Nassau Rehabilitation & Nursing Center
January 23, 2018 Certification Survey

Standard Health Citations

FF11 483.21(b)(2)(i)-(iii):CARE PLAN TIMING AND REVISION

REGULATION: 483.21(b) Comprehensive Care Plans 483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 23, 2018
Corrected date: March 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey, the facility did not ensure that the CCP was reviewed and revised timely after a fall. This was evident for one (Resident #180) of nine residents reviewed for accidents from a sample of 48 residents. Specifically, Resident #180's Comprehensive Care Plan (CCP) was not reviewed or revised timely after a fall on 12/28/17. The finding is: Resident #180 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and was severely impaired for daily decision making. The resident had difficulty focusing attention. The resident was non-ambulatory and required extensive assist of two staff members for transfers and toileting and used a chair that prevents rising daily. The resident had no falls since the prior assessment. The resident was observed in the unit dining room on 1/23/18 at 11:00 AM being supervised by staff. A Progress note dated 12/28/17 at 18: 56 (6:56 PM) documented the resident slid out of the wheelchair. The resident was noted lying on her left side on the wheel chair foot rest. The resident was unable to state what happened due to cognitive impairment. No visible injury and no change in level of consciousness (L(NAME)) was noted. The CNA in the dining room stated that she was feeding another resident when she heard another resident saying she is on the floor. When the CNA looked she saw the resident lying on her wheel chair foot rest. An Occurrence Report dated 12/28/17 documented at 6:10 PM, in the dining room, the resident was seen lying on her left side on the wheel chair foot rest and a pillow was placed under her head. The Certified Nursing Assistant (CNA) statement dated 12/28/17 documented the resident was last seen at 5:40 PM and was restrained with a Lap tray at the time of the incident. An undated Official Statement documented a staff member was feeding a resident when another resident stated Resident #180 was on the floor. The Accident/Incident Investigative Report Summary documented the CNA in the dining room at the time of the incident stated when she went to check, the resident was observed lying on the wheel chair foot rest and the Lap tray was still in place on the wheel chair. It was documented the dayroom camera was reviewed and the resident suddenly slid off her wheel chair. It was also observed that where resident sat in the dayroom was not visible to staff when all the residents are in the dayroom. The summary concluded in attempt to prevent further incident staff was counseled to ensure that the resident is placed in view of staff at all times for safety. A Lesson Plan titled Unattended Residents was attached to the Occurrence Report dated 1/4/18 (7 days after the fall) documented residents with cognitive deficits, unable to make needs known, history of falls (falls risk), elopement risk, sensory perception deficits, and on the report for illness or change in condition are to be closely monitored and placed in an area that has staff members present to supervise. The signed attendance record was also dated 1/4/18. A CCP for actual falls, dated 5/22/17 and last reviewed 1/9/18, documented the resident is at high risk for falls related to confusion and history of multiple falls in the past. The resident slid out of wheel chair on 12/28/17. No injury noted. The goal is that the resident will be free from further falls. Interventions updated on the CCP on 1/9/18 documented nursing staff was counseled to ensure the resident was placed in eye view of staff at all times for safety. The Assistant Director of Nursing Services (ADNS)/Risk Manager was interviewed on 1/22/18 at 3:33 PM and stated that the lesson plan was not initiated at the time of the Occurrence as she was not on duty. The ADNS stated that when she is not on duty the DNS would complete the Occurrence report and ensure interventions are initiated. The ADNS stated that the CCPs should be updated at the time of the fall with new interventions to prevent reoccurrence. The ADNS further stated that the RN Supervisor who initiated the CCP was supposed to updated the CCP with the fall incident and new interventions to prevent further incidents. The Registered Nurse (RN) Manager was interviewed on 1/23/18 at 11:30 AM and stated that the RNs were responsible for initiating the Occurrence report; however, it is the responsibility of the Risk Manager to initiate interventions to prevent further incidents and update the CCP. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedFebruary 22, 2018

1. The DNS and ADON immediately reviewed all comprehensive care plans and interventions for the last 3 months for resident #180. All was found to be in compliance.
2. All residents are at risk to be affected by this deficiency. The DNS/Designee will review the past 90 days of all accidents and incidents to ensure immediate interventions were put in place and that comprehensive care plans were updated timely.
3. The policy and procedure for accidents and incidents was reviewed by the DNS and ADON. The policy and procedure was found to be in compliance. The RN?s and Risk Manager/ ADNS were re-inserviced on the facility policy and procedure for accidents and incidents, including updating the comprehensive care plan.
4. The facility will develop an audit tool to check the compliance of interventions and documentation on the comprehensive care plan The audit will be done by the DNS/Designee weekly x4, monthly x3 and quarterly x 3. Negative findings will be reported to the DNS immediately. All findings will be reported to the QA committee quarterly.
5. The DNS is responsible for this Plan of Correction

FF11 483.35(a)(3)(4)(c):COMPETENT NURSING STAFF

REGULATION: 483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e). 483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. 483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. 483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 23, 2018
Corrected date: March 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview during the Recertification Survey, the facility did not ensure for one resident with a [DIAGNOSES REDACTED]. Specifically, Resident # 256 was observed lying in bed with a razor and nail clipper on top of his over bed table. The finding is: Resident # 256 has a [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems with moderately impaired cognition. The MDS also documented the resident required an extensive assist of one staff member for all personal hygiene needs. During a tour on 1/9/18 at 11:00 AM, Resident # 256 was observed lying in bed. The overbed table was in close proximity to the resident. On the overbed table was a plastic razor and metal nail clipper. There were no staff members in the room at the time of the observation. The Supervising Registered Nurse (RN) was interviewed on 1/9/18 at 11:15 AM. The RN stated the resident has Dementia and the razor and nail clipper should not have been left at his bedside. The Certified Nurse Assistant (CNA) who had cared for the resident on 1/9/18 was interviewed on 1/10/18 at 11:00 AM. The CNA stated usually she does not leave personal care items on the over bed table and she was coming back to the resident's room to shave the resident. 415.26(c)(1)(iv)

Plan of Correction: ApprovedFebruary 22, 2018

1. The nail clipper and razor were both immediately removed from the resident?s possession and properly stored. The CAN was counseled by the RNS.
2. The RNS did a full house check on every over-bed table to be free of nail clippers and razors.
3. The DNS and ADNS reviewed the plan and procedure for personal care equipment and was found to be in compliance. All nursing staff were re-inserviced on this policy by DNS/Designee.
4. The facility will develop an audit tool to ensure that all nail clippers and razors are properly stored. Audits will be done by RN?s/Unit Managers weekly x4, monthly x3 and quarterly x 3. Negative findings will be reported to the DNS immediately. All findings will be reported to the QA committee quarterly.
5. The DNS is responsible for this plan of correction.

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: 483.21(b) Comprehensive Care Plans 483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) 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 483.24, 483.25 or 483.40; and (ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 23, 2018
Corrected date: March 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the Recertification Survey, the facility did not develop or implement a comprehensive person-centered care plan for each resident to meet the resident's needs. This was identified for 3 of 48 sampled residents. Specifically, 1) Resident #626's Nutrition Care Plan documented that a knife should not be placed on the resident's meal tray. Observation revealed that the resident's lunch tray included a metal knife. 2) Resident # 243's Dental Care Plan documented Full Upper and Full Lower Dentures to be worn daily and to monitor for poor fitting dentures. The resident was observed on three days during the survey not wearing the Full Lower Denture, and on one occasion with an ill fitting upper denture. 3) Resident #127, with a history of [MEDICAL CONDITION] Disorder, had a physician's orders [REDACTED]. There was no documented evidence that a Comprehensive Care Plan (CCP) was developed for the use of side rails. The findings are: 1) Resident # 626 has a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's Brief interview for Mental Status score was 13 indicating the resident's cognition was intact. On 1/10/18 at 12:30 PM, a lunch meal observation for Resident #626 was made. The meal ticket on the resident's lunch tray documented a knife should not be on the resident's meal tray. Observation revealed that a metal knife was on the resident's tray along with other metal utensils. A dietary progress note dated 1/8/18 documented the resident had been observed by nursing to eat all of his food using a knife despite encouragement to use a spoon or a fork. The knife was to be removed from the resident's tray for safety. The family was made aware and was in agreement. The Nutrition Care plan initiated and dated 1/8/18 documented that the resident was not to have a knife on his meal trays. The Administrator was interviewed on 1/10/18 at 3:00 PM and stated that all dietary staff will be inserviced with regards to meal tray accuracy. 2) Resident #243 has a [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS score was 13, indicating the resident's cognition was intact. The MDS documented there were no dental problems and the resident required extensive assist of one staff member for personal hygiene needs. A Dental Care Plan, revised 10/9/17, documented Full Uppers and Full Lower dentures (FU and FL). Interventions included to ensure dentures are worn daily and remove at Hour of Sleep (HS). Monitor for poor fitting dentures and tenderness of gums. Observation on 1/12/18 at 12:00 PM, 1/16/18 at 10:00 AM, and 1/19/18 at 11:00 AM revealed when the resident smiled a full upper denture was in place. There was no lower denture observed in the resident's mouth during the three observations. Observation on 1/22/18 at 10:00 AM revealed as the resident spoke the full upper denture was ill fitting and was sliding down from his palate. The Certified Nurse Aide (CNA) task report, which provided direction to the CNA for resident care needs, documented use of the FU and FL as part of personal hygiene. The response history for Plan of Care for Activities of Daily Living (ADL) was reviewed. There was no documented evidence the resident had refused any part of ADL assistance, including personal hygiene in the past 30 days. During the RN interview on 1/19/18 at 11:15 AM, the RN stepped away from the desk and came back to the nursing desk with a full lower denture plate in an unlabeled plastic bag. The RN stated that she found the lower denture in the resident's bottom drawer. She also stated that she will order a Dental Consult to address the full lower denture for comfort and fit. The RN further stated that it is the responsibility of the CNA to ensure the resident is using both the Full Uppers and Full Lower Dentures and that the resident required physical assistance with personal hygiene care. CNA #1 was interviewed on 1/19/18 at 11:30 AM and stated the resident has dentures but does not want to wear them. The CNA stated that the resident refuses and she has reported his refusal. The CNA was not specific as to whom she reported the resident's refusal. The Assistant Director of Nursing Services (ADNS) was interviewed on 1/22/18 at 10:00 AM and stated the resident's dentures should have been stored in a labeled plastic cup, not in a unlabeled plastic bag. CNA #2 was interviewed on 1/22/18 at 12:30 PM and stated the resident had the full upper plate in his mouth when she arrived at 7 AM. She further stated that she offered to remove the upper denture plate and brush it, but the resident refused. The CNA further stated she reapproached the resident who agreed to remove the upper denture for brushing and to apply dental adhesive.
3) Resident #127 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Minimum Data Set (MDS) Modified Quarterly assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 7, indicating severely impaired in cognitive skills. The MDS documented that bed rails were used daily as a physical restraint and a bed alarm was also used daily. The physician's orders [REDACTED]. The CCP developed for History of [MEDICAL CONDITION] Disorder, initiated on 11/13/17, revealed no documented evidence for the use of side rails. The resident's CCPs were reviewed on 1/22/18 at 9:00 AM. There was no CCP developed for the use of the 1/2 side rails. The Assistant Director of Nursing Services (ADNS) was interviewed on 1/22/18 at 9:58 AM and stated the staff forgot to develop the CCP for the use of the 1/2 side rails. 415.11(c)(1)

Plan of Correction: ApprovedFebruary 22, 2018

1. A. The knife was immediately removed from the residents # 626 tray.
B. A dental consult was ordered for residents # 127 to evaluate for new dentures.
C. When noted, a comprehensive care plan was added for resident # 243 for bilateral side rails.
2. A. All residents have the potential to be at risk for this deficiency. All dietary staff were in-serviced on meal ticket accuracy by the FSD.
B. All residents with dentures are at risk for this deficiency. The ADON generated the list of all residents with dentures to ensure that the residents have their dentures, that they are not loose or ill fitted and that they are stored and labeled properly. A dental consult will be ordered as needed as per facility policy and procedure.
C. All residents with bilateral side rails are at risk for this deficiency. The DNS/Designee will generate the report for all bilateral side rails and ensure that each resident has a comprehensive care plan
3. A. The Administrator and Food Service Director reviewed the meal ticket policy and procedure, and it was found to be in compliance. All dietary staff will be re-inserviced on the policy and procedure by the in-service coordinator/ designee.
B. The DNS reviewed the policy and procedure for dentures and was found to be in compliance. All nursing staff will be re-inserviced on policy and procedure for dentures with a special focus on reporting missing dentures, ill-fitting dentures and resident refusal of care DNS/ Designee
C. The DNS reviewed the policy and procedure for side rails and was found to be in compliance. The RNS and MDS RN will be re-inserviced on the care plan policy and procedure by DNS/Designee.
4. A. The facility will develop and audit tool to monitor meal ticket accuracy. This audit will monitor 100 trays at random days and shifts weekly x 4, monthly x3 and quarterly x 3. Negative findings will be reported to the Director of Dietary Services immediately. All findings will be reported to the QA committee quarterly.
B. The facility will develop an audit tool to check residents who have dentures for proper storage and labeling, missing dentures, ill fitting dentures and the need of a dental consult. Random audits of residents with dentures will be done weekly x4, monthly x3 and quarterly x 3. Negative findings will immediately be reported to DNS . All findings will be reported to the QA committee quarterly.
C. The facility will develop an audit tool to check that a comprehensive care plan has been written for all residents with and order for bilateral side rails. All negative findings will be reported to the DNS/Designee for corrective action. All findings will be reported to the QA committee quarterly.
5. A. The Food Service Director will be responsible for item ?A? of this plan of correction.
B. The DNS is responsible for item ?B? of the plan of correction.
C. The DNS is responsible for item ?C? of the plan of correction.

FF11 483.25(l):DIALYSIS

REGULATION: 483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 23, 2018
Corrected date: March 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey, the facility did not ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preference. Specifically, Resident #224 receives [MEDICAL TREATMENT] treatment three times weekly. The physician's orders [REDACTED]. Review of the Medical Record and [MEDICAL TREATMENT] Communication book revealed that the Arterio-Venous (AV) Shunt was inconsistently monitored for bruit and thrill. The finding is: The facility's policy and procedure dated (MONTH) (YEAR) titled Care of the [MEDICAL TREATMENT] Resident documented to monitor for bruit and thrill each shift. Resident #224 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Minimum Data Set (MDS) Admission assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating intact cognition. The MDS also documented that the resident received [MEDICAL TREATMENT] treatment. The physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) developed for [MEDICAL TREATMENT] dated 11/29/17 documented to check and change the dressing daily at the access site; to monitor/document /report to the Physician as needed for signs and symptoms of infection to access site, redness, swelling, warmth or drainage. There was no documentation on the CCP related to the frequency of bruit and thrill monitoring. The Nurse's Progress Notes reviewed from 11/29/17 through 1/17/18 revealed that the AV shunt access was monitored for bruit and thrill for 17 shifts out of 150 shifts available. The [MEDICAL TREATMENT] Communication Book dated 11/29/17 through 1/17/18 was reviewed and revealed the four day shifts documented the AV shunt for bruit and thrill. There was a total of 21 shifts out of 150 shifts possible (at 3 shifts per day) or a total of 21 shifts out of 50 shifts from (one shift per day) in 30-day review period that the AV shunt was monitored for bruit and thrill. The Assistant Director of Nursing Services (ADNS) was interviewed on 1/22/18 at 10:00 AM and stated that the policy documented to monitor for bruit and thrill each shift. The Registered Nurse (RN) Unit Manager was interviewed on 1/23/18 at 9:50 AM and stated that the AV shunt is to be monitored every shift. The Attending Physician was interviewed on 1/23/18 at 10:00 AM and stated that she would expect, at least once a day, the staff would monitor the AV fistula/graft access for bruit and thrill. 415.12

Plan of Correction: ApprovedFebruary 22, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. On 01/23/2018 the resident # 224 AV shunt was monitored for Bruit and Thrill and documented in the T.A.R. Resident was discharged from the facility.
2. All residents receiving [MEDICAL TREATMENT] treatment have the potential to be affected by this deficiency. The ADNS generated a list of all residents who receive [MEDICAL TREATMENT] treatment to ensure that the staff is documenting for bruit and thrill each shift. All other residents? documentation was found to be in compliance.
3. The ADON and ADNS reviewed the plan and procedure for [MEDICAL TREATMENT] treatment, policy and procedure was found to be in compliance. All nurses will be re-inserviced on this policy and procedure with a special focus on entering the order correctly in the EMR system so that it appears on the T.A.R. Q shift and completing documentation. In-service will be given by DNS/ Designee.
4. An audit was developed to monitor compliance with monitoring and documentation for all residents with an AV shunt. This audit will be done by the RN?s/Unit Manager weekly x4, monthly x3 and quarterly x 3. All negative findings will be reported to the DNS/Designee immediately. All findings will be reported to the QA committee quarterly.
5. The DNS is responsible for this plan of correction.

FF11 483.45(c)(1)(2)(4)(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: 483.45(c) Drug Regimen Review. 483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. 483.45(c)(2) This review must include a review of the resident's medical chart. 483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. 483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 23, 2018
Corrected date: March 30, 2018

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 for one (Resident #256) of five sampled residents reviewed for unnecessary medications, that a recommendation made by the Registered Pharmacist (RPH), was addressed and the rationale for Physician disagreement was documented in the medical record. Specifically, Resident # 256 had RPH recommendations to discontinue or add a stop date for [MEDICATION NAME] (an anticoagulant). There was no documented evidence by the Physician in the medical record of the rationale for disagreeing with the RPH recommendations. The finding is: Resident # 256 has a [DIAGNOSES REDACTED]. The resident was admitted on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and the resident's cognition was moderately impaired. The MDS documented the use of an anticoagulant seven of seven days during the MDS review period. The monthly Medication Regimen Review (MMR) dated 12/26/17 documented a recommendation by the RPH. The RPH documented that the resident was currently receiving [MEDICATION NAME] for [MEDICAL CONDITION] without an intended stop date. The RPH documented to consider to discontinue or add a stop date now, if appropriate. The Physician checked the Disagree; State reason box without documenting a rationale for the disagreement. review of the resident's medical record revealed [REDACTED]. The Physician was interviewed on 1/19/18 at 2:00 PM and stated she usually documents the rationale in the medical record if she disagrees with the pharmacist recommendations. She further explained she had seen the resident that same day but did not document the rationale for the disagreement with the RPH in the medical record. 415.18(c)(2)

Plan of Correction: ApprovedFebruary 22, 2018

F756
1. On 01/19/2018 the PCP documented her response in resident # 256 medical record for disagreeing with the RPH.
2. All residents are at risk for unnecessary medications. The RNS will review all RPH recommendations to ensure the PCP?s document their rationale if they disagree.
3. The plan and procedure was reviewed and revised to document that the medical director will oversee and ensure proper documentation from the PCP based on the recommendation from the RPH. All RNS and PCP will be in serviced on this policy by the Medical Director.
4. An audit was created to ensure proper documentation with the rationale and compliance with this policy. Audits will be ongoing. Negative findings will be reported to the DNS/Designee for review and corrective action. All findings will be reported to the QA committee.
5. The DNS is responsible for this plan of correction.

FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: 483.60(i) Food safety requirements. The facility must - 483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. 483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 23, 2018
Corrected date: March 30, 2018

Citation Details

Based on observations, record review and staff interview during the Recertification Survey, the facility did not maintain all kitchen areas in a clean sanitary manner and in good repair. Specifically, the preparation room had a leaking drainage pipe; the preparation table drawers were in disrepair; and the supplement area floor was in need of cleaning. Additionally, the dish washing machine did not have temperatures documented on the water temperature log for 1/22/18. The findings are: During an initial tour of the main kitchen area on 1/9/17 from 9:00 AM to 9:45 AM, the following was noted: In the preparation room, there was a large sink which had a leaking drainage pipe. A large metal pan was placed on the floor underneath the leaking drainage pipe to catch the dirty draining liquid. Card board boxes filled with food items were stored on a low metal shelf in close proximity to the leaking drainage pipe. An interview with the Food Service Director (FSD) was conducted on 1/09/18 at 9:45 AM. She stated she was not made aware of the leaking drainage pipe and would contact maintenance staff to address the leak. In the preparation room, there were two cabinet metal drawers in disrepair. One of the drawers, was missing a front panel and the other drawer was observed with a heavy build up of food debris and was in need of thorough cleaning. The tube feed and supplement storage area was in need of thorough cleaning. There was a build up of debris on the floor. The floor tile near the supplement storage area was heavily stained and dirty and in need of thorough cleaning. The Food Service Director (FSD) was interviewed on 1/9/18 at 9:50 AM and stated the floor tile needs to be stripped and cleaned. A second observation in the kitchen on 1/22/18 at 10:45 AM revealed the following: The dish machine hot water temperature log was reviewed on 1/22/18 at 11:00 AM. The dish machine water temperatures for the wash cycle and final rinse cycle were not documented on the log for 1/22/18. The FSD stated that the person responsible for not documenting the water temperatures on the log this morning was not in the kitchen. She further stated that he should have documented the water temperatures prior to using the dish machine before the breakfast meal dishes were washed. 415.14(h)

Plan of Correction: ApprovedFebruary 22, 2018

1.
A. The large sink that?s drainage pipe was leaking was fixed.
B. The two cabinet metal drawers that were in disrepair and dirty was discarded.
C. The tube feeding supplement storage area was thoroughly cleaned. The floor was striped and waxed and some tiles were replaced.
D. When the employee who was responsible for logging the final rinse temperature returned he logged the temperature of the final rinse.
2. Item completion date,
item A was completed on 1/9/18.
item B was completed on 1/9/18.
item C was competed 1/9/18.
item D was completed on 1/22/18.
3. A. All kitchen employees will be in-serviced by the FSD to look for signs of pipes or water line damage and report it to FSD immediately.
B. All kitchen employees will be in-serviced by the FSD to look for signs of any broken or damaged equipment, parts of equipment?s and report it to FSD immediately.
C. All kitchen employees will be in-serviced by the FSD for cleanliness of the kitchen floor including the tube feeding supplement area and take corrective action or report to the FSD if found un clean.
D. All kitchen Staff will be in-serviced by the FSD to record dish machine temperatures for the all cycles at each meal. The FSD/ Designee will check these logs at every meal to assure temperatures are appropriate and staff is actually monitoring dish machine temperatures. All staff will be in-serviced to report any problem with the dish machine to the FSD as soon as they occur.
4. An audit tool was created to ensure compliance for all above mentioned items. Audits will be done by the FSD / designee weekly x 4, monthly x 3 and quarterly x 3.
Negative finding will be addressed immediately by the FSD.
All finding will be presented to the QA committee quarterly.
5. The FSD is responsible for this Plan of Correction.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 23, 2018
Corrected date: March 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey the facility did not ensure that each resident receives adequate supervision to prevent accidents. This was evident for one (Resident #180) of nine residents reviewed for accidents. Specifically, Resident #180 had a fall, the dining room, without adequate staff supervision. The finding is: Resident #180 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and was severely impaired for daily decision making. The resident had difficulty focusing attention. The resident was non-ambulatory and required extensive assist of two staff members for transfers and toileting and used a chair that prevents rising daily. The resident had no falls since the prior assessment. A Comprehensive Care Plan (CCP) for actual falls, dated 1/17/13 and last updated 1/9/18, documented goals that included the resident's fall risk will be reduced daily through the review date of 2/23/2018. An interventions, dated 3/18/13, included to provide close monitoring at all times. A CCP dated 5/22/13 and last updated 1/9/18 documented the resident has confusion and a history of multiple falls in the past. The CCP documented the resident slid out of her wheel chair on 12/28/17 and no injury was noted. An intervention initiated 1/2/18 documented the nursing staff was counseled to ensure the resident is placed in eye view of staff at all times for safety. A physician's orders [REDACTED]. A Progress note dated 12/28/17 at 18: 56 (6:56 PM) documented the resident slid out of the wheel chair. On arrival the resident was noted lying on her left side on the wheel chair foot rest. The resident was unable to state what happened due to cognitive impairment. The Certified Nursing Assistant (CNA) in dining room stated that she was feeding another resident when she heard another resident saying she is on the floor. When the CNA looked she saw the resident lying on her wheel chair foot rest. An Occurrence Report dated 12/28/17 documented at 6:10 PM in the dining room the resident was observed lying on her left side on the wheel chair foot rest, a pillow was placed under her head and the Nursing Supervisor was informed. The resident uses a lap tray. The assigned CNA statement dated 12/28/17 documented I was serving supper in the hallway to residents that are in their room when the nurse told me the resident slid out of the wheel chair in the dining room. The Accident Incident Investigative Summary dated 12/28/17 documented the camera was reviewed and the resident suddenly slid off her wheel chair. It also documented that where the resident was placed in the dining room was not clear for the staff to see the resident. The summary further documented that in attempt to prevent further incident staff was counseled to ensure that resident is placed in eye view of staff at all times for safety. The Licensed Practical Nurse (LPN) was interviewed on 1/22/17 at 4:20 PM and stated that she was not in the dining room at the time of the fall but the CNA brought the resident's fall to her attention. The LPN stated when she went into the dining room the resident was lying half way across the foot rest and the lap tray was still in place. 415.12(h)(1)

Plan of Correction: ApprovedFebruary 22, 2018

1. Resident #180 was moved in to eye view in order to be in eyes view while in the day room.
2. All residents who require supervision have the potential to be at risk for this deficiency . All nursing staff was re-inserviced on how to keep residents in the day room within eyes view by DNS/Designee.
3. The policy and procedure on day room coverage was reviewed by the DNS and ADON. All nursing staff were reinserviced on this policy By DNS / Designee
4. The facility developed an audit tool to ensure that all residents in the day room who require supervision are within the staff?s vision. Audits will be done by DNS/Designee weekly x4, monthly x3 and quarterly x3. Negative findings will be reported to the DNS/Designee. All findings will be reported to the QA committee quarterly.
5. The DNS is responsible for this plan of correction.

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: 483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: 483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards; 483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. 483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. 483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. 483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 23, 2018
Corrected date: March 30, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not ensure that an Infection Prevention and Control Program (IPCP) designed to help prevent the development and transmission of infection was maintained on 2 nursing units. Specifically, two Certified Nursing Assistants (CNA) who did not received the Influenza Vaccine were observed in resident's room wearing a mask under their chin. The finding is: During an initial tour observation conducted on the 4 South Nursing unit on 1/9/18 at 11:30 AM a Certified Nursing Assistant (CNA #1) was observed walking in the hallway wearing a mask under her chin. The CNA then entered a resident's room and began conversing with a resident who was in bed while wearing her mask under her chin. CNA #1 was interviewed immediately on 1/9/18 at 11:30 AM. The CNA stated that she did not take the flu shot as she had gotten sick in the past. The CNA further stated that she was in-serviced to wear her mask covering her nose and mouth at all times when in the facility. During an observation conducted on the 4 North Nursing unit on 1/17/18 at 9:55 AM, CNA #2 was observed walking in the hallway with a mask under her chin. The CNA then entered a resident's room and conversed with the resident with the mask under her chin. CNA #2 was interviewed immediately on 1/17/18 at 9:55 AM. The CNA stated that she did not receive the Influenza Vaccine but was in-serviced when wearing the mask to ensure her mouth and nose is covered at all times. The Registered Nurse (RN) Nurse Manager was interviewed on 1/17/18 at 10:00 AM and stated that an in-service was given to the CNAs regarding proper wearing of the mask covering nose/mouth to prevent the spread of infection. The RN stated that any staff that did not receive the Influenza Vaccine must wear a mask. 415.19(a)(1-3)

Plan of Correction: ApprovedFebruary 22, 2018

1. All staffs were immediately re-inserviced on the importance and necessity of wearing a flu mask.
2. All residents are at risk if facility staff is not following the policy and procedure. RN?s and department heads held a meeting to discuss the importance of wearing flu masks and to monitor their staff closely.
3. Facility policy and procedure was reviewed and in compliance. Staff was re-inserviced and educated on flu mask policy and procedure.
4. The Administrator/Designee will create and audit tool to ensure flu mask compliance. Designated rounds to ensure flu mask compliance will be done on random shifts weekly x4, and monthly thereafter until the end of flu season is announced. Negative findings will be addressed immediately. All findings will be reported to the QA committee quarterly.
5. The Administrator is responsible this plan correction.

FF11 483.10(e)(1); 483.12(a)(2):RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS

REGULATION: 483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: 483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with 483.12(a)(2). 483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. 483.12(a) The facility must- 483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 23, 2018
Corrected date: March 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey the facility did not ensure that each resident had the right to freedom from a physical restraint not required to treat the resident's medical symptoms. This was evident for one (Resident #180) of four residents reviewed for Physical Restraints. Specifically, Resident #180 has an order for [REDACTED]. The finding is: Resident #180 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and was severely impaired for daily decision making. The resident had behavior symptoms including difficulty focusing attention. The resident was non-ambulatory, required extensive to total assist of one to two staff members for all care areas, and used a chair that prevents rising daily. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The Lap tray was to be removed every two hours for 15 minutes during Activities of Daily Living (ADL) care and as needed (PRN). The physician's orders [REDACTED]. During an observation of the resident on 1/23/18 at 11:00 AM, the resident's Lap tray was released for fifteen minutes. The resident was observed for the first few minutes asleep then was awake for completion of the fifteen minute period. No agitation, weight shifting, or sliding was observed. The resident tolerated the release of the Lap tray without any Behavioral Disturbance. A Comprehensive Care Plan (CCP) dated 4/19/13, and last reviewed 1/12/18, documented the resident was at increase risk of complications with the use of lap tray as a restraint related to a history of falls and Dementia, and re-injuring self. Goals included that the resident will be engaged with the restraint monitoring program and reduction program. Interventions included to initiate restraint reduction program on an as needed (PRN) basis after restraint assessment by Interdisciplinary Disciplinary Team (IDT), out of bed (OOB) to tilt in space chair with lap tray. Lap tray to be removed every 2 hours. A 72 Hour Restraint Monitoring form dated 3/3/17 to 3/5/17, 9/1/17 to 9/3/17 and 11/29/17 to 12/1/17, completed by Licensed Practical Nurses on the day and evening shifts, documented the reason for the assessment was a Quarterly Assessment. The following behaviors were documented: On 3/3/17, on the 7:00 AM - 3:00 PM shift: resting/sitting quietly. On 3/3/17, on the 3:00 PM - 11:00 PM shift: resting/sitting quietly/leaning. On 3/4/17, on the 7:00 AM - 3:00 PM shift: resting/sitting quietly. On 3/4/17 on the 3:00 PM - 11:00 PM shift: resting/sitting quietly/leaning. On 3/5/17 on the 7:00 AM - 3:00 PM shift: leaning. On 3/5/17 on the 3:00 PM - 11:00 PM shift: resting/sitting quietly/leaning. On 9/1/17 on the 7:00 AM - 3:00 PM shift: leaning. On 9/1/17 on the 3:00 PM - 11:00 PM shift: leaning. On 9/2/17 on the 7:00 AM - 3:00 PM shift: sliding. On 9/2/17 on the 3:00 PM - 11:00 PM shift: resting/sitting quietly. On 9/3/17 on the 7:00 AM - 3:00 PM shift: leaning. On 9/3/17 on the 3:00 PM -11:00 PM shift: leaning. On 11/29/17 on the 7:00 AM - 3:00 PM shift: resting/sitting quietly. On 11/29/17 on the 3:00 PM - 11:00 PM shift: leaning. On 11/30/17 on the 7:00 AM - 3:00 PM shift: resting/sitting quietly. On 11/30/17 on the 3:00 PM - 11:00 PM shift: sleeping. On 12/1/17 on the 7:00 AM - 3:00 PM shift: leaning. On 12/1/17 on the 3:00 PM - 11:00 PM shift: resting/sitting quietly. A late entry progress note dated 12/1/17 titled MDS/Quarterly Assessment documented the resident continues to have a Lap tray when out of bed to a Geri chair. The Lap tray is removed every two hours for fifteen minutes to check skin integrity, promote mobility during activities of daily living (ADL)'s and as needed. There was no documented evidence in the progress note that a 72 hour Restraint Reduction Monitoring was completed or the lease restrictive device that was used during the reduction monitoring period. The progress note documented the Lap tray was continued because the resident attempted to get up, lean forward in the wheel chair, and is occasionally agitated. The restraint was continued. Also there was no documented evidence of a corresponding progress note in the medical record for the assessment period of 3/3/17 to 3/5/17 and 9/1/17 to 9/3/17 regarding restraint reduction monitoring. The Assistant Director of Nursing Services (ADNS) was interviewed on 1/22/18 at 3:30 PM regarding the Lap Tray restraint. The ADNS stated that the resident has had the restraint since 2013 and that on a quarterly basis the resident is assessed for restraint reduction. The evening shift Licensed Practical Nurse (LPN #1) was interviewed on 1/22/18 at 4:20 PM. The LPN stated over the four years that she has been assigned to the unit the resident has had the lap tray. The LPN stated that the resident uses the Lap tray because she is very restless, frequently shifts her body in the chair and aimlessly moves her hands and that the lap tray is released every two hours for fifteen minutes. The LPN stated she is given a 72 Hour Restraint Monitoring form and is instructed to document the resident's behavior while in the wheel chair. The LPN was asked the purpose of the 72 Hour Restraint Monitoring and if the restraint is removed at the time that she completes the monitoring sheet. The LPN stated the purpose of the sheet is to monitor the resident's behavior and movements throughout her shift while the resident is in the chair and that the Lap tray is not released at the time of monitoring. The day shift LPN #2 was interviewed on 1/23/18 at 7:35 AM. The LPN stated that she has been assigned to the unit for more than one year and that the resident uses a Lap tray for protection and safety as the resident slides down in the chair. The LPN stated that the staff is supposed to remove the tray every 2 hours for 15 minutes and for meals. When the LPN was asked if she was familiar with the 72 Hour Restraint Monitoring form, she stated the Supervisor on the unit gives her the form with instruction to monitor the resident's position, behavior and movements in the chair throughout the shift and to document the results on the 72 Hour Restraint Monitoring form. The LPN stated that during the monitoring period the Lap tray is not released. The LPN further stated when the tray is removed the resident sometimes shifts herself but is not agitated. The resident tolerates the removal of the Lap tray and there were no incidents of agitation where the staff had to reapply the Lap tray before the fifteen minute period expires. The 7:00 - 3:00 AM Certified Nursing Assistant (CNA) was interviewed on 1/23/18 at 8:02 AM and stated she cared for the resident consistently for the past four months and that the resident uses a Lap tray because the resident had a tendency to lean forward in the wheel chair. The CNA stated that every 2 hours the Lap Tray is released for 15 minutes and is also released for feeding. The CNA further stated during feeding the resident moves around so she is not left alone, however, there was never a time when the tray had to be applied due to the movement. The Director of Nursing Services (DNS) and the ADNS were interviewed concurrently on 1/23/17 at 1:00 PM regarding restraint reduction and the use of the 72 Hour Restraint Monitoring form. Both the DNS and the ADNS stated the form is used quarterly for restraint reduction and that the form was not used correctly. The DNS and the ADNS further stated the Lap Tray must be released for fifteen minutes and the results documented on the 72 Hour Restraint Monitoring form. 415.4(a)(2-7)

Plan of Correction: ApprovedFebruary 22, 2018

1. The nursing staff on the unit was re-inserviced on how to properly conduct a 72 hour restraint reduction. A 72 hour restraint reduction was done with the goal of restraint reduction.
2. All residents that could have restraints can be affected by this deficiency.
3. The policy and procedure was reviewed by the DNS and ADNS and was found to be in compliance. The licensed nursing staff was re-inserviced on the proper procedure on how to reduce restraints. In-service will be done by the DNS/Designee.
4. The DNS/Designee will monitor and observe the staff on compliance with this procedure. Audits will be done quarterly X 4. Negative findings will be reported immediately to the Administrator and DNS. All findings will be presented to the QA committee quarterly.
5. The DNS is responsible for this plan of correction.

Standard Life Safety Code Citations

DEVELOPMENT OF COMMUNICATION PLAN

REGULATION: (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 23, 2018
Corrected date: March 15, 2018

Citation Details

Based on documentation review and staff interview, the facility's Emergency Preparedness plan did not comply with Federal, State and local laws. The contact information in the Health Provider Network (HPN) Communications Directory was not current and updated timely. The findings are: On 1/10/18 between 9:00am- 2:00pm during the recertification survey, review of the facility's Communications Directory on the HPN revealed that the contact information for the roles under the twenty four hour, seven days a week facility contact and the Office of the Administrator, was not current and updated timely. This was contrary to the requirements of 10NYCRR 400.10 in that current and complete updates of the Communications Directory reflecting changes that include, but are not limited to, general information and personnel role changes as soon as they occur, and at a minimum, are completed on a monthly basis. The last time these roles were updated in the HPN was (MONTH) 12, 2014 and they indicated the contact information of a former Administrator. In an interview on 1/10/18 at approximately 12:45pm, the Administrator stated that he will update the contact information. 10NYCRR 400.10

Plan of Correction: ApprovedFebruary 8, 2018

1. The HPN contact information was updated and brought current.
2. The update was done on 1/11/18
3. The Administrator will update all roles as they occur review all HPN roles quarterly and update as needed.
4. The Administrator will report any updates or changes to the Quality Assurance committee quarterly.

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at 403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at 418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 23, 2018
Corrected date: March 15, 2018

Citation Details

Based on documentation review and staff interview, the facility's Emergency Preparedness plan did not address policies and procedures regarding the use of volunteers in an emergency. Specifically, the facility's policy did not address utilizing volunteer support of health care professionals. The findings are: On 1/10/18 between 9:00am- 2:00pm during the recertification survey, review of the facility's Emergency Preparedness plan revealed that their policy regarding the use of volunteers did not address utilizing volunteer support of health care professionals. In an emergency, facilities may need to accept volunteer support from individuals with varying levels of skills and training, including health care professionals. The facility lacked a policy addressing how to facilitate this support. In an interview on 1/10/18 at approximately 11:02am, the Administrator stated that he would update the plan to address the use of health care professional volunteers.

Plan of Correction: ApprovedFebruary 8, 2018

1. The Emergency Preparedness Manual was updated to specifically address the use of volunteer support of health care professionals.
2. The update was made on 1/10/18.
3. All staff will be in-serviced in how to easily identify all volunteer support of health care professionals in the facility at that time.
4. The Administrator and or designee will conduct monthly audits to ensure staff are knowledgeable in identifying volunteer support of health care professionals. Findings will be reported to the Quality Assurance Committee Quarterly.

SUBSISTENCE NEEDS FOR STAFF AND PATIENTS

REGULATION: [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years (annually for LTC). At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at 418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 23, 2018
Corrected date: March 15, 2018

Citation Details

Based on documentation review and staff interview, the facility's Emergency Preparedness plan did not address policies and procedures regarding the provision of subsistence needs for staff whether they evacuate or shelter in place, regarding food, water and pharmaceutical supplies. The facility's policy was not specific to providing subsistence needs for staff. The findings are: On 1/10/18 between 9:00am- 2:00pm during the recertification survey, review of the facility's Emergency Preparedness plan revealed that their policy did not specifically address subsistence needs for staff regarding food, water and pharmaceutical supplies. Their Emergency Preparedness plan did not indicate providing food and water for staff and their pharmaceutical policy only indicated that the Facility will utilize local pharmacies. Nothing specific to providing pharmaceutical supplies for staff. The facility must be able to provide for adequate subsistence for all patients and staff for the duration of an emergency or until all its patients have been evacuated and its operations cease. In an interview on 1/10/18 at approximately 11:00am, the Administrator stated that he would update the plan to include staff subsistence needs.

Plan of Correction: ApprovedFebruary 8, 2018

1. The Emergency Preparedness Manual was updated to specifically address subsistence needs for staff regarding food, water, pharmaceutical supplies.
2. The update was done on 1/10/18
3. The emergency preparedness manual will be updated annually and as needed to ensure that all information is relevant and up to date.
4. The Administrator and Director of Environmental Services will review the Emergency Manual Quarterly. Findings and updates will be reported to the Quality Assurance Committee Quarterly.