Plattsburgh Rehabilitation and Nursing Center
July 1, 2016 Certification/complaint Survey

Standard Health Citations

FF09 483.15(h)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: July 1, 2016
Corrected date: August 29, 2016

Citation Details

Based on observation during the initial tour and staff interview during the recertification survey, it was determined that the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior on 2 of 2 residential units. Specifically, floors in resident areas and wheelchairs were not clean, and wheelchair armrest upholstery were ripped. This is evidenced as follows: An indoor inspection of the facility was conducted on 06/27/2016 at 11:00 am. The corridor and resident room floors on the A-unit and B-unit were soiled with crusty dirt and dried particles. Wheelchair frames and seats were soiled with dirt and grime and the armrest upholstery was ripped. The Director of Environmental Services stated in an interview conducted on 06/29/2016 at 9:15 am, that he was aware the facility floors were getting dirty, but they are doing the best they can with both full-time housekeepers out sick, leaving housekeeping short staffed. Additionally, he stated that wheelchair cleaning is not on a set schedule and that maintenance relies upon the care staff to report unclean equipment. 10 NYCRR 415.5(h)(2)

Plan of Correction: ApprovedAugust 17, 2016

F253 HOUSEKEEPING & MAINTENANCE SERVICES
The filing of this plan of correction does not constitute an admission that the deficient practice occurred; rather it is to be in compliance as required by the issuing agency.
What Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice-
1. All floors in the residential care areas have been cleaned.
2. Resident Wheelchairs- A full house cleaning and power wash of all wheelchairs will be completed. At this time any repairs that are needed to the wheelchairs will be documented and parts will ordered.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken-
1. All residential area floors have the potential to be affected by the same deficient practice. All floors were cleaned daily.
2. A full house audit by the Rehabilitation Director was done for all wheelchair arms rests Replacement arm rests have been ordered and delivered and will be replaced.
What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur-
1. Floor cleaning schedule was reviewed and revised to address areas of high traffic to have an increased cleaning schedule.
2. A schedule for the night shift staff was developed to clean three wheelchairs per night this will ensure all wheelchairs are cleaned on a monthly basis.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur-
1. The Director of Environmental Services/ designee will inspect the floors daily to ensure cleanliness.
2. The DON created an audit tool to ensure the wheelchairs are being cleaned at night as scheduled.
3. Director of Environmental Services added wheel chair inspection on the room of day schedule to check for any tears on the wheel chair arm rests.
4. The audit will be conducted 3x a week x 4 weeks with any negative findings immediately corrected and reported to the administrator.
5. Audit findings will be presented by the Director of Enviromental Services and the Director of Nursing at the QAPI committee meeting for evaluation and follow-up as indicated.
Responsible Party - Director of Housekeeping & Maintenance

FF09 483.65:INFECTION CONTROL, PREVENT SPREAD, LINENS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 1, 2016
Corrected date: August 29, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews during the recertification survey the facility did not ensure that it maintained an Infection Control Program designed to prevent the development and transmission of disease and infection for 3 (Resident #'s 7, 11, 69) of 16 residents and 2 units of 2. Specifically, wound care for Resident #s 7, 11, and 69 was not performed in a manner to prevent the development and transmission of disease and infection. Also, the community bathroom was not maintained in a clean manner. This was evidenced by: Resident #7: The facility did not ensure that Resident #7's dressing change and linen handling was done in a manner to prevent the transmission of disease. The resident was admitted to the nursing home on 5/3/16, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. During an observation on 6/28/16 at 11:31 am, the Licensed Practical Nurse (LPN) did not wash her hands or doning gloves prior to the dressing change. The LPN was observed removing the resident's sock and the dressing was stuck to the resident's sock. The LPN donned gloves, removed the dressing on right heel wound that was opened with slough in the center with tannish colored drainage. The LPN placed the resident's right heel down on a blanket at the foot of his bed. Using the same gloves, the LPN wiped the wound with wound cleanser soaked gauze, applied [MEDICATION NAME], and started applying an [MEDICATION NAME] dressing over the wound. She removed her gloves, finished applying the [MEDICATION NAME], and picked up the soiled supplies and discarded them. The LPN picked up the resident's sock that had drainage on it, opened it and showed the resident that it was soiled with drainage before putting in hamper for cleaning. The LPN picked up the banket that had visible wound drainage on it, folded it and placed it in the resident's chair, with ungloved hands. Duriong this obsrvation of wound care the LPN did not wash her hand during the dressing change. During an interview on 6/28/16 at 3:20 pm, the LPN stated that she should have washed her hands before starting the procedure and throughout the dressing change; kept gloves on when providing care to the wound; not handled the resident's soiled sock or blanket without gloves on, and that the soiled blanket should have put in laundry. Resident #69: The resident was admitted on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented that the resident rarely/never understood and was rarely/never able to understand others. Additionally, the MDS documented that the resident had severe cognitive impairment. A review of the resident's medical record revealed [REDACTED]. Review of physician orders [REDACTED]. Review of treatment administration record documented treatment orders effective 06/16/16 to cleanse sacral wound with wound wash, apply maxsorb into wound and cover with adhesive foam dressing daily and as needed. An observation of wound care on 6/30/16 at 9:35 am by an Licensed Practical Nurse(LPN) revealed. The bedside cabinet of Resident #69 had personal items on it and had not been wiped off prior to setting wound supplies on the bedside cabinet for use during wound treatment. The LPN placed a supply of clean gloves on the bedside cabinet on top of a small light beige stuffed animal. Her name tag came into contact with the resident while she was independently positioning the resident for wound care. The LPN then used her clean gloves to place the name tag out of her work area onto her back. When the resident was positioned on her left hip the sacral wound was observed to have no protective dressing covering it, the wound was exposed and the packing was observed inside of the wound. The LPN cleansed the area with wound wash and blotted the area with clean guaze, then placed the used guaze on a white towel barrier that had been previously placed over the sheet by the LPN. The LPN then picked up the same guaze from the towel and began blotting the open wound area again.The LPN then removed the white towel from under the resident's lower back and buttock region and placed the contaminated towel on the residnt's posey roll that had been placed in the geri chair making contact with the resident's jogging pants and mechanical lift pad to the right of the LPN. The LPN then removed the posey roll from the geri chair and replaced it in the bed with the resident. Additionally, the LPN did not sign or date the wound dressing applied to the sacral area of Resident #69. During an interview on 7/1/16 at 10:30am with Infection Control/Education RN stated that the facility had done proficiency evaluations with LPN's for dressing changes for both clean and dirty wounds. She also stated that the facility had completed inservices on turn and positioning and she would have expected another staff member to have been present to assist with positioning Resident #69. Additionally, she stated that nurse initials and the date of the dressing change are expected on all dressings. Resident #11: The resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Nursing Admission/Re-admission form dated 6/21/16 documented that the resident was alert and oriented to person, place, and time (cognitively intact). The following observations were made in the resident ' s room on 6/30/16: At 8:25 am the resident was asleep in his chair in front of the over-the-bed table. A urinal, partially filled with urine was observed on the over-the-bed table sitting next to a partially eaten breakfast tray. At 8:35 am the resident was asleep in his chair in front of the over-the-bed table. The breakfast tray had been removed. The urinal, partially filled with urine, was on the over-the-bed table. At 8:52 am the resident was asleep in his chair in front of the over-the-bed table. The urinal, partially filled with urine, was on the over-the-bed table. At 9:29 am the resident was asleep in his bed. The urinal, partially filled with urine, was on the over-the-bed table. At 10:03 am the resident was asleep in his bed. The urinal was no longer on the over-the-bed table. Finding #1: On 7/1/16 at 8:17am Unit 2 the community bathroom located to the right of the solied linen room was observed . Brown substance was observed on the toilet bowl rim, thewhite toilet seat was up with brown substance on the underneath of the seat, there was a bowel movement, urine and toilet paper in the toilet bowl. A white towel with a moderate size of brown substance was identified on the bathroom floor. Additionally, used paper towels were identified on the floor in the corner near the garbage can. During an interview on 7/1/16 at 8:40 am with housekeeper #1, she stated that another housekeeper had come in late that day. As she observed the community bathroom she stated that the community bathroom should be cleaned by housekeeping but that the dirty towels should have been placed in a clear bag and tied. She also stated that it may have been a resident that left the community bathroom that way. Additionally, she stated that some staff will notify housekeeping if cleaning is needed, but there are others that will just leave the area for housekeeping to clean. During an interview on 7/1/16 at 10:30 am with the Infection Control/Education RN, she stated that Certified Nurse Aides (CNA) are taught during orientation to keep garbage bags on their person to clean up contaminated items in any place. 10NYCRR415.19(a)(1-3)

Plan of Correction: ApprovedAugust 26, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F441 INFECTION CONTROL
The filing of this plan of correction does not constitute an admission that the deficient practice occurred; rather it is to be in compliance as required by the issuing agency.
What Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice-
1. Resident #7 had no negative outcome from the deficient practice. The resident was discharged from the facility with an overall improvement of the affected area. LPN will be educated on dressing changes by the Education RN.
2. Resident #69- RN assessed area with no negative findings to the wound, as the wound continues to improve. LPN will be educated on dressing changes and documentation by the Education RN. The resident will be assessed for positioning by the physical therapist and care plan will be updated and will be communicated to the nursing staff that care for this resident.
3. Resident #11 had no negative outcome from the deficient practice. The resident was discharged from the facility.
4. Finding #1 The community bathroom was immediately cleaned and all linen/debris was removed and appropriately discarded
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken-
1. All residents that have an active medical treatment of [REDACTED].
a) DON/ Designee will review all residents that have treatment orders of dressing changes will review the plan of care.
b) DON/Designee will do an observation audit on the dressing changes to ensure treatments are done in accordance with the dressing change policies with on the spot education provided if indicated.
2. All residents that use a urinal have the potential to be affected by the deficient practice.
a) DON/Designee along with Director of Rehabilitation/ Designee will review all residents that use a urinal and provide education to the residents if indicated on appropriate placement for the urinals.
b) All staff will be educated on the appropriate placement and empting of the urinals to ensure a safe, sanitary and comfortable environment that will help prevent the development and transmission of disease and infection.
3. All residents that utilize the community bathroom have the potential to be affected by the deficient practice.
a) Education provided to all nursing and housekeeping staff on the removal of dirty linens, towels etc.
b) Housekeepers will increase the bathroom checks on their daily cleaning schedules.
c) All staff will be educated on notifying house keeping department when the community bathrooms are in need of cleaning.
What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur-
1. Infection control policies related to: Infection Control Program, Preventing Spread of Infection, Linens will be reviewed/revised to include the appropriate placement and emptying of urinals.

2. All licensed nurses will be educated on dressing techniques with appropriate competencies completed and done on an annual basis.
3. All staff will be educated and appropriate competencies will be performed that will ensure the prevention, development/transmission of disease and infection ? hand washing, linen disposal and urinal dispensing. New Employee Orientation will also be reviewed/revised to include education in all Infection Control Policies with assigned appropriate competencies.
4. Daily schedule of the housekeepers has been revised to add more bathroom check during their daily routine.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur-
1. Audits will be performed 3x a week for 4 weeks, then randomly. Audits will include, but not limited to observation of dressing changes, hand washing (DON/Designee) and environmental rounds (EVS/ Designee).
2. Audit findings will be presented by the DON/ designee at the monthly QAPI committee meeting for evaluation and follow-up as indicated.
Responsible party Director of Nursing

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: July 1, 2016
Corrected date: August 29, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during a recertification survey and complaint investigation (#NY 608), the facility did not ensure 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 were provided for 1 of 16 resident's reviewed. Specifically, Resident #67 that was to have nothing by mouth (NPO) due to dysphagia (difficulty in swallowing) was delivered an evening meal tray to his room by a facility Certified Nurse Assistant (CNA). This is evidenced by: Resident #67: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was sometimes understood and sometimes able to understand others, with severe cognitive impairment. Review of a Nurses Note dated [DATE] at 6:00 am, documented the resident had a new feeding tube placed on [DATE] and was on [MEDICATION NAME] for an upper respiratory infection he had completed 7 of 10 days of his antibiotic. Additionally, it is documented that the resident was afebrile with a temperature of 96.4 degrees Fahrenheit (F). Review of a Nurses Note dated [DATE] at 1:40 pm, documented the resident had a congested cough and was out of bed for a couple of hours. Additionally, the resident was lethargic at times and was put back to bed. Review of a Nurses Note dated [DATE], signed by the RN (Registered Nurse) Supervisor documented that at approximately 6:30 pm, the resident was accidentally given a tray at dinner time and the resident is NPO (nothing by mouth). She documented that after hearing the resident cough a Certified Nursing Assistant (CNA) immediately went into his room and removed the tray, positioned the resident up in his bed and notified the RN Supervisor. Review of an Incident and Accident Report dated [DATE] at 6:30 pm, documented the RN Supervisor assessed for difficulty breathing and noted the resident appeared slightly agitated, rhonchi (abnormal breath sounds) heard in upper lobes and immediately assessed tray for possible contents ingested. The report documented that education was provided to both CNA's, chest x-ray was ordered for [DATE]. Additionally, it documented the resident may have ingested a small portion of a hamburger and 20 ml of liquid, because there was food and drink all down the front of him. A copy of the evening meal ticket documented, Wrong bed #, this confused the new CNA. Review of a Physician order [REDACTED]. Review of a Nutrition and Food Service Communication sheet dated [DATE], documented Resident #67's room number as ,[DATE], NPO. Review of the evening meal ticket dated [DATE] documented, Resident #75's (Resident #67 's roommate) room number also as ,[DATE]. (per Social Services notes Resident #75 had changed bed assignments on [DATE]). During an interview with the RN Supervisor on [DATE] at 3:40 pm, she stated that on [DATE] at approximately 6:,[DATE]:00 pm, she was advised that CNA #1 had delivered an evening meal tray on [DATE] to Resident #67. She stated that she could not be 100 percent sure that Resident #67 did not ingest any food or fluids orally. She stated she obtained the resident's vital signs, notified the physician and was advised to monitor for changes, such as shortness of breath or difficulty breathing. The RN stated she checked in a couple of hours after the tray was delivered to him and then left at 10:00 pm that evening, after providing the next RN Supervisor with facility report. Review of the facility 24 Hour Condition Report dated [DATE], documented Resident #67 was fed orally by CNA, physician was notified, temperature 98.0 F and that a chest x-ray was ordered for [DATE]. Review of the facility 24 Hour Condition Report (night shift) dated [DATE], documented Resident #67, room ,[DATE], increased agitation, heart rate, and respiratory rate. Temperature elevation by 3 degrees. Lungs were clear, [MEDICATION NAME] (a sterile inhalation solution for difficulty breathing) given x1, oxygen saturation at 83%-85%.and supplemental oxygen was on at 2 liters. Vital signs are documented as Temperature 99.5 F-Pulse128-Respiratory Rate 32 Blood Pressure of ,[DATE] and Resident #67 left for the emergency room at 4:50 am. Review of the hospital (named) discharge summary for the admitted d [DATE], documented he was admitted with shortness of breath and increased agitation. He also had low oxygen saturation down to 83% on room air, where the resident had not required any oxygen previously. The resident was given IV fluids, systemic steroids, and triple antibiotic therapy for presumed recurrent aspiration pneumonia. Review of the hospital (named) emergency room Nursing Triage note dated [DATE], documented at 5:18 am c/o (complained of) [MEDICAL CONDITION] aspiration. Staff felt the patient aspirated on food tray given to him during the evening. Patient oxygenation at 83% on room air and is agitated. The resident did have a cough and arrived on a Non Repeater Mask receiving supplemental oxygen. Pulse of 144/min and respirations of 30/min. oxygen delivery system changed to nasal annular and oxygenation went up to 93% with noted labored breathing, hyperventilation. Lung Sounds are documented as diffuse ales (abnormal lung sounds) and cough. Review of [DATE] chest x-ray completed at 5:53 am, documented no apparent focal infiltrate and no active [MEDICAL CONDITION] disease. During an interview with the Education Registered Nurse (RN) on [DATE] at 8:36 am, she stated that the meal ticket on the tray that had been delivered to Resident #67 had the wrong bed number for tray delivery in the room. Additionally, she stated that CNA #1 would have received a full day and then an additional 4 to 5 hours of training prior to being oriented on the nursing units as a CNA. She stated CNA #1 had received actual instructions on altered textured diets and altered consistencies of fluids during the training prior to floor orientation. During an interview with the Dietary Manager on [DATE] at 9:26 am, she stated that when Resident #67 had previously gone to the hospital the facility had moved his roommate (Resident #75) to the window bed and that Dietary was not notified of the move. Additionally, that due to not being notified of the bed assignment change that the bed number on the meal ticket was incorrect. During an interview with the Education RN on [DATE] at 3:30 pm, she stated that CNA #1 would have been assigned to work beside another experienced CNA for ,[DATE] days. She also stated that CNA #1 had not worked at the facility prior and was assigned CAN floor orientation during day shift on [DATE] - [DATE]. The Education RN stated that she had not received an orientation checklist back regarding CNA #1's performance on the three days of floor orientation. She stated she did not receive any report of concerns from any staff member regarding CNA #1. Additionally, she stated that the facility protocol is 3 days of orientation with a mentor, if no concerns the new staff member goes directly to the position. Education will randomly spot check their performance, until there are no concerns. The orientation checklist is only used if problems are identified. She would not expect a shadow mentor after 3 days but she would expect other staff members to help new staff. Additionally, she stated that Resident #67's care card stated NPO and is kept behind the nurse's station-there are no care cards in the resident ' s room. During an interview with CNA #1 on [DATE] at 12:20 pm, she stated that she delivered the meal tray to the wrong resident based on the placement of the outside door name tags. She stated Resident #67 did not have a name band on. She stated that another CNA immediately removed the tray and notified the RN Supervisor. Additionally, she stated Resident #67 appeared relaxed, was his usual self and that the RN Supervisor did correct the order of the outside door name plates. During an interview with Education RN on [DATE] at 3:04 pm, she stated there was no specific education for passing meal trays in the residents' rooms provided to CNA #1. During an interview with the RN Supervisor on [DATE] at 3:25 pm, she stated that she did not remember if Resident #67 had his name band on or not. During an interview with the Director of Nursing (DON) on [DATE] at 9:09 am, she stated that for Resident #67 to have received food or fluids was outside of his specific individualized plan of care. She also stated, that CNA's are buddied up for 3 shifts and that generally she tells the new staff if they feel they need more time to let her know, however, she didn' t think she had stated that to CNA #1. Additionally, she was not sure when Resident 's #67 and #75 had changed bed assignment in the room and it would have been Social Services duty to notify dietary of room changes. During an interview with the physician on [DATE] at 9:50 am, he stated that a white patch would have been on the chest x-ray results if Resident #67 had aspirated. Additionally, he stated that he would expected the resident to have been monitored every ,[DATE] hours after the meal tray had been identified. 10NYCRR415.12

Plan of Correction: ApprovedAugust 26, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 309 PROVIDE CARE/ SERVICES FOR HIGHEST WELL BEING
The filing of this plan of correction does not constitute an admission that the deficient practice occurred; rather it is to be in compliance as required by the issuing agency.
What Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice-
1. Resident #67 ? The dinner tray was immediately removed and the resident was positioned upright. An Incident/Accident Report was immediately completed, including an RN assessment, and internal Investigation. MD was contacted, ordering a CXR and, involved C.N.A.?s were educated on resident identifiers. Close monitoring of the resident continued.Resident was transferred to acute care on 5/11/16, CXR showed no apparent infiltrate and no active [MEDICAL CONDITION] disease.
2. On 5/11/16 - Audits were done on resident #67 and resident #75 name bands, meal tickets, and room lists and appropriate corrections were made.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken-
1. All NPO residents have the potential to be affected by the same deficient practice. An audit was done on all NPO residents? name bands, meal tickets and room lists; all negative findings were immediately addressed and corrected.

What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur-
1. Policy on resident ID bands was created to provide guidance on resident identification.
2. Notification of room or bed changes policy was developed and all notifications are annotated on the daily census in which each department director will update their respective systems. All room changes or bed changes will be noted in the 24 hour report so it is communicated shift to shift.
3. Education on all related policies will be given to all staff and be included in New Employee Orientation C.N.A. competency skills list.
4. Education RN/ Designee will meet with all new C.N.As on orientation to review the orientation checklist and provide additional orientation if indicated. The completed orientation checklist will be filed in the C.N.A. training file.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur-
1. All resident ID bands will be audited for accurate identification monthly times 3 months then randomly thereafter by the DON/unit designee. Replacement bands will be readily available and replaced.
2. The Food Service Director/ Designee will generate a report from the meal ticket dietary system and compare to the daily census list on a monthly basis to ensure all residents are noted to be in the correct room and bed number. Any discrepancies will be immediately fixed.
3. Education RN/ Designee will conduct observation audits to assess the competency of new C.N.A.s. The random audits will be done weekly xs 4 weeks and monthly there after. On the spot education will be provided if indicated.
4. Audit findings will be presented by the FSD/ designee and DON/ designee at the monthly QAPI committee meeting for evaluation and follow-up as indicated.
Responsible party Director of Nursing

FF09 483.75(l)(1):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 1, 2016
Corrected date: August 29, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record revoew and interview during the recertification survey and abbrieviated survey (Case #NY 608) the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that were complete; accurately documented; readily accessible; and systematically organized. Specifically: for Resident #11, there was a lack of a Registered Nurse's (RN) co-signature on the Nursing Admission/Re-admission form that was completed by a Licensed Practical Nurse (LPN); For Resident #'s 63 and #70, there was a lack of accurate physician orders [REDACTED].#80, there was a lack of documentation to indicate that an RN assessment had taken place when the resident complained of chest pain. This was evidenced by: Resident #11: This resident was newly admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The Nursing Admission/Re-admission form dated 6/21/16 documented that the resident was alert and oriented to person, place, and time (cognitively intact). The Nursing Admission/Re-admission form completed by the Licensed Practical Nurse (LPN) #1 dated 6/21/16 at 1:00 pm, documented the form must be co-signed by an RN (Registered Nurse). There is no documented evidence that an RN co-signed the form. During an interview on 6/30/16 at 2:29 pm, with LPN #1, she stated that she completed the Nursing Admission/Re-admission form for the resident the day the resident was admitted . She stated that when she completed the form, she asked the resident questions and then completes the form. LPN #1 stated an RN does the skin assessment. LPN #1 also stated they have 24 hours to complete the assessment. She stated that she could not remember who did the skin assessment on the resident that day and that the form is supposed to be reviewed and signed off by the RN within 24 hours. During an interview on 6/30/16 at 2:41 pm, the RN Nurse Manager (RN-NM) #1 was able to identify the RN who completed and documented the skin assessment for the resident on the Nursing Admission/Re-admission form dated 6/21/16. RN-UM #1 stated that the Nursing Admission/Re-admission form should have been reviewed and signed by the RN Supervisor. She stated, by the RN signing, they are essentially saying they agree with the findings and have done their own assessment. She stated They should be assessing, then reviewing the blue form, and then signing within a 24 hour period. Resident #63: The resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident sometimes understood and sometimes understands with moderately impaired cognitive ability. Review of a Nutrition Assessment 5/7/16 and signed by the Registered Dietician on 5/15/16, documented a diet order of [MEDICATION NAME] 1.5 at 45 millliters (ml)/hr via Gastrostomy tube ([DEVICE]) (a tube inserted through the abdomen wall and into the stomach for nutritional intake) for 20 hours daily. Review of physician orders [REDACTED]. Review of Medication Administration Record [REDACTED]. Review of Medication Administration Record [REDACTED]. Review of Nutrition Care Plan effective 11/27/15 and last reviewed 5/15/16, documented the Diet as [MEDICATION NAME] 45cc/hr for 23 hours. During an interview with Licensed Practical Nurse (LPN) #1 on 6/30/16 at 2:45pm , she stated that the [MEDICATION NAME] is no longer administered in cans, it is now delivered in large bottles. She also stated that the current orders are for 21 hours as the tube feed is on hold from 12:00 pm to 3:00 pm each day. During an interview with a Dietary Technician (assists in the provision of food service and nutritional programs, under the supervision of a Registered Dietician). The Dietary Technician reviewed physician orders [REDACTED]. The Dietary Technician (DT) stated that dietary would have expected that the resident received the [MEDICATION NAME] 1.5 for the most recent nutritional recommendation of 20 hours daily on 5/7/16. The DT stated that dietary staff would be responsible to update the care plan with the current order. Resident #70: The resident was admitted to the facility 06/12/15, with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident usually understood and was usually able to understand with a Brief Interview for Mental Status (BIMS) of 7 out of 15 or severe cognitive impairment. Nutrition assessment dated [DATE], documented diet order as Resource 2.0 120cc three times a day. Physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of MAR indicated [REDACTED]. During an interview with Licensed Practical Nurse (LPN) #1 on 6/30/16 at 2:26 pm, she stated that there was not a system in place to evaluate the accuracy of nutritional supplement administration. She stated that she believed Resident #70 was receiving the 120 ml of Resouce 2 Cal as ordered not 12ml. Additionally, she stated that it was a Pharmacy printing error that should have been noted, when the two nurses double checked the orders. Resident #80: This resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was able to understand others and was able to be understood. A Transition of Care Report from the hospital dated 4/19/16, documented the resident had a primary [DIAGNOSES REDACTED]. The resident underwent [REDACTED]. A physician's orders [REDACTED]. A Nurses Note dated 5/08/16 at 8:00 am, documented the resident complained of mild chest pain at 12:15 am and her heart rate was irregular. The resident was placed on oxygen at 2 liters and was given [MEDICATION NAME] for the chest pain. The physician was notified and an EKG was scheduled for Monday. A Nurses Note dated 5/08/16 at 2:00 pm, documented the resident complained of chest pain and her pulse was irregular. [MEDICATION NAME] 50 mg was given for the chest pain. A Nurses Note dated 5/09/16 at 1:50 pm, documented the resident was experiencing labored breathing with anxiety. Oxygen saturation level was at 84% on room air. After oxygen at 4 liters was applied, resident's oxygen level increased to 94%. Family, nursing home physician and the cardiologist were notified with no new orders being written by either the physician or the cardiologist. During an interview on 6/28/16 at 10:00 am, the Registered Nurse Manager (RNM) stated the doctor should have been notified because the resident continued to experience chest pain on 5/08 at 2:00 pm. She stated that it is the policy of the nursing home to immediately notify the physician of a change or a worsening of a resident's condition. During an interview on 6/30/16 at 12:30 pm, the Registered Nurse Supervisor (RNS) reported that he had been asked by the nurse to assess the resident as she was experiencing chest pain. He stated the resident was given [MEDICATION NAME] which relieved her pain. The resident stated that she had chest pain whenever she moved her arms. The resident was not complaining of nausea and had not vomited. Her vital signs were stable. Based on his assessment the RNS stated the resident was experiencing sternal pain from her surgical incision as the pain medication would not have relieved cardiac pain. The RNS stated he did not document his assessment, that he forgot about it but that he should have documented in nursing notes. An internal investigation dated 6/29/16, documented the resident was assessed by the RNS for post surgical pain and was determined to be stable with no change in condition. The RNS did not document his assessment in the medical record. 10NYCRR415.22(a)(1-4)

Plan of Correction: ApprovedAugust 26, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 514 RES RECORDS- COMPLETE/ ACCURATE/ ACCESSIBLE
The filing of this plan of correction does not constitute an admission that the deficient practice occurred; rather it is to be in compliance as required by the issuing agency.
What Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice-
1. Resident #11 ? No negative findings from the deficient practice. The resident overall improved and was discharged home. The RN was educated on the completion of the assessment form.
2. Resident #63 ? A review of the resident?s medical record showed no negative outcome from the deficient practice, the resident remains above her usual body weight and has had no significant change in condition. The MD was immediately notified and a clarification order was obtained. Documentation was corrected, complete and accurate according to the clarifying MD orders. Nutrition Care plan was updated to reflect the MD orders.
3. Resident #70 ? A review of the resident?s medical record showed no negative findings from the deficient practice, the resident continues to remain within 2.3lbs of usual body weight and has remained medically stable. The MD was notified and a clarification order was obtained. Documentation was corrected, complete and accurate according to the clarifying MD order.
4. Resident #80 ? An internal investigation and chart review showed no negative findings the deficient practice, resident was discharged home. RNS was immediately educated on documentation guidelines.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken-
1. All new admissions and re admissions have the potential to be affected by the deficient practice.
a) All admissions and re admissions for the past 30 days will be reviewed to ensure all admission documentation is accurate with education provided if indicated.
2. All residents ordered GT feedings have the potential to be affected by the deficient practice.
a) A medical record review of all residents with a GT feeding was conducted with no negative findings.

b) All nutrition care plans for GT feedings were reviewed for accuracy with no negative findings.

3. All residents ordered liquid nutritional supplements have the potential to be affected by the deficient practice.
a) A meeting and review with the pharmacy was conducted and found the discrepancy in 12ml vs. 120ml. Found a change noted but was not picked up by pharmacy related to the small print of the monthly order. This was the only discrepancy for all the orders.
b) A medical record review of all residents with an order for [REDACTED].
4. All residents that require an RN assessment to be documented have the potential for the deficient practice. Education provided to the RNS to ensure assessments are complete and accurate and documented with appropriate progress notes when indicated.
What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur-
1. Policies related to GT feeding will be reviewed/ revised to ensure each resident?s clinical record is in accordance with accepted professional standards and practices that are complete and accurately documented.
2. Policies related to pharmacy corrections and review will be reviewed and revised. Pharmacy will provide a monthly report on all residents on a nutritional supplement, which will be reviewed by nursing and dietary to review accuracy of the orders.
3. Education of the policies will be given to appropriate nursing and dietary staff.
4. RN documentation policies and guidelines will be reviewed/revised to ensure the clinical record contains an accurate record of the resident?s assessments and progress notes.
5. Education to all RN?s will be provided regarding documentation policies and guidelines.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur-
1. Audits will be performed on all residents with GT feedings to ensure documentation of administration of GT feedings weekly xs 4 weeks, and monthly audits of MAR indicated [REDACTED]. Diet Tech/ designee will audit nutrition care plans monthly to ensure accuracy with the MD orders. All negative findings will be corrected immediately with continued education to the appropriate staff.
2. Audits will be performed on all residents on a liquid nutritional supplement monthly to ensure the MAR match the physician orders.
3. All new admissions assessments will be audited the next business day during IDT morning report to ensure all assessments are complete, reviewed and signed by an RN. x4 weeks, then randomly. All negative findings will be corrected immediately with continued education to the RN at the time of the finding.
4. A random audit will be performed 3x/wk for 4 weeks on any resident that may require an RN assessment progress note based on documentation guidelines. Noted policies/guidelines will be applied with continued education to the RN when applicable.

Responsible party Director of Nursing

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Electrical wiring and equipment shall be in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: July 1, 2016
Corrected date: August 29, 2016

Citation Details

Based on observation and employee interview during the recertification survey, it was determined that the facility did not maintain the electrical system in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 1999 Edition section 3-3 requires a minimum number of electrical outlets in resident rooms. Specifically, for 5 of 6 resident rooms observed, electrical devices utilized extension cords and multi adaptor outlets not individual wall outlets. Multi adaptor outlets are devices connected wall outlets allowing for 6 rather than one electric device to be connected to the normal power supply. The provisions of the applicable categorical waiver were not met. This is evidenced as follows: A general inspection of the facility was conducted on 06/29/2016 at 2:20 pm. In resident rooms 106, 109, 125, 210, and 219 window air conditioning units were connected to extension cords. For each room, these extension cords and other electronic devices were plugged into the same multi-adaptor outlet. The Maintenance Supervisor stated in an interview conducted on 06/29/2016 at 2:45 pm, that the facility is using extension cords and multi adaptor outlets to make due with the available outlets. 42 CFR 483.70 (a) (1); 1999 NFPA 99 3-3; 10 NYCRR 713-1.1, 711.2 (19)

Plan of Correction: ApprovedAugust 11, 2016

K 147 NFPA 101 LIFE SAFETY CODE
The filing of this plan of correction does not constitute an admission that the deficient practice occurred; rather it is to be in compliance as required by the issuing agency.
What Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice-
Approved power strips will be installed and the extension cords removed
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken-
All resident rooms have the potential to be affected by the deficient practice.
What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur-
Admissions policy will be updated to reflect that extension cords and cheaters are not allowed in the facility. Residents / family members will be notified upon admission.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur-
All resident rooms will be audited on a monthly basis using the room of day audit sheet. Any extension cords or unapproved power strips will be immediately removed with education provided if indicated.
Results of audits will be reported to the QAPI committee monthly for 3 months and quarterly there after.

Responsible party Director of Environmental Services

K301 NFPA 101:LIFE SAFETY CODE STANDARD

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 1, 2016
Corrected date: August 29, 2016

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the automatic sprinkler system was not installed in accordance with adopted regulations. The Centers for Medicare and Medicaid Services published a Final Ruling in the Federal Register on (MONTH) 13, 2008 (73 FR ) requiring all long term care facilities to have full automatic sprinkler protection in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems 1999 edition by (MONTH) 13, 2013. Specifically, automatic sprinkler system was encumbered with unacceptable obstructions and did not cover all areas. This is evidenced as follows: An assessment of the sprinkler system was conducted on 06/29/2016 at 10:50 am. The automatic sprinkler spray area (spray pattern) was obstructed with light fixtures in the Resident Lounge, A Wing shower, A-2 Unit corridor, B Wing clean utility room, B-1 Unit community bathroom, service hallway, and employee entrance Men ' s Room. A shower curtain obstructed the spray pattern in the ADS shower room, and the doors found in the hold-open position obstructed the spray pattern in the employee entrance foyer. The Maintenance Supervisor stated in an interview on 06/29/2016 at 11:55 am, that the sprinkler obstructions were an oversight by the sprinkler system installation company. 42 CFR 483.70 (a) (1); 73, FR ; 2000 NFPA 101: 19.3.5; 1999 NFPA 13: 5-6.5; 10 NYCRR 415.29, 711.2(a) (1)

Plan of Correction: ApprovedAugust 11, 2016

K 056 NFPA 101 LIFE SAFETY CODE
The filing of this plan of correction does not constitute an admission that the deficient practice occurred; rather it is to be in compliance as required by the issuing agency.
What Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice-
All room in the facility protected by the automatic sprinkler system will be audited and inspected by the sprinkler installer and the maintenance department to check for obstructions in the spray pattern.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken-
All rooms in the facility have the potential to be affected and will be inspected.
What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur-
The installation was not done correctly at the time of the install. Once the repairs are made, the sprinkler system will not be altered. Any new lighting and or fixtures will be assessed before install to ensure the spray pattern is not obstructed.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur-
Facility is currently using all the required check sheets as determined by code.
Responsible party Director of Environmental Services

K301 NFPA 101:LIFE SAFETY CODE STANDARD

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 1, 2016
Corrected date: August 29, 2016

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2000 edition section 8.3.2 requires that smoke barriers shall be continuous from floor to the underside of the roof and through all concealed spaces, such as those found above a ceiling. Specifically, 1 of 1 smoke barriers observed were not continuous through all concealed spaces. This is evidenced as follows: The A-wing smoke barrier wall (wall) was inspected on 06/30/2016 at 10:30 am. A ten-inch hole for a sprinkler pipe was found above the ceiling in the community bathroom. The Maintenance Supervisor stated in an interview conducted on 06/30/2016 at 10:30 am, that the hole found was a missed penetration. 42 CFR 483.70 (a) (1); 2000 NFPA 101 19.3.7.3, 8.3; 10 NYCRR 415.29, 711.2(a) (1)

Plan of Correction: ApprovedAugust 11, 2016

K 025 NFPA 101 LIFE SAFETY CODE
The filing of this plan of correction does not constitute an admission that the deficient practice occurred; rather it is to be in compliance as required by the issuing agency.
What Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice-
The hole was filled with approved fire barrier material.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken-
All smoke barriers will be inspected and any penetrations will be sealed with approved material.
What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur-
Policy on smoke barrier penetrations will be reviewed and updated with pertinent staff educated.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur-
Any and all work that requires penetrations in smoke barriers muse be done with the approval of the maintenance department. This are was an oversight and missed on inspection when the sprinkler pipe were installed.
Responsible party Director of Environmental Services