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Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: February 28, 2022
Corrected date: April 11, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey completed on [DATE], the facility did not ensure that Minimum Data Set (MDS) assessment was encoded and transmitted timely for each resident including a subset of items upon a residents' transfer, reentry, discharge and or death. This was identified for one (Resident #1) of one resident reviewed for the Resident Assessment Task. Specifically, after Resident #1 expired on [DATE] there was no documented evidence that the MDS was encoded and transmitted to the Centers for Medicare & Medicaid Services (CMS) System. The finding is: Resident #1 was admitted with [DIAGNOSES REDACTED]. The Entry MDS assessment dated [DATE] was in place and documented accepted in the CMS System. The Admission MDS assessment dated [DATE] was in place and documented accepted in the CMS System. The MDS with an assessment reference date of [DATE] documented the Tracking/Discharge MDS assessment for Death was 115 days overdue for completion and submission to the CMS System. A Nursing Progress note dated [DATE] at 8:22 AM documented the resident was found unresponsive in bed at 7:56 AM, not breathing, no pulse, no heart or breath sounds auscultated. There was no code called because the resident had orders for Do Not Intubate and Do Not Resuscitate in the chart. The Registered Nurse (RN#15), Minimum Data Set Coordinator, was interviewed on [DATE] at 10:12 AM and stated they were responsible for completing the discharge MDS assessment. RN #15 stated that they were working from home and had a lot going on during that time. RN #15 stated that they should have completed a death in facility MDS assessment for Resident #1 and that was an oversite. The Director of Nursing Services was interviewed on [DATE] at 4:13 PM and stated the MDS assessment should have been completed the day after the resident expired. The Director of Nursing Services stated that the MDS assessment coordinator was responsible for completing the assessment. The Director of Nursing Services stated that if the MDS coordinator was not available to complete the assessment, they should have designated the MDS assessor to complete the assessment. 415.11 | Plan of Correction: ApprovedMarch 24, 2022 Part I. Immediate Corrective Action for Residents affected: i. Resident #1 MDS was completed and submitted 2/25/2022. ii. RN #15 was educated and counseled by the Administrator on timely encoding and transmittal of the MDS assessment. Part II. Identification of other Residents: i. The facility respectfully submits that all Residents could have potentially been affected by this deficient practice. ii. The Administrator or designee will perform an audit of all residents who was discharged from the facility in the past 90 days to ensure that all Minimum Data Set assessment was encoded and transmitted timely. All negative findings will be corrected immediately. Part III. Systemic Changes made so the deficiency will not reoccur: i. Policy Titled MDS was reviewed by DON. No changes required. ii. MDS staff will be in-serviced by the Director of Nursing Services on timely encoding and transmittal the of Minimum Data Set assessment. iii. In-service lesson plan and attendance records will be kept on file for validation Part IV. Monitoring of the Corrective Action/Quality Assurance: i. The Administrator or Designee will do a weekly audit x 4 weeks and monthly x 3 to ensure that submissions are completed in a timely manner. All negative findings will be corrected immediately. ii. All findings will be reported to the Quality Assurance Performance Improvement Committee monthly for follow-up and recommendation as necessary. Part V. Responsibility/Discipline: Administrator or designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2022
Corrected date: April 11, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 230) completed on 2/28/2022, the facility did not ensure that a thorough investigation was completed to rule out neglect following a report of an incident. This was identified for one (Resident #303) of two residents reviewed for Accidents. Specifically, Resident #303 was found on the floor of their room on 6/20/2021, however, there was no documentation that an Occurrence Report investigation was completed. The finding is: The facility's policy titled Accident/Incident/Occurrence Reports (Patients/Residents) dated 9/2016 documented that all falls and/or lowered to the floor are to have an Occurrence Report completed for investigation and Quality Assurance (QA) review. Resident #303 was admitted with [DIAGNOSES REDACTED]. The 5 Day Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The resident needed extensive physical assistance of one person for bed mobility, transfers, locomotion on the unit, dressing, toilet use, and bathing. The Nursing Progress Note dated 6/20/2021 documented that at 5:15 AM the resident had an unwitnessed fall. A Certified Nursing Assistant (CNA) reported to a noise in the resident's room. The resident was observed sitting on the floor in front of their unlocked wheelchair with their right lower extremity flexed under and their left leg extended. The facility did not have an Occurrence Report related to the fall on 6/20/2021. The Director of Nursing Services (DNS) was interviewed on 2/23/2022 at 3:20 PM and stated that the facility was unable to find the Occurrence Report that was completed for the resident's fall on 6/20/2021. The DNS stated that an Occurrence Report should be completed after a resident's fall to rule out abuse, mistreatment, and or neglect. The Registered Nurse (RN) Risk Manager/Assistant Director of Nursing Services (ADNS) was interviewed on 2/23/2022 at 4:25 PM and stated that an Occurrence Report should be completed to make sure that there was no abuse, mistreatment, or neglect. The Risk Manager stated that the Occurrence Report documents information such as the date and time, room number, whether it happened on the 1st, 2nd, or 3rd shift, where the resident was when they fell . The Occurrence Report also documents if the resident fell from their bed or wheelchair and if there was any injury to make sure there was no abuse, mistreatment, or neglect. The Risk Manager stated that an Occurrence Report for Resident #303's fall on 6/20/2021 could not be found. 415.4(b)(1)(ii) | Plan of Correction: ApprovedMarch 28, 2022 Part I. Immediate Corrective Action for Residents affected: i. The clinical chart was reviewed for Resident #303 no longer resides in the facility. Part II. Identification of other Residents: i. The facility respectfully submits that all Residents could have potentially been affected by this deficient practice. ii. The Director of Nursing Services or designee will perform an audit of the 24 Hour Reports in the past 3 months to ensure that the occurrence report investigations are accessible and complete in order to make a determination if abuse, neglect, or mistreatment has occurred. Part III. Systemic Changes made so the deficiency will not reoccur: i. DON and Administrator reviewed and revised policy titled Accident/Incident/Occurrence Reports (Patients/Residents) in order to reflect occurrence reports being documented on the facility's Electronic Health Record (EHR) platform, Point Click Care (PCC). ii. All staff will be in serviced on the policy and procedure Accident/Incident/Occurrence Reports (Patients/Residents). iii. In-service lesson plan and attendance records will be kept on file for validation. iv. All accidents/incidents will be reviewed during morning meeting to ensure an occurrence report was initiated. Part IV. Monitoring of the Corrective Action/Quality Assurance: i. The Director of Nursing Services/Designee will monitor and review the electronic log and compare with the 24 hour report and morning meeting for documentation and completion. ii. The DNS or designee will conduct an audit weekly x 4 then monthly X 3 months. The Director of Nursing Services or designee will address and correct any negative findings immediately. iii. All findings will be reported to the Quality Assurance Performance Improvement Committee monthly for follow-up and recommendation as necessary. Part V. Responsibility/Discipline: Director of Nursing Services/Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2022
Corrected date: April 11, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 069) completed on 2/28/2022, the facility did not ensure that each resident representative was notified timely of a resident's transfer from the facility. This was identified for one (Resident #307) of two residents reviewed for Notification of Change. Specifically, Resident #307 was transferred to the hospital on [DATE] to rule out [MEDICAL CONDITION], however, there was no documented evidence that the resident's representative was notified of the change in the resident's condition resulting in a transfer to the hospital. The finding is: The facility policy and procedure dated 2/22/2021 for Acute Change in Condition documented nursing staff are responsible to notify the resident representative following the resident's transfer to the hospital. Resident #307 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. A physician's orders [REDACTED]. A nursing progress note dated 2/9/2020 at 5:41 PM documented the resident had an acute change in status. Moderate amount of bleeding from the rectum with formed medium bowel movement and a change in mental status was noted. The resident's abdomen was distended with positive tenderness and diminished bowel sounds. The Physician was called and ordered to send the resident to the Emergency Department (ED) to rule out [MEDICAL CONDITION]. There was no documented evidence that the resident's representative was notified of the resident's change in condition and their transfer to the hospital. The Licensed Practical Nurse (LPN) #8 was interviewed on 2/23/22 at 5:05 PM and stated that the resident's vital signs were unstable, and the Physician was notified and ordered to send the resident to the hospital on [DATE]. LPN #8 stated the RN Supervisor or designated nurse is responsible to notify the family of change in condition and transfer to the hospital, then document their observations and family notification in the medical record. LPN #1 was interviewed on 2/24/22 at 10:12 AM and stated if there was a change in the resident's condition or if the resident is being discharged to the hospital, if the Physician did not notify the family, the supervisor or the floor nurse would inform the family. LPN #1 stated whichever staff notified the family of the resident's change in condition, or transferred to the hospital, the same staff would document in the progress note. Additionally, the LPN stated that there should have been documentation in the progress note that the resident had a change in condition and was transferred out to the hospital. The Director of Nursing Service (DNS) was interviewed on 2/24/22 at 11:26 AM and stated that any change in the residents' condition including fever, medication or treatment changes and residents' transfer to the hospital, the family must be notified. The DNS further stated the Unit Nurses and or the nursing Supervisor were responsible to notify the family and to document the communication in the resident's medical record. 415.3(e)(2)(ii)(d) | Plan of Correction: ApprovedMarch 24, 2022 Part I. Immediate Corrective Action for Residents affected: i. Resident #307's clinical chart was reviewed and no longer resides in the facility. ii. LPN #8 was educated by the DON to notify residentsÆ representative of the residentsÆ change in condition and their transfer to the hospital. Nursing Supervisor no longer works at the facility. Part II. Identification of other Residents: i. The facility respectfully submits that all Residents could have potentially been affected by this deficient practice. ii. The clinical charts of all residents that were transferred to the hospital in the past 30 days were audited to ensure residentÆs representatives were notified of their transfer to the hospital. No negative findings were identified. Part III. Systemic Changes made so the deficiency will not reoccur: i. Policy titled Change in Condition was reviewed by DON and no revisions were required. All RNs and LPNs will be educated on the Change in Condition policy. ii. Unit Managers will be responsible to review all change in conditions/hospital transfers to ensure residentsÆ representative will be notified of the residentsÆ change in condition and their transfer to the hospital. iii. Any change in condition/transfer to hospital will be discussed in daily morning report to ensure family/designated representative notifications are done. Part IV. Monitoring of the Corrective Action/Quality Assurance: i. The Director of Nursing or Designee will audit all change in conditions and transfers to the hospital weekly X 4 then monthly X 3 to ensure all resident representative notifications pertaining to a resident change of condition and transfer to the hospital. The Director of Nursing Services will address and correct any negative findings immediately. ii. The result of all audits will be reported to QAPI committee monthly for follow-up and recommendation as necessary. Part V. Responsibility/Discipline: Director of Nursing Services |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2022
Corrected date: April 11, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey completed on 2/28/2022, the facility did not ensure that the medical care of each resident was supervised by a Physician. This was identified for one (Resident #66) of three residents reviewed for Pressure Ulcer (PU). Specifically, Resident #66 utilized an Ankle Foot Orthosis (AFO) brace to the right lower extremity due to paralysis. On 12/10/21 the resident was identified with an open area to the right heel and there was no documented evidence that the resident's change in skin condition was evaluated or addressed by the attending Physician until 1/7/2022 after the wound had declined to a Stage 3 pressure ulcer. Additionally, there was no documented evidence in the Physician's monthly notes that the progress of the wound was monitored by the attending Physician. The finding is: The facility's Pressure Ulcer/Skin Breakdown Clinical Protocol dated 2/22/2021 documented that during resident visits, the Physician will evaluate and document the progress of the wound healing especially for those with complicated, extensive, or poorly healing wounds. Resident #66 was admitted with [DIAGNOSES REDACTED]. A Significant change Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderately impaired cognition. The resident was at risk for developing pressure ulcer, had one Stage III unhealed pressure ulcer that was not present on admission and pressure ulcer reducing device for bed and chair was in place. A Nursing Progress Note, written by the Registered Nurse (RN) #1, Supervisor, dated 12/10/2021 documented the RN supervisor was called to the resident's room by the resident's family member to assess Resident #66's right heel for a newly identified open area by the family member. Upon assessment of the right heel a 3.0 centimeter (cm) round open red area was noted. The Physician was contacted. An order was obtained to treat the area with [MEDICATION NAME], non-stick dressing, dry clean dressing (DCD) twice a day (BID) and to remove the right lower extremity (RLE) brace each shift to check for skin integrity. A podiatry consult was ordered, and heel booties were in place. The Physician Monthly note dated 12/21/2021 documented there was no clubbing, cyanosis, [MEDICAL CONDITION], venous stasis, [DIAGNOSES REDACTED] to the extremities. The pressure ulcer section of the monthly note was blank. The Physician's monthly Progress note dated 1/18/2022 documented there was no clubbing, cyanosis, [MEDICAL CONDITION], venous stasis, [DIAGNOSES REDACTED] to the extremities. The pressure ulcer section of the monthly note was blank. The attending Physician was interviewed on 2/28/2022 at 3:39 PM and stated that they (Physician) have cared for the resident since 11/1/2021. The Physician stated that when a wound is identified nursing staff notifies the Physician and a treatment order is given. The Physician stated if they were in the facility, they would have evaluated the wound at that time and document their assessment in the progress note. The Physician stated that they (Physician) would continue to monitor the wound, however, the Wound Physician sees the resident weekly. The Physician stated during the monthly visits they (Physician) would assess the wound. However, they (Physician) were not sure if they documented their assessment as the wound care Physician is responsible to document weekly. The Physician stated that the first progress note regarding the wound for Resident #66 was documented on 1/7/2022 by them (Physician). The Physician stated that they (Physician) could not recall the circumstances around that time frame. The Physician also stated that their note titled Venous Doppler Study on 1/11/2022 did not include the wound description. The Physician stated the monthly notes dated (12/21/2021 and 1/18/2022) that documented the resident's skin was intact was an oversight. The Physician stated that usually within one to two days they would have evaluated a newly identified wound, however, they could recall why they did not evaluate this resident (#66). The Physician further stated their evaluation should have been documented in the resident's medical record, and that there should have been documentation in the resident's monthly medical note regarding the progress of the wound. The Director of Nursing Services (DNS) was interviewed on 2/28/21 at 4:37 PM and stated that the resident's attending Physician should have assessed the wound soon after notification and documented the assessment in the medical record. 415.15(b)(1)(i)(ii) | Plan of Correction: ApprovedMarch 24, 2022 Part I. Immediate Corrective Action for Residents affected: i. One resident was affected by the deficient practice. ii. Resident #66 physician was educated by the Medical Director regarding the resident care and no documented evidence that the resident's change in skin condition was evaluated or addressed in timely manner. Part II. Identification of other Residents: i. The facility respectfully submits that all Residents could have potentially been affected by this deficient practice. ii. The Director of Nursing or Designee will audit all residents with pressure injuries for primary physician documentation. All negative findings will be corrected immediately. Part III. Systemic Changes made so the deficiency will not reoccur: i. Policy titled Physician Services was reviewed by DON, Administrator and Medical Director and no revisions were necessary ii. All Primary physicians will be in-serviced on timely documentations of new pressure injuries by the Medical Director/designee. iii. In-service lesson plan and attendance records will be kept on file for validation Part IV. Monitoring of the Corrective Action/Quality Assurance: i. The Medical Director or designee will do a weekly audit x 4 then monthly X3 to ensure timely physician documentation of new pressure injuries. All negative findings will be addressed and corrected immediately. ii. All findings will be reported to the Quality Assurance Performance Improvement Committee monthly for follow-up and recommendation as necessary. Part V. Responsibility/Discipline: Medical Director/Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2022
Corrected date: April 11, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification Survey completed on 2/28/2022 the facility did not ensure that services provided met professional standards. This was identified for one (Resident #17) of 5 residents reviewed for medication administration. Specifically, Licensed Practical Nurse (LPN) #1 administered a crushed Potassium Chloride (supplement) Extended-Release tablet to Resident #17. The Manufacturer's specifications for the Potassium supplement specified that the medication should not be crushed. The finding is: The undated facility policy and procedure for Crushing of Medications documented the Physician should order the crushing of medications. The physician must document the rationale why a medication must be crushed. The Medication Administration Record [REDACTED]. Resident #17 was admitted with [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. During a medication pass observation with LPN #1 on 2/16/2022 at 10 AM LPN #1 crushed the Potassium Chloride 20 meq tablet, mixed the crushed medication with yogurt and administered the Potassium Chloride Extended-Release tablet to Resident #17. LPN #1 was interviewed on 2/16/2022 at 10 AM and stated they did not know they could not crush the Potassium Chloride medication and that a physician's orders [REDACTED]. LPN #1 stated that the tablet was too big for the resident to swallow and that is why they (LPN #1) were crushing the Potassium Chloride tablets. The Pharmacist was interviewed on 2/18/2022 at 12:00 PM and stated that nurses should not crush an Extended-Release Potassium Chloride tablet. When an Extended-Release tablet is crushed, the absorption of the medication is affected thereby affecting the efficacy of the medication. The Director of Nursing Services (DNS) was interviewed on 2/18/2022 at 5:00 PM and stated LPN #1 should not have crushed the Potassium Chloride medication without a physician's orders [REDACTED]. The Medical Director was interviewed on 2/18/22 at 5:10 PM and stated Potassium Chloride medication should not have been crushed. The nurse should have called the Physician and the Physician would have evaluated the medication use. 415.11(c)(3)(i) | Plan of Correction: ApprovedMarch 28, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I. Immediate Corrective Action for Residents affected: i. One resident was affected by the deficient practice. ii. Resident #17 was assessed by the physician 2/17/2022 after medication administration and resident had no adverse reaction from taking the medication. iii. LPN #1 was educated immediately regarding this practice by the Director of Nursing Services and a medication pass competency was conducted by DNS. iv. Physician order [REDACTED]. Part II. Identification of other Residents: i. The facility respectfully submits that all Residents could have potentially been affected by this deficient practice. No other Residents were affected. ii. The Director of Nursing completed an audit to check all residents who are receiving Potassium Chloride tablets to ensure that they are able to tolerate the size of the tablet. No other deficient findings identified. Part III. Systemic Changes made so the deficiency will not reoccur: i. Policy titled medication administration was reviewed by DON and no revisions were necessary. ii. All RNs and LPNs will be in-serviced to ensure that potassium tablet as well as other [MEDICATION NAME] coated medications cannot be crushed. An in-service will also be provided for all RNs and LPNs to check medication blister cards for any medication alerts. iii. In-service lesson plan and attendance records will be kept on file for validation. iv. The Pharmacy will add Do Not Crush as part of the instruction in the blister pack for Potassium Chloride tablet. v. A list of medications that cannot be crushed are placed at the nursing station for referrals as needed. vi. A medication pass audit/competency for all RNs and LPNs will be completed by ADNS/Designee. Part IV. Monitoring of the Corrective Action/Quality Assurance: i. The Director of Nursing or designee will complete a weekly audit x 4 and monthly x3 thereafter to check for accuracy of giving medication. Any negative findings will be corrected immediately. ii. All findings will be reported to the Quality Assurance Performance Improvement Committee monthly for follow-up and recommendation as necessary. Part V. Responsibility/Discipline: Director of Nursing/Designee |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2022
Corrected date: April 11, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey completed on 2/28/2022 the facility failed to ensure that each resident received care, consistent with professional standard of practice to prevent Pressure Ulcer (PU) development and to promote healing. This was identified for one (Resident #66) of three residents reviewed for PU. Specifically, Resident #66 was admitted with no PUs. The resident utilized an Ankle Foot Orthosis (AFO) brace to the right lower extremity. On 12/10/2021 Resident #66 was identified with a PU to the right heel. The facility staff did not consistently conduct weekly assessments. Timely assessments by the Physician were not completed. Resident #66's was identified with skin impairment and was not referred to the wound care team until 18 days after the PU was first identified. The finding is: The facility's Pressure Ulcer/Skin Breakdown Clinical Protocol dated 2/22/2021 documented the nurse shall describe and document a full assessment of a pressure sore including location, stage, length, width, and depth, and the presence of exudates or necrotic tissue. The Physician will evaluate and document the progress of the wound healing. The facility Prevention of Pressure Ulcer Injuries policy dated 2/22/2021 documented to inspect pressure points which included the heels; and to evaluate, report, and document potential changes of the skin. Resident #66 was admitted with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 8, which indicated the resident had moderately impaired cognition. The resident required extensive assistance of one staff member for bed mobility, extensive assistance of two staff members for transfers and was non ambulatory. The resident had no pressure ulcers. A Significant change MDS assessment dated [DATE] documented the resident's BIMS score was 8, which indicated the resident had moderately impaired cognition. The resident had one Stage 3 unhealed pressure ulcer that was not present on admission. A Comprehensive Care Plan (CCP) dated 9/29/2021 documented the resident had the potential for developing pressure ulcers related to [DIAGNOSES REDACTED]. A Physician's admission orders [REDACTED]. A Task List Report (directions to the Certified Nursing Assistant (CNA) for the resident's care needs) dated 9/29/2021 documented to observe skin every shift and to turn and position the resident every two hours. The Certified Nursing Assistant (CNA) Documentation Survey Report (the document where the CNAs sign to indicate care provided) for (MONTH) 2021 revealed from 12/1/2021 thru 12/9/2021 skin observations every shift were not documented for 13 out of 27 nursing shifts. Review of the Nursing Progress Notes from 11/1/2021 through 12/9/2021 had no documentation that Resident #66 had any skin impairment. There was no documented evidence that a Braden scale risk assessment was completed on admission. or at the time the wound was first identified on 12/10/2021. A Nursing Progress Note, written by the Registered Nurse (RN) #1, Supervisor, dated 12/10/2021 documented the RN Supervisor was called to the resident's room by the resident's family member to assess Resident #66's right heel for a newly identified open area by the family member. Upon assessment of the right heel a 3.0 centimeter (cm) round open red area was noted. The Physician was contacted. An order was obtained to treat the area with [MEDICATION NAME], non-stick dressing, dry clean dressing (DCD) twice a day (BID) and to remove the right lower extremity (RLE) brace each shift to check for skin integrity. A podiatry consult was ordered. A physician's orders [REDACTED]. Obtain podiatry consult. The CNA Documentation Survey Report from 12/10/2021 to 12/31/2021 indicated that the skin observations were not documented for 27 of 66 nursing shifts. A Podiatry consult dated 12/14/2021 documented that the resident was seen due to a complaint of pain to the right heel. The Podiatrist documented the resident had a Deep Tissue Injury with [DIAGNOSES REDACTED] (redness) and recommended a wound care consultation. The Physician Monthly note dated 12/21/2021 was blank under the pressure ulcer section of the note. A Wound Report, completed by the Nurse Practitioner (NP) dated 12/27/2021 documented the resident had a right heel Pressure Ulcer with an onset date of 12/10/2021. The wound etiology was pressure. The PU measured 0.5 cm length x 0.4 cm width x 0.2 cm depth. The wound was assessed as a Stage 3 PU. The Task List Report was updated on 12/27/2021 to include instructions for a right heel bootie to be worn at all times; and nursing to remove the heel bootie for transfers and skin check every shift. The Task List Report was updated again on 1/21/2022 to include the right foot AFO in place when resident is out of bed and to remove for skin checks every shift. A physician's orders [REDACTED]. Nursing to remove for skin checks, during transfers, for hygiene, every shift. Document refusals and any skin changes. An electronic Weekly Skin observation form completed by the unit nurse dated 12/15/2021 and 12/22/2021 documented the resident's skin was intact. The 12/29/2021 weekly skin observation was blank. The Weekly Skin Evaluation form, completed by the Wound Care Nurse after the wound rounds, dated 1/4/2022 documented Resident #66 had a Deep Tissue Injury to the right heel measuring 1.4 cm length x 0.3 cm width x 0.3 cm depth. A Braden Scale assessment (tool used to determine the pressure ulcer risk) dated 1/4/2022 documented a score of 16 which indicated the resident was low risk for pressure ulcer development. The Physician's monthly Progress note dated 1/18/2022 was blank under the pressure ulcer section of the note. A physician's orders [REDACTED]. Apply [MEDICATION NAME]-soaked gauze pad, followed by padded dry dressing daily and as needed. A physician's orders [REDACTED]. The CCP for potential for developing PUs was updated on 12/10/2021 to include that the resident was noted with a Pressure Injury. On 12/14/21 the wound was assessed as a Deep Tissue Injury by the Podiatrist, on 12/27/21 the wound was assessed as a Stage 3 pressure ulcer, and on 1/25/22 the wound was assessed as a Stage 4. Interventions included but were not limited to apply the right heel bootie to be worn at all times except from transfers, the resident requires the bed as flat as possible to reduce shear, treat pain as per orders prior to treatment/turning to ensure the resident's comfort, vascular consultation per Physician orders, and wound care consult as per the physician's orders [REDACTED]. An incident report dated 12/10/2021 documented the Registered Nurse (RN) Supervisor was called to the resident's room by a family member, who showed them (RN) a new open area on the resident's right heel once they took off the resident's right lower extremity brace (AFO). The Incident Report summary documented the possible cause of the open area was due to the resident wearing the AFO brace from home; and with ambulation and transfer mobility rubbing/friction due to increase activities of daily living; and due to paralysis the resident did not feel the pain to site. An observation of the resident's AFO brace was conducted on 2/28/2022 at 3:00 PM with Licensed Practical Nurse (LPN) #2. The metal screw on the inside of a small opening to the base of the AFO brace was exposed and the canvas like fabric disc that covered the opening was raised and bent, firm to touch and created an uneven surface. The raised disc area appeared to be consistent with the resident's right heel pressure ulcer. The 11:00 PM - 7:00 AM shift CNA #6 was interviewed on 2/28/2022 at 11:01 AM and stated that they have been providing care to Resident #66 for approximately three months and that Resident #66 required extensive assistance of one staff member for care. CNA #6 stated that they only check the resident's skin from the resident's waist to the knees. CNA #6 stated that on their shift the resident wears heel booties only and not the AFO. CNA #6 stated that they do not check the resident's heels on their shift, however, they check to ensure that the resident was wearing the heel booties. The 7:00 AM - 3:00 PM shift Certified Nursing Assistant (CNA #2) was interviewed on 2/28/22 at 11:19 AM and stated that the resident was on their assignment for the last three months. CNA #2 stated that the resident had a brace on one leg and around two weeks after CNA #6 started caring for the resident, CNA #6 noticed there was a dressing on the same leg. CNA #2 stated that they toilet and administer morning care to the resident. However, the resident receives their shower on the 3:00 PM-11:00 PM shift. CNA #2 stated that most morning, at the start of their shift, the resident was out of bed in their wheelchair. CNA #2 stated in the morning they took Resident #66 into the bathroom for morning care and while the resident sat on the toilet, CNA #2 checked the resident's feet then put on the resident's socks and shoes. On 12/10/21 CNA #2 stated before putting on the resident's shoe and sock they checked the resident's heel while the resident was seated on the toilet but did not recall seeing the wound. Registered Nurse (RN #1) was interviewed on 2/28/2022 at 12:17 PM and stated that they recall the day the resident's family member asked them (RN #1) to look at the resident's leg. RN #1 stated when they entered the room the resident was sitting in their wheelchair with the sock and brace removed. RN #1 stated that the wound measured approximately 3.0 cm, was round and opened, however, there was no drainage present. RN #1 stated they immediately called the Physician and obtained a treatment order and initiated a heel bootie to the right leg. RN #1 stated that heel booties were not in use for the right foot at the time due to the resident utilizing the AFO brace. RN #1 stated they were not sure who was responsible for checking the resident's skin. RN #1 further stated the staff were not aware of the resident's skin impairment until the resident's family member brought the open area of the resident's right heel to the staff's attention. Wound Care LPN #2 was interviewed on 2/28/22 at 2:45 PM and stated that they were first made aware of the wound on the morning of 12/21/2021, however, they had to leave the facility early for personal reasons. LPN #2 stated the resident was first seen on wound rounds by the covering Nurse Practitioner (NP) on 12/27/2021 and that they (LPN#2) first saw the resident's wound on 1/4/2022. LPN #2 stated at the time of the initial wound assessment RN #1 should have determined the stage of the PU and should have completed a Braden Scale risk assessment. LPN #2 stated when checking the resident's skin, the CNAs must remove the resident's socks and check their feet. LPN #2 stated that the expectation is that the CNAs remove the resident's socks and shoes and any splint or devices to check the resident's skin. The 3:00 PM-11:00 PM shift CNA #7 was interviewed on 2/28/2022 at 3:13 PM and stated they were assigned to Resident #66 on 12/9/2021. The resident required extensive assistance with toileting, and dressing. CNA #7 stated that when they assist the resident with care, they either transfer the resident onto the toilet where they are unable see the resident's heels or they transfer the resident into bed where they are able to see the resident's heels. CNA #7 stated that they could not recall on 12/9/2021, the evening before the wound was identified, if they had placed the resident on the toilet, or into their bed to provide care. CNA #7 further stated that the resident did not complain that their heels hurt during care. The attending Physician was interviewed on 2/28/22 at 3:39 PM and stated that they (Physician) have cared for Resident #66 since 11/1/2021. The Physician stated that they did not evaluate the wound and could not recall why an evaluation of the wound was not completed. The Physician stated usually within 48 hours they would have completed an evaluation, however, could not recall the circumstances during that time frame. The Physician stated the expectation is when a new alteration in the resident's skin is identified, that they would be notified by the nurse, and a treatment order is given and within one to two days the wound is evaluated by the attending Physician. The Director of Nursing Services (DNS) was interviewed on 2/28/21 at 4:37 PM and stated that the CNAs were expected to check for any changes in the resident's skin and report any changes to the nurses. The DNS stated when a new pressure ulcer is identified the unit nurse first evaluates the resident's skin then reports their findings to the Registered Nurse Supervisor for assessment of the wound. The DNS stated the resident should have been seen by the wound care nurse as soon as possible on the day of the PU identification. The DNS stated that the AFO device was brought in by the family and should have been checked by the rehabilitation department for appropriate fit. The DNS stated that a Braden scale assessment should have been completed at the time the wound was identified on 12/10/2021. The DNS stated a Braden scale risk assessment is completed on admission and when a new wound is identified. The DNS stated the Braden scale assessment dated [DATE] was incorrect because the resident was at high risk for pressure ulcer development due to a [DIAGNOSES REDACTED]. Additionally, the DNS stated that the resident's attending Physician should have assessed the wound soon after notification. The Director of Rehabilitation was interviewed on 2/28/2022 at 5:18 PM and stated that all devices including the AFO are checked for proper function and appropriateness for the resident while in the facility. The Director of Rehabilitation stated that when the resident's family brought Resident #66's AFO to the facility, the AFO was checked by the Rehabilitation department for appropriateness. They stated that the device fit appropriately and there was no damage inside the brace. The Director of Rehabilitation stated they were not made aware Resident #66's AFO was damaged. The Director of Rehabilitation acknowledged that there was no documentation regarding evaluation of Resident #66's AFO by the Rehabilitation department. The Director of Rehabilitation Department stated that the therapist who checked the AFO were expected to document their evaluation of the device. 415.12(c)(1) | Plan of Correction: ApprovedMarch 29, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I. Immediate Corrective Action for Residents affected: i. One resident was affected by the deficient practice. ii. Resident's #66 wounds were reassessed upon readmission to the facility on [DATE] and there was no change in wound status. iii. CNA #2 and CNA #6 were counseled and educated on the timely completion of skin check by DNS. RN #1 and LPN # 2 no longer work at the facility. iv. The Director of Rehabilitation was educated by the Director of Nursing Services to ensure documentation on braces/splints assessment are completed. v. Wound care physician was terminated. Part II. Identification of other Residents: i. The facility respectfully submits that all Residents could have potentially been affected by this deficient practice. ii. The Director of Nursing or designee will audit all residents with pressure injuries for the primary physician's documentation. All negative findings will be corrected immediately. iii. The Director of Nursing completed a skin assessment of all residents with braces/splints. No negative findings were identified. iv. The Director of Nursing completed an audit on the accuracy of the Braden assessment conducted by RN. No negative findings were identified. v. The ADNS/Designee will audit CNA accountability to ensure skin checks are completed on residents with Braces/splints. Any negative findings will be corrected immediately. vi. The Director of Rehabilitation audited all residents with AFO/braces/splints for proper function, fitting, and documentation in the clinical chart. No negative findings were identified. Part III. Systemic Changes made so the deficiency will not reoccur: i. Policy Titled Prevention of Pressure Ulcer Injuries and the facility's Pressure Ulcer/Skin Breakdown Clinical Protocol were reviewed by DON. No revision were made. ii. All RNs, LPNs, and CNAs will be inserviced on completion and documentation of daily skin checks performed by the CNAs. The CNA Accountability Record will be monitored by the Assistant Administrator or designee. iii. All RNs, LPNs, and CNAs will be in-serviced on wound notifications, observations, and evaluations and above policies. iv. All RNs, LPNs, and CNAs will be in-serviced to ensure body observations/evaluations are completed weekly. v. The Director of Rehabilitation will educate all rehabilitation staff on the evaluation and documentation of all AFO braces brought in by family members prior to resident use. vi. The primary physician will be in-serviced by the Medical Director/designee for timely assessment and evaluation of residents with new skin impairments. vii. In-service lesson plan and attendance records will be kept on file for validation. viii. All residents with pressure injury were re-assessed by wound MD on 3/18/2022. iix. Braden assessment for all residents will be completed quarterly. DNS will check for accuracy. ix. The facility has contracted with a new Wound Physician Group to ensure the highest quality of wound care and documentation. Part IV. Monitoring of the Corrective Action/Quality Assurance: i. The Director of Nursing or Designee will complete a weekly audit x 4 then monthly X3 to ensure documentation on all new skin impairments, completion of Braden scale, and CNA skin check documentation. The Director of Nursing or designee will address and correct any negative findings immediately. ii. The Director of Rehabilitation will complete an audit of all residents with AFO devices/splints/braces to check for proper function and documentation in the clinical chart weekly X4 then monthly x 3 months then quarterly thereafter. The Director of Rehabilitation will address and report to the IDT any negative findings immediately. iii. The Medical Director/designee will complete a weekly audit x 4 then monthly audit x 3 months then quarterly of timely physician evaluation and documentation of new wounds. The Medical Director or designee will address and report to the IDT any negative findings immediately. iv. All findings will be reported to the Quality Assurance Performance Improvement Committee monthly for follow-up and recommendation as necessary. Part V. Responsibility/Discipline: Director of Nursing Services/Designee |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 11, 2022
Corrected date: June 28, 2022
Citation Details 2012 NFPA 101: 19.1.6 Minimum Construction Requirements. 19.1.6.1 Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.) Life Safety Code Section 19.1.6 and Table 19.1.6.1 limit the height of buildings that are built of unprotected non-combustible construction (i.e., NFPA 220 Type II (000) building construction) to only two stories with a complete automatic sprinkler system. This requirement is not met as evidenced by: Based on observation and staff interview, the facility did not ensure that the nursing home building that is built of unprotected non-combustible construction (i.e., NFPA 220 Type II (000)) was not more than two stories in height. The findings are: During the Life Safety Code survey on 02/16/22 between 10:00am and 2:45pm, multiple observations made during the survey of the building revealed that the steel structural members (joists, beams) above the suspended ceiling assembly throughout the building were not provided with fire proofing. Examples include but are not limited to bare steel beams above the ceiling in the corridors on the 1st, 2nd, and Ground floors. Due to the lack of fire proofing on steel structural members and the lack of a fire resistance rated ceiling assembly (inlay drop ceiling), this building is considered to be a Type II (000) Unprotected, Non-combustible structure. The Life Safety Code prohibits Type II (000) buildings from being more than two stories in height. In an interview on 02/16/2021 at 10:30am, the Assistant Administrator/Director of Maintenance stated that the facility is in the process of doing an FSES and would filing for a time limited waiver or recurring waiver based on the outcome of the FSES report. 2012 NFPA 101: 19.1.6.1. 8.2.1, 8.2.1.2 2012 NFPA 220: 4.1 10 NYCRR 415.29 10 NYCRR 711.2(a)(1)2012 NFPA 101: 19.1.6 Minimum Construction Requirements. 19.1.6.1 Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.) Life Safety Code Section 19.1.6 and Table 19.1.6.1 limit the height of buildings that are built of unprotected non-combustible construction (i.e., NFPA 220 Type II (000) building construction) to only two stories with a complete automatic sprinkler system. This requirement is not met as evidenced by: Based on observation, staff interview and documentation review, the facility did not ensure that the nursing home building that is built of unprotected non-combustible construction (i.e., NFPA 220 Type II (000)) was not more than two stories in height. The facility did not provide an approved time limited waiver from CMS and they did not provide evidence that mitigating factors were implemented while the deficiency exists. The findings are: During the Life Safety Code survey on 02/16/22 between 10:00am and 2:45pm, multiple observations made during the survey of the building revealed that the steel structural members (joists, beams) above the suspended ceiling assembly throughout the building were not provided with fire proofing. Examples include but are not limited to bare steel beams above the ceiling in the corridors on the 1st, 2nd, and Ground floors. Due to the lack of fire proofing on steel structural members and the lack of a fire resistance rated ceiling assembly (inlay drop ceiling), this building is considered to be a Type II (000) Unprotected, Non-combustible structure. The Life Safety Code prohibits Type II (000) buildings from being more than two stories in height. In an interview on 02/16/2021 at 10:30am, the Assistant Administrator/Director of Maintenance stated that the facility is in the process of doing an FSES and would be filing for a time limited waiver or recurring waiver based on the outcome of the FSES report. During the offsite life safety code offsite post survey revisit on 5/11/2022, no approved time limited waiver from CMS was provided. Additionally, no evidence was provided that mitigating factors such as fire watchs and additional fire drills beyond the required level had been implemented as stated in the plan of correction. 2012 NFPA 101: 19.1.6.1. 8.2.1, 8.2.1.2 2012 NFPA 220: 4.1 10 NYCRR 415.29 10 NYCRR 711.2(a)(1) | Plan of Correction: ApprovedAugust 23, 2022 Part I. Immediate Corrective Action for Residents affected: i. No residents were affected by the deficient practice. Part II. Identification of other Residents: i. All residents have the potential to be affected by the deficient practice. The Medical Director is in agreement there is no additional risk to the residents. ii. On 3/15/22, the architect undertook an FSES evaluation of WaterÆs Edge Rehab and Nursing Center at Port Jefferson which failed for extinguishment safety on; Third Floor Zones 3A, 3B and 3C. Suspended ceiling replacement work to be completed during the time limited waiver period will enable the facility to PASS an FSES in Zones 3A, 3B and 3C and achieve a Life Safety Equivalency via the FSES. Part III. Systemic Changes made so the deficiency will not reoccur: i. The facilityÆs operator contracted with an architectural/engineering firm to conduct an FSES. It has been determined that the facility does not currently meet the requirements to pass the FSES. The facility has applied for a time limited waiver to BAER (Waiver # to be assigned) for work to be conducted with a completion date of 10/1/2023. Upon completion of remedial work, the facility will have completed installation of new 2-Hour fire rated suspended ceilings throughout the entire building to achieve a passing FSES score. The timeline to correct the issues identified on the FSES report is as follows: a. Evaluation of Deficiency & Recommendation of Corrective Action. Start date: 4/1/2022. End Date: 5/1/2022. Duration: 1 month. b. Preparation of Contract Documents. Start date: 5/1/2022. End Date: 8/1/2022. Duration: 3 months. c. Obtaining Local Permits & Approvals. Start date: 8/1/2022. End Date: 10/1/2022. Duration: 2 months. d. Duration of Construction. Start date: 10/1/2022. End Date: 10/1/2023. Duration: 1 year. e. Overall Time Limited Waiver Duration. Start date: 4/1/2022. End Date: 10/1/2023. Duration: 1 year and 6 months. ii. The facility is fully sprinkled, and hard-wired detectors, connected to a central alarm system, are installed in each resident room and throughout the facility. Interior finishes on walls and ceilings within the means of egress and within all resident rooms are Class A materials. The facility will implement the following additional measures to mitigate the risks to residents and staff: 1. fire watches 2. additional fire drills 3. testing the fire alarm system more frequently, immediately replacing non-functioning equipment 4. identify and mitigate the risks such as extension cords, amount of ABHR and their locations 5. conduct daily rounds to ensure all fire and smoke doors are functioning and not propped open. Any open doors are on electronically supervised hold opens and doors will shut when alarms are activated 6. provide additional extinguishers 7. properly store O2 cylinders in properly rated rooms. Thresholds will be verified weekly to ensure thresholds are not being exceeded. Ensure corridors remain unobstructed to allow for evacuation when required.ö 8. During construction, facility will perform frequent observations of the work areas to monitor resident safety. The facility already has enhanced training for fire safety with an additional focus on awareness of fire alarms, location of fire/smoke barriers and evacuation procedures. Part IV. Monitoring of the Corrective Action/Quality Assurance: i. Administrator, in conjunction with Director of Maintenance, will meet with contractors to ensure timeliness of dates as reflected in the waiver request. ii. Administrator will report any updates at the monthly QA meeting. Part V. Responsibility/Discipline: Administrator |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2022
Corrected date: April 27, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility did not ensure that fire-rated doors were provided with a legible fire-rated label. This was noted for 3 of 3 stairwells, and on a smoke barrier door on 1of 2 units. The findings are: During the Life Safety Code inspection on 02/16/22 between 10:00am and 2:45pm, it was noted that the North, South, and Center emergency exit stairwells, inspected for compliance, were not provided with legible fire-rated labels. Additionally, the fire-rated labels for the smoke barrier doors in the vicinity of resident room [ROOM NUMBER] of the 2nd floor unit were not legible. In an interview on 2/16/22 at 11:15am, the Assistant Administrator/Director of Maintenance acknowledged that the identified door labels were not legible or missing and stated that the issue would be addressed. 2012 NFPA 101: 19.3.7.8, 8.5.4.4, 7.2.1.15.2 2010 NFPA 105: 4.1.1 NYCRR 711.2(a) 10 NYCRR 415.29 | Plan of Correction: ApprovedMarch 19, 2022 Part I. Immediate Corrective Action for Residents affected: i. No residents were affected by the deficient practice ii. The Facility has contracted with a Fire Rating Contractor to perform remediation on doors found to be without a legible fire-rated label. Part II. Identification of other Residents: i. The facility respectfully submits that all Residents could have potentially been affected by this deficient practice. ii. The Environmental Service Director performed an audit on all other fire-rated doors in the facility to ensure they were equipped with a legible fire-rated label. Part III. Systemic Changes made so the deficiency will not reoccur: i. The Environmental Service Director will educate contractors and facility Maintenance Staff to ensure that fire-rated labels are not painted over or tampered with. ii. Inservice Lesson Plan and attendance records will be kept on file for validation. Part IV. Monitoring of the Corrective Action/Quality Assurance: i. The Environmental Services Director developed a monthly inspection log to ensure that all fire-rated doors are equipped with a legible fire-rated label. ii. The Director of Environmental Services will address and correct any negative findings immediately. iii. All findings will be reported to the Quality Assurance Performance Improvement Committee monthly for follow-up and recommendation as necessary. Part V. Responsibility/Discipline: Environmental Services Director |