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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 22, 2021
Corrected date: June 6, 2021
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey, the facility did not ensure that each residents' drug regimen was free from unnecessary medication. This was identified for one (Resident #63) of 5 residents reviewed for unnecessary medications. Specifically, Resident #63 has [DIAGNOSES REDACTED]. The finding is: Resident #63 was admitted to the facility with [DIAGNOSES REDACTED]. A Significant change Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 6, which indicated severe cognitive impairment. The resident had no behavior problems and required extensive assistance of one to two staff members for all activities of daily living. The resident received Antipsychotic and Antidepressant medications during seven of seven assessment days. A physician's orders [REDACTED]. The Physician Desk Reference documented a Boxed Warning: Phenothiazine- Antipsychotic are not approved for the treatment of [REDACTED]. Resident #63 was observed in bed on 4/16/2021 at 11:49 AM. The resident was awake and responsive. No behaviors were observed A Second observation was made on 4/19/2021 at 3:05 PM. Resident #63 was observed sitting in a wheelchair in the resident's room. No behaviors were identified. A Comprehensive Care Plan (CCP) for Cognition dated 11/6/2019 documented the resident had cognitive loss and Dementia. The resident had a BIMS Score of 8 (moderately impaired cognitive status), difficulty making decisions, and was disoriented to time and situation. A CCP dated 8/14/2018 for [MEDICAL CONDITION] Drug use related to Major [MEDICAL CONDITION] as evidence by altered mood state (Depression/Anxiety/Mania) documented the resident was on Antipsychotic medications as Adjunct treatment of [REDACTED]. Interventions included to assess the effectiveness of the medications and monitor for side effects and to attempt non-pharmacological interventions An Interdisciplinary Team Conference Note dated 3/4/2021 documented the resident is pleasant, cooperates but is withdrawn, and remains on medication for Depression. The resident interacts with staff, relates well with roommate, and selectively participates in activities. The resident has no behavior issues but does have episodes of restlessness. Social worker visits for support, monitors mood and behavior, reviews Advance Directives and remains available for issues or concerns. A Psychiatry Consult dated 4/2/2020 documented the resident was seen for regular scheduled follow up visit and current medication was [MEDICATION NAME] 20 mg by mouth daily. The resident was delusional with poor judgement. [DIAGNOSES REDACTED]. A Progress note dated 4/2/2020 at 3:02 PM documented the resident was seen on rounds by the Psychiatrist and new orders to start [MEDICATION NAME] 1 mg every 12 hours. A Progress note dated 4/2/2020 at 4:03 PM documented the resident was seen on rounds by the attending Psychiatrist and recommended to start [MEDICATION NAME] 1mg twice daily for Moderate Depression. The Attending Physician was made aware and in agreement with the recommendations. A review of the nurse's notes dated 3/26/2020 to 4/2/2020 was conducted and there was no documented evidence of behaviors except the nursing progress note dated 3/30/2020 when the resident refused a shower. The staff offered a bed bath and the resident agreed. A Psychiatry Consult dated 5/21/2020 documented the resident was depressed, sad, very fearful, needed a lift to get out of bed. Current medication: [MEDICATION NAME] 20 mg daily and [MEDICATION NAME] 1 mg twice daily. [DIAGNOSES REDACTED]. Recommendations was made to increase [MEDICATION NAME] to 2 mg twice daily. A Progress note dated 5/21/2020 documented the resident was seen by phone visit with Psychiatrist who is aware of the resident's fearful behavior. The resident voiced the same to the Physician who recommended to increase [MEDICATION NAME] to 2 mg twice daily from 1 mg. The Progress notes dated 5/21/2020 to 5/28/2020 documented increase [MEDICATION NAME] was in progress due to Depression with no adverse reaction. A Progress note dated 5/28/2020 at 5:04 PM documented the resident was seen by Psychiatrist on rounds today on the 7:00 AM-3:00 PM shift and ordered to discontinue [MEDICATION NAME] 2mg and to give [MEDICATION NAME] 1 mg twice daily. A Progress note dated 5/29/2020 at 1:25 PM documented the resident was followed up by the Psychiatrist on 5/28/2020 and the resident was noted with Extrapyramidal Symptom (EPS) with the increased [MEDICATION NAME] 2 mg dose. Recommendation to resume 1 mg twice daily A Pharmacy recommendation dated 6/15/2020 at 4:21 PM recommended to taper [MEDICATION NAME] ([MEDICATION NAME]) then discontinue and indicate use for Depression. The recommendation was denied by the Physician due to behavioral symptoms. A Psychiatry Evaluation dated 6/18/20 documented the resident wants to leave the unit with the roommate and was even more confused than previously and was more depressed. The current medications were [MEDICATION NAME] 20 mg daily and [MEDICATION NAME] 1 mg twice daily. A Progress note dated 6/18/2020 documented the resident had a facetime follow-up with the Psychiatrist due to anxiety, accusatory behavior, and elopement attempts. The resident was to start [MEDICATION NAME] at 5:00 PM. The day shift Certified Nursing Assistant (CNA) was interviewed on 4/20/21 at 2:54 PM and stated that she has cared for the resident for the past three years. The CNA stated that the resident is confused and voiced she was afraid today. The CNA stated during care that the resident was not combative and that she has never seen the resident being combative with the roommate. The CNA stated the resident does not have a happy personality and was not tearful. The CNA stated occasionally the resident tries to leave the unit but does not seek out exit doors. The CNA further that stated for the past several months the resident has not tried to get on the elevator. The 7:00 AM-3:00 PM shift Licensed Practical Nurse (LPN) was interviewed on 4/20/21 at 3:08 PM and stated the LPN has cared for the resident for years. The LPN stated the resident is cooperative and was not combative with staff or other residents. The LPN stated that the resident was started on the Psychotic medication because she was more depressed. The LPN stated that the resident was not coming out of the resident's room as much and had a decrease in appetite. The LPN further stated that the resident was usually pleasant and cooperative. The 3:00 PM - 11:00 PM shift LPN was interviewed on 4/20/21 at 3:36 PM and stated that they have cared for the resident for about a year and a half. The LPN stated normally the resident is docile and very quiet, and that sometimes the resident would ask staff to talk to the resident. The LPN stated after talking and reassurance the resident was okay. The LPN stated the resident was not confrontational and did not have altercations with the roommate. The LPN stated that the resident never exhibits any aggressive behavior during care and staff did not report any resident behaviors to the LPN. The LPN stated that the resident is very fearful at times and always ask if staff was mad at the resident. The 3:00 PM - 11:00 PM CNA was interviewed on 4/20/21 at 3:58 PM and stated when the regularly assigned CNA was not working then she was assigned to care for the resident. The CNA stated the resident was on the quiet side, mostly stays in the room and would propel the wheelchair around the room. The CNA further stated that the resident was not combative with care. The 3:00 PM-11:00 PM Registered Nurse (RN) Supervisor was interviewed on 4/20/21 at 4:07 PM and stated she was familiar with the resident. The resident was very calm. The RN stated the resident would ask the staff if they were mad at the resident and that after the staff reassurance the resident would be okay. The RN stated that there were no reports of combative behavior regarding the resident. The resident's Physician was interviewed on 4/22/21 at 2:00 PM. The physician stated that he does not start residents on [MEDICAL CONDITION] medications, and that he defers the start of all Antipsychotic medications and the evaluation of the medication to the Psychiatrist, who are the experts. The Physician stated when the resident developed EPS from the use of [MEDICATION NAME], that the medication was discontinued. The Physician stated that he respects recommendations made by the consultant Psychiatrist and that the Psychiatrist would be the person to answer questions regarding the use of the Antipsychotic medication. The Physician stated that at the time of the Pharmacy recommendation he did not feel the resident was ready for a reduction as the resident was upset and crying all the time. An attempt was made to interview the current Psychiatrist on 4/22/21 at 1:59 PM, no response, unable to leave message as the mailbox was full. The Director of Nursing Services (DNS) was interviewed on 4/22/2021 at 4:39 PM and stated that the resident did not have a Psychotic [DIAGNOSES REDACTED]. The DNS further stated that non-pharmacological interventions should be attempted prior to the start of an Antipsychotic medication. The DNS further stated that behaviors that warranted the start of the medication should be documented. 415.12(l)(1) | Plan of Correction: ApprovedMay 20, 2021 The facility acknowledges that all residents have the potential to be affected by this deficient practice Resident # 63 was affected by this deficient practice Identification of others The drug regimen reviews of all residents receiving antipsychotics will be reviewed to ensure all recommendations have been addressed All licensed nurses will be in-serviced on the facilities drug regimen review policy, and the facilities protocol on documenting resident behaviors by the RN educator / designee. All MDís, PAís, NPís will be in-serviced on the facility policy on drug regimen review by RN educator / designee Systemic measure to prevent reoccurrence The facilities policy on drug regimen review was reviewed on 5/11/21 with the administrator medical director and DNS with no changes made. Quality assurance The administrator and Director of nursing created an audit tool to monitor drug regimen review follow up and ensure behaviors are documented appropriately to justify the need for continued use of antipsychotic medication. The director of nursing / designee will conduct a bi-weekly audit on 25% of all drug regimen of residents on antipsychotic medication bi-weekly x 8 weeks then monthly thereafter until 100% compliance is achieved Any negative audit findings will be immediately address by the DNS/designee with an onsite teaching/Inservice and disciplinary action as needed. The findings of these audits will be discussed by the DNS/Designee at the QA meetings monthly x3 months, then quarterly in order to review and discuss any unfavorable patterns that may prevent achieving 100% compliance. The director of nursing is responsible for the correction and completion of this deficiency. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 22, 2021
Corrected date: June 6, 2021
Citation Details Based on observations, interviews, and record review during the Recertification Survey completed on 4/22/2021, the facility did not ensure that the resident environment remained as free of accident hazards as possible. Specifically, a patio exit door, situated in the 1st floor dining room was not secured with a properly functioning alarm or door hardware to prevent unauthorized entry and exit. The findings are: The Policy and Procedure for Identifying Residents at Risk for Elopement/Wandering, dated (MONTH) 2013, was reviewed. The facility policy documented under item #14 Environmental Services is responsible to check for functionality daily at exits and maintain a log. During an observation on 04/20/2021 at 4:00 PM, the patio exit door, situated in the dining room, was observed to have opened on its own due to a draft which caused the door alarm to sound. The alarm reset (stopped sounding) within 15 seconds without any intervention from facility staff. The door had a keypad situated immediately to the right of the exit door which displayed red led lights indicating that the alarm is activated. The red lights no longer remained illuminated after 15 seconds when the alarm stopped sounding. On 04/20/2021, at 4:10 PM, the Administrator was called to observe the exit door alarm at which time surveyor opened the door with no mechanical resistance. The alarm immediately sounded and reset itself without intervention from facility staff. The door was examined and appeared to have the latch hardware removed and the panic bar disabled thus making it possible to open the door from the inside or the outside without any physical resistance. At 4:12 PM the Administrator stated that his understanding was that the door could not be opened from the outside and that the alarm had to be reset via a code entry by staff. He was not aware of the keypad re-setting itself or the absence of the latch hardware. He stated that the 1st floor dining room has not been in use since the outbreak of Covid in (MONTH) 2020, however, stated the 1st floor was accessible to residents for the purpose of visiting the bakery or attending rehabilitation sessions. On 04/20/21, at 4:15 PM, the door alarm was triggered again in the presence of the Administrator to confirm that the alarm and door were not functioning properly. The alarm reset itself within 15 seconds of triggering without intervention from staff and the door opened without any mechanical resistance. On 04/20/21 at 4:40 PM, two maintenance workers entered the dining room and examined the door. Maintenance Worker # 1 and # 2 stated that they did not know how the alarm should function regarding resetting itself without staff intervention. They both were unaware of who removed the latch hardware or disabled the panic bar. On 04/20/2021, at 5:30 PM, an outside vendor (electrical contractor) was called to assess the door alarm. A review of the contractor's invoice documented that he was unable to reprogram the door alarm and would have to order a replacement to make proper adjustments. He documented that the room would have to be on staff access only until proper repair can take place. On 04/20/2021, at 5:35 PM, the Administrator stated that a new alarm keypad/alarm hardware was on order and that the facility would ensure that the room would remain locked and secured, with door closed until the device was repaired. A letter dated 4/20/2021 was provided by the Administrator to the surveyor which documented the 1st floor dining room will remain locked and residents will not have access to this room. A copy of the Door Lock Test Log for the period of (MONTH) 2021-April 2021 was reviewed. The log indicated that daily checks of the Dining Room were completed. On 04/21/2021, at 08:15 AM, the 1st floor dining room door was observed to be open and unsecured upon arrival by a surveyor. No staff were observed in the local vicinity supervising the room. The Director of Engineering was interviewed on 04/21/2021 at 11:00 AM. He stated that he checks the different areas, including the 1st floor dining room daily and documents his findings in the log- book. He stated that the door hardware was likely removed because staff were getting locked out when going onto the patio but could not recall by whom or when it was removed. He was not aware that the alarm was resetting itself after 15 seconds. He stated that the alarm should require staff intervention to reset. A locksmith was observed on 4/21/2021, at 1:00 PM to remove a defective panic bar and install a new device. The surveyor observed a new panic bar and latch hardware. The alarm keypad/alarm was not repaired. The Director of Recreation was interviewed on 4/21/2021, at 4:30 PM and stated that residents of both the 2nd and 3rd floor were permitted to go to the first floor, except the residents who were on contact and droplet precautions. The Director of Recreation stated that it was common for residents to come to the 1st floor bakery and request snacks and beverages. She further stated that residents of the 3rd floor did have access to the first floor, via the elevator, up until 4/18/2021, at which time the unit was placed on contact and droplet precautions. On 4/22/2021, at 3:00 PM, the Director of Nursing Services confirmed that the residents on the third floor were not on droplet/contact precautions until 4/18/21 as identified by the Recreation Director. 415.12(h)(1) | Plan of Correction: ApprovedMay 15, 2021 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. All facility residents were placed on q15 minutes check to ensure each residentís safety X 24 hours from 4/20/21-4/21/21. The Main Dining Room was placed on 30 minutes check to ensure residentís safety X 24 hours from 4/20/21-4/21/21. On 4/20/2021 the facility brought in an outside vendor to assess door alarm. On 4/21/2021 the facility brought in a locksmith and a defective panic bar was removed and a new panic bar and latch hardware was installed. On 4/21/2021 the Facility Maintenance Director installed a new exit [MEDICATION NAME] to the facilityís Main Dining Room Door. On 4/23/2021 an outside vendor installed a new Keypad alarm on the main dining room door. 2.IDENTIFICATION OF OTHERS. A. The Facility acknowledges that all residents have the potential to be affected by this deficient practice, no residents were affected by this deficient practice based on q15 minutes check conducted 4/20/2021 and 4/21/2021. B. All Maintenance staff will be in serviced on the Facilityís Policy and procedure for identifying residents at risk for elopement/wandering dated 8/2013, on checking the doors for functionality and maintaining a log with special emphasis on checking the door for functioning latch hardware and proper alarm systems by the RN Educator/Designee. C. The Lesson plan will be kept on record for validation. 3.SYSTEM MEASURES TO PREVENT RE(NAME)CURRENCE. A. The facility policy and procedure for identifying residents at risk for elopement/wandering dated 8/2013 was reviewed on 5/11/2021 by the Administrator, Medical Director, DNS with no changes made. 4. QUALITY ASSURANCE (Ongoing Monitoring) A. The administrator created an audit tool to monitor facility doors for safe and proper function. B. The maintenance director /Designee will conduct audits on facility doors weekly x 8 weeks then bi weekly x 4 weeks then monthly thereafter until 100% compliance is achieved. C. Any negative audit findings will be immediately address by the Administrator/designee with an onsite teaching/Inservice and disciplinary action as needed. D. The findings of these audits will be discussed by the administrator /Designee at the QA meetings monthly x3 months, then quarterly in order to review and discuss any unfavorable patterns that may prevent achieving 100% compliance. E. The Administrator is responsible for the correction and completion of this deficiency. |
Scope: Isolated
Severity: Actual harm has occurred
Citation date: April 22, 2021
Corrected date: June 6, 2021
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews during the Recertification and Abbreviated Survey (Complaint #NY 858) completed on 04/22/2021, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice. Specifically, Resident #135 had a history of [REDACTED]. Resident #135 was admitted to the facility on [DATE] with instructions from the hospital to provide [MEDICATION NAME] 100 mg three times a day for a total of 300 milligrams (mg) per day. The resident received half the amount of [MEDICATION NAME] from 3/6/2020-3/23/2020. Subsequently, Resident #135 experienced [MEDICAL CONDITION] activity with a subtherapeutic [MEDICATION NAME] level of 1.3 microgram/milliliter (mcg/mL) (therapeutic range 10-20 mcg/mL). This resulted in harm to Resident #135 that was not an immediate jeopardy. The finding is: The facility's policy, dated 4/2017 titled, Admission Process documented that the attending physician/designee will obtain the resident's medical history and perform a physical examination within 48 hours of admission to the facility. Based on this information the physician will develop a medical plan of care and write orders to meet this plan. The facility policy did not include a process for medication reconciliation upon admission to the facility. Resident #135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/7/2020 Admission Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score. The MDS documented that the resident had short- and long-term memory problems and had severely impaired cognitive skills for daily decision making. The Hospital Discharge instructions dated 3/5/2020 documented a discharge order of [MEDICATION NAME] Suspension, 100 mg, orally three times a day. The hospital records available to the facility did not include a [MEDICATION NAME] level (blood test). The facility Physician's (MD) #1 order dated 3/5/2020 ordered [MEDICATION NAME] 50 mg chewable tablet, chew one tablet (50 mg) by oral route three times a day for [DIAGNOSES REDACTED]. A Medication Reconciliation Form, created on 3/5/2020 by Registered Nurse (RN) #3 documented that My signature below indicates that discharge medications have been reviewed for accuracy in transcription onto our admission orders [REDACTED]. The admission assessment however was completed by RN #4. The Nursing Admission Progress Note written by the RN #4 (the admission nurse) dated 3/5/2020 documented that the MD (unidentified) was notified of the resident's condition and diagnosis. The orders were reconciled, obtained, and read back for accuracy. Review of the progress note revealed that the resident was stable. There was no documentation regarding the [MEDICATION NAME] dosage or a need to lower the dosage of [MEDICATION NAME]. In addition, there was no order for blood work to obtain a [MEDICATION NAME] level. The Physician History and Physical (H&P), created on 3/5/2020 and completed on 3/6/2020 by Admitting MD #2, documented that medications were reviewed. There was no documentation in the H&P regarding a rationale for decreasing the hospital discharge orders of [MEDICATION NAME] 100 mg three times a day to 50 mg three times a day. There was no documented laboratory follow up for [MEDICATION NAME] levels. Review of the Medication Administration Record [REDACTED]. A nursing progress note dated 3/23/2020 documented that the nurse was called into the resident's room by therapy staff due to possible [MEDICAL CONDITION] activity. The resident was noted with clammy skin, scant amount of spit up on the resident's chest, and was pale in color. The Physician Assistant (PA) #1 was notified. PA #1's note dated 3/23/2020 documented that the resident was seen for a one-time episode of [MEDICAL CONDITION]. Orders included bloodwork to obtain a [MEDICATION NAME] level. The nursing progress note dated 3/23/2020 documented the resident was seen by the Nurse Practitioner (NP) (unidentified) and ordered laboratory work up including complete blood count (CBC) with differential, Basic Metabolic Panel (BMP) and [MEDICATION NAME] level. The laboratory results of Resident #135 dated 3/24/2020 documented [MEDICATION NAME] level of 1.3 micrograms/milliliter (mcg/mL) (Therapeutic range 10-20). A nursing progress note dated 3/24/2020 documented that laboratory results were reviewed with the PA #1 and the [MEDICATION NAME] orders were increased to 50 mg twice a day and 100 mg at hour of sleep for 3 days (for a total of 200 mg per day) and then repeat the [MEDICATION NAME] level. PA #1's order dated 3/24/2020 documented to repeat CBC, BMP and the [MEDICATION NAME] Level in three days (3/27/2020). The repeat [MEDICATION NAME] level on 3/27/2020 was 1.9 mcg/ml (Therapeutic range 10-20). A nursing progress note dated 3/27/2020 documented that lab results were reviewed with a PA #2 and ordered to send the resident to the emergency room due to low hemoglobin and hematocrit levels to rule out a Gastrointestinal (GI) bleed. The Director of Nursing Services (DNS) was interviewed on 04/19/2021 at 10:20 AM. She stated that the nurse (RN #4) who completed the admission assessment for Resident #135 on 3/5/2020 is no longer employed at the facility. The 2nd floor unit Licensed Practical Nurse (LPN), charge nurse, was interviewed on 4/19/2021 at 11:00 AM. The LPN stated that she recalled Resident #135 and also recalled the resident having [MEDICAL CONDITION] activity. She stated the general admitting process is for the admitting RN to discuss the medications with the physician based on the hospital discharge instructions and then determinations are made for medications and the dosages. She stated that an RN on the following two nursing shifts is responsible to ensure that the medication orders are being followed and the care plan is being carried out. She stated if a medication dosage was changed from what was written on the hospital discharge instructions, there should have been a note written. Attending MD #1 was interviewed on 4/20/2021 at 8:26 AM. He stated that if a resident is new to the facility, we try to keep the medications consistent with the hospital discharge instructions, unless the medication is not in the formulary (a list of medications approved for use in the facility) or something that is very expensive. He stated the facility does not change any medications until the facility staff gets to know the resident and assesses how the resident is reacting to their prescribed medications. PA #1 was interviewed on 4/20/21 at 10:44 AM. She stated that the facility would only lower the [MEDICATION NAME] dosage if there were high levels of the drug indicating toxicity and the resident was symptomatic. She stated she reads the hospital notes and follows the discharge instructions. PA #1 was re-interviewed on 4/20/2021 at 12:21 PM. She stated that she reviewed the hospital discharge instructions earlier in the day on 4/20/2021 and it appeared that Resident #135 was stable on 300 mg of [MEDICATION NAME] per day for a long time. She stated she was unable to find a [MEDICATION NAME] level prior to admission to the facility. She stated it would be her preference to get a baseline [MEDICATION NAME] level at the time of the admission. She stated that the H&P was done by MD #2. MD #1 was re-interviewed on 4/20/2021 at 2:39 PM. He stated the medications in the hospital discharge paperwork should be reviewed by the physician during the history and physical evaluation. He stated that if there is nothing remarkable, we do not need to change the medications. He stated typically he would order a [MEDICATION NAME] level upon admission if he did not know the [MEDICATION NAME] level. He stated if a resident is stable on 300 mg of [MEDICATION NAME] per day and there are no signs of toxicity upon admission and no known [MEDICATION NAME] level, then the dosage should not be changed. MD #2, who was the admitting MD and had completed the H&P for Resident #135 was interviewed on 4/21/2021 at 9:13 AM. He stated we absolutely follow the medication instructions in the hospital discharge unless there is a reason not to; for instance, if the resident is on a blood thinner and the resident is bleeding. He stated the admitting nurse reviews the medications and calls the doctor. He stated normally we check the discharge instructions from the hospital. However, he could not recall if he reviewed the hospital discharge instruction for Resident #135 when he completed the H&P. He stated he was surprised that this happened, and it was an error. The DNS was re interviewed on 4/21/2021 at 12:22 PM. She stated inconsistency with staffing and education are concerns and could affect admissions being done consistently according to policy and procedures. She stated that she is aware that she has to enforce the admission process, which has to be standardized. The Medical Director, MD #3, was interviewed on 4/22/2021 at 9:10 AM. He stated that if a dosage of a medication was lowered or changed from the hospital discharge instructions upon admission, there should be a medical justification for the change in the dosage and documentation in the notes. He stated the general procedure is for the physician or physician's team member to review the hospital discharge instructions to ensure accuracy. He stated if a resident is having [MEDICAL CONDITION], it could indicate that the dosage of medication is subtherapeutic. He stated that the dosage of [MEDICATION NAME] should not have been changed upon admission without medical justification and that the admitting physician or associate is expected to review the hospital paperwork. 415.12 | Plan of Correction: ApprovedMay 15, 2021 Immediate Corrective Action. The facility acknowledged that Resident #135 was affected by this deficient practice. A.A full inhouse audit of all residents admitted between 3/22/21- 5/10/21 was conducted by the DNS/Designee on 5/12/21 on medication reconciliation with no negative findings. B. All RNís will be educated on the facilityís Revised policy dated 5/11/2021 on the Admission Process with special emphasis on medication reconciliation on 5/12/21 by the RN Educator. All Registered nurses that conduct admissions were in-serviced on 5/12/21 on the facilityís Revised policy on the Admission Process with special emphasis on the medication reconciliation. 2. Identification of others. A. The facility acknowledges that all residentís have the potential to be affected by this deficient practice. No other residents were affected by this deficient practice based on facility audits from 3/22/21 - 5/10/21 on medication reconciliation with no negative findings. B. All licensed Nurses will be in serviced on the facility revised policy on Admission Process with special emphasis on medication reconciliation and any deviation from the discharge summary will have a note documenting the reason for the change by the RN Educator/ Designee. All Physicians, Physicians Assistant, nurse practitioners will be in serviced on the facilityís revised policy on the Admission Process with special emphasis on medication reconciliation to ensure that all discharge medications not followed by the MD will be reflected by a clinical justification note in the medical record. The Lesson plan will be kept on record for validation. 3.Systemic Measures to Prevent Reoccurrence. A. The Facilityís Policy on the Admission Process was reviewed and revised on 5/11/2021 to include the medication reconciliation process by the Administrator, Medical Director and DNS to include that on admission/re-admission all residentsí discharge medications list will be reviewed by the admission nurse, and by the supervisor on the following shift. To ensure accuracy and to ensure the all-discharge medications not followed by the md will be reflected by a clinical justification note in the medical record. 4. Quality Assurance (ongoing monitoring) A. The Administrator created an audit tool to monitor the residentís medication for accuracy on medication reconciliation on admission/re-admission. B. The RN educator /Designee will conduct audit on 20% of all admissions and readmissions weekly x 8 weeks, then bi -weekly x 1 month then monthly thereafter until 100% compliance is achieved. Audit results will be given to the DNS/Designee for review. D. Any negative audit findings will be immediately address by the DNS/Designee with onsite teaching/Inservice and disciplinary action as needed. E. The finding of these audits will be discussed by the DNS/Designee at the QA meetings monthly x 3 months, then quarterly in order to review and discuss any/all unfavorable patterns that may prevent achieving 100% compliance. F. The DNS is responsible for the correction and completion of this deficiency. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 22, 2021
Corrected date: June 6, 2021
Citation Details Based on observations, interviews, and record review during the Recertification Survey completed on 4/22/2021, the facility did not ensure that a safe, functional, sanitary, and comfortable environment for residents, staff and the public was provided. Specifically, a patio exit door, situated in the 1st floor dining room was not secured with a properly functioning alarm or door hardware to secure authorized entry and exit. The findings are; The Policy and Procedure for Identifying Residents at Risk for Elopement/Wandering, dated (MONTH) 2013, was reviewed. The facility policy documented under item #14 Environmental Services is responsible to check for functionality daily at exits and maintain a log. During an observation on 04/20/2021 at 4:00 PM, the patio exit door, situated in the dining room, was observed to have opened on its own due to a draft which caused the door alarm to sound. The alarm reset (stopped sounding) within 15 seconds without any intervention from facility staff. On 04/20/2021, at 4:10 PM, the Administrator was called to observe the exit door alarm at which time surveyor opened the door with no mechanical resistance. The alarm immediately sounded and reset itself without intervention from facility staff. The door was examined and appeared to have the latch hardware removed and the panic bar disabled thus making it possible to open the door from the inside or the outside without any physical resistance. At 4:12 PM the Administrator stated that his understanding was that the door could not be opened from the outside and that the alarm had to be reset via a code entry by staff. He was not aware of the keypad re-setting itself or the absence of the latch hardware. On 04/20/21, at 4:15 PM, the door alarm was triggered again in the presence of the Administrator to confirm that the alarm and door were not functioning properly. The alarm reset itself within 15 seconds of triggering without intervention from staff and the door opened without any mechanical resistance. On 04/20/21 at 4:40 PM, two maintenance workers entered the dining room and examined the door. Maintenance Worker # 1 and # 2 stated that they did not know how the alarm should function regarding resetting itself without staff intervention. They both were unaware of who removed the latch hardware or disabled the panic bar. On 04/20/2021, at 5:30 PM, an outside vendor (electrical contractor) was called to assess the door alarm. A review of the contractor's invoice documented that he was unable to reprogram the door alarm and would have to order a replacement to make proper adjustments. On 04/20/2021, at 5:35 PM, the Administrator stated that a new alarm keypad/alarm hardware was on order and that the facility would ensure that the room would remain locked and secured, with door closed until the device was repaired. On 04/21/21, at 08:15 AM, the 1st floor dining room door was observed to be open and unsecured upon arrival by surveyor. No staff were observed in the local vicinity supervising the room. The Director of Engineering was interviewed on 04/21/2021 at 11:00 AM. He stated that he checks the different areas, including the 1st floor dining room daily and documents his findings in the logbook. He stated that the door hardware was likely removed because staff were getting locked out when going onto the patio but could not recall by whom or when it was removed. He was not aware that the alarm was resetting itself after 15 seconds. He stated that the alarm should require staff intervention to reset. A locksmith was observed on 4/21/2021, at 1:00 PM to remove a defective panic bar and install a new device. The surveyor observed a new panic bar and latch hardware. The alarm keypad/alarm was not repaired. On 04/22/2021, at 11:22 AM, the Administrator demonstrated that a Sti-Exit alarm device was installed on the dining room / patio exit door. 415.29 | Plan of Correction: ApprovedMay 20, 2021 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. All facility residents were placed on q15 minutes check to ensure each residentís safety X 24 hours from 4/20/21-4/21/21. The Main Dining Room was placed on 30 minutes check to ensure residentís safety X 24 hours from 4/20/21-4/21/21. On 4/20/2021 the facility brought in an outside vendor to assess door alarm. On 4/21/2021 the facility brought in a locksmith and a defective panic bar was removed and a new panic bar and latch hardware was installed. On 4/21/2021 the Facility Maintenance Director installed a new exit [MEDICATION NAME] to the facilityís Main Dining Room Door. On 4/23/2021 an outside vendor installed a new Keypad alarm on the main dining room door. 2.IDENTIFICATION OF OTHERS. A. The Facility acknowledges that all residents have the potential to be affected by this deficient practice, no residents were affected by this deficient practice based on q15 minutes check conducted 4/20/2021 and 4/21/2021. B. All Maintenance staff will be in serviced on the Facilityís Policy and procedure for identifying residents at risk for elopement/wandering dated 8/2013, on checking the doors for functionality and maintaining a log with special emphasis on checking the door for functioning latch hardware and proper alarm systems by the RN Educator/Designee. C. The Lesson plan will be kept on record for validation. 3.SYSTEM MEASURES TO PREVENT RE(NAME)CURRENCE. A. The facility policy and procedure for identifying residents at risk for elopement/wandering dated 8/2013 was reviewed on 5/11/2021 by the Administrator, Medical Director, DNS with no changes made. 4. QUALITY ASSURANCE (Ongoing Monitoring) A. The administrator created an audit tool to monitor facility doors for safe and proper function. B. The maintenance director /Designee will conduct audits on facility doors weekly x 8 weeks then bi weekly x 4 weeks then monthly thereafter until 100% compliance is achieved. C. Any negative audit findings will be immediately address by the Administrator/designee with an onsite teaching/Inservice and disciplinary action as needed. D. The findings of these audits will be discussed by the administrator /Designee at the QA meetings monthly x3 months, then quarterly in order to review and discuss any unfavorable patterns that may prevent achieving 100% compliance. E. The Administrator is responsible for the correction and completion of this deficiency. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 22, 2021
Corrected date: May 22, 2021
Citation Details 2012 NFPA 101: 19.3.6.2 Corridors are separated from use areas by walls constructed with at least ½-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. 2012 NFPA 101: 19.3.6.2.2* Corridor walls shall have a minimum 1/2-hour fire resistance rating. 2012 NFPA 101: 19.3.6.2.3* Corridor walls shall form a barrier to limit the transfer of smoke. Based on observation and staff interview, it was determined that the facility did not ensure that corridor walls were smoke resistant in accordance with NFPA 101, 2012 edition. This was noted on 1 of 3 floors within the facility. During the life safety portion of the recertification survey on 4/20/2021 at 11:03am, the following was observed: On the 2nd floor between rooms 216 and the bathroom, new sheetrock had been installed. The sheetrock located above the ceiling tile lacked firestopping along the seams of the sheetrock. Additionally, a 2 inch by 2 inch section of sheetrock was missing, allowiing for the passage of smoke between the corridor and the adjacent rooms. In an interview on 4/20/2021 the time of the findings, the Director of Maintenance stated that they installed new, larger doors to accommodate larger wheelchairs and he will seal up the gaps. 2012 NFPA 101: 19.3.6.2 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedMay 6, 2021 A. No residents were affected by the deficient practice. B. All residents have the potential to be affected by the deficient practice. C. 1. The Director of Maintenance fire stopped the new sheetrock above the ceiling on the 2nd floor by room 216 he additionally sealed a 2î x 2î missing section of sheetrock conforming with 2012 NFPA 101 standards. 2. The Director of Maintenance will conduct a monthly audit to ensure all firestopping meets NFPA standards. D. 1. The Director of Maintenance/designee will report finding of audit to administrator. 2. Administrator will report findings of this audit at the next quarterly QA meeting. E.The Director of Maintenance is responsible for the correction of this deficiency. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 22, 2021
Corrected date: May 22, 2021
Citation Details 19.3.2 Protection from Hazards 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safe guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 19.3.2.1.3 The doors shall be self-closing or automatic closing. 19.3.2.1.5. Hazardous areas shall include, but shall not be restricted to, the following: 1. Boiler and fuel-fired heater rooms 2. Central /bulk laundries larger than 100ft2 (9.3 m2) 3. Paint shops 4. Repair shops 5. Rooms with soiled linen in volume exceeding 64 gallon (242L) 6. Rooms with collected trash in volume exceeding (242L) 7. Rooms or spaces larger than 50 ft2 (4.6m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction 8. Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard Based on observation and staff interview, the facility failed to ensure that doors to hazardous areas were self-closing or automatic closing. Specifically, doors did not positively latch into their frames. This occurred on 1 of 3 floors within the facility. The findings are: On 4/16/2021 between the hours of 11am and 4:30pm during the recertification survey, the following was observed: On the 1 floor, the electrical room door did not positively latch into its' frame when tested . In the main storage room, the door to the corridor lacked a bolt to latch the door into the frame. In an interview on 4/16/2021 at 12:38pm, the Director of Maintenance stated he will fix the door and replace the latch. | Plan of Correction: ApprovedMay 6, 2021 A. No residents were affected by the deficient practice. B. All residents have the potential to be affected by the deficient practice. C. 1.The Director of Maintenance repaired the faulty striker plate for the electric room door and replaced the door knob on the main storage room, both doors are now conforming with 2012 NFPA 101 standards. 2. The Director of Maintenance will conduct a monthly audit to ensure all hazardous areas meet 2012 NFPA 101 standards. D. 1.The Director of Maintenance/designee will report finding of audit to administrator. 2. Administrator will report findings of this audit at the next quarterly QA meeting. E. The Director of Maintenance is responsible for the correction of this deficiency. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 22, 2021
Corrected date: May 22, 2021
Citation Details 2012 NFPA101: 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 2010 NFPA 13: 8.5.5.2* Obstructions to Sprinkler Discharge Pattern Development. 8.5.5.2.1 Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.5.5.2. Based on observation and staff interview, the facility failed to ensure that building was fully sprinklered and that there were no obstructions to the sprinkler discharge pattern. This occurred on 1 of 3 floors within the facility. On 4/16/2021 between the hours of 11am and 4:30pm during the recertification survey, the following was observed: The Nursing Office located on the 1st floor did not have sprinkler protection. The kitchen storage room contained a cardboard box within 18 inches of the sprinkler deflector. In an interview on 4/16/2021 at approximately 12:20pm with the Director of Maintenance he stated he will have the sprinkler company install a sprinkler in the room. He also stated he will remove the boxes away from the sprinkler. | Plan of Correction: ApprovedMay 6, 2021 A. No residents were affected by the deficient practice. B. All residents have the potential to be affected by the deficient practice. C. 1. The Director of Maintenance had the facilityís sprinkler vendor install sprinkler protection in the 1st floor Nursing Office and removed the cardboard box that was within 18 inches of the sprinkler deflector now conforming with 2012 NFPA 101standards. 2. The Kitchen Staff were re-inserviced on 2010 NFPA 13: 8.5.5.2* Obstructions to Sprinkle Discharge Pattern Development and told to make sure nothing is stored within 18 inches of a sprinkler deflector. 3. The Director of Maintenance will conduct a monthly audit to ensure all of the sprinkler system meet NFPA 101 standards. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 22, 2021
Corrected date: May 22, 2021
Citation Details 2012 NFPA 101: 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 2012 NFPA 101: 9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility. Based on observation and staff interview, an electronic supervisory device was not provided on the RPZ valve located in an inground vault approximately 30 yards from the facility. The findings include: During the life safety portion of the recertification survey on 4/20/2021 at 1:00 pm it was observed that two shut off valves on the RPZ valve located in an underground vault that serves the facility sprinkler system, were not provided with electronic supervisory devices. In an interview on 4/20/2021 at 1:04pm with the Corporate Director of Maintenance, he stated the vault is on the sister facility's property and locked to prevent entry or tampering. He further stated there is no monitoring device on the valve, but the sprinkler main in the building is supervised and an alarm would register at the fire alarm panel if the system lost water pressure. 2012 NFPA 101 10 NYCRR 711.2 (a) | Plan of Correction: ApprovedMay 6, 2021 A. No residents were affected by the deficient practice. B. All residents have the potential to be affected by the deficient practice. C. 1. The Director of Maintenance had the facilityís fire alarm vendor install supervisory alarm on the two shut off valves of the RPZ conforming with 2012 NFPA 101 standards. 2. The Director of Maintenance will conduct a quarterly audit to ensure all areas of the facilityís fire sprinkler system including the RPZ shut off valves meets 2012 NFPA 101 standards. D. 1. The Director of Maintenance/designee will report finding of audit to administrator. 2. Administrator will report findings of this audit at the next quarterly QA meeting. E. The Director of Maintenance is responsible for the correction of this deficiency. |