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Scope: Isolated
Severity: Actual harm has occurred
Citation date: January 18, 2022
Corrected date: March 4, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during the Recertification Survey and the Abbreviated Survey (Complaint # NY 066), completed on 1/18/2022, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #364) of four residents reviewed for Accidents. Specifically, Resident #364 required total dependence of two persons for bathing. Certified Nursing Assistant (CNA) #5 provided a shower to Resident #364 without the assistance of another staff member. Resident #364 fell out of the shower chair and sustained a fall with a head injury. Subsequently, Resident #364 was transferred to the hospital and was admitted with a [DIAGNOSES REDACTED]. This resulted in actual harm to Resident #364 that is not Immediate Jeopardy. The finding is: The facility's policy titled Abuse Mistreatment and Neglect dated (MONTH) 2019 documented the term neglect shall mean failure to provide timely, consistent, safe, adequate, and appropriate services, treatment, and/or care. The facility's policy titled Showering a Resident Using the Shower Chair dated (MONTH) 2019 documented that the resident is transferred from bed to the shower chair after the (shower chair's) safety latches are locked. The resident is secured with the safety belt and transported to the shower room. The resident is then transported into the shower. An undated in-service manual titled Shower Chair and Seat Belt documented that before giving a shower the shower chair should be inspected for safety and proper functioning, including the presence of a seat belt, which is attached securely and the buckle is functioning properly. If the conditions are met, transfer the resident to the shower chair, and the seat belt must be secured around the resident's waist. The resident should never be left alone in the shower chair. Eye contact is maintained on the resident and the shower chair at all times. Resident #364 was admitted with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident was rarely or never understood and the Brief Interview for Mental Status (BIMS) was not conducted. The MDS documented that Resident #364 required extensive assistance of two persons for bed mobility, transfer, dressing, toilet use, and personal hygiene; and total dependence of two persons for bathing. A Comprehensive Care Plan (CCP) for Activity of Daily Living (ADL) dated 3/19/2021 documented Resident #364 required assistance with ADLs as evidenced by confusion, Dementia, and limited mobility. The interventions included but were not limited to providing the assistance of two staff members for bathing/showering twice weekly and as necessary; assistance of two staff members for dressing; and assistance of two staff members for transfers from the wheelchair to the bed with a rolling walker. A CCP for Falls dated 3/19/2021 documented Resident #364 was at risk for falls/accidents/incidents as evidenced by unsteady gait, poor balance related to impaired cognition, muscle weakness and atrophy, and abnormalities of gait and mobility. Interventions included but were not limited to anticipate the resident needs and minimize environmental hazards. The Nursing Admission assessment dated [DATE] documented Resident #364 had a fall risk score of 16 which indicated that the resident was at high risk for falls. The Kardex report (a brief overview summary of the resident's plan of care and treatment that is utilized by the CNAs) as of 5/6/2021 documented that Resident #364 required the assistance of two persons with bathing/showering two times weekly and as necessary. The resident also required two-person assistance with dressing and transferring. The CNA Intervention and Tasks Documentation Survey Report (The CNA Accountability Record) documented that a shower was provided to the resident on 5/5/2021 at 10:42 AM with the extensive assistance of one person. The report had no documented evidence that a shower was provided to the resident during the evening shift (3 PM - 11 PM) on 5/5/2021. The Accident/Incident (A/I) Investigation dated 5/5/2021 documented that at 6 PM, CNA #5 reported that Resident #364 was on the ground in the bathroom. CNA #5 who was assigned to the resident stated that Resident #364's shower was just completed. CNA #5 turned around to get a pair of gloves so they (CNA #5) could apply lotion to the resident and when CNA #5 turned back around the resident was on the ground. CNA #5 notified the Registered Nurse Supervisor (RNS #4). RNS #4 went to the bathroom and observed the resident on the floor laying on the right side in front of the shower chair. RNS #4 assessed the resident and noted a large hematoma to the right side of the head and a small reddened area to the upper back. The floor was wet from the shower. CNA #6 was interviewed and stated that they (CNA #6) assisted CNA #5 with the resident's transfer from the wheelchair to the shower chair so that the resident could be showered. CNA #6 stated that they (CNA #6) did not witness the fall. An investigative summary dated 5/6/2021 documented that Resident #364 was non-ambulatory. Resident #364 required assistance of two people and the use of a rolling walker for transfers. The resident was unable to give a statement. New orders were obtained to send the resident out to the emergency room for head trauma. CNA #5 was interviewed and stated that the shower was finished, they (CNA #5) had turned around to get a new pair of gloves so they could apply lotion to the resident, and the resident fell from the shower chair. A re-enactment was performed with the involved staff. Upon investigation, it was determined that the safety belt was not used when the resident was in the shower chair. The resident was admitted to the hospital with [REDACTED]. The hospital records dated 5/5/2021 documented CT scan results indicating Final Diagnostic Impression: Head Injury and Traumatic Intracranial Subdural Hematoma. CNA #5 was interviewed on 1/14/2022 at 11:30 AM and stated that they (CNA #5) were assigned to Resident #364 on the evening of 5/5/2021. CNA #5 stated that Resident #364 was transferred from the bed into the shower chair with the assistance of CNA #5 and CNA #6. CNA #5 stated that CNA #6 had to leave to assist the nurse with a situation with another resident. CNA #5 stated that they (CNA #5) completed the shower alone. CNA #5 stated that when the shower was completed they (CNA #5) turned around for a new pair of gloves so they could apply lotion to the resident. CNA #5 turned back around and observed Resident #364 on the floor. CNA #5 stated that they did not witness the fall but could see that Resident #364 had hit their head because there was redness and slight bleeding. CNA #5 stated they immediately notified RNS #4. RNS#4 came to assess the resident and then CNA #6 returned to assist with getting the resident back into the chair. CNA #5 stated that they did not secure Resident #364 with the safety belt while the resident was in the shower chair. CNA #5 stated that they received in-service education on showering residents during orientation but was not aware of the need to use the safety belt until they were educated after the incident. CNA #5 was re-interviewed on 1/18/2022 at 1:16 PM and stated that they (CNA #5) was a new CNA and had only provided showers to the residents who needed one person's assistance. CNA #5 further stated that they (CNA #5) do not know the shower procedure that requires two-person assistance. CNA #6 was interviewed on 1/14/2022 at 11:41 AM and stated that they (CNA #6) assisted CNA #5 in transferring Resident #364 the evening of 5/5/2021 to prepare the resident for a shower. CNA #6 was not aware if the safety belt was fastened around the resident. CNA #6 stated that they (CNA #6) then stepped out of the room to help the nurse with another resident. CNA #6 stated that they did not know if Resident #364 got their shower or not. CNA #6 stated that they did not witness the resident fall and they returned to the room after the incident had happened to assist the RN supervisor and CNA #5 with the resident. CNA #6 was re-interviewed on 1/18/2022 at 1:20 PM and stated that when a resident requires two-person assistance with a shower then the shower should be provided with two staff members. CNA #6 stated that they would have assisted CNA #5 with showering Resident #364 if they were not called to assist with another resident. CNA #6 stated that they would have also stayed and assisted CNA #5 with post-shower care and transfers because Resident #364 required two-person transfer assistance. RNS #4 was interviewed on 1/13/2022 at 9:48 AM and stated that they (RNS #4) were the RNS supervisor on the evening shift on 5/5/2021. RNS #4 stated that they were notified by CNA #5 that Resident #364 fell in the bathroom. RNS #4 went into the bathroom and assessed the resident. The resident was observed on the floor laying on the right side, and redness was noted on the resident's head. RNS #4 stated that the Nurse Practitioner (NP #1) ordered the resident to be sent to the hospital for further evaluation. The NP #1 was interviewed on 1/14/2022 at 11:18 AM and stated that they (NP #1) were in the facility the evening of 5/5/2021 and they (NP #1) were made aware of Resident #364's fall in the bathroom. NP #1 stated they noted the presence of a forehead Hematoma and ordered the resident to be sent out to the emergency room for further evaluation and a computerized tomography (CT) scan. NP #1 stated based on their assessment of the resident at the time of the incident, there was a potential for severe injury because of the site of the hematoma on the head. The Director of Nursing Services (DNS) was interviewed on 1/18/2022 at 11:05 AM and stated they (DNS) investigated the incident related to Resident #364's fall. The DNS stated that the CNAs were expected to use the safety belt to secure residents while in shower chairs and through re-enactment it was discovered that the CNAs did not use the safety belt. The DNS stated that Resident #364 sustained a head injury with a Subdural Hematoma. The DNS was re-interviewed on 1/18/2022 at 12:28 PM and stated that two staff were expected to provide shower care to Resident #364. On 5/5/2021, two staff members did provide the shower to Resident #364. The DNS stated that since the shower was completed, CNA #6 was not expected to stay in the bathroom. The Administrator and the DNS were interviewed concurrently on 1/18/2022 at 2:03 PM and stated that the original manufactured shower chairs did not have a safety belt feature. The facility had re-designed the shower chairs and added safety belts for extra safety. They both stated that staff were educated and were expected to use the safety belt when providing a shower. 415.12(h)(1) | Plan of Correction: ApprovedFebruary 11, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Directed Plan of Correction F689 Free of Accident Hazards/Supervision/Devices The Westhampton Care Center submits that its policies, procedures, and systems are in place to ensure that each resident receives supervision and assistive devices to prevent accidents. This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have systems in place to maintain compliance with this all requirements. To ensure residents are free from accidents, receive appropriate assistive devices and supervision all policies, procedures and systems have been reviewed and revised as necessary. 1.The following actions were accomplished for the residents identified in the sample: Resident #364 sustained a subdural hematoma as a result of an accident/incident on 5/5/2021. As a result of the accident/incident resident #364 was discharged on [DATE]. All staff involved were made aware of the deficiency issued by the Department of Health. Corrective actions included policy reviews, new policy development as well as staff re-education for all personnel involved in this event. Both CNA #5 and #6 involved in the incident on 5/5/2021 were in-serviced on shower chair safety on 5/6/2021. Employee CNA #5 is no longer employed by the facility. (Last day of employment 11/1/21) Employee CNA #6 is no longer employed by the facility. (Last day of employment 8/7/21) 2. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents who require a two-person assistance for bathing, showering, have been reviewed to ensure each residentís required level of assistance is accurately reflected on the residentís and the CNA instructions or Kardex. Any inconsistencies were corrected upon identification. All nursing staff, licensed and unlicensed, were re-educated on the requirement to adhere to the plan of care and provide two-person assistance when noted. The failure to follow the plan of care, is considered as a form of abuse and neglect. All residents who require a 2 person assist for bathing and utilization of a shower chair have been reviewed to ensure that adequate supervision will be provided in accordance with the CNA instructions. The report will be provided to the Director of Nursing. 3.The following measures and / or systemic changes will be implemented to ensure the deficient practice identified does not recur: The facility policy: Shower Equipment/Safety and Abuse, Neglect, Mistreatment policy were both reviewed and were found to be compliant and include: o Evaluation and assessment of any resident post fall and/or incident. o The completion of incident/accident, a thorough investigation, including employee statements, interviews, and documentation. The new policy and procedure for CNA documentation of resident care was developed based on the CNA Orientation of care provided to residents in point click care. For further clarification CNAs will now see the level of assist required for bathing and showering prior to documenting the level of assist provided. This has been completed for ALL Westhampton residents. All licensed nurses and CNAs will be reeducated to ensure that all patients receive adequate supervision and proper use of assistive devices to prevent accidents, including the use of shower chairs. The CNAs lesson plan will include the policy and procedure and the requirement to review the assistance that the resident/patient require while providing care, the need to ensure equipment is safe to be used and ensure the shower chair safety belt was secured and able to be utilized during the shower of a resident/patient. All Westhampton Care Center employees were re-educated on the State and Federal regulations on response to abuse, neglect, exploitation, or mistreatment, and/or misappropriation of funds of an individual residing in a residential health care facility. The education program included, but was not limited to: o Identification of suspected abuse, neglect, exploitation, or mistreatment, and/or misappropriation of funds. o The response to an alleged allegation of abuse, neglect, exploitation, or mistreatment, and/or misappropriation of funds. o The report of allegations to facility Administration and to DOH/other agencies o Investigation of all allegations. o It is the responsibility of all staff to report any suspicion of abuse, neglect, exploitation, or mistreatment, and/or misappropriation of funds to oneís supervisor immediately, in accordance with the policy and procedure. 4. The facilityís compliance will be monitored utilizing the following quality assurance system: A Quality Assurance Committee meeting was held on (MONTH) 10, 2022, to discuss this deficiency and a root cause analysis was completed. The facility has developed audit tools to monitor compliance with staff adherence with policies and procedures, including the proper use of shower chairs (safety belt and locking) for showering residents and utilizing the correct amount of staff assistance in accordance with each residentís plan of care. 25% of all residents requiring 2-person assist for bathing in shower chairs will be randomly audited by the Director of Nursing or designee(s) on every shift, every month for six months. Any deficiencies will be corrected at the time of the audit and staff will be counseled and/or terminated accordingly. All audit findings will be reported to the QA Committee monthly for six months for evaluation and follow-up actions. Results of the audit will be presented to the QAPI Committee monthly to ensure P(NAME) effectiveness. The QAPI Committee will take additional actions as necessary to ensure compliance. Following this six-month period, the QA Committee will decide of the need for continued auditing and at what frequency. Person Responsible: The Director of Nursing Compliance Date: 3/4/2022 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2022
Corrected date: March 4, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey completed on 1/18/2022 the facility failed to ensure an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases including COVID-19 infection was implemented on 2 of 5 nursing units. Specifically, 1) during the medication pass observation on Unit 2 on 1/11/2022, the Licensed Practical Nurse (LPN) #1 did not wear appropriate personal protective equipment (PPE) when providing medications and checking blood sugar for Resident #26 who was on contact and droplet precautions; in addition, LPN#1 did not wear gloves while administering insulin; 2) on Unit 2 two certified nursing assistants (CNA #1 and #2) did not wear appropriate PPE when adjusting Resident #68 in bed, who was on contact and droplet precautions; 3) on Unit 4, a family member of Resident #55, who was on contact and droplet precautions, was observed exiting the resident's room and walking down the hallway wearing a disposable gown. The findings were: The facility's policy titled Administration and Preparation of Insulin Injection, dated (MONTH) 2019, documented to don (put on) gloves prior to insulin administration. The facility's policy titled Personal Protective Equipment-Gowns, Aprons, Other Protective Coverings, dated (MONTH) 2020, documented that personnel must wear a gown, apron, or other protective covering when performing tasks that will likely soil the employee's clothing with blood, body fluids, secretions, or excretions. The facility's policy titled Transmission-Based Precautions, dated (MONTH) 2020, documented that healthcare personnel caring for patients on contact precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning (putting on) upon room entry and discarding before exiting the patient room is done to contain pathogens; and healthcare personnel caring for patients on droplet precautions wear a gown, gloves, mask, and goggles. 1) Resident #26 was admitted with [DIAGNOSES REDACTED]. The 10/18/2021 Annual Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. A physician's orders [REDACTED]. On 1/11/2022 at 8:15 AM on Unit 2, an observation was made of Resident #26's medication administration. Signs affixed to Resident #26's door included Contact Precautions, Droplet Precautions, and Stop and Report to Nurse Before Entering Room and there was a sign showing how to put on PPE. The LPN medication nurse (LPN #1) was wearing an N95 mask and a surgical mask on top of the N95. LPN #1 entered Resident #26's room and performed a fingerstick to check the resident's blood sugar. LPN #1 put gloves on but did not put on a gown or goggles. After LPN #1 performed the fingerstick they (LPN #1) exited the room and were asked by the surveyor if a gown and goggles should have been used as the resident was on contact and droplet precautions. LPN #1 stated that they (LPN #1) probably should have put a gown and goggles on. LPN #1 then proceeded to prepare Resident #26's medications at the medication cart, including oral medications, eye drops, and an insulin pen, and then re-entered the resident's room and administered these same medications. LPN #1 did not put on a gown, eye goggles, or gloves upon room entry and did not wear gloves when administering the insulin to the resident's abdomen. LPN #1 was observed coming in contact with the resident's bedsheets and clothing during the medication administration. The only time LPN #1 put on gloves was to administer the eye drops. LPN #1 was asked by the surveyor if gloves should have been worn when administering insulin and LPN #1 stated they (LPN #1) probably should have. The Director of Nursing Services (DNS) was interviewed on 1/11/2022 at 9:30 AM and stated that LPN #1 definitely should have been wearing full PPE, including a gown, gloves, and goggles, when caring for a resident in a room that is on contact and droplet precautions and should have been wearing gloves when administering insulin. The DNS stated whenever staff go in the rooms with contact and droplet precaution signs the staff are supposed to wear full PPE. The Infection Preventionist (IP) was interviewed on 1/12/2022 at 10:36 AM and stated if staff are touching a resident who is on contact and droplet precautions, this is considered providing care. The staff must put on full PPE, including gowns, gloves, and eye goggles when entering the room, and then remove the PPE before exiting the room. The IP further stated that LPN #1 was supposed to wear gloves when administering insulin. The Inservice Coordinator (IC) was interviewed on 1/12/2022 at 10:44 AM and stated that for residents on contact and droplet precautions all PPE must be put on at the resident's doorway, including gowns and goggles, and then the PPE must be removed before leaving the room. The IC further stated LPN #1 should have worn gloves when administering insulin. The Administrator was interviewed on 1/14/2022 at 12:21 PM and stated all staff are supposed to adhere to the infection control guidelines and wear PPE appropriately. 2) Resident #68 was admitted with [DIAGNOSES REDACTED]. The 11/13/2021 Annual Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. A physician's orders [REDACTED]. Two Certified Nursing Assistants (CNA #1 and #2) were observed positioning Resident #68 in the bed (the resident had slid down in bed) on 1/11/2022 at 8:27 AM. Signs affixed to Resident #68's door included Contact Precautions, Droplet Precautions, and Stop and Report to Nurse Before Entering Room. Both CNAs were wearing N95 masks and surgical masks on top of the N95 masks and had put on gloves. Both CNAs were not wearing eye goggles or gowns. CNA #1 and CNA # 2 were interviewed concurrently on 1/11/2022 at 11:23 AM. The CNAs stated they (CNA #1 and #2) were in a rush, and were supposed to wear gowns and goggles. Both CNA #1 and CNA #2 stated they had made a mistake. The Director of Nursing Services (DNS) was interviewed on 1/11/2022 at 9:30 AM and stated the staff are supposed to wear full PPE whenever they are in the rooms with contact and droplet precaution signs when providing care to the residents. The DNS stated the two CNAs (CNA #1 and CNA #2) should have had gowns and goggles on when coming in contact with Resident #68. The Infection Preventionist (IP) was interviewed on 1/12/2022 at 10:36 AM and stated if staff are touching a resident who is on contact and droplet precautions, this is considered providing care. The staff must put on full PPE, including gowns, gloves, and eye goggles when entering the room, and then remove the PPE before exiting the room. The IP stated this is to protect the staff and the residents. The Inservice Coordinator (IC) was interviewed on 1/12/2022 at 10:44 AM and stated that for residents on contact and droplet precautions all PPE must be put on at the resident's doorway, including gowns and goggles, and then the PPE must be removed prior to leaving the room. The Administrator was interviewed on 1/14/2022 at 12:21 PM and stated all staff are supposed to adhere to the infection control guidelines and wear PPE appropriately. 3) Resident #55 was admitted with [DIAGNOSES REDACTED]. The 11/5/2021 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A physician's orders [REDACTED]. Review of the Visitors Expectations Fact Sheet, which was located at the reception desk in the lobby Revised on 1/3/2022, documented: If your loved one is on isolation precautions you must wear all necessary PPE while visiting a resident room. There is signage on the resident room doors indicating isolation precautions and to see the nurse before entering. Instructions on how to apply and remove PPE, including a gown, were taped to the resident room doors. PPE must be removed before exiting the room. LPN #2 was observed preparing medications for administration outside of Resident #55's room on 1/11/2022 at 9:04 AM. Signs affixed to Resident #55's door included Contact Precautions, Droplet Precautions, and Stop and Report to Nurse Before Entering Room. The door was closed. While the nurse was preparing the medications, a family member came out of Resident #55's room wearing a disposable gown, asked LPN #2 to untie the gown from the back, and then walked down the hallway with the gown still on in full view of LPN #2. Moments later another staff member noticed the family member walking down the hallway with the gown on, asked the family member to remove the gown, and reminded the family member that the gown has to be removed before exiting the resident's room. LPN #2 was interviewed on 1/11/2022 at 10:43 AM and stated gowns are not to be worn in the hallway. The Infection Preventionist (IP) was interviewed on 1/12/2022 at 10:36 AM and stated that staff have to educate and remind families to remove gowns when a family member exits the resident's room. The IP stated LPN #2 should have asked the family member to remove the gown before walking down the hallway. The IP stated families are educated about wearing PPE and there are signs on the doors that instruct how to put on and remove PPE. Resident #55's family member was interviewed on 1/13/2022 at 10:14 AM and stated that they (the family member) did not know the protocol and no staff member had explained the protocols to them. The family member stated they (the family member) were not given instructions in the lobby when being screened. The receptionist was interviewed on 1/14/2022 at 10:11 AM and stated that the family members are given the fact sheet and are told there are precautions on certain units and there are signs on doors to see the nurse for help to put on PPE. The Administrator was interviewed on 1/14/2022 at 12:21 PM and stated families have to be continually reminded about the proper use of PPE. 415.19(a)(1-3) | Plan of Correction: ApprovedFebruary 11, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Directed Plan of Correction F880 Infection Prevention & Control The Westhampton Care Center submits that it has an infection prevention and control program in place to provide a safe, sanitary, and comfortable environment for itsí residents to prevent the development and transmission of COVID-19 infections. This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have a procedure in place to maintain compliance with all requirements. In an effort to enhance the infection prevention at the Westhampton Care Center the facility has reviewed existing policies, procedures and systems and revised as necessary. 1.The following actions were accomplished for the residents identified in the sample: Residentís #26 received medications from LPN #1 without the appropriate use of personal protective equipment (PPE) (goggles and gown) as the resident was on contact and droplet precautions. Resident #26 was monitored, without signs and symptoms of infection. LPN #1 is without signs or symptoms of infection. Resident #68 was cared for by CNA #1 and CNA #2 without the appropriate use of PPE as the resident was on contact and droplet precautions. Resident #68, CNA #1, CNA #2 was monitored and found to be without signs or symptoms of infection. A family member of resident #55 was observed exiting the residentís room without disposing of their gown in the patientís room prior to exiting. LPN #2 untied the visitors gown, and another staff member reminded the family member to remove his gown prior to exiting the residentís room. All residents located on the identified unit were evaluated and monitored for signs and symptoms of a communicable disease. Residents of the unit did not display any signs and symptoms related to the infection control breach. LPN #1, LPN #2, CNA #1, CNA #2 were all counseled and disciplined in accordance with the facilityís progressive discipline process. All aforementioned staff members were re-educated on the use of PPE and the importance of PPE use by residentís families. LPN#2 is no longer employed at the facility. 2. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: It is critical that all staff adhere to the use of PPE for all residents on contact/droplet precautions to minimize the spread of [MEDICAL CONDITION]. All residents are at risk of exposure of [MEDICAL CONDITION] and illness when staff, residents and residentís visitors do not follow PPE protocols. The facility identified all residents who are on isolation precautions. All residents who are on isolation were all reviewed to ensure there was appropriate signage on the door, instructing employees and visitors to don PPE prior to entering the room and before leaving the room. In-service was provided to all staff on how to don and doff PPE; the need to practice hand hygiene; and the importance of standard precautions. 3.The following measures and / or systemic changes will be implemented to ensure the deficient practice identified does not recur: The facility policy: Transmission Based Precaution, Hand Hygiene, Standard Precaution, Blood Pathogens, Visitor Expectations were reviewed and no further revisions were made to the policy. New Yellow Signs have been made; one for the outside of the door reminding staff and visitors to put all PPE on PRIOR to entering the room and the second, for reminding staff and visitors for removing PPE upon exiting. All staff will be in-serviced on infection prevention and control with emphasis on types of isolation, the appropriate PPE, appropriate Donning and Doffing of PPE, and the monitoring visitors for compliance. A letter has given and will continue to be handed to every visitor upon checking-in to visit residents, in addition to taking the visitors temperature, the visitors COVID test, etc. The letter reminds each visitor the PPE requirements in place. 4. The facilityís compliance will be monitored utilizing the following quality assurance system: A Quality Assurance Committee meeting was held on (MONTH) 10, 2022 to discuss this deficiency. A monthly audit will be conducted to ensure and monitor standard and transmission-based precautions are adhered to in order to prevent the spread of infection will be done by the Infection Preventionist. All audits findings will be reported to the QA Committee monthly for six months for evaluation and follow-up actions. Results of the audit will be presented to the QAPI Committee monthly to ensure P(NAME) effectiveness. The QAPI Committee will take additional actions as necessary to ensure compliance. Following this six-month period, the QA Committee will decide of the need for continued auditing and at what frequency. Person Responsible: The Director of Nursing Compliance Date: 3/4/2022 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2022
Corrected date: March 4, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 754) completed on 1/18/2022 the facility did not ensure that each resident's representative was immediately informed when there was a need to alter treatment significantly. This was identified for one (Resident #314) of one resident reviewed for choices. Specifically, Resident #314's family member was not informed when the facility staff initiated a gradual dose reduction of the antipsychotic medication, [MEDICATION NAME], on 5/5/2021. The finding is: The facility Family Notification policy dated 7/2019 documented that the facility must immediately notify the resident's interested family member when there is a need to alter treatment significantly. Resident #314 was admitted on [DATE] with the [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #314 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated Resident #314 had severely impaired cognition. Resident #314 received an antipsychotic medication 6 of 7 days and a gradual dose reduction was done on 5/5/2021. The Hospital Discharge summary dated 5/4/2021 documented to continue [MEDICATION NAME] 25 milligrams (mg) orally (PO) at bedtime and [MEDICATION NAME] 12.5 mg PO in the morning for a total of 37.5 mg daily. The Admission Summary note dated 5/4/2021 at 23:02 (11:02 PM) documented Registered Nurse (RN) #2 reconciled medications with Resident #314's family member and reviewed Resident 314's medications with the Physician Assistant (PA). The Facility physician's orders [REDACTED]. The order was discontinued on 5/5/2021. The physician's orders [REDACTED]. The Nurse's Note dated 5/5/2021 at 19:41 (7:41 PM) by Licensed Practical Nurse (LPN) #5 documented Resident #314 was on [MEDICATION NAME] gradual dose reduction day 1 of 7 days. Psychiatric consultation dated 6/1/2021 documented that Resident #314 had a history of [REDACTED]. Current psychoactive medication included [MEDICATION NAME] 25 mg, half a tablet, and [MEDICATION NAME] 2.5 mg intramuscular injection. The psychiatrist documented Resident #314 physically attacked staff and there was a concern for Resident #314 and other Residents' safety. The recommendation was to add [MEDICATION NAME] 125 mg twice a day if not medically contraindicated and to continue other medications. The Medical Director's note dated 6/1/2021 documented that Resident #314's chart was reviewed, and the case was discussed with the unit nurse. Resident #314 returned from the emergency room after evaluation for ongoing agitation and combativeness. A recent [MEDICATION NAME] gradual dose reduction was initiated by the attending physician. The Medical Director documented that they will attempt to better manage combative and aggressive behaviors with [MEDICATION NAME] to start at 125 mg in the morning and 250 mg in the evening with increased dosing if needed. The [MEDICATION NAME] at 12.5 mg will be discontinued. The attending physician was updated with the plan. The medical record lacked documented evidence of notification to Resident #314's family regarding the [MEDICATION NAME] dose reduction. Resident #314's Family member was interviewed on 1/12/2022 at 1:38 PM. The Family member stated that they did not get any updates from the facility until Resident #314's behavior was out of control in (MONTH) 2021. The Family member stated that on 6/1/2021 they called the facility and spoke with LPN #4. The Family member asked LPN #4 what medications Resident #314 was receiving because Resident #314 was stable on [MEDICATION NAME] at home. The Family member stated they were informed by LPN #4 that Resident #314 was no longer on [MEDICATION NAME]. The Family Member stated that they were never informed of any adjustments to Resident #314's [MEDICAL CONDITION] medications and were not aware that Resident #314 had received Psychiatric evaluations at the facility. The attending physician or psychiatrist never reached out to them about the dosage adjustments nor to obtain a history regarding Resident #314's medication use. RN #2, the Admission Nurse, was interviewed on 1/12/2022 at 2:04 PM. RN #2 stated that they reconciled the medication for Resident #314 with PA #1 by going over the hospital discharge list. RN #2 stated that they did not review the prescribed amount of [MEDICATION NAME] with Resident #314's family member. The Attending Physician was interviewed on 1/12/2022 at 2:12 PM and stated that the Medical Director and the Psychiatrist managed all the resident's [MEDICAL CONDITION] medication regimens. The Attending Physician further stated that they did not have a conversation with Resident #314's Family member regarding the gradual dose reduction of [MEDICATION NAME]. LPN #5 was interviewed on 1/12/2022 at 3:51 PM and stated that they did not call Resident #314's family member to inform them of the change in treatment orders for [MEDICATION NAME]. LPN #6 was interviewed on 1/12/2022 at 4:15 PM and stated that they entered the order into the medical record on 5/5/2021 and did not call the family member to inform them of the change in the [MEDICATION NAME] orders. LPN #4, Unit Manager, was interviewed on 1/13/2022 at 10:14 AM and stated that they (LPN #4) had previously spoken to the family member, however, did not discuss [MEDICATION NAME] dose reduction until 6/1/2021. PA #1 was interviewed on 1/13/2022 at 10:55 AM and stated that typically they reconcile the hospital medications with what was received at home and what was recommended by the hospital. PA #1 stated that they did not discuss a gradual dose reduction of [MEDICATION NAME] with Resident #314's family member on 5/4/2021. RN #4 was interviewed on 1/13/2022 at 3:55 PM. RN #4 stated that they were the RN Supervisor for the building overnight on 5/5/2021 and did not inform the family member of the change in [MEDICATION NAME] dosage. RN #4 stated that nurses are expected to document family notification of change in treatments in the medical record. The Director of Nursing Services (DNS) was interviewed on 1/14/2022 at 10:26 AM and stated that the nursing staff are expected to notify family members of changes in treatment. The DNS further stated the nursing staff should have called Resident #314's family member to update them on the [MEDICATION NAME] dose reduction. 415.3(e)(2)(ii)(c) | Plan of Correction: ApprovedFebruary 22, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F580: Notification of Changes The Westhampton Care Center submits that its policies, procedures, and systems are in place to ensure that each residentís representative is immediately informed when there was a need to alter treatment significantly. This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have a procedure in place to maintain compliance with all requirements. In an effort to enhance the care furnished to our residents, we have reviewed of our existing policies, procedures and systems and revised as necessary. 1.The following actions were accomplished for the residents identified in the sample: Resident #314ís was admitted to the facility on 5.4.21. The Hospital Discharge summary dated 5/4/2021 prescribed [MEDICATION NAME] 25 milligrams (mg) orally (PO) at bedtime and [MEDICATION NAME] 12.5 mg PO in the morning for a total of 37.5 mg daily. Resident #314ís family member was not informed of changes in the residentís medication; a gradual dose reduction for [MEDICATION NAME], discontinuation of [MEDICATION NAME] on 6.1.21 and the addition of new medications. The Medical Director, the Director of Nursing, Administrator, and interdisciplinary team were in-serviced on the importance of immediate notification of a residentís change in treatment significantly (such as, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) to the family members or designated representative. ï All licensed staff were made aware of the deficiency issued by the Department of Health and the reason for the deficiency was failure to notify the family. ï All licensed staff were educated on the requirement to immediately notify family/designated representatives of any resident changes in treatment. ï Staff were counseled accordingly. The policy and procedure regarding Antipsychotic Medications was reviewed and revised. All staff were educated on the policy revision and policy revision as well as staff reeducation for all personnel involved in this event. Resident #314 as resident was discharged on [DATE]. 2. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ï A report was received from the Pharmacy Consultant to determine all residents prescribed antipsychotics. ï All residents who are prescribed antipsychotic medications were reviewed to determine: o If the family or designated representative was notified when gradual dosage reduction (GDR) of the medication was ordered and the residentís response to the GDR. ï A formal in-service was held for all licensed nursing and medical staff. Guidance documents included an antipsychotic template to ensure all required documentation is noted in the medical record. 3.The following measures and / or systemic changes will be implemented to ensure the deficient practice identified does not recur: The facility policy Gradual Dose Reductions and Psychoactive Medications was reviewed by the Medical Director, Director of Nursing and Administrator and revised. Revisions included: notification of new medication (and diagnosis) to resident, family and designated representative, medication reconciliation, gradual dose reduction, care planning, documentation, education for the resident and family members, and all new resident admissions with psychiatric diagnosis, on psychoactive medications and/or displaying behavioral symptoms are to be seen by psychiatry as soon as it can be scheduled. o All licensed nursing and medical staff were educated on the policy revisions. The facility has reviewed and updated the Psychiatrist Consultation/Progress note/GDR Evaluation consult form. Revisions include a nursing section to the form which asks if there was a change in medication regimen? And if yes, who was the designated representative notified? Followed by a line for the nurses signature with the date. The pharmacy consultant will review all residents on psychoactive medications, recommend residents for GDR, with rationale. The pharmacy consultant report shall be distributed at the pharmacy and therapeutic meeting to identify areas for improvement and successes. The pharmacy consultant will report to the Medical Director and the Director of Nursing if the policy is not adhered to. 4. The facilityís compliance will be monitored utilizing the following quality assurance system: A Quality Assurance Committee meeting was held on (MONTH) 10, 2022 to discuss this deficiency and the root cause analysis completed. The facility has developed audit tools to monitor compliance with staff adherence with policies and procedures. That includes: o Date GDRs of antipsychotics o Notification of resident, family, or representative for GDR of psychoactive medication. o Residents on [MEDICAL CONDITION]/antipsychotic medications are seen and evaluated by the psychiatrist in accordance with the revised policy and procedure. o Any noncompliance will be corrected at the time of the finding and documented. The Director of Nursing or designee will conduct full auditing (100%) to ensure compliance with informing the resident and/or the family member the GDR of their antipsychotic medication. All audits and findings will be reported by the DON to the QA Committee monthly, for six months. o Results of the audit will be presented to the QAPI Committee monthly to ensure P(NAME) effectiveness. o The QAPI Committee will take additional actions as necessary to ensure compliance. o Following this six-month period, the QA Committee will decide of the need for continued auditing and at what frequency. Person Responsible: The Director of Nursing Compliance Date: 3/4/2022 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2022
Corrected date: March 4, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 754) completed on 1/18/2022 the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice for one (Resident #314) of one Resident reviewed for choices. Specifically, Resident #314 had a history of [REDACTED]. Resident #314 was hospitalized after a fall at home and was discharged to the facility with recommendation to receive [MEDICATION NAME] 37.5 mg total daily. The facility Physician prescribed [MEDICATION NAME] 12.5 mg daily without obtaining Resident #314's history for [MEDICATION NAME] usage and did not obtain a psychiatry consult until 20 days after the gradual dose reduction when the resident started to exhibit behavioral changes. The finding is: The facility's Gradual Dose Reduction and Psychoactive Medication policy dated 7/2019 documented all residents on psychoactive medications must have a psychiatric consultation and follow up as per the attending Physician's recommendations and orders. When the order is written for a psychoactive drug, an appropriate [DIAGNOSES REDACTED]. Resident #314 was admitted with the [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #314 had a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognitive function. The MDS documented that Resident #314 had no signs and symptoms of [MEDICAL CONDITION], no indicators of [MEDICAL CONDITION], no physical behaviors directed towards others and no verbal behaviors directed towards others during the assessment period. The MDS further documented Resident #314 exhibited wandering behavior 1 to 3 days of the assessment period. Resident #314 received an antipsychotic medication 6 of 7 days and the gradual dose reduction was done on 5/5/2021. The Hospital Admission History and Physical dated 4/26/2021 documented that Resident #314 had presented to the hospital after a fall at home. Home medications included Quetiapine ([MEDICATION NAME]) 25 milligram (mg) tablet daily at bedtime. Resident #314's behavior was documented as appropriate and cooperative. The plan of care documented to continue home medications including [MEDICATION NAME] 25 mg. The Hospital Discharge summary dated 5/4/2021 documented to continue [MEDICATION NAME] 25 mg orally (PO) at bedtime and [MEDICATION NAME] 12.5 mg PO in the morning (a total of 37.5 mg daily). The Facility Physician's admission orders [REDACTED]. The order was discontinued on 5/5/2021. The physician's orders [REDACTED]. The Admission Summary note dated 5/4/2021 at 23:02 (11:02 PM) documented Registered Nurse (RN) #2 reconciled medications with Resident #314's family member and reviewed the medications with the Physician Assistant (PA). The physician's orders [REDACTED]. The Nurse's Note dated 5/5/2021 at 19:41 (7:41 PM) by Licensed Practical Nurse (LPN) #5 documented Resident #314 was on [MEDICATION NAME] gradual dose reduction day 1 of 7 days. The Nursing Progress Note dated 5/9/2021 documented Resident #314 was self ambulating, calling out, and cursing at staff. Resident #314 was redirected several times. Activities, snacks and toileting provided with little effect. Gradual dose reduction of [MEDICATION NAME] was in progress. The Nursing Progress Notes dated 5/10/2021 documented Resident #314 was on day 6 of 7 of the gradual dose reduction of [MEDICATION NAME]. Resident #314 was noted to stand up from the wheelchair multiple times unassisted and was encouraged to ask staff for help prior to standing alone. Resident #314 was noted to become argumentative towards staff. The Physician's progress note, written by the attending Physician, dated 5/10/2021 at 14:58 (2:58 PM) documented Resident #314 was aggressive with staff at times as witnessed by the Physician. The plan was to monitor the resident's behaviors. The Physician documented that the resident had a recent gradual dose reduction which may need adjustment. The Nursing Progress Note dated 5/11/2021 documented Resident #314 was on day 7 of 7 for the gradual dose reduction. Resident #314 was alert, pleasantly confused, non-compliant and frequently got out of bed unassisted. The nursing progress note dated 5/12/2021 documented that bloodwork was unable to be obtained this morning by the technician. Resident #314 was screaming out and yelling at the technician. The Nursing Progress Note dated 5/12/2021 documented Resident #314 was verbally aggressive during care and was screaming at the staff. The Physician's progress note dated 5/12/2021 at 14:52 (2:52 PM) documented that Resident #314 was seen with variable mentation and Dementia and associated combative behaviors. The attending Physician documented a recent gradual dose reduction of [MEDICATION NAME] and the plan was to address the variable mentation and to follow the resident's clinical status. The physician's progress note dated 5/14/2021 at 14:30 documented that Resident #314 was seen for deconditioning, unsteady gait, Advanced Dementia, a decrease of awareness of limitations, and inherent non-adherence to staff direction. The plan was to follow the clinical status on the recent [MEDICATION NAME] gradual dose reduction. The Nursing Progress Note dated 5/16/2021 documented Resident #314 was noted to self ambulate into other resident rooms. Redirected multiple times with no effect. Resident #314 noted to become aggravated at times. The Nursing Progress Note dated 5/18/2021 documented Resident #314 was restless with attempts to self transfer. Resident #314 became aggressive several times this shift with staff redirection. The Social Work note dated 5/18/2021 at 11:54 AM documented Resident #314 would benefit from a room change onto the secure unit to ensure the resident's safety as Resident #314 required additional oversight. The Nursing Progress Note, written by the Licensed Practical Nurse (LPN) #4, dated 5/19/2021 documented Resident #314 ambulated with staff in the hallway, was extremely resistive to care despite a gentle approach. A two-person approach was utilized with no effect. Resident #314 was swinging fists at staff. The attending Physician was notified and no new orders were obtained. The attending Physician instructed to send the resident to the hospital if the resident (behavior) can not be managed (at the facility). Resident #314 remains irritable but no longer physically combative. The nursing progress note dated 5/25/2021 documented Resident #314 exhibited with increased agitation and aggressive behaviors. Resident #314 was walking into other residents rooms, yelling at their roommate to get out of bed, and yelling at staff when being redirected. The Psychiatric Evaluation dated 5/25/2021 documented the nursing staff reported that Resident #314 was combative and physically aggressive towards staff but was easily redirected. Resident #314's behavior was unpredictable. The primary medical history [DIAGNOSES REDACTED]. Resident #314 was noted to be uncooperative with poor insight/judgment during the interview. The plan was to recommend the continuation of current medications which included [MEDICATION NAME] 12.5 mg and a follow-up in 3 months. On 5/31/2021 LPN #4 documented that the attending Physician was called. The Physician stated to LPN #4 if the staff cannot handle Resident #314, send Resident #314 to the hospital. Resident #314 was extremely unpredictable and aggressive. Resident #314 continued to be combative with staff despite a gentle approach. Resident #314 got out of bed and ran at staff, yelling with fists up to threaten staff. The resident was beginning to swing fists at staff again. As per the attending physician's orders [REDACTED].#314 was sent to the hospital for evaluation. The Skilled Nursing Facility to Emergency Department Communication Form (Transfer Form) dated 5/31/2021 documented Resident #314 was combative and aggressive and needed psychiatric evaluation. Resident #314's mental status was documented as anxious, combative, agitated, and alert with Dementia. Resident #314's Family member was interviewed on 1/12/2022 at 1:38 PM. The Family member stated that they did not get any updates from the facility until Resident #314's behavior was out of control in (MONTH) 2021. The Family member stated that on 6/1/2021 they called the facility and spoke with LPN #4. The Family member asked LPN #4 what medications Resident #314 was receiving because Resident #314 was stable on [MEDICATION NAME] at home. The Family member stated they were informed by LPN #4 that Resident #314 was no longer on [MEDICATION NAME]. The Family Member stated that they were never informed of any adjustments to Resident #314's [MEDICAL CONDITION] medications and were not aware that Resident #314 had received Psychiatric evaluations at the facility. The attending physician or psychiatrist never reached out to them about the dosage adjustments nor to obtain a history regarding Resident #314's medication use. RN #2, the Admission Nurse, was interviewed on 1/12/2022 at 2:04 PM. RN #2 stated that they reconciled the medication for Resident #314 with PA #1 by going over the hospital discharge list. RN #2 stated that they did not review the prescribed amount of [MEDICATION NAME] with Resident #314's family member. The Hospital Discharge Medication List dated 5/4/2021 documented Resident #314 was prescribed Quetiapine ([MEDICATION NAME]) 25 mg tablet 1 tablet oral daily at bedtime and Quetiapine ([MEDICATION NAME]) 25 mg 0.5 tablet oral (PO) daily for a total of 37.5 mg per day. The medication list had handwritten check marks next to the medications listed. The Attending Physician was interviewed on 1/12/2022 at 2:12 PM and stated that the Medical Director directed them (Attending Physician) to globally taper [MEDICATION NAME] in the facility for all residents. The Attending Physician stated that they (Attending Physician) were following the Medical Director's orders and was not involved in managing Resident #314's [MEDICAL CONDITION] medication regimen throughout Resident #314's stay at the facility. The Physician was not aware of the resident's historical use of [MEDICATION NAME] for behavior management. The Attending Physician stated the Medical Director managed the resident's [MEDICAL CONDITION] medication regimen. The Physician stated that the dosage was so low that it was atypical to be effective but anecdotally has observed residents in the past who became unstable like Resident #314. The Attending Physician stated that they did not have a conversation with Resident #314's Family Member, hospital physicians or community physician regarding the use of [MEDICATION NAME] and history of mental health diagnosis. The Attending Physician further stated that they did not review the hospital records to further assess Resident #314's [MEDICAL CONDITION] regimen. PA #1 was interviewed on 1/13/2022 at 10:55 AM and stated that they reconciled the hospital medications with what was received at home and what was recommended by the hospital. PA #1 stated that the Attending Physician would review the medication regimen again and make the final adjustments. PA #1 stated that they did not recall initiating a gradual dose reduction of [MEDICATION NAME] for Resident #314. LPN #3 (Unit Manager of unit 5) was interviewed on 1/3/2022 at 9:51 AM. LPN #3 stated they worked with Resident #314 when they covered various shifts on Unit 5 in (MONTH) 2021. Resident #314 was very restless and wandered through the hallways in the beginning of Resident #314's stay. LPN #3 stated that Resident #314's room was changed to the Dementia locked unit to maintain Resident #314's safety. LPN #4, Unit Manager of Unit 3, was interviewed on 1/13/2022 at 10:14 AM and stated that on 5/18/21, they received Resident #314 on Unit 3. LPN #6 (the Unit 5 Manager on that day) told them that the gradual dose reduction for Resident #314 was not working and the Attending Physician had directed Resident #314 to be moved to the Dementia Unit as an alternative to adjusting the psychiatric medication. LPN #4 stated that Resident #314 was very erratic from the first day they were transferred to Unit 3. Initially, Resident #314 would visit the activities but eventually refused them. Resident #314 would then stay in the room and place their bed sheets over their head. Throughout the course of Resident #314's stay, Resident #314 became more aggressive, unpredictable and too confused to respond appropriately to interventions. Resident #314 would yell at others, wander into other resident's rooms and make them feel unsafe by putting up fists and using threatening language. Redirection was totally ineffective, and Resident #314 was suspicious of everyone who was around them. LPN #4 stated that they (LPN #4) sustained bruising from the physical attacks Resident #314 would inflict. LPN #4 stated that staff tried diversional activities for Resident #314 with no success. LPN #4 stated that they regularly communicated the challenges with the attending Physician. LPN #4 stated that they expressed concern for Resident #314 and the ineffectiveness of the gradual dose reduction, but the Attending Physician told them to just continue to redirect Resident #314. LPN #4 stated that the Attending Physician did not take any consideration for the nurses expressed concerns that Resident #314 was a danger to themselves and others and the Physician refused to adjust Resident #314's [MEDICAL CONDITION] medication. LPN #4 stated that they spoke with Resident #314's family member about the violent behaviors and the family member informed LPN #4 the that Resident #314 did not have these behaviors at home and was stable on 25 mg of [MEDICATION NAME] per day. PA #2, the consulting psychiatric physician's assistant, was interviewed on 1/13/2022 at 11:18 AM. PA #2 stated that they received a referral from the social worker for an evaluation and reviewed the case with nursing regarding Resident #314's combative behavior on 5/24/2021. PA #2 stated that they reviewed the medical history in the record, and the nursing notes when they evaluated Resident #314. Resident #314 was a poor historian and PA #2 did not speak with the family member bout the resident's history. PA #2 was not aware that Resident #314 received [MEDICATION NAME] prior to admission and of the resident's historical mental health diagnosis. PA #2 stated that they refrain from using [MEDICATION NAME] without a known history and will try to utilize other medications. PA #2 stated that they were not aware of any psychiatric history for Resident #314 and thought that mood stabilization would be better treated with [MEDICATION NAME]. PA #2 stated that they never worked with the Medical Director regarding Resident #314 and did not speak with the Attending Physician. PA #2 further stated that the attending Physician makes the final determination regarding the prescription recommendations. Certified Nursing Assistant (CNA) #3, the regularly assigned Unit 3 Dayshift CNA for Resident #314, was interviewed on 1/13/2022 at 11:47 AM. CNA #3 stated that Resident #314 was very pleasant and wandered around the unit in the beginning of the stay on Unit 3. Resident #314 would participate in activities and interact with the other residents. Resident #314 later refused to get out of bed and accept assistance from CNA #3. Resident #314 became combative towards others and was aggressive with staff. Redirection and reapproaching was not working with Resident #314. The Medical Director was interviewed on 1/13/2022 at 1:28 PM. The Medical Director stated that they were not involved with Resident #314's care until they were reviewing medical records for antipsychotic medication usage on 6/1/2021. The Medical Director stated that they observed Resident #314's order for [MEDICATION NAME] which was 12.5 mg daily and thought it was unnecessary because it was so low. The Medical Director then reviewed Resident #314 with the nursing staff and was informed of Resident #314's decline and worsening behaviors. The Medical Director stated they were surprised that Resident #314 was doing poorly and was not informed by either the attending physician, the psychiatrist, or nursing prior to 6/1/2021. The Medical Director stated that they did not direct the staff to lower [MEDICATION NAME] dose for Resident #314. However, the staff follows the facility protocol for dose reduction if the resident did not have a history of significant mental illness. The Medical Director stated that they would not have made a drastic reduction from 37.5 mg to 12.5 mg and would have instead reduced the medication to 12.5 mg twice a day for a total of 25 mg daily. The Medical Director stated that had they been informed of Resident #314's instability, they would have added [MEDICATION NAME] sooner, prior to 6/1/2021, to help with mood stabilization. 415.12 | Plan of Correction: ApprovedFebruary 11, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F684 Quality of Care The Westhampton Care Center submits that its policies, procedures, and systems are in place to ensure that all residents receive treatment and care in accordance with professional standards of practice. This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have a procedure in place to maintain compliance with all requirements. In an effort to enhance the treatment and care provided to our residents, we have reviewed of our existing policies, procedures and systems and revised as necessary. 1.The following actions were accomplished for the residents identified in the sample: Resident #314ís was admitted to the facility on 5.4.21. The Hospital Discharge summary dated 5/4/2021 prescribed [MEDICATION NAME] 25 milligrams (mg) orally (PO) at bedtime and [MEDICATION NAME] 12.5 mg PO in the morning for a total of 37.5 mg daily and the resident was not seen by the psychiatrist until 5/25/22. Resident #314 were discharged on [DATE]. The policy and procedure regarding Antipsychotic Medications was reviewed and revised to include the following: o All licensed staff, including medical staff, were educated on the policy revisions and the need to identify new residents on psychoactive medications, reconcile their medications and identify preadmission history of [DIAGNOSES REDACTED]. o All licensed staff, including Medical Director and medical staff were educated on the need to ensure a resident on an antipsychotic medication and/or with mental health [DIAGNOSES REDACTED]. 2. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ï A report was received from the Pharmacy Consultant to determine all residents prescribed antipsychotics. ï A report was run from the EMR to determine residents exhibiting aggressive and/or inappropriate behavior to determine if residents have been evaluated by a psychiatrist or another practitioner as warranted. Residents with behaviors that have not been seen will be scheduled. ï All residents who are prescribed antipsychotic medications were reviewed to determine: o If the resident has been seen by a psychiatrist as needed and in accordance with the facilityís policy and procedure. o Residents not seen by psychiatry will be scheduled with the psychiatrist. ï A formal in-service was held for all licensed nursing and medical staff. Guidance documents included an antipsychotic template to ensure all required documentation is noted in the medical record and residents are seen by psychiatry as needed and in accordance with the revised Westhampton Care Centerís policy and procedure. ï The Medical Director met with the Medical Staff to re-educate all on the revised policy and procedure. 3.The following measures and / or systemic changes will be implemented to ensure the deficient practice identified does not recur: The policy and procedure regarding Antipsychotic Medications was reviewed and revised to include the following: o All licensed staff, including medical staff, were educated on the policy revisions and the need to identify new residents on antipsychotic medications, reconcile their medications and identify preadmission history of [DIAGNOSES REDACTED]. o All licensed staff, including Medical Director and medical staff were educated on the need to ensure a resident on an antipsychotic medication and/or with mental health [DIAGNOSES REDACTED]. The pharmacy consultant will continue to review all residents on antipsychotic medications, make recommendations for GDRs and/or changes in medications, effectiveness, and the need for an evaluation of the resident by a psychiatrist in accordance with the policy and procedure. The pharmacy consultant will report to the Medical Director and the Director of Nursing if the policy is not adhered to. 4. The facilityís compliance will be monitored utilizing the following quality assurance system: A Quality Assurance Committee meeting was held on (MONTH) 10, 2022, to discuss this deficiency. The facility has developed audit tools to monitor compliance with staff adherence with policies and procedures. That includes: o Date of GDRs of an antipsychotic medication o Notification of resident, family, or representative for GDR. o Residents on [MEDICAL CONDITION]/antipsychotic medications are seen and evaluated by the psychiatrist in accordance with the revised policy and procedure. o Any noncompliance will be corrected at the time of the finding and documented. The Director of Nursing or designee will conduct full auditing (100%) to ensure compliance with informing the resident and/or the family member about a GDR of their antipsychotic medication. All audits and findings will be reported by the Medical Director and to the QA Committee monthly, for six months. o Results of the audit will be presented to the Medical Director and QAPI Committee monthly to ensure P(NAME) effectiveness. o The Medical Director will monitor practitioners that are completing a GDR without the consultation/evaluation by psychiatry. o The Medical Director will direct corrections of practitioners as needed. o The QAPI Committee will take additional actions as necessary to ensure compliance. o Following this six-month period, the QA Committee will decide of the need for continued auditing and at what frequency. All audits findings will be reported to the QA Committee monthly for six months for evaluation and follow-up actions. Results of the audit will be presented to the QAPI Committee monthly to ensure P(NAME) effectiveness. The QAPI Committee will take additional actions as necessary to ensure compliance. Following this six-month period, the QA Committee will decide of the need for continued auditing and at what frequency. Person Responsible: The Medical Director Compliance Date: 3/4/2022 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2022
Corrected date: March 4, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 066) completed on 1/18/2022, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health (NYSDOH) for one (Resident #364) of four residents reviewed for Accidents. Specifically, Resident #364 was care planned for two-person assistance for bathing. however, the resident was showered only by one Certified Nursing Assistant (CNA) and was not properly secured with a safety belt while sitting on the shower chair. Subsequently, Resident #364 fell to the floor and sustained a head injury resulting in a Subdural Hematoma. The facility did not report the incident to the NYSDOH. The finding is: The facility's policy titled Abuse Mistreatment and Neglect dated (MONTH) 2019 documented the term neglect shall mean failure to provide timely, consistent, safe, adequate, and appropriate services, treatment, and/or care. All evidence is reviewed by the Administrator, Director of Nursing Services (DNS), and a decision is made to notify the NYSDOH. The facility's policy titled Showering a Resident using the Shower Chair dated (MONTH) 2019, documented to secure the resident with a safety belt in the shower chair to transport the resident. Resident #364 was admitted with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident was rarely or never understood and the Brief Interview for Mental Status (BIMS) was not conducted. The MDS documented that Resident #364 required extensive assistance of two persons for bed mobility, transfer, dressing, toilet use, and personal hygiene; and total dependence of two persons for bathing. A Comprehensive Care Plan (CCP) for Activity of Daily Living (ADL) dated 3/19/2021 documented Resident #364 required assistance with ADLs as evidenced by confusion, Dementia, and limited mobility. The interventions included but were not limited to providing the assistance of two staff members for bathing/showering twice weekly and as necessary; assistance of two staff members for dressing; and assistance of two staff members for transfers from the wheelchair to the bed with a rolling walker. The Accident/Incident (A/I) Investigation dated 5/5/2021 documented that at 6 PM, CNA #5 reported that Resident #364 was on the ground in the bathroom. CNA #5 who was assigned to the resident stated that Resident #364's shower was just completed. CNA #5 turned around to get a pair of gloves so they (CNA #5) could apply lotion to the resident and when CNA #5 turned back around the resident was on the ground. CNA #5 notified the Registered Nurse (RN) Supervisor (RN #4). RN #4 went into the bathroom and observed the resident on the floor laying on the right side in front of the shower chair. RN #4 assessed the resident and noted a large hematoma to the right side of the head and a small reddened area to the upper back. The floor was wet from the shower. An investigative summary dated 5/6/2021 documented that upon investigation it was determined that the safety belt was not used when the resident was in the shower chair. The facility ruled out abuse, neglect, or mistreatment. There was no documentation that the NYSDOH was notified of the resident's injury. The Director of Nursing Services (DNS) was interviewed on 1/18/2022 at 11:05 AM and stated they (DNS) had reviewed and investigated the incident related to Resident #364's fall. The DNS stated that the CNAs were expected to use the safety belt to secure the resident while the resident was sitting in the shower chair and through re-enactment, it was discovered that the CNAs did not use the safety belt. The DNS stated that Resident #364 sustained a head injury and was found to have a Subdural Hematoma. The DNS further stated that the incident did not need to be reported to NYSDOH because there was a breach of the facility's policy and not of the resident's plan of care. The Administrator and the DNS were interviewed concurrently on 1/18/2022 at 2:03 PM and stated that the original manufactured shower chairs did not have a safety belt feature. The facility had re-designed the shower chairs and added safety belts for extra safety. They both stated that the staff were educated and expected to use the safety belt when providing a shower. 415.4(b)(2) | Plan of Correction: ApprovedFebruary 11, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F609 Reporting of Alleged Violations The Westhampton Care Center submits that its policies, procedures, and systems are in place to ensure the reporting of alleged violations of abuse, neglect, exploitation, or mistreatment are reported timely. This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have a procedure in place to maintain compliance with all requirements. In an effort to enhance our reporting system, we have reviewed of our existing policies, procedures and systems and revised accordingly. 1.The following actions were accomplished for the residents identified in the sample: Resident #364 sustained a subdural hematoma as a result of a fall from a shower chair on 5/5/2021. The facility did not report the accident/incident to the NYSDOH as required. Resident #364 was discharged on [DATE]. Employee CNA #5 is no longer employed by the facility. (Last day of employment 11/1/21) Employee CAN #6 is no longer employed by the facility. (Last day of employment 8/7/21) The facility Administrator, Medical Director and Nursing Administration were made aware of the failure to report to the DOH and the deficiency. All staff members involved in the incident and investigation of resident #364ís fall in (MONTH) of 2021 were educated on the regulations and the importance and requirement of ensuring that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported to the NYSDOH timely. 2. The following corrective actions will be implemented to identify other residents who may be affected by the same deficient practice: An audit of all residents for the past six months who had an accident/incident that resulted in a bodily injury, an injury of unknown origin or there was an injury related to the failure to follow the plan of care has been reviewed to determine if: o An Investigation was completed. o If the incident was required to be reported to the NYSDOH or other agency, in accordance with the regulation. All deficient audit findings addressed and/or corrected at the time of the audit. 3. The following measures and / or systemic changes will be implemented to ensure the deficient practice identified does not recur: The facility policies and procedures for Accidents and Incidents, and Abuse Prohibition Policies were reviewed by the Administrator, Medical Director and the Director of Nursing and no changes were necessary. The policy and procedure for CNA documentation of resident care was developed based on the CNA Orientation of care provided to residents in point click care. For further clarification CNAs will now see the level of assist required for bathing and showering prior to documenting the level of assist provided. This has been completed for ALL Westhampton resident. All Westhampton Care Center employees were re-educated on the State and Federal regulations on response to abuse, neglect, exploitation, or mistreatment, and/or misappropriation of funds of an individual residing in a residential health care facility. The education program included, but was not limited to: o Identification of suspected abuse, neglect, exploitation, or mistreatment, and/or misappropriation of funds. o The response to an alleged allegation of abuse, neglect, exploitation, or mistreatment, and/or misappropriation of funds. o The report of allegations to facility Administration and to DOH/other agencies o Investigation of all allegations. o It is the responsibility of all staff to report any suspicion of abuse, neglect, exploitation, or mistreatment, and/or misappropriation of funds to oneís supervisor immediately, in accordance with the policy and procedure. The facility educated all licensed nurses and CNAs on the appropriate use of the shower chair safety belt. The education included: o The CNAs lesson plan included the requirement to review the assistance that the resident/patient required while providing care, the need to ensure equipment was safe to be used and ensure the shower chair safety belt was secured and able to be utilized during the shower of a resident/patient. 4. The facilityís compliance will be monitored utilizing the following quality assurance system: A Quality Assurance Committee meeting was held on (MONTH) 10, 2022, to discuss this deficiency and the root cause of this deficient practice. A monthly audit will be conducted by the Director of Nursing or designee to ensure all accidents and incidents, if applicable, have been reported to the NYSDOH in accordance with the policy/procedure. Any noncompliant findings will be corrected immediately. All audit findings will be reported to the QA Committee monthly for six months for evaluation and follow-up actions. Results of the audit will be presented to the QAPI Committee monthly to ensure P(NAME) effectiveness. The QAPI Committee will take additional actions as necessary to ensure compliance. Following this six-month period, the QA Committee will decide of the need for continued auditing and at what frequency. Person Responsible: The Director of Nursing Compliance Date: 3/4/2022 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2022
Corrected date: March 18, 2022
Citation Details 2012 NFPA 101: 9.1.3.1 Emergency generators and standby power systems shall be installed, tested , and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2010 NFPA 110: 5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. 5.6.5.6.1 The remote manual stop station shall be labeled. Based on observation and staff interview, the facility failed to ensure that a remote manual stop station was installed for 1 generator that serves the buildings' emergency electrical system. The finding is: On 1/14/2022 between the hours of 9:00am and 4:30pm during the life safety recertification survey, it was observed that the facility had 1 generator that services the facilities emergency electrical system. The generator located outside the building, did not contain an emergency shut off switch outside the room housing the prime mover. In an interview on 1/14/2021 at 11:20am, the Director of Maintenance stated they can install an emergency shut off button. 2010 NFPA 110 2012 NFPA 101 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedFebruary 11, 2022 The center provides the following Plan of Corrections (P(NAME)) without admitting or denying the validity or existence of the alleged deficiencies. The P(NAME) is prepared and executed solely because it is required by the provisions of the federal and state law. The facility reserves all the rights to contest the survey findings through dispute resolution, final appeal proceedings or any administration or legal proceedings. K918 Electrical Systems 1. The Facility Generator will have a manual stop installed outside of the generator roomís enclosure by Commander Power Systems. 2. Engineering staff will be educated on inspecting and maintaining the generator manual stop. 3. A facility inspection has been conducted and has been found to comply. 4. Audit will be conducted monthly by Engineering Director/ designee. Findings of the audit will be submitted to QAPI for review and recommendations. Person Responsible: Engineering Director Compliance Date: 3/18/22 |