Riverside Center for Rehabilitation and Nursing
December 13, 2016 Certification/complaint Survey

Standard Health Citations

FF09 483.15(a):DIGNITY AND RESPECT OF INDIVIDUALITY

REGULATION: The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 13, 2016
Corrected date: January 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey the facility did not promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality for 2 (Resident #'s 32 and #33) of sixteen (16) residents reviewed and 2 of 2 units. Specifically: for Resident #32, the facility did not ensure the resident received nail care and was toileted upon request; for Resident #33, the facility did not ensure facility staff provided privacy while performing a finger stick blood glucose; and for Resident #50, the facility did not provide the resident with a clean geri-chair, seat cushion, wedge cushion or mechanical lift pad. This is evidenced by: Resident #32: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as usually understands and usually understood. A Brief Interview of Mental Status (BIMS) score of 2/15 documented a decision making impairment. It also documented the resident received anti-anxiety medication. Finding #1: During an observation on 12/8/16 at 11:05 am, Resident #32 was observed in the hall outside the nurses station on the North Unit. The resident's daughter was requesting assistance from the staff to toilet the resident. The resident was also verbalizing the need to go to the toilet. During an observation on 12/8/16 at 11:15 am, Resident #32 was continuing to say she needed to go to the bathroom. The resident was seated in her wheelchair (w/c) outside the nursing station on the North unit. Residents #32's daughter requested assistance from a staff member to help toilet her mother. The staff member who was asked walked down the hall looking for someone to assist her and told several Certified Nursing Assistants (CNAs) that the resident wanted to go to the bathroom. The staff member was observed walking off the unit after telling the resident's daughter that someone would come and assist her shortly. During an observation on 12/8/16 at 11:35 am, the resident continued to sit in the wheelchair outside the nursing station saying she needed to go to the bathroom or she was going to wet herself. During an observation on 12/8/16 at 11:50 am, the resident was toileted by the Registered Nurse Unit Manager (RNUM) and Licensed Practical Nurse (LPN) after the RNUM became aware that the resident had been repeatedly asking to go to the bathroom. A review of a physicians order dated 10/7/16, documented the following: Assure resident is toileted every 3 hours throughout the day. Every day at 6 am, 9 am, 1 pm, 4 pm and 7 pm. A review of the Comprehensive Care Plan (CCP) documented the resident is a 2 person assist for toileting. Resident is to be turned and positioned every 2 hours and toileted every 3 hours and as needed (PRN). During an interview on 12/8/16 at 11:45 am, the Physical Therapist (PT) stated she didn't have thie resident on her resident list for any treatment. She stated that when the resident's daughter asked her for help with toileting the resident she looked at the assignment for the day to identify the CNA who the resident was assigned to. She further stated that when she looked for the CNA to tell her that the resident was asking to be toileted she was unable to find her. She also stated she had never relayed the message to the CNA, but had told the other staff that the resident was asking to go to the bathroom. She stated she thought someone would address the resident's request and had left the unit without checking if that had been done. During an interview on 12/08/16 at 1:00 pm, the RNUM stated that the resident had a toileting schedule, but she should have been toileted if she was asking and should not have had to wait 45 minutes. She stated she didn't know if the CNA had toileted the resident according to the schedule, but that other staff members could toilet a resident after looking at the CNA care card (directs resident care). She stated when she overheard this writer asking PT who she had informed that the resident needed toileting, she immediately got the LPN to help and they toileted the resident. She further stated the resident had briefs on because she has a history of incontinence even with frequent toileting. She stated she didn't remember if the resident was wet when they toileted her. During an interview on 12/8/16 at 2:15 pm, the CNA assigned to the resident stated she had not toileted the resident before she left the floor. She stated the residents daughter was visiting and at the time the resident refused. She also stated she had left the floor and had not informed anyone that the resident had not been toileted. She further stated that she was assigned to the resident, but if the resident needed to go to the bathroom someone should have taken her and not made her wait so long. Finding #2: During an observation on 12/8/16 at 12:30 pm, Resident #32 was sitting in her wheelchair in the dining room during lunch. She was observed scratching her arms with her finger nails that were observed to be long with jagged edges. There was gray dirty matter under her finger nails on both hands. During an observation on 12/12/16 at 3:00 pm, Resident #32 was sitting in her wheelchair in the hall outside her room. Her finger nails were long and jagged with brownish colored matter under her nail beds on the three fingers of her right hand. Her other fingernails on both hands were observed to have gray matter under them. During an observation on 12/13/16 at 2:45 pm, Resident #32 was sitting in her wheelchair in the hall outside her room. Her fingernails remained jagged with gray matter under 8 out of 10 nail beds. A review of a nursing note dated 12/09/16 at 5:01 pm, documented the following: Called to the unit to observe scratches on residents buttocks from scratching herself, cream applied and an abd pad (dry clean dressing) for covering, dr. (doctor) aware, no new orders. A review of the residents' CNA care card documented the resident is scheduled for a shower every Tuesday. During an interview on 12/12/16 at 3:30 pm, the CNA giving care to the resident stated the resident's receive nail care and the male resident's are shaved on their shower day. She stated that Resident #32 was due for her shower on Tuesday. She also stated it is usually given in the morning before her hair appointment. She stated the resident was very interested in her physical appearance and always wanted to look nice. During an interview on 12/13/16 at 10:45 am, the RNUM stated that the residents are scheduled once a week for a shower or bath. She stated that on that day the CNA's do personal care like cleaning of nails and shaving. She stated that it can be done more often if needed. She stated she tries to monitor this. She also stated that Resident #32 was particularly aware of her appearance and that this was something that had been important to her before being admitted to the facility. During an interview on 12/3/16 at 2:50 pm, the CNA caring for the resident stated the resident had been showered on 12/12/16 in the morning. She stated she wasn't sure why her nails hadn't been cleaned. She stated the residents have that done regularly on the day of their shower. Resident #33: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident could understand and could be understood. A Brief Interview of Mental Status (BIMS) score of 3/15 documented a decision making impairment. It also documented the resident received medication to control blood sugar. During an observation on 12/7/2016 at 11:15 am, the Licensed Practical Nurse (LPN) administrating medication approached the resident holding a glucometer (an instrument used to obtain blood sugar results), pricked Residents #33's 2nd finger on her right hand and obtained the blood sample to measure her blood glucose, while the resident was sitting in the hall in front of the nurses station. There were at least six other residents sitting in the hall watching. During an observation on 12/8/2016 at 11:05 am, the LPN administrating medication approached the resident holding a glucometer (an instrument used to obtain blood sugar results), pricked Resident #33's finger on her left hand and obtained the blood sample to measure her blood glucose while the resident was sitting in the hall in front of the nurses station. There were 4 residents sitting in the hall across from the nursing station. There was no explanation given to the resident prior to pricking the resident's finger other than telling Resident #33 give me your finger. The LPN quickly walked away from the resident and back to her medication cart. A review of a physician order [REDACTED]. During a record review, the Electronic Medication Administration Record [REDACTED] Fingerstick Orders: From (MONTH) 6, Everyday, Before Meals (AC), FSB Only, Other: follow house protocol for fingerstick below 60. Fingerstick's scheduled for 7:30 am, 11:30 am, and 4:30 pm. During an interview on 12/8/16 at 11:20 am, the LPN stated that she always does the residen's' fingerstick's in the hall. She further stated she does this, because they are all there getting ready for lunch. She also stated that she supposed it was not the facilities policy to do the fingerstick in the hall. The LPN further stated that she should have brought the resident to her room. She stated she didn't know if the resident is care planned for the FS to be done in the hall in view of other residents, but didn't think that Resident #33 minded. She stated that no one had ever complained. When asked if she should explain the procedure, the LPN stated that the resident knows what is being done when she says give me your finger. During an interview on 12/8/16 at 2:48 pm, the RNUM stated that fingerstick's performed on the residents should be done in the privacy of their rooms. She stated the resident was not care planned to have her FS done in the hall around other residents. She stated all procedures should be explained to the resident before beginning the procedure and that the LPN would need to be re-educated on how to give care when performing a fingerstick. She stated none of the Diabetic resident's were care planned to have their fingersticks done in the hallway and that the LPN should certainly be aware of this. During an interview on 12/12/16 at 10:15, the Director of Nursing (DON) stated that the LPN who performed a fingerstick on Resident #33 should have been aware that when doing a procedure the resident needs to be brought to their room. She stated that no matter how small the procedure or how quick it is, that it is important to provide the resident with a private place when providing any care. The DON also stated that this to protect the residents privacy. She further stated the LPN had been disciplined and would need to be re-educated by staff development. Resident #50: During an observation on 12/7/16 at 9:35 am, Resident #50 was observed sitting in her geri-chair in her room on the South Unit. The inside and outside of the chair sides, the footrest and the headrest were soiled with dried food and liquid stains. The cushion that the resident was sitting on was observed to be soiled with crusted material as well as loose crumbs on it. During an observation on 12/8/16 at 2:15 pm, Resident #50's geri-chair was stored in the bathroom and observed to have the inside and outside of the chair sides, the footrest and the headrest soiled with dried food and liquid stains. The cushion that the resident would sit on was observed to be soiled with crusted material as well as loose crumbs on it and the wedge cushion was soiled with multiple dried materials. During an observation on 12/12/16 at 3:20 pm, Resident #50's geri-chair was stored in the bathroom and was noted to be a different clean geri-chair. The cushion on the geri-chair was observed to be soiled with crusted material as well as loose crumbs and the wedge cushion was soiled with multiple dried materials. Furthermore, the mechanical lift pad on the chair was soiled with crusted dried particles. During an interview on 12/12/16 at 3:25 pm, the Registered Nurse Manager (RNM) stated, these things (seat cushion, wedge cushion and lift pad) should have been cleaned, this is terrible. The lift pad could have been sent to laundry and the seat and wedge cushion should have been cleaned. 10NYCRR 415.5(a)

Plan of Correction: ApprovedJanuary 25, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
#32 RNUM & LPN toileted resident when they became aware of residents need to use the toilet, #32 nail care provided (cut & cleaned). #33 Care Plan reviewed and does not identify any alternate resident?s preference for finger stick outside general privacy practices. #50 resident?s geri-chair was cleaned and soiled equipment was removed and clean equipment provided. Mechanical lift pad removed for cleaning.
? How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
Interdisciplinary team to review and reassess all residents on toileting schedules. All residents' fingernails were checked for cleanliness, jagged ends and length and nail care was provided as needed.
All wheelchairs requiring deep cleaning were pressure washed within the week.
? What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
Housewide reeducation on toileting programs was initiated. All residents on a toileting program will be audited by the Nurse Manager weekly for compliance and reported to QA monthly.
Reeducation on policy of nail care. Audit tool initiated for LPNs to check nail care on resident's scheduled shower day and report to QA monthly.
Director of Plant Operations initiated a new wheel chair pressure washing cleaning schedule for two evenings/week with 3-rooms identified each night to provide a thorough pressure washing cleaning of each wheelchair every 3-months. Nursing staff to provide general wheelchair cleaning and maintain a log of all wheelchairs cleaned. There is a list in the C.N.A. daily book of the assigned chairs for cleaning (non-pressure-washing) by CNAs' once per month.
Nursing staff will be reeducated on the practice of placing soiled lift pads in dirty linen containers to be processed by laundry. In Laundry the ?Lift Pad Inspection? log tracks all lift pads by number and date of being washed as well as general condition of lift pad. All pads will be tallied every Wednesday to ensure cleaning has occurred at least once in the past week.
Reeducation provided to all LPNs/RNs on Policy and Procedure for proper finger sticks/glucose monitoring and dignity associated with the task.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Audits on nail care and toileting schedule will be completed 3-times per week by LPN when performing skin checks during resident shower to ensure that resident?s nails are cleaned and trimmed and that the toileting schedule has been followed for residents on such a schedule. These audits will be reported to QA by the unit manager.
Wheel chair washing logs (pressure washing log and CNA log) will be collected by plant operations and nursing and submitted to QA for review to monitor that all wheelchairs are receiving monthly cleaning.
Plant operations will collect Lift Pad Inspection log to report to QA that pads are being washed at least once weekly.
Education will report to monthly QA that all LPNs/RNs are educated on Finger Stick P&P.
For continuous quality improvement, the nature and frequency of the audits will be reviewed and revised as determined by the QA Committee for 3 months with change in processes as indicated.
? The date for correction and the title of the person responsible for correction of each deficiency.
1/27/2017 by Director of Nursing/Nursing Education and Director of Plant Operations

FF09 483.35(i)(3):DISPOSE GARBAGE & REFUSE PROPERLY

REGULATION: The facility must dispose of garbage and refuse properly.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 13, 2016
Corrected date: January 27, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not dispose of garbage and refuse as required by adopted regulations. Chapter 1 Subpart 14 State Sanitary Code Section 14-1.150 requires that outside refuse storage areas are to be kept clean. Specifically, the trash compactor and wooden stairs leading to the trash compactor area were not clean. This is evidenced as follows: The trash compactor area was inspected on 12/06/2016 at 8:55 am. The trash compactor and wooden stairs leading to the compactor were heavily soiled with black oily drip marks and stains. Cigarette butts littered this area. The Director of Plant Operations stated in an interview conducted on 12/06/2016 at 8:55 am that compactor and area should be cleaned daily, the facility property is non-smoking and staff were told not to smoke behind the building where the dumpster is located. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.150

Plan of Correction: ApprovedJanuary 7, 2017

? What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
An old metal cigarette container was removed from the area of the dumpster, no smoking signs were placed around the area of the dumpster and the stairs to the compacter were pressure washed.
? How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
Audit of the grounds revealed no other areas with excessive litter or heavily soiled outdoor working areas.
? What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
Dumpster stairs will be pressure washed on a monthly basis (weather permitting) as well as installing new stairs. Staff members receive education on no-smoking policy during annual fire safety mandatory training
? How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Progress on all corrections to be brought forward to Quality Assurance meeting to identify when permanent smoking signs are installed and stairs replaced. Reports on monthly pressure washing of the dumpster stairs will be reported in monthly quality assurance meeting. For continuous quality improvement, the nature and frequency of the audits will be reviewed and revised as determined by the QA Committee for 3 months with change in processes as indicated.
? The date for correction and the title of the person responsible for correction of each deficiency.
1/27/2017 by Director of Plant Operations

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: December 13, 2016
Corrected date: January 27, 2017

Citation Details

Based on observation, record review, and staff interview during the recertification 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 are to be at the correct concentration and that food preparation equipment are to be kept clean. Specifically, the concentration of quaternary ammonium compound (QAC) was less than that stated on the manufacture's label directions and various food contact surfaces required cleaning. This is evidenced as follows. An inspection tour of the kitchen was conducted on 12/06/2016 at 8:20 am. Equipment washing and sanitizing was taking place in the pot washing 3-compartment sink. The concentration of QAC used in the sanitizing rinse sink was measured at less than 150 parts per million (ppm), and the manufacturer's label directions stated the concentration is to be between 150 ppm and 400 ppm. The microwave oven, table mixer, can opener, and slicer were not thoroughly cleaned and were soiled with food particles. The Food Service Director stated in an interview conducted on 12/06/2016 at 8:50 am, that he is not sure why the sanitizing chemical concentration was low, but that the solution would be remade. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.110, 14-1.112

Plan of Correction: ApprovedJanuary 7, 2017

? What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
The Sanitizing Rinse Sink was drained and refilled with the concentration level reaching between 150-400 parts per million per manufactures direction. Microwave oven, table mixer, can opener and slicer were thoroughly cleaned day of findings.
? How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
Staff reeducation on proper procedures to reach required concentration levels in Sanitizing Rinse Sink and how to properly clean equipment initiated day of findings.
? What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
New procedure initiated and posted ?Procedure to test titration level? instructing on how to reach optimum level of sanitizing concentration. ?Sanitation Audit? created and initiated that audits the 3-bay sanitizing sink in AM and PM and audits/instructs cleaning of Can opener/blade and base, Slicer, Food Processor, and Microwave oven.
? How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Sanitation Audit will be reported to Monthly QA. For continuous quality improvement, the nature and frequency of the audits will be reviewed and revised as determined by the QA Committee for 3 months with change in processes as indicated.
? The date for correction and the title of the person responsible for correction of each deficiency.
1/27/2017 by Food Service Director

FF09 483.25(h):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 13, 2016
Corrected date: January 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification and abbreviated survey (Case # NY 7816) the facility did not ensure the resident environment remained as free of accident hazards as is possible; and that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #78) of 16 resident's reviewed. Specifically, the facility did not ensure that they identified Resident #77 as at risk for placing non food items in her mouth and did not implement interventions to protect the resident from ingesting non food items. This is evidenced by: Resident #78: The resident was admitted to the nursing home on 9/23/15, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident sometimes understood and was sometimes understood by others. A Certified Nursing Care (CNA) Guide, (a document that lets the CNA know what care to deliver to a resident) dated 9/14/16, under preventative skin care documented not to leave the resident alone in the bedroom when in her wheel chair. Additionally, it documented to bring her in last just before being served as the resident may grab at other residents drinks and tended to spill her own drinks unless supervised. Also, under meal comments it documented general safe swallowing strategies (i.e. small bites, small sips, alternate solids and liquids thru the meal) and that the resident was to be in the dining room for all meals. On 12/7/16 at 8:45 am, the resident was observed in the hall near the atrium area with magazines in her hand. At 3:30 pm, the resident was in the atrium area in her wheelchair near a table that had a stack on newspapers on it. There were no staff observed near or in the atruim area on either of the above occasions. During an observation on 12/9/16 at 2:30 pm, the resident was sitting next to the nursing station, in her wheelchair, next to the medication cart. The open trash container attached to the cart was full and directly in front of the resident at knee level. The narcotic book was open in her lap and there were papers from the book on the floor in front of her. The surveyor notified the nurse, who was sitting at the nursing station, that the resident needed to be checked. The nurse got up, took the book and papers from the resident and sat back down at the nursing station, leaving the resident next to the carts open trash container. A facility investigation dated 9/10/16, documented that the daughter arrived to the mothers room on 9/10/16 at approximately 10:05 am and found the resident in her wheelchair chewing on a wad of paper. It documented that the resident was care planned for behaviors and was to be brought in last to the dining room just before being served as she may grab at other residents' drinks and tended to spill her own drinks unless supervised. It documented that the resident was on mechanical soft diet with nectar thick liquids. Additionally, it documented that a facility wide re-education was given for Dining Precautions for residents at risk for aspiration due to aphasia. There was no documented evidence in the progress note of the incident on 9/10/16 and no documented evidence in the Comprehensive Care Plan or CNA Care Guide that the resident had a history of [REDACTED]. During an interview on 12/8/16 at 9:30 am, CNA #4 stated that she had seen the resident put plastic lids or placemat paper in her mouth, but she had never reported it because everyone saw it. Additionally, CNA #4 stated that she thought it had not happened in a couple weeks. During an interview on 12/8/16 at 9:45 am and 12/13/16 at 2:00 pm, CNA #3 stated that the resident would put things in her mouth mostly in the dining room if she was not watched. Additionally, CNA #3 stated that there was nothing documented on the care card to let them know that the resident did this. Also, CNA #3 stated that she thought the reason the resident was not allowed in her room was because she got agitated and yelled out. During an interview on 12/8/16 at 9:50 am, the Registered Nurse Manager (RNM) stated that she was aware that the resident put non food items in her mouth i.e. napkins and plastic syrup packets, and that there should be a care plan in place to address these behaviors. Additionally, the RNM stated that there was no plan in writing to protect the resident from putting things in her mouth. During an interview on 12/8/16 at 12:15 pm, the Administrator stated that they had a discussion with the family after the 9/10/16 incident and did not see it as a problem at the time because the resident did not choke and she was care planned to be brought in the dining room last. During an interview on 12/13/16 at 7:45 am, the resident's daughter stated that on 9/10/16, her sister who came in to visit, found the resident, alone in her room with her breakfast tray chewing on a large wad of paper towel. During an interview on 12/13/16 at 1:30 pm, CNA #5 stated that the resident did have a history of putting non food items in her mouth such as napkins and flatware. 10NYCRR 415.12(h)(1)

Plan of Correction: ApprovedJanuary 25, 2017

? What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
Resident #78, Profile Care Card updated to reflect resident has a history of putting non-food items in her mouth due to dx of dementia; if resident shows signs of agitation prior to meals, bring into dining room last; no napkins, placemats or condiments at place setting?. Behavior care plan updated with ?Resident is to have non-food items taken away from her as staff sees appropriate such as small items/paper products. If there is a specific item the resident becomes fixated on, staff is to remove that item from the accessible area. Staff will attempt to redirect the resident away from the area of concern and/or offer a snack/food item as appropriate.?
? How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
House audit completed to identity other residents with potential to place non-food items in their mouths and of the residents identified, Profile Care Cards and Behavior Care Plans were updated to include measures to remove non-food items from meals as well as non-food items outside of meal times/dining rooms.
? What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
Residents with the potential to place non-food items in their mouth will be identified as at risk for choking and both profile care card and care plans will address the issue during meal times as well as during all other non-meal activities.
? How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Meal audits will be conducted twice weekly and reported to QA monthly to confirm identified residents do not have non-food items placed at the meal table. Those residents will be audited to ensure non-food items are being addressed outside of meals. For continuous quality improvement, the nature and frequency of the audits will be reviewed and revised as determined by the QA Committee for 3 months with change in processes as indicated.
? The date for correction and the title of the person responsible for correction of each deficiency.
1/27/2017 by RN Unit Managers

FF09 483.13(c)(1)(ii)-(iii), (c)(2) - (4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 13, 2016
Corrected date: January 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey, the facility did not ensure that all alleged violations were thoroughly investigated for three (3) (Resident #'s 22, 46 and #54) of sixteen (16) residents reviewed. Specifically: For Resident #22, the facility did not initiate an Accident and Incident Report for the investigation of an accidental incident and protect the resident from further accidental incident's when facility staff did not report witnessing a resident self propelling their wheelchair over Resident #22's left foot; For Resident #46, the facility did not ensure a thorough and accurate investigation was completed for the resident's fall out of a wheelchair when the facility's investigation did not identify that facility staff did not follow the resident's careplan, did not protect the resident from further neglect and did not report the incident to the Department of Health; For Resident #54, the facility did not ensure an investigation was completed to determine the root cause of a sudden drop (32) in the resident's Finger Stick Blood Glucose (FSBG). This is evidenced by the following: Resident #22: The resident was admitted on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident could understand and was understood. A Brief Interview of Mental Status (BIMS) dated 11/15, documented a decision making impairment. During an observation on 12/7/16 at 11:30 am, the resident was seated in the hall in his wheelchair (w/c) outside the nurses station on the unit. The resident's w/c was observed backed up against the wall with the resident's feet protruding into the hallway. A resident from another unit was observed self propelling her w/c through the hall and ran over Resident #22's left foot. Resident #22 yelled out stating Jesus Christ my foot, she just ran over my foot! The Licensed Practical Nurse (LPN) ran over to the resident, asked him if his foot was okay and called a Certified Nursing Assistant (CNA) to take the resident to his room. The Physical Therapist (PT) present on the unit stopped the resident who ran over Resident #22's foot and told her she needed to be more careful. During an observation on 12/8/16 at 9:30 am, Resident #22 was observed sitting in the hallway in his w/c. The resident's w/c was backed up against the wall by the nurses station and his feet were protruding into the hall. Other residents were observed self propelling their w/c's in the hallway. During an interview on 12/8/16 at 9:35 am, this writer asked Resident #22 how his foot was. He stated his foot was sore. At this point the RNUM approached the resident questioning when this happened. During a record review on 12/8/16 at 10:17 am, the RNUM documented Resident #22 had an incident on 12/7/16, where another resident had wheeled over his right foot. She also documented the resident had indicated he had some pain and received Tylenol. A review of the nursing notes and the 24 hour report did not include documented evidence of the incident dated 12/7/16. During an observation on 12/8/16 at 9:40 am, the Registered Nurse Unit Manager (RNUM) who overheard Resident #22 state his foot was sore asked the resident what happened to his foot. The resident stated that another resident had run over it the day before. She asked the resident if he was okay and took him to his room to look at his foot. During an interview on 12/8/16 at 9:35 am, this writer asked Resident #22 how his foot was. He stated his foot was sore. At this point the RNUM approached the resident questioning when this happened. During an interview on 12/8/16 at 9:40 am, the RNUM stated she was not aware of the incident regarding Resident #22 and another resident. The RNUM stated she had not been informed that the resident's foot had been injured. She stated she would need to start an Incident and Accident report and would need to assess the resident. She stated she needed to take the resident to his room to look at his right foot. She also asked what staff members were present at the time of the incident. She further stated no Incident or Accident report had been started, because she was unaware of the incident. The RNUM stated the physician and residents family had not been notified for the same reason. During an interview on 12/12/16 at 10:00 am, the Director of Nursing (DON) stated that whenever a resident has an injury that an Incident and Accident (I & A) report needed to be done. She also stated that the LPN should have notified the RNUM immediately and that the RNUM should have assessed the resident for injury. She further stated the RNUM should then call the physician and the residents health care proxy to notify them of what had happened. The DON stated that the LPN would need to be reducated as to what her scope of practice was and what steps the facility expects to be done if a resident has an injury. She stated she was aware that there had been a delay in the I & A being started for Resident #22 because the LPN had not notified the RNUM. The DON stated because of the delay in starting the investigation there was a delay in an assessment of the resident and any corrective measures that may be needed. During an interview on 12/8/16 at 10:20 am, the LPN stated she had looked at the residents foot when the CNA brought him to his room on 12/7/16. She stated she looked at his foot and that the resident was fine. She stated she hadn't seen any swelling or bruising on the residents foot. She further stated she told the LPN that was assigned to the lower hall and had that patient for medication pass about the incident. She also stated she had not told the RNUM, the supervisor, or the DON about the injury to the residents foot because he was fine. When asked if it was in her scope of practice to assess a resident she stated that she had not assessed him. The LPN stated that Resident #22 was fine, had no injuries to his foot and other than informing the other LPN, she had not documented anything in the residents chart about the incident. Resident #46: The resident was admitted to the nursing home on 2/9/11, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. A Certified Nursing Care (CNA) Guide (a document that lets the CNA know what care to deliver to a resident) dated 11/28/16, documented that the resident was to have a pummel foam cushion in the wheelchair with a side cushion placed on the right side to prevent slouching, elevation leg rests (please keep elevated to prevent hips from sliding), dycem placed and taped to the entire backrest and entire cushion to prevent slipping and an abductor spacer to place in between knees with projections behind the knees. During an observation on 12/6/16 at 9:00 am, the resident was reclined in a geri chair in the dining room. The was left side of the resident's face was ecchymotic (black and blue) and there was a dressing on the resident's mid forehead. A Nursing Progress note dated 12/3/16 at 9:09 pm, documented that the resident had fallen forward from her wheelchair, striking her forehead and nose on the floor. It documented that there was an area where the skin on the forehead sloughed downward, but was still attached and that there was a moderate amount of bleeding. It documented that facial and nasal x-rays were done at 8:30 pm and that the forehead was still oozing blood. It documented that the resident was arousable, would not open her eyes and was resistive to all movements of the extremities. A Fall Report dated 12/3/16, for the fall occurring on 12/3/16 at 5:35 pm, documented that the resident leaned forward in the wheelchair and fell out striking her forehead and face on the floor. It documented a 1 inch avulsion area to the forehead and swelling to the bridge of her nose. Additionally, it documented that the fall was observed. The Root Cause for falls documented that there was no potential abuse and the rationale was that the care plan was followed and the resident's insite was poor, making her at risk. An unsigned facility form titled, A&I Findings, Root Cause and Initial Action Review, documented current intervention: Request for therapy and interdisciplinary team to evaluate need for belt in wheelchair. IDCT review and recommendation: provided a lounge chair. IDCT determination of abuse: no abuse. Rationale: cause identified, resident observed falling out of the wheel chair and the care plan was followed. However, the facility's Root Cause Form was blank in the areas for the IDCT team to sign. A review of video footage on 12/8/16 at 5:00 pm by the surveyor and the Administrator of the South dining room dated 12/3/16, showed the resident being wheeled into the dining room by CNA #1 at approximately 5:10 pm. The resident was wearing a hospital gown, there was no protrusion of a pummel cushion noted between her legs and there were no leg rests on the chair. The resident was not visible at the table, however the camera captured multiple staff in the dining room bringing residents in and serving dinner. During an interview on 12/8/16 at approximately 5:15 pm, the Administrator stated that he first saw the video on 12/5/16 and was so upset over other things he observed on the camera that he had not noticed that the resident's care planned leg rest was not in place, but that as a result of the other issues witnessed on the video the CNA who cared for the resident was terminated on 12/5/16. During an interview on 12/12/16 at 9:15 am, the Administrator stated that after interviewing and checking the schedule, the person assigned to the resident the evening of the fall was not the CNA who was terminated on 12/5/16. Additionally, the Administrator stated that the responsible CNA was suspended for the remainder of her shift on 12/8/16 and returned to work early on 12/9/16 so she could receive education. During an interview on 12/12/16 at 9:35 am, the Director of Nursing (DON) stated that when an incident occurs, the supervisor starts the investigation and that statements are obtained at the time of the incident and the Administrator does the investigations. Additionally, the DON stated that their interviews should have been conducted and the Department of Health contacted prior to 12/9/16. Also, the DON stated that the IDCT usually met the next day to go over the incident and sign off on the Root Cause Review form, but did not think it was discussed in morning report. During an interview on 12/12/16 at 10:15 am, the Registered Nursing Supervisor (RNS) stated that it was her responsibility to determine what happened and if the care plan was followed. The RNS stated that she was not positive if the legs were on the wheelchair and that she kind of went through to see if the resident was supposed to be in a wheelchair and did not recall seeing any assistive devices in the care plan, unless she was looking in the wrong place. Additionally the RNS stated that she did not know how to access the CNA Care Guide in the electronic medical record. During an interview on 12/12/16 at 11:50 am, the Certified Nursing Assistant (CNA) assigned to the resident, stated that she did not look at the resident's care card until after the fall and that she did not have the pummel cushion or the leg rests on. Additionally, the CNA stated that she had never put the pummel cushion in the resident's chair and did not even know what it was. The CNA stated that the RNS was aware that the pummel and leg rests were not on and after the incident, the RNS showed her what the pummel cushion was and how to use it. Resident #54: The resident was admitted to the nursing home on 9/7/16, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. The facility did not ensure that an investigation was completed to determine the root cause of the resident's sudden drop (32) in their Finger Stick Blood Glucose (FSBG), 3 hours after insulin was administered for an elevated (591) FSBG. (FSBG target range 90-130mg/dl) A Nurse's Note dated 9/7/16 at 9:09 pm, documented that at 8:00 pm the resident's blood sugar was 591. The MD was called, a message left and the resident received 8 units of [MEDICATION NAME] insulin. It documented that at 9:09 pm, the MD called back with no new orders and that the resident's repeat FSBG was 174. A SBAR (Situation, Background, Assessment, Recommendation) (a note used to facilitate prompt and appropriate communication) note dated 9/8/16 at 1:41 am, documented that the resident was observed unresponsive on the floor next to his bed with cool clammy skin and his oxygen saturation was 86% (normal 95 - 100 and admission vital signs documented an oxygen saturation of 98% on room air). It documented that at 11:15 pm, the resident's FSBG was 38, the resident was given 1 milligram (mg) of intramuscular (IM) [MEDICATION NAME] (emergency medicine used to treat severe [DIAGNOSES REDACTED] (low blood sugar) in patients with diabetes) and a repeat FSBG was 46. A second dose of IM [MEDICATION NAME] was given at 11:28 pm and the resident's blood sugar rose to 54. It documented a repeat FSBG of 67, but not the time the FSBG was done. Additionally, it documented that the resident was new to the facility that day, the MD would be notified before the end of the shift or with any new changes. A Nurses Note dated 9/8/16 at 5:55 am, documented that the resident was found lying on the floor unresponsive and cool to touch with a FSBG of 32 at 11:00 pm. It documented that [MEDICATION NAME] IM was administered and the residents FSBG at 12:00 am was 67. Additionally, it documented that oxygen at 2 liters/nasal cannula was administered for an oxygen saturation of 87% and that the resident's pupils were constricted. During an interview on 12/13/16 at 10:30 am, the Director of Nursing (DON) stated that they did not look further into the incident to ensure that the resident was not given the wrong (type) insulin or wrong dose (of insulin). During an interview on 12/13/16 at 1:30 pm, the MD stated that he would have expected an investigation into the fact that the resident's blood sugar went from 591 to 32 in 3 hours. Also, the MD stated that if the resident was given 8 units of [MEDICATION NAME] his blood sugar would not have dropped that far and that it was likely that the resident received the wrong dose (of insulin). 10 NYCRR 415.4(b)(1)(2)(3)

Plan of Correction: ApprovedJanuary 26, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practices;
Resident # 22 was assessed by an RN and signs and symptoms of injury and was medicated for pain. An Incident & Accident report was initiated and completed by the RN.
Resident # 46 profile care card was reviewed and revised to reflect the appropriate current care planned mobility equipment of a geri-chair and needed positioning devices.
Resident # 54 was discharged (9/10/16) and readmitted (11/7/16) to the facility. Upon readmission the diabetic care plan was initiated.
? How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
Profile Care Cards were reviewed to ensure all mobility devices/equipment matched current therapy recommendations
All Profile Care Cards audited to ensure appropriate devises/equipment were in place per therapy recommendations.
Finger Sticks were all reviewed and insulin orders audited from 9/1/16 to 12/7/16. The attending physician was notified of all identified errors for review and recommendations.
I&A?s were reviewed for
? What measures will be put in place or what systemic changes will be made to ensure that the deficient practice does not recur;
Reeducation for all staff on abuse prevention, including properly informing supervisor of all incidents of accidents that may cause a potential injury.
Reeducation to all licensed nursing staff to report finger sticks (below 60 or above 400) on the 24 hour report
Reeducation on all licensed nursing staff on initiating and completing I&As (Incident and Accident) including confirming profile care card measures were followed and of all staff to report to supervisor of any potential incident or accident that may cause harm.
Add to ?I&A Fall Report? under ?Environmental Review?: Presence of leg rest and/or positioning devices on wheelchair.
All Incident and Accident (I&A) reports will be reviewed weekly by interdisciplinary team falls rounds and presence of appropriate wheelchair equipment/devices identified on the I&A will be checked against profile care card to ensure all are current and in place and followed appropriately.

Interdisciplinary team will review I&As during morning report up to five times weekly to ensure completion of the I&A and that the nature of the incident is reflected on the 24 hour morning report. The I&As will be logged on the morning report QA sheet which will be tracked for evidence of completion for QA.
? How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
All Incident & Accident reports and complaints of abuse will be tallied and reported to monthly quality assurance for monitoring of thoroughness, completion and frequency. For continuous quality improvement, the nature and frequency of the audits will be reviewed and revised as determined by the QA Committee for 3 months with change in processes as indicated.
? The date for correction and the title of the person responsible for correction of each deficiency.
1/27/2017 the Interdisciplinary team and administration will be responsible.

FF09 483.20(m), 483.20(e):PASRR REQUIREMENTS FOR MI & MR

REGULATION: A facility must coordinate assessments with the pre-admission screening and resident review program under Medicaid in part 483, subpart C to the maximum extent practicable to avoid duplicative testing and effort. A nursing facility must not admit, on or after January 1, 1989, any new residents with: (i) Mental illness as defined in paragraph (m)(2)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission; (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for mental retardation. (ii) Mental retardation, as defined in paragraph (m)(2)(ii) of this section, unless the State mental retardation or developmental disability authority has determined prior to admission-- (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for mental retardation. For purposes of this section: (i) An individual is considered to have "mental illness" if the individual has a serious mental illness defined at §483.102(b)(1). (ii) An individual is considered to be "mentally retarded" if the individual is mentally retarded as defined in §483.102(b)(3) or is a person with a related condition as described in 42 CFR 1009.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 13, 2016
Corrected date: January 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview during a recertification survey the facility did not ensure that the Pre-Admission Screening and Resident Review (PASSR) was completed prior to admission for 2 (Residents #'s 13, and 39) of sixteen (16) residents reviewed. Specifically, for Resident #'s 8 and 39, the facility did not complete a New York State (NYS) PASSR using the required Department of Health (DOH) Screen Form DOH-695 (2/2009) prior to the residents' admission to the facility. This is evidenced by: The facility's admissions policy dated 9/30/2014 documents the following: For an applicant to be considered for admission to the facility a completed/current Patient Review Instrument (PRI) and PASRR/Screen are required. If the PASSR reveals a need for a Level II review, such review shall be completed and reviewed prior to a bed offer being made to an applicant. Such a review shall determine if the facility is able to meet the residents Level II requirements. Resident #13: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident was understood and usually understands. A Brief Interview of Mental Status (BIMS) 3/15 documented a decision making impairment. It also documented the resident received antipsychotic medication. During a record review there was no documented evidence of a NYS PASSR DOH 695 having been completed prior to the resident #13 admission to the facility. During an interview on 12/8/16 at 4:00 pm, the Administrator (AD) for the facility stated that the Social Worker has all the resident's PASSR records if they are not in the residents' electronic medical records. He further stated that the SW should review the residents records when they are admitted and that the SW should notify the administrator if the PASSR is missing. He stated that he was aware that the PASSR needs to be completed on each resident before the resident is admitted . During an interview on 12/12/16 at 11:00 am, the Social Worker (SW) for the facility stated that there was no PASSR completed for Resident #13 at the time of admission. He stated the resident was admitted to the facility from the community and that there wasn't a certified screener available to complete the PASSR. He further stated after the resident was admitted , he reviewed the paper work and was supposed to follow up on making sure the PASSR was done. He stated he did not do this. The SW also stated he was aware that a NY DOH 695 PASSR is required before a resident is admitted to the facility and is not really sure why this was not done. He further stated he was not sure how the facility determined they could meet the resident's needs before admissions given the PASSR was not done. Resident #39 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident was understood and could understand. A Brief Interview of Mental Status (BIMS) 10/15 documented a decision making impairment. It also documented the resident received antidepressant medication. During a record review there was no documented evidence of a NYS PASSR DOH 695 having been completed prior to the residents' admission to the facility. However, a PASSR from another facility was found in the residents' medical record dated 5/13/2016. During an interview on 12/07/16 at 9:00 am, the Registered Nurse Unit Manager (RNUM) for the facilities North Unit stated that the PASSR's are in the electronic medical record. She further stated if they had not been scanned into the residents electronic record that they have a copy of it in the Social Worker's office. She also stated the Social Worker (SW) is the person designated to review the PASSR when the resident is admitted to the facility. During an interview on 12/08/16 at 7:45 am, the Administrator for the facility stated that the SW takes care of reviewing the residents' PASSR. The Administrator stated that he is PASSR certified and can complete the PASSR if he knows one is needed. He stated that he was aware that the PASSR in the residents record is not the correct form needed and was not sure why the discharging facility used this type of form when it is not compliant with the NYS regulation. He also stated he was unsure who was suppose to do the PASSR before the resident was admitted . During an interview on 12/8/16 at 2:00 pm, the SW stated that the facility that discharged the resident sent a PASSR to them on the day the resident was admitted to the facility. He also stated he did not realize that it was not a DOH 695 form and that he thought it was a valid form. He stated he needed to review the facility policy on what was required on the PASSR's to prevent errors like this from happening. 10NYCRR415.11(e)

Plan of Correction: ApprovedJanuary 7, 2017

? What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
Resident #13 & #39 both had a new PASSR screen completed from a qualified screener
? How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
House Audit on all residents to ensure each has an appropriately approved DOH PASSR Screen
? What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
All admissions will be audited for presence an approved NYS PASSR Screen Form DOH-695 (2/2009) prior to offer of admission.
? How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Social Worker will complete an audit check list of new admissions that indicates the presence of appropriate PASSR Screen prior to offer of admission and results will be reported to QA. For continuous quality improvement, the nature and frequency of the audits will be reviewed and revised as determined by the QA Committee for 3 months with change in processes as indicated.
? The date for correction and the title of the person responsible for correction of each deficiency.
1/27/2017 by Social Worker and Nursing Home Administrator

FF09 483.25:PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 13, 2016
Corrected date: January 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, for 3 (Resident #'s 50, 54, and #61) of sixteen residents reviewed. Specifically for Resident #54, the facility did not ensure the physician was notified when the resident was found on the floor unresponsive with a significant drop in blood sugar, that an order from the Medical Doctor (MD) to discontinue the before meals insulin was carried out, that an investigation was initiated to determine the root cause of a sudden drop (32) in Finger Stick Blood Glucose (FSBG), (3 hours after the administration of insulin for an elevated FSBG of 591), that the physician's admission history and physical (done on following day) included documentation of the above event and what changes were made to the medication regime and that the resident received the correct dose of insulin coverage according to the Physician (MD) order. Additionally, the facility did not ensure that Resident #50 was assessed for pain prior to five dressing changes. The resident exhibited an escalation in behavior during the treatment of [REDACTED]. Additionally, treatments were not discontinued and/or postponed given her escalation in behavior/distress. Also, for Resident #61, the facility did not ensure that the resident's pain was managed during a pressure ulcer dressing change. Resident #54: The resident was admitted to the nursing home on 9/7/16, at approximately 2:30 pm, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. A Policy for [DIAGNOSES REDACTED]/[MEDICAL CONDITION] dated 2/2010, documented that all licensed nurses would treat a resident with a blood glucose level of less than 60 mg/dl. Additionally, it documented that the cause of [DIAGNOSES REDACTED] should be determined to prevent or minimize future episodes. Finding #1: The facility did not ensure that the physician was notified when the resident was found unresponsive on the floor of his room with a significant drop in blood sugar. A Physician (MD) Admission order dated 9/7/16, documented: -[MEDICATION NAME] 5 units subcutaneous (SQ) daily before breakfast. -[MEDICATION NAME] 2 units SQ daily before meals. -[MEDICATION NAME] per sliding scale before meals and at bedtime daily for FSBG (finger stick blood glucose) of: 71 - 180; give 0 units 181 - 250; give 2 units 251 - 300; give 4 units 301 - 350; give 6 units 351 - 400; give 8 units For FSBG less than 60 or more than 400 contact MD A Nurses' Note dated 9/7/16 at 9:09 pm, documented that at 8:00 pm the resident's FSBG result was was 591. The Medical Doctor (MD) was called, a voice message was left and the resident was administered 8 units of [MEDICATION NAME] insulin. It documented that at 9:09 pm, the MD called back with no new orders and that the resident's repeat FSBG was 174. A SBAR (Situation, Background, Assessment, Recommendation) (a note used to facilitate prompt and appropriate communication) note dated 9/8/16 at 1:41 am, documented that the resident was observed unresponsive on the floor next to his bed with cool clammy skin and his oxygen saturation was 86% (normal 95 - 100). (Admission vital signs documented an oxygen saturation of 98% on room air). It documented that at 11:15 pm the resident's FSBG was 38, the resident was given 1 milligram (mg) of intramuscular (IM) [MEDICATION NAME] and a repeat FSBG was 46. A second dose of IM [MEDICATION NAME] was given at 11:28 pm, and the resident's FSBG rose to 54. It documented a repeat FSBG of 67. Additionally, it documented that the resident was new to the facility that day, the MD would be notified before the end of the shift or with any new changes. A Nurses Note dated 9/8/16 at 5:55 am, documented that the resident was found lying on the floor unresponsive and cool to touch with a FSBG of 32 at 11:00 pm. It documented that [MEDICATION NAME] IM was administered and the residents FSBG at 12:00 am was 67. Additionally, it documented that oxygen at 2 liters/nasal cannula was administered for an oxygen saturation of 87% and that the resident's pupils were constricted. During an interview on 12/13/16 at 10:30 am, the Director of Nursing (DON) stated that even though the resident was new to the facility the Licensed Practical Nurse(LPN) followed the hypoglycemic protocol and it did not require MD contact unless there was no response to the second dose of [MEDICATION NAME]. Additionally, the DON stated that she did not know where the doses of [MEDICATION NAME] were documented as given besides in the progress note. During an interview on 12/13/16 at 1:30 pm, the MD stated that he would have expected to be called when the resident's blood sugar dropped so significantly. Finding #2: The facility did not ensure that they investigated to determine the root cause of a sudden drop (32) in Finger Stick Blood Glucose (FSBG), 3 hours after being given insulin for an elevated (591) FSBG A Nurses Note dated 9/7/16 at 9:09 pm, documented that at 8:00 pm the resident's blood sugar was 591. The MD was called and a message left and the resident was given 8 units of [MEDICATION NAME] insulin. It documented that at 9:09 pm, the MD called back with no new orders and that the residents repeat FSBG was 174. A SBAR (Situation, Background, Assessment, Recommendation) (a note used to facilitate prompt and appropriate communication) note dated 9/8/16 at 1:41 am, documented that the resident was observed unresponsive on the floor next to his bed with cool clammy skin and his oxygen saturation was 86% (normal 95 - 100, and admission vital signs documented an oxygen saturation of 98% on room air). It documented that at 11:15 pm the resident's FSBG was 38, the resident was given 1 milligram (mg) of intramuscular (IM) [MEDICATION NAME] and a repeat FSBG was 46. A second dose of IM [MEDICATION NAME] was given at 11:28 pm, and the resident's blood sugar came up to 54. It documented a repeat FSBG of 67 but not the time it was done. Additionally, it documented that the resident was new to the facility that day, the MD would be notified before the end of the shift or with any new changes. A Nurses Note dated 9/8/16 at 5:55 am, documented that the resident was found lying on the floor unresponsive and cool to touch with a FSBG of 32 at 11:00 pm. It documented that [MEDICATION NAME] IM was administered and the residents FSBG at 12:00 am was 67. Additionally, it documented that oxygen at 2 liters/nasal cannula was administered for an oxygen saturation of 87% and that the resident's pupils were constricted. During an interview on 12/13/16 at 10:30 am, the Director of Nursing (DON) stated that they did not look further into the incident to ensure that the resident was not given the wrong insulin or wrong dose. During an interview on 12/13/16 at 1:30 pm, the MD stated that he would have expected an investigation into the fact that the resident's blood sugar went from 591 to 32 in 3 hours. Also, the MD stated that if the resident was given 8 units of [MEDICATION NAME] his blood sugar would not dropped that far and that it was likely that the resident received the wrong dose. Finding #3: The facility did not ensure that an order from the MD to discontinue the before meals insulin was carried out. A Physician (MD) Admission order dated 9/7/16, documented [MEDICATION NAME] 2 units subcutaneous SQ daily before meals A Nurses Note dated 9/9/16 at 6:13 pm, documented that the resident was seen by the MD for admission and that a new order was received to discontinue the resident's before meal [MEDICATION NAME] insulin. A Medication Administration Record [REDACTED]. During an interview on 12/13/16 at 2:40 pm, the Registered Nurse Manager (RNM) stated that she would have discontinued the order at the time she wrote the note and did not know why the [MEDICATION NAME] was still on the MAR for staff to administer. When the surveyor asked to see the written documentation that she discontinued the [MEDICATION NAME], the RNM stated that she did not know where it was or how to access it. During an interview on 12/7/16 at 10:10 am, the Director of Nursing (DON) that there was no formal system for checking for medication errors and that the nurses would notify her if they noticed a medication error. When the surveyor asked the DON how the nurses would notice a medication error if they could only see what medication they had to give at any certain time, the DON stated, that's a good question. Additionally, on 12/13/16 at 2:50 pm, the DON stated that she was not aware that the resident still received the [MEDICATION NAME]after it was discontinued. Finding #4: The facility did not ensure that the physician's admission history and physical done on following day, included documentation of the event and what changes were made to the medication regime. A Nurses Note dated 9/7/16 at 9:09 pm, documented that at 8:00 pm the resident's FSBG was 591, the resident was given 8 units of [MEDICATION NAME]and a message left was left for the MD. It documented that at 9:09 pm, the MD called back with no new orders and that the residents repeat FSBG was 174. A Nurses Note dated 9/9/16 at 6:13 pm, documented that the resident was seen by the MD for admission and that a new order was received to discontinue the resident's before meal [MEDICATION NAME] insulin. A Physician (MD) Admission History and Physical dated 9/9/16, documented under past medical history: diabetes. There was no documentation of the Hyper/hypoglycemic events or that he ordered changes to the meal time [MEDICATION NAME] insulin. During an interview on 12/13/16 at 1:30 pm, the MD stated that he should have documented on the resident's blood sugar issues when he came in on 9/9/16. Finding #5: The facility did not ensure that the resident received the correct dose of insulin coverage according to the Physician (MD) order A Physician (MD) Admission order dated 9/7/16 documented: [MEDICATION NAME] per sliding scale before meals and at bedtime daily for Fingerstick blood glucose (FSBG) of: 71 - 180; give 0 units 181 - 250; give 2 units 251 - 300; give 4 units 301 - 350; give 6 units 351 - 400; give 8 units For FSBG less than 60 or more than 400 contact MD A Medication Administration Record [REDACTED] date time FSBG units administered units due per MD order 9/10 11:30 am 195 0 2 A Physician (MD) order dated 11/22/16 documented: [MEDICATION NAME] per sliding scale before meals and at bedtime daily for a FSBG of: 150 - 200; give 2 units 201 - 250; give 4 units 251 - 300; give 6 units 301 - 350; give 8 units 351 - 400; give 10 units over 400; give 10 units For FSBG less that 60 or more than 400 contact MD A Medication Administration Record [REDACTED] date time FSBG units administered units due per MD order 12/2 12:23 pm 205 2 4 12/3 12:00 pm 152 0 2 12/4 7:30 am 228 2 4 12/5 7:53 am 155 0 2 During an interview on 12/7/16 at 2:40 pm, when the Licensed Practical Nurse (LPN) was shown the fingersticks she did with the corresponding sliding scale insulin she administered, she stated that those were the wrong doses for the fingersticks. Additionally, the LPN stated that she was not aware that she made the medication errors. During an interview on 12/7/16 at 3:35 pm, the Registered Nurse Manager (RNM) stated that she was not aware of the medication errors, but she should have been. Additionally, the RNM stated that she did not know who would be checking for errors in the insulin dosages and that there was no way to pick up on these error the way the Electronic Medication System is set up. During an interview on 12/7/16 at 10:10 am, the Director of Nursing (DON) stated that she was not aware of the wrong insulin doses being given and that there was no formal system for checking for medication errors. Additionally, the DON stated that the nurses would notify her if they noticed a medication error. When the surveyor asked the DON how the nurses would notice a medication error when they could only see what medication they had to give at any certain time, the DON stated that's a good question. Resident #50: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severely impaired cognition and was rarely able to make self understood. During an observation on 12/6/16 at 11:30 am, Resident #50 was positioned in her geri-chair in her room. The resident was yelling aloud which was heard by the DOH surveyor in an area approximately six rooms away. When the DOH surveyor entered the resident room and introduced herself the resident responded by yelling nonsensical words. During an observation on 12/7/16 at 9:35 am, the resident was sitting in her geri-chair in her room. The resident was yelling aloud names, help me and nonsensical words. During an observation on 12/8/16 at 10:00 am, the resident was sitting in her geri-chair in her room. The resident was yelling aloud names and nonsensical words. On 12/8/16 at 1:30 pm, dressing changes were observed on five wounds: two on the left lateral foot, one on the left lateral knee, one on the ischium and one on the sacrum. The resident was positioned on her right side in her bed to allow access to the wounds. The Wound Registered Nurse (WRN) performed the wound care, the Director of Nursing (DON) was on the residents right side holding hands with the resident, CNA #1 was on the residents left side talking to and touching the residents shoulder and back, CNA #2 was standing away from the bed writing the measurements of the wounds as directed by the WRN. At approximately 1:50 pm, CNA #3 entered the room and stood along side the DON and bent to be face to face with the resident and spoke with her in a calm manner. At the start of the wound care the resident began to yell and resist the treatment by attempting to move her body, arms and legs. The resident was in distress during the treatment (her behavior would escalate to turning her head and biting her pillow, yelling louder, physical resistance, and using curse words). The resident's behavior was erratic and clearly escalated with the cleansing of the second foot wound and the sacral wound. The staff members in the room were speaking with the resident about things she liked to hear in attempts to keep her calm. During the third wound treatment, the DON asked for the first time if the resident was in pain and the resident responded by yelling, using no words. The DOH surveyor left the room at the end of the treatment to the last wound. The Medication Administration Record [REDACTED]. Left lateral foot, cleanse open areas with normal saline, apply santyl (ointment that cleans wounds to clear the way for healthy tissue) to open skin only, cover with [MEDICATION NAME] (all-in-one dressing for fluid handling). Change daily and prn (as needed). The time of treatment to be done is documented for 10:00 pm. 2. Left and right buttock wound, cleanse with normal saline, pack wounds with calcium alginate (Dressing absorbs exudates and maintains a moist wound environment), cover with abd pad (fluffy dressing) and affix with medfix tape. Change daily and prn (as needed). The time of treatment to be done is documented for 10:00 pm. 3. Left knee skin tear, cleanse with normal saline, apply wound gel (provides the proper healing environment for a wound) and dry dressing, daily and prn. The time of treatment to be done is documented for 10:00 pm. The Medication Administration Record [REDACTED]. [MEDICATION NAME] (pain reliever and a fever reducer) 1,000 milligrams (mg) at 8:00 am, 4:00 pm and 10:00 pm. 2. [MEDICATION NAME] (opioid pain medication used to treat moderate to moderately severe pain) 50 mg prn for pain, limit to every six hours. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Left knee skin tear, cleanse with normal saline, apply wound gel and cover with xeroform ([MEDICATION NAME] Wound Dressing) and dry dressing every other day and as needed (prn). The time of treatment to be done is documented for 10:00 pm. 2. Left and right buttock wounds, cleanse with normal saline, pack wounds with silver alginate (antimicrobial, highly absorbent wound dressing), cover with dry dressing. The time of treatment to be done is documented for 10:00 pm. 3. Left lateral foot, cleanse open areas with normal saline, apply silver alginate and cover with [MEDICATION NAME]. The time of treatment to be done is documented for 10:00 pm. The MAR indicated [REDACTED]. [MEDICATION NAME] 1,000 mg at 8:00 am, 4:00 pm and 10:00 pm. 2. [MEDICATION NAME] 50 mg prn for pain, limit to every six hours. The MAR indicated [REDACTED]. The Comprehensive Care Plan dated 12/6/16 and titled Impaired skin integrity documented the goals: will have current ulcers/lesion resolved, resident will have no pain with treatment. Documented for approaches: monitor for pain prior to dressing change and medicate per MD order, treatment per MD order. During an interview on 12/8/16 at 3:00 pm the Infection Control Nurse (ICN)/WRN stated that the only time she sees Resident #50 is during wound rounds. WRN stated the Resident does yell all of the time, but she should be medicated prior to the wound rounds. During an interview on 12/8/16 at 3:15 pm the Registered Nurse Manager (RNM) stated she had not been present for Resident #50's dressing change in months. Resident #50 does yell all the time, she receives no medications to calm her and she is not been seen by Psych since (MONTH) (YEAR). RNM stated she told the Licensed Practical Nurse (LPN) to medicate the Resident with the prn [MEDICATION NAME] before the dressing change. RNM reviewed the medication administration in the computer and stated the LPN medicated Resident #50 at 10:30 am. RNM stated the Resident should be medicated one hour prior to the dressing changes. During an interview on 12/8/16 at 3:30 pm the Certified Nurse Aide #4 (CNA) stated that Resident #50 becomes agitated and is in pain during wound rounds and the dressing changes. CNA #4 stated that the Resident always yells, but her behavior during dressing changes is much different. During an interview on 12/8/16 at 3:35 pm the DON stated the wound round that day took way too long. The DON stated this was the first time she had been present for Resident #50's wound round and dressing changes, and that the Resident was in distress. The Resident should have been medicated for pain prior to the dressing changes. During an interview on 12/12/16 at 3:20 pm LPN #1 stated that Resident #50's behavior escalates during the dressing changes. Resident #50 gets the Tylenol prior to the 10:00 pm dressing change and she does not think it works. Resident #50's behavior during the dressing change is definitely anxiety and pain. During an interview on 12/12/16 at 1:30 pm the Medical Director stated, if pain is a factor during the dressing change she should be given the [MEDICATION NAME] before the dressing change, antianxiety is not the answer. Resident #50 does not see very well, maybe there was too many people around during the dressing change. Any resident should be assessed for pain prior to a dressing change and medicated for pain. During an interview on 12/13/16 at 1:50 pm the DON stated that the facility tries to get the proper equipment to position residents with pressure sores and prevent pain. DON had no answer why nurses were not medicating Resident #50 with pain medication prior to her dressing changes. The dressing changes have been separated to different segments to decrease the time frame of the dressing change treatment. DON would hope the Registered Nurse Managers were identifying pain and having residents medicated prior to dressing changes. Resident #61: The resident was admitted to the nursing home on 5/19/14 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident usually understood and was understood by others. A Comprehensive Care Plan (CCP) dated 12/2/16, documented that the resident would have no pain with treatment and to monitor for pain prior to the dressing change and medicate per MD order. A physician (MD) order dated 9/6/16, documented [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 milligrams (mg) three times a day at 8:00 am, 2:00 pm, and 8:00 pm. During a dressing change observation on 12/7/16 at 11:40 am, the resident was observed wincing and stated that it hurt when staff removed the dressing that was stuck to the wound on the right heel and when the Licensed Practical Nurse (LPN) was cleansing the wound. The LPN stated that she knew that hurt and continued with the procedure. The resident stated that it hurt while having the dressing done and when her foot was moved during the procedure. During an interview on 11/7/16 at 12:00 pm, the Registered Nurse Manager (RNM) stated that the nurses had not reported that the resident was having pain during the dressing change. Additionally, the RNM stated that there was no way to look at the pain scale history to evaluate the effectiveness of the pain regime a resident is on. During an interview on 12/12/16 at 2:45 pm, the LPNstated that the resident did not usually have pain with the dressing change, but she reported it to the RNM. Additionally, the LPN stated that she did not document the resident's pain in the medical record but should have. During an interview on 12/12/16 at 3:00 pm, the RNM stated that the resident gets [MEDICATION NAME] three times daily, and was scheduled at 2:00 pm to coincide with her dressing changes and was not aware that the dressing change was not being done around that time. Additionally, the RNM stated that later in the day the LPN reported that the resident had pain during the dressing change and that she thought that she reported it to the MD but that she did not document it but should have. 10NYCRR 415.12

Plan of Correction: ApprovedJanuary 27, 2017

? What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
#54 resident was discharged and readmitted at a later date to the facility where an RN assessment was completed on 12/9/16. Care plan for diabetes was initiated. RN counseled and reeducated.
#50 Pain assessment completed, medication orders reviewed on 12/9/16 with new orders. Wound care treatment was divided to be completed amongst two shifts. #50 will be medicated one hour prior to wound care.
#61 The pressure ulcer of the heel is healed. RN pain assessment; no pain noted in healed area.
? How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
All finger sticks were reviewed and insulin orders audited from 9/1/16 to 12/7/16. The attending physician was notified of all identified errors for review and recommendations. Physicians reviewed and documented on all residents with fingerstick/insulin orders.
Medication error reports were completed for each incident with associated discipline notice for each error. All nurses were reeducated on the proper procedure to identify when to notify the MD regarding changes in finger stick blood glucose results outside parameters.

All residents with wounds will be evaluated by wound care team for pain prior to and during wound care. Pain management will be addressed based on evaluation.

? What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
Once per shift EMR finger stick report is reviewed. Any discrepancy is addressed with the nurse.
Reeducation for clinical nursing staff on the proper procedures to identify when to notify the MD regarding changes in finger stick blood glucose outside parameters was completed.
Unit Manager/Supervisor to ensure MD is made aware. Unit Manager/Supervisor to document any results outside the parameters of residents' glucose readings on the 24 hour report for review by the interdisciplinary team.
Identified all residents with wounds and evaluated pain management orders.
MD Wound rounds are scheduled once weekly with WRN. Residents who are scheduled to see the Wound MD will have their dressings completed during this round.

All residents will be evaluated for signs/symptoms of pain prior to and during wound care. Medication will be administered as ordered. Reeducation for nursing staff regarding administration of pain medication prior to and during wound care was completed.

? How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Once per shift EMR finger stick report is reviewed. Any discrepancies will be addressed with the nurse.
Audits will be conducted for all residents with wounds to ensure evaluation and effective management of pain prior to and during wound care. This audit will focus on 4 (four) wounds, any new admissions admitted with wounds, or any newly acquired wounds, two days a week for one month, then weekly for two months, and reported at QA monthly. For continuous quality improvement, the nature and frequency of the audits will be reviewed and revised as determined by the QA Committee for 3 months with change in processes as indicated.
? The date for correction and the title of the person responsible for correction of each deficiency.
1/27/2017 by the Assistant Director of Nursing/Nurse Educator

FF09 483.25(m)(2):RESIDENTS FREE OF SIGNIFICANT MED ERRORS

REGULATION: The facility must ensure that residents are free of any significant medication errors.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 13, 2016
Corrected date: January 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during a recertification survey the facility did not ensure that residents were free of any significant medication errors for five Residents (#46, 54, 56, 61, 71) of sixteen residents reviewed. Specifically for Residents #54, the facility did not ensure that he did not receive [MEDICATION NAME]before meals when the MD requested that it be discontinued and for Resident #s 54, 56,and 61, that they received the correct dose of insulin per their Medical Doctor (MD) ordered sliding scales. This is evidenced by: Resident #54 The resident was admitted to the nursing home on 9/7/16 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. Finding #1 The facility did not ensure that the resident received the correct dose of insulin coverage according to the Physician (MD) order. A Physician (MD) Admission order dated 9/7/16 documented: [MEDICATION NAME] per sliding scale before meals and at bedtime daily for Fingerstick blood glucose (FSBG) of: 71 - 180; give 0 units 181 - 250; give 2 units 251 - 300; give 4 units 301 - 350; give 6 units 351 - 400; give 8 units For FSBG less than 60 or more than 400 contact MD A Medication Administration Record [REDACTED] date time FSBG units administered units due per MD order 9/10 11:30 am 195 0 2 A Physician (MD) order dated 11/22/16 documented: [MEDICATION NAME] per sliding scale before meals and at bedtime daily for FSBG of: 150 - 200; give 2 units 201 - 250; give 4 units 251 - 300; give 6 units 301 - 350; give 8 units 351 - 400; give 10 units over 400; give 10 units For FSBG less that 60 or more than 400 contact MD A Medication Administration Record [REDACTED] Date Time FSBG Units administered Units due per MD order 12/2 12:23 pm 205 2 4 12/3 12:00 pm 152 0 2 12/4 07:30 am 228 2 4 12/5 07:53 am 155 0 2 Finding #2 The facility did not ensure that an order from the MD to discontinue the before meals insulin was carried out. A Physician (MD) Admission order dated 9/7/16, documented [MEDICATION NAME] 2 units subcutaneous SQ daily before meals A Nurses Note dated 9/9/16 at 6:13 pm, documented that the resident was seen by the MD for admission and that a new order was received to discontinue the resident's before meal [MEDICATION NAME] insulin. A Medication Administration Record [REDACTED]. During an interview on 12/13/16 at 2:40 pm, the Registered Nurse Manager (RNM) stated that she would have discontinued the order at the time she wrote the note and did not know why the [MEDICATION NAME] was still on the MAR for staff to administer. When the surveyor asked to see the written documentation that she discontinued the [MEDICATION NAME], the RNM stated that she did not know where it was or how to access it. During an interview on 12/13/16 at 2:50 pm, the Director of Nursing (DON) stated that she was not aware that the resident still received the [MEDICATION NAME]after it was discontinued. Resident #61 The resident was admitted to the nursing home on 5/19/14 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident usually understood and was understood by others. A Physician (MD) order dated 1/16/16, documented: Humalog insulin per sliding scale at 7:30 am and 4:30 pm; for FSBG of: 201 - 250; give 2 units 251 - 300; give 4 units 301 - 350; give 6 units 351 - 400; give 8 units over 400; give 10 units For FSBG less than 60 or more than 400 contact MD A Medication Administration Record [REDACTED] Date Time FSBG Units administered Units due per MD order 10/2 4:26 pm 266 0 4 10/4 5:11 pm 346 8 6 10/15 3:30 pm 250 2 4 10/19 5:16 pm 233 6 2 11/1 4:42 pm 255 8 4 12/2 4:30 pm 350 4 6 Resident #56 The resident was admitted to the nursing home on 10/14/15 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident sometimes understood and was usually understood by others. A Physician (MD) order dated 4/4/16, documented: Humalog insulin per sliding scale daily at 4:30 pm; for FSBG of: 71 - 180; give 0 units 181 - 250; give 4 units 251 - 300; give 8 units 301 - 350; give 10 units 351 - 400; give 12 units For FSBG less than 60 or more than 400 contact MD A Medication Administration Record [REDACTED] Date Time FSBG Units administered Units due per MD order 9/3 3:55 pm 182 0 4 9/23 3:57 pm 323 8 10 10/6 3:30 pm 182 0 4 Interviews: During an interview on 12/7/16 at 2:40 pm, when the Licensed Practical Nurse (LPN) was shown the Fingersticks she did with the corresponding sliding scale insulin she administered, she stated that those were the wrong doses for the Fingersticks. Additionally, the LPN stated that she was not aware that she made the medication errors. During an interview on 12/7/16 at 3:35 pm, the Registered Nurse Manager (RNM) stated that she was not aware of the medication errors but she should have been. Additionally, the RNM stated that she did not know who would have been checking for errors in the insulin dosages and that there was no way to pick up on these error the way the Electronic Medication System is set up. During an interview on 12/7/16 at 10:10 am, the Director of Nursing (DON) that she was not aware of the wrong insulin doses being given and that there was no formal system for checking for medication errors. Additionally, the DON stated and that the nurses would notify her if they noticed a medication error. When the surveyor asked the DON how the nurses would notice a medication error when they could only see what medication they had to give at any certain time, the DON state, that's a good question. 10NYCRR 415.12(m)(2)

Plan of Correction: ApprovedJanuary 25, 2017

? What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
#54 resident was discharged and readmitted at a later date to the facility where an RN assessment was completed on 12/9/16.
#61Per MD review and new orders for finger sticks to one time daily
#56 Per MD review, adjustments made to sliding scale.
? How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
All residents on finger sticks were reviewed that day and every shift going forward. Finger stick orders were audited from 9/1/16 to 12/7/16. The attending physician was notified of all errors.
Medication error reports completed for each nurse found with deficient practice
? What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
Every shift audits on all finger sticks and any discrepancies will be addressed.
Reeducation for current clinical nursing staff and for new clinical nursing staff for the proper procedures to identify when to notify the MD regarding changes in Finger Stick Blood Glucose parameters.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Report to Monthly QA the once a shift finger stick audits. For continuous quality improvement, the nature and frequency of the audits will be reviewed and revised as determined by the QA Committee for 3 months with change in processes as indicated.
? The date for correction and the title of the person responsible for correction of each deficiency.
1/27/2017 by Director of Nursing

FF09 483.20(k)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 13, 2016
Corrected date: January 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification and abbreviated (#78 Case # 60 ) survey the facility did not ensure the services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care for three Residents (#46, 61, 78) of 10 residents reviewed in phase 1. Specifically for Resident #61, who had a pressure sore to her heel, the facility did not ensure that the resident's care planned foot bootie and elevation leg rest were in place. Also, the facility did not ensure that instead of a gerichair, Resident #46 was in a wheel chair with dycem, a pummel cushion, side cushion for positioning and elevated leg rests . Additionally, the facility did not ensure that Resident #78 was ambulated. Resident #61 The facility did not ensure that the resident's care planned foot bootie and elevation leg rest were in place. The resident was admitted to the nursing home on 5/19/14 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident usually understood and was understood by others. A Certified Nursing Care (CNA) Guide, (a document that lets the CNA know what care to deliver to a resident) dated 12/2/16, documented that the resident was to have a to the right foot bootie on when out of bed and a right elevating foot rest at all times. During observations on 12/6/16 at 8:45 am, 12:45 pm and 2:40 pm, 12/7/16 at 8:45 - 9:00 am, 9:20 am, 10:00 am and 11:30 pm the resident was in her wheelchair. The resident had socks on and her right foot did not have a foot bootie on it and there was not foot rest on her wheelchair. During an interview on 12/7/16 at 11:50 am, the Resident's CNA stated that the resident used to have a blue thing on her foot but she had not seen it since she returned to work over a week ago. Additionally the CNA stated that the resident did not have a leg rest for her wheel chair that she knew of. During an interview on 11/7/16 at 11:55 am, the Licensed Practical Nurse (LPN) stated that she was not sure if the resident had any offloading devices on her foot. When the LPN checked the CNA Care Card, she stated that the resident was supposed to have a right foot bootie and a leg rest. Additionally, the LPN stated that she thought those were discontinued. During an interview on 11/7/16 at 12:00 pm the Registered Nurse Manager (RNM) stated that the care plan should be followed. Resident #46 The facility did not ensure that the resident was in a wheel chair with a pummel cushion, side cushion for positioning and elevated leg rests instead of a gerichair with out the devices. The resident was admitted to the nursing home on 2/9/11 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. A Certified Nursing Care (CNA) Guide, (a document that lets the CNA know what care to deliver to a resident), dated 11/28/16, documented that the resident was to have a pummel foam cushion in wheel chair with a side cushion placed on the right side to prevent slouching, elevation leg rests (please keep elevated to prevent hips from sliding, dicem placed and taped to the entire backrest and entire cushion to prevent slipping, and an abductor spacer to place in between knees with projections behind the knees. A nursing referral for Rehabilitation Screen dated 11/28/16, documented to please assess for position and may benefit from a gerichair. The Occupational Screen was completed on 11/29/16 and documented that the resdinet was observed to be optimally positioned with the current seating accommodations. that she was noted with upright posture, the bilateral lower extremities were offloaded. It documented that the NM was informed that the resident must be properly aligned with the given positional equipment when in the chair at all times. During observations on 12/6/16 at 9:00 am, 12:45 pm, and 2:50 pm, 12/7/16 at 8:45 - 9:00 am, 12:30 pm, and 3:30 pm the resident was noted to be sitting in a reclining gerichair instead of a wheelchair and had no pummel cushion, dycem, or an abductor spacer. During an interview on 12/12/16 at 10:00 am, Certified Nursing Assistant (CNA) #3 stated that she thought the resident had been in the gerichair since her fall on 12/3/16 and that she did not think that the pummel cushion, dicem and side cushion was used in the gerichair. During an interview on 12/12/16 at 3:00 pm the Registered Nurse Manager stated that the resident was put in the gerichair after the fall and none of the nurses reported that the resident was in it. Additionally the RNM stated that by not using the wheelchair with the dycem, pummel, and abductor spacer that staff were not following the care plan. Resident #78 The facility did not ensure that the resident was ambulated. The resident was admitted to the nursing home on 9/23/15 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident sometimes understood and was sometimes understood by others. A Certified Nursing Care (CNA) Guide, (a document that lets the CNA know what care to deliver to a resident), dated 12/6/16 documented that the resident was ambulatory with a walker, was full weight bearing, one assist, and under mobility documented recommended for walk to dine program. During multiple observations from 12/6 - 12/9/16 the resident was not observed ambulating. During an interview on 12/8/16 at 9:30 am, the resident's Certified Nursing Assistant (CNA)#4 stated that she had taken care of the resident for approximately one month, had not ambulated her, and was not aware that the resident was supposed to be ambulated. The CNA #4 stated that tasks to be done lit up on their Kiosk but ambulation did not light up. Additionally the CNA #4 stated that she did not know what recommend walk to dine program was and had never asked anyone. During an interview on 12/8/16 at 9:45 am, the Registered Nurse Manager (RNM) stated that she had not seen the resident ambulate in a long time and that the resident should be ambulated to the diningroom if she was willing. During an in interview on 12/8/16 at 3:30 pm, the Director of Therapy (DT) stated that the old physical therapist put the resident on the walk to dine program and that meant the resident was supposed to be ambulated to dining. Additionally, the DT stated that she had not received any referrals from the nurses regarding issues with ambulation. During an interview on 12/13/16 at 1:30 pm, the CNA #5 stated that the resident was supposed to be ambulated but has not been because of behaviors and staffing.

Plan of Correction: ApprovedJanuary 20, 2017

* What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
#61 Profile Care Card reviewed and confirmed that the booties & leg rest are to be present. Resident previously care planned to refuse wearing of booties.
#46 Profile Care Card reviewed and revised to include proper wheelchair (geri-chair) and positioning devices and discontinued equipment no longer on order.
#78 Profile Care Card reviewed and revised, referral to physical therapy to assess ambulation status
? How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
Therapy did complete their monthly review to ensure that residents wheel chairs and positioning devises were in place in accordance to the Profile Care Cards as per the therapy recommendations and this review continues monthly to ensure continued compliance.
? What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
Any new skin alterations will have therapy referral sent for positioning. Residents who refuse to wear such devices will be addressed in the resident profile care card with approaches to encourage resident to be compliant.
A Weekly LPN Audit Binder including those residents identified to require a photographic depiction of the positioning devices will be kept in the dining room where an LPN will check the resident for proper positioning during meals at least 3 times per week. LPNs will also check to assure the recommended proper pressure relieving devices are present at such time.
The Weekly Audit Binder will include the list of residents participation grid that identifies those residents to partake in the ?Walk to Dine? program and the LPN will check off those residents who participated in the walk to dine (to the dining room) at least 3 times per week.
Therapy will provide photographic depiction of optimal placement of position devices for resident with multiple positioning devices for the wheelchair which will be placed in resident?s closet door for staff?s viewing. Staff will be educated on identifying Profile Care Cards with such positioning devices.
? How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
The Weekly Audit Binder will be collected by the RN Unit Manger to assure that the audits were performed at least 3 times in a week and tally the findings (of positioning devices, walk to dine and pressure relieving devices) and reports will continue as such for 1 month and then reduced in accordance to QA recommendations per sufficient compliance being achieved. The Walk to Dine schedule will be audited for 5 days per week of documented participation times 1 month and reported to QA for further recommendations.
? The date for correction and the title of the person responsible for correction of each deficiency.
1/27/2017 by RN Unit Managers

Standard Life Safety Code Citations

K307 NFPA 101:DOORS WITH SELF-CLOSING DEVICES

REGULATION: Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 13, 2016
Corrected date: January 27, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the hazardous areas were not protected in accordance with adopted regulations. NFPA 101, Life Safety Code 2012 edition section 19.2.2.2.7 requires that the self-closing doors to hazardous areas be held open only with devices that release upon activation of the facility fire alarm and automatic sprinkler systems or loss of power. Specifically, the doors to the maintenance shop and the laundry room were held open with non-compliant devices. This is evidenced as follows. The doors to the maintenance shop and laundry room were inspected on 12/07/2016 at 2:15 pm. These doors were held open with devices that will not release upon activation of the fire alarm or sprinkler systems or loss of power. The Director of Plant Operations stated in an interview conducted on 12/07/2016 at 3:30 pm, that during the day, the soiled linen section of the laundry room is held open with a door magnet and that he did not know that the maintenance shop and laundry room doors could only be held open with devises connected to the fire alarm and sprinkler systems. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.2.2.2.7; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.2.2.2.6, 7.2.1.8.2

Plan of Correction: ApprovedJanuary 7, 2017

? What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
No resident areas were affected by the doors identified and identified doors were closed
? How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
The affected doors will remain in the closed position (with signage stating: Please Keep this Door Closed at All Times) until the modifications can be made. All devices that held the door in the open position have been removed.
? What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
Both doors identified will be modified with Self-Closing Devices connected to the fire alarm and sprinkler system and inspections of non-self-closing doors will be made to ensure no devices are present that prevent the door from not releasing upon activation of the fire alarm or sprinkler system.
? How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
A log will be maintained inspecting the 2-doors identified for being in the appropriate closed position that will be reported to QA until the doors are modified to possess self-closing mechanisms in which will be reported to QA with approval for need to continue the inspection until doors are brought to code. For continuous quality improvement, the nature and frequency of the audits will be reviewed and revised as determined by the QA Committee for 3 months with change in processes as indicated.
? The date for correction and the title of the person responsible for correction of each deficiency.
1/27/2017 by Director of Plant Operations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 13, 2016
Corrected date: January 27, 2017

Citation Details

Based on observation and employee interview during the recertification survey, it was determined that the facility did not utilize power strips in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.2.3.6 and The Centers for Medicare and Medicaid Services notice from the Director of the Survey and Certification Group S&C 14-46-LSC permits the use of Special-purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL -1 to power patient care-related electrical equipment and Relocatable Power Taps (RPT) listed as UL 1363 to power non-patient-care related electrical equipment. Specifically, non-compliant power strips were used to power non patient care-related equipment in resident areas on 2 of 2 resident units. This is evidenced as follows. The North and South resident units were inspected on 12/07/2016 at 2:15 pm. In resident room N-122, a non-compliant power strip was used to power a radio and a lamp; in the Physical Therapy room, a non-compliant power strip was used to power a computer and monitor; in the Occupational Therapy Suite, a non-compliant power strip was used to power the computer; and in the social worker office, a non-compliant power strip was used to power the computer. The Director of Plant Operations stated in an interview conducted on 12/07/2016 at 3:30 pm, that he thought the power strips found were compliant and that he did not consider the desk area in physical therapy and the social worker office as resident areas. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.2.3.6; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3

Plan of Correction: ApprovedJanuary 7, 2017

? What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
All non-compliant power strips were removed from the patient care vicinity
? How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
Facility wide inspection to remove any further non-compliant power strips from patient care vicinity was completed
? What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
The use of the Electrical Safety Log will continue with any findings to be reported to monthly QA that will include routine inspections will be created to check for and remove any non-compliant power strips in patient care vicinity. New power strips that meet the UL 1363 requirements will be used in non-patient care rooms.
? How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Findings on any non-compliant power strips in patient care vicinity (audited through the established Electrical Safety log) will be reported to QA on a monthly basis to determine the need for ongoing inspections for non-compliant power strips. For continuous quality improvement, the nature and frequency of the audits will be reviewed and revised as determined by the QA Committee for 3 months with change in processes as indicated.
? The date for correction and the title of the person responsible for correction of each deficiency.
1/27/2017 by Director of Plant Operations

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 13, 2016
Corrected date: January 27, 2017

Citation Details

Based on staff interview and record review during the recertification survey, it was determined that the facility did not exercise the emergency generator as required by adopted regulations. NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.4 requires that emergency power standby systems (emergency generator), including all appurtenant components, shall be inspected weekly and exercised under load for 30 minutes at least monthly. Specifically, during 2 of the last 12 months, the emergency generator was not exercised under load conditions for at least 30 minutes. This is evidenced as follows. The test logs for the emergency generator were reviewed on 12/07/2016. The (MONTH) (YEAR) and the (MONTH) (YEAR) load tests were conducted for 25 minutes each. The Director of Plant Operations stated in an interview conducted on 12/07/2016 at 10:00 am, that the generator load test is controlled on an automatic timer and that he did not know why the tests for (MONTH) (YEAR) and (MONTH) (YEAR) were less than 30 minutes. 42 CFR 483.70 (a) (1); 2010 NFPA 110 8.4; 10 NYCRR 415.29, 711.2(a)(1); 1999 NFPA 99 3-4.4.1, 3-4.4.2; 1999 NFPA 110 6-4

Plan of Correction: ApprovedJanuary 7, 2017

? What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
Generator has been exercised under full load conditions for at least 30 minutes since the deficient practice was identified.
? How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
Weekly generator testing continues per policy.
? What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
?Test Exercise Log? which is the Monthly Generator testing log will be revised including the phrase (minimum of 30 minutes) for load testing. The self-timing mechanism dictating the length of time that the generator operates under the testing exercise was increased to ensure at least 30 minutes are ran during the monthly test.
? How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Logs will be changed to include verbiage that identifies that the load test was exercised for at least 30 minutes, this log will include the signature of the staff member completing the test, the Director of Plant Operations and the Nursing Home Administrator will initial that the test is in compliance with the testing parameters. For continuous quality improvement, the nature and frequency of the audits will be reviewed and revised as determined by the QA Committee for 3 months with change in processes as indicated.
? The date for correction and the title of the person responsible for correction of each deficiency.
1/27/2017 by Director of Plant Operations and the Nursing Home Administrator