Queens Nassau Rehabilitation and Nursing Center
April 7, 2017 Certification Survey

Standard Health Citations


REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 7, 2017
Corrected date: June 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and record review during the Recertification Survey the facility did not ensure that services were provided in accordance with each resident's written plan of care for 1 of 1 resident reviewed for Activities out of a total Stage 2 sample of 24 residents. Specifically, Resident #69 was observed not wearing a Physician-ordered right hand mitten. The finding is: Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/11/2017 Quarterly Minimum Data Set (MDS) assessment documented that the resident was rarely or never understood. The MDS documented that the resident's cognitive skills for daily decision making were severely impaired, the resident required total assistance for all areas of activities of daily living (ADLs), and the resident received nutrition through a feeding tube. A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP), dated 6/11/2015, titled Behavioral Problem that is disruptive or dangerous to self or other residents documented that the resident is combative during care--kicks, hits, grabs, bites and bangs his right hand on the lap tray and other objects and wears a right hand mitten OOB to protect from injury. The CCP further documented that the resident can pull out the feeding tube and may attempt to remove mitten by biting on the straps. An intervention included to release the hand mitten every 2 hours and when needed to check skin integrity, give ROM, and hygiene. A CCP, dated 6/11/2015, titled Potential for discomfort, injury, and loss of autonomy related to use of physical restraint--right hand mitten OOB/in bed documented that the reason for the mitten was to protect from injury because the resident bangs his right hand on his lap tray/objects, pulls out the feeding tube, and removes the abdominal binder. On 4/5/2017 at 1:24 PM Resident #69 was observed in the hallway in his geri-chair on the second floor near the nursing station. The resident was sleeping and did not have the right hand mitten on. On 4/5/2017 at 2:16 PM Resident #69 was observed in the same location in the hallway and had not been moved since the earlier observation. At this time the resident was wheeled into the day room for an activity; however, he was not wearing the right hand mitten. On 4/6/2017 at 8:10 AM Resident #69 was observed in bed. There was no other resident or staff member in the room. The resident did not have the right hand mitten on. The hand mitten was observed at the head of the resident's bed. On 4/6/2017 at 8:13 AM Resident #69's Certified Nursing Assistant (CNA) was interviewed and observed the resident. The CNA said he had taken the mitten off when he fed the resident (the resident receives recreation feedings in addition to tube feeding) and that he was going to put it back on when he dressed the resident and got him out of bed. On 4/6/2017 at 8:38 AM the Registered Nurse (RN) Unit Manager was interviewed. He stated that the mitten is needed because the resident bangs his right hand, and the hand mitten should have been on. On 4/7/2016 at 9:21 AM the Activities Director was interviewed. He stated that the resident has a history of banging his right hand when he gets agitated in an activity, and the resident has to be removed from the room. On 4/7/2017 at 10:14 AM the CNA who was assigned to Resident #69 on 4/5/2017 during the 7 AM-3 PM shift was interviewed by phone. She stated that she did not put on the right hand mitten because she was under the assumption that as long as the resident is calm the mitten does not have to be on. She stated that if the resident gets agitated she would put the mitten on. On 4/7/2017 at 12:11 PM the Director of Nursing (DNS) was interviewed. He stated that we (the nursing staff) need to clarify with the (CNA) staff when the mitten is supposed to be on. 415.11(c)(3)(ii)

Plan of Correction: ApprovedApril 25, 2017

I. Resident #69 was observed not wearing his right hand mitten. Two identified nursing staff did not consistently follow the care plan for the application and removal of the mitten.
a. The Residents? comprehensive care plan was reviewed by the interdisciplinary team to assure adequate interventions were in place. There were no changes necessary at this time.

b. The policy and procedure on use of restraints, was reviewed by the director of nursing, medical director and in-service director and revised as necessary.
c. The director of nursing met with the two nursing staff identified on survey and provided 1:1 counselling and education on following the policy on restraints with emphasis on use of hand mittens.

d. All nursing staff will be re-educated by the in-service director on this policy with emphasis on the use of hand mittens.
II. All residents who use hand mittens were identified to be at risk for this deficient practice.
a. The director of nursing, medical director, and in-service director reviewed and revised as necessary the policy on use of restraints.
b.All nursing staff will be immediately re-educated on the policy and procedure for restraints with emphasis on application and removal of hand mittens.
c. All care plans for residents using hand mittens have been reviewed to ensure all nursing staff are following the plan of care.

III. To ensure the highest standard of care/services are provided by qualified persons/per care plan and to prevent recurrence, the following measures have been initiated:

a. Policy and procedure for use of restraints was reviewed and revised as necessary.
b. All nursing staff will be re-educated immediately on the policy for the use of restraints with an emphasis on releasing and re-applying hand mittens.
c. All nursing staff will be educated on the policy for use of restraints upon hire, annually and as needed to ensure care is provided by qualified persons.

IV. As part of our QA program the in-service director will perform the following tasks:
a. The in-service director will evaluate all nursing staff with the use of a competency test. This will provide evidence that nursing staff are well informed and have a clear understanding of the purpose and function of restraint use and the proper application and removal of the mittens. Findings will be reported to the director of nursing/ administrator and be reviewed at the quality assurance meetings.

b. Licensed nursing staff will monitor for compliance and will report any issues to the director of nursing/ administrator. The facility will continue to use this assessment tool upon hire, annually and as needed to ensure efficient care is provided.
Responsible Party: Director of Nursing

Standard Life Safety Code Citations


REGULATION: Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table, unless otherwise permitted by through, Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: April 7, 2017
Corrected date: N/A

Citation Details

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver(s) to be continued. Time Limited Waiver Expires 10/02/2018. K161 S/S=B The facility did not ensure that the nursing home building that is built of unprotected non-combustible construction (i.e., NFPA 220 Type II (000)) was not more than two stories in height with a complete automatic sprinkler protection system. 10NYCRR 711.2(a)(1) NFPA 220 NFPA [PHONE NUMBER]:

Plan of Correction: ApprovedApril 28, 2017

The facility wishes the waiver to be continued.
The building is a 4 story sprinklered building. The non-combustible structure is currently unprotected. Due to this, the facility has filed a FSES (Fire Safety Equivalency Spreadsheet). We have submitted a plan for the work required to achieve equivalence to the DOH Bureau of Architectural and Engineering review and are awaiting their approval.
Once approved, we will submit the plan to the NYC building department to obtain the permit for the work.
The facility wishes the waiver to be continued.
Responsible person: Director of Maintenance