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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 7, 2025
Corrected date: March 8, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey dated 04/22/2024 through 05/01/2024, the facility did not maintain an Emergency Preparedness Plan that was reviewed and updated at least annually. Specifically, updated copies of the plan were not maintained in the locations designated by the facility. This could affect all residents at the facility. This is evidenced by: The document titled, Emergency Preparedness Planning and Resource Manual, and updated 04/18/2024 states that copies of the Emergency Management Plan are to be distributed to the Director of Nursing, Assistant Director of Nursing, Maintenance Director, Housekeeping Director, nursing units, and front desk. During an interview on 05/01/2024 at 9:45 AM, Front Desk receptionist #1 stated that they did not have a copy of the emergency plan, but a copy was supposed to be at the Front Desk. During an interview on 05/01/2024 at 9:50 AM, Maintenance Director #1 stated that they did not have a copy, but they are supposed to have a copy of the emergency plan. During an interview on 05/01/2024 at 9:52 AM, Housekeeping Director #1 stated that they did not have a copy of the emergency plan. During an interview on 05/01/2024 at 10:05 AM, Director of Nursing #1 stated that they and the Assistant Director of Nursing did not have a copy but are supposed to have a copy of the emergency plan. During an interview on 05/01/2024 at 1:33 PM, Administrator #1 stated that copies of the emergency plan should had not been distributed to the Director of Nursing, Assistant Director of Nursing, Maintenance Director, Housekeeping Director, nursing units, and front desk. 42 Code of Federal Regulations 483. 73mattress was on and functioning. The resident was rolled to the left, no dressing was in place on the sacrum. The wound was approximately 1 centimeter x 1 centimeter x 0. 1 centimeters with granulation tissue. Per Licensed Practical Nurse Manager #1, the dressing was removed just prior to the wound physician evaluation. Licensed Practical Nurse Manager #1 cleansed the wound, placed [MEDICATION NAME] and calcium alginate cut to size into the wound bed and covered with a bordered dressing. During a telephone interview on 12/31/2024 at 10:16 AM, Licensed Practical Nurse Manager #1 stated when a resident had weight loss, nursing was responsible to update the registered dietitian. The registered dietitian also had access to weights in the medical records. When a resident developed a new pressure ulcer, the registered dietitian would be notified. For weight loss and pressure ulcers, the registered dietitian typically assessed with [REDACTED]. During a telephone interview on 1/2/2025 at 12:57 PM, Registered Dietitian #9 they stated if a resident lost weight they became notified during the high-risk meeting held every week. If a resident had a significant weight loss of 5 or more pounds, the unit Manager notified them. They would then assess the resident, write a note, and possibly add more calories and protein. They typically assessed weight loss as soon as they were notified. The unit Manager was also responsible to notify them of new wounds. They would assess as soon as they were notified, write a note, and possibly add interventions. They first became aware the resident had a new pressure ulcer around 12/20/2024 when they did their assessment. The resident was already on several supplements however they switched one of the supplements for 2 Cal which was higher in protein and calories. They stated they should have been notified sooner for assessment and their assessment was not timely. They stated they addressed the resident's weight loss in their 12/20/2024 note, they could not recall if they were notified, and the assessment was not done timely. During a telephone interview on 1/7/2024 at 1:37 PM, the Director of Nursing stated nursing should be looking at weights when they were obtained and if significant loss was noted, nursing should notify the registered dietitian. Nursing should also notify the registered dietitian for new pressure ulcers. They expected the registered dietitian to assess weight loss in 2 weeks and new pressure ulcers within a couple of days. They were not aware Registered Dietitian #9's assessment for weight loss took 11 days and that was not timely. When it took Registered Dietitian #9 two and a half weeks to reassess the resident's nutritional needs after they developed a new pressure ulcer, it was not done timely. 10NYCRR 415. 12(c)(1) | Plan of Correction: ApprovedFebruary 3, 2025 1. Residents #1 and #3 are no longer residents of the facility. The nurse managers for residents #1 and #3 were provided written education for not following the facilities policy in regard to orders management/transcriptions and weight loss. The dietician was also provided written education on the facility weight loss and wound management policy. 2. A facility wide audit was completed on 12/20/2024 of all residents' weights, any identified weight loss was confirmed with a reweight and communicated via documentation in the resident records to the medical provider, dietitian, and then reviewed with MDS. There were no other residents identified with unaddressed weight loss, finding no other residents having been impacted by the deficient practice. 3. A facility wide audit was conducted on 12/06/2024 that included a head-to-toe skin check on all residents to identify skin issues that may have not been documented or with wound care orders, this includes an audit of all residents being followed by an outside wound care service, ensuring that all orders from the most recent visit were transcribed as written. The audit identified that no other residents were impacted. 4. The facility medical orders management policy (#6011) was reviewed, finding it to be appropriate and not followed by staff resulting in deficient practice. The facility weight policy (#8220) was reviewed, found to be appropriate and not followed by staff, resulting in the deficient practice, the skin management policy (#8162) was reviewed and revised to clarify nurse managers expectations of: * following resident active wounds by documenting the results of the visit in the residents' record and notifying the medical provider and dietitian. *the required immediate review of the outside wound consultants visits to include transcribing the consultant orders the same day as the visit. *Add a progress note acknowledging that they completed the transcriptions, documentation, and in house medical/dietitian notification of the visit. 5. Education has been given to the nurse managers and DON on medication orders management/transcriptions, consult visits, weight changes, and skin management policy updates. 6. The DON is completing weekly audits while holding a weekly skin and weight meeting with MDS, nurse managers, and the dietitian present. The audit includes: A. Keeping a running list of all active wounds in the facility on a spreadsheet B. Checking that all wound orders including consultant visits for the residents are present and correct weekly on the spread sheet. C. Checks that the care plans are present and appropriate for all active wounds. D. Ensures dietitian and medical notifications are present in the record from the nurse managers. E. That the dietitian has completed a resident assessment within 72 hours of any new wounds or confirmed weight loss and that recommended supplements are ordered as found appropriate. 7. The deficiency will be brought to the next QAPI meeting and reviewed with the committee, the weekly audit results will also be brought to the monthly QAPI meeting until 90 days of 100% compliance is obtained. The weekly skin and weight meeting with the IDT will remain indefinitely as a new facility process to ensure continued compliance. 8. Weekly audit of all dietitian notes will be pulled and reviewed at the weekly wound and weight management meeting and brought to QA to ensure compliance that resident assessment was completed within 72 hours of any new wounds or confirmed weight loss. After 4 weeks we will move to monthly audits x 3 months. Then review with QAPI to determine the frequency going forward. 9. The DON/designee is responsible for the completion and compliance of this plan. |