Ghent Rehabilitation & Nursing Center
July 13, 2016 Certification Survey

Standard Health Citations

FF09 483.20(d), 483.20(k)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.25; and any services that would otherwise be required under §483.25 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2016
Corrected date: September 9, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification survey, the facility did not ensure that it developed a comprehensive care plan (CCP) that included measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs for 2 (Resident #s 75 and 82) of 23 residents reviewed. Specifically, for Resident #75, the resident developed a pressure sore on 6/16/16, but the CCP was not written until 7/12/16. Specifically for Resident #82 the resident had a [DIAGNOSES REDACTED]. This was evidenced by: Resident #75: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact. The Pressure Ulcer Identification and Progress Note form, documented the resident developed a Stage III pressure sore on the buttock that measured 1.4 centimeters (cm) long and 0.6 cm wide on 6/16/16. There was slough to the wound bed and the skin around the wound was macerated. The Comprehensive Care Plan (CCP) for Skin Breakdown/Pressure, which included measurable objectives and timetables was dated 7/12/16. During an interview on 7/13/16 at 12:51 pm, the Registered Nurse Manager reviewed the resident record and stated the CCP for this resident's Stage III pressure ulcer was not written until 7/12/16. He stated it should have been written when the wound was discovered, but was not. He stated this was an oversight. Resident #82: This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as being able to understand others and was able to be understood. A physician's orders [REDACTED]. A Discharge Summary from the hospital dated 6/21/16, documented the resident with a history of compression fractures of the spine. She came into the emergency room with increasing pain in her low back, radiating up her spine. She was admitted and started on [MEDICATION NAME] for pain. The resident was discharged from the hospital on [DATE]. A History and Physical dated 6/27/16, documented the resident was diagnosed with [REDACTED]. CT scan showed a new fracture as of 6/21/16. The Policy and Procedure (P&P) for Interdisciplinary Care Planning with a revision date of 01/2016, documented it is the policy of the facility to assess and analyze each resident's comprehensive assessment and develop a plan of care, service, and treatment which is individualized and appropriate to the resident's strengths, needs, and goals. During an interview on 7/13/16 at 9:55 am, the Registered Nurse Manager (RNM) stated the resident receives [MEDICATION NAME] and [MEDICATION NAME] for compression fractures. Physical therapy had been split in half due to the resident's pain and that she requires 1:1 encouragement to ambulate. This admission is the second time the resident had been in the nursing home for compression fractures. The RNM stated it is the policy of the nursing home to have a pain care for a resident who experienced pain and took medication to relieve the pain. The RNM stated this resident should have had a pain care plan and that she is usually more organized. 10NYCRR415.11(c)(1)

Plan of Correction: ApprovedAugust 5, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F279
Corrective Action regarding affected residents:
The facility strives to use the assessment results to develop, review and revise the resident?s comprehensive care plan (CCP).
Resident # 75
Medical record review for Resident # 75 was conducted. The findings showed that the resident developed a Stage 3 pressure area on 6/16/16. The medical record and facility documents documented the area had been appropriately assessed and treated per physician?s orders. The area was monitored and discussed weekly during Wound Care meeting. On 7/12/16 it was noted that a Comprehensive Care Plan (CCP) for Skin Breakdown had not been initiated at the time of discovery on 6/16/16. A CCP for the area was initiated on 7/12/16.
Resident # 82
Medical record review for Resident # 82 was conducted. Based on the findings, the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A pain assessment was completed on 6/24/16 and appropriate treatment for [REDACTED].
Identification of other residents possibly affected and corrective actions taken:
For similar residents who may be affected, medical records were audited and were reviewed for Comprehensive Care plans to address those residents with actual skin breakdown and for those residents at risk to develop skin breakdown.
For similar residents who may be affected, medical records were audited and were reviewed for Comprehensive Care plans to address those residents with pain.
Measures put into place or systematic changes put in place to ensure the deficient practice does not recur:
All licensed nurses will receive education on facility policy related to the development, review and revision of CCP.
The Registered Nurse will initiate a CCP upon admission/readmission, with significant changes, change in medical condition/acute illness for any area identified to include those residents with skin breakdown and pain management.
How the current action will be monitored to ensure the deficient practice does not recur:
Comprehensive Care Plans will be audited for all triggered areas that are identified on admission, readmission, significant change or change in medical condition. Licensed nursing staff will audit weekly for 4 weeks and then monthly for 3 months. The Director of Nursing and/or designee will report audit results at the QAPI committee meeting quarterly until compliance is satisfactory and maintained. Audits will continue as needed and determined by the QAPI committee. Audits will continue as needed and determined by the QAPI committee.
Responsible Party and Date for Correction:
The Director of Nursing will be responsible to ensure compliance by 9/9/16.

FF09 483.25(l):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2016
Corrected date: September 9, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure that each resident's drug regimen was free from unnecessary drugs for one ( Resident #8) of 7 residents reviewed for psychoactive medication use during the recertification survey. Specifically: there was lack of adequate indication for use of a PRN (as needed) antianxiety medication for the resident and lack of consistent monitoring of effectiveness of the prn medication. This is evidenced by: Resident #8: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed that the resident sometimes understands, was usually understood and had severely impaired cognition. It also identified that the resident had behaviors of rejecting care, and physical and verbal behaviors to others. Physician orders [REDACTED]. The Medication Administration Record [REDACTED]. The back of the MAR indicated [REDACTED]. Positive effectiveness was documented on 6/2, 6/23 and 6/25/16. There was no documentation regarding the reason [MEDICATION NAME] was given on 6/14 and 6/22/16 or whether it was effective. There was no documentation on the MAR indicated [REDACTED]. The effectiveness of the 6/5/16 [MEDICATION NAME] was found in the nurses notes for that day. There was no documented evidence in the nurses notes that [MEDICATION NAME] was given on 6/14 and 6/22/16 or of the effectiveness of [MEDICATION NAME] once given. Review of a nurses note dated 6/28/16 at 8:00 pm, documented that the resident was self transferring several times while up in the wheelchair. Re-direction had short term effect. PRN [MEDICATION NAME] was given, resident asleep in bed at the time. The (MONTH) (YEAR) MAR, documented that [MEDICATION NAME] was given on 7/7/16, for anxiety, however there was no documentation regarding it's effectiveness on the MAR. There was no documentation regarding the effectiveness of the [MEDICATION NAME] in the nurses notes. Review of the Nurses notes dated 7/6/16 at 8:00 pm, documented that the resident self transferred several times, short term redirection had short term effect, increased agitation noted. PRN [MEDICATION NAME] given at 4:00 pm. The resident stopped self transferring. During an interview on 7/13/16 at 10:17 am, the Registered Nurse Manager (RNM) stated that self transferring is not an appropriate reason for giving [MEDICATION NAME]. You should try to find out why he is wanting to self transfer. He said the [MEDICATION NAME] should be used for his agitation. The RNM looked at the MAR for (MONTH) and saw there was no documentation on the back of it for why the [MEDICATION NAME] was given or if it was effective. He stated it should be there with the date and time given, why it was given and the follow up of the effectiveness During interview on 7/13/16 at 10:39 am, the Licensed Practical Nurse (LPN) Charge stated she would give the [MEDICATION NAME] to the resident if he was agitated/combative, it does work. She stated she would not give it for self transferring. She said you should document the reason giving the prn, what you did before giving the [MEDICATION NAME] , ie. try redirection, walking- he used to deliver wood and still thinks he needs to. If redirection is not effective-still aggressive/combative, then you would give the [MEDICATION NAME]. 10NYCRR415.12(I)(1)

Plan of Correction: ApprovedAugust 5, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F329
Corrective action regarding affected residents:
The facility strives to ensure that there is adequate indication for use and adequate monitoring of effects for those residents receiving [MEDICAL CONDITION] medication.
Resident # 8
Review of the medical record was conducted. The findings showed that there was a lack of documentation found when the resident received as needed doses of [MEDICATION NAME] (anti-anxiety). The resident has behavioral anxiety and exhibits various forms of agitated state. The medical record and the Medication Administration Record (MAR) did not consistently indicate the specific reason the medication was being administered. On other occasions there was documentation for the reason for administration, but lacked documentation for the effectiveness of the medication. The resident is being monitored for behaviors that indicate the use of [MEDICATION NAME] and the effectiveness of the medication. Both the indication for use and effectiveness of the medication are documented accordingly in the nursing progress notes and the MAR.
Identification of other residents possibly affected and corrective actions taken:
For similar resident who may be affected, medical records were audited for indication of medication use and documentation of it?s effectiveness in both the nursing notes and on the MAR.

Measures put into place or systematic changes put in place to ensure the deficient practice does not recur:
All licensed nurses will receive education on the facility policy on documentation expectations. An emphasis will be placed on specific documentation for as needed (prn) [MEDICAL CONDITION] medication administration.
Any resident receiving prn [MEDICAL CONDITION] medication will be placed on the twenty-four hour report, indicating reason for administration, effectiveness of medication and the completion of MAR and nursing note. This information will be discussed during clinical report Monday- Friday (The weekend information will be discussed on the following business day).
How the current action will be monitored to ensure the deficient practice does not recur:
Audits will be conducted weekly to ensure compliance of documentation, adequate indication of use and monitoring of effectiveness.
Licensed nursing staff will audit weekly for 4 weeks and then monthly for 3 months. The Director of Nursing and/or designee will report audit results at the QAPI committee meeting quarterly until compliance is satisfactory and maintained. Audits will continue as needed and determined by the QAPI committee.
Responsible Party and Date for Correction:
The Director of Nursing will be responsible to ensure compliance by 9/9/16.

FF09 483.35(i):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2016
Corrected date: September 9, 2016

Citation Details

Based on observation, manufacturer's directions review, and staff interview during the recertification survey, it was determined that the facility did not adhere to generally accepted food sanitation practices. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Chapter 1 Subpart 14 State Sanitary Code, the community standard for food service establishments operating in New York State both state that chemicals used in food equipment sanitizing to kill bacteria are to be at the correct concentration and that food temperatures thermometers are to be calibrated. Specifically, the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than that required by the manufacturer and 3 of 4 thermometers were not calibrated. This is evidenced as follows. The kitchen was inspected on 07/11/2016 at 10:00 am. The concentration of QAC used in the sanitizing rinse sink, the third sink, was measured at 70 degrees Fahrenheit (F) and found to be less than 100 parts per million (ppm). The manufacturer's label directions stated the concentration is to be between 200 ppm when the solution is between 65 F and 75 F. When thermometers were checked for calibration using the standard method in an ice bath, the temperatures read 32 F, 20 F, 27 F, and 19 F. The Director of Culinary Services stated in an interview conducted on 07/11/2016 at 10:00 am, that the pre-mix mechanism could be broken and that thermometers are calibrated in a small cup of ice water and not in a large container with more ice than water. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.85, 14-1.112

Plan of Correction: ApprovedAugust 5, 2016

F371
Corrective Action regarding affected residents:
On 7/11/16 it was determined that the sanitizer solution in the third bay of the 3-bay sink did not test at the proper sanitizing concentration level. The maintenance department was called to check the pump. The pump was found to have air in the line. The bottle of quaternary ammonium compound chemical sanitizing rinse had been changed at the end of shift the night before (7/10/16) and was not utilized again prior to the surveyor testing it on 7/11/16. The air was bled from the line. The sanitizer solution was re-tested at the proper temperature range (65-75 degrees Fahrenheit) and was within the acceptable concentration ppm level (200-400) for the quaternary ammonium compound chemical sanitizing rinse, prior to the first use on 7/11/16. No resident nor dishware was affected, as the 3-bay sink had not been set up for usage at the time of the surveyor?s inspection.
On 7/11/16, calibration of manual thermometers was checked and deemed incorrect. The Director of Culinary Services immediately re-calibrated the thermometers in the method shown by the surveyor.
Identification of other residents possibly affected and corrective actions taken:
On 7/11/16 it was determined that the sanitizer solution in the third bay of the 3-bay sink did not test at the proper sanitizing concentration level. The maintenance department was called to check the pump. The pump was found to have air in the line. The bottle of quaternary ammonium compound chemical sanitizing rinse had been changed at the end of shift the night before (7/10/16) and was not utilized again prior to the surveyor testing it on 7/11/16. The air was bled from the line. The sanitizer solution was re-tested at the proper temperature range (65-75 degrees Fahrenheit) and was within the acceptable concentration ppm level (200-400) for the quaternary ammonium compound chemical sanitizing rinse, prior to the first use on 7/11/16. No resident nor dishware was affected, as the 3-bay sink had not been set up for usage at the time of the surveyor?s inspection.
On 7/11/16, calibration of manual thermometers was checked and deemed incorrect. The Director of Culinary Services immediately re-calibrated the thermometers in the method shown by the surveyor.
Measures put into place or systematic changes put into place to ensure the deficient practice does not recur:
In-Services for all culinary staff on the following:
? How to properly calibrate an analog thermometer.
? How to properly test the quaternary ammonium compound chemical sanitizing rinse in the 3rd bay of the 3-bay sink and what to do if the sanitizing solution ppm level is not correct.
In-service for Dietary, Nursing, Activities, Rehab and Central Supply
? How to utilize digital thermometers and replace the battery. (Acquisition of digital thermometers, that do not require calibration, were put into use replacing analog thermometers on 7/19/16.)
How the current action will be monitored to ensure the deficient practice does not recur:
Sanitizer solution ppm levels are recorded daily, before use of 3 bay sink. The Director of Culinary Services will audit sanitizer solution ppm level readings daily for 4 weeks, weekly for 4 weeks and then monthly for three months.
Thermometers have been changed to digital which do not require calibration.
Director of Culinary Services will report results at the QAPI meetings quarterly until compliance is satisfactory and maintained. Audits will continue as needed and determined by the QAPI committee.
Responsible party and date for correction:
The Director of Culinary Services will be responsible to ensure compliance by 9/9/16.

FF09 483.75(l)(1):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2016
Corrected date: September 9, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure that clinical records on each resident were maintained in accordance with accepted professional standards and practices that were complete and accurately documented for 3 ( Resident #'s 7, 8 and 23) of 23 residents reviewed during the recertification survey. Specifically: For Resident #7, there was lack of documentation of notification to the Medical Doctor (MD) for this resident's change in condition. For Resident #8, there was lack of documentation on the Medication Administration Record (MAR) of medications given; there were errors in dates in nurses notes and on the Medication Assistance Record(MAR). For Resident #23, there was lack of documentation of why an antipsychotic medication was needed. This is evidenced by: Resident #7: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident usually understands, was usually understood and had a Brief Interview of Mental Status of 4/15 or severely impaired cognition. Nurses notes documented: 5/23/16 at 2:15 pm, the resident was alert, verbal, slowly responds when speaking. The resident had a BM (bowel movement) today with mucous and shreds of blood noted. Oral fluids were offered and encouraged .Poor solid food intake present with only bites of meals being consumed today. The resident stated I'm fine denied discomfort when assessed. This afternoon, resident attending activity program, appears in good spirits. 5/23/16 at 10:00 pm, new order to be on 5/24/16 for CBC (complete blood count) . poor appetite for pm meal, no blood noted on rectal area, no complaint of pain/discomfort 5/24/16 at 6:00 am, the resident slept all night, had no complaints, there was no bleeding. 5/24/16 at 2:45 pm, lab draw for CBC .the NP was aware of urine dark amber color- check urine with dip, clear catch. New order for one can of Boost (nutritional supplemental drink) with each meal. the resident ate nothing for breakfast and 25 % of lunch. During interview on 7/13/16 at 11:41 am, the Registered Nurse Manager (RNM) stated that neither of the notes on 5/23/16 mentioned notifying the RN or Supervisor about the blood in the BM. He stated it appeared the MD (Medical Doctor) was notified because there was an order for [REDACTED]. He stated there should have been a nurses note that the doctor was called and what he was told about the resident. He stated that neither note on the 23 rd mentioned notifying the RN or Supervisor about the blood/mucous in the resident's BM. Resident #8: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set of 5/26/16, assessed that the resident sometimes understands, was usually understood and had severely impaired cognition. It also identified that the resident had behaviors of rejecting care, physical and verbal behaviors to others. Physician orders [REDACTED]. The medication Administration Record (MAR) for (MONTH) (YEAR), documented the prn [MEDICATION NAME] given on: 6/2, 6/5, 6/7, 6/14, 6/22, 6/23, and 6/25/16. There was a nurses note of 6/26/16 at 2:45 pm, that the resident was combative and received [MEDICATION NAME] at 8:50 am with positive effect. There was another nurses note on 6/26/16 at 10:20 pm, that the resident received prn [MEDICATION NAME] at around 3:00 pm for agitation with positive effect. There was no [MEDICATION NAME] documented on the MAR for 6/26/16. The (MONTH) (YEAR) MAR, documented the [MEDICATION NAME] was given on 7/7/16, for anxiety, however, there was no documentation on the MAR regarding the effectiveness. The back of the MAR documented the resident received [MEDICATION NAME] on 7/8/16 for increased anxiety. Nurses notes dated 7/6/16 at 8:00 pm, documented the resident self transferred several times, short term redirection had short term effect, increased agitation noted. PRN [MEDICATION NAME] given at 4:00 pm. The resident stopped self transferring. This [MEDICATION NAME] administration was not on the (MONTH) (YEAR) MAR. During interview on 7/13/16 at 10:17 am, the Registered Nurse Manager (RNM) looked at the MAR for (MONTH) (YEAR) and saw there was no documentation on the back of it for why the [MEDICATION NAME] was given on 6/14/16 and 6/22/16 or documentation regarding the effectiveness of the prn medication. He stated it should be there with the date and time given, why it was given and the follow up of the effectiveness. He stated the first nurses note with the 6/26/16 date was probably wrong since there was a note after it dated 6/25/16. He stated the [MEDICATION NAME] given on 6/26/16 in nurses notes should have been documented on the MAR. He looked at the (MONTH) (YEAR) MAR and said the 7/7 on the front and 7/8/16 on the back were errors. The 7/6/16 nurses note of the [MEDICATION NAME] should have been documented on the MAR. Resident #23: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident was understood, usually understands, and had moderately impaired cognition. It further documented behaviors of rejecting care, wandering daily. A nurses note dated 5/13/16 at 11:05 am, documented that prn [MEDICATION NAME] 1 mg IM (intramuscularly) was given by this writer. The resident tolerated well. Will observe for grogginess. There was no documentation why the [MEDICATION NAME] was needed. During interview on 7/13/16 at 12:08 pm, the RNM (Registered Nurse Manager) stated he wrote the 5/13/16 note. He stated [MEDICATION NAME] was given for increased agitation. He was asked what that meant and said he didn't know it was not in the nurses note. He found a Nurse Practitioner note of 5/13/16, that documented that the NP (Nurse Practitioner) was asked to see the resident for increased agitation, had been targeting another resident on the unit that morning. He stated that he believed there had not been any resident to resident altercation that day. He had the behavior log for the resident and stated that there was no behavior documented on the day shift except for 5/22/16. He stated he had talked with the NP about the resident's targeting behavior on 5/13/16. He also stated that it was not the best documentation of the need for the [MEDICATION NAME]. 10NYCRR415.22(a)(1-4)

Plan of Correction: ApprovedAugust 5, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F514
Corrective action regarding affected residents:
The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized.
Resident # 7
Based on the medical record review and interview of the licensed nurse, the nurse stated that the physician was on the nursing unit on 5/23/16 at approximately 4:00 pm. The physician was made aware of the resident having mucous with shreds of blood in the stool. The nurse documented in the nursing note, using block style documentation. The nurse wrote this note at 10:00pm. The nurse did not make notation that at approximately 4:00 pm she informed the physician of the resident?s condition and that the physician wrote an order for [REDACTED]. On 5/24/16, the Nurse Practitioner was made aware of the resident having further symptoms and new orders were written. All licensed nurses will receive in-service education on the importance of adequate and thorough documentation.
Resident # 8
Review of the medical record was conducted. The findings showed that there was a lack of documentation found when the resident received as needed doses of [MEDICATION NAME] (anti-anxiety). The medical record and the Medication Administration Record (MAR) did not consistently indicate the specific reason why nor the effectiveness of the medication being administered. On other occasions there was documentation for the reason for administration, but lacked documentation for the effectiveness of the medication. At times, both the indication for use and effectiveness of the medication are documented accordingly in the nursing progress notes and the MAR. The MAR and nursing notes had some discrepancies with dates as to when the medication was administered.
All licensed nursing staff will receive in-service education on the facility policy regarding documentation expectations. An emphasis will be provided on the importance of adequate and thorough documentation in regard to behavioral documentation, reason for medication and effectiveness of medication.
Resident # 23
Review of the medical record and staff interview was conducted. The findings showed that there was a lack of documentation for the administration of prn doses of [MEDICATION NAME]. The medical record did not indicate the specific reason the medication was being administered. An interview was conducted with both the licensed nurse and Nurse Practitioner (NP), who both stated that on 5/13/16 the resident was exhibiting an exacerbation of agitation and was making attempts to swing at other residents. The licensed nurse stated that the staff monitors the resident closely but was not able to calm her. The nurse made the NP aware, who then ordered a one time dose of [MEDICATION NAME] to be administered by injection.
All licensed nursing staff will receive in-service education on the facility policy regarding documentation expectations. An emphasis will be provided on the importance of adequate and thorough documentation in regard to behavioral documentation, reason for medication and effectiveness of medication.
Measures put into place or systematic changes put in place to ensure the deficient practice does not recur:
For similar residents who may be affected, medical records were audited for thorough documentation that includes actual event time, reason/indication for prn medication and follow up for effectiveness of medication.
How the current action will be monitored to ensure the deficient practice does not recur:
Licensed nursing staff will audit 10 random charts on each unit weekly for 4 weeks and then monthly for 3 months to ensure correct dates and times are documented and appropriate documentation was completed. The director of Nursing and/or designee will report the results of these audits to the QAPI Committee quarterly until compliance is satisfactory and maintained. Audits will continue as needed and determined by the QAPI committee.
Responsible party and date for correction:
The Director of Nursing will be responsible to ensure compliance by 9/9/16.

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows: (a) separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and (b) the area that is mechanically ventilated, sprinklered, and has ceramic or concrete flooring; and (c) in an area that is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted in accordance with NFPA 99 and Compressed Gas Association. 8-6.2.5.2 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2016
Corrected date: September 9, 2016

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not maintain liquid oxygen transferring areas in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 1999 edition section 8-6.2.5.2 (a) requires that transferring of liquid oxygen from one container to another shall be accomplished at a location separated from any portion of a facility wherein patients are housed by a separation of a fire barrier of 1-hour fire-resistive construction. Specifically, the liquid oxygen transferring area did not meet the requirements of a 1-hour fire resistance construction. This is evidenced as follows: The liquid oxygen transferring area walls were inspected on 07/13/2016 at 10:10 am. One 4-inch diameter hole was found above the ceiling in the Rehabilitation Room office The Director of Maintenance stated in an interview conducted on 07/13/2016 at 10:15 am, that he did not know who or how the hole in the oxygen transferring room was made. 42 CFR 483.70 (a) (1); 1999 NFPA 99 8-6.2.5.2 (a); 10 NYCRR 415.29, 711.2(a) (1)

Plan of Correction: ApprovedAugust 5, 2016

K143
Corrected action regarding affected residents:
The hole was patched in wall above the drop ceiling in the rehab office adjoining the oxygen room with approved fire caulk.
Identification of other residents possibly affected and corrective actions taken:
All of the other fire walls were inspected for holes with none found.
Measures put into place or systematic changes put in place to ensure the deficient practice does not recur:
An in-service will be conducted with all maintenance staff concerning the proper fire resistant patching of walls following any penetration to the fire walls. All outside contractors will be made aware of the necessity of patching holes in the fire walls with an approved fire resistant caulk following any work in which the fire wall was penetrated. The director of Maintenance will pre-approve any work where a fire wall will be breached and inspect the work before the contractor exits the facility to ensure proper fire resistant patching.
How the current action will be monitored to ensure the deficient practice does not recur:
When a fire wall is penetrated, the Director of Maintenance will inspect all work to ensure that it was patched with an approved fire resistant product.
Responsible party and the date of correction:
The Director of Maintenance will be responsible to ensure compliance by 9/9/2016.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. (a) Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation. (b) Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside. 4-3.1.1.2 (NFPA 99), 8-3.1.11.1 (NFPA 99), 18.3.2.4, 19.3.2.4

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2016
Corrected date: September 9, 2016

Citation Details

Based on observation and staff interview during the standard recertification survey, it was determined that the facility did not store pressurized oxygen cylinders in accordance with adopted regulations. NFPA 99, Standard for Health Care Facilities, 1999 Edition section 4-3.5.2.2(b)2 states that empty oxygen cylinders shall be segregated from full cylinders to avoid confusion and delay if a full cylinder is needed hurriedly. Specifically, full and empty oxygen cylinders were not segregated in the oxygen transfer and cylinder storage area. This is evidenced as follows: The oxygen transfer and cylinder storage area was inspected on 07/12/2016 at 9:30 am. Full and empty oxygen cylinders were stored together and mixed in the same racks. The Director of Maintenance stated in an interview conducted on 07/12/2016 at 10:50 am, that he did not know that full and empty cylinders of oxygen had to be kept segregated. 42 CFR 483.70 (a) (1); 1999 NFPA 99 4-3.5.2.2(b)2; 10 NYCRR 415.29, 711.2(a)(26)

Plan of Correction: ApprovedAugust 5, 2016

K076
Corrected action regarding affected residents:
In the oxygen fill room, the full and empty oxygen cylinders were placed into separate racks with proper signage stating full or empty tanks.
Identification of other residents possibly affected and corrective actions taken:
In the clean utility rooms on each wing, the signage was changed to differentiate between full and empty tanks with an added notation that the full tanks may be in different states of capacity (oxygen bleeds off over time with the portable tanks). Signs were also added to direct emergency oxygen needs to the crash cart.
Measures put into place or systematic changes put in place to ensure the deficient practice does not recur:
An in-service will be conducted with all maintenance and nursing staff concerning the proper placement of full and empty oxygen tanks.
How the current action will be monitored to ensure the deficient practice does not recur:
The Director of Maintenance will conduct inspections of oxygen storage areas to ensure compliance weekly for 4 weeks then monthly for 3 months. The Director of Maintenance and/or designee will report audit results at the QAPI committee meeting quarterly until compliance is satisfactory and maintained. Audits will continue as needed and determined by the QAPI committee. Audits will continue as needed and determined by the QAPI committee.
Responsible party and the date of correction:
The Director of Maintenance will be responsible to ensure compliance by 9/9/2016.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Where required by section 19.1.6, Health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7. Required sprinkler systems are equipped with water flow and tamper switches which are electrically interconnected to the building fire alarm. In Type I and II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specific areas where State or local regulations prohibit sprinklers. 19.3.5, 19.3.5.1, NPFA 13

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2016
Corrected date: September 9, 2016

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the automatic sprinkler system was not installed in accordance with adopted regulations. The Centers for Medicare and Medicaid Services published a Final Ruling in the Federal Register on (MONTH) 13, 2008 (73 FR ) requiring all long term care facilities to have full automatic sprinkler protection in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems 1999 edition by (MONTH) 13, 2013. Specifically, automatic sprinkler system was encumbered with unacceptable obstructions and did not cover all areas. This is evidenced as follows. An assessment of the sprinkler system was conducted on 07/12/2016 at 9:30 am. Light fixtures obstructed the automatic sprinkler spray area in resident rooms 113, 114, 305, 306, 311, 312, 313, and 314; the Central Supply room; the Director of Nursing storeroom; the Wing 1 Storage room and Personal Storage room; the wheelchair storeroom; and the Wing 3 B-leg corridors. Ventilation ductwork obstructed the automatic sprinkler spray area in the Wing 2 Storage rooms and the Wing 3 Storage room. Piping obstructed the automatic sprinkler spray area in in the Housekeeping Storage room. The Director of Maintenance stated in an interview on 07/12/2016 at 10:50 am, that he believes that the obstructions found were from the original construction. 42 CFR 483.70 (a) (1); 73, FR ; 2000 NFPA 101: 19.3.5; 1999 NFPA 13: 5-6.5; 10 NYCRR 415.29, 711.2(a) (1)

Plan of Correction: ApprovedAugust 5, 2016

K056
Corrected action regarding affected residents:
All of the infractions that were discovered by the inspector during the survey will be corrected by either modifying the fixture/equipment or the sprinkler equipment to fall within the acceptable clearances.
Identification of other residents possibly affected and corrective actions taken:
A thorough inspection will be conducted by the Director of Maintenance to ensure compliance with acceptable clearances. Any infractions that are discovered will be corrected by either modifying the fixture/equipment or the sprinkler equipment to fall within the acceptable clearances.
Measures put into place or systematic changes put in place to ensure the deficient practice does not recur:
Any installation of fixtures or equipment on or near the ceiling, made by staff or outside contractors, must be pre-approved by the Director of Maintenance.
How the current action will be monitored to ensure the deficient practice does not recur:
The Director of Maintenance will monitor any fixtures or equipment that will be mounted on or near the ceiling to ensure compliance of clearance from sprinkler heads.
Responsible party and the date of correction:
The Director of Maintenance will be responsible to ensure compliance by 9/9/2016.