Elderwood at Ticonderoga
April 28, 2016 Certification/complaint Survey

Standard Health Citations

FF09 483.20(g) - (j):ASSESSMENT ACCURACY/COORDINATION/CERTIFIED

REGULATION: The assessment must accurately reflect the resident's status. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. A registered nurse must sign and certify that the assessment is completed. Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. Under Medicare and Medicaid, an individual who willfully and knowingly certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or an individual who willfully and knowingly causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty of not more than $5,000 for each assessment. Clinical disagreement does not constitute a material and false statement.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 28, 2016
Corrected date: June 27, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey and abbrieviated survey (Case #NY 426), the facility did not ensure the accuracy of the Minimum Data Set for 7 (Resident #s 1, 16, 20, 28, 38, 52 and #74) of 15 residents reviewed. Specifically, for Resident #'s 16, 38 and 52, the facility coded enabler bars as restraints in the Restraint section of the MDS. Additionally, for Resident #38, the facility coded the MDS (Section O) for Respiratory Therapy with no documented evidence the resident received a required lung assessment between 3/4/16 and 3/7/16 from a Registered Nurse (RN). The facility did not accurately code the Respiratory Therapy section of the MDS for Resident #37 when the EMAR (electronic Medication Assistance Record) dated 3/2016, documented that respiratiry therapy was provided on 6 rather than 7 days during the time period of 3/23/16 and 3/29/16. Also, the facility did not accurately code the Bladder and Bowel (Section H) of the MDS dated [DATE] for Resident #74, who has a foley catheter, when the MDS documented that the resident was always incontinent of urine. This was evidenced by: Resident #16: The facility did not ensure the accuracy of the Minimum Data Set (MDS). Enabler bars were coded as restraints. This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was moderately cognitively impaired (Section C0500 totaled 8), but able to make herself understood and was able to understand others. Section P0100 A documented the resident had bed rail restraints used daily for the evaluation period (4/8/16 through 4/14/16). The Comprehensive Care Plan (CCP) did not document a restraint for this resident. physician progress notes [REDACTED]. The ADL (Activities of Daily Living) Care Plan/Nurse Aide Care Card dated 5/7/14, did not document the use of a restraint. During an interview on 4/26/16 at 1:30 pm, the Registered Nurse Manager (RNM) stated the MDS RN incorrectly coded the use of enabler bars for mobility as a restraint on the MDS. She stated the enabler bars were not a restraint for this resident, so the enabler bars should not have been coded as a restraint. Resident #38: Finding 1: The facility did not ensure the correct coding on the Minimum Data Set (MDS) for restraints. This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was cognitively intact (Section C0500 totaled 14), and able to make himself understood and was able to understand others. Section P0100 A documented the resident had bed rail restraints used daily for the evaluation period dated 3/1/16 through 3/7/16. The Comprehensive Care Plan (CCP) for Siderails dated 6/5/15, documented the resident had requested side rails for mobility. The Activities of Daily Living (ADL) Care Plan/Nurse Aide Care Card dated 6/5/15, did not include the use of restraints. During an interview on 4/26/16 at 1:30 pm, the Registered Nurse Manager (RNM) stated the enabler bars were not an actual restraint for this resident. The RNM stated that the MDS dated [DATE], was inaccurately coded for restraints During an interview on 4/26/16 at 1:40 pm, the RN Supervisor reviewed the RAI (resident Assessment Instrument) guidelines and stated the definition of Restraints for the MDS was identified as an item that restricts the voluntary movement of the resident. She stated the MDS for Resident #38 was coded incorrectly and needed to be corrected. She also stated she had noticed there had been an increase in percentage of restraints in use on the Casper Reports for the facility. Finding 2: The facility did not ensure the coding was accurate on the Minimum Data Set (MDS) for respiratory therapy. This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact, and able to make him self understood and to understand others. The Physician order [REDACTED]. A review of the Electronic Treatment Administration Record (ETAR) dated 3/2016, revealed no documented evidence of RN [MEDICAL CONDITION] Assessment/Auscultation of Lung Sounds between 3/4/16 and 3/7/16. During an interview on 4/27/16 at 11:30 am, the Registered Nurse Manager (RNM) stated she could not find a Policy and Procedure for the Respiratory Therapy Program. During an interview on 4/28/16 at 8:00 am, the Director of Nursing (DON) stated that the Licensed Practical Nurse (LPN) does the exercises and the Registered Nurse (RN) performs the lung sounds/assessment. The Rehabilitation Nursing Program is overseen by the MDS Nurse (an RN). The DON stated the Respiratory Therapy Program would be more of a maintenance program and acknowledged that the MDS Registered Nurse was documenting the respiratory treatment being received by specific residents on the MDS as Respiratory Therapy. The DON stated that she had been unable to locate a Respiratory Therapy Policy and Procedure or Protocol for the Respiratory Therapy Program. The DON stated the program had been in place over 6 months and the MDS RN had been employed at the facility over one year. During an interview on 4/28/16 at 10:10 am, the Registered Nurse (RN) Supervisor stated that she did not perform the respiratory exercises a lot because she was not on the medication cart. She stated that the RespiratoryTherapy Program was a program that the MDS RN initiates. The MDS RN, evaluates the residents on the program and reviews with the IDT (Interdiscipl;inary Team) and the physician. The RN produced a Policy and Procedure for the Respiratory Therapy Program she had been instructed to provide to the survey team from the DON, earlier that day. The RN was asked to review the Respiratory Therapy Program that she had recently handed to the survey team and after reviewing the Respiratory Therapy Policy and Procedure, she then stated she had never seen that Policy and Procedure previously to providing it to the survey team. Resident #52: The facility did not ensure the coding for physical restraints was accurate on the Minimum Data Set (MDS). This resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was moderately cognitively impaired (Section C0500 totaled 9), was able to make her needs known and able to understand others. Section P0100 A documented the resident had bed rail restraints used daily for the evaluation period dated 2/19/16 through 2/25/16. The Activities of Daily Living (ADL)/Nurse Aide Care Card did not include documention regarding the use of a restraint. The physician progress notes [REDACTED]. During an interview on 4/26/16 at 1:30 pm, the RNM stated the MDS RN is a new graduate RN and had no Long Term Care experience. She stated that she inaccurately coded the use of enabler bars for mobility, as restraints. Additionally, it was stated that the enabler bars were not an actual restraint for this resident per the RNM. During an nterview on 4/26/16 at 1:40 pm, the RN Supervisor stated that after reviewing the definition of Restraints for the MDS, in the RAI Manual, that the enabler bars did not restrict the resident's freedom of movement or normal access to the residents'. She stated the MDS's were coded incorrectly and will need to be corrected. She additionally stated that she had noted an increase in facility percentage of restraints in use on the Casper Reports for the facility Resident #37: The facility did not accurately code the Respiratory Therapy section of the Minimum Data Set (MDS). This resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had moderately impaired cognition (Section C0500 totaled 12), was able to make himself understood and was able to understand others. Section O400 D documented the resident had received respiratory therapy 6 of the 7 days of the evaluation period (3/23/16 through 3/29/16). A Physician order [REDACTED]. The resident was to relax the shoulders and facial muscles, and without puffing the cheeks inhale slowly and deeply through the nose. The resident was then to exhale slowly through pursed lips as though [MEDICATION NAME] or lightly flickering candle flames. Staff were to stress that exhalation should be 3 times as long as inhalation. This was to be performed every evening shift for promotion of lung expansion and circulation related to anxiety, shortness of breath, wheezing, other chronic [MEDICAL CONDITIONS] and chronic [MEDICAL CONDITION]. Staff were to implement breathing exercises, observe and document oxygen saturation, respirations, heart rate and time spent with the resident which should be 15 minutes daily, 7 days each week. A Registered Nurse (RN) was to auscultate the lung sounds on Monday and Friday. A Physician order [REDACTED]. The EMAR (electronic Medication Assistance Record) dated 3/2016, documented that between 3/23/16 and 3/29/16, the resident performed deep/pursed lip breathing exercises up to 3 sets of 10 respirations as tolerated on 6 days. During an interview on 4/26/16 at 11:52 am, RN #1 stated she had been instructed to document that breathing exercises (Respiratory Therapy) were completed by the resident even if they were not done. She stated she had attempted to do the exercises with the resident, but he was not capable of doing the exercises because of the severity of his lung disease. During an interview on 4/28/16 at 9:15 am, this resident stated that staff did not perform the Respiratory Therapy with him. During an interview and observation on 4/28/16 at 9:25 am, RN #2 was asked to perform the Respiratory Therapy as described on the ETAR, the RN explained to the resident that she was there to perform his Respiratory Therapy exercises with him, then put the automatic blood pressure cuff and oxygen sensor on the residents left arm and finger. The RN then began instructing the resident to take a deep breath and slowly breathe out. At 9:27 am, the RN and the resident began a verbal conversation (not related to the specific respiratory therapy) that ended at 9:29 am. At 9:29 am, the RN then instructed the resident to take a deep breath in, and squeeze it all out, the RN then stated the resident's oxygen level was at 97% and pulse was 83 beats per minute. At 9:30 am, she asked the resident if he was feeling calmer, and the resident stated it feels like air is staying in my upper belly while placing his right hand on his right upper abdomen. The RN stated the resident was doing great and delivered some possible reasons for the feeling of air that had been described by the resident. At 9:32 am she began the breathing exercises again, and at 9:33 am the RN asked the resident to cough, which he did. The resident then stated it makes me more out of breath. The breathing exercises ended at 9:34 am. This exercise was not completed as directed on the ETAR. During an interview on 4/28/16 at 9:40 am, after the breathing exercises with RN #2, the resident stated that staff had not performed the exercises with him before, and that this was new to him. During an interview on 4/28/16 at 10:27 am, the RNM stated she did not perform the Respiratory Therapy on this resident, and she was not aware if the therapy was normally performed on this resident. During an interview on 4/28/16 at 11:48 am, a Licensed Practical Nurse (LPN) stated she attempted to do the breathing exercises with this resident, but he was not usually capable of completing them. She stated she was not trained to do the breathing exercises with the resident, but she followed the directions on the EMAR. Resident #74: The facility did not accurately code the Bladder and Bowel Section of the Minimum Data Set (MDS). This resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had severely impaired cognition and rarely/never was able to make himself understood and rarely/never understood others. A physician's orders [REDACTED]. Monitor every shift with output for [MEDICAL CONDITION]. A Nurses Progress Note dated 3/10/16 at 9:47 pm, documented the resident had a urine output of 30 ml from his Foley. A Nurses Progress Note dated 3/17/16, at 1:10 pm, documented the resident had a urine output of 25 ml from his Foley. The Electronic Treatment Administration Record (ETAR), documented the resident received Foley care every shift from (MONTH) 1 to (MONTH) 21, (YEAR) on the evening shift. The MDS dated [DATE], in Section H Bladder and Bowel, under urinary continence, documented that the resident was always incontinent of urine. During an interview on 3/28/16 at 9:40 am, the nurse supervisor, reviewed the MDS dated [DATE], and stated the MDS had been incorrectly coded as a 3, which coded the resident as being always incontinent. She stated the MDS should have been coded a 9, not rated, as the resident had an indwelling Foley catheter. 10NYCRR415.11(b)

Plan of Correction: ApprovedJune 20, 2016

1. How will the facility correct the deficiency as it relates to the individual(s)
The coding of enabler bars as restraints for Resident # 16, 38, 52 was corrected and resubmitted
The coding of respiratory therapy for Resident # 37, 38 was corrected and resubmitted
The coding of bladder function for Resident # 74 was corrected and resubmitted

2. How will the facility act to protect residents in similar situations
A review of other residents utilizing an enabler bar was conducted and any inaccurate coding for restraint use was corrected.
A review of all residents receiving respiratory therapy was conducted and any inaccurate coding was corrected.
A resident of all residents with an indwelling catheter was conducted and any inaccurate coding for bladder function was corrected.

3. Measures that the facility will take or the systems it will alter to ensure that the problem does not recur
The MDS Nurse received re-education regarding the coding of restraints, bladder function and respiratory therapy
The Respiratory therapy program will be reviewed by the interdisciplinary team and Medical Director and a policy written accordingly. Education will take place with all licensed nurses. A review of the residents receiving the therapy will take place for appropriateness and effectiveness. The completion of each component of the therapy as ordered by the medical provider will be monitored and any failure to complete will be addressed. Resident refusals or inability to tolerate the program will be brought to the attention of the medical provider for review and revision.
Nursing staff received education regarding their responsibility to communicate and report any inability to complete their job as assigned.

4. How will the facility monitor its performance to ensure that the solutions are sustained
The original auditing of MDS documentation for accuracy of coding of enabler bars, respiratory therapy and bladder function will continue:
? weekly X 4
? monthly X 3
? Review with QAA committee to determine future scheduling
Auditing will be done during plan care meetings. With at least 25 residents reviewed per month.

The auditing will increase to the review of CASPER data on a monthly basis with a focus on any area with an increase in facility percentile. MDS data will be reviewed for accuracy.
The QAA Committee will receive the results of the CASPER review on a quarterly basis

5. Dates when corrective action will be completed and who will be responsible for ensuring the corrective action is implemented
a. The date of correction - 6/27/16
b. Responsible person - Director of Nursing

FF09 483.25(l):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic 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: April 28, 2016
Corrected date: June 27, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and resident interviews during the recertification survey and abbrieviated survey (Case #NY 426), the facility did not ensure that each resident's drug regimen was free from unnecessary drugs for 1 (Resident #37) of 15 residents reviewed for psychoactive medications. Specifically, for Resident #37 the facility did not update the Comprehensive Care Plan to reflect that he received [MEDICATION NAME] rather than [MEDICATION NAME] for anxiety, and staff did not document non-pharmacological interventions prior to administering the medication. This was evidenced by: Resident #37: This resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition, was able to make himself understood and was able to understand others. A Physician order [REDACTED]. The Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] Medications, with a revision date of 4/20/16, documented the resident received [MEDICATION NAME] for his anxiety. The Electronic Medication Administration Record [REDACTED]. On each occasion there was no documentation of non-pharmacological interventions prior to administration. During an interview on 4/28/16 at 10:45 am, the Registered Nurse Manager reviewed the resident record and stated non-pharmacological interventions were supposed to be attempted prior to administration of the PRN [MEDICATION NAME], and that none were documented on 4/2, 3 or 4/2016. 10NYCRR 415.12(I)(1)

Plan of Correction: ApprovedJune 21, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. How will the facility correct the deficiency as it relates to the individual(s):
The comprehensive care plan for resident # 37 was updated to reflect the use of the appropriate [MEDICAL CONDITION] medication as well as the reason for use
A pattern is noted to the use of the prn antianxiety medication which is ordered for shortness of breath. The medication regimen for resident # 37 was reviewed with the medical provider and adjustments were made in the treatment plan based on the resident?s need for routine medication for shortness of breath each night.

2. How will the facility act to protect residents in similar situations
Use of prn [MEDICAL CONDITION] medications will be audited monthly with the assistance of the consultant Pharmacist. The med regime will be reviewed for appropriateness and effectiveness.
Care plans will be reviewed for the accuracy of specific medications and treatments. Adjustments will be made accordingly.
The specification of non-pharmacological interventions for any resident receiving a prn [MEDICAL CONDITION] medication will be reviewed. The documentation of the use of these interventions will also be clarified and monitored.

3. Measures that the facility will take or the systems it will alter to ensure that the problem does not recur
Education will be provided to the Nursing staff/phsyicians regarding the use of [MEDICAL CONDITION] medications and the use of non-pharmacological interventions
The care plan team will formulate individualized care plans which promote the use of non-pharmacological interventions plan.
Audits to be estimated at 25 records per month to be reviewed.

4. How will the facility monitor its performance to ensure that the solutions are sustained
The auditing of prn [MEDICAL CONDITION] medication use will continue with the assistance of the consultant Pharmacist during his visits which occur monthly; Audit results will be shared with Nursing management and the medical provider for the identification of trends and patterns. All residents currently on psychotherapeutic medications will be reviewed monthly and whenever there is a change.
The use of non-pharmacological interventions will continue to be audited:
? Weekly X 4
? Monthly X3
? Review by QAA Committee to determine further scheduling
The facility will review at least 25 medical records per month which includes prn [MEDICAL CONDITION] med usage for new admissions and per MDS scheduled review.

The auditing of the updating of the care plan with changes in the treatment plan will take place:
? Weekly X 4
? Monthly X3
? Review by QAA Committee to determine further scheduling

5. Dates when corrective action will be completed and who will be responsible for ensuring the corrective action is implemented
a. The date of correction - 6/27/16
b. Responsible person: Director of Nursing

FF09 483.35(i):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 28, 2016
Corrected date: June 27, 2016

Citation Details

Based on observation, manufacturer's directions review, and staff interview during the rertification survey, it was determined that the facility did not adhere to generally accepted food sanitation practices. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Chapter 1 Subpart 14 State Sanitary Code, the community standard for food service establishments operating in New York State both state that chemicals used in food equipment sanitizing to kill bacteria are to be at the correct concentration. Specifically, the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than that required by the manufacturer. This is evidenced as follows: The kitchen was inspected on 04/26/2016 at 9:00 am. Equipment washing and sanitizing was taking place in the large 3-compartment sink. The concentration of QAC used in the sanitizing rinse sink, the third sink, was measured at 72 degrees Fahrenheit (F) and found to be 0 parts per million (ppm). The manufacturer s label directions stated the concentration is to be between 150 ppm and 400 ppm when the solution is between 65 F and 75 F. The Dining Services Director stated in an interview conducted on 04/26/2016 at 9:30 am, that the sanitizer is checked twice per day, and she does not know why the concentration was too low. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.112

Plan of Correction: ApprovedJune 20, 2016

The facility has corrected the deficiency of not adhering to generally accepted food sanitation practices for the correct concentration used in food equipment sanitizing, specifically the FDA Guidelines and Chapter 1 Subpart 14 of the State Sanitary Code, the community standard for food service establishments operating in New York State. The Dietary Department has created a new log to track and verify their sanitization process of food equipment.
Initially an audit of the sanitizing sink will be conducted daily. The ongoing frequency of the audit to be determined by input of the QA Committee.
Per manufacturer?s recommendations, a new policy outlining the correct temperature of wash sink water, test concentration water temperature, recording process and minimum acceptable temperature of the water in the sanitizing sink has been established and put in use. The sanitizing sink will be tested for breakfast, lunch and dinner and will be reviewed by the Manager on a daily basis. All staff have been educated on the new form and proper process for sanitation.
The Dietary Department will report on a monthly basis at the QAPI meeting for 3 consecutive months with 100% compliance of the 3 Compartment Sink Log. With approval from the QAPI committee, the Dietary Department will then report quarterly for 1 year with 100% compliance. The Dietary Department will look to recommendations from the QAPI committee for further reporting instructions.
Responsible Party: Director of Support Services

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 28, 2016
Corrected date: June 27, 2016

Citation Details

Based on personnel record review, staff interview, and infection control policy review during the recertification survey it was determined that the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease for 1 of 10 employee records reviewed during the recertification survey. Specifically, the facility did not ensure an employee that did not receive the influenza vaccine (vaccine) would wear a hospital face mask while in resident areas. This is evidenced by the following. The personnel records for maintenance employee #1 (the employee) were reviewed on 04/26/2016. This review revealed that the employee declined the influenza vaccine on 04/12/2016. On 04/26/2016 at 9:55 am, the employee was found on the Adirondack Unit by the nurse station and was not wearing a hospital face mask. On 04/27/2016 at 6:55 am and again at 8:05 am, the employee was found on the Adirondack Unit outside the common dining room and was not wearing a hospital face mask. The Director of Clinical Operations stated in an interview conducted on 04/26/2016 at 12:30 pm, that the employee should have been wearing a mask when on resident units. The infection control policy Influenza Vaccination Program was reviewed on 04/26/2016. This policy states that staff refusing the vaccine will wear a mask when in resident care areas, but it is silent on how staff will be monitored for compliance with wearing a mask. 10NYCRR483.65

Plan of Correction: ApprovedMay 26, 2016

1. How will the facility correct the deficiency as it relates to the individual(s)
The staff member was re-educated regarding the use of a mask and donned a mask
2. How will the facility act to protect residents in similar situations
A review was conducted of those staff members who did not receive a flu shot. This list was re-circulated.
Influenza was determined no longer prevalent on 5/20/16

3. Measures that the facility will take or the systems it will alter to ensure that the problem does not recur
Observation will be done of the staff who must comply with wearing a mask, by their supervisor. This will be initiated at the onset of the declaration of the prevalence of influenza and will remain in place until there is declaration that it is no longer prevalent
Review and communication of the facility infection control policy and procedure. Our current policy calls for marking our name tags with colored dots if the tag wearing has had a shot. All staff will be reminded and encouraged to look for the dot or a face mask during flu season.
Annual infection control training
Reminders in paychecks of those who must wear masks as to the status of the flu season
We will expect department heads to maintain an active list of those staff who are not vaccinated and communicate the need for mask usage during prevalent flu season.

4. How will the facility monitor its performance to ensure that the solutions are sustained
While influenza is prevalent, the observations of staff who are required to wear a mask will take place each day by nursing staff. Any non-compliance will be reported to the Director of Clinical Operations. These findings will be shared with the QA committee.

5. Dates when corrective action will be completed and who will be responsible for ensuring the corrective action is implemented
a. June 27, (YEAR)
b. Responsible person: Director of Clinical Operations

FF09 483.65:INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 28, 2016
Corrected date: June 27, 2016

Citation Details

Based on observation and staff interview during a recertification survey, the facility did not ensure that it maintained an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for 2 (Adirondack and Patriot Units) of 2 nursing units. Specifically, the facility did not ensure that clean linens were appropriately handled. This was evidenced by: During an observation on the Adirondack Unit on 4/25/16 at 11:14 am, a Certified Nursing Assistant (CNA) carried clean linens against her uniform and left them in a resident's room. During an observation on the Adirondack Unit on 4/25/16 at 11:45 am, a CNA carried 2 bundles of clothing protectors against her uniform and distributed them in the dining area and to residents on the unit. During an observation on the Patriot Unit on 4/27/16 at 6:35 am, a CNA carried clean linens against her uniform and into a resident's room. During an observation on the Patriot Unit on 4/27/16 at 8:00 am, a CNA carried a bundle of clothing protectors against her uniform and distributed them on top of resident meal trays with food and beverages on the trays. During an interview on 4/28/16 at 12:05 pm, the Director of Nursing stated that staff should not carry clean linens against their uniform, and that this had been addressed in inservices. She also stated she did not believe there was a policy and procedure that specifically addressed handling of clean linen, but staff should know their uniforms were not clean and carrying linens against the uniform could cause an infection control issue. 10NYCRR 415.19(a)(1-3)

Plan of Correction: ApprovedJune 20, 2016

1. How will the facility correct the deficiency as it relates to the individual(s)
The Nursing assistants noted to handle linen inappropriately received re-education regarding the correct handling of linen to prevent the spread of infection; this included education to place the clothing protector on a clean surface during transport vs. against a uniform


2. How will the facility act to protect residents in similar situations
Staff handling of linen to prevent the spread of infection is monitored each shift and any improper handling is addressed

3. Measures that the facility will take or the systems it will alter to ensure that the problem does not recur
The facilities Infection Control Program policy and procedure will be reviewed and revised to include the handling of linen.
Education will be provided regarding the revised policy and procedure. All current staff were ins-erviced immediately by the DON on proper procedures for handling clean linen. Starting on (MONTH) 10th all new staff and current staff attending the annual in-service program receive updated linen handling processes.


4. How will the facility monitor its performance to ensure that the solutions are sustained
Environmental rounds, observing for appropriate linen handling will be conducted:
? Daily X 2 weeks
? Weekly X 4
? Monthly X 3
? At least quarterly or as determined by the QAA Committee

5. Dates when corrective action will be completed and who will be responsible for ensuring the corrective action is implemented
a. The date of correction ? 6/27/16
b. Responsible person ? Director of Nursing

FF09 483.75(o)(1):QAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS

REGULATION: A facility must maintain a quality assessment and assurance committee consisting of the director of nursing services; a physician designated by the facility; and at least 3 other members of the facility's staff. The quality assessment and assurance committee meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and develops and implements appropriate plans of action to correct identified quality deficiencies. A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 28, 2016
Corrected date: June 27, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey it was determined the facility did not maintain a quality assessment and assurance committee consisting of the Director of Nursing Services; a physician designated by the facility; and at least three other members of the facility staff; and identified issues with respect to which quality assessment and assurance activities are necessary and develops and implements appropriate plans of action to correct identified quality deficiencies. Specifically, the Quality Assurance Committee meetings does not include a physician that attends. Additionally, the facility recently began a respiratory therapy program for some residents and were inaccurately coding the Minimum Data Set (MDS). Also, the facility had no Policy & Procedure (P&P) in regards to the respiratory treatments. This was evidenced by: During an interview on 4/25/16 at 10:20 am, the Director of Nursing (DON) stated that the Quality Assurance (QA) Coordinator was the Administrative Assistant. During an interview on 4/28/16 at 12:05 pm, the Administrative Assistant (AA) stated that she was not the QA Coordinator. She was part of the QA team and she was responsible to take the minutes, and set up the meeting dates. The QA Committee met monthly and the attendees included the Administrator, DON, Unit Managers (UM), Physical Therapy, Dietary, Social Service, and the MDS Coordinator. The Medical Director did not attend the QA meetings, although he does receive an invitation. The DON will start the meeting and review the previous meeting's minutes. The meeting minutes are not forwarded to anyone. The areas for improvement are called studies, the deficiency plan of corrections are given to people as studies. There are no subcommittees. The MDS Coordinator is now working on respiratory therapy which was started this past winter, which might have something to do with scoring the MDS. The Nurse Manager report on inhalers and making sure the treatments are given on time and how many residents are on respiratory therapy. Resident #38: The facility did not ensure the correct coding on the MDS for respiratory therapy. This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact (Section C0500 totaled 14), was able to make him self understood and able to understand others. The Physician order [REDACTED]. The Electronic Treatment Administration Record (ETAR) dated 3/2016, documented that between 3/4/16 and 3/7/16, there was no documented RN [MEDICAL CONDITION] Assessment/Auscultation of Lung Sounds. During an interview on 4/27/16 at 11:30 am, the RNM stated she could not find a Policy and Procedure for the Respiratory Therapy Program. During an interview on 4/27/16 at 11:30 am, the RNM stated the Respiratory Therapy Program was more for the treatment of [REDACTED]. During an interview on 4/28/16 at 8:00 am, the Director of Nursing (DON) stated the Respiratory Therapy Program purpose was to expand the lungs for comfort and to decrease anxiety for residents on oxygen, that had [MEDICAL CONDITION] and the [DIAGNOSES REDACTED]. The DON also stated that the Licensed Practical Nurse does the exercises and the Registered Nurse perform the lung sounds/assessment. The Rehabilitation Nursing Program is overseen by the MDS Nurse (an RN). The DON stated the Respiratory Therapy Program would be more of a maintenance program and acknowledged that the MDS Registered Nurse was documenting the respiratory treatment being received by specific residents on the MDS as Respiratory Therapy. The DON stated that she had been unable to locate a Respiratory Therapy Policy and Procedure or Protocol for the Respiratory Therapy Program. Additionally, the DON stated, the MDS RN tells the Interdisciplinary Team (IDT) when she (the MDS RN) will be picking up a resident on Respiratory Therapy for reasons such as [MEDICAL CONDITION] or oxygen use. The DON stated the program had been in place over 6 months and the MDS RN had been employed at the facility over one year. During an interview on 4/28/16 at 10:10 am, the Registered Nurse Supervisor stated the Respiratory Therapy Program was to mobilize secretions, lung expansion, and for low mobility patients. She stated that she did not perform the respiratory exercises a lot because she was not on the medication cart. Additionally, it was stated that the RespiratoryTherapy Program was a program that the MDS RN initiates. The MDS RN, evaluates the residents on the program and reviews with the IDT and the physician. The RN supervisor stated she had done the lung assessments and that RN's did not need specialized training, she just listened to all 4 lobes (front and back). The RN then produced a Policy and Procedure for the Respiratory Therapy Program she had been instructed to provide to the survey team from the DON, earlier that day. The RN was asked to review the Respiratory Therapy Program that she had recently handed to the survey team and after reviewing the Respiratory Therapy Policy and Procedure, she then stated she had never seen that Policy and Procedure previously to providing it to the survey team. Resident #37: The facility did not accurately code the Respiratory Therapy section of the Minimum Data Set (MDS). This resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had moderately impaired cognition (Section C0500 totaled 12), was able to make himself understood and was able to understand others. Section O400 D documented the resident had received respiratory therapy 6 of the 7 days of the evaluation period (3/23/16 through 3/29/16). A Physician order [REDACTED]. The resident was to relax the shoulders and facial muscles, and without puffing the cheeks inhale slowly and deeply through the nose. The resident was then to exhale slowly through pursed lips as though [MEDICATION NAME] or lightly flickering candle flames. Staff were to stress that exhalation should be 3 times as long as inhalation. This was to be performed every evening shift for promotion of lung expansion and circulation related to anxiety, shortness of breath, wheezing, other chronic [MEDICAL CONDITIONS] and chronic [MEDICAL CONDITION]. Staff were to implement breathing exercises, observe and document oxygen saturation, respirations, heart rate and time spent with the resident which should be 15 minutes daily, 7 days each week. A RN was to auscultate the lung sounds on Monday and Friday. A Physician order [REDACTED]. The Electronic Medication Assistance (EMAR) for 3/2016, documented that between 3/23/16 and 3/29/16 the resident performed deep/pursed lip breathing exercises up to 3 sets of 10 respirations as tolerated on 6 days. During an interview on 4/26/16 at 11:52 am, RN #1 stated she had been instructed to document breathing exercises (Respiratory Therapy) were completed by the resident even if they were not done. She stated she had attempted to do the exercises with the resident, but he was not capable of doing the exercises because of the severity of his lung disease. During an interview and observation on 4/28/16 at 9:25 am, RN #2 was asked to perform the Respiratory Therapy as described on the ETAR, the RN explained to the resident that she was there to perform his Respiratory Therapy exercises with him, then put the automatic blood pressure cuff and oxygen sensor on the residents left arm and finger. The RN then began instructing the resident to take a deep breath and slowly breathe out. At 9:27 am, the RN and the resident began a verbal conversation (not related to the specific respiratory therapy) that ended at 9:29 am. At 9:29 am, the RN then instructed the resident to take a deep breath in, and squeeze it all out, the RN then stated the resident's oxygen level was at 97% and pulse was 83 beats per minute. At 9:30 am, she asked the resident if he was feeling calmer, and the resident stated it feels like air is staying in my upper belly while placing his right hand on his right upper abdomen. The RN stated the resident was doing great and delivered some possible reasons for the feeling of air that had been described by the resident. At 9:32 am she began the breathing exercises again, and at 9:33 am the RN asked the resident to cough, which he did. The resident then stated it makes me more out of breath. The breathing exercises ended at 9:34 am. This exercise was not completed as directed on the ETAR. During an interview on 4/28/16 at 9:15 am, this resident stated that staff did not perform the Respiratory Therapy with him. During an interview on 4/28/16 at 9:40 am, after the breathing exercises with RN #2, the resident stated that staff had not performed the exercises with him before, and that this was new to him. During an interview on 4/28/16 at 10:27 am, the RNM stated she did not perform the Respiratory Therapy on this resident, and she was not aware if the therapy was normally performed on this resident. During an interview on 4/28/16 at 11:48 am, a Licensed Practical Nurse (LPN) stated she attempted to do the breathing exercises with this resident but he was not usually capable of completing them. She stated she was not trained to do the breathing exercises with the resident but she followed the directions on the EMAR. 10NYCRR415.27(a-c)

Plan of Correction: ApprovedMay 26, 2016

1. How will the facility correct the deficiency as it relates to the individual(s)
A QAA Committee meeting was held and the Medical Director was in attendance
MDS coding inaccuracies were corrected and re-education was provided to the nurse responsible for the completion of the MDS

2. How will the facility act to protect residents in similar situations
The chairmanship of the QA committee has been reassigned to the SNF administrator
The DON will be the ?second seat? on the committee.
The Medical Director is a member of the committee and we have structured the dates of quarterly meetings to meet his needs.
A cover sheet will be maintained that identifies that a meeting occurred as signed by the SNF administrator. This will include the date and the name of those in attendance.
We will follow the QAPI model which includes subcommittees targeted at specific issues. Our first will be a subcommittee on our respiratory program. The committee will include individuals with knowledge on the subject. With the first subcommittee goal to consider draft policies and procedures for our respiratory program.

3. Measures that the facility will take or the systems it will alter to ensure that the problem does not recur
Part 1 - The minutes of the QA committee will be presented to the campus CEO who will initial the attendance of the Medical Director and the distribution of minutes.
Part 2- As changes are made to policies and procedures, the revised policies will be reviewed by the QA committee who will approve any amendments before distribution.
The policy and procedure for the respiratory program will be reviewed, edited, re-educated and any changes implemented.


4. How will the facility monitor its performance to ensure that the solutions are sustained
Part 1 The maintaining of a file of the coversheets of the QA committee and its subcommittees. Showing the members up of the committee and actual attendance
Part 2 The respiratory care program will be reviewed and revised as necessary. Re-education will be provided.
We will conduct audits to include the completion of the cover sheets, MDS coding accuracy, and policy and procedure revisions, weekly for a month then monthly for 3 months and quarterly thereafter.
We will maintain a file of the performance of the committee and the minutes? cover sheets available for committee meetings and subcommittee meetings.
Policies and procedures will be maintained and organized in a useful way and all appropriate parties will have access.
5. Dates when corrective action will be completed and who will be responsible for ensuring the corrective action is implemented
a. June 27, (YEAR)
b. Responsible person ? SNF Administrator

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Where required by section 19.1.6, Health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7. Required sprinkler systems are equipped with water flow and tamper switches which are electrically interconnected to the building fire alarm. In Type I and II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specific areas where State or local regulations prohibit sprinklers. 19.3.5, 19.3.5.1, NPFA 13

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 28, 2016
Corrected date: June 27, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, it was determined that the automatic sprinkler system was not installed in accordance with adopted regulations. The Centers for Medicare and Medicaid Services published a Final Ruling in the Federal Register on (MONTH) 13, 2008 (73 FR ) requiring all long term care facilities to have full automatic sprinkler protection in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems 1999 edition by (MONTH) 13, 2013. Specifically, automatic sprinkler system was encumbered with unacceptable obstructions and did not cover all areas. This is evidenced as follows. An assessment of the sprinkler system was begun on 04/26/2016 at 1:30 pm and finished on 04/27/2016 at 8:40 am. Light fixtures obstructed the automatic sprinkler spray area in the Patriot Unit stairwell & Duct Inspection room, the Dental Basement corridor & entrance, and the Library. The sprinkler spray area was obstructed with the movable exam light rail in Dental room [ROOM NUMBER], with the a shower curtain without the acceptable upper mesh in the Patriot Unit C-shower room, and with storage within 18-inches of the sprinkler head in the Adirondack Unit E-storage room. The Plant Engineer stated in an interview on 04/27/2016 at 9:45 am that the sprinkler installation company must have installed sprinkler heads in the wrong places. 42 CFR 483.70 (a) (1); 73, FR ; 2000 NFPA 101: 19.3.5; 1999 NFPA 13: 5-6.5; 10 NYCRR 415.29, 711.2(a) (1)

Plan of Correction: ApprovedMay 25, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility will correct the deficiency of the automatic sprinkler system that was encumbered with unacceptable obstructions and did not cover all areas in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems 1999 edition. The facility has begun a plan to relocate light fixtures causing obstructions in the Patriot unit stairwell & Duct Inspection room, the Dental basement corridor & entrance, and the Library to meet NFPA 13 standards. (completed 4/28/16) The moveable exam light rail in Dental room [ROOM NUMBER] was removed since the department is closed and no plan to reopen has been established. (completed 5/24/16). The shower curtain in the Patriot Unit C-shower room was removed with a compliant upper mesh shower curtain on 4/28/16. Storage within 18-inches of the sprinkler head in the Adirondack Unit E-storage room was removed on 4/27/16.
The facility has developed a schedule to review all sprinkler head installation points during its quarterly automatic sprinkler inspections started with the next scheduled inspection on (MONTH) 26, (YEAR). The facility has reviewed their policy on Above the Ceiling Work and reeducated staff on the policy. All contracted vendors and contractors will be educated on the policy prior to beginning jobs that require work above the ceiling in sprinklered areas. All staff have been reeducated to use acceptable upper mesh shower curtains in all storage and shower rooms. All nursing and maintenance staff have been reeducated not to store items on the top shelves of storage racks/shelving units or within 18 inches of sprinkler heads.
The facility will report at the monthly QAPI meetings to discuss and review their findings regarding sprinkler head compliance. The facility will conduct quarterly inspections of automatic sprinkler heads for NFPA 13 compliance and conduct in-house monthly rounding of automatic sprinkler head obstructions. The facility will report its initial inspection of automatic sprinkler head obstructions and corrections at the (MONTH) (YEAR) QAPI meeting and will continue on a monthly basis. The quarterly inspection reports for the automatic sprinkler system will be reviewed at the QAPI meeting following the receipt of the inspection report. The facility will look to recommendations from the QAPI committee for further reporting instructions.
Responsible Party: Director of Support Services

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames. 8.3, 19.3.7.3, 19.3.7.5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 28, 2016
Corrected date: June 27, 2016

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2000 edition section 8.3.2 requires that smoke barriers not have holes or unsealed spaces from floor to the underside of the roof and through all concealed spaces, such as those found above a ceiling and be maintained with a 1 hour fire resistance rating. Specifically, for 1 of 1 smoke barriers observed were not continuous through all concealed spaces and the fire resistance rating was not maintained. This is evidenced as follows. The Adirondack Unit smoke barrier wall (wall) was inspected on 04/27/2016 at 10:45 am. In the corridor, an 8-foot by 18-inch structural metal beam without fire resistance protection and several spaces filled with mineral wool insulation that was partially coated with fire seal were found. In the shower room, 5-foot length of 6-inch by 4-inch spaces filled with mineral wool insulation that was not fire-sealed was found. In A-Consultation room, a 3-inch by 1-inch unsealed hole was found. And spaces filled with mineral wool insulation that was partially coated with fire seal were found in rooms 204 & 209 and in the foyer to Door #6. The Plant Engineer stated in an interview conducted on 04/27/2016 at 11:30 am that he does not know why the unsealed spaces and holes were found as this wall had been checked before. 42 CFR 483.70 (a) (1); 2000 NFPA 101 19.3.7.3, 8.3; 10 NYCRR 415.29, 711.2(a) (1)

Plan of Correction: ApprovedMay 25, 2016

The facility will correct the deficiency of not maintaining smoke barriers in accordance with adopted NFPA 101 Life Safety Code 2000 edition section 8.3.2 which requires smoke barriers not have holes or unsealed spaced from floor to the underside of the roof and through all concealed spaces, such as those found above a ceiling and be maintained with a 1 hour fire resistance rating. The facility has begun a plan to sheet rock, scribe, box in beams, and fire caulk the 8 foot by 18 inch structural metal beam in the corridor, the 5 foot by 6 inch by 4 inch space in the shower room and the 3 inch by 1 inch in the A-Consultation room. The areas found in rooms 204 & 209 have been completely coated with fire seal.
The facility has developed a schedule to review all vertical shafts and smoke barriers for NFPA 101 Life Safety Code compliance. The facility has reviewed their policy on Above the Ceiling Work and reeducated staff on the policy. All contracted vendors and contractors will be educated on the policy prior to beginning jobs that require work above the ceiling.
The facility will report at the monthly QAPI meetings to discuss and review their findings regarding vertical shaft and smoke barrier audits. The facility plans to review all smoke barriers and vertical shafts within 90 days following the completion of the project following the first report at the (MONTH) 20, (YEAR) QAPI meeting. Following the 90 day completion report, the facility will look to recommendations from the QAPI committee for further reporting instructions.
This project will be completed by (MONTH) 22, (YEAR), with all review of vertical shafts and smoke barriers completed by (MONTH) 20, (YEAR).
Responsible Party: Director of Support Services