated he was unable to find the resident's RW, so he used the resident's roommate's walker. RN #1 stated he could not recall if he used a gait belt with the resident. RN #1 stated that he left the resident unattended in the bathroom while he investigated a commotion that was occurring in the hallway. He heard Resident #115 vocalize and when he reentered the resident's bathroom, she was sitting on the floor in front of the toilet. RN #1 stated he should not have left the resident unattended in the bathroom. Review of a facility document entitled Standard of Care Safety/ Prevention of Falls dated 9/2012 revealed to encourage the appropriate use of mobility devices/ aides issued for the resident. Referrals to PT as indicated for evaluation and recommendations for appropriate interventions. Follow the recommendations for transfers and ambulation per therapy. Place specific interventions on the Care Guide, toilet the resident per Care Guide. 415.12 (h)(1)

Plan of Correction: ApprovedJune 4, 2017

1. IDT convened on Resident #115?s A/I from the 4/24/17 on 4/28/17. The IDT recommended nursing and therapy staff education not to leave Resident #115 on the toilet alone. Care plan was updated on 4/28/17 not to leave Resident #115 on the toilet alone. Bed alarm was removed from the residents? bed when it was indentified by state surveys. Administrator and DON removed bed alarm, as it was not a care planed intervention to meet the residents? needs. The IDT did not find it an appropriate 4/28/17. RN#1 was educated on resident safety and educated not to leave Resident #115 on the toilet alone per care plan update.
2. Therapy staff and IDT will be inserviced by the Administrator on the proper procedure for completing evaluations and A/I interventions per facility policy. This in-service will include providing safety interventions in a timely manor 6/16/17.
3. Director of Therapy will conduct a full audit all resident assistance devices and alarms by 6/16/17. To be reviewed at Quarterly QAPI/QAA Meeting 6/30/2017 and determined at this time by Vice President of Clinical Services if it is necessary to continue.
4. The IDT will review all residents care plans to determine if they need additional interventions as they relate to preventing falls by 6/16/17. Results to be reviewed at Quarterly QAPI/QAA Meeting 6/30/2017.
5. Audit of two prior months A/I?s by the administrator for safety interventions start date of 5/22/17 and will continue until the next Quarterly QAPI/QAA. To be reviewed at Quarterly QAPI/QAA Meeting 6/30/2017 and determined at this time by Vice President of Clinical Services if it is necessary to continue.
6. Person responsible: Administrator

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 1, 2017
Corrected date: July 12, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard Survey completed on 5/1/17, the facility did not ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. One (Resident #5) of four residents reviewed for impaired skin integrity had an issue involving incomplete fecal incontinence care and lack of timely communication by certified staff to nursing staff of the resident's painful, reddened skin. The finding is: 1. Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS documented that the resident requires extensive staff assistance for toilet use and personal hygiene, is always incontinent of bowel and bladder, was identified at risk for pressure ulcers, and had no pressure ulcers or moisture associated skin damage (MASD). Review of the comprehensive Care Plan (CCP) dated 10/28/16 revealed the resident was identified at risk for pressure sore development and had actual skin impairment related to decreased mobility, incontinence and the presence of MASD. The CCP was revised on 3/27/17 with planned interventions to keep the resident's skin clean and dry. The CCP documented that the resident has bladder incontinence with planned interventions for staff to provide incontinence checks every two to three hours and report any areas of redness or skin breakdown to the nurse. Review of the Medication Administration Report (MAR) dated (MONTH) (YEAR) revealed the resident had an active order for the application of an Antifungal cream every day and evening shift for MASD since 3/18/17. Review of a Provider Wound Treatment Assessment and Order dated 4/13/17 revealed the following: - the resident had MASD on the right mid buttock measuring 1.0 centimeter (cm) long by ( x) 1.5 cm wide x <0.1 cm deep - the MASD had a macerated (softening and breaking down of skin as a result of prolonged exposure to moisture) peri-wound which had declined and had a scant amount of exudate (drainage) - there were two healed areas on the right buttock. No treatment order was documented. Observation on 4/27/17 at approximately 1:40 PM revealed two certified nurse aides (CNAs #3 and #4) entered the resident's room to transfer the resident to bed and provide incontinence care. The observation revealed that the resident was incontinent of a large amount of brown, non-formed soft stool which covered the entire front and back of the brief. The stool was observed on the resident's abdomen past the umbilicus (belly-button) and over the entire buttocks. CNA # 3 cleansed the resident from front to back; however the CNA did not spread the resident's legs to obtain easier access/ visualization of the resident's genitalia. While CNA #3 was cleansing the resident, the resident winced and said ow several times. CNA #3 stated she was done and the surveyor then asked CNA #3 and CNA #4 to reposition the resident to visualize the entire female genitalia and thoroughly cleanse the internal genitalia. CNA #3 wiped each side of the genitalia around the urinary meatus (opening to the bladder) and a large amount of fecal material was cleansed from the area. The resident's genitalia was observed to be extremely red and the resident winced and said ow as the CNA provided care. After completing the incontinence, no barrier cream was applied. Continued observation of CNA #3 on 4/27/17, from approximately 1:45 PM to 2:10 PM, revealed the CNA did not speak to a nurse; she performed other duties on the floor, gave report to the evening shift CNA and only stated that the resident was changed. During an interview on 4/27/17 at approximately 3:00 PM, the evening shift Licensed Practical Nurse (LPN #2) stated that she was not informed about any skin issues regarding Resident #5 by the day shift LPN or the CNA. Observation on 4/27/17 at approximately 3:05 PM revealed CNA #5 and CNA #6 entered the resident's room to provide personal care in preparation for the LPN to provide a skin treatment. In the presence of LPN #2, CNA #5 washed copious amounts soft brown stool from the resident's female genitalia and buttocks. Resident #5 expressed discomfort stating ouch, oh my goodness that's sore, ow. During the observation in the presence of LPN #2, the CNAs did not reposition the resident's legs to obtain easier access/ visualization of the resident's female genitalia. CNA #5 stated she was finished cleansing the resident and the surveyor asked the CNA to visualize the folds of the buttocks which revealed there was a moderate amount of brown stool remaining on the resident's buttocks. While CNA #5 washed the area, the resident again expressed discomfort. Continued observation revealed LPN #2 applied Antifungal cream using a 4x4 (four inch by four inch) gauze dressing to the resident's external and internal female genitalia. Brown fecal material was observed on the 4x4 dressing while the LPN was applying the cream. The LPN did not re-cleanse the area, nor reapply the treatment. The resident was stating ow my crotch is hurting. During an interview on 4/27/17 at approximately 3:16 PM, LPN #2 stated that she observed the resident's reddened female genitalia and that while there was some previous minor irritation, this was new and the pain was new and the CNA should have reported it to the nurse. During an interview on 4/27/17 at approximately 3:25 PM, CNA #5 stated that she has provided personal care to the resident in the past and this is the first time she could recall her having pain/ discomfort. 415.12

Plan of Correction: ApprovedJune 6, 2017

1) Resident #5 ?IDT updated CCP/Kardex to include specific guidance for incontinence checks, care and reporting areas of concern (redness, breakdown) to nursing. 5/15/2017.
2) Residents who are incontinent of bowel have been identified as being at risk for deficient practice. A full house audit will be completed ADON/Designee to determine those residents who are incontinent of bowel. With updates to CCP as indicated related to incontinent care.5/26/17
3) All Nursing (ADON/RCC/Off Shift Nursing Supervisors), LPN and CNA staff will be educated by DON/Designee on proper technique to be used for incontinent care per current Standards of Care and will be required to demonstrate proper technique. All C.N.A.?s will receive education related to importance of reporting issues to Nursing and will sign an acknowledgement letter which will be kept in their personnel file.
4) DON/Designee will complete incontinent care proficiency checks on all C.N.A.?s on all shifts no less often than monthly with re-education and counseling provided as indicated. Proficiency checks will become part of each employees file. Results of these checks will be reviewed at the Quarterly QAA meeting and ongoing frequency determined at that time, completed by 6/30/2017.
5) To be reviewed at Quarterly QAPI/QAA Meeting 6/30/2017.

6) DON responsible.

FF10 483.75(g)(1)(i)-(iii)(2)(i)(ii)(h)(i):QAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS

REGULATION: (g) Quality assessment and assurance. (1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (g)(2) The quality assessment and assurance committee must : (i) Meet at least quarterly and as needed to coordinate and evaluate activities such as identifying issues with respect to which quality assessment and assurance activities are necessary; and (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; (h) Disclosure of information. A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section. (i) Sanctions. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 1, 2017
Corrected date: June 30, 2017

Citation Details

Based on interview and record review conducted during the Standard survey completed on 5/1/17, the facility did not maintain a Quality Assessment and Assurance (QAA) Committee consisting of the Director of Nursing, a Physician designated by the facility and at least three other members of the facility's staff that meets at least quarterly. The finding is: 1. During an interview on 4/25/17 at approximately 9:30 AM the Administrator and Director of Nursing (DON) revealed the facility has a QAA Committee that meets quarterly consisting of the DON and at least three other facility members. The interview further revealed the Medical Director nor Physician is present for the QAA Committee meetings. Review of the QAA Committee meeting attendance sheets for 6/3/16, 10/10/16, and 1/27/17 revealed the Medical Director nor a Physician was present at the meetings. Interview with the Medical Director on 4/28/17 at approximately 2:23 PM revealed, By default I'm on the QAA committee. I used to attend the meetings but they are a horrible, horrible waste of time. If there are issues that come out of those meetings, nursing staff or the Administrator will bring them to my attention. Review of facility policy entitled Quality Assessment and Assurance Committee Peer Review Committee, dated 10/04 revealed the QAA committee consisting of at least the following: Administrator or designee, Director of Nursing, and at least three other members of the facility staff representing the professional services provided shall report its activities, findings and recommendations as often as necessary but on at least a quarterly basis to at least one member of the governing body and a physician designated by the facility. 415.27(b)(3)

Plan of Correction: ApprovedJune 6, 2017

1. Quarterly ?QAPI/QAA? meetings identified by the department of health as not meeting regulation 483.75 (g) will be reviewed by the Medical Director and signed off on. Date for completion 5-26-2017.
2. The Medical Director will as of 5-26-2017 will attend every quarterly QAPI/QAA meeting. In addition no Quarterly QAPI meeting will be held without the minimum requirements for the QAPI/QAA committee membership are in attendance. Date for completion 5-26-2017.
3. At all Quarterly QAPI/QAA committee meetings, a Clinical Corporate Officer will participate in the facilities QAPI/QA committee to ensure the facility is in compliance with this regulation.
4. Absolut Facilities Clinical Chief Officer/or designee will conduct an in-service with Absolut Care of Houghton?s Quality Assurance committee, including Director of Nursing, Medical Director and Administrator. Which will include the importance of following federal regulations regarding QAPI/QAA and its membership requirements? Including regulation 483.75 (g) which outlines the minimum requirements for the QAPI/QAA committee membership. To be reviewed at Quarterly QAPI/QAA Meeting 6/30/2017.
5. Person responsible: Absolut Facilities Clinical Chief Officer.

E3BP 402.5(c):REQUIREMENTS BEFORE SUBMITTING A REQUEST FOR

REGULATION: Section 402.5 Requirements Before Submitting a Request for a Criminal History Record Check. ...... (c) The provider shall obtain the signed, informed consent of the subject individual in the form and format specified by the Department which indicates that the subject individual has: (1) been informed of the right and procedures necessary to obtain, review and seek correction of his or her criminal history information; (2) been informed of the reason for the request for his or her criminal history information; (3) consented to the request for a criminal history record check; and (4) supplied on the form a current mailing or home address.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: May 1, 2017
Corrected date: June 30, 2017

Citation Details

Based on interview and record review during the Standard survey completed on 5/1/17, Criminal History Record Check (CHRC) consent forms were not completely filled out. Issues included, the Authorized Person did not complete form DOH CHRC 102, Acknowledgment and Consent Form For Fingerprinting and Disclosure of Criminal History Record Information. Specifically, Section 3 -Agency Authorized Person Information, was not completed. This affected four of five employee files reviewed for CHRC compliance. The finding is: 1. Review of the personnel files for Employee #2 (Helping Hand), Employee #3 (Certified Nurse Aide), Employee #4 (Agency Certified Nurse Aide) and Employee #5 (Certified Nurse Aide), on 4/26/17 and 4/27/17 revealed the DOH CHRC 102 form, Acknowledgement and Consent Form for Fingerprinting and Disclosure of Criminal History Record Information, was not completely filled out. Further record review at these same times revealed Section 3- Agency Authorized Person Information was blank for all four employees, including the Signature of the Authorized Person section. Interview with the Human Resources/ Medical Records Coordinator (Authorized Person) on 4/26/17 at approximately 2:30 PM revealed she has been the Authorized Person for a few months and during that time, she has not completed Section Three of any CHRC Form 102 because she was not trained to do so. Per Part 402 - Criminal History Record Check; A provider requesting a criminal history record check pursuant to this Part shall do so by completing and submitting a form developed and provided by the Department after consultation with the Division and transmitting two sets of fingerprints to the Department. An authorized person, and only an authorized person, shall complete such form and shall submit the original with the authorized person's signature (not a facsimile signature) and two sets of fingerprints to the Department not more than ten days (excluding Saturdays, Sundays and legal holidays) after taking the fingerprints of the prospective employee. The Department shall maintain such form, in the form and format prescribed by the Department 402.6(b)

Plan of Correction: ApprovedMay 25, 2017

1. ?DOH CHRC 102? forms identified by the department of health as incomplete in section three were addressed immediately by the Human Resource Director.
2. A 100% facility audit has been completed of all active employee charts to ensure proper compliance with regulation 402.5 (c). This audit will insure all sections of the ?DOH CHRC 102? form have been completed with special attention to section three. All identified sections will be completed and incompliance by 5-26-2017. Date for completion 5-26-2017.
3. Absolut facilities management will conduct an in-service with Absolut Care of Houghton?s Human Resource Director and Administrator. Which will include the proper completion of all sections of ?DOH CHRC 102? form to be completed with special attention to section three. Date for completion 5-26-2017.
4. With all new hires the ?DOH CHRC 102? form will be audited monthly by the Administrator/designee to ensure compliance and will be reviewed at the quarterly QAPI meeting. This process will continue for a period of three months at which time it will be re-evaluated by the QAPI Team. To be reviewed at Quarterly QAPI/QAA Meeting 6/30/2017.
5. Person responsible: Administrator

FF10 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: 483.10 (c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. (iv) The right to receive the services and/or items included in the plan of care. (v) The right to see the care plan, including the right to sign after significant changes to the plan of care. (c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-- (i) Facilitate the inclusion of the resident and/or resident representative. (ii) Include an assessment of the resident?s strengths and needs. (iii) Incorporate the resident?s personal and cultural preferences in developing goals of care. 483.21 (b) Comprehensive Care Plans (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident?s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident?s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 1, 2017
Corrected date: June 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility did not periodically review and revise the Comprehensive Care Plan (CCP). Four (Resident #32, 53,100,115) of 32 residents reviewed for CCP's did not have Care Plan revisions to reflect Resident to Resident physical encounters and interventions (#53, 100) , Advanced Directive changes (#32), and the use of a bed alarm (#115). The findings are: 1. Resident #32 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE] revealed the resident is severely cognitively impaired. Review of the MOLST (Medical Orders for Life Sustaining Treatment - conveys resident wishes regarding cardiopulmonary resuscitation (CPR - artificial ventilation and chest compressions) and other life sustaining treatment) signed by the Physician on [DATE] included the following: -DNR Order: Do Not Attempt Resuscitation (CPR) (Allow Natural Death). -Comfort measures only. Comfort measures are medical care and treatment provided with the primary goal of relieving pain and other symptoms and reducing suffering. Reasonable measures will be made to offer food and fluids by mouth. Medication, turning in bed, wound care and other measures will be used to relieve pain and suffering. Oxygen, suctioning and manual treatment of [REDACTED]. -Do not intubate (DNI). Do not place a tube down the patient's throat or connect to a breathing machine that pumps air into and out of lungs. Treatments are available for symptoms for shortness of breath, such as oxygen and [MEDICATION NAME]. -Do not send to the hospital unless pain or severe symptoms cannot be otherwise controlled. -No feeding tube. -No IV (intravenous - within vein) fluids. -Determine use or limitation of antibiotics when infection occurs. Review of Care Plan, Care Plan Closed Date [DATE], included the following: -Focus: Advanced Directives - DNR, MOLST -Goal: Wishes will be honored throughout her stay. -Interventions: Limited Medical Interventions, DNI, send to hospital if necessary, no feeding tube, determine use or limitation of antibiotics when infection occurs. Interview with the Registered Nurse (RN) Director of Nursing (DON) on [DATE] at 10:49 AM revealed, I would expect the changes from the updated MOLST to be reflected on the Care Plan as soon as those changes were made. The Social Worker and/ or nurse is responsible to make the updates on the Care Plan. 2. Resident #53 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, is understood, and understands. Review of a Progress Notes, and Behavior Note dated [DATE] revealed the Resident #53 had a male resident (Resident #100) that lacks capacity in her room. Review of Progress Notes, and Incident Note dated [DATE] included, Resident #53 was noted to be engaging in promiscuous behaviors with another resident (Resident #100) in the hallway this evening. Review of Care Plans revealed the Care Plan was not revised to include the above behaviors or interventions for the behavior. 3. Resident #100 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is severely cognitively impaired, is understood, and understands. Review of Progress Notes, Behavior Note dated [DATE] revealed Resident #100 was in a cognitively intact female resident's room (Resident #53). Review of Progress Notes, Behavior Note dated [DATE] included, Noted to be kissing [MEDICATION NAME] with the other resident (Resident #53). Review of Care Plan revealed the Care Plan was not revised to include the above behaviors or interventions for the behavior. During an interview on [DATE] at approximately 8:10 AM the Social Worker stated that Resident #100 lacks capacity and the Care Plan should be revised to include these behaviors and interventions to keep both Resident #100 and Resident #53 safe. Review of facility policy entitled Care Plans, dated ,[DATE], included to update the Care Plan routinely with changes in resident status and maintain Care Plan for accurate and current reflection of resident. 4. Resident #115 was admitted on [DATE] and has a [DIAGNOSES REDACTED]. Additionally, the MDS documented that the resident has had a fall since admission without injury and requires extensive assist of one staff member with transfers, ambulation and toileting needs. Review of the CCP with a revised date of [DATE] revealed the resident is at risk for falls related to a history of falls, dementia [DIAGNOSES REDACTED]. The CCP did not include the use of a bed alarm. Review of the Kardex (guide used by staff to provide care) dated [DATE] revealed the guide did not include the use of a bed alarm. During an interview on [DATE] at 12:14 PM, Registered Nurse (RN) #2 stated that a bed alarm is not documented on the Kardex and does not believe the resident uses a bed alarm. During an observation with RN #2 on [DATE] at approximately 12:17 PM a bed alarm was observed on the resident's bed under the bottom sheet. During an interview on [DATE] at 12:25 PM, Certified Nurse Aide (CNA) #1 stated that the resident has had a bed alarm for approximately six months. During an interview on [DATE] at 12:27 PM, Licensed Practical Nurse (LPN) #1 stated the resident has had a bed alarm for quite a while but could not recall a specific date when the alarm was placed. During an interview on [DATE] at 3:41 PM, the MDS Coordinator stated she attends the Care Plan meetings. The MDS Coordinator further stated, if a resident utilizes a bed alarm, it should be documented on the resident's Kardex and Care Plan. Review of a facility policy and procedure entitled Care Plans dated ,[DATE] revealed each discipline is responsible to update the Care Plan daily as a change with a resident condition warrants a new focus, goal or intervention. Review of a facility document entitled Standard of Care Safety/ Prevention of Falls dated ,[DATE] revealed to place specific interventions on the Care Guide. 415.11(c)(2)(iii)

Plan of Correction: ApprovedJune 6, 2017

1) IDT (DON, ADON, RCC's, Administrator, Social Worker, Therapy, MDS Coordinator, and Activity's Director)review of survey findings for necessary CCP revisions, completed 5/1/2017.
? Resident # 32 ? IDT reviewed resident?s CCP. Education provided to IDT of the team regarding updating CCP to reflect revisions to resident?s plan of care immediately. This includes changes in resident status, changes in plan of care and should be a current, accurate reflection of the resident. Resident #32 CCP was closed prior to corrective action being done to the CCP due to resident passing at facility on 4/28/2017.
? Resident # 53 ? IDT revised resident?s CCP to include a focus and interventions for history of sexual aggression which may include agitation with re-direction.
? Resident # 100 ? IDT revised resident?s CCP to reflect interventions necessary to keep resident #100 safe from victimization related to his lack of capacity and sexually inappropriate behaviors.
? Resident # 115 ? IDT reviewed resident?s status and appropriateness for use of bed alarm. The bed alarm was discontinued for resident #115. Care plan accurately reflects resident?s current status. IDT members educated regarding the need to verify accuracy of care plan to resident?s current status.
2) All residents have been identified as being at risk for deficient practice. The facility will complete an audit by 6/2/17, of all CCP?s with special focus on resident to resident issues, Advanced Directives and the use of alarms to ensure all care plans accurately reflect current status with clinically appropriate goals and interventions.
3) The DON/ADON will provide education by 6/2/17 to all members of the IDT to review the regulation and expectation related to maintaining and updating plan of care
The IDT ? will complete random weekly audits of no less than 5 care plans per week to ensure the CCP reflects the most current care needs. Any issues identified will result in further education and counseling as indicated. Weekly audits will continue until the next Quarterly QAPI meeting where ongoing frequency and need for adjustments will then be determined. To be reviewed at Quarterly QAPI/QAA Meeting 6/30/2017.
4)DON responsible

ZT1N 713-1:STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 1, 2017
Corrected date: June 30, 2017

Citation Details

Based on observation and interview during the Standard survey completed on 5/1/17, resident rooms did not meet New York State Standards for Nursing Home Construction Projects. Issues included, resident rooms were not equipped with at least one light fixture for night lighting, that shall be switched at the entrance to each resident room. This affected one (200 Unit) of four resident units. The findings are: 1. Observations on the 200 Unit, on 4/27/17 from approximately 12:15 PM until 12:55 PM, revealed Resident Rooms #201, 202, 203, 206, 207, 208, 209, 211, 212, 213, and 214 were not equipped with night lighting fixtures. 2. Observations on the 200 Unit, on 4/27/17 from approximately 2:15 PM until 2:25 PM revealed the Environmental Services Director attempted to determine what the light switches at the room entrances, in Resident Rooms #207 and 208, controlled and found that the switches did not control any lighting fixtures nor any duplex electrical outlets in these rooms. Interview with the Environmental Services Director on 4/27/17 at approximately 2:20 PM revealed he did not know what the light switches at the entrances to any of the 200 Unit Resident Rooms controlled. Interview with the Corporate Maintenance Director on 4/27/17 at approximately 2:40 PM revealed the 200 Unit was an addition to the original building, and the addition was constructed around 1992. The New York State Standards for Nursing Home Construction Projects Completed or Approved between (MONTH) 2, 1990 and (MONTH) 31, 2010, 713-3, states residents' rooms shall have general lighting and night lighting. It further states a reading light shall be provided for each resident and at least one light fixture for night lighting shall be switched at the entrance to each resident room. 713-3.25(d)

Plan of Correction: ApprovedJune 6, 2017

1. A 100% facility audit has been completed of all resident rooms to ensure proper night lighting, to meet building code New York state standards of construction 713-1. Date for completion 5-19-2017.
2. Maintenance, nursing, dietary, housekeeping, activities and management personnel have received an in-service on the importance of a doorway switch operating a functioning night lighting fixture in each resident?s room. Staff educated to use the computed based maintenance system to inform the maintenance department and administrator of indentified night lighting issues. Date for completion 5-26-2017.
3. Maintenance Director will install wall mounted lights by 6-29-17 for all effected rooms found in the internal audit of resident rooms and those room identified by the state.
4. All resident rooms doors will be audited monthly by the Administrator/designee after the lighting correction is made, to ensure compliance. Findings will be reviewed at the quarterly QAPI meeting. This process will continue for a period of three months at which time it will be re-evaluated by the Maintenance Director and Administrator. To be reviewed at Quarterly QAPI/QAA Meeting 6/30/2017.
5. Person responsible: Administrator.

FF10 483.25(b)(1):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES

REGULATION: (b) Skin Integrity - (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual?s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 1, 2017
Corrected date: June 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 5/1/17, the facility did not provide a resident having pressure ulcers with necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. One (Resident #125) of three residents reviewed for pressure ulcers had issues that involved a delay in the assessment of a pressure injury and treatment order recommendations made by the Wound Specialist were not initiated as planned. The finding is: 1. Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/12/17 revealed the resident is cognitively intact, is understood, and understands. Review of a Provider Pressure Injury Assessment and Orders form, signed and dated by the Wound Specialist Physician on 4/20/17 revealed an assessment of a DTPI (deep tissue pressure injury, discolored intact skin due to damage of underlying soft tissue) located on the bottom of the L (left) foot. The assessment documented an approximate date of onset as 4/12/17. The pressure injury measured 7 cm (centimeters) in length (L) x (by) 3 cm in width (W) x 0 cm in depth (D). The treatment order documented on the form was [MEDICATION NAME] (a gel like dressing that promotes healing). Review of the entire medical record revealed there was no assessment of the bottom of the left foot 4/12/17 through 4/19/17. Review of an Order Summary Report with a date range of 4/1/17 through 4/27/17 revealed there was no Physician's order for a treatment to the bottom of the left foot. Review of the Treatment Administration Record (TAR) dated 4/1/17 through 4/30/17 revealed there was no treatment provided to the bottom of the left foot 4/21/17 through 4/30/17. Interview with the Wound Specialist Physician on 4/28/17 at approximately 9:53 AM revealed, I would expect the treatment that I ordered was being done. If the facility MD (medical doctor) did not agree with what I ordered, I would expect the facility MD to order a new treatment, and I would expect to be notified of the new treatment plan. Interview with the Primary Physician on 4/28/17 at approximately 1:58 PM revealed, I would expect nursing to advise that there is an ulcer, and that I would be notified. I would also expect when the Wound MD sees the patient that the recommendations would be forwarded to me for approval. Review of a Provider Pressure Injury Assessment and Orders form, signed and dated by the Wound Specialist Physician on 4/28/17 revealed the pressure ulcer on the lateral bottom of the left foot measured overall 8.5 cm (L) x 3.5 cm (W); of which 5.0 cm (L) x 3.5 cm (W) x <0.1 cm (D) presented as a DTPI, and 4.0 cm (L) x 3.5 cm (W) x <0.2 cm (D) presented as a Stage III pressure ulcer. The recommended treatment order by the Wound Specialist Physician was documented as Santyl (sterile ointment to remove dead tissue) apply to both areas. Observation of the left lateral foot on 4/28/17 at approximately 9:53 AM revealed a pressure ulcer that measured overall approximately 8.5 cm (L) x 3.5 cm (W). Within the overall wound approximately 5 cm (L) x 3.5 cm (W) of ulcer was intact (DTI), and approximately 4 cm (L) x 3.5 cm (W) was open (Stage III). The pressure ulcer had macerated (softness as a result of wetness) edges, a scant amount of drainage, and no signs or symptoms (s/s) of infection. Review of Treatment Administration Record (TAR) dated 4/4/17 through 4/30/17 revealed there was no treatment provided to the bottom of the left foot 4/21/17 through 4/30/17. Review of TAR dated 5/1/17 through 5/31/17 revealed there was no treatment provided to the bottom of the left foot on 5/1/17. Review of the Clinical Physician Orders revealed the following order with a start date of 4/29/17; Apply Santyl to left lateral foot wound once daily. Cover with DSD (dry sterile dressing). Observation of the left foot on 5/1/17 10:36 AM revealed the left foot was wrapped in Kerlix (sterile gauze dressing used to wrap wounds) with an ABD pad (absorbent dressing) covering the wound base. The ABD dressing was observed to have a moderate amount of dried drainage on the pad. Interview with Licensed Practical Nurse (LPN #5) on 5/1/17 at approximately 9:52 AM revealed, I worked the weekend (4/29/17 and 4/30/17), I wrapped his legs in ace wraps (elastic bandage) but didn't change the Kerlix. I didn't see a treatment in the TAR but we didn't have a treatment nurse either on the weekend and I usually don't get a chance to do my treatments because of time. Interview with the Director of Nursing (DON) on 5/1/17 at approximately 9:54 AM revealed, The ADON (Assistant Director of Nursing) put the treatment order into the computer system but never sent it (the order) to the TAR, so the treatment was not completed Friday, Saturday, or Sunday. Review of facility policy entitled Assessment and treatment of [REDACTED]. - It is the practice of this facility to ensure residents having pressure ulcers receive necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. - Initiate appropriate treatment per treatment protocol and physician order. 415.12(c)(2)

Plan of Correction: ApprovedJune 6, 2017

1. Resident # 125 wound assessments, orders and treatment plan reviewed and updated to reflect current wound numbers, status and plan of care.
2. Implement a structured process to communicate the Wound Specialist recommendations to the resident?s PCP within 24 hours for approval and orders. The process will be as follows: The RCC nurses round with the Wound Specialist to assess wound status, barriers to healing, and discuss recommendations. At the completion of Wound Rounds the RCC?s will document current status in the resident?s wound assessment(s), update the PCP of changes, review Wound Specialist recommendations with PCP and obtain orders as necessary.
3. For those residents not seen by the Wound Specialist the RCC/Nursing Supervisor will complete the weekly Wound Assessment(s), update PCP on current status, discuss treatment options/recommendations and obtain orders as necessary.
4. The facility will complete an audit weekly for 6 weeks of all residents with wounds to ensure the Wound Round process as described in number 2 above has been fully implemented and followed. Any issues identified will result in further education and counseling as indicated. At the completion of the initial 6 week audit if no issues are identified the audit will be completed monthly for 3 months. Random audits will continue until the next quarterly QAA meeting where ongoing frequency and need for adjustments will then be determined.
5. Education of nursing staff for entering PCP treatment orders into the PCC system to transfer correctly to the resident?s treatment record for completion and documentation.
6. Provide education to LPN,RN staff on all shifts regarding the expectation for treatment documentation and completion to be done as ordered. Staff found not to be following the resident?s treatment plan as ordered will be subject to counseling and disciplinary action.
7. The facility will complete an audit of no less than 5 treatment records weekly to ensure ordered treatments are accurately present on the TAR and are being completed and documented as ordered. If no further issues are identified the audit will be conducted monthly for 3 months.
8. All Audits be reviewed at Quarterly QAPI/QAA Meeting 6/30/2017.
9. DON responsible.