Manhattanville Health Care Center
November 20, 2018 Certification Survey

Standard Health Citations

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: 483.25(d) Accidents. The facility must ensure that - 483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and 483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 20, 2018
Corrected date: January 18, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records reviewed, and interviews conducted during the refortification survey, the facility did not ensure that the residents who were assessed for elopement risk were adequately supervised. Specifically, Resident #33 was not provided with wander guard according to the physician order. In addition, there was no proper documentation by the Certified Nursing Assistant (CNA) in the resident's CNA documentation Record indicating that the resident's wander guard is in place and being monitored by staff to prevent accident, unsafe wandering and/or elopement. This was evident for 1 of 2 residents reviewed for accident/elopement risk out of a Sample of 41 residents. The Findings are: The facility's policy and procedure for Prevention of Elopement and Unsafe Wandering dated 6/2018 documented: Once determined as at risk for elopement, the resident' at risk for elopement status is reflected on the resident's clinical record. i.e. progress notes. MD/NP will be notified and an order for [REDACTED]. The Policy further stated that the CNA instructions is updated to reflect the placement of Watchmate; The CNA checks the placement of the Watchmate every shift, if found missing, it must be reported to the nurse using the stop and watch form and must be replaced immediately. The Resident Accountability form/Census is completed by the CNA each shift. Resident #33 is [AGE] years old admitted to the facility on [DATE]. Active [DIAGNOSES REDACTED]. On 11/14/18 at 10:20 AM, and 11:17 AM, the State Surveyor observed Resident #33 wandering around the floor and toward the exit door, and at 11:19 AM, towards the elevator doors. The resident appeared confused and was unable to engage in conversation with the State Surveyor. There was no wander guard observed either on the ankles or wrists. There was no staff monitoring resident at this time 1 staff was observed in the day room and other staff were observed providing care for residents in their rooms. On 11/15/18 from 11:211 AM to 11:31 AM the resident was also observed wandering in the elevator and on the unit unsupervised with no wander guard in place. On 11/16/18 at 10:30 AM Resident was observed wandering in the hall-way - unsupervised, noted with wet pant. No wander guard observed on the resident. The Quarterly Minimum Data Set (MDS) - Version 3.0, dated 08/16/2018 documented that the resident cognitive status is moderately impaired, on antipsychotic medication. The MDS also indicated that resident is occasionally incontinent of bowel and bladder. The MDS further indicated that the resident requires supervision for Bed mobility, transfer, walk in room/corridor, Locomotion on/off unit, and eating, and is extensive assistance of 1 staff for dressing, toilet use, personal hygiene, and bathing. No wandering behavior documented on MDS. The revised Comprehensive Care Plan (CCP) dated 12/27/2016 documented elopement as an identified risk as evidenced by resident observed wandering to another floor. Watchmate (wander guard) in place and functioning. The revised (CCP ) for elopement dated 05/03/2017 documented that resident's Elopement risk assessment score is 10. Watchmate intact. physician's orders [REDACTED]. The revised elopement care plan dated 08/04/2018 documented that resident is at risk for elopement, noted with behavior of wandering, and has Wander guard in place. Review of Nursing behavior/elopement monitoring notes between 11/01/2018 and 11/16/2018 documented that resident continues to wander and is being re-directed by staff. There is no documentation that resident's wander guard is checked. There is also no documentation that resident has ever been observed removing the wander guard. The revised elopement care dated 11/05/2018 documented that the resident is at risk for elopement, continue to wander in hallway, redirected as needed. There was no documentation that resident has wander guard in place. A review of the Resident CNA Documentation Records dated between 11/01/2018 and 11/16/2018 did not indicate that the resident's wander guard was checked for placement and functionality. There is no documentation that the wander guard was being monitored by CNA every shift. On 11/16/18 at 12:30 PM the CNA #3 was asked if resident had wander guard. CNA #3 checked both wrists and ankles. No wander guard was found. On 11/16/18 at 12:42 PM an interview was conducted with CNA #3. CNA #3 stated that sometimes resident removes the wander-guard, but could not recall the the last time the wander guard was observed on the resident. CNA stated that there is no place to document the wander-guard placement in the CNA accountability record, and that they just report to the nurse if the wander guard is not found on the resident. On 11/19/18 at 09:33 AM an interview was conducted with the Licensed Practical Nurse LPN #1. LPN #1 stated that the resident sometimes wander around to other floor and is always re-directed by the staff. LPN stated that Wander guard should be checked every shift by the CNA and to report to the charge nurse if not found on the resident. LPN further stated that the resident likes to take it off and hide it sometimes and also stated that the wander guard monitoring is documented in the CNA accountability record every shift. On 11/19/18 at 12:35 PM an interview was conducted with the social worker SW #5. SW stated that the resident is always seen in the nursing station and is constantly monitored and re-directed if noted with inappropriate behavior like putting on dirty cloth or putting on shoes incorrectly. SW also stated that the resident follows direction most of the time, and that the resident was moved to a private room on the unit because he was not getting on with other residents on the previous unit where he was sharing a room. 415.12(h)(2)

Plan of Correction: ApprovedDecember 26, 2018

F 689: Free of Accident Hazards/Supervision/Devices
I. Immediate
Resident #33
1. On 11/14/18 the resident was re-assessed for their risk for elopement and it was determined that the elopement risk score was 10, making him a high risk for elopement. Watchmate was reapplied on 11/14/18.
2. On 12/18/18 the IDT team met to review the current safety precautions in place for Resident #33. A review of the CNA accountability record found that there were instructions for checking the presence of the watchmate every shift. The risk for elopement CCP was updated to reflect resident?s behavior of removing the watchmate.
3. On 11/26/18 the Charge Nurse and the CNA assigned to Resident #33 were given disciplinary action by DNS/Designee for failure to follow facility policy and procedure regarding residents who are at risk for elopement and wear a watchmate.


II. Identification of others
1. The facility respectfully states that all residents who are at risk for elopement were potentially affected.
2. An ongoing list of all residents with physicians? orders for a watchmate was compiled by DNS on 11/28/18. This list was utilized by the DNS/Designee to ensure that any missing/malfunctioning watchmates were replaced. Any issues were immediately corrected.
III. Systemic Changes
1. The facility reviewed the policy and procedure for ?Prevention of Elopement and Unsafe Wandering? and found it to be compliant with current standards of practice.
2. On 1/2/19 all nursing staff will be re-inserviced on the facility policy for ?Prevention of Elopement and Unsafe Wandering.? The lesson plan will focus on the following:
? The Elopement Risk Audit tool is utilized upon: admission, readmission, quarterly, annually, and significant change. A score of 7 or more indicates a high risk for elopement.
? When a resident is found to be a high risk for elopement, an MD/NP order will be obtained.
? The resident will be placed on the 24 hour report so that all IDT team members will be aware.
? A list of residents with high risk for elopement will be provided in each Nursing unit on a monthly basis and as needed.
? An elopement careplan will be initiated by the licensed nurse.
? All interventions from the careplan will be transcribed to the CNA Accountability Record. Assigned CNAs are responsible for documenting the presence of the watchmate every shift. If the watchmate is found to be missing, the CNA must immediately report this to the charge nurse.
? The 12-8 Supervisor is responsible for checking the function of all watchmates daily and documents these findings in a log that is found in the nursing office.
? Residents at risk for elopement will have an orange dot on their ID band.
? Residents who refuse to wear a watchmate will be placed on hourly monitoring and all medical records (physician?s orders, careplan, progress notes, CNAAR) will be updated to reflect this refusal.

IV. Quality Assurance
1. The DNS developed a QA audit tool to track the facility?s compliance with monitoring residents who are at risk for elopement. The audit will be conducted by the RNS/Designee weekly for 2 residents per unit x 4 weeks and then monthly x 6 months thereafter.
V. Person Responsible for this F-Tag
DNS

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: November 20, 2018
Corrected date: January 18, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that nutrition and hydration were provided in a manner consistent with the resident's assessment. Specifically, a resident with a physician's orders [REDACTED]. This was evident for 1 of 8 residents reviewed for Nutrition out of a sample of 41. (Resident #110) The findings are: Resident #110 has severely impaired cognition and is diagnosed with [REDACTED]. The most recent Annual Minimum Data Set ((MDS) dated [DATE] documents that the resident requires the extensive assistance of one person for eating and requires a mechanically altered diet. On 11/16/18 at 12:42 PM, Resident #110 was observed in the Floor Day Room (FDR) with his lunch tray in front of him. The resident's meal ticket on his tray listed that the resident is to receive chopped fish, chopped cornbread, sippy cup, and lip plate. The resident was observed to have a full filet of fish on his tray and a large square piece of cornbread. No sippy cup or lip plate was observed on the resident's tray. The resident was observed picking up full fish filet with his hands and biting into it. The fish tore apart in the resident's hands and was left hanging out of his mouth while he attempted to chew it. After several minutes, an aide was observed going to the resident and using a knife to chop up the cornbread on the resident's tray. On 11/19/18 at 12:39 PM, the resident was again observed with no sippy cup or lipped plate present. A standard circular plate and plastic cup with a straw was present on the tray. The physician's orders [REDACTED]. The Rehab Orders list that the resident is to use a lip plate and sippy cup for each meal. The resident's Nutrition Comprehensive Care Plan (CCP) active since 10/2/13 and last updated on 10/05/18 document that the resident is on a chopped diet with nectar thick liquids and requires a mechanically altered diet due to impaired swallowing related to [DIAGNOSES REDACTED]. An undated list of Special Devices - Delivery and Pickup Sign Sheet lists Resident #110 as having a sippy cup and lip plate ordered. The CNA Documentation Record - Resident Nursing Instructions for 11/2018 documents under Eating/Toileting that the resident has a chopped consistency diet and requires lip plate and sippy cup for each meal. An interview was conducted with the resident's Certified Nursing Assistant (CNA), CNA #2 on 11/19/18 at 12:53 PM. CNA #2 has worked in the facility for [AGE] years and with Resident #110 for approximately 6 months. The resident requires total assistance of one person. The CNA is not aware of any special dietary device orders for the resident. On 11/20/18 at 10:04 AM an interview was conducted with Regional Clinical Manager for Dietary (RCMD). Once a resident has been ordered adaptive dietary devices (lip plate and sippy cup), the dietician is made aware by the occupational therapy and/or speech therapy department and the order is communicated by the Nursing Department to the Kitchen. The Kitchen then inputs the order into the meal tracker system and the order is then printed onto the residents'' meal tickets. The dietary staff who puts together the meal trays are responsible for ensuring that dietary devices on the meal ticket are present. The RCMD is not aware of any auditing or rounds that are specifically done to ensure that the special dietary devices are on a resident's tray. There are extra devices on hand if they are thrown out or misplaced. Spot checks are conducted by the Dietary Department; however, the RCMD is not aware of any log that is kept re: the outcome of these spot checks. Dietary devices are sent back down to the kitchen after each meal to be washed before the next meal. An interview was conducted with Regional Food Service Director (RFSD) on 11/20/18 at 10:13 AM. The Dietary Department is responsible for ensuring that the resident's meal ticket is updated to indicate that a dietary device has been ordered. A list of residents on adaptive devices is checked by dietary staff during tray line service. All kitchen staff, especially those on the tray line, check the list to ensure they are aware of residents who should be receiving adaptive dietary devices. The list is also checked after every meal to ensure that items come back down to the kitchen and do not go missing. There are extra devices kept in the kitchen and the Rehabilitation Department is made aware in the event a device goes missing and needs to be replaced. RFSD is unaware that Resident #110 had any adaptive dietary devices missing from his tray on 11/16 and 11/19/18. He will be checking with kitchen staff to determine the reason that the resident did not have the sippy cup and lip plate on his tray. On 11/20/18 at 10:51 AM, an interview was conducted with the Charge Nurse for the resident's unit, Registered Nurse (RN) #1. She has worked in the facility and on the resident's unit for 8 months. The RN checks the trays for devices and then hands the tray to CNA to provide to the resident during each meal time. The RN cannot recall if there was a sippy cup and/or lip plate on the resident's tray during the last few meal times observed by the SA. If the RN notices that items are missing from a resident's meal tray, the RN calls down to the kitchen to have them replaced. She is not aware of any documentation that is kept regarding whether an adaptive device is present or missing. An interview was conducted with RN/Assistant Director of Nursing (ADNS) on 11/20/18 at 11:47 AM. ADNS stated that when the meal trucks are delivered to the unit during meal time, the dietary devices should already be on the tray. The Nursing staff will then place the used dietary devices in the pantry and dietary aides will pick them up at the completion of each meal to wash them for the next meal. The Charge Nurse is responsible for ensuring that the dietary devices are placed on the tray. The CNAs are also responsible since devices are on their CNA Documentation Record. No Quality Assurance audits or spot checks are currently being done to ensure that adaptive dietary devices are in place. 415.12(i)(1)

Plan of Correction: ApprovedDecember 26, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Manhattanville P(NAME) F692
I. Immediate Corrective Action:
1) On 11/20/18 Resident #110 was provided with assistive feeding devices as per physician order.
2) On 11/20/18 OT reassessed resident?s ability to determine if any other assistance required to promote independence in eating.
3) On 11/20/18 the SLP reassessed resident to determine if the current diet consistency appropriate for resident #110.
4) The CCP for resident # 110 was reviewed and updated by RNS.
5) On11/20/18 the FSD issued a disciplinary counseling to the food service staff responsible for ensuring tray accuracy.
6) On 11/29/18 and 12/1/18 the DNS/Designee issued disciplinary counseling to RN Charge nurse and CNA responsible for ensuring resident # 110 received accurate meal tray as per MD order.
II. Identification of Others:
1) The Facility respectfully states that all residents were potentially affected by inaccurate meal tray tickets.
2) The Food Service Director (FSD) obtained a list of all current assistive feeding devices used in the facility. This list was used by the FSD to ensure all adaptive devices were accurately placed on both the residents? meal tracker ticket and on the residents? tray.
III, Systemic Changes:
1) The FSD, Rehab Director in conjunction with the RD reviewed the Facility P/P for providing Assistive Devices at meals and found same to be compliant. This P/P will be re inserviced to all Food Service Workers and Nursing staff by 1/4/19. The lesson plan will focus on:
? All new/readmissions are assessed by Rehab staff for the use of assistive devices
? MD will review and order assistive devices as indicated
? Rehab will provide the assistive device to the Food Service Director and inform RNS/RN.
? RNS/RN will document specific device on CCP and CNAAR.
? Dietary Staff will ensure device is on tray during tray set up
? CNA will check presence of device on meal tray prior to serving resident meal and report to charge nurse if missing.
? Charge nurse will call Dietary for any missing devices.

2) The FSD and RD reviewed the Facility Diet Manual and found same to be compliant. The P/P for ensuring tray line accuracy and delivery will be re inserviced by the FSD. The lesson plan will focus on:
? All new admissions, readmissions and residents with change in condition will be assessed by the Speech therapist and Dietician.
? Recommendations for individual diet order will be referred by rehab to MD for physician order [REDACTED]. ? Physician orders [REDACTED].
? Individual Meal tray tickets containing resident name, Diet type/consistency and food preferences are printed FSD/Designee.
? Tray line staff reading and validating each meal ticket for accuracy on the tray line.
? The Tray line checker ensures all items on the tray are accurate.
? The Unit CNA will check meal tray ticket with items on tray for accuracy reporting any discrepancies immediately to charge nurse.
? Charge Nurse will contact the kitchen requesting accurate meal tray for resident
? The Food Service Staff will bring a correct tray to the unit.

IV. Quality Assurance:
1) The FSD in conjunction with Rehab staff developed an audit tool to monitor facility?s compliance with ensuring that nutrition and hydration are provided in accordance with individual resident assessment.
2) This audit will be done by the FSD for 3 trays per unit for breakfast ,lunch and dinner daily x I month followed by 1 tray per unit for breakfast, lunch and dinner three times weekly x 12 months.
3) The DNS developed an audit tool to monitor tray accuracy on resident units including assistive feeding devices. This audit will be done by the RNS for 1 tray per unit daily x 1 week followed by 1 tray per unit weekly x 6 months.
Any issues will be immediately corrected. All findings will be forwarded to QA Committee for follow up as indicated.
V. Person(s) Responsible for this Ftag:
Food Service Director

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: November 20, 2018
Corrected date: January 18, 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 that a resident received necessary services to prevent new ulcers from developing. Specifically, a resident with a physician's orders [REDACTED]. This was evident for 1 of 3 residents reviewed for Pressure Ulcer/Injury out of a total sample of 41 residents (Resident #39). The finding is: Resident #39 is severely cognitively impaired with a [DIAGNOSES REDACTED]. The resident's most recent Quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident had no unhealed PUs, and the resident is at risk for developing PUs. On 11/15/18 at 9:10 AM and 11/16/18 at 9:38 AM, Resident # 39 was observed sleeping in bed. On both occasions, there were no heel lifts or heel booties observed on the resident's feet or in the resident's room. On 11/19/18 at 3:07 PM the charge nurse for the unit, Registered Nurse (RN) #1, was present when SA observed that there were no heel lift devices present in the resident's room or personal closet. The Pressure Ulcer Comprehensive Care Plan (CCP) dated 8/14/18 documented Resident #39 has a potential for alteration in skin integrity as the result of having a history of PUs on bilateral heels. The right heel PU was resolved on 5/29/18 and the left heel PU was resolved on 8/14/18. Interventions included assessing resident, identifying risk factors using the Braden Scale, initiating protocol for PU treatment upon identification of PU, skin care daily, and skin checks every shift. The Impaired Skin Integrity CCP initiated 2/6/14 and most recently updated on 11/8/18 documented the resident was at high risk for skin breakdown due to impaired mobility, incontinence, and fragile skin. Interventions included administering medications and treatments as ordered, Certified Nursing Assistant (CNA) evaluation of skin condition daily, and completion of the Braden Scale. A Nursing Note dated 8/14/18 documented the resident's left heel PU had healed. The resident had very fragile skin and the heel lift order was to be continued. The Physicians Orders, renewed on 11/1/18, documented that the resident is to have bilateral heel lifts when in bed. This order was originated on 3/6/18. The Braden Scale initiated on 11/7/18 documented the resident as having a score of 13 indicating that the resident is at moderate risk for PU development. The resident's risk factors include very limited sensory perception, occasionally moistness, being chairfast, having very limited mobility, and friction and shearing. A review of the resident's Medication Administration Record [REDACTED]. An interview was conducted with the resident's CNA, CNA #1, on 11/19/18 at 11:58 AM. CNA #1 has worked for the facility for 8 months and with resident #39 for approximately 2 months. The resident requires total assistance with all activities of daily living. She usually takes the resident out of bed later in the morning, and the resident usually does not go back to bed throughout the day unless she has an accident or bowel movement. CNA #1 was aware the resident has a wedge cushion for positioning while in bed, but she was not aware of any other devices or equipment ordered for resident while she is in bed. CNA #1 is also unaware of the resident having any skin conditions or history of PUs. The resident is provided with lotion every day and periguard to the feet, sacrum, and groin area as preventative measures to ensure that her skin remains in good condition. The CNA is made aware of all devices and equipment orders for the resident by looking at her chart on the computer and by looking at what devices are currently present in her room. If the CNA notices that a device has been ordered for the resident but is not in her room, CNA #1 will let the nurse know. CNA #1 is aware of what heel booties are but was unsure of what would be considered heel lifts. On 11/19/18 at 2:54 PM, an interview was conducted with the charge nurse for the unit, RN #1. She has worked in the facility and on the resident's unit for approximately 8 months. RN #1 is aware that Resident #39 had a PU on her heel but states that it was healed. The resident continues to have a pressure relieving mattress. She had a physician's orders [REDACTED]. Upon checking the resident's chart and reviewing the current physician's orders [REDACTED].#1, heel lifts are made of foam and have circular cutouts so that when it is placed under the resident's heels, there is less pressure on the area while sleeping. The CNA is responsible for putting the heel lift in place for the resident. The charge nurse at night should do a visual check to ensure that devices are in place. RN #1 stated that she was not aware of whether the heel lifts and/or booties were documented on any type of accountability or treatment record. The physician's orders [REDACTED]. After observing that there were no heel lifts in the resident's room, the RN stated that she would contact the Rehabilitation (Rehab) Department to obtain a new device. An interview was conducted with the Director of Rehabilitation (DOR) on 11/20/18 at 10:27 AM. The DOR stated that the wound care nurse will recommend that a pressure relieving device, such as heel lifts, are needed for a resident. The wound care nurse will then secure an order from the Medical Doctor (MD), fill out an interim communication sheet and collaborate with the rehab department to ensure that the device is distributed. The Rehab Department will clarify the order to ensure that the device has been issued but does not complete an actual Rehab Assessment. Heel lifts are actually heel booties, which are cushioned individual booties that cover the entire foot and heel area and that are held in place with a Velcro strap. The facility does not have a separate device identified as heel lifts and does not utilize a foam device with heel impressions in them. The CNA accountability record is utilized to ensure that devices are in place. Part of the facility's Quality Assurance and Performance Improvement (QAPI) plan is that the Rehab Department checks the physician's monthly orders on a regular basis and ensures that the device that is ordered for the resident is in place and being utilized. The Rehab Department is not responsible for monitoring the presence and usage of heel lifts. On 11/20/18 at 12:04 PM, an interview was conducted with RN/Wound Care Nurse, RN #2. RN #2 has worked in the facility for approximately 6 years. Any pressure relieving devices ordered for a resident (heel booties/lifts) are documented on the CNA Documentation Record; and, the CNAs are the primary staff that are responsible for tracking the devices and ensuring that they are in place. The CNA would be the one to report any missing devices to the charge nurse. As of right now, there is no formal log or schedule for audits/spot-checks of pressure relieving devices. Spot-checks for pressure relieving devices are done sporadically, and there is no set schedule. Most of the time, the charge nurses on the unit are responsible for conducting spot-checks. 415.12(c)1

Plan of Correction: ApprovedDecember 26, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Manhattanville P(NAME) F 686
I. Immediate Corrective Action:
1) On 11/15/18 Resident #39 was reassessed by the WCN and has no impairment in skin integrity.
2) On 11/15/18 Bilateral heel cushions were provided by the WCN.
3) On 11/29/18 the DNS/Designee provided Disciplinary Action to the assigned CNA.
4) On 11/29/18 the DNS/Designee provided Disciplinary Action to the Charge nurse for not ensuring heel pressure relief devices were in place.
II. Identification of Others:
1) On 11/29/18 the WCN obtained a list of all residents with Physician orders [REDACTED].
2) This list was used by the WCN to ascertain if all residents needing heel pressure relief devices were provided with them and this intervention was included on the CNAAR and CCP. Any identified issues were immediately corrected.

III. Systemic Changes:
1) The DNS in conjunction with the WCN and Medical Director reviewed the facility P/P for Prevention and Management of Pressure injuries and found same to be compliant. This P/P will be re-inserviced to all nursing and Rehab staff by 12/28/18. The inservice will focus on:
? RN responsibility for assessing all residents at risk for skin breakdown utilizing the Braden Risk assessment on admission/readmission, quarterly and upon significant change.
? RN will complete a full body skin inspection for all new admissions, readmissions and upon significant change.
? The RNS will initiate an individualized CCP for residents at risk for skin breakdown.
? The RN will enter all specific pressure relief devices on the CCP and CNAAR
? The IDT team will develop and review CCP plan of care including pressure relief devices residents at risk for skin impairment at admission CCP meeting, quarterly and as needed.
? The Rehab Dept. will provide pressure relief and off-loading devices in accordance with MD orders documenting same in medical record.
? Inservice will include visual display of devices used for pressure relief of heels including off-loading heel lift suspension boots and heel pads.
? WCN will be responsible for conducting Unit rounds to ensure pressure relief devices are implemented.
? CNA will report to Charge nurse/RNS any devices that cannot be located or are in need of repair.
Inservice Records and Sign In sheets will be kept on file for validation

IV. Quality Assurance
1) The WCN developed an audit tool to monitor the facility?s compliance with ensuring residents receive the necessary services to prevent pressure injuries.
2) This audit will be completed weekly for all pressure relief devices by the Wound Care Team weekly x 4 weeks followed by monthly x 6 months.
3) Any issues will be corrected immediately. All findings will be shared with QA Committee for follow up as needed.
V. Person Responsible for this FTag:
DNS