Park Ridge Nursing Home
October 17, 2018 Certification Survey

Standard Health Citations

FF11 483.20(g):ACCURACY OF ASSESSMENTS

REGULATION: §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 17, 2018
Corrected date: December 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 3 of 24 residents reviewed for Minimum Data Set (MDS) Assessment accuracy, the facility did not ensure that MDS Assessments accurately reflected the residents' status. The issues involved inaccurate coding of the resident's mental status, mood, pain and hospice (Resident #264), inaccurate coding of mental status, mood and pain (Resident #66), and inaccurate coding of mental status, pain or preferences for customary routine and activities (Resident #59). This is evidenced by the following: 1. Resident #264 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 8/28/18, revealed that the resident was not in a persistent vegetative state (not conscious), was sometimes able to understand other people, and was sometimes understood by other people (responds adequately to simple, direct communications). The Brief Interview for Mental Status, the interview for mood assessment to determine signs of depression, and the interview to assess the resident for pain were not completed with the resident. Hospice care was not checked off as being provided on the MDS Assessment. During an observation of meal time on 10/11/18 at 12:33 p.m., the resident was being fed by a staff member who was conversing with the resident, and the resident was occasionally answering the staff's questions. In an interview on 10/16/18 at 4:29 p.m., Registered Nurse (RN)/Manager #1 stated that sometimes the resident chooses to talk with staff and sometimes she will not. She said the resident was better when her daughter visited. RN Manager #1 said that the resident can talk and be understood. RN Manager #1 said she did not interview the resident because the resident chose not to talk to her that day. RN Manager #1 said that she was unaware of the coding regulations in the MDS Assessment manual regarding the interview process. She said that not checking hospice was a mistake as the resident has been receiving hospice care for quite a while. 2. Resident #66 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 8/15/18, revealed that the resident had clear speech, was sometimes understood by others, and was sometimes able to understand others. The resident interviews for mental status, signs of depression, and pain interview was documented as not attempted due to the resident being rarely or never understood. In an observation on 10/15/18 at 12:50 p.m., the resident was eating lunch in the dining area, pleasantly confused, and conversing with staff. In an interview on 10/16/18 at 11:40 a.m., RN Manager #1 stated that the resident was able to answer yes or no questions. She said the resident will ask if she wants something or tell staff when she is in pain. 3. Resident #59 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 8/10/18, revealed that the resident had clear speech, was able to understand others (clear comprehension), and was understood by others (able to express ideas and wants). The resident interviews to assess mental status, mood, or preferences for customary routine and activities were documented as not attempted due to the resident being rarely or never understood. Review of the current Comprehensive Care Plan revealed that the resident had impaired communication and approaches included to face the resident when speaking, allow the resident time to respond, make sure the resident understands, and encourage the resident to communicate. Observations on 10/15/18 at 2:33 p.m. and on 10/16/18 at 2:37 p.m. revealed the resident was interacting with staff and answering questions appropriately. In an interview on 10/12/18 at 1:17 p.m., RN Manager #2 stated that she was not aware that she should have attempted the interview with the resident per the regulations. When interviewed on 10/17/18 at 10:43 a.m., the RN MDS Coordinator stated that they have a contract nurse and the Nurse Managers are assisting with the MDS Assessments. The RN MDS Coordinator said staff should have attempted the interviews with the identified residents according to the regulations. She said she needs to review the instructions with all the staff completing the MDS Assessments to make sure they are being done accurately. (10 NYCRR 415.11(b))

Plan of Correction: ApprovedNovember 9, 2018

1. Identified residents (#264,66,59) reviewed to ensure accuracy with MDS Section B 700 & 800 and Interview sections. Determined that each of the residents identified could be interviewed as per section B 700. Nurse Managers identified were provided education related to coding regulations in the MDS Assessment manual regarding the interview process.
Responsible Party: DON/MDS Coordinator
2. MDS Coordinator reviewed all current MDS? to identify inconsistencies related to interviews of residents. An additional seven residents MDS? were identified as having inconsistencies of interview sections of the MDS. All residents identified are scheduled to have a corrective MDS completed to ensure compliance of coding regulations in the MDS Assessment.
Responsible Party: NM/MDS Coordinator
3. MDS Assessment Manual reviewed for coding regulations related to resident interview process. All interdisciplinary team members responsible for MDS completion that includes interviews will be educated on the interview process and expectations of MDS completion compliance. In addition, the interdisciplinary team will determine if the resident is interviewable or not to ensure the entire team is coding appropriately. The determination of residents' ability to be interviewed will be reviewed at the weekly RUGS meeting in the resident look back period.
Responsible Party: MDS Coordinator/Interdisciplinary Team
4. On a monthly basis a random audit of MDS? will be completed to ensure compliance of MDS interview and hospice coding accuracy.
Responsible Party: ADON/MDS Coordinator
5. Compliance will be monitored utilizing the quality audit process review. Results of the monthly audit will be submitted to the ADON who will review the results, evaluate, address any variation to compliance and ensure continued adherence to the coding regulations. Results will be reported to the PRLC QAPI Committee for a minimum of 6 months. The QAPI Committee will determine the scope and duration of the audits based on the results of the facility and Nurse Managers findings.
Responsible Party: ADON

FF11 483.24(a)(1)(b)(1)-(5)(i)-(iii):ACTIVITIES DAILY LIVING (ADLS)/MNTN ABILITIES

REGULATION: §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 17, 2018
Corrected date: December 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #18) of one resident reviewed for rehabilitation, the facility did not provide the treatment and services outlined in the resident's plan of care to maintain functional ability. Specifically, the resident was not consistently ambulated by staff per therapy recommendations. This is evidenced by the following: Resident #18 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 7/4/18, revealed that the resident had moderately impaired cognition, required extensive assist of one staff member for ambulation, and did not have functional impairment in Range of Motion. The Physical Therapy Discharge Summary, dated 7/3/18, documented under 'gait' that the resident was able to ambulate with a walker, contact guard (hands on), and the minimum assist of staff with any weight shifts. The Assessment/Discharge Plan included that staff were able to demonstrate competency for safe mobility. The Comprehensive Care Plan, dated as last reviewed on 10/15/18, and the current Shahbaz (Certified Nursing Assistant-CNA) closet care plan included that the resident had a history of [REDACTED]. Approaches included, but were not limited to, to encourage the resident to wear sneakers while ambulating, assist to ambulate with a wheeled walker and to use two staff assist and wheelchair follow for ambulation when weak or fatigued. Intermittent observations throughout the day on 10/11/18, 10/15/18, and 10/16/18 revealed the resident self-propelling his wheelchair back and forth from his room to the dining room or being pushed in his wheelchair by staff. Review of the Activities of Daily Living Detail Report, from 9/16/18 through 10/15/18, revealed documentation that the resident ambulated with staff in his room on ten occasions for the month, and ambulated in the corridor/unit on just four occasions for the month. Review of the maintenance therapy for ambulation record revealed documentation that the resident ambulated with the therapy aide on four occasions from 7/18/18 through 10/15/18. Interviews conducted on 10/16/18 included the following: a. At 9:52 p.m., the Licensed Practical Nurse stated that the resident used to have a lot of behaviors such as agitation and refusals. She said the resident has been much better lately including using his call bell for assist more instead of self-transferring. b. At 2:34 p.m., the Shahbaz (CNA) stated that the resident frequently self-transfers and that he can ambulate. She said that staff do not ambulate with the resident because the resident feels safer in his chair. Interviews conducted on 10/17/18 included the following: a. At 12:25 p.m., the Physical Therapist stated that the resident requires one assist and ideally should be ambulated by staff daily. She said the resident was on maintenance therapy and that sometimes the resident refuses, but he should at least be ambulated to the dining room and back. The Physical Therapist said if the resident refuses, she would expect staff to re-approach. If refusals go on for several days, then it should be brought to morning meeting so the team can review. The Physical Therapist said that if a resident can walk, she wants them to walk. b. At 1:57 p.m., the Rehabilitation Aide stated that the resident walked for her that day and did very well. She said the resident was on her schedule once a week and that the Shahbazs should be ambulating the resident daily. (10 NYCRR 415.12(a)(1)(ii))

Plan of Correction: ApprovedNovember 9, 2018

1. Identified resident's (#18) plan of care was reviewed and revised to include ambulation to meals. Physical Therapy Screen was completed and determined that he did not have any loss any function with ambulation. Communicated to cottage staff change in plan of care for resident. In addition, placed revised care plan/care card in cottage huddle to ensure communication to all caregivers in cottage.
Responsible Party: Physical Therapy/Nurse Manager
2. All identified residents who have received therapy recommendations for ambulation were identified and care plans reviewed. In addition, Caretracker reports were reviewed to determine compliance with ambulation plan of care.
Responsible Party: DON/ADON
3. Revised Care Card guidelines to include ?If resident refuses or is not able to meet expectations of intervention on care card notify RN or LPN nurse leader immediately for further evaluation.? All nursing staff educated on revised Care Card Guidelines and expectations of following plan of care and therapy recommendations.
Responsible Party: DON/ADON/NM/designee
4. On a monthly basis a random audit of residents identified for ambulation will be completed to ensure residents therapy recommendations are in compliance to include refusal documentation and revision to plan of care.
Responsible Party: ADON/Nurse Managers/Therapy/designee
5. Compliance will be monitored utilizing the quality audit process review. Results of the monthly audit will be submitted to the ADON who will review the results, evaluate, address any variation to compliance and ensure continued adherence to the policy. Results will be reported to the PRLC QAPI Committee for a minimum of 6 months. The QAPI Committee will determine the scope and duration of the audits based on the results of the facility and Nurse Managers findings.
Responsible Party: ADON/designee

FF11 483.21(b)(2)(i)-(iii):CARE PLAN TIMING AND REVISION

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(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: October 17, 2018
Corrected date: December 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #28) of five residents reviewed for non-pressure related skin conditions, the facility did not ensure that a resident's care plan was revised to reflect the resident's current condition related to her risk for skin issues. This is evidenced by the following: Resident #28 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/4/18, revealed that the resident had severely impaired cognition, had no skin issues, and required extensive assist of staff for dressing. The current Comprehensive Care Plan and Current Shahbaz (Certified Nursing Assistant) Closet Care Plan revealed that the resident had an increased risk for accidental skin tears and bruises due to frail, thin, dry skin that tears easily. The care plans revealed that the resident had chronic ecchymosis (bruise-like) areas of the left hand and arm related to capillary leakage. Approaches included, but were not limited to, to place geri-sleeves (sleeve-like skin covers) to the arms daily as tolerated. Review of the nursing progress notes, from 9/1/18 through 10/16/18, revealed a single nursing note that staff attempted to apply the geri-sleeves but the resident refused. During observations on 10/11/18 at 9:56 a.m., 10/15/18 at 12:56 p.m. and 2:15 p.m., and on 10/17/18 at 11:13 a.m., the resident was dressed and was not wearing geri-sleeves. Both of the resident's arms were uncovered revealing large bruise like areas of the left hand and forearms. Interviews conducted on 10/17/18 included the following: a. At 11:35 a.m., the Shahbaz stated that she did not attempt to apply the resident's geri-sleeves. The Shahbaz said that she had not put them on the resident or seen any geri-sleeves in the resident's room for the past two weeks and was not sure why. At that time, the Shahbaz searched the resident's room and found one geri-sleeve. The Shahbaz said that the resident's skin was very fragile and that she should wear the geri-sleeves. b. At 12:14 p.m., the Licensed Practical Nurse stated that the resident was refusing the sleeves. She said if the resident was refusing the sleeves, staff should write a progress note and attempt again. c. At 12:49 p.m., the Nurse Manager and Nurse Practitioner stated that if the resident continues to refuse geri-sleeves, staff should use long sleeved shirts to protect the resident's arms. After surveyor intervention, the Nurse Manager stated she tried to apply the new sleeves she obtained, but the resident refused to wear them and was currently wearing a long sleeve shirt. (10 NYCRR 415.11(c)(2)(iii))

Plan of Correction: ApprovedNovember 9, 2018

1. Identified #28 resident provided with 2 new geri-sleeves (arm protectors) immediately. Based on the resident?s history of refusing geri-sleeves the care plan and care card was revised to reflect that resident may be dressed in long sleeves for protection or may wear geri-sleeves if resident is agreeable. Primary Shahbaz was immediately re-educated to report all refusals to RN or LPN and to be knowledgeable to resident?s plan of care. Staff informed of care plan and card revisions.
Responsible Party: Cottage Nurse Manager
2. Interview staff to determine residents who refuse care planned interventions. Any residents identified as refusing care or treatments will be discussed with the interdisciplinary team to determine an individualized plan of care. Care plan revisions will be made based on residents' choices and needs.
Responsible Party: DON/ADON
3. Care Plan Policy reviewed. Determination made that no revision of policy was indicated. All nursing staff will be educated using the Care Card Guidelines with an emphasis of responsibility to follow the plan of care, to communicate residents choices and revision of resident?s care plan to meet their individualized needs.
Responsible Party: DON/ADON/Designee
4. On a monthly basis a random audit of the residents who refused interventions will be completed to ensure Care Plan Compliance. Audit will include completion of refusal documentation and revision to plan of care to include the resident's voice.
Responsible Party: ADON/Nurse Managers/designee
5. Compliance will be monitored utilizing the quality audit process review. Results of the monthly audit will be submitted to the ADON who will review the results, evaluate, address any variation to compliance and ensure continued adherence to the policy. Results will be reported to the PRLC QAPI Committee for a minimum of 6 months. The QAPI Committee will determine the scope and duration of the audits based on the results of the facility and Nurse Managers findings.
Responsible Party: ADON/designee

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 17, 2018
Corrected date: December 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, an interview, and record review conducted during the Life Safety Code Survey, it was determined that for one of four pieces of Patient Care Related Electrical Equipment (PCREE) reviewed, the facility did not properly maintain equipment. Specifically, patient sit to stand lifts were not maintained in accordance with the manufacturer's specifications. The findings include: Observations conducted on 10/11/18 at 9:55 a.m. revealed a battery powered Invacare Reliant RPS 350 stand up lift outside Resident room [ROOM NUMBER] (Cottage 200). A review of the manufacturer's specifications and maintenance manual for the lift revealed a monthly institutional safety inspection including, but not limited to, the base, the mast, the lift arms and linkage, the electric [MEDICATION NAME], and slings. A review of the facility policy, #BIO226 - Alternative Equipment Maintenance, revealed maintenance schedules will be based upon a risk assessment and work histories for a minimum of two years shall be evaluated for the initial assessment and annually following. In an interview on 10/12/18 at 2:08 p.m., the Clinical Engineering Supervisor stated that they are doing an annual inspection on the lifts anf are following the Manufacturer's Recommendations for the lifts. He said they are not doing a monthly inspection, he would expect the nursing staff to do the monthly inspection. He said he was not aware of a monthly requirement for the lifts. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99: 10.5.2.1, 1.5.3.1, 10.5.3.1.2, 10.5.6.1.1)

Plan of Correction: ApprovedNovember 9, 2018

1. Immediate corrective action taken was to perform the required preventative maintenance inspection. No issues were found, and the lift was returned to service.
2. To identify other potentially deficient areas, the Manager of Facilities Engineering established a spreadsheet inventory of all lifts with corresponding manufacturer?s maintenance recommendations. Each lift was inspected per manufacturer?s recommendations and deemed to be safe.
3. Systemic changes put in place to prevent the deficient practice include:
a. Manager of Facilities Engineering will now be liaison to RRH Clinical Engineering Department with oversight of all Patient Care Related Electrical Equipment work orders, and compliance with manufacturers recommended preventative maintenance program until an Alternative Equipment Maintenance Program is established specifically for Park Ridge Living Center.
b. Manager of Facilities Engineering will monitor weekly TMS System Work Order Reports from the RRH Clinical Engineering Department.
c. Manager of Facilities Engineering will oversee development of Alternative Equipment Maintenance Program.
4. Manager of Facilities Engineering will monitor compliance through TMS Work Order Completion Report and Clinical Engineering Preventative Maintenance Compliance Report to be submitted to the Quality Assurance Committee.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: October 17, 2018
Corrected date: December 16, 2018

Citation Details

Based on observations and interviews conducted during the Life Safety Code Survey, it was determined that for two of two emergency power systems, the facility did not provide compliant remote annunciation. Specifically, the remote annunciators were not installed in a commonly occupied work station. The findings include: Observations conducted on 10/11/18 at approximately 10:30 a.m. revealed that an annunciator panel for the emergency generator for the TCC (Transitional Care Unit) was located on the wall in the TCC mechanical room. An interview with the Director of Facilities revealed that was the only location for the annunciator panel, and it could probably be heard from the hall when it goes off, but he was not sure if staff members would know what it was. An observation on 10/12/18 at 2:27 p.m. revealed that the generator remote annunciator for the cottages was located in the back room of the Pole Barn. In an interview at that time, the Director of Facilities stated that the maintenance staff work between 7:30 a.m. and 5:00p.m. He said the remote annunciator would not be heard by maintenance staff. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99: 6.4.1.1.17, 6.5.1)

Plan of Correction: ApprovedNovember 9, 2018

1. Immediate action was taken to arrange relocation of annunciator panels for both generators. In TCC, the new annunciator panel will be located in the Nurses' Station. For the Cottages, the Pole Barn generator annunciator panel will be located in the Nurses' Office of Cottage 100. Both areas are commonly occupied all three shifts by nursing staff. The work is scheduled to be completed on (MONTH) 20, (YEAR).
2. There are no other generators that would be impacted.
3. Systemic changes will be to educate Nursing staff on the new annunciator panels and what to do in case of alarm.
4. Compliance with the corrective action will be the responsibility of the Manager of Facilities Engineering, who will report completion and compliance of the project and education of staff to the Quality Assurance Committee.