Nassau Rehabilitation & Nursing Center
November 10, 2016 Certification Survey

Standard Health Citations

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 10, 2016
Corrected date: January 5, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews during the standard recertification survey, the facility did not ensure that all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated for one of one resident reviewed for abuse and neglect in a total sample of twenty two Stage two residents (Resident # 60). Specifically, the facility did not ensure that a thorough investigation was completed after Resident #60 alleged that a Certified Nursing Assistant (CNA) refused to put her to bed and one Licensed Practical Nurse (LPN) told the resident that she did not have time to give her oxygen. Additionally, the facility did not notify the Department of Health of the allegation of possible neglect and mistreatment. The finding is: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Date Set (MDS) assessments dated 6/18/15 and 9/21/16 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. An interview was held with Resident #60 on 11/9/16 at 11:00 AM. The resident stated that she was mistreated and had an altercation with a 3:00 PM to 11:00 PM shift LPN and a 3:00 PM to 11:00 PM shift CNA about two weeks ago. The resident stated that the LPN was verbally nasty to her after she requested Oxygen and that the LPN told her that she did not have time for that. The resident stated that the LPN did not address her request to go to bed after the CNA stated to her that she did not have time to put her to bed. The resident stated that she reported this to the registered Nurse (RN) supervisor the next morning. The resident stated that the CNA was also nasty and refused to put her to bed because she did not have time and that the resident was an added onto the CNA's assignment. The resident stated that she has sores on her bottom and that the sores were bothering her from sitting in the chair so long. The resident stated that she did not go to bed until the 11:00 PM shift CNA came on duty. The resident stated that she requested the Oxygen approximately 6:00 PM and she requested to go to bed about 7:30 PM. The resident stated that she reported this to the RN supervisor the next morning. A facility investigation documented that the CNA did not put the resident back to bed as requested and that the LPN informed the CNA to put the resident back to bed. The investigation documented that the CNA was suspended for mistreatment of [REDACTED]. The investigation report was not investigated to determine that there was no abuse, neglect or mistreatment of [REDACTED]. There is no documented statement from the LPN on the issue of the oxygen or that she reported the CNA's refusal to put Resident #60 back to bed. An interview was held with the RN on 11/10/16 at 9:30 AM. The RN stated that she completed the investigation on Resident #60. The RN stated that the LPN was an agency nurse and that the facility informed the agency to not have the LPN return. The RN stated that the CNA was suspended because the facility felt that the LPN should have called the supervisor to inform her that the CNA did not take care of the resident as instructed. The RN stated that all staff are educated on abuse, neglect and mistreatment. The RN stated that she felt the investigation was completed and that she felt it did not have to be called in to the State although the disciplinary notice documented that the CNA mistreated a resident. An interview was held with the Director of Nursing Services (DNS) on 11/10/16 at 9:45 AM. The DNS stated that she did not feel that the Department of Health needed to be called and informed of the allegations since we informed the agency that the LPN must be removed from the schedule permanently and we suspended the CNA for two days. 415.4(b)(1)(ii)

Plan of Correction: ApprovedNovember 30, 2016

I. Immediate Corrective Action
Resident #60?s investigation and medical record was reviewed by the Medical Director, Administrator and DNS. Staff members involved in this investigation who resident #60 alleged violation of mistreatment, neglect and/or abuse are no longer rendering care to this resident.
This was completed by 11/10/16

II. Identification of Others
1 - The facility respectfully acknowledges that all residents have the potential to be affected by this issue.
2 - The DNS and Social Worker reviewed all accident/incidents, complaints and grievances over the past 3 months to assure that there were no alleged violations involving mistreatment, neglect and/ or abuse of a resident. No alleged violations were found.
This review was completed by 12/2/16

III. System Changes
1 - The policy and procedure for ?Resident Abuse? and ?Accident / Incident Reporting? was reviewed and revised by the Administrator and DNS.
This was completed on 11/28/16
2 - The In-service Director / Designee will in-service all staff on Resident Abuse and the importance of reporting / investigating allegations of mistreatment, neglect and / or abuse. Additionally there will be an in service for all managerial staff and social workers regarding the criteria for a reportable case and review the Nursing Home Incident Reporting Manual.
This in-service was completed by 12/16/16

IV - QA
1 - The DNS has developed an audit tool to check that all resident complaints are fully investigated in order to rule out mistreatment, neglect and / or abuse. This tool will also include any investigations that need to be reported to the Department of Health is done in a timely manner. This audit tool will be done on all resident care complaints X 3 months by the DNS/designee.
2 - Any quality assurance issues will be reported to the administrator for immediate corrective action.
3 - Audit findings will be presented to the QA committee quarterly for evaluation and follow up as indicated. The outcome of this audit will be quantified and reported to the QA committee by the DNS.

V. The date for correction and title of the person responsible for the correction of the deficiency.
The DNS will be responsible for the compliance of this issue by 1/5/17

Standard Life Safety Code Citations

K307 NFPA 101:COOKING FACILITIES

REGULATION: Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 10, 2016
Corrected date: February 15, 2017

Citation Details

2011 NFPA 96: 10.2.6 Automatic fire-extinguishing systems shall be install in accordance with the terms of their listing, the manufacturer ' s instructions, and the following standards where applicable: (1) NFPA 12 (2) NFPA 13 (3) NFPA 17 (4) NFPA 17 2009 NFPA 17A: 7.2 Owner ' s Inspection. 7.2.1 On a monthly basis, inspection shall be conducted in accordance with the manufacturer ' s listed installation and maintenance manual or the owner ' s manual. 7.2.2 At a minimum, this quick check or inspection shall include verification of the following: (1) The extinguishing system is in its proper location. (2) The manual actuators are unobstructed. (3) Tamper indicators and seals are intact. (4) The maintenance tag of certificate is in place. (5) No obvious physical damage or condition exists that might prevent operation. (6) The pressure gauge (s), if provided, shall be inspected physically or electronically to ensure it is in the operable range. (7) The nozzle blowoff caps, where provided, are intact and undamaged. (8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated. Based on observation and staff interview, the facility failed to ensure that at a minimum, quick checks were being performed on the extinguishing equipment in the kitchen of the facility. The findings are: On 11/7/2016 between the hours of 9am and 2pm during the recertification survey, the following was observed: The pull station for the Ansul system near the entrance door in the kitchen was noted to contain an inspection tag. The tag contained the semi-annual inspection dated (MONTH) (YEAR). On the reverse side, the columns for the monthly quick check with date and initials was not filled out. In an interview on 11/7/2016 at approximately 10:45 am with the Director of Maintenance, he stated he was unaware that monthly inspections needed to be performed and documented along with the semi- annual inspection. He also stated he would start inspecting the system monthly. 2011 NFPA 96 2009 NFPA 17A 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedDecember 8, 2016

1.A visual inspection will be conducted monthly by the maintenance department, the tag will be signed indicated that it was inspected.
2.The monthly quick check was done on 11/8/16.
3.The maintenance staff has been in-serviced to visually check the ansul system monthly. The Director of Environmental Services will ensure that the quick check has been conducted.
4.The Director of Environmental Services or his designee will conduct a monthly audit to ensure the inspection is being done properly. Findings from the audit will be reported to the Quality Assurance committee quarterly.

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 10, 2016
Corrected date: February 15, 2017

Citation Details

2012 NFPA 99: 11.3.4 Signs 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING Based on observation and staff interview, the facility failed to ensure that oxygen storage rooms were provided with the appropriate sign with the correct wording. This occurred on 3 of 5 floors of the facility. The findings are: On 11/4/2016 and 11/7/2016 between the hours of 8:30am and 2pm during the recertification survey, the following was observed: Oxygen storage rooms were noted to be located on the 5th, 4th, and 3rd floors of the facility. These storage rooms lacked the required signs containing, at a minimum the words Caution: Oxidizing gas(es) stored within no smoking . In an interview on 11/4/2016 at approximately 10 am with the Director of Maintenance, he stated he could replace the signs on the oxygen rooms. 2012 NFPA 99:5 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedDecember 8, 2016

1. Signs were installed to read Caution: oxidizing Gas(es) stored within No Smoking.
2.The original Oxygen signs were removed, the new signs were installed on the oxygen room doors on the 5th, 4th, and 3rd floors on 11/4/16.
3. Department heads and all oxygen handlers will be in-serviced on the the requirements of proper signs on the oxygen room doors. During routine rounds to each unit the Director of Environmental Services or his designee will check to see that the new signs are in place and report immediately if there is an issue.
4. The Director of Environmental Services will conduct monthly audits to ensure compliance. Findings will be reported to the Quality Assurance Committee quarterly.