Eastchester Rehabilitation and Health Care Center
December 21, 2018 Complaint Survey

Standard Health Citations

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 21, 2018
Corrected date: February 6, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during an abbreviated survey (NY 018), the facility did not ensure the development and implementation of comprehensive person-centered care plan for a resident. This was evident in 1 out of 4 residents sampled (Resident #1). Specifically, the facility did not ensure a comprehensive care plan was developed, with measurable goals and person-centered interventions to address several blisters, some of which were ruptured, on Resident #1's left 2nd, 3rd, 4th and 5th toe. Findings: Resident #1 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 12/20/2017 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) and scored 8/15, associated with moderate impairment of cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). The facility policy and procedure titled, Comprehensive Care Plan (CCP), dated 12/2015 states that the Comprehensive Care Plan (CCP) will be individualized, defining the problems/needs identified from each discipline's assessment, attainable goals and interventions. Each resident's CCP shall be reviewed and updated by the interdisciplinary team as per MDS 3.0 schedule and if the resident's condition warrants it. A Nurse's Progress Note by the Registered Nurse Supervisor #1 (RNS #1) dated 12/27/2017 at 1:04 PM, documented that RNS #1 was called to Resident #1's room by the attending nurse and the resident was noted with opened areas to the 2nd, 3rd, and 4th left toes. All 5 left tarsal digits noted with multiple fluid blisters and a blood- filled blister to the great toe. A Nurse's Progress Note by RN#2 (Wound Nurse) dated 12/27/2017 at 5:01 PM, documented that she assessed Resident #1's left foot. The left first toe had multiple blood-filled blisters, left 2nd toe with ruptured blister; left 3rd toe with ruptured blister, left 4th toe with ruptured blister; and left 5th toe with fluid filled blister. The treatment included xeroform dressing and dry pressure dressing daily and as needed. A Physician's Progress Note dated 12/27/2017 at 5:22 PM, documented that Resident #1 was seen for abrasion (skin tear) to left 2nd, 3rd and 5th toes. A Physician's Progress Note dated 12/28/2018 at 1:10 PM, documented that Resident #1 was receiving wound care for multiple opened blisters on the left toes. Record review revealed that a skin impairment CCP was not initiated with interventions in place to address Resident #1's skin condition. RN #2 was interviewed on 06/08/2018 at 11:42 AM and stated that RNS #1 called her to assess Resident#1's left foot on 12/27/2017, and she observed the blisters on the resident's toes and that a CCP was not created to address the blisters on the resident's left foot. The Director of Nursing Service (DNS) was interviewed on 12/21/2018 at 4:40 PM and stated that a Care Plan (CP) on Skin Alteration should have been created whether the resident received treatment or not and that any RN could have created the CP. 415.11 (c)(1)

Plan of Correction: ApprovedJanuary 4, 2019

The facility will develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs with measurable goals and person-centered interventions to address resident?s needs.
The following actions were taken for residents affected by the deficient practice at the time of occurrence:
1. At the time of the notification and investigation of the occurrence the resident #1 was no longer a resident at the facility.
2. A. RNS # 1 was re-interviewed and will receive a 1:1 counseling regarding his/her responsibility for the development and implementation of a person-centered comprehensive care plan for residents with newly developed skin impairments.
B. RN #2 was re-interviewed and will also receive a 1:1 counseling regarding his/her responsibility for the development and implementation of a person-centered comprehensive care plan for residents with newly developed skin impairments.
C. An audit will be conducted by (whomever you assign) on all residents with newly developed skin impairments over the past three months to ensure a person-centered comprehensive care plan is in place with measurable objectives and timeframes to meet the resident?s needs. Any negative findings will be immediately corrected and person-centered care plan will be developed and implemented.
3. A. The policy and procedure for Comprehensive Care plans was reviewed by the DNS and revised specifically related to development and implementation of a person-centered care plan when a resident develops a new skin impairment.
B. All licensed nurses will be in-serviced on the newly revised policy and procedure by (whomever you assign).
4. An audit tool was developed by the QA Committee to ensure compliance. The audit will be conducted by (whomever you assign/designee) on all residents who develop skin impairments weekly x 3 months, monthly x 3 months and then as directed by the QA Committee. Any negative findings will be immediately reported to the Administrator and QA Committee for further action.
5. The DNS will be responsible for compliance with this F tag.

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 21, 2018
Corrected date: February 6, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated survey (NY 018), the facility did not ensure that an accident was investigated. This was evident for 1 out of 4 residents sampled (Resident #1). Specifically, Resident #1 was noted to have open areas and blisters to the left foot toes after a Certified Nursing Assistant (CNA) reported bumping the resident's foot with a Geri-Chair. The facility did not investigate the accident to rule out abuse, neglect or mistreatment. Findings: Resident #1 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 12/20/2017 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) and scored 8/15, associated with moderate impairment of cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). The facility policy and procedure titled, Accident-Investigation Data Collection, dated 11/2003 states that all accidents will be investigated, documented and reported to the New York State Department of Health as appropriate. A review of the facility's Accident/Incident Reports for 12/01/2017 through 12/31/2017 revealed no incident report regarding an accident involving Resident #1 on 12/27/2017, when a CNA hit the resident's left foot with a Geri-Chair. A Nurse's Progress Note by the Registered Nurse Supervisor #1 (RNS #1) dated 12/27/2017 at 1:04 PM, documented that the attending nurse called RNS #1 to Resident #1's room. The resident was noted with opened areas to the 2nd, 3rd, and 4th left toes. All 5 left tarsal digits noted with multiple fluid blisters and a blood- filled blister to the great toe. The CNA stated that while the resident was lying in bed, the padded section of the Geri-Chair bumped the resident left great toe. The resident verified that the chair bumped her left great toe. A Nurse's Progress Note by RN #2 (Wound Nurse) dated 12/27/2017 at 5:01 PM, documented she assessed Resident #1's left foot. The left first toe with multiple blood-filled blister, left 2nd toe with ruptured blister; left 3rd toe with ruptured blister, left 4th toe with ruptured blister; and left 5th toe with fluid filled blister. The treatment included xeroform dressing and dry pressure dressing daily and as needed. RNS #1 was interviewed on 06/08/2018 at 03:04 PM and stated that she received a report from Resident #1's nurse stating that the resident's toes were open. She stated that the CNA (not the assigned CNA to the resident) reported that the same great toe was bumped by the Geri-chair of another resident. She stated that the CNA reported that the resident's foot was hanging off the bed while the resident was lying in bed and that the chair bumped into the resident's left foot while she was transporting the resident's roommate in the Geri chair. RN #1 stated she asked the CNA to write a statement. The CNA admitted she bumped the resident's left foot with the Geri-chair and she reported it to the Charge Nurse. RN#1 also stated that she made an occurrence report and gave the statements to the Director of Nursing (DNS). Licensed Practical Nurse #1 (LPN #1) was interviewed on 06/22/2018 at 11:15 AM and stated that she no longer works at the facility. According to LPN #1, a CNA (cannot recall the name) notified her that the resident had opened areas to the left toes. The resident was in bed and had her left foot extended out of the bed and that the CNA bumped the resident's left foot with the resident's roommate's Geri-chair. LPN #1 stated she cleaned the area and notified RN#1. She further stated that RN #1 did not make an incident report and that RN #1 told her that it was an existing blister that popped, and an incident report was not needed. The resident confirmed that a wheelchair hit her foot. CNA # 1 was interviewed on 06/23/2018 at 11:41 AM and stated that she was pushing one of Resident #1's roommate in a recliner chair (Geri-chair) and did not see Resident #1's left foot hanging out of the bed. She bumped the resident's left foot with the Geri-chair and observed skin tear and bleeding on the 4th toe. She realized that she hit Resident #1's foot with the Geri-Chair when she heard the resident cried out. She does not recall if Resident #1 had blisters on her toes prior to the incident. She wrote a statement of the incident and gave it RN #1. The Director of Nursing (DNS) was interviewed on 06/08/2018 at 3:04 PM and stated that she cannot find the facility investigation of the incident for the incident on 12/27/2017 involving the CNA bumping Resident#1's foot with the Geri-chair. She stated that she was not the DNS at the time of the incident. During a follow-up interview with the DNS on 12/21/2018 at 4:30 PM, she stated that RN#1 assessed the resident's toes after the CNA reported bumping the resident left foot with the Geri-chair. 415.4 (b)

Plan of Correction: ApprovedJanuary 4, 2019

The facility will ensure that all allegations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated so as to prevent further potential abuse, neglect, exploitation, or mistreatment.
The following actions were taken for residents affected by the deficient practice at the time of occurrence:
1. At the time of the notification and investigation of the occurrence the resident #1 was no longer a resident at the facility.
2. A. RN #1 was re-interviewed and she again verbalized that she completed an incident report. She was provided with a 1:1 in-service by the DNS on the importance of completing an incident/occurrence report and ensuring an investigation is initiated and brought to the attention of the DNS.
B. An audit will be conducted by the DNS/designee of all accident and incident reports over the 3 months to ensure an investigation was completed. Any negative findings will be immediately corrected and investigation initiated.

3. A. The policy and procedure for Accident Investigation Data Collection was reviewed by the DNS and was revised specifically related to initiating and completing an investigation of all occurrences.
B. All employees will be in-serviced on the newly revised policy and procedure by ADON/Designee.
4. An audit tool will be developed by the QA Committee to ensure compliance. The audit will be conducted by the ADNS/Designee on all occurrences weekly x 3 months, monthly x 3 months and then as directed by the QA Committee. Any negative findings will be immediately reported to the Administrator and QA Committee for further action.
5. The DNS will be responsible for compliance with this F tag.