Steuben Center for Rehabilitation and Healthcare
March 21, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.24(a)(2):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: (a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2017
Corrected date: May 16, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for two of four residents reviewed for Activities of Daily Living (ADLs), the facility did not provide the necessary care and services to maintain personal hygiene. Issues involved lack of assistance with showers (Residents #39 and #99) and lack of fingernail care and facial hair removal (Resident #39). This is evidenced by the following: 1. Resident #39 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 12/8/16, included the resident is severely cognitively impaired, did not have behaviors, did not reject care, it was important to choose type of bathing, was totally dependent on one staff for bathing and personal hygiene. The Comprehensive Care Plan (CCP), last revised on 3/15/17, and the current Certified Nursing Assistant (CNA) Kardex, included that the resident requires physical assist with bathing and extensive assist of one for personal hygiene. The current Shower Schedule revealed that the resident was scheduled for a shower on Saturday evenings. Review of the Response History (tracks what care is provided), from 2/20/17 through 3/20/17, revealed documentation of two showers (2/25/17 and 3/4/17). There was no documentation of any refusals. Review of Progress Notes, from 2/20/17 through 3/20/17, revealed no documentation that care was refused or not provided. When observed on 3/16/17 at 10:33 a.m., the resident's fingernails were filled with brown debris, there was several days worth of facial hair that was not removed, and his dentures were dirty. At 4:10 p.m., the resident still had brown debris under his nails and his facial hair was not removed. When observed on 3/17/17 at 11:00 a.m., the resident's nails were still filled with brown debris. Interviews conducted on 3/17/17 included the following: a. At 10:14 a.m., Day Staff #1 said there are 38 residents on her unit and usually 3 CNAs. They said about two showers are completed a day so residents get a bed bath instead of a shower. b. At 10:23 a.m., Day Staff #2 said there are usually three CNAs on the day shift who complete vitals and give showers, in addition to other cares. Day Staff #2 said they help staff to get things done, including showers. She said that there are also three CNAs on the evening shift, sometimes four CNAs, who complete showers, too. c. At 11:28 a.m., Day Staff #3 said there are normally only 3 CNAs so they provide care for 13 to 14 residents each. They cannot complete all the care, and some showers get missed and the residents get bed baths instead. Staff #3 cared for the resident the previous day and said that she could not get to the shaving or his nails because she did not have time and she said that she knew the resident's nails looked awful. d. At 11:38 a.m., Day Staff #4 said that the resident's nails were not done because she could not get to it. Staff #4 said that that no showers were completed that day, only bed baths. Staff #4 said she finally got to shave the resident that day, it has been several days. e. At 3:30 p.m., Evening Staff #5 and Evening Staff #6 said that there are two to three CNAs on the evening shift and showers are not always done. Evening Staff #6 said she thought the resident received a shower a few weeks ago on a Saturday evening. She said that the resident does not refuse care. At 3:41 p.m., Evening Staff #5 said he has not given the resident a shower in the last two months. When interviewed on 3/21/17 at 11:01 a.m., 12:30 p.m., and 1:45 p.m., the Director of Nursing (DON) said showers should be done according to the shower schedule and nails should be done on shower day. She said if a shower is not given, then a bed bath and nails should still be done. The DON said staff should be checking the resident's nails daily for cleanliness. She said if care is not provided, staff should let the Licensed Practical Nurse or Nurse Manager know. The DON said staff should be documenting when showers are given and document if it is refused so that it shows up on the 24-hour Report. She said there is no Nurse Manager on the resident's unit and she is currently responsible for those duties. The DON said she was not aware that showers were not being done. She said if a resident consistently refuses care, she would talk with resident for an alternative method. 2. Resident #99 has a [DIAGNOSES REDACTED]. Review of the Nursing Progress Notes, from 1/26/17 through 3/20/17, revealed on 2/10/17 that the resident refused care and treatment and had an increase in verbal outbursts. The CCP, last revised on 2/1/17, and the current CNA Kardex included that the resident requires limited assist with bathing and limited assist of one for personal hygiene. Review of the Response History (tracks what care is provided), from 2/19/17 through 3/20/17, revealed the resident refused showers on 3/1/17, 3/6/17, and 3/9/17. However, there was no documentation of showers being given. The MDS Assessment, dated 2/21/17, documented that the resident's cognition is moderately impaired for decision making, did not have behaviors, did not reject care, it was important to choose type of bathing, was totally dependent on one staff for bathing, and required supervision of one for personal hygiene. The current Shower Schedule included that the resident was to have showers on Monday morning. Prior to this, her usual shower day was Saturday then Friday, and approximately a week ago it was changed to Monday due to her room change. The CCP does not reflect that the resident has been refusing showers. Interviews conducted on 3/17/17 included the following: a. At 10:30 a.m., LPN #1 stated that she was not aware that the resident was refusing showers. At the same time, LPN #2 stated she remembers that the resident had a shower on the night shift, when she was covering nights, and that must have been over a month ago. b. At 10:45 a.m., CNA #1 stated she would report that the resident refused showers. CNA #1 said she has never given the resident a shower but she washes her up good. When interviewed on 3/21/17 at 11:00 a.m., the DON stated that showers should be given according to the scheduled shower day. She said if care is not provided, staff should let the Licensed Practical Nurse or Nurse Manager know. She said staff should be documenting when showers are given and document if it is refused so that it shows up in the 24-hour Report. She said there is no Nurse Manager on the resident's unit and she is currently responsible for those duties. The DON said she was not aware that showers were not being done. She said if a resident consistently refuses care, she would talk with resident for an alternative method. The (MONTH) (YEAR) facility policy, Personal Hygiene/Grooming included that a bath or shower is scheduled weekly per the Unit shower schedule and a bed bath would be given on all other days. Nail care will be provided on shower day and facial hair would be groomed as needed with morning/evening care. The date and time that care was provided and the name and title of the individual providing care should be documented in the resident's Point Click Care system (electronic medical record) for ADLs. If a resident refuses assistance with care needs, the reason(s) why and intervention taken is to be documented by the LPN. (10 NYCRR 415.12(a)(3))

Plan of Correction: ApprovedApril 13, 2017

Resident #39 and resident #99 have had ADL care provided per care plan.
The bathing schedule has been checked and verified for residents # 39 and #99.
IDCPT meeting has been held to verify with resident/responsible party that bathing schedule is agreed upon and is consistent with the care plan.
All residents have the potential to be affected by the deficient practice.
All resident shower schedules/preferences have been reviewed with care plan updates where indicated. Nail care with bathing and shaving has also been added to all resident care plans as appropriate.
The DON has reviewed the Policy and Procedure in regards to ADL care, specifically documentation of bathing/nail care and shaving to assure that the residents are receiving care per their individualized care plan.
Bathing schedules have been discussed with all residents/responsible party to assure that resident care plan is consistent with their preferences

Nursing staff has been educated on the above policy for ADL completion, documentation and notification of supervisor for resident refusals of care.
Using a standardized and uniform Quality Assurance audit tool, the Nurse Manager/designee will conduct a weekly audit X4, then monthly X3 of 10% of all residents to assure that bathing/nail care and shaving is performed and documented as per care plan.
Results of these audits will be presented to the Quality Assurance Committee monthly.
Responsible person: DNS

FF10 483.24(a)(b):ADLS DO NOT DECLINE UNLESS UNAVOIDABLE

REGULATION: (a) Based on the comprehensive assessment of a resident and consistent with the resident?s needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: (1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section, ? (b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: (1) Hygiene -bathing, dressing, grooming, and oral care, (2) Mobility-transfer and ambulation, including walking, (3) Elimination-toileting, (4) Dining-eating, including meals and snacks, (5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2017
Corrected date: May 16, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for one (Resident #39) of four residents reviewed for Activities of Daily Living (ADLs), the facility did not provide the necessary services to maintain and/or improve ambulation. Specifically, the resident was not consistently ambulated per the care plan and as recommended by Physical Therapy. This is evidenced by the following: Resident #39 has [DIAGNOSES REDACTED]. The most recent Minimum Data Set Assessment, dated 12/8/16, documented that the resident had severe impairment of cognitive function, could transfer, ambulate in his room, and ambulate in the corridor with extensive assist of two staff. A Physical Therapy (PT) discharge summary (most recent prior to survey), dated 1/30/17, documented that the resident is currently ambulating 350 feet with a two-wheeled walker and contact guard assist of staff. Additionally, it includes that the resident's prognosis to maintain this current level of functioning is excellent with strong family support and consistent staff support. The Comprehensive Care Plan (CCP), dated as revised 3/8/17, and the current Certified Nursing Assistant (CNA) Bedside Kardex Report revealed that the resident requires assist with ADLs related to confusion, impaired balance, limited mobility, limited Range of Motion, and psychiatric medication (anti-depressant) use. Interventions include, but are not limited to, extensive assist of two for transfers, for staff to ambulate the resident in his room and corridor with extensive assist of two staff, and that the resident is to walk to meals with contact guard of two staff with the wheelchair to follow. The CCP also includes no shoes but to use slipper socks to avoid pressure to the heels due to the pressure injury to the right heel. During observations on 3/17/17, 3/20/17, and 3/21/17, the resident was being wheeled in a wheelchair from his room down the hall to the dining room (approximately 100 feet to 150 feet) by staff to breakfast and/or lunch. Review of the medical record revealed the following: a. The Plan of Care Response History (electronic medical record used by staff to record assist with ADLs), from 2/20/17 through 3/17/17, revealed documentation by staff that the resident ambulated 25 of 78 opportunities to meals. b. A Licensed Practical Nurse (LPN) Progress Note, dated 2/16/17, documented that the podiatrist requested that the resident not wear the black shoes he had on and the podiatrist applied a type of padding as a pressure relieving device. The podiatrist said he would speak with the Social Worker. There is no further documentation regarding any special footwear. c. In a nursing progress note, dated 3/2/17, the Registered Nurse documented that a family member had concerns about the resident's ambulation status. The family member requested an ambulation evaluation as the resident has not been ambulating to meals. There was no further documentation related to these concerns or staff addressing them. Review of medical progress notes revealed the following: a. On 2/15/17, the resident had an upper respiratory infection (cold) and an over-the-counter [MEDICATION NAME] was prescribed. b. On 3/9/17, the resident was seen for increased coughing and again the [MEDICATION NAME] was prescribed. The resident was also seen for a urinary tract infection and started on an antibiotic. c. On 3/16/17, the physician documented that both the resident's cough and infection have improved. A Rehabilitation Screening Request Form, dated 3/16/17, included a request for a PT evaluation due to resident having increased difficulty with standing for transfers, but does not include any mention of ambulation. A PT re-evaluation, dated 3/20/17 after surveyor intervention, revealed that the resident was being seen for muscle weakness and difficulty in walking. The functional mobility assessment of transfers included that the resident was total dependence and uses a stand lift for transfers and for gait, and was a maximum assist with 15 feet and a walker. Recommendations include that the resident goes back on Restorative PT. Additionally, included under Patient and Caregiver goals it is documented that the resident wants to improve performance with transfers and ambulation and to decrease the need of assistance from caregivers. The resident's potential for achieving rehab goals includes that he demonstrates good rehab potential as evidenced by his ability to follow two-step directions, active participation in skilled treatment, active participation with plan of treatment, and strong family support. Interviews conducted on 3/17/17 included the following: a. At 2:24 p.m., staff member #1 stated that the resident has not walked for weeks due to a heel ulcer. Staff member #1 said that it is painful and that they were unaware if therapy was notified. b. At 3:30 p.m., staff member #2 stated that this resident cannot walk anymore due to a heel ulcer. Interviews conducted on 3/20/17 included the following: a. At 10:59 a.m., staff member #3 stated that the resident has not walked for approximately six weeks since he got the heel ulcer that is painful and still being treated. b. At 11:36 a.m., staff member #4 stated that the resident has declined, has not been feeling well, and is not walking. The staff added that the heel is getting better. c. At 3:41 p.m., staff member #5 stated that this resident does not ambulate at all and has not for several weeks. Staff member #5 said the resident does not even stand for staff and now requres a stand lift for transfers. d. At 4:10 p.m., the Director of Rehabilitation stated that if a resident is unable to follow therapy recommendations (i.e., ambulate), the standard policy is to report to nursing, document, change the care plan, and send a referral to therapy. He said that the resident had been walking up to 350 feet in (MONTH) when they discharged him from therapy. He said that if the resident has a heel ulcer, there are several options they can come up with (i.e., special shoe) so the resident can continue to walk. He stated that he was not aware that this resident has not been walked. Interviews conducted on 3/21/17 included the following: a. At 9:28 a.m., 11:01 a.m., and 12:30 p.m., the Director of Nursing (DON) stated she is the acting RN for this unit in the absence of a Nurse Manager. The DON said she was not aware that this resident was not being walked per his plan of care. She said that staff should notify the LPN or herself of changes in condition so a referral could be sent to therapy. She said that the resident has been very sick with several infections that contributed to his weakened state. b. At 9:46 a.m., the physician stated that this resident has a heel ulcer and had a recent urine infection but he could still walk with non-skid socks. He said that if a resident does not continue to walk, he would lose ground. The physician said that he is aware that PT is going to work with the resident again. When asked if the resident's decline was preventable, he stated that he did not know. A physician's note, dated 3/21/17 and submitted prior to the survey exit on 3/21/17, documented that the resident's weakness was due to a urinary tract infection, a terrible cold, and a heel ulcer, which is improving but his ambulation got quite poor. It also includes that he could only now walk 100 feet which is a marked decline from before, and hopefully PT will restore it in due time. Review of the current facility policy, Change in a Resident Condition, includes that the attending physician will be promptly notified of changes in the resident's condition (i.e., changes in physical condition or level of care). Review of the current facility policy, Care Planning Process, includes that assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. (10 NYCRR 415.12(a)(1)(ii))

Plan of Correction: ApprovedApril 13, 2017

Resident #39 has been Re-evaluated by physical therapy and occupational therapy with PT/OT services in place per Resident ADL needs.
IDCPT meeting held with Resident #39, ADL status updated per Resident need.
All residents have the potential to be affected by the deficient practice.
All current resident?s Care Plans and most recent Therapy recommendations for ADL status has been reviewed to assure that the care plans reflect the resident?s current performance accurately.
Any concerns identified were immediately corrected and updated on ADL Care plan.
The DON has reviewed the Policy and Procedure in regards to ADL care, specifically documentation of care provided and the procedure for reporting discrepancies in resident performance and care plan directions.
Nursing staff have been educated on the above policy to include documentation of ADL performance levels and communication with supervisor regarding changes in resident performance that may indicate a resident change in condition.
Using a standardized and uniform Quality Assurance audit tool, the ADON/designee will conduct a weekly audit X4, then monthly x3 of 10% of all residents to assure that the performance of the resident is reflected in the ADL/Mobility instructions for staff.
Results of these audits will be presented to the Quality Assurance Committee monthly.
Responsible Person: DNS

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic 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: March 21, 2017
Corrected date: May 16, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for one (Resident #122) of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regime is free of unnecessary medications. Issues involved the initiation of a [MEDICAL CONDITION] medication without adequate indication for use, including a lack of thorough documentation of specific target behaviors, use of behavioral interventions and incomplete documentation after initiation to determine effectiveness of the medication. This is evidenced by the following: Resident #122 has [DIAGNOSES REDACTED]. Nine of nine medical provider notes, dated 7/21/16 through 12/21/16, documented no active [MEDICAL CONDITION], depression, suicidal or homicidal ideation. A review of Nursing Progress Notes, dated 11/21/16 through 12/21/16, prior to start of [MEDICATION NAME], revealed four of six Comprehensive Care Path Notes, (CCPN) were not completed for Cognition/Behavior (were blank). A CCPN, dated 11/29/16, revealed the resident was easily agitated, refuses medications and treatment, appears angry, continue to monitor. A CCPN, dated 12/7/16, revealed the resident had verbal outbursts towards others, easily agitated, refuses medications and treatment, and appears angry. A physician note, dated 12/21/16, documented that on interaction with the patient, has a very labile mood with sudden yelling when asked question, and then when clarified, he appears as if nothing has just transpired. The physician's assessment and plan include dementia with behavioral issues, place on [MEDICATION NAME] and will continue [MEDICAL CONDITION] waiting. A Review of Nursing Progress Notes, dated 12/22/16 through 1/21/17, included a CCPN, dated 12/30/16, which is blank for cognition and behaviors and another, dated 1/21/17, which revealed easily agitated. A Comprehensive Care Plan (CCP), revised 12/30/16, for non-compliance and resistance to care includes interventions to allow resident to make decisions about treatment regime, educate regarding non-compliance with treatment or care, if refuses cares, leave and reapproach five to ten minutes later. A CCP, dated 1/6/17, documented that the [MEDICAL CONDITION] medications that the resident uses are related to pain management and dementia. Interventions include to monitor and record occurrence of target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff and others, and document, report adverse reactions and pertinent labs to physician. A review of three Behavior Notes, dated 1/19/17, 2/5/17 and 3/12/17, revealed the sections for Pharmacological Interventions, Non-Pharmacological Interventions, Results of Interventions, and Notifications had been left blank/not completed. A Minimum Data Set (MDS) Assessment, dated 3/14/17, revealed that resident's cognition is moderately impaired, no hallucinations, delusions, behavioral symptoms, rejection of cares or wandering. A physician order, dated 3/17/17, directs [MEDICATION NAME] Tablet Delayed Release 125 milligrams, two tablets three times a day for behavior. In an observation on 3/17/17 at 8:35 a.m., the resident was asleep in bed. A Visual/Bedside Kardex Report, printed 3/20/17, for Behavior/Mood, revealed that the resident, at times, chooses to put himself on his bedroom floor to sleep. Observations and interviews conducted on 3/20/17 included the following: a. At 9:32 a.m., the resident was asleep in his bed. b. At 10:27 a.m., the Activities Director (AD) said the resident has not had any behaviors since last fall. She said the resident may have occasional behaviors related to cares and the approach is to leave and re-approach. She said that when he was ambulating, he would seek food and was verbally abrasive to staff. c. At 1:06 p.m., Licensed Practical Nurse (LPN) #1 said the resident has been mellow lately and will usually allow care. LPN #1 said he does not hallucinate or have delusions, does not wander and if he rejects care, staff leave and reapproach. She said he has not harmed himself or any other resident and does not leave his room. LPN #1 said the physician started [MEDICATION NAME] due to refusals of care and bad language. She said staff usually chart behaviors for a while when a new medication is started. d. At 1:19 p.m., Certified Nursing Assistant (CNA) #1 said that the resident behaviors include refusing to get out of bed, yelling and cussing. She said she will ask him if he is in pain, change him, reposition him and he usually calms right down. e. At 1:25 p.m., the Assistant Director of Nursing (ADON) said she thought the medication was started due to aggressive behaviors. She said once the medication was started, the behaviors should have been tracked. f. At 4:27 p.m., the resident was awake and in bed. The resident said he did not have any pain, the food is okay, and he did not need anything. g. At 4:31 p.m., CNA #2/Primary Evening said that the resident's behaviors include swearing and agitation with certain cares, like being washed up or changed at night. CNA #2 said she knows the resident also refuses medications at times. She said she redirects him by walking away and tells him she will be back later. She said, It is all in the approach with him. Observations and interviews conducted on 3/21/17 included the following: a. At 9:12 a.m., the resident was asleep in bed. b. At 9:17 a.m., CNA #3 said she has no problems with the resident and can provide care. She also said, It is all in how you approach him. At that time, CNA #4 said she has been here quite a long while and does not have any problems providing care. She said he is just like the rest of us, he has good and bad days. CNA #4 said if he does start cussing, she just walks away and returns later and then he is fine. c. At 10:03 a.m., CNA #3 said that aides can document resident behavior in the computer. d. At 10:15 a.m., a Nurse Practitioner (NP) said the resident has been okay with her but has a history of being quite verbally aggressive and can refuse care and medications. The NP said he has yelled at staff but has not hurt himself or anyone that she is aware of. She said a [MEDICATION NAME] level ([MEDICATION NAME] Acid) should be monitored every so often. e. At 10:42 a.m., the Director of Nursing (DON) said the nurses were re-educated to use the behavior note category on the computer. She said the resident's behaviors would be verbally and physically abusive to staff and food seeking. She said the behaviors should be tracked in the nursing notes. When asked how the use of the [MEDICATION NAME] would be evaluated, the DON said, The facility does not have anything in place right now, to quantify the behaviors prior to the quarterly Gradual Dose Reduction (GDR) meetings. She said that the physician will review all Nursing Progress Notes prior to the quarterly GDR meeting. Interviews conducted on 3/21/17 included the following: a. At 12:51 p.m., a physician said he would not read all the Nursing Progress Notes regarding behaviors, prior to a GDR meeting. He said he would talk to the nurses, specifically the day shift. He said this was a significant dose of [MEDICATION NAME] and blood work should have been ordered to evaluate the level. The physician said the resident's specific behaviors were dementia with behavioral problems and his behaviors were not answering questions, refusing treatment, becoming angry with the nurses and not answering their questions. The physician said he rounds with the nursing staff on each resident and was not aware of any behavior logs. He said he can talk to the resident now, ask questions, so he thought it was a good idea to put the resident on [MEDICATION NAME]. b. At 1:05 p.m., LPN #1 said residents have the right to refuse medications, food, treatment and cares. c. At 1:13: p.m. LPN #2 and LPN #3 said residents have the right to refuse everything, that is their right. d. At approximately 1:15 p.m., the ADON said a resident has the right to refuse. She said staff are to re-approach at least three times, then if not successful, notify a supervisor. Review of a facility policy, Behavior Assessment and Monitoring, revised (MONTH) 2014, directed that non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medication to manage behavioral symptoms, unless clinically contraindicated. When medications are prescribed for behavioral symptoms, the care plan will include rationale for use, specific target behaviors and expected outcomes, dosage, duration, monitor for efficacy and adverse consequences and plans for GDR. If the resident is being treated for [REDACTED]. Staff will continue to document, either in progress notes, behavior assessment forms, or other comparable approaches specific information about problem behavior or moods. Nursing staff and physician will monitor for side effects and complications related to psychoactive medications, for example, lethargy, abnormal involuntary movements, anorexia or recurrent falling. If psychoactive medications are used to treat behavioral symptoms of dementia, the nursing staff and attending physician will periodically reconsider their indication and consider whether the medication can be tapered or document why tapering should not be attempted. (10 NYCRR 415.12(l)(1-2))

Plan of Correction: ApprovedApril 13, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #122 has been assessed by the Physician with documentation regarding the ongoing need for the [MEDICATION NAME] and directions for further laboratory monitoring of the medication
An IDCPT meeting has been held to review the plan of care for resident #122 to assure that behaviors are appropriately documented, tracked and addressed as indicated.
All residents that have psycho active medication ordered have a potential to be affected by the deficient practice.
All resident?s that have an ordered psychoactive medication have been reviewed with specific target behaviors outlined for documentation/non pharmacological intervention purposes
The DON has reviewed/revised as necessary the Policy and Procedure in regards to behavior assessment and monitoring.
A monthly behavior monitoring meeting will be held to discuss resident behaviors/medication and related documentation
Nursing staff has educated on the above policy for documenting behaviors, non-pharmacological interventions for behaviors, monitoring of side effects of medications and monitoring of residents when medication changes have occurred.
Using a standardized and uniform Quality Assurance audit tool, the SW/designee will audit 10% of all resident on psychoactive medications weekly X4, then Monthly X3 to assure that all documentation is in place in the EMR/resident medical record.
Results of these audits will be presented to the Quality Assurance Committee monthly.
Responsible Party: Director of Nursing


FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2017
Corrected date: May 16, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, it was determined for one (Resident #150) of five residents reviewed for accident hazards, the facility did not ensure that the residential environment remained as free of potential accident hazards as possible. Specifically, unsecured medications and treatment supplies in the resident's room were accessible to wandering residents. This is evidenced by the following: Resident #17 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment, dated, 1/12/17, revealed that the resident's cognitive skills for daily decision making are severely impaired and ambulates on the unit with supervision/oversight of one staff member. Resident #150 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS Assessment, dated 1/15/17, revealed the resident is cognitively intact. Physician orders, dated 3/9/17, included to saturate a cotton ball or gauze with Maalox and apply to the resident's abdominal area wound stoma and cover with an abdominal pad. On 3/13/17 at 12:15 p.m., during an interview, there was a bottle of Geri-Lanta (generic Mylanta/antacid) and several packages of No-Sting (a protective film for the skin) on top of the resident's overbed table. At that time, the resident said, That stuff should not be there. A Visual/Bedside Kardex Report, printed 3/17/17, directed no scissors at bedside. The current Comprehensive Care Plan, did not include self -administration of medications. Observations and interviews conducted on 3/17/17 included the following: a. At 9:02 a.m., in Resident #150's room , there was a bottle of Geri-Lanta and a bottle of Milk of Magnesia (MOM, a laxative) on the dresser and a pair of scissors on the overbed table. The resident was not in her room and the door was open. b. At 2:16 p.m., a Licensed Practical Nurse (LPN) said she did not know why there was a bottle of MOM in the resident's room. The LPN said she would need to ask the Nurse Manager. c. At 2:23 p.m., the LPN said there are wandering residents on the unit, including Resident #17, who could enter this room and access the medications and scissors. The LPN said to self-administer medications, the resident would need a physician order [REDACTED]. d. At 2:31 p.m., the LPN and surveyor went into the resident's room. The resident was not in the room and the door was open. The LPN said she was going to remove the Geri-Lanta and MOM from the room now. Also at that time, the top drawer to the resident's bureau was observed to be open/unlocked. There were supplies in the drawer including zinc oxide, talc powder, Calmoseptine, Periguard, No Sting pads, normal saline, and triple antibiotic ointment. LPN #1 said if these supplies were going to be stored here, the drawer needs to be locked, a pair of scissors remained on top of the overbed table. The LPN said the scissors should be secured elsewhere. When interviewed on 3/20/17 at 11:50 a.m., Resident #150 said, Resident #17 has come into my room on several occasions and one time, she took my coffee. During an interview on 3/21/17 at 11:23 p.m., a Registered Nurse/Nurse Manager said the resident did not have an order or assessment to self-medicate and that the medications had been removed from the room. (10 NYCRR 415.12(i))

Plan of Correction: ApprovedApril 13, 2017

Room for resident #150 was cleared of all items that could be a potential hazard and the resident has since been discharged from the facility.
All residents have the potential to be affected by the deficient practice.
All resident rooms have been inspected for potential hazards to assure that there are no further areas of concern.
A full house audit was conducted to review any resident that self administers medications/treatments and none were found.
The DON has reviewed/revised the Policy and Procedure on self-medication administration of medications/treatments.

Nursing staff has been educated on the self- medication administration policy and the need to keep potentially hazardous items in secure locations.
Residents/families have received a letter regarding the self medication administration policy and following policy concerning providing residents with medications/treatment supplies
Using a standardized and uniform Quality Assurance audit tool, the ADON/designee will conduct a weekly audit X4, then Monthly X3 of 10% of all resident rooms to assure that there no potentially hazardous items present.
All residents that have orders for self administration of medications will be reviewed upon admission, quarterly annually and with significant changes to assure that self administration of medications remains appropriate
Results of these audits will be presented to the Quality Assurance Committee monthly.
Responsible Person: DNS

FF10 483.10(d)(3)(g)(1)(4)(5)(13)(16)-(18):NOTICE OF RIGHTS, RULES, SERVICES, CHARGES

REGULATION: (d)(3) The facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. §483.10(g) Information and Communication. (1) The resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. (g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including: (i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes - (A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section; (B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act. (C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and (D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.) [§483.10(g)(4)(ii) will be implemented beginning November 28, 2017 (Phase 2)] (iii) Information regarding Medicare and Medicaid eligibility and coverage; [§483.10(g)(4)(iii) will be implemented beginning November 28, 2017 (Phase 2)] (iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program; [§483.10(g)(4)(iv) will be implemented beginning November 28, 2017 (Phase 2)] (v) Contact information for the Medicaid Fraud Control Unit; and [§483.10(g)(4)(v) will be implemented beginning November 28, 2017 (Phase 2)] (vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives: (i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and (ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community. (g)(13) The facility must display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. (g)(16) The facility must provide a notice of rights and services to the resident prior to or upon admission and during the resident?s stay. (i) The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. (ii) The facility must also provide the resident with the State-developed notice of Medicaid rights and obligations, if any. (iii) Receipt of such information, and any amendments to it, must be acknowledged in writing; (g)(17) The facility must-- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in paragraphs (g)(17)(i)(A) and (B) of this section. (g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident?s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility?s per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility?s per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident?s date of discharge from the facility. v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: March 21, 2017
Corrected date: N/A

Citation Details

Resident #61 was discontinued from Medicare Part A services on 10/4/16 and continued to remain in the facility under custodial care. There was no evidence that the appropriate liability and appeals notice was given to the resident/representative. When interviewed on 3/21/17 at 9:00 a.m., the Senior Accountant stated that another facility had an issue with liability notices so corporate told her to send the Advance Beneficiary Notice if residents were staying at the facility, and a Medicare Non-Coverage two-day cut letter is issued if residents are discharged to home. (10 NYCRR 415.3(g)(2)(i))

Plan of Correction: ApprovedApril 14, 2017

No plan of correction required

FF10 483.10(e)(3):REASONABLE ACCOMMODATION OF NEEDS/PREFERENCES

REGULATION: 483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: (e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2017
Corrected date: May 16, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for one (Resident #44) of four residents reviewed for Activities of Daily Living (ADLs), the facility did not provide reasonable accommodations to meet individual needs and preferences. Specifically, the resident did not have hearing aids in place. This is evidenced by the following: Resident #44 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/27/16, documented that the resident's cognitive skills for daily decision making are moderately impaired. The resident has moderate difficulty to hear, requiring the speaker to increase the volume and speak distinctly and has a hearing aid. Review of the Progress Notes dated 10/31/16 through 3/16/17, did not include resident's refusals to wear or broken hearing aids. The physician orders, dated 2/15/17, included to secure hearing aids in the medication cart at bedtime and to clean them every Thursday night. The Comprehensive Care Plan, last revised on 2/19/17, and the current Certified Nursing Assistant (CNA) Kardex included that the resident wears bilateral hearing aids. The (MONTH) (YEAR) Treatment Administration Record (TAR) included to clean the resident's hearing aids every Thursday night and to secure them in the medication cart at bedtime. Observations and interviews conducted on 3/16/17 included the following: a. At 11:10 a.m., a family member said that he finds the resident is often without her hearing aids and the nurse is supposed to be putting them in. b. At 11:32 a.m. and 3:24 p.m., the resident was in her room and was not wearing hearing aids. c. At 3:28 p.m., Licensed Practical Nurse (LPN) #1 and LPN #2 both said that the nurse is supposed to put in the residents' hearing aids and leave them in place for the entire day. d. At 3:57 p.m., LPN #2 opened a drawer of the medication cart that contained boxes of hearing aids. LPN #2 said that both the resident's hearing aids were in the cart and that they were never put in that day. She said that LPN #1 never told her that the resident did not have her hearing aids. LPN #2 said that the nurse should sign for the hearing aids on the TAR. After reviewing the (MONTH) (YEAR) TAR and Medication Administration Record, [REDACTED]. e. At 4:20 p.m., the resident was in the TV room and was not wearing hearing aids. When asked if her hearing aids were in the resident shook her head no. When asked if she usually wears them, the resident nodded her head yes. When asked if she knew why they were not in today, the resident shook her head no. Observations and interviews conducted on 3/17/17 included the following: a. At 8:45 a.m., the resident was in the dining room for breakfast, was dressed in day clothes, and she did not have her hearing aids in. At 8:52 a.m., LPN #1 entered the dining room and provided the resident with medications but did not put in the hearing aids. At 11:27 a.m., the resident was in her room with the TV on and did not have her hearing aids in. b. At 11:31 a.m., LPN #1 said she has not had time to put the resident's hearing aids in place. LPN #1 said she has too much to do and too many orders to take off. At 11:52 a.m., LPN #1 said she just put in the resident's hearing aids. LPN #1 said she thought the resident's hearing aids were not in because one of the strings (that attaches the hearing aid to a shirt) has been broken for at least two weeks. c. At 11:57 a.m., the Registered Nurse Manager (RNM) said that the resident's hearing aids are in the medication cart and the nurses are responsible for putting them in. She said the hearing aids should be placed in the resident's ear early in the morning, around breakfast time. She said the resident should have her hearing aids during an activity. The RNM said the placement of the hearing aids should be on the TAR so the nurses can sign that it is completed. The RNM said that no one told her the string on the hearing aid was broken. She said that if the resident refuses the hearing aids, it should be documented. (10 NYCRR 415.5 (e)(1))

Plan of Correction: ApprovedApril 13, 2017

The hearing aids for resident #44 have been checked by audiologist?s office and are in good working order and repaired.
LPN #1 and #2 have been educated on following MD orders and appropriately signing the treatment record.
All residents with the need for hearing aids have the potential to be affected by the deficient practice.
All in house residents with the need for hearing aids have been reviewed to ensure that devices are in good working order and that it is designated in the treatment record as to their application and removal daily.
The DON has reviewed the Policy and Procedure r/t the use of hearing aids specifically assuring that staff are appropriately documenting for the insertion and removal of devices and that the devices are in good working order.
All nursing staff have been educated on the above mentioned policy regarding the use of hearing aids and proper documentation of their use.
Using a standardized and uniform Quality Assurance audit tool, the Nurse Manager/designee will conduct an audit of all in house residents weekly x4 weeks, then monthly x3 months that require hearing aids to assure that the devices are put in place and removed daily, are in good repair, functioning properly, and nurses are signing in treatment record per day shift and evening shift.
Results of these audits will be presented to the Quality Assurance Committee monthly for review.
Responsible Party: DNS

FF10 483.25(g)(2):SUFFICIENT FLUID TO MAINTAIN HYDRATION

REGULATION: (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- (2) Is offered sufficient fluid intake to maintain proper hydration and health.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2017
Corrected date: May 16, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, it was determined for one (Resident #27) of one resident reviewed for [MEDICAL TREATMENT], the facility did not ensure that fluid intake was monitored to maintain proper hydration and health. Specifically, facility staff did not monitor on a daily basis a prescribed fluid restriction for a resident requiring [MEDICAL TREATMENT] treatments. This is evidenced by the following: Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the [MEDICAL TREATMENT] Communication Book, dated 1/13/17 through 3/13/17, revealed that the resident is on a 1,500 ml fluid restriction per day. The Minimum Data Set (MDS) Assessment, dated 1/18/17, revealed that the resident is cognitively intact and receives [MEDICAL TREATMENT]. A Comprehensive Care Plan, revised 1/25/17, revealed that the resident is on a 1,500 ml fluid restriction per day. A Visual/Bedside Kardex Report, dated 2/27/17, documented that the resident is on a fluid restriction with meals (breakfast 360 ml, lunch 120 ml, and dinner 120 ml). Physician orders, dated 2/28/17, directed dietary to serve 600 milliliters (ml) fluid per day (360 ml at breakfast, 120 ml at lunch and 120 ml at dinner), nursing to provide 420 ml per day (150 ml on the day and evening shifts, and 120 ml on the night shift), and provide supplement equal to 480 ml per day (a total of 1,500 ml). Interviews conducted on 3/20/17 included the following: a. At 9:42 a.m., Licensed Practical Nurse (LPN) #1 said the resident is on a 1,500 ml fluid restriction/day. LPN #1 said on her shift (7:00 a.m. to 3:00 p.m.) the resident only takes about 60 ml of fluid so that he can save the allotted amount to use for extra coffee. When asked by the surveyor how the 24-hour fluid intake is monitored, LPN #1 said, The computer tallies the intake for the day. b. At 11:15 a.m., a Registered Nurse Manager (RNM) said it is the responsibility of the nurses to monitor the fluid intake each day. At that time, the RNM reviewed both the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The RNM said she did not know how this occurred. She said the Diet Technician (DT) probably had the information. c. At 11:20 a.m., the DT said the resident is on a 1,500 ml fluid restriction which is monitored by the nurses on either the MAR indicated [REDACTED]. d. At 12:06 p.m., the DT said she and the Registered Dietitian/Nutritionist (RDN) had reviewed the medical record and the fluid intake had not been monitored from 2/27/17 through 3/20/17. e. At 12:14 p.m., a Certified Nursing Assistant (CNA)/Days said she records the resident mealtime fluid intake on the computer. The CNA said she thinks he is on a 1,500 ml fluid restriction and gets 360 ml of fluid at lunch. f. At 12:15 p.m., a Dietary Worker said the resident gets 120 ml of fluid at lunch, unless he wants more coffee. She said she has to ask a nurse if he can have more coffee and added that he takes just a swallow of liquid for his pills so that he can have extra coffee. g. At 1:31 p.m., the Assistant Director of Nursing (ADON) said dietary is responsible to tally and monitor the 24-hour fluid intake/restriction. h. At 2:06 p.m., the Director of Nursing (DON) said the fluid restriction had been reordered when the resident returned to the facility in (MONTH) (YEAR). The DON said she does not know why it is not on the MAR indicated [REDACTED]. She said she thought monitoring fluids was a collaborative effort between nursing and dietary. At that time, the DT said she only reviews fluid intakes during an acute episode, like a urinary tract infection or use of an antibiotic. Additionally, the (MONTH) (YEAR) MAR, dated 1/16/17 through 1/31/17, revealed the ordered fluid intake for nursing was not met for 31 of 48 opportunities (23 were less than the diet order and 8 were greater than the diet order). The (MONTH) (YEAR) MAR, dated 2/1/17 through 2/23/17, revealed the ordered fluid intake for nursing was not met 47 of 69 opportunities (46 were less than the diet order and one was greater than the diet order). The Documentation Survey Reports, dated 1/12/17 through 1/31/17 and 2/1/17 through 2/28/17, documented the resident's dining fluid intakes for each meal. The resident's intake had not been tallied for a 24-hour total. (10 NYCRR 415.12(j))

Plan of Correction: ApprovedApril 13, 2017

Resident #27 has had a Nutritional Assessment completed to assure that his fluid needs are being met.
MD evaluation completed on resident #27 with no new orders noted.
IDCPT meeting held with resident #27 and family to review the plan of care, and ordered fluid restriction being maintained.
All residents that have an ordered fluid restriction have the potential to be affected by the deficient practice.
All resident?s that have an ordered fluid restriction will be reviewed by clinical dietary and nursing staff to assure that needs are met.
Any concerns identified have been corrected per MD orders, care plans, Kardex and MAR
The DON has reviewed/revised the Policy and Procedure in regards to hydration and fluid restrictions to further clarify the ongoing monitoring of fluid intake for those residents on a fluid restriction.
Daily totals of fluids consumed for residents with fluid restrictions will be provided by nursing and reviewed by the IDCPT daily to ensure needs are met.
Nursing and Dietary staff have been educated on the documentation of fluid intake for those residents on a fluid restriction and the ongoing management of said restrictions.
Using a standardized and uniform Quality Assurance audit tool, the Diet Tech/designee will audit all residents with a fluid restriction to assure compliance with the Physician Orders.
Results of these audits will be presented to the Quality Assurance Committee monthly for the first 3 months, then quarterly thereafter.
Responsible person: Director of Nursing