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NYS Health Profiles
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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 23, 2019
Corrected date: October 4, 2019
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not provide adequate documentation for the appropriateness of administration of a PRN (as needed) [MEDICAL CONDITION] Medication. This was evident for one (Resident # 101) of five residents reviewed for Unnecessary Medications. Specifically, Resident # 101, a newly admitted resident, was administered [MEDICATION NAME] (generic [MEDICATION NAME], an antianxiety medication) on multiple occasions without documentation of the specific behaviors being exhibited, resident specific non-pharmacological interventions attempted, or assessment of the effectiveness of the medication. The finding is: Resident # 101 was admitted to the facility on [DATE] for short term rehabilitation with [DIAGNOSES REDACTED]. The Admission MDS assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) Score of 12, indicating that the resident was moderately impaired in cognition. The MDS documented the resident's Mood score was nine, which indicated Mild Depression. There were no behaviors documented during the assessment period. The MDS documented there were no Antipsychotic, Antidepressant, Antianxiety or Hypnotic medications administered during the assessment period of 7/2/19-7/9/19. The resident's Behavior Comprehensive Care Plan (CCP) dated 7/5/19 documented the resident's behavior was disruptive, the resident yells out, refuses redirection and was non-compliant with call bell use. The interventions include to distract the resident, use prompting, encourage and redirect. A Nursing Progress Note dated 7/9/19 at 7:49 AM documented the resident was noted with agitation and was yelling out to nursing staff for information regarding why he was in the facility. The additional behavior described was the resident was attempting to stand and self ambulate. The resident was redirected with positive effect. A Nursing Progress Note dated 7/9/19 at 7:55 PM documented the resident was having behavioral issues (not described) and the Physician was called. A physician's orders [REDACTED]. There was no documentation in the progress notes or CCP describing the specific resident's behavior that warranted the use of the medication, no documented non-pharmacological interventions attempted and no follow up documented addressing the effectiveness of the medication. The Medication Administration Record [REDACTED]. A Psychiatric Consultation dated 7/15/19 documented the resident was cooperative but had increased confusion and forgetfulness. The [DIAGNOSES REDACTED]. [MEDICATION NAME] 0.25 mg PO (by Mouth) twice daily and [MEDICATION NAME] (Quetiapine) (an Antipsychotic) 25 mg PO QHS (every Hour of Sleep) were added to resident's medication regimen. A Nursing Progress Note dated 7/15/19 at 12:33 PM documented the resident's agitation as verbally yelling and refusing to stay seated. The note documented that the resident was standing without assistance. The Physician was called and an order for [REDACTED]. The MAR indicated [REDACTED]. The [MEDICAL CONDITION] Medication CCP developed on 7/2/19 and updated on 7/15/19 documented the resident was seen by the Psychiatrist on 7/15/19 and [MEDICATION NAME] and [MEDICATION NAME] (Quetiapine, an antipsychotic) were added to the resident's medication regimen. No further descriptions of the reasons for the medication, no updated review of the goals and interventions were documented. A Physician's Note dated 7/24/19 at 3:38 AM documented that [MEDICATION NAME] 0.5 mg IM was ordered for complaint by the nursing staff of agitation with no further description of the behaviors exhibited. The Medication Administration Record [REDACTED]. The Psychiatric Consultation dated 7/29/19 documented the resident was seen for forgetfulness, increased confusion and repetitive questioning wanting to know why he was in the nursing home. [DIAGNOSES REDACTED]. The [MEDICATION NAME] ([MEDICATION NAME]) was increased to 0.5 mg PO twice daily, discontinue the [MEDICATION NAME] (Quetiapine), start Trazadone (an Antidepressant) 50 mg PO QHS and [MEDICATION NAME] ( a Mood Stabilizer) 125 mg PO every morning. The MAR indicated [REDACTED]. There was no documentation of the behavior, non-pharmacological interventions attempted or documentation of the effectiveness of the medication. The resident was observed on 8/19/19 at 9:00 AM and during lunch at 1:00 PM. He stated that something was wrong but he did not know what. The resident denied pain. The resident was observed to refuse the lunch tray. The resident stated he was confused and tired. The Behavior CCP, developed 7/5/19 and last updated on 8/21/19, documented the resident with increased agitation, repeatedly asking for his family, non-compliance with transfer status and that the most recent BIMS indicates severe impairment at this time. The resident was observed on 8/23/19 at 9:57 AM. The resident was in bed, the room was dark and his head was covered the blanket. The Licensed Practical Nurse (LPN)/Charge Nurse was interviewed on 8/23/19 at 9:45 AM. The LPN stated the resident is still on a rehabilitation program and is expected to be discharged home. The LPN stated that he goes to the rehabilitation program in the afternoon, usually after lunch, because in the morning he prefers not to get out of bed and is more alert in the afternoon. The LPN stated that the resident is not aggressive, but has had increased confusion and wants to go home. The LPN further stated that the resident's agitation is exhibited by multiple questions because he has poor recall and that he was not violent. The Psychologist was interviewed on 8/23/19 at 10:53 AM and stated the resident was having adjustment difficulties with anxiety with cognitive deficit, was non-compliant and had a [DIAGNOSES REDACTED]. The resident's short term memory problem was the reason he asks repetitive questions and is confused. The resident's Social Worker (SW) was interviewed on 8/23/19 at 11:15 AM. The SW stated that the resident is very confused, has no [MEDICAL CONDITION] and is not a danger to himself or others. The resident's 7:00 AM-3:00 PM Certified Nursing Assistant (CNA) was interviewed on 8/23/19 at 11:30 AM. The CNA stated that the resident was confused and does not always want care. The CNA stated that the resident responds well to talking about the resident's family. The CNA stated that the resident has had no aggression but will raise his voice. The CNA further stated that the resident often refuses assistance at meals and wants to stay in his bed. . The resident's Attending Physician was interviewed on 8/23/19 at 11:42 AM. The Physician stated that when the nurses called for a medication the resident's behaviors were described as serious and that was the reason for the medication orders. The Physician stated that Dementia is very difficult to treat and sometimes the medications work and sometimes they do not. The MD sated that he would again review the chart, examine the resident and review the medication needs. The Director of Nursing Services (DNS) was interviewed on 8/23/19 at 12:00 PM. The DNS stated that non-pharmacological interventions should be documented prior to the administration of the stat medications. The Registered Nurse/RN on the 3:00 PM-11:00 PM shift was interviewed on 8/23/19 at 1:10 PM. The RN stated that the physician was called for the resident's increased anxiety. The RN stated that the resident had been unable to calm down and the Physician was called and gave a telephone order. The RN was unable to give further details of the behavior or interventions that had been attempted by the unit nursing staff. 415.12(l)(2)(i) | Plan of Correction: ApprovedSeptember 13, 2019 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-758 Free from Unnecessary [MEDICAL CONDITION] meds/PRN use Immediate Corrective Action: Resident #101 was seen by the Psychiatrist for review of his [MEDICAL CONDITION] medications. The psychiatrist discontinued the [MEDICATION NAME] and initiated a dose reduction on the standing [MEDICATION NAME]. The notes regarding PRN [MEDICAL CONDITION] medication usage were reviewed and the Nurses were individually inserviced by the DNS. Complete 9/12/2019 Identification of other residents that may have been affected: The DNS audited all residents that utilized PRN [MEDICAL CONDITION] x 60 days retrospectively. Appropriate documentation was noted on the PRN use of [MEDICAL CONDITION]. Complete: 9/13/2019 Systematic Changes: The policy for [MEDICAL CONDITION] medications were reviewed. No revision was required. An Inservice will be completed for all Licensed Nursing staff, educating on the appropriate documentation of behaviors, interventions, and the follow-up on the effectiveness of the interventions and/or medication administration of PRN [MEDICAL CONDITION]. Responsible Party: Assistant Director of Nursing / Designee Completion: 10/4/2019 Ongoing Monitoring: The Director of Nursing Services has developed an audit tool and will audit PRN [MEDICAL CONDITION] usage, for appropriate documentation and follow-up on the effectiveness of the medication. The DNS/designee will follow-up with the nurse responsible, if appropriate documentation is not present. All PRN doses will be audited for a period of 6 months. Results of auditing will be reported to the QA committee, Monthly. Responsible party: Director of Nursing / Designee On going |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 23, 2019
Corrected date: October 4, 2019
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification survey, the facility did not ensure each resident was treated treated in a dignified manner that promotes maintenance or enhancement of his or her quality of life. This was identified for one (Resident #269) of one resident reviewed for dignity. Specifically, the facility did not ensure Resident # 269 was dressed in his own clothes while in eating lunch in the dining room on 8/21/19. The resident was observed dressed in a Hospital gown. The finding is: Resident # 269 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) Assessment had not been completed as of 8/21/19. Resident #269 was observed being wheeled into the unit dining room on 8/21/19 at 12:20 PM by a Certified Occupational Therapy Assistant (COTA). The resident was dressed in double hospital gowns and a white sheet covered his legs. The resident was observed being wheeled back to his room at 1:00 PM. There were 16 residents in the Dining Room and 6 staff members assisting with tray delivery and feeding. The resident's 7:00 AM -3:00 PM Certified Nursing Assistant (CNA) was interviewed on 8/21/19 at 1:00 PM and stated the resident was admitted a few days ago and she dressed him in hospital gowns because he has no clothes. Upon observation of the resident's closet, with the CNA present, no clothing or personal belongings were present. She stated she did not inform any one about the resident having no clean clothes. The unit Medication Licensed Practical Nurse (LPN) was interviewed on 8/21/19 at 1:08 PM and stated that no one informed her about the resident's lack of clothes. The unit Charge LPN was interviewed on 8/21/19 at 1:10 PM. She was unaware that the resident had no clothes to wear. The unit Charge LPN was interviewed on 8/22/19 at 10:32 AM. The Charge LPN stated that Resident #269 was admitted on [DATE]. She stated that they investigated the resident's missing clothing on 8/21/19 and found 4 pairs of soiled pants and 5 Tee Shirts in a white mesh bag in the hamper. She stated the soiled clothing was in a white mesh bag which indicates that laundry will be done by family. The Charge LPN stated that the Social Worker called the family on 8/21/19 afternoon and was told that the family wanted the facility to do the resident's the laundry. She stated that the resident was observed wearing his own clothes until 8/20/19. She stated that the assigned CNA should have notified the unit Medication LPN Nurse or Charge LPN that the resident had ran out of clothing. She also stated that the Rehabilitation Department Director has been told to provide inservice to their staff regarding appropriate attire for out of room and public places. She stated that upon admission the Concierge asks the family if they would do the Laundry or would like the facility to do it and emails a notification to all the concerned Departments. She stated that there is only one Concierge who was out last week and returned to work on 8/20/19. She further stated that the Concierge did not meet with the resident or the family and sent no email to the Departments notifying the Departments of the plan for laundering the resident's clothing. The COTA was interviewed on 8/22/19 at 12:16 PM. She stated that she provided Occupational Therapy (OT) to the resident in his room on the morning of 8/21/19 and the CNA helped wash him but could not find clean clothes to dress him so she dressed the resident with double gowns and a sheet covered his legs. The COTA further stated the resident is alert and oriented and wanted to go into the dining room for Lunch. She stated the CNA did try to find clothes and she should have communicated with nurses about the clothing issue. The Housekeeping Director was interviewed on 8/22/19 at 10:47 AM and stated that he was notified on 8/21/19 afternoon by the Nurses that the resident had run out of clothes to wear. The Director of Nursing Services (DNS) was interviewed on 8/22/19 at 2:00 PM. He was unaware that there was no replacement to cover the Concierge was out and stated he would look into it. 415.3(c)(1)(i) | Plan of Correction: ApprovedSeptember 11, 2019 F-550 Resident Rights/Exercise of Rights Immediate Corrective Action: Rehab staff were immediately inserviced by the Rehab Director with regards to resident dignity and bringing residents to the dinning room in a gown. Housekeeping/Laundry completed a laundry cycle for this resident to assure he had adequate clothing available. The family was contacted to provide additional clothing. Facility provided additional clothing from donation stock to assure enough for clothing was available. Completed 8/26/2019 Identification of other residents that may have been affected: Housekeeping Director completed a house wide audit. This audit assessed the amount of clothing each resident had, assuring it was sufficient enough for their stay in the facility, accommodating for the length of the laundry cycle. Residents identified as not having enough clothing were reported to nursing, housekeeping, and social work. The resident/families will be encouraged to provide additional clothing. Completed 8/27/2019 Systematic Changes: The Resident?ÇÖs Personal Possessions Policy and Procedure was reviewed. No revision was required. It was identified that this resident did not arrive with a sufficient amount of clothing. Inservice will be completed, educating the nursing staff, rehab staff, and housekeeping/laundry staff. Inservice will focus on reporting to department heads, those residents that require additional clothing. Responsible Party: Assistant Director of Nurses / Designee Completion date: 10/4/2019 Ongoing Monitoring: Housekeeping will continue an audit of clothing weekly, consisting of each 1 unit per week for 3 months. Residents noted without sufficient amount of clothing will be followed-up by Social Work and/or Nursing. Results will be reported to the QA committee, Monthly Responsible Party: Housekeeping Director / Designee On going |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 23, 2019
Corrected date: December 13, 2019
Citation Details 2012 NFPA 101: 9.2 Heating, Ventilating, and Air-Conditioning. 9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. 2012 NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. 5.4.8 Maintenance. 5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: Standard for Fire Doors and Other Opening Protectives Chapter 19 Installation, Testing, and Maintenance of Fire Dampers 19.4* Periodic Inspection and Testing. 19.4.1 Each damper shall be tested and inspected 1 year after installation. 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. 19.4.2 All tests shall be completed in a safe manner by personnel wearing personal protective equipment. 19.4.3 Full unobstructed access to the fire or combination fire/ smoke damper shall be verified and corrected as required. 19.4.4 If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in place if so equipped. This requirement is not met as evidenced by: Based on documentation review and staff interview during the recertification survey, there was no documentation of the required four-year maintenance of the fire/smoke dampers associated with the building's heating, ventilation and air conditioning (HVAC) systems. The findings are: During a documentation review on 08/23/19 at approximately 10:50am, there was no documentation of the required four-year maintenance of the fire/smoke damper associated with the building's HVAC systems. In an interview during the exit conference on the same day at approximately 1:55pm, the Director of Maintenance stated that there are no records on file from the previous maintenance director for the damper maintenance and that the required test would be completed. 2012 NFPA 101: 9.2 2012 NFPA 90A 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedSeptember 16, 2019 Immediate Action: Facility contacted fire alarm vendor to conduct the 48 month fire damper inspection. Identification of other residents: At this time there were no residents affected by this practice. Systematic Changes: The Director of Maintenance/ Designee will audit 48 month fire damper inspection annually for 4 years to ensure continued compliance. QA: Keep a log of the required 48 month inspection to ensure that the inspection is done timely to ensure NFPA compliance. Responsible Party: Maintenance Director or Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 23, 2019
Corrected date: December 13, 2019
Citation Details 2012 NFPA 101: 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25: 13.4.2 Check Valves. 13.4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate correctly, move freely, and are in good condition. 2011 NFPA 25: 14.2 Internal Inspection of Piping. 2011 NFPA 25: 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. This requirement is not met as evidenced by: Based on observation, documentation review and staff interview during the recertification survey, the facility did not ensure that the automatic sprinkler systems are inspected, tested , and maintained in accordance with the requirements of 2011 NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Reference is made to the lack of an up to date five-year check valve inspection, and there was no documentation to indicate that an internal inspection of the sprinkler piping was completed within the last five years. The findings are: During a documentation review on 08/23/19 at approximately 10:45am, the following was noted: - There was no documentation for an up to date five-year check valve inspection. The last documented check valve inspection was completed on 04/23/13. - There was no documentation of an internal inspection of the sprinkler piping completed within the last five years for the sprinkler system that has been in operation for over five years. In an interview during the exit conference on the same day at approximately 1:50pm, the Director of Maintenance stated that the required tests would be scheduled with the sprinkler company. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 13.4.2, 14.2.1 10 NYCRR 415.29 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedSeptember 16, 2019 Immediate Action: Facility contacted fire safety vendor to conduct both the five year check valve inspection and five year internal pipe inspection. Identification of other residents: At this time there were no residents affected by this practice. Systematic Changes: The Director of Maintenance/ Designee will audit the five year check valve inspection and five year internal pipe inspection annually to ensure compliance. QA: Keep a log of these 2 required 5 year inspections to ensure that the inspections are done in a timely fashion. Responsible Party: Maintenance Director or Designee |