Our Lady of Peace Nursing Care Residence
July 26, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2017
Corrected date: September 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 7/26/17, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Two (Residents #271, 322) of six residents reviewed for unnecessary medications had issues involving the lack in attempt of a gradual dose reduction (GDR) of an antipsychotic medication; the lack of evidence of behavioral concerns and supporting documentation to support the continued use of the antipsychotic medication. The findings are: 1. Resident #322 was admitted [DATE] with diagnoses which include unspecified dementia with behavioral disturbances, diabetes, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS-a resident assessment tool) dated 5/9/17 revealed the resident is severely cognitively impaired. Review of the Care Plan with a start date of 10/13/16 revealed the resident has behaviors which include attempting to self-transfer and can become combative with care. Review of the Medication Administration Record [REDACTED]. The medication had a start date of 7/18/16 and an end date of 6/13/17. Additionally, there was an order for [REDACTED]. Review of Interdisciplinary Notes dated 1/2/17 through 6/12/17 lacked documentation of any behaviors to warrant the use of antipsychotic medications. Review of Daily Charting for behavioral symptoms dated 1/1/17 to 6/12/17 revealed there was no documentation of the resident having any behaviors. Review of a pharmacy recommendation dated 6/7/17 revealed the resident was receiving two antipsychotics but needs to have evidence in the chart of the following conditions exist: The symptoms being are identified as being due [MEDICAL CONDITIONS] (auditory/visual/other hallucinations, delusions), the behavior symptoms present a danger to the resident or others. The symptoms are significant enough that the resident is experiencing inconsolable/persistent distress, a significant decline in function or substantial difficulty receiving needed care. The Physician neither agreed or disagreed. He checked the other box with the following notation: [MEDICATION NAME] one mg PO (by mouth) continues at bedtime and discontinue [MEDICATION NAME] Bid. The recommendations were signed 6/12/17. Review of the MAR indicated [REDACTED]. During intermittent observation of the resident on 7/24/17 and 7/25/17 between approximately 10:05 AM and 12:30 PM revealed there were no verbal outbursts, no attempts to self-transfer, and no hitting. The resident was calm and pleasant. Review of Interdisciplinary Notes, 24 Hour Unit Reports, and Daily Charting for behavioral symptoms lacked dated 6/13/17 through 6/30/17 lacked documentation of the resident's response to the discontinuation of the [MEDICATION NAME]. Interview with Assistant Director of Nursing (ADON) on 7/24/17 at 11:45 PM revealed there were no other notes and confirmed when a GDR occurs staff should be monitoring and documenting resident behaviors for 10-14 days following the GDR. Interview with Director of Nursing (DON) on 7/25/17 at 11:25 AM revealed the resident was flagged for BMRC (Behavior Management Review Committee) because he had no [DIAGNOSES REDACTED]. Interview with the Consultant Pharmacist on 7/25/17 at 12:30 PM revealed there should have been a GDR sooner or documentation of contraindications for the GDR. There should also be documentation of the resident's behavior following the discontinuation of an antipsychotic medication. Review of a facility policy entitled Guidelines for Charting and Documentation dated 12/16 revealed the purpose of charting and documentation is to provide a complete account of the resident's care, treatment, response to the care, signs, symptoms and the progress of the resident's care. Review of a facility policy entitled Antipsychotic Medication with a revised date of 5/2017 revealed the physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risk to the resident and others. The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. 2. Resident # 271 was admitted to the facility on [DATE] with diagnoses of dementia, major [MEDICAL CONDITION], and hypertension (HTN). Review of the Minimum Data Set (MDS- resident assessment tool) dated 5/12/17 revealed the resident is severely cognitively impaired, sometimes understands and is sometimes understands. Section E - Behavior documented the resident exhibited hallucinations and delusions during the assessment look back period. Section N - Medications documented the resident received antipsychotic medication during the assessment look back period. Review of a physician order [REDACTED]. Review of a physician order [REDACTED]. Review of a current physician order [REDACTED]. Review of the Medication Administration Records (MAR) dated (MONTH) 20, (YEAR) through (MONTH) 25, (YEAR) revealed the resident was administered [MEDICATION NAME] 0.25 mg as ordered. Review of the Interdisciplinary Team (IDT) Notes dated 11/1/16 through 7/25/17 revealed there were no documented behavioral concerns. Review of the Physicians Progress notes dated 1/1/17 through 6/30/17 revealed there were no documented behavioral concerns or documentation to support the continued the use of [MEDICATION NAME]. Review of the Behavior Symptoms Resident Detail report dated 1/1/17 through 7/25/17 revealed there were no behavior symptoms documented, except one Yes response documented on 6/6/17. There was no additional information documented to describe the behavior. Review of the Certified Nurse Aide (CNA) Daily Charting dated 1/1/17 through 7/25/17 revealed no documented evidence that the resident exhibited any behavioral symptoms. Review of a Psychoactive Medication Evaluation form dated 7/14/17 reveled resident has delusions/ hallucinations at times, can become paranoid with staff at times and may refuse care. Resident seen by psychologist 2/18/16 for delusions/ paranoia. Additional review revealed a documented comment; IDT dis: 7/19/16 no adverse behaviors at this time. The last dose change documented was 7/20/16. Review of a Psychoactive & Sedative/Hypnotic Utilization By Resident report for records updated between 6/1/2017 and 7/26/17 prepared by the Consultant Pharmacist printed on 7/26/17 revealed the following documentation: - 6/16 resident displays paranoia; s/s (sign/ symptoms) cont (continue) - 12/16 cont (continue) s/s intermitt (intermittently) - 6/17 sees dead people- behav (behavior) cont but epis- epis (episode to episode) controll (controlled) by redirection ? During interview on 7/25/17 at approximately 9:20 AM, the Registered Nurse (RN #1) Unit Manager stated she attends the BMARC Behavior Modification Assessment Review Committee meetings along with Social Worker, the Pharmacy Consultant, Assistant Director of Nursing (ADON). The discussion is based on what the nursing staff reports to her. RN #1 stated she reviews the documentation from the nurses and from the CNA's. The RN stated she would expect behaviors to be documented in the Nursing Progress Notes. I usually get my information from what I see, from what the staff tell me and I bring this information to the meetings for discussion. I didn't think documentation was an issue. During interview on 7/25/17 at approximately 9:30 AM, the Consultant Pharmacist stated his information is gathered from the Unit Manager and the Social Worker during monthly meetings. They tell me what happens, I go by their word, I was unaware there was poor documentation. I don't necessarily read the nursing documentation. I have no time to review the entire medical record. I'm only in the facility for a limited amount of time. The Consultant Pharmacist stated typically there should be supporting documentation for the use of [MEDICAL CONDITION] medications. During an interview on 7/25/17 at approximately 9:47 AM, the Social Worker (SW) stated she usually copies and pastes her information from month to month on her assessments and gathers her information from the nursing staff. The SW stated the resident did see dead people in her television in the past but can't recall when and did not document the episode. The SW further stated, she (the resident) does hallucinate and refuses care at times. During interview on 7/25/17 at approximately 10:03 AM, the Physician stated he relies on the nursing staff to inform him of accurate information and he would expect the resident's behaviors to be documented. Additionally, the Physician stated, I should have added supporting documentation for the use of the med. During an additional interview on 7/25/17 at approximately 12:59 PM, the Consultant Pharmacist stated that the resident should have had a GDR of the [MEDICATION NAME] or a documented rational for the continued use. During an interview on 7/26/17 at approximately 12:23 PM, CNA #2 stated she has been at the facility for about a year. The CNA further stated that the resident does not have any behaviors and has not had any recent episodes of seeing dead people that she is aware of. During interview on 7/26/17 at approximately 2:15 PM, the Director of Nursing (DON) stated that she expects accurate documentation from nursing and supporting documentation from the Physician. If it's not documented then it wasn't done. Review of a policy entitled Nursing Summaries and/or Assessments with a revised date of 12/16 revealed under Management/Behavior section: the documentation should describe any problem(s) noted during the month and the frequency of such problem(s). Indicate if the resident was belligerent, friendly, cooperative, etc. Review of the policy entitled Behavioral Assessments, Intervention and Monitoring revised 5/2017 revealed under the Monitoring section; The IDT will monitor the progress of the individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. 415.12(l)(1)

Plan of Correction: ApprovedAugust 16, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F329:
Corrective Action Taken for the Affected Two Residents:
- Resident #322 had a chart review conducted by the attending physician who reduced the [MEDICATION NAME] to .5 mg daily on (MONTH) 25, (YEAR). Behavior charting was initiated for 14 days to monitor condition during reduction of medication. Future reviews are scheduled for the Behavior Modifying and Review Committee to continue gradual dose attempts.
- Resident #271 had a chart review conducted by the attending physician who reduced the [MEDICATION NAME] to .125 mg daily on (MONTH) 25, (YEAR). Behavior charting was initiated for 14 days to monitor condition during reduction of medication. Future reviews are scheduled for the Behavior Modifying and Review Committee to continue gradual dose attempts.
Identification of Other Affected Residents and Corrective Action:
? All residents receiving [MEDICAL CONDITION] medications have the potential to be affected by untimely gradual dose reductions. The facility will identify those residents through a [MEDICAL CONDITION] drug regimen review conducted by the Behavior Modifying and Review Committee on (MONTH) 16, (YEAR). The Committee will review [MEDICAL CONDITION] medication dose, [DIAGNOSES REDACTED]. MD orders will be obtained and the resident will be placed on behavior charting for 14 days to monitor condition. Careplans will be adjusted accordingly by the Social Worker.
? Future Behavior Modifying and Review Committee dates will assigned to each resident to assure gradual dose reductions are evaluated timely and consistently and documentation is present to support the evaluation.
Measures or Systematic Changes to Prevent Recurrence:
? Behavior Modifying and Review Committee Recommendation Form has been revised to include last gradual dose reduction and next scheduled review.
? All Unit Managers and Social Work staff will be in-serviced on the (1) Antipsychotic Medication and (2) Behavioral Assessment, Intervention and Monitoring Policy and Procedures by the Administrator. All Nurses will be inserviced on the (1) Antipsychotic Medication and (2) Behavioral Assessment, Intervention and Monitoring Policy by the Education Dept.
? A [MEDICAL CONDITION] drug regimen review will be added to the MDS/Care Plan Review Audit with each resident's scheduled Annual/Quarterly/Significant Change assessments with recommendations provided to the attending physician.
How Corrective Action is Monitored and Person Responsible:
? The [MEDICAL CONDITION] drug regimen reviews will be turned into Director of Social Work on a weekly basis.
? The Director of Social Work or designee will compile statistical data on a monthly basis. Trend analysis data will be presented monthly to the Quality Assurance Committee by the Director of Social Work, or designee, for evaluation and recommendations for improvements as needed.
The responsibility of attaining and maintaining compliance is assigned to the Director of Social Work.

Standard Life Safety Code Citations

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2017
Corrected date: September 15, 2017

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 7/26/17, the Communication Room was not protected by a supervised automatic sprinkler system and did not meet the conditions for the room to be exempt from being sprinklered. This affected one of one Basement. The finding is: 1. Observation in the Basement on 7/24/17 at approximately 8:45 AM revealed the Communication Room was not protected by an approved supervised automatic sprinkler system. Further observation revealed the Communication Room measured approximately 10 feet wide by 18 feet long and the only entrance into the Communication Room was through the Electric Room, which was also not sprinklered. Interview with the Facilities Director on 7/26/17 at approximately 2:25 PM revealed the Communication Room contains data lines and phone lines and this room has never had sprinkler coverage. Further interview revealed the walls of the Communication Room are poured concrete, which would provide a two-hour fire resistance rating and the door between the Communication Room and Electric Room has a 90-minute fire resistance rating. According to National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 edition, sprinkler protection shall be required in electrical equipment rooms, with the exception: sprinklers shall not be required where all of the following conditions are met: (a) the room is dedicated to electrical equipment only, (b) only dry-type electrical equipment is used, (c) equipment is installed in a two-hour fire-rated enclosure including protection for penetrations, (d) no combustible storage is permitted to be stored in the room. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.5, 19.3.5.1, 9.7, 9.7.1, 9.7.1.1 2010 NFPA 13: 8.15, 8.15.10.1, 8.15.10.3

Plan of Correction: ApprovedAugust 18, 2017

K351:
Immediate Corrective Action Taken:
Contractors were contacted to provide assessment of the Communication Room and provide a bid for installation of a supervised automatic sprinkler to this 10 feet x 18 feet poured concrete room. Installation will be scheduled as soon as possible and will be completed by 9/15/17.
Identification of other Affected Areas:
All other areas of Our Lady of Peace have supervised automatic sprinkler coverage (which is inspected quarterly) with the exception of the Electric Room located in the basement which is exempt from the sprinkler requirement.
Measures to Prevent Recurrence:
All other areas of Our Lady of Peace have supervised automatic sprinkler coverage as required. Assuring these system are inspected quarterly is the responsibility of the Facilities Director. The maintenance staff have been re-educated on the NFPA 13, Standards for the Installation of Sprinklers, 2010 edition by the Director of Facilities.
Monitoring of Corrective Action:
The Director of Facilities will assure the communication room has a supervised sprinkler system installed by 9/15/17 which will be reported to the Quality Assurance Committee for any further recommendations.
The responsibility for compliance with K351 is the Director of Facilities.