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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during an abbreviated survey (NY 917), the facility did not provide person-centered care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being for three of six residents (Resident #2 #3 #5) reviewed for Accidents. Specifically, (1) Resident #2 was identified as high risk for aspiration (choking) and was to be fed via percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube that allows nutrition directly through your stomach.) Resident #2 physician orders [REDACTED]. (2) Resident #3 was evaluated by speech and deemed to be at risk for aspiration, a physician's orders [REDACTED]. Resident #3 was given a dog biscuit which Resident #3 ate and subsequently began coughing and noted with abnormal lung sounds (stridor). (3) Resident #5 was identified at risk for aspiration, Resident # 5 was evaluated by speech with recommendations for nothing by mouth (NPO). Medication administration records dated (MONTH) 2025 indicated multiple medication administration by oral route. The findings are: The policy titled Accidents and Incidents Investigating and Reporting dated 5/2024 documented all accidents or incidents involving residents shall be investigated using the Report of Incident/Accident Form including the circumstances surrounding the accident or incident, the names of witnesses and their accounts, and other pertinent data as necessary or required. The facility policy titled Aspiration Precautions dated 5/2024 documented aspiration precautions were defined as measures taken to reduce the risk of aspiration during eating, drinking, and other activities. Nursing staff were responsible for monitoring residents for signs of aspiration risk, implementing precautions and communicating changes in condition. The Speech Language Pathologists assess swallowing function and recommend appropriate dietary modifications and interventions. Provide direct supervision for residents with high aspiration risk and observe for signs of difficulty such as coughing and choking. Documents observations in the resident's medical record. Resident #2 was a [AGE] year-old readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (an assessment tool) dated 1/03/2025 documented resident had a Brief Interview for Mental Status score of 6/15 which indicated a significant cognitive deficit. Resident #2 had an advanced directive dated 12/30/2024 which included Send to hospital, when medically necessary. A review of the Patient Review Instrument dated 12/26/2025 documented (19) Eating = 5 Tube of [MEDICATION NAME] feeding for primary intake of food. (Not just for supplemental nourishments.) The speech therapy evaluation dated 12/30/2024 documented resident should have nothing by mouth (NPO). The physician orders [REDACTED]. Any drug which cannot be crushed, may be given whole in applesauce. Physician orders [REDACTED]. [MEDICATION NAME] Tablet Delayed Release 20 MG Give 2 tablet by mouth every 12 hours for acid indigestion for 2 Weeks. Start Date: 1/17/2025, Discharge/Death 1/28/2025 [MEDICATION NAME] Oral Capsule 30 MG (Oseltamivir [MEDICATION NAME]) Give 1 capsule by mouth one time a day for flu for 5 days Start Date 1/26/2025, Discharge/Death 1/28/2025 Tylenol Oral Tablet 325 MG ([MEDICATION NAME]) Give 2 tablet by mouth every 6 hours as needed for pain. Start Date 1/13/2025, Discontinue 1/26/2025 The Medication Administration Record [REDACTED]. Multiple attempts to reach Physician Assistant #1 on 2/14/2025, 2/20/2025 and 2/ 5 were unsuccessful. (2) Resident #3 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #3's Minimum Data Set (an assessment tool) dated 11/8/2024 documented a Brief Interview for Mental Status score of 8/15 which signified a moderate cognitive deficit. Physician order [REDACTED]. A Speech Language Pathology Screen dated 9/14/2023 documented discharge status and recommendations documented puree consistencies. A nursing progress note dated 12/25/2025 documented Resident was given dog treat (solid consistency) to feed dog and resident subsequently ingested said dog treat. The note further documented resident presents with a persistent cough with stridor (Stridor is a high-pitched, [MEDICATION NAME] or noisy sound that occurs when breathing. It is caused by an obstruction or narrowing in the upper airway). The physician progress notes [REDACTED].#3 ate the treat with subsequent fit of coughing, stridor noted at the time but resolved. The facility accident and incident report dated 12/27/2025 documented during pet therapy the resident asked if he could give the dog a treat, Resident #3 was given a dog treat to feed dog, resident ingested dog treat which was a milk bone treat, Registered Nurse Supervisor was immediately notified. Registered Nurse Supervisor completed an assessment, resident noted with a persisting cough with slight stridor noted to lungs, resident refused vital signs at the time and the physician was made aware. During an interview conducted with the Speech Language Pathologist on 2/13/2025 at 1 PM they stated Resident #3 would present with immediate cough and throat clear with all intakes which indicates that he is at risk for aspiration with solid foods. They further stated resident could not tolerate a solid dog biscuit. (3) Resident #5 was admitted to the facility with a medical [DIAGNOSES REDACTED]. The review of the Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score- 15 indicating intact cognition for decision making, eating not attempted due to medical condition or safety concerns, feeding tube on admission, while a resident, the resident received through [MEDICATION NAME] or tube feeding-51% or more, for the Resident. The review of the Order Recap Report dated 1/11/2025 documented Tube Feed diet, nothing by mouth. The review of the physician orders [REDACTED]. The review of the Medication Administration Record [REDACTED]. Multiple attempts to reach Physician Assistant #1 on 2/14/2025, 2/20/2025 and 2/ 5 were unsuccessful. On 2/13/2025 at 2:20 PM, the Director of Nursing was interviewed and stated the nurses are aware of the residents with feeding tube. The Director of Nursing stated that Residents who are assessed to have nothing by mouth (NPO) should have orders to administer medication thru the feeding tube. They further stated staff are aware of Residents #5 feeding tube and should have notified the physician to change the order to reflect the medication be administered via the feeding tube. On 2/13/2025 at 1:18 PM, Medical Doctor #1 was interviewed and stated residents who are assessed to have nothing by mouth (NPO) should have orders to administer medication thru the feeding tube. They further stated Resident # 3 should not have consumed the dog biscuit. 10 NYCRR 415.12(h)(1) | Plan of Correction: ApprovedApril 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Corrective Action: Resident # 2 and Resident #3 no longer reside at the facility. The MEDICATION ORDERS FOR [REDACTED]. Nursing and Activity staff directly involved in the care of Resident #2 and Resident #3 were immediately re-educated on proper dietary restrictions and swallowing precautions, ensuring that residents with GT who are NPO are maintained NPO and are not administered anything by mouth. The Medical Director in-serviced the medical staff involved on providing a person-centered care including but not limited to reviewing recommendations from other disciplines such as the speech pathologist recommendations as well as the consultant pharmacy recommendations. In addition, providers were educated on ordering medication routes according to residents?ÇÖ plan of care such ordering medication via [DEVICE] when residents are NPO. II. Identification: All residents with NPO order or that are aspiration precautions or altered diets have the potential to be affected by this finding. The Director of Nursing audited all residents with a Gastrostomy tube to review their NPO status to ensure medications orders are to be administered via GT. Any finding was addressed immediately. The residents with altered diet orders were audited to ensure they only receive food or meal services according to their diet orders. The Activity Department was provided with an up-to-date list of residents on altered diets, food allergies [REDACTED]. III. Systematic Changes: The policies titled Accidents and Incidents Investigating and Reporting, and Aspiration Precautions were reviewed by the Director of Nursing, Administrator and Medical Director and no revisions were necessary. The clinical staff, Nursing, PT/OT, and medical providers were re-educated on ensuring residents are provided person-centered care and services necessary to meet and maintain the highest practicable physical, mental and psychological wellbeing, as well as, ensuring the following: 1. Providing supervision for residents who are at risk for aspiration and choking and are on altered diets 2. Ensuring that residents with GT who are NPO are maintained NPO and are not administered anything by mouth 3. Ensuring residents with GT receive the right evaluation by the physician including following recommendations from the speech pathologist. 4. Examples of hazards and supervision, ensuring that the resident environment is free from hazards. Unit Managers/Designee will monitor residents with NPO order to ensure the facility provides person-centered care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being New admissions with a feeding tube will be monitored during morning meetings to ensure the medication route is according to residents?ÇÖ plan of care. Activity Department will receive an up-to-date list of residents on altered diets, food allergies [REDACTED]. A log sheet will be maintained by the activities department to verify the daily receipt of this report. The menu and diet report will be disbursed to both nursing units and to all areas activities will take place for easy reference by all staff. IV. Monitoring: The Director of Nursing/ Designee will audit residents who have a Gastrostomy Tube and NPO to ensure medications are ordered via the right route (GT) weekly X 4 weeks, monthly X 3 months. Director of Nursing /Designee will audit 10 residents with altered diet orders randomly during activity programs to ensure they only receive food according to their plan of care at activity programs weekly X 4 weeks, monthly X 3 months. The result of all audits will be presented to QAPI committee for review and feedback monthly for the duration of audit. V. Responsible Party: The Director of Nursing. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Abbreviated Survey (NY 917) the facility did not ensure that each resident's representative was immediately informed when a resident had a change in condition or the potential for change of condition requiring physician intervention. This was identified for one (Resident #1) of six residents reviewed for Quality of Care. Specifically, on 1/26/2025 and 1/27/2025 Resident #1 presented with fever, [MEDICAL CONDITION](increased heart rate) [MEDICAL CONDITION] (low blood pressure) and critical lab results including a HGB (hemoglobin) 4.9g/dl (normal range is 13.0-17.0g/dl). The resident's representative was not informed of the change in condition, or the interventions provided. The finding is: The facility's policy titled Change in Condition, last reviewed by the facility on 09/18/2024, documented the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical mental condition and/or status. The policy further documented a significant change of condition is a decline in the resident's status that requires interdisciplinary review and or revision to the plan of care and impacts more than one area of the resident's health status. Resident #2 was an [AGE] year-old readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (an assessment tool) dated 1/03/2025 documented resident had a Brief Interview for Mental Status score of 6/15 which indicated a significant cognitive impairment. Resident #2 had an advanced directive dated 12/30/2024 which included Send to hospital, when medically necessary. A Physician Encounter note dated 1/26/2025 at 12:00AM documented the Chief Complaint / Nature of Presenting Problem as Patient evaluated for fever, [MEDICAL CONDITIONS]. Reviewed documents from 1/24/205 regarding chest x-rays with bilateral interstitial lung markings which was presumed as likely [MEDICAL CONDITION] etiology. Patient currently on [MEDICATION NAME] renal dosing since 1/25/2025. However, spiking fever with blood pressure 76/47 requires immediate fluid bolus and Tylenol 1gram versus 650milligrams. The heart rate 113, ordered EKG, fever 102.0 on repeat 101, initiating cooling measures [MEDICAL CONDITION] protocol. Patient currently [MEDICAL CONDITION] protocol. The note further documented Stat fluid bolus for blood pressure initially 76/47. Improvement after 500cc, repeat blood pressure 102/68 which is reassuring. [MEDICAL CONDITION] pulse from 113 =>94 status [REDACTED]. Ordered [MEDICATION NAME] 1 gram now followed by [MEDICATION NAME] 1 gram for 4 days for total 5-days treatment. The encounter further documents the plan is to manage at facility versus transfer. There is no documented evidence the provider notified the Resident Representative. A nursing progress Note dated 1/26/2025 at 4:09PM documented Resident #2 was noted with a temporal temperature of 101.1F, hypotensive (low blood pressure) and [MEDICAL CONDITION] The note documented the Nurse Practitioner was made aware new order for Intravenous bolus initiated, Intravenous Meropenem 1gram, [MEDICATION NAME] 1gram, labs and chest x-ray to be obtained. A nursing progress note dated 1/27/2025 at 3:11AM, documented the writer was called to assess resident with abnormal lung sounds; upon assessments lungs auscultated to have crackles bilaterally and only responsive to painful stimuli. Resident was suctioned, vital signs stable (no documented measurements) outside of temp of 99.9 ongoing care in progress. There is no documented evidence the resident representative was notified. A review of the Lab results dated 1/27/2025 documented a critical level of HGB (hemoglobin) 4.9g/dL (critically low) (normal range 13.0-17.0g/dL), HCT (hematocrit test) 17% (critically low) (normal range 39.0-50%) and Sodium 161 mmol/L (critically high) (134-145 mmol/L). There is no documented evidence the resident representative was notified. The Resident's Representative (primary contact) was interviewed on 2/13/2025 at 12:32 PM and stated the facility did not notify them when the resident was started on antibiotics for [MEDICAL CONDITION] protocol. They further stated they were not aware until they arrived at the funeral home that Resident #1 was experiencing symptoms [MEDICAL CONDITION]. Resident Representative stated they visited Resident #1 frequently and wanted to be notified if Resident had any changes in their medical condition. Residents Representative stated they would have demanded Resident #1 sent to the hospital if they were aware of the blood pressure readings below 90 or abnormal lung sounds. During an interview conducted on 2/15/2025 at 2PM with Nurse #2 they stated they were called to assess Resident #1 they observed the resident with abnormal lung sounds and not responsive to verbal or tactile stimuli. They further stated they did not notify the Resident Representative or the Physician. During an interview conducted on 2/13/2025 at 1:24PM Registered Nurse Supervisor #1 stated on 1/27/2025 they received a call from the lab at approximately 6:30PM and was informed Resident #1's hemoglobin and hematocrit results were critically low (4.9g/dl 17%), they stated they called the Nurse Practitioner on duty and informed them of the results. They stated they did not call the resident's Representative and could not provide an answer as to why not. Multiple attempts were made on 2/14/2025, 2/20/2025 and 2/21/2025 to contact Physician Assistant #1 without success. During an interview on 2/13/2025 at 10:22 AM, the Director of Nursing Services stated the facility staff should have called the resident's representative and advised them of changes with the resident's medical condition and new interventions. 10 NYCRR 415.3(f)(2)(ii)(a) | Plan of Correction: ApprovedMarch 17, 2025 I. Corrective Action: Resident # 2 is no longer in the facility. The Director of Nursing (DON) conducted a comprehensive review of their medical records to identify lapses in communication. The findings were discussed in a staff meeting to emphasize the importance of timely notification to residents?ÇÖ representatives. II. Identification: All residents had the potential to be affected by the same deficient practice. The facility conducted a comprehensive audit of all current residents?ÇÖ medical records over the past 30 days to identify any instances where there are changes in condition that occurred without proper notification to the residents?ÇÖ representative. Any findings identified will be addressed immediately. III. Systematic Changes: The facility?ÇÖs policy titled ?Ç£Change of Condition?Ç¥ was reviewed by the Director of Nursing and Medical Director and no revision was required. RN?ÇÖs, LPN?ÇÖs and Medical Providers will be educated on the policy of Change of Condition and emphasize the importance of timely and documented communication with residents and their representatives. Newly hired license nurses and medical providers will undergo this training during orientation process. IV. Monitoring: The DON will review the 24-hour reports with any resident with a change of condition and verify if resident and the representative were notified of the changes. Audit will be completed daily X 1 week; once weekly X 4 months; once monthly X 3 months; once every 6 months X one year. Results of these audits will be reviewed during the monthly Quality Assurance and Performance Improvement (QAPI) meetings monthly until compliance is sustained. V. Responsible Party: Director of Nursing/Designee |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (NY 917) the facility did not ensure the physician reviewed the resident's total program of care, including treatments at each visit and a decision about the continued appropriateness of the resident's current medical regimen for 2 out of 6 residents (Resident #5, #2) reviewed for Quality of Care. Specifically, (1) Resident #2 was admitted to the facility with orders for nothing to be administered by mouth and a feeding tube the facility did not address Resident #2 ability to receive oral medication or include an order for [REDACTED].#5 was admitted with orders for nothing by mouth with a feeding tube, Resident #5 was evaluated on 1/19/2025 by Physician Assistant #1 with orders including [MEDICATION NAME] tablet, [MEDICATION NAME] tablet and [MEDICATION NAME] capsules to be administered by mouth. (3) The pharmacy review for resident #5 recommended to discontinue [MEDICATION NAME] (medication used in the treatment of [REDACTED]. Nurse practitioner #1 initiated the new medication but did not discontinue the [MEDICATION NAME]. For 30 days resident received both medications. The findings are: The facility Physician's Visit policy dated 2/1/2016 and last revised 1/2020 documented the attending physician must make visits in accordance with applicable state and federal regulations. The attending physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. 1) Resident #2 was an [AGE] year-old readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Minimum (MDS) data set [DATE] documented resident had a Brief Interview for Mental Status score of 6/15 which indicated a significant cognitive impairment. Resident #2 had an advanced directive dated 12/30/2024 which included Send to hospital, when medically necessary. A review of the Patient Review Instrument dated 12/26/2025 documented (19) Eating = 5 Tube of [MEDICATION NAME] feeding for primary intake of food. (Not just for supplemental nourishments.) The speech therapy evaluation dated 12/30/2024 documented resident should have nothing by mouth (NPO). The physician orders [REDACTED]. The physician order [REDACTED]. Any drug which cannot be crushed, may be given whole in applesauce. Physician orders [REDACTED]. [MEDICATION NAME] Tablet Delayed Release 20 MG Give 2 tablet by mouth every 12 hours for acid indigestion for 2 Weeks. [MEDICATION NAME] Oral Capsule 30 MG (Oseltamivir [MEDICATION NAME]) Give 1 capsule by mouth one time a day for flu for 5 days. Tylenol Oral Tablet 325 MG ([MEDICATION NAME]) Give 2 tablet by mouth every 6 hours as needed for pain. Medication Administration Record [REDACTED]. Multiple attempts to reach Physician Assistant #1 on 2/14/2025, 2/20/2025 and 2/ 5 were unsuccessful. During an interview conducted with the Medical Director on 2/12/2025 at 3PM they stated the physician/practitioner should review the recommendations from the speech pathologist for the resident's intake status. They further stated if a resident is deemed nothing by mouth (NPO) there should be physician order [REDACTED]. 2) Resident#5 was admitted to the facility with a medical [DIAGNOSES REDACTED]. The review of the Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score- 15 indicating intact cognition for decision making, eating not attempted due to medical condition or safety concerns, feeding tube on admission, while a resident, the resident received through [MEDICATION NAME] or tube feeding-51% or more, for the Resident. The review of the Order Recap Report dated 1/11/2025 documented Tube Feed diet, nothing by mouth. The review of the physician orders [REDACTED]. The review of the Medication Administration Record [REDACTED]. Multiple attempts to reach Physician Assistant #1 on 2/14/2025, 2/20/2025 and 2/21/2025 were unsuccessful. 3) The medication Regimen review dated 1/10/2025 documented consultant pharmacy recommendations including currently receiving [MEDICATION NAME] ([MEDICATION NAME]) by PEG (feeding tube) for benign prostate hypertrophy which should not be crushed. Please consider discontinue and start Silodosin ([MEDICATION NAME]) 8 Mg daily opened spinked in applesauce and given via GT. The physician/ prescriber response indicated Agree; Will do signed and dated by the prescriber on 1/13/2025. The physician order [REDACTED]. The Medication Administration Record [REDACTED]. The Medication Administration Record [REDACTED]. During an interview conducted with Nurse Practitioner #1 on 2/13/2025 at 2pm they stated they reviewed the recommendations from the pharmacy. They further stated they agreed to switch to Silodosin ([MEDICATION NAME]) which could be given via the feeding tube. Nurse Practitioner #1 stated [MEDICATION NAME] should have been discontinued and it was an oversight. They stated they would do it immediately. 10NYCRR 415.15(b)(2)(iii) | Plan of Correction: ApprovedMarch 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Corrective Action: Resident #2 no longer resides in the facility. Resident #5 orders for both [MEDICATION NAME] and [MEDICATION NAME] were corrected and updated accordingly. Resident #2 and Resident #5 medical providers involved in the care were re-educated by the Medical Director regarding ordering medication route administration according to residents?ÇÖ plan of care, aspiration precautions, NPO status, and medical conditions. In addition, they were re-educated on Drug Regimen Reviews and interventions are implemented completely. II. Identification: All residents with a GT (Gastrostomy tube) have the potential to be affected by this finding. The facility conducted a review of all residents who are on GT to ensure NPO orders are in place as indicated and to ensure residents who are NPO have orders to have their medications administered via Gastrostomy Tube (GT). No negative findings were identified. All Residents with drug regimen review have the potential to be affected by this finding. All drug regimen reviews for the last 30 days were audited to ensure the recommendation and interventions were followed and implemented completely. No negative findings were identified III. Systematic Changes: The Director of Nursing and Administrator reviewed the facility?ÇÖs policy titled Physician's Visit and Enteral Feedings Safety Precautions and no revisions were necessary. Licensed nursing staff, dieticians and medical providers were re-educated on the policies. RN?ÇÖs and LPN?ÇÖs will perform daily checks to ensure that medication orders are being followed as per the updated care plan, including verifying that no oral medications are given to residents who are NPO and have a GT. Unit Managers/Designee will monitor residents with NPO orders to ensure they are maintained as NPO and are not administered anything by mouth. All medical providers were educated by the Medical Director on the comprehensive review of the pharmacy consultant drug regimen review to ensure all recommendations are followed thoroughly including transcribing/discontinuing orders. In addition, they were re-educated regarding ordering medication route administration according to residents?ÇÖ plan of care, aspiration precautions, NPO status, and medical conditions. IV. Monitoring: The Director of Nursing/ Designee will audit residents who have a Gastrostomy Tube and NPO to ensure medications are ordered via the right route (GT) weekly X 4 weeks, monthly X 3 months. The Director of Nursing/Designee will audit the pharmacy consultant Drug Regiment Review to ensure all recommendations are followed thoroughly, including transcribing/discontinuing orders, monthly X 3 months. The result of all audits will be presented to QAPI committee for review and feedback for the duration of audit. V. Responsible Party: The Director of Nursing |