Monroe Community Hospital
February 7, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.10(a)(1):DIGNITY AND RESPECT OF INDIVIDUALITY

REGULATION: (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident?s individuality. The facility must protect and promote the rights of the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2017
Corrected date: April 4, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for one of four residents reviewed for dignity and 1 of 11 dining rooms observed during the noon time meal, the facility did not provide care in a manner that enhanced the residents' dignity. The issues involved incomplete covering of a resident during care, a nursing call system out of reach (Resident #626) and staff standing over residents during meals while assisting with feeding (Residents #241, #568, and #626). This is evidenced by the following: 1. Resident #626 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 12/27/16, documented that the resident is cognitively intact. The Comprehensive Care Plan, last updated 1/26/17, revealed that the resident is dependent for all aspects of bathing, dressing, grooming, and feeding. Interventions included to promote dignity and independence in care, the use of a sip and puff (an assistive technology used to send signals to a device using air pressure by sipping (inhaling) or puffing (exhaling) on a straw, tube or wand) attached to the wheelchair, and a sip and puff call light within reach when unattended. The Certified Nursing Assistant (CNA) Care Card, dated 2/3/17, included that the resident is a total assist with bathing, grooming, and meals. The resident is to have a sip and puff call bell system nearby so he can call for help as needed and a sip and puff to propel his wheelchair. When interviewed on 2/1/17 at 2:21 p.m., the resident said he cannot move and he relies on staff to feed him and clean him. He said that they leave him naked when they are washing him and that he wants privacy. He said he does not want his privates hanging out. The resident said the facility has taken away his dignity and he cries every day because of the level of care he is provided. During an interview on 2/2/17 from 3:45 p.m. to 5:00 p.m., the resident informed the Registered Nurse Manager (RNM) that the CNAs leave him completely naked and exposed when washing him. During an observation on 2/3/17 at 9:01 a.m., the resident was in bed in the middle of his morning care and had a small towel covering his groin area and his hips were exposed. There was another small towel just above it exposing his chest and all extremities. When the resident was turned onto his right side, his entire backside was exposed. The resident's eyes were closed through the entire bath. When interviewed at that time, the CNA said she was not using a bath blanket because it had gotten wet. At 9:40 a.m., CNA #1 returned to the room to feed the resident. CNA #1 was standing over the resident while feeding him. The resident's head was looking downward. After CNA #1 left the room, the resident said the staff stand over him to feed him all the time. He said he kept his eyes closed throughout the bath because it is embarrassing lying naked and exposed. When interviewed on 2/3/17 at 10:02 a.m., CNA #1 said she did not think that using two towels was a problem to cover the resident. She said she asked the resident in the past if it was ok. CNA #1 said she was supposed to use a bath blanket or sheet to cover the parts of the resident that was not being washed. She said the resident said it was ok. CNA #1 said that she did not think the resident was covered appropriately when he was repositioned on his side, exposing his entire backside. CNA #1 said she should not be standing up while feeding the resident but the resident does not mind. When interviewed on 2/7/17 at 8:59 a.m. and 12:56 p.m., the RNM said that staff are instructed to sit when feeding residents. She said the resident does not like staff sitting to feed him because the tilt-in space chair is so high. The resident is tall and he does not like to be feed upward and prefers to be fed at the same height. During care, residents should have as much covered as possible. She said only the part of the body being washed should be exposed while the rest of the body should be covered using a bath blanket or towel. The RNM said that the resident never shared with her that staff are not maintaining coverage or felt he was being treated undignified. She said she goes into the resident's room everyday. During an observation and interview on 2/7/17 at 1:14 p.m., the resident was located in his room in his wheelchair with his back to the door. The sip and puff wand used to navigate the wheelchair was attached to the wheelchair but was not in reach. The resident said he could not reach it and did not have his call bell to call for help. The call bell was located inside the bathroom attached to the tray table. The resident said he had no way of calling or obtaining assistance. When asked if he could reach the sip and puff wand, the resident attempted and said he could not. The surveyor asked the resident if he minded when the staff fed him while standing up. He responded, Who in their right mind would like to be fed that way? At that time, the RNM was asked to come to the room and was asked to locate the call bell. The RNM located the call bell in the bathroom and placed it near the resident and said it should be next to him on the tray table. The RNM said to the resident, But you can wheel out if you needed something. The resident said he could not because the sip and puff wand slipped out of his mouth and the wand was not staying near his mouth so he could reach it. The RNM attempted to adjust the wheelchair sip and puff wand but was unable to have it stay near the resident's mouth. She said she would call therapy to adjust it. 2. During an observation of lunch on 2/1/17 at 12:32 p.m. in the Friendship 3 West dining room, CNA #3 was observed going back and forth between Resident #568 and Resident #241 to feed them while standing. At 12:41 p.m., the RN Assistant Nurse Administrator was observed entering the dining room and placed a chair next to Resident #241. CNA #3 continued to feed Resident #568 while standing but sat down to finish feeding Resident #241. CNA #3 did not have any difficulty reaching Resident #241 to feed him. Review of the CCP and CNA Care Card for both residents revealed they are dependent upon staff for assistance with meals and are not care planned to be fed by staff standing up. Review of the MDS Assessment for both residents revealed that they are severely cognitively impaired. Interviews conducted on 2/7/17 included the following: a. At 11:26 a.m., the RNM said that she expects staff to sit down and interact with residents while they are feeding them. She said she does not currently have any residents that are care planned to be fed with staff standing up. The RNM said that if staff stand to feed residents it can make the residents feel rushed, it is a dignity issue. b. At 12:07 p.m., the RN Assistant Nurse Administrator stated that she is not sure whether a resident should be care planned to be fed with staff standing up. She said if residents are fed standing up it can make the resident feel rushed and uncomfortable. (10 NYCRR 415.5(a))

Plan of Correction: ApprovedMarch 17, 2017

F 241 483.10(a)(1)
In direct response to the questions listed in the correspondence/letter from NYSDOH dated (MONTH) 21, (YEAR), and received by the Facility via DOH HCS Portal link transmittal on (MONTH) 21, (YEAR) along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Staff assigned to Resident #626 will be required to participate in in-service training that will (1) discuss the proper way to position both the resident?s sip and puff devices used to direct his wheelchair and to summon staff, (2) proper use of a bath blanket to insure dignity during personal care, and (3) determining the resident?s preference when being fed (C.N.A. stands or sits). In the case(s) of Residents 568 and 241 the residents? preference for being fed will also be determined. Two of the three residents in question are taller and tend to sit high in their chars. These residents have in the past requested to be fed by a C.N.A. in a standing position. Once all preferences are determined the residents? plans of care will be revised accordingly.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any resident who utilizes a sip and puff or any resident who is fed while the C.N.A. is standing has the potential to be affected. Any resident has the potential to be affected by a failure to properly cover the resident during personal care.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
In the case of Resident #626 the Facility will (1) provide in-service training to applicable staff regarding dignity and the proper use of a bath blanket, (2) determine the resident?s preference regarding being fed and do so accordingly, and (3) instruct the C.N.A. assigned to the Resident to check his sip and puff devices during every round. The licensed unit nurse will also verify sip and puff placement at least one time per shift. Residents 568 and 241 will be assessed for feeding preference and fed accordingly. Care plans will be revised for all three residents where applicable. The Facility will also develop a once per shift monitoring requirement for any resident who utilizes a sip and puff device. In-service will be provided to applicable nursing staff on (1) maintaining dignity during the provision of care, (2) proper feeding technique, and (3) the placement of sip and puff devices.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Quality Assurance Coordinator shall appoint one person who shall be responsible to verify the sip and puff monitoring to be performed by the unit nurses. Such verification shall occur weekly for one month and monthly thereafter. The QA Coordinator shall appoint a Committee of at least three persons who shall monitor meal times and identify any residents who are fed by C.N.A.?s who are in standing positions. Unless stipulated in the resident?s plan of care these instances will be reported to the Assistant Director of Nursing for remediation. The QA Coordinator shall assign the appropriate Nurse Manager to verify that Resident #626 is receiving personal care in a dignified fashion. Such verification should occur daily for one week, weekly for one month, and monthly thereafter. All results of monitoring shall be reported to the Quality Assurance Committee at the regularly scheduled meeting following the completion of the monitoring.
5. The date for correction action and the title of the person responsible for correction of this deficiency:
April 4, (YEAR)
Director of Nursing

FF10 483.45(b)(2)(3)(g)(h):DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

REGULATION: The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-- (2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2017
Corrected date: April 4, 2017

Citation Details

Based on observations, interviews, and record reviews, it was determined that for six of ten residential units reviewed for medication storage, the facility did not ensure that all drugs and biologicals were securely stored in accordance with State and Federal laws. Issues involved unlocked, unsupervised medication carts on residential units Hope 2, Hope 3, Hope 4, and Faith 5; undated medications stored and in use on the residential unit Friendship 2 East, and narcotic reconciliation sheets signed prior to a medication count on the residential unit Friendship 2 West. This is evidenced by, but not limited to, the following: In an observation on 2/1/17 at 9:15 a.m., a medication cart was observed on residential unit Hope 4 that was left unlocked and unattended in the hallway in front of a resident's room. All of the drawers could be opened and contained multiple medications for approximately 20 residents. In addition, there were two vials of insulin on top of the cart, each were inside of a clear plastic specimen cup. After two minutes, Licensed Practical Nurse (LPN) #1 returned to the medication cart at 9:17 a.m. She said she was in the resident's room, but was not in sight of the medication cart. She said there is a resident on the floor that wanders and she should have locked the cart. Observations and interviews conducted on 2/6/17 included the following: a. At 9:11 a.m., Registered Nurse (RN) Manager #1 said that the medication carts should be locked if the cart is out of the nurse's sight. She said she knows that pills cannot be left on top of an unattended cart but she was not sure if it was ok to leave other medications like insulin. b. At 9:24 a.m., the RN Assistant Director of Nursing said she expects nurses to lock the medication cart if it is unattended and out of their sight. She said the nurses should be sure that medications are not left on top of an unattended cart. She said she has seen insulin vials left on the top of the medication carts if they are inside a specimen cup, but they should be put away as soon as possible. c. At 2:04 p.m., the medication storage cart on Friendship 2 East contained a vial Humalog insulin that was open and in use but not dated. When interviewed at that time, LPN #2 said the vial should have been dated when it was opened because they have to be discarded after 28 days. Additionally, a vial of Lantus was dated opened 1/8/17. LPN #2 said that should have been discarded the previous day. d. At 2:19 p.m. on the Friendship 2 West residential unit, the narcotic reconciliation shift to shift count sheet was signed for the 3:00 p.m. count with the evening shift. When interviewed at that time, LPN #3 said he had signed that space in the morning by mistake and should not have signed it until after he counted narcotics with the evening shift. When interviewed on 2/7/17 at 8:10 a.m., RN Manager #2 stated that the LPN should not have signed the shift to shift narcotic reconciliation sheet until after the count was completed. (10 NYCRR 415.18(d)(e)(1-4))

Plan of Correction: ApprovedMarch 2, 2017

F431 483.45(b)(2)(3)(g/h)
In direct response to the questions listed in the correspondence/letter from NYSDOH dated (MONTH) 21, (YEAR), and received by the Facility via DOH HCS Portal link transmittal on (MONTH) 21, (YEAR) along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
As no resident was identified or specified on the CMS 2567 the question is not applicable.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any resident has the potential to be affected by an outdated medication.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Facility will provide in-service to all applicable licensed nursing personnel regarding (1) locking of medication carts when not in sight, (2) storage of outdated drugs or biologicals, and (3) proper procedures for signing off narcotic reconciliation sheets. Once presented, the Facility will begin to monitor the three problematic areas of concern to insure that carts are properly locked, narcotic sheets are signed off properly, and drugs and biologicals are stored properly. Any medication discovered outdated during the monitoring shall be given to the pharmacist for immediate disposal. The nurses in question (unlocked cart, improper narcotic sheet) will be presented with disciplinary action in accordance with the Facility?s Employee Code of Conduct.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Quality Assurance Coordinator shall appoint a committee of three persons who shall (1) monitor med carts to verify they are properly locked when unattended, and (2) check narcotic reconciliation sheets to verify their proper completion. A second committee shall be appointed, one of whom shall be a pharmacist, that will monitor medication storage areas for outdated drugs and biologicals. Outdated items will be removed immediately. Monitoring shall occur weekly for one month, monthly for two months, and quarterly thereafter. Monitoring results will be presented to the Quality Assurance Committee at the regularly scheduled meeting subsequent to the monitoring.
5. The date for correction action and the title of the person responsible for correction of this deficiency:
April 4, (YEAR)
Director of Nursing

FF10 483.60(i)(1)-(3):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: (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. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2017
Corrected date: April 4, 2017

Citation Details

Based on observations, interviews and record reviews, it was determined that for one of one main kitchen, the facility did not prepare food in a sanitary manner. Specifically, food was found hot holding below 140 degrees Fahrenheit (F). This is evidenced by the following: Observations conducted on 2/6/17 starting at approximately 11:29 a.m. revealed three pans of pork loin hot holding in a hot holding oven for use in the Cafeteria. The first pan of pork loin was found hot holding between 119F - 122F. The second pan was hot holding at 118F. The third pan was a small pan containing six pieces of pork loin found hot holding at 110F. In an interview at that time, the Executive Chef stated that the pork was cooked to 170F and then pulled from the oven and sliced. He said the pork was placed into hot holding approximately 40 minutes ago. When checked, the hot holding oven thermometer showed that the oven was holding at approximately 250F. In an interview on 2/6/17 at approximately 12:00 p.m., Cook #1 stated that once the pork loin was cooked it took about 15 minutes to get it sliced and get it into the hot holding unit. A review of the facility Policy #B017 Food Handling Guideline revealed that the company's policy for hot holding is 140F. In an interview on 2/7/17 at 10:40 a.m., the Food Service Director stated that residents on that program (Meal Voucher) can get meals out of the cafe, Monday to Friday, any meal--breakfast, lunch, dinner. The Meal Voucher list revealed that there were 58 residents who participate in the meal voucher program. (10 NYCRR 415.14(h))

Plan of Correction: ApprovedMarch 17, 2017

F371 483.60(i)(1)-(3)
In direct response to the questions listed in the correspondence/letter from NYSDOH dated (MONTH) 21, (YEAR), and received by the Facility via DOH HCS Portal link transmittal on (MONTH) 21, (YEAR) along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
As no resident was identified or specified on the CMS 2567 the question is not applicable. It should be noted, however, that the food in question was discarded immediately and none was served.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any resident has the potential to be affected by food that is not held at the proper temperature.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The facility maintenance staff will check the hot holding pan cabinet to insure it is in proper working order. Once working order is verified, the Facility will conduct daily temperature checks of cafeteria hot holding pans to insure the temperature is maintained at 140 degrees. Dietary staff shall be provided in-service training regarding the importance of holding pan temperatures.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Quality Assurance Coordinator shall be responsible for monitoring and verifying that Dietary Staff has conducted holding pan temperature checks in a timely manner and that holding temperature coincide with Facility policy (140 degrees). Such monitoring shall occur weekly for one month and monthly thereafter. Monitoring results will be presented to the Quality Assurance Committee at the regularly scheduled meeting subsequent to the monitoring.
5. The date for correction action and the title of the person responsible for correction of this deficiency:
April 4, (YEAR)
Director of Food & Nutrition

FF10 483.80(a)(1)(2)(4)(e)(f):INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: (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: (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 (facility assessment implementation is Phase 2); (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. (4) A system for recording incidents identified under the facility?s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (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: February 7, 2017
Corrected date: April 4, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews, it was determined that for one (Resident # 626) of one observation of care, proper infection control techniques were not followed. Issue involved the lack of appropriate glove changing and handwashing during personal care and hygiene. This is evidenced by the following: Resident # 626 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/27/16, documented that the resident requires total assistance for all cares. During an observation of personal care and hygiene on 2/3/17 at 9:01 a.m., the CNA donned gloves and washed the resident's peri-rectal area. She then turned the resident to the right side and continued to wash the resident's buttock and back, placing a pink soaker pad and clean brief under the resident. Without removing her gloves, the CNA applied a white barrier cream on the resident's buttocks, then wiped her gloved hands on the clean brief, applied hydrofore (petroleum based ointment) from a jar to the resident's back, dressed the resident, touched the closet and bathroom door handles, applied the lift sling, put the resident's shoes on and then removed her gloves. When interviewed on 2/3/17 at 10:02 a.m., the CNA said she was aware that she did not remove her gloves during the morning care procedures. The CNA said she should have changed her gloves. Interviews conducted on 2/7/17 included the following: a. At 10:19 a.m., the Infection Control Nurse said the CNA should have removed her gloves and washed her hands instead of wiping them on the brief. b. At 12:56 p.m., the Registered Nurse Manager said she would have expected the CNA to change gloves after applying the barrier cream to the resident's buttocks. The facility policy, Handwashing/Hand Hygiene, dated (MONTH) (YEAR), directed to wash hands after routine resident care activities involving direct resident contact. (10 NYCRR 415.19(b)(4))

Plan of Correction: ApprovedMarch 2, 2017

F441 483.80(a)(1)(2)(4)(e)(f)
In direct response to the questions listed in the correspondence/letter from NYSDOH dated (MONTH) 21, (YEAR), and received by the Facility via DOH HCS Portal link transmittal on (MONTH) 21, (YEAR) along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The C.N.A. who provided care on the day in question will be required to undergo remedial education to insure hand washing/glove changing techniques are understood. A general in-service will also be given to staff regarding hand washing and glove changing.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any resident has the potential to be affected by a failure to properly change gloves while providing care.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Facility will provide in-service to all applicable nursing staff regarding hand washing and proper glove technique. The C.N.A. in question will undergo remedial education. Staff will be randomly observed to insure proper infection control measures are being taken regarding hand washing and changing gloves.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Quality Assurance Coordinator shall appoint a committee of three persons who randomly monitor hand washing and glove changing techniques. The individual C.N.A. in question shall be able to demonstrate knowledge regarding the proper technique(s) upon the completion of remedial education. Monitoring shall occur weekly for one month, monthly for two months, and quarterly thereafter. Monitoring results will be presented to the Quality Assurance Committee at the regularly scheduled meeting subsequent to the monitoring.
5. The date for correction action and the title of the person responsible for correction of this deficiency:
April 4, (YEAR)
Director of Nursing

FF10 483.10(i)(7):MAINTENANCE OF COMFORTABLE SOUND LEVELS

REGULATION: (i)(7) For the maintenance of comfortable sound levels.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2017
Corrected date: April 4, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for three (Residents #69, #288, and #344) of four residents reviewed for comfortable sound levels on Friendship 2 West, the facility did not ensure comfortable sound levels. Specifically, residents complained that staff were loud and disruptive in the hallways. This is evidenced by the following: Resident #344 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 12/15/16, revealed that the resident's cognition is moderately impaired and has adequate hearing. The Registered Nurse Manager (RNM) identified the resident as interviewable. Resident #69 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/18/16 revealed that the resident's cognition is intact, and has adequate hearing. Resident #288 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/25/17, revealed that the resident's cognition is moderately impaired, and has adequate hearing. The RNM identified the resident as interviewable. Observations conducted on 2/6/17 on Friendship 2 West included the following: a. At 1:38 p.m. to 2:38 p.m., a Certified Nursing Assistant (CNA) was observed exiting Resident room [ROOM NUMBER] and yelling to the Unit Clerk who was seated at the nurses' station (past several resident rooms, approximately 50 feet) that she needed assistance with a transfer. The Unit Clerk yelled back that she would get someone and then paged for CNA assistance. When interviewed at that time, the Unit Clerk said that it was common practice for the CNAs to yell down the hallway. b. At 2:27 p.m., a Licensed Practical Nurse (LPN) was heard yelling down the hallway past two residents' rooms (approximately 30 feet) to the Unit Clerk who was seated at the nurses' station, and was then heard talking loudly to a family in the hallway. c. At 2:38 p.m., the same LPN was observed yelling down the hallway past two resident's rooms, the shower suite, and the nurses' station (approximately 75 feet) to a staff member pushing a stretcher with a resident on it and said, Hey, how are you doing? When interviewed on 2/2/17 at 10:30 a.m. and on 2/7/17 at 8:41 a.m., Resident #344 said it is especially noisy during change of shift, and during lunch and supper because the staff yell back and forth. The resident said he also hears the staff yelling for assistance with transfers. Interviews and observations conducted on 2/7/17 included the following: a. At 8:48 a.m., Resident #69 was wearing headphones to watch television. When interviewed at that time, she said she uses the headphones to help block out the noise. She said it is noisy with staff yelling down the hallway to each other. b. At 8:54 a.m., Resident #288 said that the night staff talk, laugh, and carry on all night keeping him awake. He said during the day and evening shifts the staff stand outside the resident rooms and yell down the hallway. He said there is a male nurse who is very loud even when he is just talking. The resident said he did not report this to the RNM or Social Worker recently because when he does report things, nothing happens or changes. Resident #288 said he did go to the Administrator about the noise and nothing has changed. He said he requested to be moved to a room away from the nurses' station because of the noise but that has not happened yet. c. At 9:05 a.m., the RNM said that normally the complaints she receives about noise are that a roommate's television is too loud or that the off shifts (evenings and nights) are too loud. She said that in (MONTH) (YEAR), Resident #288 requested a room change because of noise but there was no private room available. She said she spoke to the staff about the noise in (MONTH) or (MONTH) and the resident has not complained since. The RNM said she has noticed CNAs yelling down the hallway to the Unit Clerk for assistance. She said she has spoken to staff about the noise in the past. (10 NYCRR 415.5(h)(5))

Plan of Correction: ApprovedMarch 2, 2017

F 258 483.10(l)(7)
In direct response to the questions listed in the correspondence/letter from NYSDOH dated (MONTH) 21, (YEAR), and received by the Facility via DOH HCS Portal link transmittal on (MONTH) 21, (YEAR) along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Staff assigned to Friendship 2 West will be required to undergo extensive in-service training designed to (1) recognize unacceptable noise levels, and (2) take appropriate action to maintain noise at acceptable levels.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any resident could be affected by unacceptable noise levels. Facility staff will interview (those who are interviewable) the rest of the residents on Friendship 2 West to determine the full extent of the unit noise concerns. The Facility will also review its records to determine if other complaints of noise levels have been received about other units of the building.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The facility will analyze the noise levels on Friendship 2 West (and any other applicable unit) and develop a strategy to minimize noise to acceptable levels. Consideration will be given to issues that include, but are not necessarily limited to (1) noise from televisions, radios, etc., (2) noise from loud staff conversation or yelling down hallways, (3) excessive noise on the night shift, (4) noise at meal time, and (5) noise at shift change time. A strategy will be developed to minimize noise levels. Staff will be provided in-service training regarding minimizing noise levels. Once the strategy is implemented the three residents identified in the resident sample as well as two others to be chosen will be periodically surveyed to evaluate the noise levels.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Quality Assurance Coordinator shall appoint a Committee of three persons who shall be responsible for monitoring noise levels on Friendship 2 West (and any other applicable unit). Such monitoring shall initially be conducted for minimum periods of ten minutes three unannounced times per day for 10 business days. Said monitoring shall then occur three ten minute periods per week. The QA Coordinator shall also appoint at least one person to conduct interviews with the designated residents regarding noise levels. These interviews should occur weekly for one month and monthly thereafter. All results of monitoring shall be reported to the Quality Assurance Committee at the regularly scheduled meeting following the completion of the monitoring.
5. The date for correction action and the title of the person responsible for correction of this deficiency:
April 4, (YEAR)
Director of Nursing

FF10 483.10(g)(14):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)

REGULATION: (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2017
Corrected date: April 4, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during a Recertification Survey and complaint investigation (#NY 443), it was determined that for one (Resident #189) of four residents reviewed for abuse, neglect, and mistreatment, the facility did not notify the physician of the change in a resident's physical condition. Specifically, the physician was not notified of an incident resulting in a bruise. This is evidenced by the following: Resident #189 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/11/16, included that the resident's cognition is severely impaired, had no skin issues, and was not receiving an anticoagulant. The Comprehensive Care Plan (CCP), dated 12/16/16, included that the resident was at risk for skin breakdown due to a history of previous breakdown, diabetes, poor nutrition, history of [MEDICAL CONDITION] and has a history of skin tears related to fragile skin. Additionally, the resident is receiving aspirin and anticoagulants. The CCP does not include that the resident bruises easily or to monitor for bruising. Physician Orders, dated 12/17/16, included that the resident receives Aspirin 81 milligrams daily. The Certified Nursing Assistant (CNA) Care Card, dated 1/11/17, did not include any behaviors or skin issues. The Accident/Incident Report Form, dated 1/11/17, revealed that the resident had a bruise on the right lower arm and photos were taken by security. There was no description or measurements of the bruise. The report did not include that a medical provider was notified of the injury. The Investigative Report, dated 1/15/17, revealed that on 1/11/17, the resident was very upset with the evening shift CNA. She reported that the CNA mistreated her including pulling her hair and injuring her arm immediately after care was rendered. The resident does attend [MEDICAL TREATMENT] and receives anticoagulants and bruises very easily. The report did not include that a medical provider was notified of the injury. Progress Notes, the 24-hour report, and the Provider Communication Book did not include that a medical provider was notified of the incident or bruise. During an observation and interview conducted on 2/1/17 at 12:35 p.m., the resident said that a CNA pulled her to the floor and pulled her hair. She said it was a terrible thing. The resident showed the surveyor her right arm which had a reddened area around the forearm. Interviews conducted on 2/6/17 included the following: a. At 9:11 a.m., the Registered Nurse (RN) Manager said that bruise was a significant injury, appeared to be a grab mark, and the physician should have been notified of the injury. b. At 10:48 a.m., the Director of Nursing said that the resident had a suspicious bruise on the forearm and another bruise near the elbow. He said he would have expected the medical provider to be notified of the bruise at the time of the incident. c. At 11:46 a.m., the Nurse Practitioner said she was not aware of the bruise. She said she would have expected medical to be contacted at the time of the incident in order to assess the bruise. When interviewed on 2/7/17 at 8:47 a.m., the RN Evening Supervisor said he did not call the medical provider regarding the bruising. (10 NYCRR 415.3(2)(ii)(a))

Plan of Correction: ApprovedMarch 17, 2017

F 157 483.10(g)(14)
In direct response to the questions listed in the correspondence/letter from NYSDOH dated (MONTH) 21, (YEAR), and received by the Facility via DOH HCS Portal link transmittal on (MONTH) 21, (YEAR) along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Facility Nursing Staff shall complete an assessment of Resident #189 to insure her plan of care and MDS accurately reflect her fragile skin condition and anticoagulant therapy. A skin assessment shall also be performed to determine the presence of bruising (if any). Facility unit staff shall be provided in-service training regarding the importance of physician notification.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any resident who experiences a bruise that is not reported to the physician has the potential to be affected. The Facility shall conduct an audit of all incident reports indicating bruising from (MONTH) 1, (YEAR) to the present to insure the medical providers were notified.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Facility shall establish an audit procedure to insure that bruises have been properly reported to the medical provider. Incident reports (which reflect any time a bruise is discovered on a resident) shall be monitored to verify physician notification. In-service training shall be provided to both unit and supervisory nursing staff regarding the importance of proper and timely provider notification.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Quality Assurance Coordinator shall appoint a committee of at least two persons to conduct monitoring of daily incident reports to verify that bruising and other applicable situations have been properly reported to the physician. The results of the monitoring shall be reported to the Quality Assurance Committee at each regularly scheduled committee meeting subsequent to the completion of the monitoring. Reporting shall occur monthly for three months and quarterly thereafter.
5. The date for correction action and the title of the person responsible for correction of this deficiency:
April 4, (YEAR)
Director of Nursing

FF10 483.20(e)(k)(1)-(4):PASRR REQUIREMENTS FOR MI & MR

REGULATION: (e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: (1) Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident?s assessment, care planning, and transitions of care. (2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. (k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. (1) A nursing facility must not admit, on or after January 1, 1989, any new residents with: (i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services; or (ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission- (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability. (2) Exceptions. For purposes of this section- (i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital. (ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual- (A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital, (B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and (C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services. (3) Definition. For purposes of this section- (i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1). (ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter. (k)(4) A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2017
Corrected date: April 4, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, it was determined that for one (Resident #235) of one resident reviewed for Pre-Admission Screen Resident Review (PASRR), the facility did not provide a required Level II evaluation after hospitalization for a significant physical illness to determine the need for continued mental health services. This is evidenced by the following: Resident #235 has [DIAGNOSES REDACTED]. A Notice of Determination of the Need for Specialized Services/PASRR, dated 7/1/08, directs psychiatric evaluation within 14 days after admission or a written psychiatric plan of care, twice monthly initial follow-up by a mental health worker, and therapeutic group treatment at least once weekly. A Hospital and Community Patient Review Instrument (PRI), dated 10/22/10, revealed the resident had a hospital admission on 10/12/10 due to dyspnea (shortness of breath), probable exacerbation (increased severity of a disease or any of its signs or symptoms) of [MEDICAL CONDITION]. A SCREEN Form: Department of Health (DOH)-695 (2/2009), dated 10/29/10, included handwritten remarks: Replacement Screen, Do Not Thin, and unable to locate original. Additionally, Item 23 Level I Review for Possible Mental Illness (MI) is marked no and there is a handwritten note has [DIAGNOSES REDACTED]. Items 24, 25, and 26 are all marked no and the guidelines direct to proceed to Item 36 Patient/Resident/Person Disposition, which is a skip pattern for Categorical Determinations, which include evaluation for Level II Referrals. A SCREEN Form: DOH-695 (2/2009), dated 12/11/15, revealed that Item 23 is marked yes for having a serious mental illness. Items 24, 25 and 26 are marked no. The guidelines direct if item 23 or items 24-26 are marked yes proceed to Categorical Determinations. The Screener did not complete that section, and proceeded to Patient/Resident/Person Disposition. A Minimum Data Set Assessment, dated 1/13/17, documented the resident has a Level II PASRR for a serious mental illness, no cognitive impairments, and no [MEDICAL CONDITION], behavioral symptoms, rejection of care, or wandering. A Comprehensive Interdisciplinary Care Plan (CP), dated 1/24/17, for PASRR, includes approaches for a written psychiatric plan of care, twice monthly follow-up by a mental health worker, and therapeutic group treatment at least once weekly. The CP for Cognitive Losses/Behavior/Mood reveals the resident has an extensive history of psychiatric issues and that the PASRR indicates he requires mental health services of a lesser intensity, and he receives mental health services monthly. Interviews conducted on 2/2/17 included the following: At 3:09 p.m., a Social Worker (SW) said the resident is receiving mental health services but she did not know what specifically. When the surveyor asked the reason for the PASRR completion in 2010 and (YEAR), the SW said the (YEAR) PASRR had been done because, at that time, she had been unable to locate any PASRR in his chart. The SW said she would need to check if there was a hospitalization for psychiatric issues. Additionally, the SW said if it was determined by the facility that there was a change in required mental health services, she would contact the agency responsible for re-evaluating the resident for Level II services. She said the agency had actually been at the facility the day before to reevaluate residents for Level II services and had determined several residents no longer needed those services. Interviews conducted on 2/3/17 included the following: a. At 9:32 a.m., the SW said she had reviewed the medical record and back in 2010, this resident had been hospitalized for [REDACTED]. The SW said that a nurse from the local Psychiatric Center was currently visiting the resident on a monthly basis. The SW said the resident's original admission was in 2008 and the Level II completed then directed a psychiatric evaluation within 14 days after admission or a written CP; twice monthly follow up with mental health worker, and therapeutic group treatment. The SW said the resident is now stable, has a mental health worker, and attends facility activity programs. The SW said the resident's current CP revealed monthly mental health visits. b. At 3:19 p.m., a SW note to the surveyor revealed a mental health worker visits monthly and has done this for the past three years. c. At 3:42 p.m., the Director of Social Work (DSW) said a re-evaluation for Level II services had not been found and she would call the agency to see if they had one on file. During an interview on 2/6/17 at 11:21 a.m., the DSW said she had called IPR0, spoke with the Assistant Director (AD) of the agency who said the only Level II on file for this resident was from 2008. The DSW said she reviewed the scenario with the AD who said the resident required another Level II evaluation and she would start the process. The DSW said the SW would be submitting a PRI and all the other required forms for the Level II update. The facility did not have a Policy for PASRR/Level II. (10 NYCRR 415.11(e))

Plan of Correction: ApprovedMarch 2, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 285 483.20(e)(k)(1)-(4)
In direct response to the questions listed in the correspondence/letter from NYSDOH dated (MONTH) 21, (YEAR), and received by the Facility via DOH HCS Portal link transmittal on (MONTH) 21, (YEAR) along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The Facility has requested a new, updated PASRR for Resident #236. Once received, the Facility will revise the care plan to insure it corresponds to the PASRR recommendations.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any resident with a mental health [DIAGNOSES REDACTED].
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The facility will conduct an audit of all residents with a mental health [DIAGNOSES REDACTED]. The audit will verify whether the resident received a new PASRR at the time of acute hospitalization . If not, a new PASRR will be requested. The Facility will also conduct an audit to insure care plans correspond to PASRR recommendations. A PASRR policy regarding residents with mental health [DIAGNOSES REDACTED].
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Quality Assurance Coordinator shall appoint a Committee of three persons, one of whom shall be the Director of Social Work who shall serve as Chairperson, to conduct an audit of residents with mental health [DIAGNOSES REDACTED]. The audit will verify if (1) a new PASRR was generated at the time of an acute hospitalization , and (2) the care plan corresponds to recommendations made on the PASRR. Such monitoring shall occur once per year. Monitoring results will be presented to the Quality Assurance Committee at the regularly scheduled meeting subsequent to the monitoring.
5. The date for correction action and the title of the person responsible for correction of this deficiency:
April 4, (YEAR)
Director of Social Work

E3BP 402.5(c):REQUIREMENTS BEFORE SUBMITTING A REQUEST FOR

REGULATION: Section 402.5 Requirements Before Submitting a Request for a Criminal History Record Check. ...... (c) The provider shall obtain the signed, informed consent of the subject individual in the form and format specified by the Department which indicates that the subject individual has: (1) been informed of the right and procedures necessary to obtain, review and seek correction of his or her criminal history information; (2) been informed of the reason for the request for his or her criminal history information; (3) consented to the request for a criminal history record check; and (4) supplied on the form a current mailing or home address.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: February 7, 2017
Corrected date: April 4, 2017

Citation Details

Based on interviews and record reviews, it was determined that for six of eight employee files reviewed for the Criminal History Record Checks (CHRC), the facility did not ensure that the consent form was completed in the format specified by the New York State Department of Health. Specifically, the Authorized Person did not complete Section 3 of the DOH CHRC 102 form. This is evidenced by the following: During a review of employee files for CHRC checks on 2/3/17 between approximately 1:00 p.m. and 2:18 p.m., it was revealed that the Authorized Person who received the DOH CHRC 102 form did not complete Section 3 of the form for Environmental Services Worker #1, Certified Nursing Assistant (CNA) #1, CNA #2, CNA #3, CNA #4, CNA trainee #1 and Food Service Worker #1. In an interview at that time, the Human Resources Manager stated that he did not know why Section 3 of the CHRC consent form was not completed. He said it is his expectation that Section 3 be filled out. He said it should not have been left blank. (10 NYCRR 1-402.5(c))

Plan of Correction: ApprovedMarch 2, 2017

R610 402.5(c)
In direct response to the questions listed in the correspondence/letter from NYSDOH dated (MONTH) 21, (YEAR), and received by the Facility via DOH HCS Portal link transmittal on (MONTH) 21, (YEAR) along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
As no resident was identified or specified on the CMS 2567 the question is not applicable.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any resident has the potential to be affected by an improperly processed CHRC.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Facility will provide in-service to all applicable human resource, security, or other staff whose job it may be to process CHRC 102 forms. The in-service will emphasize the proper completion of Section 3 of the form.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Quality Assurance Coordinator shall appoint a committee of two persons who shall verify that all CHRC forms have been completed in accordance with DOH instructions. Monitoring shall occur each month at the time of new employee orientation. Monitoring results will be presented to the Quality Assurance Committee at the regularly scheduled meeting subsequent to the monitoring.
5. The date for correction action and the title of the person responsible for correction of this deficiency:
April 4, (YEAR)
Human Resource Manager

FF10 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: 483.10 (c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. (iv) The right to receive the services and/or items included in the plan of care. (v) The right to see the care plan, including the right to sign after significant changes to the plan of care. (c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-- (i) Facilitate the inclusion of the resident and/or resident representative. (ii) Include an assessment of the resident?s strengths and needs. (iii) Incorporate the resident?s personal and cultural preferences in developing goals of care. 483.21 (b) Comprehensive Care Plans (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: February 7, 2017
Corrected date: April 4, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, it was determined that for 1 (Resident #287) of 37 residents reviewed for care planning, the facility did not ensure the resident participated in the development and implementation of his care plan. Specifically, a recommendation to implement a change in treatment was not discussed with the resident. This is evidenced by the following: Resident #287 has [DIAGNOSES REDACTED]. A Minimum Data Set Assessment, dated 11/26/16, revealed the resident's cognition is intact, no rejection of cares, and total dependence on staff for personal hygiene. A Medical Consultation, dated 1/27/17, at a Colorectal Surgery Clinic, revealed the resident was seen for a follow up visit for pilonidal disease. The resident reports continued peri-rectal drainage that is usually bloody. The Care Plan included recommendations for a Sitz bath (a warm, shallow bath that cleanses the perineum, which is the space between the rectum and the vulva or scrotum, can be used for everyday personal hygiene or to provide relief from pain or itching in the genital area) one or two times daily, keep affected area clean, shift sitting position every twenty minutes, and to call the physician if the resident develops further rectal drainage or pain. In an interview on 2/2/17 at 9:03 a.m., the resident said that he had a recent appointment with a Colorectal Surgeon. He said the surgeon wants me to take a bath, to soak in the tub, but they have not tried that yet. The resident said his appointment was on 1/27/17, and the discharge summary was in his chart. Observations and interviews conducted on 2/2/17 included the following: a. At 3:42 p.m., a Unit Secretary said she had not filed this consult yet but the Nurse Practitioner (NP) reviewed it. The consult form had a check mark date 1/27/17, and initials written on it. Review of medical orders, dated 1/25/17 to 2/1/17, did not direct a Sitz bath. b. At 3:56 p.m., a Registered Nurse/Nurse Manager (RN/NM) reviewed the consult form and said it had been reviewed and initialed by a NP. The RN/NM said there were no orders for a Sitz bath and if the NP did not want to follow the recommendations, a note should have been written. The RN/NM said she would follow up with the NP to find out what happened. Review of a NP note, dated 2/2/17, revealed nine refusals of care, dated 10/9/16 to 1/22/17. Interviews conducted on 2/3/17 included the following: a. At 8:58 a.m., the RN/NM said she spoke with the NP on 2/2/17 and after that, the NP wrote an order for [REDACTED]. b. At 9:12 a.m., a NP said, Colorectal surgeons are consultants. We are the primary, we make the decisions. When asked if she had discussed the recommendations with the resident, the NP said, No, I did not talk to him prior to yesterday (2/2/17). I talked to him and examined him and I documented all the times he has declined regular care. The resident has had a pilonidal cyst for about ten years. He often refuses daily care. His natal cleft looks fine, no drainage. I did tell the resident that if he is going to cooperate with his care, Sitz baths are fine, but if he refuses that, he will be reported to the colorectal surgeon. At that time, the RN/NM joined the conversation and advised the NP that the resident had received a Sitz bath the previous night. c. At 9:16 a.m., the resident said he had received a Sitz bath the previous evening and that it felt good. A review of Progress Notes, dated 2/2/17 through 2/5/17, revealed the resident refused one daytime Sitz bath but did accept a Sitz bath later that day, in the evening. (10 NYCRR 415.11(c)(2)(ii))

Plan of Correction: ApprovedMarch 17, 2017

F 280 483.10(c)(2)(i-ii, iv, v) 483.21(b)(2)
In direct response to the questions listed in the correspondence/letter from NYSDOH dated (MONTH) 21, (YEAR), and received by the Facility via DOH HCS Portal link transmittal on (MONTH) 21, (YEAR) along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Resident #287?s care plan will be discussed with him in detail and he shall be provided the opportunity for input as well as acceptance or rejection of any part of the plan. The Facility shall insure that the resident is invited to attend all future care plan meetings. The Facility shall also insure the resident understands the recommendation made for him regarding Sitz baths.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any resident who does not attend the care planning process has the potential to be affected and is identifiable by their attendance or lack thereof. The Facility will insure that all residents are invited to care plan conferences.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The facility will devise a system wherein it is assured that residents are invited to all care plan conferences. Each resident shall receive a written invitation that shall include the dates for all anticipated care plan conferences to be held throughout the year. The written invitation shall also inform the resident of the right to participate in the care planning process and encourage the resident to do so. Documentation shall be provided explaining why a resident refuses to participate or fails to attend. Applicable staff shall be provided in-service training regarding the requirements for care plan attendance and participation by residents.
The Facility shall also develop a tracking tool to insure that residents are adequately informed of recommendations that may be made for them by outside specialists.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Quality Assurance Coordinator shall appoint a Committee of three persons who shall be responsible for monitoring resident attendance at care plan meetings. Such monitoring shall occur monthly for three months and quarterly thereafter. The Facility shall also monitor specialist recommendations to insure resident notification. Such monitoring shall be conducted monthly for three months and quarterly thereafter. All results of monitoring shall be reported to the Quality Assurance Committee at the regularly scheduled meeting following the completion of the monitoring.
5. The date for correction action and the title of the person responsible for correction of this deficiency:
April 4, (YEAR)
Director of Social Work

Standard Life Safety Code Citations

K307 NFPA 101:FIRE ALARM SYSTEM - INSTALLATION

REGULATION: Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2017
Corrected date: April 4, 2017

Citation Details

Based on observations made during the Life Safety Code Survey, it was determined that for 6 (Faith first, second, third, fourth, fifth, and sixth floors) of 14 resident use floors and 2 (Faith and Friendship Basements) of 3 basements, the facility did not properly maintain the fire alarm system. Specifically, locations of fire alarm control units lacked smoke detectors. This is evidenced by the following: 1. Observations in the presence of the Assistant Director of Facilities Services on 2/2/17 at approximately 1:15 p.m. revealed two fire alarm control units located in an electrical room in the Faith building basement. One unit was marked as 'Node 5 Faith 1 and Basement', and the other unit was marked as 'Node 3 Faith 2-7'. There was not an electrically supervised smoke detector in this room and the location was not a normally occupied space. 2. Observations in the presence of the Assistant Director of Facilities Services on 2/2/17 at approximately 1:50 p.m. revealed a fire alarm control unit located in an electrical room in the Friendship building basement. The unit was marked as 'Node 4 Friendship basement'. There was not an electrically supervised smoke detector in this room and the location was not a normally occupied space. The 2010 edition of NFPA 72, National Fire Alarm and Signaling Code, states: In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s), notification appliance circuit power extenders, and supervising station transmitting equipment to provide notification of fire at that location. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.3.4.1, 9.6.1.3, 2010 NFPA 72: 10.15)

Plan of Correction: ApprovedApril 19, 2017

K341
In direct response to the questions listed in the correspondence from NYSDOH dated (MONTH) 21, (YEAR) and received by the Facility via DOH HCS Portal Link transmittal on (MONTH) 21, (YEAR), along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
As there were no residents identified on the CMS 2567 the question is not applicable. MONROE COMMUNITY HOSPITAL HAS SUBMITTED A LETTER TO THE DEPARTMENT OF HEALTH FROM A THIRD PARTY FIRE SAFETY VENDOR INDICATING THE FACILITY IS IN COMPLIANCE WITH NFPA 72 2010.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Improperly maintained fire alarm systems that result in alleged missing smoke detectors have the potential to affect any resident. The Facility shall identify such missing detectors by conducting an audit of the locations of the fire control panels.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
Once the Facility completes the audit described in #2 above, a list will be compiled of all missing (if any) smoke detectors. The Facility shall then install smoke detectors, or a reasonable and acceptable alternative, in each area identified in the audit. Once installed, these detectors will become a permanent part of the system and will be checked concurrently with the Facility?s normal maintenance and inspection(s) of the fire alarm system. Members of the Facility Service (Maintenance) Staff shall be provided review training regarding the required location of smoke detectors.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Director of Facilities Services shall provide a listing of all missing smoke detectors to the Quality Assurance Coordinator. The Director of Facilities Services shall then inform the QA Coordinator when all smoke detectors have been installed. The QA Coordinator shall then verify the installation of the detectors has been completed. The new detectors will be added to the Facility?s fire system inspection schedule and checked for operability accordingly. The installation of the newly added detectors will also be reviewed by the Quality Assurance Committee at the Committee?s meeting subsequent to the installation. MONROE COMMUNITY HOSPITAL HAS SUBMITTED A LETTER TO THE DEPARTMENT OF HEALTH FROM A THIRD PARTY FIRE SAFETY VENDOR INDICATING THE FACILITY IS IN COMPLIANCE WITH NFPA 72 2010.

5. The date for correction action and the title of the person responsible for correction of this deficiency.
April 4, (YEAR)
Director of Facilities Services

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

REGULATION: Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2017
Corrected date: April 4, 2017

Citation Details

Based on interviews and record reviews, it was determined that for one of one FM-200 fire suppression systems, the facility did not test alarm initiating devices. Specifically, the facility did not perform annual testing on smoke detectors and a pull station. The findings include: A review of facility inspection records on 2/3/17 at approximately 10:02 a.m. revealed that the Simplex Grinnell had performed two inspections on the FM-200 suppression system in the past year. The inspection by Simplex Grinnell, dated 6/29/16, which was an annual inspection of the alarm initiating devices, indicated that two of two ionization smoke detectors, two of two photo smoke detectors and one of one pull stations associated with the FM-200 system were not inspected. An inspection of the FM-200 system on 1/5/17 also did not indicate that the alarm initiating devices had been inspected. The previous inspection of the alarm initiating devices was more than a year old. The Director of Facilities services called the representative from Simplex Grinnell who stated that they had not inspected the alarm initiating devices, that it was missed. The 2010 Edition of NFPA 72: National Fire Alarm and Signaling Code states that manual pull station and system smoke detector must be functionally tested annually. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.3.4.1, 9.6.1.3, 2010 NFPA 72:14.4.5)

Plan of Correction: ApprovedMarch 7, 2017

K345
In direct response to the questions listed in the correspondence from NYSDOH dated (MONTH) 21, (YEAR) and received by the Facility via DOH HCS Portal Link transmittal on (MONTH) 21, (YEAR), along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
As there were no residents identified on the CMS 2567 the question is not applicable.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Improperly inspected fire alarm systems have the potential to affect any resident. The Facility shall insure the system is fully inspected on an annual basis.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Facility shall require its inspection vendor to correct its mistake and complete the fire system inspection in accordance with annual inspection requirements. The Director of Facilities Services shall schedule the necessary inspections to insure timely completion. The Director of Facilities Services shall develop a log to track the timely completion of fire system inspections.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Director of Facilities Services shall provide a copy of the fire systems inspection schedule and log(s) to the Quality Assurance Coordinator at the time of the completion of each inspection. The inspection results will be verified and reported to and reviewed by the Quality Assurance Committee at the time the logs are submitted.
5. The date for correction action and the title of the person responsible for correction of this deficiency.
April 4, (YEAR)
Director of Facilities Services

K307 NFPA 101:OPERATING FEATURES - OTHER

REGULATION: Operating Features - Other List in the REMARKS section any LSC Section 18.7 and 19.7 Operating Features requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included in Form CMS-2567.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2017
Corrected date: April 4, 2017

Citation Details

Based on interviews and record reviews conducted during the Life Safety Code Survey, it was determined that 8 of 17 staff members were not aware of facility fire procedures. Specifically, the door tagging provisions outlined in the facilities fire plan. This is evidenced by the following: A review of the facilities fire plan revealed that the door to the fire room was to be marked with a yellow tag to indicate that it is the fire room. If the room had been evacuated, additionally mark the door with an orange tag to indicate an evacuated room. Interviews conducted on 2/6/17 at 9:57 a.m. and 2:38 p.m. included the following: a. Housekeeper #1 said she did not know what the orange tag was used for. b. Social Worker #1 said she thought that there was a sticker to tag doors, but was not sure where they were located. c. Dietician #1 said she did not know where the tags were located. She said that one tag means that there is a fire and the other one means that there is someone in the room. d. CNA #1 stated the room checked tag goes on the door if you check the room, even if there is a resident inside. e. RN Nurse Manager #1 stated that you put the resident in a room, then check the room, and put an orange tag on the room meaning that it has been checked. f. Housekeeper #2 said she did not know what the orange tag was for and did not know where the tags were located. g. LPN #1 said she did not know if you put both tags on the fire room door if it has also been evacuated. h. The Director of IT stated that you only put the fire tag on the fire room door, even if it has been evacuated. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.7.2.1.1)

Plan of Correction: ApprovedMarch 7, 2017

K700
In direct response to the questions listed in the correspondence from NYSDOH dated (MONTH) 21, (YEAR) and received by the Facility via DOH HCS Portal Link transmittal on (MONTH) 21, (YEAR), along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
As there were no residents identified on the CMS 2567 the question is not applicable.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any resident has the potential to be affected by staff who are unaware of fire procedures. The Facility develop a program to insure better staff knowledge in this regard.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Facility shall develop an ongoing program designed to insure staff retains a sound working knowledge of fire procedures. The Facility?s Staff Development Coordinator shall work with the Director of Security and the Risk Management Committee to establish a program of fire safety education that will be comprised of the following: (1) In-service training covering fire safety procedures, (2) fire drills, and (3) unannounced testing on fire procedures. Staff will be required to satisfactorily perform in each area by displaying a working knowledge of the fire safety program. Those who fail to meet performance standards for the program(s) will be required to attend remedial training.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Staff Development Coordinator shall work with the Director of Security and Chairperson of the Risk Management Committee to develop a program of fire safety training that will include (1) fire safety procedure training, (2) fire drills, and (3) unannounced testing. Each employee will be required to demonstrate an acceptable level of fire safety knowledge. Those who fail to do so will be placed in remedial training. Once the program is created each employee will be required to meet certain timeframes to complete the training. Training will begin upon the P(NAME) completion date. Results of the training shall be reported to the Quality Assurance Committee on an ongoing basis.
5. The date for correction action and the title of the person responsible for correction of this deficiency.
April 4, (YEAR)
Staff Development Coordinator

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2017
Corrected date: April 4, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for 3 (Hope building second, third, and fourth floors) of 14 resident use floors, the facility did not properly maintain the sprinkler system. Specifically, sections of suspended ceiling grids were secured to sprinkler piping. This is evidenced by the following: Observations above the suspended ceilings on 2/6/17 from approximately 2:00 p.m. to 2:30 p.m. revealed sections of the suspended ceiling grid were secured to and hung from sprinkler piping using metal wire. This was observed in the following hallway locations of the Hope building: outside Resident room [ROOM NUMBER]HW4, outside Resident room [ROOM NUMBER]HW17, outside Resident room [ROOM NUMBER]HW6, outside Resident room [ROOM NUMBER]HW5, and two additional locations outside Resident room [ROOM NUMBER]HW6. In an interview at that time, the Director of Facility Services stated that it was probably from the original construction back in 1996. The 2011 edition of NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems, states sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.3.5.1, 9.7.5,2011 NFPA 25:5.2.2.2)

Plan of Correction: ApprovedMarch 7, 2017

K353
In direct response to the questions listed in the correspondence from NYSDOH dated (MONTH) 21, (YEAR) and received by the Facility via DOH HCS Portal Link transmittal on (MONTH) 21, (YEAR), along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
As there were no residents identified on the CMS 2567 the question is not applicable.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any resident has the potential to be affected by material(s) improperly hung on sprinkler system pipe. The Facility shall remove the material(s) and reinstall it properly and in accordance with applicable code(s).
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Facility shall inspect all areas of the building to identify any locations where suspended ceiling grids are improperly hung from sprinkler system pipes. A list of locations of such suspended ceiling grids shall be compiled. Upon identification of location(s), the ceiling grids will be properly reinstalled. The Facilities Services staff shall be provided in-service training regarding the proper installation of suspended ceiling grids.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Director of Facilities Services shall provide the list of ceiling grid locations to the Quality Assurance Coordinator. The Director of Facilities Services shall inform the QA Coordinator at the time of the completion of re-installation. Upon such notification the QA Coordinator shall appoint a committee of three persons to verify the proper completion of the work in question. The inspection results will be verified and reported to and reviewed by the Quality Assurance Committee at the time the logs are submitted. The Director of Facilities Services shall conduct an annual review of the building?s suspended ceiling grids to insure they remain properly installed. The annual review shall also be reported to the QA Committee.
5. The date for correction action and the title of the person responsible for correction of this deficiency.
April 4, (YEAR)
Director of Facilities Services