The Baptist Home at Brookmeade
June 12, 2017 Certification Survey

Standard Health Citations

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (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: June 12, 2017
Corrected date: July 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure that comprehensive care plans with measurable objectives, time frames and appropriate interventions were initiated to address urinary incontinence and active medical [DIAGNOSES REDACTED].#25). The findings are: Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Urinary Incontinence According to the Admission Minimum Data Set (MDS; a resident assessment tool) of 2/24/17, the resident had no cognitive impairment, required extensive assistance of two people for transfers and toileting, extensive assistance of one person for locomotion, was wheelchair bound, and was continent of bladder function. The resident was subsequently assessed on the Quarterly MDS dated [DATE] and showed that the resident was occasionally incontinent of bladder function (less than seven episodes of incontinence in a 7-day period). A review of the resident's comprehensive care plan showed no measurable goals, time frames and interventions to address the decline in the residents bladder status, nor was there was any documentation to explain the change in the resident's condition. A review of the Certified Nurse Aide documentation for the month of (MONTH) (YEAR) showed that the resident continued to have episodes of incontinence. The unit Registered Nurse manager was interviewed on 6/12/17 at 3:42 PM regarding the care plan that addresses the decline in urinary continence. She stated she reviewed the resident's comprehensive care plan and could not find one. b. Medical Conditions The resident's May-June (YEAR) medication regimen included the following medications: [REDACTED] - [MEDICATION NAME] 5 mg daily for Hypertension - Atorvastatin 40 mg daily for [MEDICAL CONDITION] - [MEDICATION NAME] 40 mg daily for Heart Failure - [MEDICATION NAME] 20 mg daily [MEDICAL CONDITION] - Senna plus 2 tabs daily for constipation - Tylenol 650 mg daily for pain unspecified. The resident's plan of care did not address the use of these medications and medical conditions. The unit RN manager was interviewed on 6/12/17 at 3:42 PM and stated that she could not find any care plans to address the above conditions and medications after reviewing the resident's comprehensive care plan. 415.11(c)(1)

Plan of Correction: ApprovedJune 29, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Comprehensive Care Plan to address the decline in resident #25 bladder status has been addressed and added to the care plan.
The plan of care to address the medications and medical condition for resident #25 has been addressed and added to the comprehensive care plan.
A review of all urinary incontinence and active medical [DIAGNOSES REDACTED]. All urinary incontinence care plans have been revised to show measurable goals, time frames and interventions to address any decline in the resident?s bladder status. All medical condition care plans have been reviewed and revised to address the use of medications and medical conditions.
The Interdisciplinary Team which includes RN Unit Managers, Dietary, Rehabilitation Services, Social Worker have been in-serviced to ensure urinary incontinence care plans are revised to show measurable goals, true frames and interventions and that all medical condition care plans include the use of medications and medical conditions.
An audit tool has been created to monitor resident urinary incontinence care plans to show measurable goals, treatments and interventions and to monitor medical condition care plans to include the use of medications and medical conditions.
The MDS Coordinator will conduct these audits weekly to ensure compliance.
The MDS Coordinator will report these findings to the DON to address follow up as neede4d.
The MDS Coordinator will report these findings to the QAPI Committee on a monthly basis.

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: June 12, 2017
Corrected date: July 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure that all the medications prescribed and administered to 1 of 5 residents (Resident #84) reviewed for unnecessary medications were necessary. Specifically, there was lack of parameters to determine the need for the administration of [MEDICATION NAME] as medication of choice when it was given on multiple occasions. The findings are: Resident #84 is a [AGE] year old female and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's (MONTH) (YEAR) medication regimen included the following medications for pain: [MEDICATION NAME] every 3 days, [MEDICATION NAME] 650 mg every 6 hours as needed for pain on a scale of 1-5 and, [MEDICATION NAME] concentrate 100 mg/5 ml (give 5 mg) every 4 hours as needed. A review of the Medication Administration Records the months of (MONTH) (YEAR) and (MONTH) (YEAR) revealed that [MEDICATION NAME] was administered on the following dates: 5/25, 5/27, 5/28, 5/29 and on 6/10. There was no documentation in the resident's clinical record as to the level of the resident's pain and why [MEDICATION NAME] was the medication of choice on those dates when administered. The unit Registered Nurse manager was interviewed on 6/12/17 at 2:30 PM regarding the lack of parameters for the use of the [MEDICATION NAME] and she stated that she would contact the physician. 415.12(l)(1)

Plan of Correction: ApprovedJune 29, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Parameters to determine the need for administration of [MEDICATION NAME] as medication of choice has been clarified and added for resident #84.
A housewide review has been conducted to ensure that all medications prescribed and administered have parameters in place where necessary.
The nurses and physicians have been in-serviced to ensure that all the medication prescribed and administered have parameters in place where necessary. The facility policy and procedure had been reviewed and revised to include that all the medication prescribed and administered have parameters in place where necessary.
An audit tool has been created to monitor that all medication prescribed and administered have parameters in place where necessary.
The RN Unit Manager will conduct these audits weekly to ensure compliance.
The RN Unit Managers will report findings to the DON to address follow up as needed.
The RN Unit Managers will report findings to the QAPI Committee Meeting monthly.
Responsible party:
Director of Nursing Services

FF10 483.25(e)(1)-(3):NO CATHETER, PREVENT UTI, RESTORE BLADDER

REGULATION: (e) Incontinence. (1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. (2)For a resident with urinary incontinence, based on the resident?s comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident?s clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident?s clinical condition demonstrates that catheterization is necessary and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. (3) For a resident with fecal incontinence, based on the resident?s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 12, 2017
Corrected date: July 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the most recent recertificaiton survey, the facility did not ensure that care and treatment were provided to 1 of 3 residents (#25) reviewed for urinary incontinence to address the decline in urinary continence, and to potentially restore the resident's previous level of urinary continence status to the extent possible. The findings are: Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Admission Minimum Data Set (MDS; a resident assessment tool) of 2/24/17, the resident had no cognitive impairment, required extensive assistance of two people for transfers and toileting, extensive assistance of one person for locomotion, was wheelchair bound, and was continent of bladder function. The resident was subsequently assessed on the Quarterly MDS dated [DATE] and showed that the resident was occasionally incontinent of bladder function (less than seven episodes of incontinence in a 7-day period). The resident's comprehensive care plan showed no measurable objectives, time frames and appropriate interventions to address the decline in the residents bladder status, nor was there was any documentation to explain the change in the resident's condition. The Certified Nurse Aide documentation for the month of (MONTH) (YEAR) showed that the resident continued to have episodes of incontinence. The unit Registered Nurse manager was interviewed on 6/12/17 at 3:42 PM regarding the care plan that addresses the decline in urinary continence. She stated she reviewed the resident's comprehensive care plan and could not find one. The resident was interviewed on 6/12/17 at 4:12 PM and stated that there were different reasons why he was incontinent at times. He stated that at times he has to wait after he rings the bell for assistance. At the time of this interview, a urinal was present in the resident's room. He stated that he uses the urinal when he is in bed during the night time. 415.12(d)(2)

Plan of Correction: ApprovedJune 29, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The comprehensive care plan to include the care and treatment for [REDACTED].?s bladder status has been addressed and added to resident #25?s plan of care. Documentation to explain the change in the resident?s condition has been added to the medical record.
To ensure residents who have changes in bladder incontinence receive appropriate treatment and services to restore continence to the extent possible have been reviewed and those resident care plans have been revised and documentation to explain the change has been written in the resident?s medical record.
The Interdisciplinary Team which includes Dietary, PT, OT, SLP, Social Work and RN Unit Managers, have been in-serviced to ensure the residents who have changes in bladder incontinence are receiving appropriate treatment and service to restore continence to the extent possible and that there is documentation to explain the change in the medical record.
The RN Unit Manager will conduct these audits weekly to ensure compliance.
The RN Unit Managers will report findings to the Director of Nursing to address follow up as needed.
The RN Unit Managers will report findings to the QAPI Committee monthly.
Responsible:
DON

FF10 483.10(g)(14):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)

REGULATION: (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 12, 2017
Corrected date: July 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure that the designated representative of one of one resident (#10) reviewed for notification of change was promptly informed of the need to alter the resident's dietary care plan. Specifically, the resident's designated representative was not informed promptly of the need for swallowing therapy and change in the consistency of the resident's diet. The findings are: Resident #10 is a [AGE] year old female with [DIAGNOSES REDACTED]. A note by the Speech and Language Pathologist (SLP) dated 5/3/17 revealed that the resident was seen for swallowing evaluation and that skilled swallowing treatment was recommended for 5 weeks to improve safety and tolerance of a least restrictive diet. The discharge note by the SLP dated 5/24/17 stated that a regular diet with cut-up meats into bite size pieces was recommended for the resident. A review of the resident's record revealed no evidence that the resident's designated representative was notified of the need for the change in the resident's care plan at the time the change was initiated to include the swallowing evaluation and therapy. The designated representative was interviewed on 6/8/17 at 12:02 PM and stated that she was not always notified of the need to change the resident's treatment. She further stated that she was not aware of the need for the therapy by the SLP until after the fact. The unit Registered Nurse manager (RN#1) was interviewed on 6/9/17 at 11:35 AM if she had informed the family about the changes in the resident's treatment plan mentioned above. RN #1 stated that the expectation was that the SLP would be the one to notify the family of the changes. The SLP was interviewed on 6/9/17 at 12:10 PM and stated that when the resident was about to be discharged from therapy, she called the family to inform them that the plans were being made to discharge the resident from therapy. She stated she thought that nursing had informed the family of the need for therapy. The SLP stated that it was important for the family to be informed promptly due to the risk associated with the change in the consistency of the resident's diet and lack of family knowledge. 415.3(e)(2)(ii)(c)

Plan of Correction: ApprovedJune 29, 2017

The Designated Representative of resident #10 was again notified of the need to change the resident's treatment on (MONTH) 1, (YEAR).

A review of all residents currently on Speech/Language Therapy has been completed and all designated representatives of those residents on Speech/Language Therapy have been notified that resident is on Speech/Language Therapy and if any changes or alteration to a resident?s plan of care was necessary.
The Interdisciplinary Team that includes: attending physician, RN Unit Manager, Social Services, PT, OT and SLP and Dietary have been in-serviced that the designated representative of the resident must be notified promptly if there is a need to alter the resident?s dietary care plan.
The facility policy and procedure on notification of changes (injury/decline/room, etc.) to the resident?s designated representative has been renewed and revised to address that the Speech/Language Therapist must ensure that the designated representative be promptly informed of the need to alter the dietary care plan and the Speech/Language Therapist will document such in the medical record.
An audit tool has been created to monitor that the Speech/Language Therapist notifies the resident?s designated representative of the need to alter the dietary care plan.
The Rehabilitation Director will conduct these audits weekly to ensure compliance.
The Rehabilitation Director will report the findings to the Administrator to address follow up as needed.
The Rehabilitation Director will report the findings to the QAPI Committee.
Responsible:
Rehabilitation Director

Standard Life Safety Code Citations

K307 NFPA 101:ILLUMINATION OF MEANS OF EGRESS

REGULATION: Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 12, 2017
Corrected date: June 23, 2017

Citation Details

2012 LSC 101 7.8 Illumination of Means of Egress. 7.8.1.1 Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided in 7.8.1.2.2 7.8.1.2.1 Artificial lighting shall be employed at such locations and for such periods of time as are necessary to maintain the illumination to the minimum criteria values herein specified. 7.8.1.4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area. Based on observation and interview, the facility did not ensure that the illumination of the means of egress on resident units was installed and maintained in accordance with 7.8. This was evidenced by manually operated wall-mounted switches installed on 3 of 3 corridors to the resident dining rooms and in the dining rooms that, when turned to the off position, turned the lights off in the three corridors and the three dining rooms. This would not ensure that required and sufficient lighting would be continuously in operation and capable of automatic operation without manual intervention. The findings are: During the life safety tour conducted on 6/7/17 and 6/8/17 between the hours of 11:30 and 2:00 PM, manually operated wall mounted light switches were noted in the short corridors leading to the resident dining rooms and within the dining rooms. When these switches were manually turned to the off position, all lights in these corridors and in the dining rooms were turned off. There are required emergency exits located within each of the dining rooms. In an interview at the time of the findings, the Director of Support Services stated that this current system was missed when the corridor lights on resident units were changed. He further stated that the lights will be tied into the existing lights in the adjacent corridors to provide continuous illumination. 2012 NFPA 101: 19.2.8, 7.8.1.1, 7.8.1.2.1, 7.8.1.4* 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJune 20, 2017

No residents have been found to have been affected by the deficient practice.
When the switches are manually turned to the off position in the short corridors leading to the resident dining rooms, required and sufficient lighting will be continuously in operation and capable of automatic operation without manual intervention.
An electrician was on site on (MONTH) 8, (YEAR) and will have a follow up visit on (MONTH) 21, (YEAR).
The Director of Support Services will report at the monthly Quality Assurance Performance Improvement Committee on progress and completion of project.
July 18, (YEAR)
Responsible:
Director of Support Services