Massapequa Center Rehabilitation & Nursing
November 2, 2017 Certification Survey

Standard Health Citations

FF10 483.10(i)(3):CLEAN BED/BATH LINENS IN GOOD CONDITION

REGULATION: (i)(3) Clean bed and bath linens that are in good condition;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2017
Corrected date: December 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews during the recertification survey, the facility did not provide bed linens in good condition for all residents. This was identified for 2 of 28 Stage 2 sampled residents. Specifically, during room observations, Resident # 71 and Resident # 436 were noted to have worn bed linens with multiple, small holes identified. The findings include: The facility's policy titled Linen and Laundry, revised 9/07, documented that all resident's receive daily: 1 large sheet, 1 draw sheet (if needed), 1 pillow case and 1 rubber sheet (if needed). The Policy documented that all bed linen is to be changed a minimum of twice weekly or as required. The facility's policy titled: Sorting and Folding Linen, reviewed and revised 1/2015, documented that linen is to be inspected for damage and/or stains. 1) Resident #71 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) Score of 8, indicating the resident has moderately impaired cognition. The MDS documented the resident was always incontinent of urine and frequently incontinent of bowel. The MDS documented the resident required extensive staff assistance in most activities of daily living including bed mobility and transfer. There were no behavior symptoms documented in the MDS. During room observations on 10/30/17 at 1:15 PM, 10/31/17 at 10:00 AM and 11/2/17 at 10:00 AM, Resident # 71 was observed with worn bed sheets with multiple holes. The mattress was visible through the holes. There was an odor of urine present in the area near the bed during each observation. The resident was interviewed on 10/30/17 at 1:15 PM, 10/31/17 at 10:00 AM and 11/02/2017 at 11:19 AM. Resident #71 was unable to recall when the sheets were changed on her bed or when she was last showered. On 11/02/2017 at 10:00 AM, the Licensed Practical Nurse (LPN)/Head Nurse on the 7:00 AM-3:00 PM shift on the resident's unit accompanied the surveyor to Resident # 71's bedside. The LPN acknowledged that the bottom sheet of the resident's bed was worn and that the sheet should be changed immediately. The LPN stated that the resident's sheets are changed on the resident's shower days which are Monday and Thursday. The LPN stated that the resident had a shower documented on Monday 10/30/17 and that the sheets should have been changed then. The Unit Housekeeper was interviewed on 11/02/2017 at 10:15 AM. The housekeeper stated that the residents' mattresses are washed by housekeeping when the Certified Nursing Assistant (CNA) removes the sheet when the residents are showered twice a week. The housekeeper stated that she washed the resident's mattress on Monday when the resident was taken to the shower. Resident # 71's CNA from the 7:00 AM-3:00 PM nursing shift was interviewed on 11/2/17 at 1:15 PM. The CNA stated that the resident had been showered on Monday (10/30/17) and that the sheets were changed at that time. The CNA stated that she had not noticed the holes in the bottom sheet. The CNA stated that when a sheet is worn or torn it would be thrown out. 2) Resident # 436 has [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident did not have a BIMS score. The resident was assessed by staff as having modified independence (some difficulty in new situations only) related to cognitive skills for daily decision making. The MDS documented that the resident required staff assistance in all activities of daily living. Resident # 436 was observed on 10/30/17 at 1:00 PM in his room. The bed sheet was noted to have multiple wear holes in the bottom sheet. The resident was interviewed at that time and stated he did not know when the sheets were last changed. The resident's CNA from the 7:00 AM-3:00 PM shift was interviewed on 11/2/17 at 1:15 PM. The CNA stated that she had not noticed the holes in the resident's sheets. The CNA stated that she grabs the sheets when needed and does not necessarily inspect them. If a torn or worn sheet is noticed, the CNA stated that the sheet would be thrown away. The Director of Housekeeping was interviewed on 11/02/2017 at 1:00 PM. The Director stated the laundry is inspected during the laundering when they are placed on the Ironer. The Director stated that when worn sheets are missed by the Laundry staff, the nursing staff are to observe, separate and remove the sheets from use and to send them back to the laundry where they are recycled. The Director of Nursing Services (DNS) was interviewed on 11/2/17 at 1:30 PM. The DNS stated that the Laundry, Housekeeping and Nursing Departments are expected to work together and are responsible to monitor the residents for the linens and all areas of patient care. The DNS stated that it is expected that the staff would not use sheets with holes for the residents. 415.5(h)(3)

Plan of Correction: ApprovedNovember 20, 2017

1 -WHAT CORRECTIVE ACTION(S) WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE?
? The bed linen on residents? #71 and #436 were immediately removed and put out of service, and replaced with new linen.
? Re-education on the Linen and Laundry Policy was reviewed with the two CNA?s involved and the Environmental Supervisor was made aware.

2- HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN?
? All bed linen was checked by the Nurse Managers on all units to ensure residents linens were not worn or ripped. Any issues or concerns were corrected immediately and brought to the Director of Environmental services, DON and Administration.
3-WHAT MEASURES WILL BE PUT IN PLACE OR WHAT SYSTEMIC CHANGES YOU WILL MAKE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT (NAME)CUR?
? A contract with a new linen company has been obtained, and delivery will start as of
November 22, (YEAR).
The Linen and Laundry and Sorting and Folding Linen Policy were reviewed and no revisions were required.
? Re-education on the Linen and Laundry Policy and the Sorting and Folding Linen Policy was reviewed with all laundry staff.
? Re-education on the Linen and Laundry Policy will be reviewed with all nursing.

4-HOW THE CORRECTIVE ACTION(S) WILL BE MONITORED TO ENSURE THE DEFICIENT PRACTICE WILL NOT RECUR, ie., WHAT QUALITY ASSURANCE PROGRAM WILL BE PUT INTO PRACTICE?
? An observational audit of resident bed linens will be conducted 10 times per week for the first quarter, then 10 times per month for the next three quarters, and then randomly thereafter to ensure residents bed linen are without issues. The results of this audit will be forwarded to our PICG monthly. Any issues/concerns will be reported to the Director of Environmental, DON and Administrator and will be corrected immediately.


5 - RESPONSIBLE PERSON- Director of Environmental Services

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2017
Corrected date: December 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and record review during the Recertification Survey the facility did not ensure that care was provided in accordance with each resident's written Comprehensive Care Plan (CCP) for 1 (Resident #21) out of 1 resident reviewed for Pain Control from a total Stage 2 sample of 28 residents. Specifically, Resident #21 had a physician's orders [REDACTED]. Additionally, there was inconsistent documentation in the Medication Administration Record [REDACTED]. The finding is: The facility's policy titled, [MEDICATION NAME] ([MEDICATION NAME]) Patches, last revised (MONTH) 2013, states that in the Electronic Medical Record (EMR) both nurses will indicate the removal and discard of the patch by documenting in the EMR. Resident #21 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/22/2017 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented the resident experienced pain almost constantly and the intensity was severe. Resident #21 had a physician's orders [REDACTED]. Resident #21 had additional physician's orders [REDACTED]. --Remove the [MEDICATION NAME] every 72 hours after initial application, dated 6/8/2016 and last renewed on 10/27/2017, with a protocol to obtain witness signature, flush down the toilet; and --Witness nurse must document removal of [MEDICATION NAME] every 3 days, dated 6/8/2016 and last renewed on 10/27/2017. During the medication administration observation for Resident #21 on 10/30/2017 at 9:33 AM a new [MEDICATION NAME] was due to be applied and the old one removed. The Licensed Practical Nurse (LPN) medication nurse was observed removing the old [MEDICATION NAME]. When the LPN removed the [MEDICATION NAME] there was no other nurse present as a witness. The LPN then proceeded to the hallway to call a Registered Nurse (RN) Supervisor to observe the discarding of the patch. Review of the MAR for (MONTH) (YEAR) revealed for the order Witness Nurse Must Document Removal of [MEDICATION NAME] Patch, the witness nurse initials are present every 3 days, including the RN supervisor's initials for Oct. 30, (YEAR); however, the RN supervisor did not witness the removal of the patch. Included in this physician's orders [REDACTED]. For the month of (MONTH) (YEAR) there is only one documentation for the site on [DATE] and one documention for the dosage on Oct. 24. On 11/1/2017 at 9:27 AM the RN supervisor that documented as being the witness nurse to the removal of the patch on Oct. 30, (YEAR) was interviewed. She stated that the intent of the order is to witness the discarding of the patch, not the removal. She stated that when she documented her initials in the MAR indicated [REDACTED]. On 11/1/2017 at 1:54 PM the Director of Nursing Services (DNS) was interviewed. She stated that a nurse can witness the removal of the patch, but the intent is that the discarding of the the patch is documented. She stated that the order to witness the removal of the patch is created automatically by the computer when the [MEDICATION NAME] is ordered. On 11/1/2017 at 2:19 PM the unit RN Charge Nurse where Resident #21 resides was interviewed. This nurse had documented her initials as witnessing the removal of the patch in the (MONTH) (YEAR) MAR indicated [REDACTED]. 24, and Oct. 27. For Oct. 18 she documented right chest for the site of the patch; there was no site documented for Oct. 24 or Oct. 27. She stated that sometimes, time permitting, she observes the removal of the patch. She stated that the site of the patch can be added manually in the computer. On 11/2/2017 at 9:39 AM the Attending Physician was interviewed. She stated that the order to witness the removal of the patch is created automatically by the computer when the [MEDICATION NAME] is ordered. She stated she thinks the intent of the order was just to document that a nurse witnessed the patch being discarded. She stated that the Policy and the EMR system can be revised to clarify the responsibilities of the witness nurse. 415.11(c)(3)(ii)

Plan of Correction: ApprovedNovember 20, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1-WHAT CORRECTIVE ACTION(S) WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE?
? The nurses involved with Resident #21 were educated on the importance of following the order exactly as written.
? The Sigma order set for Resident #21 for [MEDICATION NAME] ([MEDICATION NAME]) Patches will be revised to have the second nurse witness the removal and disposal of the [MEDICATION NAME] ([MEDICATION NAME]) patch.
? The Sigma order set for Resident #21 for [MEDICATION NAME] ([MEDICATION NAME]) Patches will also have a mandatory hard stop for the nurse to include the site and dose.

2- HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN?
? An audit of all residents who currently have an order for [REDACTED].
? All current order sets for a [MEDICATION NAME] ([MEDICATION NAME]) Patch were discontinued, and replaced with the revised Sigma order set. This includes a second nurse to witness the removal and disposal of the [MEDICATION NAME] ([MEDICATION NAME]) patch and documentation of the site and dose.
? The revised order set was completed as of 11/20/17 and 100% of residents who currently have an order for [REDACTED].

3-WHAT MEASURES WILL BE PUT IN PLACE OR WHAT SYSTEMIC CHANGES YOU WILL MAKE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT (NAME)CUR?
? The Sigma order set for [MEDICATION NAME] ([MEDICATION NAME]) Patches will be revised to have the second nurse witness the removal and disposal of the [MEDICATION NAME] ([MEDICATION NAME]) patch.
? The Sigma order set for [MEDICATION NAME] ([MEDICATION NAME]) Patches will also have a mandatory hard stop for the nurse to include the site and dose.
? The [MEDICATION NAME] ([MEDICATION NAME]) Policy was reviewed and revised to include the second nurse to witness the removal and disposal of the [MEDICATION NAME] ([MEDICATION NAME]) patch, as well as to document the site and dose.
? All nurses will be in-serviced on the revised policy.

4-HOW THE CORRECTIVE ACTION(S) WILL BE MONITORED TO ENSURE THE DEFICIENT PRACTICE WILL NOT RECUR, ie., WHAT QUALITY ASSURANCE PROGRAM WILL BE PUT INTO PRACTICE?
? An audit of 100% of any new orders for a [MEDICATION NAME] ([MEDICATION NAME]) patch will be reviewed monthly for the first quarter, then quarterly for the next three quarters, and then randomly thereafter to ensure that all residents have the order correctly placed in Sigma, and that there are two nurses? signatures documented in the MAR for the removal and disposal of the [MEDICATION NAME] ([MEDICATION NAME]) patch, site and dose. The results of this audit will be forwarded to our PICG monthly. Any issues/concerns will be reported to the DON and Administrator and will be corrected immediately.
5-RESPONSIBLE PERSON- Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2017
Corrected date: December 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and documentation review during the recertification survey, the facility did not demonstrate a testing and maintenance program for patient care related electronic equipment (PCREE) on the resident units in 1 of 2 resident buildings. Additionally, the facility did not provide evidence for the inspection of a resident personal electronic device. The findings include: During the Life Safety Code survey on 10/20/17 between 10:00am and 3:00pm, the facility did not provide evidence of the testing and maintenance for the mattress pumps, oxygen concentrators, and a wheel chair charger in the resident rooms and use areas in the Broadlawn Building. Various PCREE's, and a resident personal electronic device were missing inspection stickers. Examples included the following: 3rd floor: - a mattress pump in resident room [ROOM NUMBER]. - a wheelchair charger in resident room [ROOM NUMBER] - a mattress pump in resident room [ROOM NUMBER] 2nd floor: - an oxygen concentrator in resident room [ROOM NUMBER] - an oxygen concentrator in use near resident room [ROOM NUMBER] - a mattress pump in resident room [ROOM NUMBER] In an interview on the same day at approximately 11:00am, the Director of Engineering stated that the identified mattress pumps and oxygen concentrators are rental equipment, and that he would check with the rental company for the testing and maintenance records. He further stated that the facility contracted an outside company for the testing/maintenance of the other PCREE's in the building and that he would immediately contact them to test/maintain the equipment in question. He also stated that he would have the maintenance person inspect the wheelchair charger for safety. The testing/maintenance records for each of the identified mattress pumps and oxygen concentrators were not provided at the conclusion of the survey. 2012NFPA101 2012NFPA 99 NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedNovember 20, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
All items were inspected and given inspection stickers.
Mattress Pump for room [ROOM NUMBER], 333 and 235 were inspected by Hill-Rom and proper tag was placed on pump.
Oxygen Concentrator for room [ROOM NUMBER] and 238 were inspected by New York Home Health Care and proper tag was placed on the concentrator.
The wheelchair charger in room [ROOM NUMBER] was inspected by engineering staff and proper tag was placed on the charger.
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken
A full house audit will be conducted of all mattress pumps, oxygen concentrators and wheelchair chargers to ensure proper inspection and tags are in place. Any issues discovered will be corrected immediately and reported to the Director of Engineering and the Administrator.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur
Reviewed and revised the Patient?s Personal Electric Equipment Policy to reflect that a work order is submitted to the Engineering department prior to using personal electric equipment.
All nursing staff, engineering and materials management staff will be educated on the Patient?s Personal Electric Equipment policy to ensure a work order is submitted to the engineering department for proper inspection and tagging prior to use.
Reviewed and revised the Medical Equipment Management Plan Policy to reflect the addition of Hill-Rom and NY Home Health Care for incoming electrical inspections.
The materials management and engineering departments were educated on the Medical Equipment Management Plan policy to ensure all medical devices have proper inspection and tagging prior to use.
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice
100% of patient electrical devices and patient use medical equipment will be reviewed to ensure current inspection and appropriate tags are in place. The results of this audit will be presented at our PICG quarterly for one year and then randomly thereafter. Any issues/concerns will be reported to the Director of Engineering and the Administrator and will be corrected immediately.
5. Responsible Party
Director of Engineering