Momentum at South Bay for Rehabilitation and Nursing
April 7, 2017 Certification Survey

Standard Health Citations

FF10 483.70(i)(1)(5):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: (i) Medical records. (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 (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: April 7, 2017
Corrected date: May 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that medical records were accurately documented. This was evident for 1 of 1 resident reviewed for death (Resident #293) and two of three residents reviewed for Urinary Incontinence (Resident's #119 and #168), in a total Stage 2 sample of 17 residents. Specifically, 1) Resident #293's, Physician's Assessment/Progress Note lacked complete documentation reflecting the resident's Advance Directives, Date of Birth, Consultations, Laboratory results and Room Number. 2) Resident #119 was identified to have a decline in bladder function from always continent to frequently incontinent and there was no documented evidence that a physician's bladder assessment was completed to determine the cause/type of the decline. 3) Resident #168 was identified to have a decline in bladder function from occasionally incontinent to always incontinent and there was no documented evidence that a physician's bladder assessment was completed to determine the cause/type of the decline. The findings are: 1) Resident #293 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. A Hearing/Speech/Language/Dysphasia Screening Form Consultation dated 2/9/17 was completed. A Do Not Resuscitate (DNR) form was signed and in effect by the resident on 2/17/17. laboratory results dated [DATE] were completed. A Physician's Assessment/Progress Note dated 2/22/17 had no documented evidence that the resident had a DNR order. There was a space under the title of Advance Directives that could have been checked by the Physician but was blank. Additionally, the Physician's assessment/Progress Note had missing information regarding the resident's Date of Birth, Weight, Room Number, Consultations and Laboratory test results. An interview was held with the Director of Nursing Services (DNS) on 4/7/17 at 10:30 AM. The DNS reviewed the Physician's Assessment/Progress Note dated 2/22/17 and stated that there was missing information and that the form should be filled out completely by the Physician. The Physician was not available for interview.
2) Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 5-day Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #119 had clear speech, could understand and be understood. The resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #119 was cognitively intact. The resident required extensive assistance of two staff members for toileting and was always continent of bladder. The Nursing Admission Evaluation, Comprehensive Admission Assessment (CAA) section 6 Urinary Incontinence dated 1/11/2017 documented under the Comment section that Resident #119 was continent of bladder. A Readmission Significant Change MDS assessment dated [DATE] documented the resident's continency status had declined and the resident was now frequently incontinent of urine. The Nursing Admission Evaluation, CAA section 6 Urinary Incontinence dated 2/28/2017 documented under the Comment section that Resident #119 had a significant change in continence and was frequently incontinent of bladder. The Physician's Assessment/Progress notes dated 1/28/2017 through 4/2/2017 were reviewed. The notes did not address the change in the resident's continence status. An interview was conducted on 04/05/2017 at 10:11 AM with the Certified Nursing Assistant (CNA) who cares for Resident #119. The CNA stated that since the resident returned from the hospital he has been incontinent, but has improved a great deal, since he is in less pain. The CNA stated that the resident can tell her when he needs to use the toilet and has accidents only occasionally, sometimes in his sleep. An interview was conducted with the Minimum Data Set (MDS) Registered Nurse (RN) on 04/07/2017 at 9:45 AM. The RN stated that she completes the MDS for the 2 West unit and was familiar with Resident #119. The RN stated that the resident had triggered for a significant change MDS when he returned from the hospital due to a change in continence. The RN stated that either she or the RN Unit Manager would update the Comprehensive Care Plan (CCP) to reflect the resident's current status. The RN was not aware if the physician had a form for bladder assessment to determine the type of incontinence. An interview was conducted with the resident's Primary Care Physician on 04/07/2017 at 1:00 PM. The Physician stated that he would document in the residents' progress note the resident's continence status, and that it must have been an oversite if not there. The Physician stated that without the chart he could not say what he had written on the assessment/progress note form. The Physician stated that he was not sure if there is a form or a section on the assessment form that was specific to a resident's continence status and that they (the facility) would have to review the documentation they use for assessment of the residents so they can include the continence status, reason for incontinence and potential of the residents to regain continence. 3) Resident #168 had [DIAGNOSES REDACTED]. Resident #168 was admitted to the facility on [DATE], and was readmitted to the hospital on [DATE] to Rule Out a GI (Gastrointestinal) bleed. The resident was readmitted to the facility on [DATE], then discharged to the hospital on [DATE] for a blood transfusion and was readmitted to the facility on [DATE]. The resident was discharged home on[DATE]. The Initial Nursing assessment dated [DATE] documented that Resident #168 was incontinent of urine. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #168 had clear speech, could understand and be understood. The resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating that Resident #168 was cognitively intact. The resident required extensive assist of one staff person for toilet use. The resident was occasionally incontinent of urine. The Significant Change MDS dated [DATE] documented that Resident #168 had a BIMS score of 13 indicating that the resident was cognitively intact. The resident required extensive assist of one staff member for toileting and the resident was now always incontinent of urine. The Nursing Admission Evaluation, CAA section 6 Urinary Incontinence dated 12/19/2016 documented that Resident #168 had been incontinent of bladder since re-admission and that the resident was placed on a bladder schedule. The physician progress notes [REDACTED]. Review of the Physician Assessment/Progress Note form does not include an assessment of continence. The Physician Admitting/Annual History and Physical dated 12/12/2016 documented the GU ([MEDICAL CONDITION]) system section as normal. There was no area on the form that documented the resident's continence status. The Physician's Assessment/Progress notes dated 12/14/2016 through 2/8/2017 were reviewed. The notes did not include an assessment of the resident's continence status. An interview was conducted with the Registered Nurse (RN) Director of Nursing Service (DNS) on 04/07/2017 at 11:20 AM. The DNS stated that she was sure that the physician's assess the resident's continence status. The DNS did not state if the physician assessment would be documented in the medical record. An interview was conducted with the resident's Primary Care Physician on 04/07/2017 at 12:33 PM. The Physician stated that he recalled Resident #168 and that the resident went home to reside with her son. The Physician stated that he discusses the resident's continence status with the nursing staff and knows that the staff have a plan of care for the residents. An interview was conducted on 04/07/2017 at 12:47 PM with the RN unit manager of unit that Resident #168 had resided on. The RN stated that she was not aware of a specific form that the physician uses for continence assessment, but that the physician does sign off on the resident's care plan meeting minutes. 415.22(a)(1-4)

Plan of Correction: ApprovedApril 26, 2017

1.) The respective physicians for resident # 293, #119 and # 168 were notified and the clinical record was updated to reflect accurate and complete documentation and assessments as required.
2.) All residents in the facility have the potential for being affected by the deficient practice. The Medical Director will audit 10% of all physician assessments/progress notes for the past 30 days for accuracy. Review completed, no findings (4/26/17)
3.) The facilities physician assessment form will be reviewed and revised to include bladder assessments. All physicians and physician extenders will be educated on the new form and the requirement to complete all sections of forms and assessments.
4.) The Medical Director will randomly audit 10% of new/quarterly physician assessments monthly for 6 months or until 100% compliance achieved. The results of the audit will be reported to the Administrator and presented at the quarterly QA meeting.
5.) The Medical Director is responsible for the correction.
Date of correction 5/26/17

Standard Life Safety Code Citations

K307 NFPA 101:INTERIOR WALL AND CEILING FINISH

REGULATION: Interior Wall and Ceiling Finish 2012 EXISTING Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2 Indicate flame spread rating(s). _____________________

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 7, 2017
Corrected date: May 25, 2017

Citation Details

2012 NFPA 101: 19.3.3.2* Interior Wall and Ceiling Finish. Existing interior wall and ceiling finish materials complying with Section 10.2 shall be permitted to be Class A or Class B. Based on observation and staff interview, the facility did not provide documentation to indicate that wall coverings in egress corridors had a flame spread rating of Class A or Class B. This was noted on one of two floors in the facility. The findings are: On 3/31/17 between 8:30am- 2:00pm during the recertification survey, wallpaper was observed on walls of egress corridors in the B & C wings on the 1st floor. There was no documentation provided at the time of the survey to indicate the flame spread rating of the wallpaper. In an interview on 3/31/17 at approximately 1:15pm, the facility consultant stated that he would provide the specifications with the flame spread ratings. There was no documentation provided by the survey exit date. 2012 NFPA 101: 19.3.3.2 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMay 5, 2017

No residents were affected by the citation
Documentation was obtained that provided the flame spread rating as Class A for the corridors in question. (4/10/17)
The Director of Environmental Services will obtain documentation regarding flame rating of materials from any/all contractors prior to construction/renovation or remodeling at the facility and communicate such to the Administrator (5/25/17 and on-going)
The Director of Environmental Services will maintain such information in a separate binder
The Director of Environmental Services is responsible for this deficiency