Monroe Community Hospital
May 4, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.20(b)(1)(2)(i)(iii):COMPREHENSIVE ASSESSMENTS & TIMING

REGULATION: §483.20 Resident Assessment The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. §483.20(b) Comprehensive Assessments §483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychological well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnosis and health conditions. (xi) Dental and nutritional status. (xii) Skin Conditions. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. §483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.) (iii)Not less than once every 12 months.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for 5 of 40 residents reviewed for Comprehensive Assessments, the facility did not conduct and/or sign off initial or periodic comprehensive Minimum Data Set (MDS) Assessments. Specifically, an admission comprehensive assessment was not completed (Resident #130), quarterly MDS Assessments were not completed (Residents #8 and #12), and quarterly MDS Assessments were not signed off as being completed (Residents #2 and #3). This is evidenced by the following: 1. Resident #130 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility policy, Comprehensive Interdisciplinary Care Plan, included that the interdisciplinary team will review the Care Area Assessments (CAAs) to determine which problem area needed to be addressed in the Comprehensive Care Plan (CCP) or the rationale not to proceed with care planning for that triggered care area. The resident did not have a comprehensive admission MDS Assessment completed after admission including the CAAs. When interviewed on [DATE] at 2:23 p.m., the Registered Nurse (RN) Clinical Manager/Assessment Nurse said that a quarterly MDS Assessment was done but not an admission MDS Assessment. She said the resident should have an admission assessment. She said that the MDS nurses are now attending care plan meetings, but she was not at the [DATE] meeting for the resident. She said the RN Nurse Manager (RNM) was at the meeting. She said the team does review the CAAs but there are none for the resident. When interviewed on [DATE] at 4:09 p.m., the RNM said that the clinical manager completes the MDS Assessments, reviews the CAAs, and then writes the CCP. When interviewed on [DATE] at 9:11 a.m., the RN Perspective Payment System (PPS) Manager who oversees the MDS department, said the resident should have had an admission MDS Assessment completed by the RN Clinical Manager, and the RNM should have completed the CAAs and reviewed the CCP with the family. 2. Resident #8 was admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. The resident still resides in the facility. The resident's last MDS Assessment was a quarterly, dated as completed on [DATE]. Resident #12 was readmitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. The resident still resides in the facility. The last MDS Assessment was a quarterly dated as completed on [DATE]. When interviewed on [DATE] at 9:11 a.m., the RN PPS Manager said that Resident #8's last assessment was completed on [DATE] and a quarterly assessment should have been completed in March. She said Resident #12 was due for a quarterly or a significant change MDS Assessment in (MONTH) but it was missed. 3. Resident #2 was readmitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. The last accepted MDS Assessment was a quarterly, dated as completed on [DATE]. The computer system included: nursing home tracking date was [DATE], was created on [DATE], and that it is current but not accepted or batched. Resident #3 was readmitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. The resident still resides in the facility, and the last MDS Assessment available was dated as completed on [DATE]. When interviewed on [DATE] at 9:11 a.m., the RN PPS Manager said that she used to have a scheduler who would ensure that the MDS Assessments were completed. She said starting (MONTH) 1st, the computer software was supposed to do that. She said that they ran a report and found some late MDS Assessments but it appears some were still missed because there was a glitch in the computer software. She said Resident #3's last MDS Assessment was completed on [DATE] when he was discharged but staff never signed off on the assessment. She said Resident #2 expired on [DATE], and the MDS Assessment was completed but never signed off, therefore it was not accepted. (10 NYCRR 415.11(a)(,[DATE]))

Plan of Correction: ApprovedMay 25, 2018

F636
In direct response to the questions listed in the correspondence from NYSDOH dated (MONTH) 17, (YEAR) and received by the Facility via DOH HCS Portal Link transmittal on (MONTH) 17, (YEAR), along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The MDS for residents 2, 3, 8, 12, and 130 will be thoroughly reviewed to insure they are timely and completed accurately and signed accordingly.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Residents who may be similarly affected may be identified by determining if the admission, comprehensive assessment is complete; whether a quarterly MDS has been completed; or whether the quarterly MDS is outdated.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The PPS Manager will develop a system/procedure which will verify whether or not all scheduled MDS?s have been completed and signed in a timely and accurate fashion and in accordance with assessment requirements. The Clinical Nurse Managers will be assigned the responsibility to audit all MDS?s for their respective nursing units and submit the results of the audits to the PPS Manager. As part of the audit, the Clinical Nurse Managers shall be required to indicate what, if anything, was found incorrect on any MDS and what steps they took to rectify the situation. The PPS Manager will then verify the audit results and submit a summary to the Deputy Director and QAPI Coordinator. The Clinical Nurse Managers will be provided in-service training regarding the new system/procedure and the importance of accurate and timely MDS completion.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The QAPI Coordinator shall appoint a committee comprised of the Clinical Nurse Managers who shall also be designated to complete audits for review by the QAPI Committee. Such audits shall be completed monthly for six months and then quarterly thereafter. Audit results will be presented to the QAPI Committee at regularly scheduled meetings.
5. The date for correction action and the title of the person responsible for correction of this deficiency.
July 10, (YEAR)
PPS Manager

FF11 483.12(a)(3)(4):NOT EMPLOY/ENGAGE STAFF W/ ADVERSE ACTIONS

REGULATION: §483.12(a) The facility must- §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 10, 2018

Citation Details

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for three of eight employees reviewed, the facility did not screen for findings of abuse. Specifically, the employees were not run through the New York State Nurse Aide Registry prior to starting work. This is evidenced by the following: 1. On 5/1/18 from 1:35 p.m. to 2:12 p.m., eight employee files were provided to the surveyor for review. The files showed that Nurse Aide Registry checks for prior abuse findings were performed by the facility on 4/27/18 for three Certified Nursing Assistants (CNA) hired on: 9/4/17, 9/7/17, and 11/29/17. An interview with the Human Resources Manager (HRM) revealed they were not sure why the Nurse Aide Registry checks were run so late. The HRM stated that they could not find any documentation showing an earlier check of the Nurse Aide Registry was performed for the three CNAs in question. An interview with the Assistant Personnel Analyst (APA) revealed the CNAs were agency staff, and when she noticed the registry checks were not in the packet of information, she ran them. The APA said that the nursing office schedules agency staff and completes the nurse aide registry checks. 2. Interview with Clerk #1 in the nursing office on 5/1/18 at 2:22 p.m. revealed the Nurse Aide Registry checks usually come from the agency, and she does not run them personally. When interviewed Clerk #2 revealed they would normally run the Nurse Aide Registry check if it does not come with the agency information. 3. On 5/3/18 at 10:19 a.m., the Assistant Director of Nursing (ADON) was interviewed about abuse pre-screening related to the Nurse Aide Registry. The ADON stated that most of the process is done in Human Resources. She said they verify that CNA certification registrations are valid and would imagine they are looking for abuse as part of the abuse screening. Further interview with the ADON revealed she thinks the Nurse Aide Registry check is done by someone in personnel or staff in the nursing office would do it for the agency people. (10 NYCRR 415.4(b)(1)(ii)(b))

Plan of Correction: ApprovedMay 25, 2018

F606
In direct response to the questions listed in the correspondence from NYSDOH dated (MONTH) 17, (YEAR) and received by the Facility via DOH HCS Portal Link transmittal on (MONTH) 17, (YEAR), along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
As there were no residents identified on the CMS 2567 the question is not applicable.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any resident has the potential to be affected by a failure to verify staff via the Nurse Aide Registry.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Facility will review and revise its policy regarding the verification of applicants/employees through the Nurse Aide Registry. The policy will stipulate that Human Resources assumes all responsibility for the employment verifications processes Once completed in-service education will be presented to all applicable personnel (Human Resources, Nurse Schedulers, those with hiring authority, etc.) regarding the new policy. Current employee files will also be audited to insure they include Nurse Aide Registry checks. Scheduling staff shall be advised they cannot assign persons to work until the verification process is complete. Such verification shall be all inclusive and shall address the use of Nurse Agency Personnel as well as Facility employees.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Human Resource Manager shall advise the Quality Assurance Coordinator upon the completion of the aforementioned policy revisions. Upon completion the QA Coordinator shall appoint a committee of three persons to audit current employee files for Nurse Aide Registry checks. Additionally, a second committee shall be appointed to audit Nurse Aide Registry checks for newly hired employees. Such audits shall occur bi-monthly for three months and monthly thereafter. Results of all audits shall be reported to the QAPI Committee at its regularly scheduled meetings.
5. The date for correction action and the title of the person responsible for correction of this deficiency.
July 10, (YEAR)
Human Resources Manager

FF11 483.10(g)(14)(i)-(iv)(15):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC.)

REGULATION: §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 676), it was determined that for one (Resident #73) of two residents reviewed for notification of change, the facility did not notify the resident's representative timely with a change in condition requiring hospitalization . This is evidenced by the following: Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/6/17, revealed that the resident's cognition was severely impaired. A Registered Nurse (RN) progress note, dated 10/30/17, revealed that the resident was febrile, and diaphoretic (sweating heavily) with lung sounds identified as crackles bilaterally to the nipple line. The Nurse Practitioner was notified and the resident was sent to the hospital. There was no documentation that the resident's representative was notified that the resident had a change in condition and was sent to the hospital. A RN Manager (RNM) progress note, dated 11/1/17 at 11:37 a.m., revealed that the resident's representative was not aware that the resident was transferred to the hospital on [DATE]. The RNM notifed the family member that day. Interviews conducted on 4/30/18 included the following: a. At 1:49 p.m., the RNM said that the resident's representative called her on 11/1/17 to inform her that she would be coming in to visit the resident that day. The RNM said that it was at that time that she notified the resident's representative that the resident was in the hospital. The RNM said that the off-shift supervisor is responsible for notifying family members of changes in condition or hospitalization s that occur after normal business hours. b. At 2:14 p.m., RN #1 said that she was not aware that the resident's representative had not been notified of his hospitalization on [DATE]. She said that normally, when the resident is sent out to the hospital during off-shift hours, the nursing supervisor fills out the appropriate paperwork and notifies the family prior to transferring the resident to the hospital. Interviews conducted on 5/1/18 included the following: a. At 1:00 p.m., the Assistant Director of Nursing (ADON) said it is her expectation that the staff notify the family of a change in condition or hospitalization . She said the supervisor contacts the physician to receive an order to send the resident to the hospital. She stated that it is the responsibility of the nursing supervisor or physician to call the resident's representative to update them on the resident's condition. The ADON said the facility does not have a policy regarding notifying resident's representative of a change in condition and/or hospitalization . b. At 3:52 p.m., RN #2 said that she was the Nursing Supervisor on 10/30/17 when the resident was transferred to the hospital. She said it was the first time that she used the new system to send a resident to the hospital. RN #2 stated that she did not realize that she did not call the family until she received a call from the ADON. RN #2 said that during shift report with the oncoming supervisor, she did not report that the resident's representative needed to be notified. (10 NYCRR 415.3(e)(2)(ii)(d))

Plan of Correction: ApprovedMay 25, 2018

F580
In direct response to the questions listed in the correspondence from NYSDOH dated (MONTH) 17, (YEAR) and received by the Facility via DOH HCS Portal Link transmittal on (MONTH) 17, (YEAR), along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The Facility assigns notification responsibility to a number of different professionals depending upon the circumstances. Typically, notification of a resident?s family or legal representative is done by the Supervising RN, the RN Nurse Manager, or the Social Worker. The Facility will re-educate all of these individuals regarding the importance of proper and timely notification.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any resident has the potential to be affected by a failure to properly notify a family member or legal representative.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Facility will create a new ?Notification Form? which will delineate the possible reasons for family or legal representative notification. The form will be designed to be a part of the Facility?s Electronic Medical Record System and will automatically remind staff about notification whenever it becomes appropriate. All applicable staff will be provided in-service education regarding the use of this new form.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Director of Nursing shall notify the Quality Assurance Coordinator when the design of the notification form has been completed and is ready for use in the EMR system. The QA Coordinator shall appoint a committee of at least three persons to conduct monitoring of proper and timely notification(s). Once in use, notification(s) of family members or legal representatives shall be monitored on a monthly basis for one quarter and quarterly thereafter. The results of the monitoring shall be reported to the QAPI Committee at regularly scheduled meetings.
5. The date for correction action and the title of the person responsible for correction of this deficiency.
July 10, (YEAR)
Director of Nursing

FF11 483.25(g)(1)-(3):NUTRITION/HYDRATION STATUS MAINTENANCE

REGULATION: §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for three (Residents #133, #374, and #395) of five residents reviewed for tube feedings, the facility did not ensure that each resident maintained to the extent possible, acceptable parameters of nutritional and hydration status. The issue involved the lack of consistent monitoring of the actual volume of feeding provided. This is evidenced by the following: 1. Resident #395 was admitted to the facility on [DATE] and readmitted on [DATE] and 4/20/18 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 4/4/18, revealed that the resident had severely impaired cognition and received a tube feeding. During a continuous observation of the resident on 5/3/18, the tube feeding pump was turned off from 9:20 a.m. to 10:00 a.m. during care. Review of the Registered Dietitian (RD) note, dated 4/4/18, revealed that the resident had an enteral feed (nutrition provided through a tube placed in the stomach) and received nothing by mouth. The resident received Glucerna (liquid nutrition specially formulated for diabetics) 1.2 via the tube feeding at 60 milliliters (ml) per hour continuously (24 hours per day). The resident's estimated need was 2,232 calories and 104 grams of protein. The tube feeding provided 1,728 calories and 86 grams of protein. Weekly weights were ordered for four weeks to monitor weight status as the current tube feeding regimen was below the resident's estimated needs, and the resident had a history of [REDACTED]. Review of the current Comprehensive Care Plan (CCP) revealed interventions to include monitoring weights monthly, provide a high calorie tube feeding formula to promote weight maintenance, and to monitor laboratory values. The 4/20/18 physician's orders [REDACTED]. The NP note revealed that the regimen would continue until the resident was stable and then the bolus feedings would be restarted. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed there was no documentation of the total daily volume of tube feeding that was infused. Interviews conducted on 5/4/18 included the following: a. At 9:31 a.m., the Certified Dietitian/Nutritionist stated that she does not look at the tube feeding pumps to determine if a resident is receiving the amount ordered by the physician. b. At 9:32 a.m., Registered Dietitian (RD) #1 said they try not to have a resident on continuous feeding (24 hours per day) for quality of life. She said they like to have the resident off the tube feeding for at least two hours. She said it would be up to nursing staff to notify dietary if the resident was not getting the tube feeding amount ordered in 24 hours. c. At 9:33 a.m., RD #2 stated that she was the RD for the resident's nursing unit and has been following the resident. She said the current goal was to maintain the resident's weight with the Glucerna 1.2 at 60 mls per hour over 24 hours. She said she requested weekly weights to monitor the resident because the current tube feeding was providing fewer calories than what the resident was previously on. d. At 10:50 a.m., the two Assistant Directors of Nursing (ADON) were interviewed together. They said that every nurse on every shift monitors the tube feeding delivery. They said that the nurses program the pump for volume and rate, and when the amount that is set has infused, it alarms. The ADONs stated that after 24 hours, the nurse should check the pump to be sure the volume was infused. They said they were not aware the resident was receiving continuous (24 hours/day) tube feeding and stated they do not like to do that for quality of life. They said that if the pump is shut off for cares or medications, there is no way to make up the amount. The ADONs stated that the RD usually readjusts the tube feeding to 22 hours to allow time off the pump for care. They stated that the medical provider would increase the rate per RD suggestions to meet the caloric needs. e. At 11:16 a.m., the Licensed Practical Nurse (LPN) stated that she checks the date and time written on the tube feeding bottle. She stated she does not know the total volume to be infused or when the tube feeding should end. She stated that the pump is shut off for about 5 minutes for each medication and about 30 minutes each time the resident receives care. The LPN said that she would only report to the Registered Nurse Manager (RNM) or RD if the tube feeding was shut off for an hour or two. f. At 11:53 a.m., the RNM stated that the resident should be on Glucerna 1.2 at 60 ml/hour continuously. At that time, the pump history (72 hour look back period) was reviewed. The RNM said the history was accidentally erased when she and the RD looked at the pump. The RNM said no one was looking to see if the volume was being delivered as ordered. She said the nurses are just signing the TAR that the tube feeding was infusing at 60 ml/hour. g. At 12:11 p.m., the NP said was not aware that the resident's current tube feeding was slightly less than the required calories for weight maintenance for the resident. 2. Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 2/9/18, revealed that the resident had severely impaired cognition and received a tube feeding for nutrition. Review of the current physician's orders [REDACTED]. The 1/11/18 dietary note included that the current regimen of [MEDICATION NAME] 1.2 at 60 ml/hour for 20 hours provides 1,440 calories and 67 grams of protein. Review of the (MONTH) (YEAR) TAR revealed there was no documentation of the total daily volume of tube feeding that was infused. On 5/4/18 at 11:30 a.m., the RNM stated that if the resident gets 60 ml/hour for 20 hours per day, he would get 1,200 ml in 24 hours and 3,600 ml in 72 hours. At that time, the 72 hour pump history was reviewed and it revealed the resident received 2,867 ml in 72 hours, 733 ml less than ordered. The RNM stated that the nurses are not verifying the volume infused. 3. Resident #374 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/2/18, revealed that the resident was in a chronic vegetative state and received tube feedings for nutrition. The current physician's orders [REDACTED]. Total volume is 1,500 ml. Review of the (MONTH) (YEAR) TAR revealed there was no documentation of the total daily volume of tube feeding that was infused. On 5/4/18 at 11:57 a.m., the RNM stated that the resident gets 85 ml/hour for 16 hours but upon entering the room, the tube feeding pump was set at 190 ml/hour. The RNM rechecked the order and found that it was now 190 ml/hour. The RNM said that the total volume infused over 72 hours should be 4,500 ml. The 72-hour history on the tube feeding pump was 4,385 ml. The RNM stated that was115 ml less than ordered. (10 NYCRR 415.12(g)(2))

Plan of Correction: ApprovedMay 25, 2018

F692
In direct response to the questions listed in the correspondence from NYSDOH dated (MONTH) 17, (YEAR) and received by the Facility via DOH HCS Portal Link transmittal on (MONTH) 17, (YEAR), along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
For Residents 133, 374, and 395 the Facility shall review current tube feed orders and work with the Medical Providers to revise orders (as necessary) so that the orders don?t call for 24 hour continuous tube feeding. Volume will also be specified in the order and nursing staff will sign off and verify that the proper volume was administered.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents who have tube feedings shall be reviewed to insure that orders are not written for 24 hour continuous feeding and that volume is specified in each order.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Medical Director, the Chief Dietitian, and the Director of Nursing shall collaborate to establish a protocol wherein tube feed orders shall not be written for 24 continuous hours, orders shall specify the volume to be administered, a Registered Dietitian will calculate the volume, and the nursing staff shall sign off and verify that the volume was administered to the resident. Once the protocol is developed, in-service education will be offered to all applicable staff including medical providers, dietitians, and licensed nursing personnel.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Quality Assurance Coordinator shall appoint a committee of at least three persons to monitor the efficacy of the newly developed tube feeding protocol. Orders, volume, sign off, and verification shall be monitored weekly on all tube feed residents for one month, monthly for a quarter, and quarterly thereafter. Results of the monitoring shall be reported to the QAPI Committee at regularly scheduled meetings.
5. The date for correction action and the title of the person responsible for correction of this deficiency.
July 10, (YEAR)
Chief Dietitian

FF11 483.25(i):RESPIRATORY/TRACHEOSTOMY CARE AND SUCTIONING

REGULATION: § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #840) of two residents reviewed for respiratory care and oxygen, the facility did not provide care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, the resident was on oxygen without physician orders [REDACTED]. This is evidenced by the following: Resident #840 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 4/20/18, included that the resident was cognitively intact and was on oxygen. Observations related to oxygen included the following: a. On 4/27/18 at 9:24 a.m., the resident was in her room, oxygen was being administered via nasal cannula at 3 liters via a wall meter. The resident stated that she was supposed to be on 4 liters and added that she was a little short of breath. b. On 4/27/18 at approximately 2:00 p.m., the resident was being administered 4 liters oxygen, resting comfortably in bed, and in no acute distress. c. On 4/30/18 at 1:48 p.m. and again at 4:00 p.m., the resident was being administered 3 liters oxygen via the wall unit and again was slightly short of breath with prolonged speech. Review of the admission history and physical, dated 4/13/18 and signed by the Nurse Practitioner, included that the resident was dependent on oxygen due to a [DIAGNOSES REDACTED]. Under amount of oxygen in use and type (nasal cannula vs mask) nothing was checked. Review of current physician orders [REDACTED]. Review of the Comprehensive Nursing Care Plan revealed no care plan related to oxygen administration that included person centered goals and interventions. Review of the (MONTH) (YEAR) Treatment Administration Records (TAR) revealed the following: a. Oxygen saturations were checked periodically from 4/13/18 through 4/17/18 on either room air, on 2 to 3 liters and/or on 3 to 4 liters with saturations of 97 percent to 100 percent oxygen levels. b. No oxygen saturation levels were documented from 4/19/18 through 4/28/18. c. From 4/29/18 through 5/1/18 oxygen saturation levels were again checked periodically on either room air, 2 to 3 liters and/or 3 to 4 liters. Saturation levels ranged from 94 percent to 96 percent. Review of progress notes revealed the resident was transferred to acute on 5/1/18 for mental status changes. In interviews on 5/1/18 at 11:35 a.m., at 3:34 p.m., and again on 5/4/18 at 12:13 p.m., the Registered Nurse Manager (RNM) stated that oxygen administration is usually a nursing judgement and that they usually start at 2 liters and go from there if a resident is having trouble breathing. He said they would then get a physician order. The RNM said if a resident was on continuous oxygen, there should be a physician order [REDACTED]. He said he would expect the orders to be noted on the TARS so all staff, including float nurses and agency nurses, would know how much oxygen to put the resident on. He said staff should have notified him when there was no order for the oxygen on the resident's TAR. The RNM said he would expect the oxygen to be care planned. He said the care plan would usually include to titrate the oxygen to greater than or equal to 97 percent saturation, assess respiratory status, and include tubing management. In an interview on 5/3/18 at 9:41 a.m., the Licensed Practical Nurse (LPN) stated that if a resident was admitted on oxygen, she would check the TARS to make sure the liters are correct. The LPN said she would check the saturation levels every four hours and every shift depending on the orders or what is in the computer and make sure the oxygen saturation was 92 percent or greater. (10 NYCRR 415.12(k)(6))

Plan of Correction: ApprovedMay 25, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F695
In direct response to the questions listed in the correspondence from NYSDOH dated (MONTH) 17, (YEAR) and received by the Facility via DOH HCS Portal Link transmittal on (MONTH) 17, (YEAR), along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The Facility was unable to take any corrective action in this instance as Resident 840 expired on (MONTH) 14, (YEAR).
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any resident receiving oxygen without an order may be affected by the same deficient practice. The Facility will verify that all residents receiving oxygen have an appropriate order.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
Nurse Managers will be instructed to compile a listing of all residents receiving oxygen on their respective units. Staff will then be assigned to verify that all residents who have been listed have an active, appropriate order. In-service education will be provided to medical providers, licensed nursing staff, and respiratory therapists regarding the importance of obtaining an order for [REDACTED].
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Quality Assurance Coordinator shall appoint a committee of at least there persons to audit the lists of oxygen patients provided by the Nurse Managers to verify each resident has an active order Monitoring shall occur monthly for three months and quarterly thereafter. Monitoring results shall be reported to the QAPI Committee at regularly scheduled meetings.
5. The date for correction action and the title of the person responsible for correction of this deficiency.
[DATE], (YEAR)
Director of Nursing

FF11 483.25(b)(1)(i)(ii):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER

REGULATION: §483.25(b) Skin Integrity §483.25(b)(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 4, 2018
Corrected date: July 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey,it was determined that for one (Resident #130) of three residents reviewed for pressure ulcers, the facility did not provide the necessary services to prevent the development of, or promote the healing of, a pressure sore. Specifically, the resident had a pressure ulcer that was observed with a soiled dressing on and that per documentation was not changed for two days and a second observation of the pressure ulcer with no dressing. This is evidenced by the following: Resident #130 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 2/4/18, includes that the resident was cognitively intact and had a Stage II pressure ulcer. The current Comprehensive Care Plan included, but was not limited to, the resident had a Stage II pressure ulcer that was now resolved, and interventions included to clean well after incontinence care, to notify medical team of changes to the integumentary system (skin), use a pressure reducing cushion in the wheelchair, and weekly skin rounds. Review of physician orders, dated 3/2/18, revealed an order for [REDACTED]. When interviewed on 4/26/18 at 11:11 a.m., the resident stated that she had not been changed since 6:00 a.m., requested the surveyor to get someone to change her, and gave permission to the surveyor to observe care. At that time, during observation of incontinent care, the resident was incontinent of large amounts of urine and stool. A border foam dressing was on the coccyx and soiled with stool. The resident also had a very reddened rectal crease and labia. After the resident was cleansed, the Certified Nursing Assistant (CNA) applied barrier cream to the buttocks area. An air mattress was on the bed but was not inflated. When interviewed at that time, the CNA stated that she had not changed the resident since she arrived at 7:00 a.m. as there were only four CNAs on as someone called in sick. She said at the request of the surveyor, she would inform the nurse that the dressing was soiled. In an observation of wound care with the Licensed Practical Nurse (LPN) on 5/1/18 at 8:53 a.m., the resident was incontinent of urine and stool. There was no dressing on the resident's coccyx and she had a small open Stage II pressure ulcer. The whole rectal crease and labia were bright red. The border foam dressing was applied after cleansing and barrier cream applied to the buttocks but not to the labia. The resident stated that she had not had a dressing on her buttocks for several days because staff do not change it when it falls off. When interviewed on 5/1/18 at 9:08 a.m., the LPN stated she did not think that the resident had a current pressure ulcer but the foam dressing was being used for prevention. She said that no one told her the dressing had fallen off or that the resident had the redness to the rectal area or labia. She said that if a dressing falls off, the CNAs should let the nurse know. Review of Wound Rounds in the Electronic Medical Record revealed a note, dated 5/1/18, that included the resident has a Stage II pressure ulcer on the coccyx measuring .5 centimeters x .5 centimeters with surrounding [DIAGNOSES REDACTED] (redness of skin) and pale pink nongranulating tissue. The last note in Wound Rounds for the coccyx prior to 5/1/18 was dated 2/7/18 and documented the area was healed. In an interview on 5/2/18 at 4:09 p.m. and on 5/4/18 at 12:01 p.m., the Registered Nurse Manager stated that she expects staff to inform the nurse when a dressing is soiled or falls off so it can be changed. She said she was not aware of the redness of the labia. Review of the treatment records and progress notes at that time revealed that the dressing was signed off as completed on 4/25/18, 4/28/18, and 5/1/18 (after surveyor intervention). There was no documentation that the dressing was changed after the observation of the soiled dressing on 4/26/18 or after 4/28/18. (10 NYCRR 415.12 (c)(1)(2))

Plan of Correction: ApprovedMay 25, 2018

F686
In direct response to the questions listed in the correspondence from NYSDOH dated (MONTH) 17, (YEAR) and received by the Facility via DOH HCS Portal Link transmittal on (MONTH) 17, (YEAR), along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The Assistant Director of Nursing will convene a meeting of the medical provider and the unit care team to discuss the efficacy of the current dressing and physician?s order (as it appears as though the use of the cream is inhibiting the dressing from staying in place). Once reviewed, an intervention will be determined and the resident shall be placed on an observation schedule that coincides with the revised intervention.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Facility staff shall perform wound rounds to monitor residents with dressings and insure the dressings are in place and properly applied.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Facility shall review all CNA care cards to insure wounds and dressings are identified for the CNA?s. The Facility shall then develop a procedure whereby the unit charge nurse is notified whenever (1) a CNA finds a resident with a missing dressing, and/or (2) wound rounds discover a resident with a missing dressing. In-service education will be offered to CNA?s and unit staff regarding steps that should be taken in the case(s) of missing dressings.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Quality Assurance Coordinator shall appoint committees to monitor (1) the completion of the CNA care cards to insure they include wounds and dressings, and (2) the timely and proper completion of wound rounds. Monitoring shall occur monthly for three months and quarterly thereafter. Monitoring results shall be reported to the QAPI Committee at regularly scheduled meetings.
5. The date for correction action and the title of the person responsible for correction of this deficiency.
July 10, (YEAR)
Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:AISLE, CORRIDOR, OR RAMP WIDTH

REGULATION: Aisle, Corridor or Ramp Width 2012 EXISTING The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5. 19.2.3.4, 19.2.3.5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 10, 2018

Citation Details

Based on observations and interview conducted during the Life Safety Code, it was determined that for 5 (Faith second and third floors, Hope second and fourth floors, and Friendship third floor) of 14 resident use floors, the facility did not properly maintain corridor width. Specifically, furniture was stored in corridors and was not properly secured and/or projected more than 24-inches into the required corridor width. The findings are: 1. Observations in the presence of the Director of Facilities during the initial tour of the facility on 4/26/18 between 9:45 a.m. and 2:00 p.m. revealed the following: a. There was a piano, three tables, and two chairs stored in the egress corridor on the Faith building third floor East Wing outside the dining room. None of the items were affixed to the floor or wall, and left between 5 feet 8 inches and 7 feet 4 inches of usable width. b. There was an armchair stored in the egress corridor on the Faith building second floor next to Resident Room FA2E09. The chair was not affixed to the floor or wall and left 5 feet 6 inches of usable width. c. There was a chair stored in the egress corridor in the Hope building by the second-floor nurses' station and three other chairs stored near the elevators. None of the items were affixed to the floor or wall, and left between 5 feet 6 inches and 6 feet 1-inch of usable width. Interview with the Facilities Director revealed there is usually only one chair in the area by the nurses' station. d. There was a small sitting bench stored in the egress corridor in the Hope building fourth floor near the elevators, and the item left 5 feet 8 inches of usable width. 2. Observations on 4/27/18 at 9:28 a.m. revealed a loveseat stored in the egress corridor on the Friendship building third floor West near the nurses' station. The furniture was not affixed to the wall or the floor and left 6 feet three inches of usable width. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.3.4(5))

Plan of Correction: ApprovedMay 25, 2018

K232
In direct response to the questions listed in the correspondence from NYSDOH dated (MONTH) 17, (YEAR) and received by the Facility via DOH HCS Portal Link transmittal on (MONTH) 17, (YEAR), along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
As there were no residents identified on the CMS 2567 the question is not applicable.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any improperly placed furniture which blocks a corridor and obstructs egress has the potential to negatively affect any resident.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Facility shall undertake four measures to rectify the problem of obstructing egress which subsequently creates inadequate corridor width. (1) A regular schedule of monitoring the corridors to maintain corridor width and adequate egress shall be implemented. (2) The Director of Facilities Services shall individually assess various locations throughout the building on a unit by unit basis to determine if any furniture may be properly affixed to insure the integrity of egress. (3) Furniture shall be affixed and maintained to insure egress in those areas identified (if any) by the Director of Facilities Services. (4) In-service education will be provided to all applicable staff regarding the necessity to maintain corridor width(s) and adequate egress.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Director of Facilities Services shall notify the Quality Assurance Coordinator upon the completion of the assessment of unit by unit locations for the installation of affixed furniture. The placement of type of each piece of furniture shall be identified. The Quality Assurance Coordinator shall appoint a committee of at least three individuals to monitor (1) that the affixed furniture remains in place as installed, and (2) corridor egress remains unobstructed. Such monitoring shall take place weekly for one month, monthly for one quarter, and quarterly thereafter. The results of the monitoring shall be reported to the QAPI Committee at its regularly scheduled meetings.
5. The date for correction action and the title of the person responsible for correction of this deficiency.
July 10, (YEAR)
Director of Facilities Services

DEVELOPMENT OF EP POLICIES AND PROCEDURES

REGULATION: (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: May 4, 2018
Corrected date: July 10, 2018

Citation Details

Based on an interview and record review conducted during the emergency preparedness review in conjunction with the Life Safety Code Survey, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, emergency and disaster specific scenarios identified on a Hazard Vulnerability Assessment (HVA) did not have corresponding disaster plans. The findings are: On 5/1/18 through 5/4/18 the facility provided the surveyor with an emergency preparedness plan (EPP) binder and a HVA, dated 6/27/17. A review of the HVA revealed identified risks including, but not limited to, snow fall, ice storm, and technology crime. Further review of the EPP revealed no specific policies and procedures for dealing with snow fall, ice storm, and technology crime scenarios. (42 CFR 483.73(b) - Emergency Preparedness)

Plan of Correction: ApprovedJune 6, 2018

E013
In direct response to the questions listed in the correspondence from NYSDOH dated (MONTH) 17, (YEAR) and received by the Facility via DOH HCS Portal Link transmittal on (MONTH) 17, (YEAR), along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
As there were no residents identified on the CMS 2567 the question is not applicable.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
An Emergency Preparedness Plan that identifies potential hazards but does not offer corresponding policies that are clear and concise may have a potential negative effect on all residents in an emergency situation.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Facility shall develop policies for those areas identified in its Emergency Preparedness Plan for which there are no clear, concise corresponding policies. Those shall include the development of policies for snow fall, ice storms, and technology crime scenarios. The Facility shall also perform an annual audit of its Emergency Preparedness Plan to insure all hazards that have been identified within the plan have corresponding policies and procedures. The Facility shall present in-service training to all applicable staff regarding any newly developed policies or procedures.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Associate Executive Director shall assume responsibility for the development of policies addressing snow fall, ice storms, and technology crime. Upon the completion of the policies the Associate Executive Director shall submit the new policies to the Quality Assurance Coordinator who shall place them on the agenda for approval by the QAPI Committee. The Quality Assurance Coordinator shall also appoint a Committee of three persons to conduct annual audits of the Emergency Preparedness Plan to insure any Hazard identified has a corresponding policy. The first audit will be conducted upon the QAPI Committee approval of the aforementioned new policies. The results of the audits shall be reported to the QAPI Committee at regularly scheduled meetings.
5. The date for correction action and the title of the person responsible for correction of this deficiency.
July 10, (YEAR)
Associate Executive Director