Oceanside Care Center Inc
September 22, 2017 Certification Survey

Standard Health Citations

FF10 483.10(f)(1)-(3):SELF-DETERMINATION - RIGHT TO MAKE CHOICES

REGULATION: (f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. (f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. (f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 22, 2017
Corrected date: October 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews during the Recertification Survey the facility did not ensure that each resident had a right to choose schedules consistent with his or her interests for 1 of 1 resident reviewed for Choices from a total Stage 2 sample of 28 residents. Specifically, Resident #158 requested a shower after being admitted to the facility but did not receive one until five days after admission. The finding is: Resident #158 was admitted to the facility on [DATE] after a right Total Knee Replacement (TKR) operation. Other [DIAGNOSES REDACTED]. The Initial Nursing assessment dated [DATE] documented the resident could make his needs known verbally and had normal hearing and speech. The assessment also documented the resident had a soft cast to the right leg. The admission nursing note dated 9/14/2017 at 6:30 PM documented the resident was alert and oriented to person, place, and time. A Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) dated 9/14/2017 documented the resident required extensive assist of two persons for bathing. A Physical Therapy CCP dated 9/15/2017 documented the resident was weight-bearing-as-tolerated (WBAT) to the right leg. The hospital discharge instructions dated 9/14/2017 documented the right TKR dressing should stay on for one week following surgery, which was performed on 9/11/2017. The discharge instructions also documented the resident may shower on post-op day number two as long as the waterproof dressing was intact, but do not take a bath or soak the incision. On 9/18/2017 at 12:22 PM Resident #158 was interviewed. He stated that his knee surgery was on 9/11/2017 (Monday) and that he had not received a shower in the hospital and did not receive one since being admitted to the facility on [DATE] (Thursday). He stated that he asked the aide for a shower over the weekend but was told that his shower was not yet on the schedule. Review of the CNA Accountability Record (CNAAR) documented that the resident received a shower on the 9/18/2017 (Monday) and that he is scheduled for showers on Mondays and Thursdays, 3 PM-11 PM shift. On 9/20/2017 at 9:24 AM the CNA who was assigned to the resident over the weekend was interviewed. She stated it was the general routine to give a resident a shower when they are admitted from the hospital. She stated that she did not give the resident a shower because it was scheduled for Monday. On 9/20/2017 at 9:32 AM the Registered Nurse (RN) Charge Nurse was interviewed. She stated residents will be offered a shower when they are admitted . She stated the resident could have received a shower over the weekend if he requested it and he did not have to wait for an assigned shower day. On 9/20/2017 at 10:28 AM the Director of Nursing Services (DNS) was interviewed. She stated that if the resident requested a shower over the weekend, he could have gotten one, unless there were restrictions, such as a rehab assessment that restricted movement. On 9/21/2017 at 10:05 AM the CNA that was assigned to Resident #158 on 9/15/2017 (the day following admission) during the 7 AM-3 PM shift was interviewed. She stated that she gave the resident a bed bath because she was directed by her supervisor not to get the resident up until Physical Therapy assessed him. She stated that residents are supposed to get showers the day after admission. She stated we are supposed to ask them if they want a shower. On 9/21/2017 at 11:56 AM the Rehabilitation Department director was interviewed. She stated the resident was weight-bearing-as-tolerated before he was admitted and that nursing could have gotten him out of bed before the rehab assessment. On 9/22/2017 at 10:51 AM the RN Supervisor on the unit during the day shift (7 AM-3 PM) on 9/15/2017 was interviewed. She stated that in the morning on 9/15/2017 when the resident was being cleaned he had not been assessed by Physical Therapy yet. She stated she had not noticed on the hospital discharge instructions that the resident had a waterproof dressing and did not have to wait until his dressing was removed before he could receive a shower. She stated that there was an ace bandage on the resident's right leg covering a dressing that could not be removed until 9/18/2017. The facility's Policy and Procedure titled Bathing the Resident-Shower dated (MONTH) (YEAR) documented that new admitted residents are offered bathing preferences, i.e. showers/bed bath. 415.5(b)(1-3)

Plan of Correction: ApprovedOctober 6, 2017

I- Resident # 158 is no longer in the facility.
A) The CNA was provided with a 1:1 in-service by the ADNS regarding the facility's Policy and Procedure on residents preference specific to bathing. 9/20/2017

II- All newly admitted residents have the potential to be affected by this practice. The DNS and ADNS revised the policy and procedure on bathing the resident to reflect the resident choice regarding bathing preferences. The charge nurse on the unit will review all documentation on the accountability records monthly and revise the care plan accordingly. 10/31/2017
III- To ensure that the highest standard of care is maintained and to prevent reoccurrence, the following measures were implemented:
A) The policy and procedure on bathing the resident was reviewed and revised to reflect resident right to make choices regarding bathing preference.
B) The policy and procedure includes preferences for various types of bathing such as showers, century tub bath and bed baths. These preferences are highlighted on the CNA accountability record and are offered on the day of admission. The charge nurse on the unit will review all the accountability records monthly and update care plans as needed.
C) All Nursing staff will be in-serviced by the in-service coordinator on the revised policy and procedure for bathing the resident. All Registered Nurses will be re-in-service by In-service Coordinator on reviewing the entirety of Discharge Instructions from the hospital. This in-service will be part of the orientation package for all nursing staff and part of the annual mandatory in-service. 1:1 in-services will be given as needed. 10/31/2017
IV- As part of the Quality Improvement Program, the ADNS/designee will audit all newly admitted patient CNA accountability record every two weeks for the next 3 months and then monthly for the next 2 quarters. Negative findings will be reported immediately to the DNS. Audit results will be reviewed during the quarterly Improvement Meetings for the next 3 quarters. 10/31/2017
V- The DNS/ADNS will be responsible for the correction of the deficient practice. 10/31/2017

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 22, 2017
Corrected date: September 23, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA101:19.2.3.4* Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following: (1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width. (2)*Where corridor width is at least 6 ft (1830 mm), noncontinuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted. (3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted. (4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met: (a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in.(1525 mm). (b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency. (c)*The wheeled equipment is limited to the following: i. Equipment in use and carts in use ii. Medical emergency equipment not in use iii. Patient lift and transport equipment (5)*Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met: (a) The fixed furniture is securely attached to the floor or to the wall. (b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2). (c) The fixed furniture is located only on one side of the corridor. (d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2). (e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by a distance of at least 10 ft (3050 mm). (f)*The fixed furniture is located so as to not obstruct access to building service and fire protection equipment. (g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space. (h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8. Based on observation and staff interview, the facility failed to ensure that corridors serving as a means of egress were kept clear. Specifically, wheeled equipment stored within the corridor reduced the corridor width to less than 60 inches. This occurred on 1 of 3 resident units within the facility. The finding is: On 9/21/2017 between the hours of 8:30am and 3:30pm during the recertification survey, the following was observed: On the South 1 nursing unit, the corridor width was reduced to 36 inches. Two wheelchairs were noted to be on both sides of the corridor near room [ROOM NUMBER]. In an interview on 9/21/2017 at approximately 11:20am with the Director of Maintenance, he stated there is very little storage area within the facility. In a concurrent interview with the DNS, she stated they use the corridor to store resident's wheelchairs, hampers and clean linen carts but they will come up with a solution for storage. 2012 NFPA 101

Plan of Correction: ApprovedOctober 4, 2017

I- The facility addressed this immediately by removing several wheeled equipment items from the corridor. No specific residents were known to be affected by this practice. 9/21/2017
II- All residents on this unit have the potential to be affected by this practice. 9/21/2017
III- The facility removed several wheeled equipment items from the corridor. 9/21/2017
IV- The Nursing and Maintenance departments will continue to monitor the corridor to ensure that the appropriate means of egress are kept clear. Any negative findings will be corrected immediately and brought to the quarterly Quality Improvement Assurance Committee to ensure continued compliance. 9/21/2017
V- Responsible team members to ensure corrective action and oversee compliance is Director of Maintenance, Nursing Administration and Administration. 9/21/2017

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

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 22, 2017
Corrected date: September 23, 2017

Citation Details

I160 s/s=D 14-1.43 Storage of food; general requirements. (b) Food and containers of food and food wrapping materials are not to be stored under exposed or unprotected sewer lines. The storage of same in toilet rooms is prohibited. Based on observation and staff interview, the facility failed to ensure that containers of food were not stored under unprotected sewer pipes. This occurred in the basement of the facility. The finding is: On 9/21/2017 between the hours of 8:30am and 3:30 pm during the recertification survey, the following was observed: The food storage room located in the basement was noted to contain a 3inch waste pipe. Underneath the waste pipe, containers of dry food (rice, flour) was being stored. In an interview on 9/21/2017 at approximately 10:00am with the Director of Maintenance, he stated he could add a catch underneath the pipe to prevent contamination. 10NYCRR 415.14

Plan of Correction: ApprovedOctober 4, 2017

I- The facility addressed this immediately by installing a protective covering underneath the pipe to prevent any potential contamination. No specific residents were known to be affected by this practice. 9/21/2017
II- All the residents have the potential to be affected by this practice. 9/21/2017
III- The facility?s maintenance department installed a protective covering underneath the pipe to prevent any potential contamination. 9/21/2017
IV- The Maintenance Department will continue to monitor the area to ensure the protective covering remains in place. Any negative findings will be corrected immediately and brought to the quarterly Quality Improvement Assurance Committee to ensure continued compliance. 9/21/2017
V- Responsible team members to ensure corrective action and oversee compliance is Director of Maintenance and Administration. 9/21/2017