St Anns Community
September 11, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 11, 2017
Corrected date: October 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regimen is free of unnecessary medications. The issues involved lack of Gradual Dose Reduction (GDR) of [MEDICAL CONDITION] medications (Resident #30) and continued administration of bowel medications (Resident #27). This is evidenced by the following: 1. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 8/21/17, revealed that the resident has severe impairment of cognitive function, used antipsychotic, antianxiety, and antidepressant medication, had inattention which fluctuates, is tired or has little energy nearly every day, and had no hallucinations, delusions, physical or verbal behaviors, wandering, or rejection of care. The current physician's orders [REDACTED]. The current Comprehensive Care Plan (CCP) includes that the resident is on psychotherapeutic medications with the goal that the resident's mental status and behavior will remain well controlled with the support of medication throughout the stay or through the next review. Interventions included to discuss a reduction in dosing when target behaviors are absent and/or are easily altered for specified periods of time, but no less than quarterly. There is also a care plan for behavior which included a 2/22/16 addendum that there is noted improvement with the introduction of [MEDICATION NAME] in (MONTH) (YEAR). The current Certified Nursing Assistant (CNA) Care Card does not include any behavioral care except to ask the resident if she wants the fan pointed at her to help reduce her anxiety at times. The Nurse Practioner (NP) Visit Note, dated 11/14/16, documented that the resident is sleeping well at night and her mood is stable. The NP received an email from the resident's family member that stated mostly at dinner time, the resident has periods of anxiety and yelling, and has had to be returned to her room. The family member feels the resident is definitely better on the medications and is reluctant to taper them. Review of Medical Provider Notes from 1/6/17, revealed the resident's behaviors are well controlled but the family member does not want the medications changed. Review of the Clinical Notes Report from 1/1/17 through 9/8/17 included the following behavior documentation: a. On 1/1/17, the resident spit out Milk of Magnesia. b. On 3/6/17, the Social Worker (SW) met with resident who was pleasant and engaged. The resident occasionally switched subjects, but was easily redirected. The resident said yes to feeling down and having no energy. c. On 3/9/17, the resident was a little edgy when offered medications. She took the medications with persuading. d. On 5/19/17, the resident refused [MEDICATION NAME] (pain) stating it does not work. e. On 5/24/17, the SW met with resident and she was pleasant, but refused to complete the mood interview. The resident was at her baseline which included occasionally calling out. Review of the 4/10/17 [MEDICAL CONDITION] Nursing Note for [MEDICATION NAME] documented that the effects on the resident's target symptoms were better. No other [MEDICAL CONDITION] Notes regarding [MEDICATION NAME] were found. Review of the 4/13/17, 5/10/17, and 6/8/17 Pharmacy Recommendations included to attempt a GDR on [MEDICATION NAME], and [MEDICATION NAME], respectively. The response from the physician each time was that the family member declines to attempt a GDR. Review of the Nursing 30/60 Day Form, signed by the physician on 7/28/17, revealed the resident had chronic depression, anxiety, and paranoia and that had been reviewed several times with the family member who is a Nurse Practitioner. The family member feels [MEDICATION NAME] that the resident's mood and sense of well being are improved on the current medications and requests that no medications changes be made. Symptoms documented include that the resident feels better after getting [MEDICATION NAME] and that staff often observe anxiety, tearfulness, and wanting to go home. The psychiatric information included that the affect and mood are neutral. There is no documentation of a psychiatric consultation since admission. When observed on 9/7/17 at 11:56 a.m., the resident was sitting at a table in her wheelchair quietly waiting for lunch. At 12:07 p.m., the resident's family assisted the resident to eat lunch. Twice during that time, the resident said she wanted her shoes on (she was wearing slippers) and once she said that she feels terrible. When her family asked her how she was, she responded she feels sick. No other behaviors were noted. When observed on 9/7/17 at 3:33 p.m., the resident was awake in bed and stated she would do some paperwork. On 9/8/17 at 3:29 p.m., the resident was observed in bed awake looking at the ceiling. On 9/11/17 at 8:56 a.m., the resident was observed in a wheelchair quietly waiting for breakfast. She dozed a bit, off and on. When interviewed on 9/7/17 at 3:33 p.m., the evening shift Licensed Practical Nurse (LPN) #1 stated that once in a while the resident will cry or yell, maybe every two weeks. She said the staff do one on one with her, bring her to her room, but never have to give her an as needed medication. LPN #1 said she cannot remember documenting behaviors for the resident because she has not had any severe behavior. Interviews conducted on 9/11/17 included the following: a. At 9:00 a.m., LPN #2/days said the resident's behaviors vary between yelling for her family and being very quiet. She said the resident asked to call the police once. She said the resident does not go on and on about things. LPN #2 stated she does not see any depression, hallucinations, or delusions with the resident. She said the resident gets [MEDICATION NAME] for anxiety and is doing well. She said the anxiety is well controlled. LPN #2 said the resident's mood, behavior, and personality have been pretty stable for at least a year. b. At 9:14 a.m., the Registered Nurse Manager (RNM) stated that the resident's behaviors fluctuate. She said the resident is not combative. She said sometimes the resident will yell out that she is sick, but is easily redirected. The RNM reviewed the electronic record and stated that she believes the [MEDICATION NAME] was changed in mid to late (YEAR). She said [MEDICATION NAME] was started in (MONTH) (YEAR) and has not been changed, and the as needed [MEDICATION NAME] was discontinued in (MONTH) (YEAR). She said there were no changes with the routine [MEDICATION NAME]. The RNM said that the family does not want any changes with the resident's medications. c. At 10:07 a.m., the Director of Nursing (DON) stated that she has only worked at the facility for one month and does not know the resident. She said that [MEDICAL CONDITION] medications are reviewed at each medical visit and after a year, a GDR should be attempted in two separate quarters. d. At 10:27 a.m., NP #1 stated that she has worked at the facility for five weeks and has not seen the resident. She said it is usually up to the physician to begin a GDR and have the NP follow up. She said it is documented that the family does not want a GDR and that is an acceptable reason not to attempt a GDR. e. At 11:35 a.m. by telephone, NP #2 said that she is only working on-call now, but was working full time and did not see any behaviors displayed by the resident. She said she understood from the family member that the resident yelled at the dinner table. NP #2 said that the regulations and pharmacist instruct to do a GDR twice in a year in two different quarters. She said the family member does not want this done. f. At 12:49 p.m. by telephone, the physician stated that in her last visit note she documented that there have been no behaviors in the previous 60 days, the resident was sleeping okay and her mood was neutral. The physician said she is aware of the regulations regarding GDR and is not able to do anything about that situation. She said that the family member is a NP and has repeatedly requested no GDRs be done. She said she will not argue with a family that really feels the resident benefits from these medications for quality of life. She said, My hands are tied. Review of the (MONTH) 2002 facility policy, Antipsychotic Drugs, directed that antipsychotics should not be used if one or more of the following is the only indication: wandering, poor self-care, restlessness; impaired memory, anxiety, depression, [MEDICAL CONDITION], unsociability, indifference to surroundings, fidgeting, nervousness, uncooperativeness, or agitated behaviors that do not represent danger to the resident or others. 2. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 8/3/17, revealed that the resident had moderate impairment of cognitive function, required extensive assist of staff for toileting and was frequently incontinent of bowels. Current physician orders [REDACTED]. The CCP, dated as last reviewed on 8/12/17, includes that the resident has a [DIAGNOSES REDACTED]. Review of the BM Report from 8/26/17 through 9/8/17 revealed that the resident had 37 BM's in that time frame and 12 of them were listed as loose. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of Nursing Progress Notes for the same time frame revealed that the resident is up on the night shift daily requesting to use the commode from one to five times during the shift. In an interview on 9/6/17 at 11:23 a.m. and again on 9/8/17 at 11:48 a.m., the CNA stated that the resident goes to the bathroom a lot. She said that the resident has several BMs a day and has for a while. The CNA said that staff will notify the nurse if the BMs are very hard or very loose like watery, but hers are not. She said that the BMs are not formed but are soft. The CNA said that the resident's bottom is very dry and slightly red because she wipes a lot but has no open areas. Interviews conducted on 9/8/17 included the following: a. At 3:34 p.m., LPN #3 stated that she checks both the No BM Report and the full BM report but she did not notice how many BMs the resident had. b. At 3:37 p.m., evening LPN #4 stated she just reviews the No BM Report for the previous six shifts. c. At 3:21 p.m., and again on 9/11/17 at 11:41 a.m., the RNM stated that during each shift the nurses are expected to review the No BM Report in the computer to see who has not had a BM in the previous six shifts. She said the report only includes who has not had a BM. The RNM said that the LPNs would not know who is having too many BMs unless the CNAs tell them. She said that the CNAs can only view their shift in the computer system when they document a resident's BMs. The RNM said that the CNAs know to notify the nurse if residents do not have a BM or if it is loose. She said the facility would have to rethink their process. When interviewed on 9/11/17 at 10:49 a.m., the NP stated that she does not cover this resident as a patient but that it is a lot of BMs. She said she would expect to be notified in order to decide to hold or cut down on the medications. The (MONTH) (YEAR) facility policy, Bowel Management, directed that nursing will monitor the bowel regimen daily and ensure the resident is having regular bowel patterns. (10 NYCRR 415.12(l)(1))

Plan of Correction: ApprovedOctober 4, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F329
1.
Corrective Action:
On 9/19/2017 the family of resident #30 was contacted to discuss the benefits of a gradual dose reduction of [MEDICATION NAME] and [MEDICATION NAME]. [MEDICAL CONDITION] note completed regarding the target symptoms for [MEDICATION NAME] have been added.
Responsible Party:
Director of Nursing
Identification of other residents affected:
On 9/27/2017 a chart audit has been completed for all residents receiving a [MEDICAL CONDITION] medication to ensure either a GDR or a contraindication has been documented.
Responsible Party:
Director of Nursing
Systemic Changes:
Policy TX 155 has been updated to include guidelines related to a tailored drug regimen (GDR). Education provided to nursing staff on Policy #TX 155 [MEDICAL CONDITION] (Psychoactive) Medication.
Responsible Party:
Director of staff education
Director of Nursing
Completed by 10/27/2017
Quality Assurance:
A monthly review of pharmacy GDR recommendations will be audited to ensure that GDR is appropriate or contraindicated and documented by medical for three months. All findings will be reported monthly at QAA.
Responsible Party:
Director or Nursing
Director of Quality
First audit to be complete by
11/10/2017
2.
Corrective Action:
On 9/15/2017 the NP was notified of loose stools for resident #27 and ordered to hold laxative and stool softener in the event of loose stools.
Responsible Party:
Nurse Manager
Identification of other residents affected:
On 9/27/2017 Bowel records for all residents have been reviewed for too many bowel movements and loose stools. Anyone identified with loose stools will have and order to hold bowel medications if appropriate.
Responsible Party:
Director of Nursing
Systemic Plan:
Reeducation provided to nursing staff on process for reporting loose stools.
Responsible Party:
Nurse Manager
Director of Nursing
Completed by 10/27/2017
Quality Assurance:
10 residents who are on bowel medications will be audited monthly. Reviews will include frequency/consistency of stool to ensure medications are appropriate.
Responsible Party:
Director of Nursing
Nurse Manager
Director of Quality
First audit to be completed by 11/10/2017


FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 11, 2017
Corrected date: October 27, 2017

Citation Details

Based on observations and interviews conducted during the Recertification Survey, it was determined that for three (Cherry Grove, Magnolia Crescent, and Apple Blossom) of six residential units, the facility did not ensure that the resident environment remained as free of accident hazards as possible. The issue involved hot water temperatures that exceeded 120 degrees Fahrenheit (F) in faucets that were accessible to residents. The is evidenced by the following: 1. During observations and an interview conducted on 9/6/17 between 3:05 p.m. and 3:52 p.m., the water temperatures at sinks in the resident rooms revealed the following: in Room #3205 (Cherry Grove) it measured 123.4F, in Room #2203 (Magnolia Crescent) it measured 125.0F, and in Room #1203 (Apple Blossom) it measured 123.1F. When interviewed at that time, the Director of Maintenance stated that another maintenance staff member had reported that twice last week the water temperatures were high on the Magnolia Crescent unit, but when he went back to recheck them they were fine. He said the water temperatures are always checked first thing in the morning. 2. When interviewed on 9/7/17 at 8:30 a.m., a Certified Nursing Assistant on the Cherry Grove unit stated that sometimes the residents think the water is hot but the staff do not. She said it takes a while to get the water temperature up there, but once it does, it is hot. 3. When interviewed on 9/8/17 at 3:48 p.m., Resident #8 stated that the water can get very hot. She said the girls adjust it for her by adding cold water. She said the water was not bad that day but it is often hot and she is careful. (10 NYCRR 415.29, 415.29(a)(1), 415.29(f)(6))

Plan of Correction: ApprovedOctober 4, 2017

F 323
Corrective Action:
On 9/8/2017 the valve was dialed back to decrease the flow of hot water. That same day the vendor was contacted to review a rebuild of the mixing valve. Vendor will complete the installation of the rebuilt mixing valve on 10/16/2017.
Responsible Party:
Facilities Supervisor
Identification of other residents affected:
On 9/28/2017 all 72 rooms have been tested to ensure the temperature is below 120.
Responsible Party:
Facilities Supervisor
Systemic Changes:
Education has been established to review the work flow of how to test and report water temperatures immediately if above 120. This will be delivered to all maintenance staff.
Responsible Party:
Director of staff education
Facilities supervisor
Complete by:
9/27/2017
Quality Assurance:
A weekly audit of one household (12 rooms) for all room water temperatures will be completed. Audits will be reviewed monthly at the QAA meeting for three months.
Responsible Party:
Facilities supervisor
Director of Quality
Administrator
First Audit to be complete by:
11/10/2017

FF10 483.25(g)(1)(3):MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

REGULATION: (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident?s comprehensive assessment, the facility must ensure that a resident- (1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident?s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 11, 2017
Corrected date: October 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #49) of four residents reviewed for nutrition, the facility staff did not ensure that the resident maintained acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrated that this was not possible. The issue involved a lack of consistent monitoring for a resident experiencing significant weight loss. The is evidenced by the following: Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment, dated 7/26/17, revealed that the resident's cognition is severely impaired, and requires supervision and set-up assistance only for eating. Review of Nutrition Progress Note, dated 5/5/17, revealed that the Registered Dietician (RD) reviewed re-weighs obtained by facility staff that appeared to support significant weight loss quantified as 13 percent weight loss in six months and 4 percent weight loss in one month. On 5/8/17, the RD documented that three re-weighs confirmed significant weight loss. In addition to Mighty Shakes (fortified milkshake containing increased calories and protein) that had already been added to meals, she suggested adding a high calorie supplement, three times daily, with medication pass to prevent further weight loss. A Medical Provider Problem Visit Note, dated 5/8/17, revealed that the resident's appetite remained fair to good, was eating 50 to 75 percent of meals, and had variability in her weights. Weight loss is also listed on the Master Problem List, dated 5/9/17. There is no mention of adding a supplement to enhance the resident's nutritional intake. Review of weight records revealed that the resident's weight was 169 pounds (lbs.) on 5/1/17, 170 lbs. on 6/1/17, 164 lbs. on 7/2/17, and 156 lbs. on 8/1/17. This reflects a loss of 13 lbs. after the initial recommendation to add the high calorie supplement. The Nutrition Progress Note, dated 7/31/17, revealed that the resident had a significant weight loss in the six month look-back period between (MONTH) and July. The RD suggested adding a high calorie supplement, three times daily with medication pass, in addition to already receiving Mighty Shakes, and referenced Nutrition Notes from 5/5/17 and after for recommendations and re-weigh information. Review of Progress Notes and Nutrition Assessments revealed that there was no documentation from the RD between 5/8/17 and 7/31/17. Review of the current medical orders revealed that the high calorie supplement was ordered on [DATE] and the resident started receiving the supplement on 8/2/17. Interviews conducted on 9/11/17 included the following: a. At 10:00 a.m., the RD stated that in her Clinical Note, dated 5/8/17, she did suggest adding a high calorie supplement. She said the process for informing staff of nutritional supplement recommendations was to send an email to the Nurse Manager, Clinical Coordinator, and medical provider. She said if the team agreed with the recommendation, the medical provider would give the order to the Nurse Manager and Clinical Coordinator to be entered into the electronic record. She said that the RD can add Mighty Shakes without a medical order because it is considered a meal intervention. She said that is tried first instead of adding a medication pass supplement right away. b. At 10:55 a.m., the RD stated that she had reviewed email communications following her recommendation on 5/8/17 and there was no documentation regarding a decision whether to add the high calorie supplement. She stated that following a recommendation she typically makes a note to herself to follow-up in about a week. The RD thought that it was a period when the resident's weight had stabilized and the Mighty Shakes appeared to be working. She stated that if the resident continued to lose weight at the rate she had been losing that would have been an extra reminder to follow-up. The RD said she did not follow-up in that case. c. At 11:34 a.m., the Nurse Practitioner (NP) stated that when the RD makes a recommendation for a supplement, it is sent via email to the Nurse Manager, Clinical Coordinator, and the NP. She said that she would order the supplement if she were in-house, otherwise, nursing enters a verbal order. The NP said once the supplement was ordered she would expect that the supplement is obtained. She said if the supplement was unavailable, nursing would notify the NP, and the resident would be monitored with weekly weights. She stated that she would expect the resident's weight to plateau after starting a supplement. She said if there was no improvement in four weeks another intervention would be tried. She said if there was a sustained weight loss and no intervention was working, then she would talk to the family about hospice. Review of the facility policy for nutritional supplements, dated 1/10/12, directed that the Medical Pass Supplement be ordered for four weeks the first time. The Dietician/Technician will then do a follow-up documentation in the Integrated Note section of the chart, and determine the need to continue the supplement. (10 NYCRR 415.12(i)(1))

Plan of Correction: ApprovedOctober 4, 2017

Immediate Action:
Verified order supplement implemented on 8/1/2017.
Responsible Party:
Clinical dietician
Identification of other residents affected:
A chart review was completed on all residents receiving supplements for appropriate orders based on dietician recommendations.
Responsible Party:
Clinical dietician
Completed by:
9/27/2017
Systemic Changes:
Nurse leaders and clinical dietician staff will receive formal reeducation on implementing supplement recommendations.
Responsible Party:
Director of staff education
Completed by 10/27/2017
Quality Assurance:
All residents who are identified on the monthly quality measure report triggering for weight loss will be reviewed for appropriate nutritional supplement.
Responsible Party:
Clinical Dietitian
Director of Quality
First Audit to be complete by:
11/10/2017

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 11, 2017
Corrected date: October 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #12) of two residents reviewed for indwelling urinary catheters (tube inserted into the bladder to drain urine, also known as a Foley catheter), the facility did not provide appropriate treatment and services to prevent potential catheter related complications. The issue involved the resident's catheter was not changed as ordered and a urology consult was not scheduled as ordered in a timely manner. This is evidenced by the following: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/17/17, revealed that the resident is cognitively intact. In an observation and interview with the resident on 9/11/17 at 11:28 a.m., the resident had a leg drainage bag attached to her urinary catheter containing a small amount of dark yellow urine. The resident said that her catheter had not been changed in a long time. She said it has been changed once since her admission to the facility. The resident said she did not know why her catheter was not changed monthly like it was before she came to the facility. She said that it was supposed to be changed last week because it was leaking and it hurt. She said that she was still waiting for that to be done. The resident said she was concerned that she now had an infection because of the leaking and her blood pressure was low. She said that she does not usually get more symptoms due to the numbness from the [MEDICAL CONDITION]. The resident said that she used to go to the urologist's office to have the catheter changed. She said that she does not go anymore because the facility will not transport her as it cost too much and she cannot afford it until her Medicaid kicks in. Review of the facility's electronic medical record revealed the following: a. Admission medical orders, dated 5/9/17 and signed by the Nurse Practitioner (NP) and the Registered Nurse (RN), directed a Foley catheter for incontinence, to use a size 18 French 30 cubic centimeters (cc) balloon, to flush daily with 60 cc of sterile normal saline and that the resident has a urology appointment on 5/30/17 at 2:00 p.m. b. In a Problem Visit Note, dated 5/10/17, the NP documented that the resident requires an indwelling catheter and that the catheter is to be changed monthly at an outside urology office. The NP will review with staff to determine if the catheter can be changed at the facility. c. In a 5/12/17 Admission History and Physical Note, the physician documented that the resident goes out for monthly Foley changes. d. A Nursing Progress Note, dated 5/14/17, included that the catheter was changed because it fell out and was replaced with a 16 French 10 cc balloon. On 6/24/17, a Nursing Note included that it was changed due to leaking. e. A new physician order, dated 9/1/17, included to change the Foley every four weeks and to use an 18 French 30 cc balloon. f. The July, August, and (MONTH) (YEAR) Treatment Administration Records and Nursing Progress Notes, from 6/13/17 through 9/8/17, do not include any documentation that the Foley had been changed since 6/12/17. g. There is no documented evidence in the medical record that the urology consult occurred. Interviews conducted on 9/8/17 included the following: a. At 12:50 p.m., and again at 2:30 p.m., the RN Manager (RNM) said that she thought the catheter was changed on 9/1/17 because the Licensed Practical Nurse (LPN)/Clinical Coordinator (CC) was called to help and a verbal order was written. The RNM said that she could not find documentation that it was done or why. The RNM said that she called the urology office and was told that the resident's 5/30/17 appointment was cancelled. She said it was supposed to be rescheduled but it never was. She said that she did not know why it was cancelled or by whom, but that it should have been rescheduled. b. At 1:08 p.m., the LPN/CC stated that he received a verbal order on 9/1/17 from the NP to change the catheter but he could not remember why. He said that he saw that the catheter was being changed monthly prior to admission but added that the facility does not always change them monthly. c. At 1:29 p.m. and again on 9/11/17 at 10:40 a.m., the NP stated that while she was not the caregiver at the time, it is her expectation that the catheter would have been changed every four weeks per her previous routine, especially due to her history of infections. She said that she would have expected that the urology appointment was scheduled. She said if the appointment was cancelled for any reason the medical team should have been notified. The NP said if the physician orders [REDACTED]. When interviewed on 9/11/17 at 1:29 p.m., the RNM said that the resident's catheter was supposed to be changed last week after the 9/1/17 order was written but she could not find any documentation that it was done. She said that the resident's catheter was still leaking so staff would change it that day. She said medical wanted the urology appointment rescheduled and she did it that day. (10 NYCRR 415.12)

Plan of Correction: ApprovedOctober 4, 2017

F 315
Immediate Action:
Foley catheter order entered and changed for resident #12 on 9/13/2017. Appointment made with urology on 9/8/2017.
Responsible Party:
Nurse Manager
Identification of other residents affected:
All residents with Foley catheters have been reviewed to ensure an order is in place to change Foley catheter as recommended and follow up appointments have been made as appropriate.
Responsible Party:
Director of Nursing:
Completed by:
10/3/2017

Systemic Plan:
Reeducation provided to the nursing leaders to check for orders on all new Foleys and to ensure an appointment and other recommendations have been followed. Admission order sheets revised to reflect Foley catheter order recommendations.
Responsible Party:
Director of staff education
Director of Quality
Complete by 10/27/2017
Quality Assurance:
Audit all new admissions with Foley catheters for orders and follow up urology appointments will be completed monthly for three months. Audits will be reviewed at QAA monthly.
Responsible party:
Director of Nursing:
First Audit complete by:
11/10/2017

FF10 483.25(b)(1):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES

REGULATION: (b) Skin Integrity - (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual?s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 11, 2017
Corrected date: October 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 895), it was determined that for two of two residents reviewed for pressure ulcers, the facility did not provide the necessary services to prevent the development of, or promote healing of, a pressure sore. The issues involved the lack of a skin assessment upon admission to the facility (Resident #12) and the lack of a Registered Nurse skin assessent and physician notification (Resident #4). This is evidenced by the following: 1. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) Assessment, dated 5/22/17, revealed that the resident is cognitively intact and had one Stage II (partial thickness/superficial loss of skin) pressure ulcer and one unstageable deep tissue (deep tissue injury is suspected due to discoloration of skin but not open) pressure ulcer. Review of a hospital discharge summary revealed that on 5/8/17, the Physician's Assistant documented during a wound/skin evaluation that the resident's skin was completely intact at that time, but that there was evidence of healed pressure injuries of both buttocks. Recommendations included a pressure relieving mattress and a barrier ointment to the buttocks to protect the skin twice daily. The Nursing Admission Note, dated 5/9/17, signed by the Licensed Practical Nurse (LPN), includes that the resident was admitted to the facility at 2:40 p.m. It does not include any documentation that a skin assessment was completed. Review of the facility admission orders [REDACTED]. It does not include any other skin care instructions or assessments. A Problem Visit Note, dated 5/10/17 and signed by the NP, included that the resident was being seen for admission to long term care. The note included that the resident was sitting in her wheelchair during the examination and that she sleeps in a recliner chair. It does not include information related to skin assessments, issues or preventive care. Review of the Physician Admission History and Physical-Long Form, dated 5/12/17, revealed that the physician noted, during an exam, deep tissue injuries to the resident's inner buttocks that were very concerning. The physician requested a specialty mattress, a chair cushion, and a skin consultation. Additionally, the physician documented that it is going to be very challenging given the resident's persistence regarding sleeping in a chair. Review of the first Wound Care Flow Sheet in the electronic medical record and signed by the NP, revealed that on 5/17/17, a skin assessment was completed that revealed a deep tissue injury of the left buttocks and a Stage II pressure ulcer of the right buttocks, measuring 2.4 centimeters (cm) x 1.7 cm that had a start date of 5/12/17. Treatments were recommended at that time. Review of the first Weekly Skin Observation Note in the electronic health record, dated 5/20/17 and signed by the LPN, included that the resident had a left heel blister, a right buttock pressure ulcer and a groin rash. During an interview on 9/8/17 at 12:50 p.m., the RN/Nurse Manager stated that she could not find any admission skin assessment. She said that the LPN completes the form and does the initial skin review, then the RN verifies the skin assessment. The RN Manager said she could not find any documentation that this was done and it should have been. During an interview on 9/11/17 at 10:40 a.m., the NP stated that skin checks should be done by nursing on admission, and if they see any concerns they should contact the skin care team and myself. She said especially if the resident was in her wheelchair at the time of the examination and unwilling to be transferred. Review of the current facility policy, Skin Care Management, directed that nursing skin observation will be completed upon admission, re-admission and intra-facility transfers. Weekly skin (head to toe) observation to be completed and documented by the nurse in the electronic health record. 2. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/9/17, includes that the resident is cognitively intact and had no skin issues. A Nursing Progress Note, dated 6/20/17 and signed by a LPN, documented a Certified Nursing Assistant (CNA) reported a linear shaped open area to the left inner thigh that measured 4 cm x 1 cm. The LPN documented that she applied a post-op dressing and notified the nursing supervisor. The Weekly Skin Observation Form, dated 6/24/17 and signed by the same LPN, documented that there were no abrasions, bruises or pressure ulcers. The LPN documented a skin tear on the left inner thigh. The Weekly Skin Observation Form, dated 7/1/17 and signed by a RN, documented that there were no pressure ulcers or skin tears. Review of a Nursing Progress Note, dated 7/7/17 and signed by the same LPN, documented an open area on the left inner thigh, that measured 3.7 cm x 1.2 cm with 0.4 cm depth. The NP Note, dated 7/7/17, documented that she was asked to assess the resident's thigh wound as noted on 6/20/17. The NP documented that the wound was located on the medial aspect of the upper left thigh directly where the resident's briefs rub. The NP documented that the resident chronically wore two sets of briefs at a time. The NP assessed the wound on the left thigh as an unstageable pressure ulcer, measuring 3.7 cm. x 1.7 cm with 50 percent slough (dead tissue) and ordered a treatment. Interviews conducted on 9/8/17 included the following: a. At 10:50 a.m., the LPN stated that on 6/20/17 a CNA reported that when she was dressing the resident she saw an open area. The LPN examined the open area on the left inner thigh. The LPN stated she notified the supervisor of the open area and applied a dressing to protect it. The LPN stated a skin check is completed on a resident's shower day. She stated the resident is examined from head to toe. The LPN stated if a skin issue is observed the supervisor is notified, assesses the area, and calls the medical provider for a treatment order. b. At 11:10 a.m., a RN Supervisor stated she worked on 6/20/17, and she recalled the LPN calling her regarding the resident having a skin issue. She stated she did not examine the area or recall any details of that date. The RN Supervisor said that she must have been busy not to respond, because that is her responsibility. c. At 11:30 a.m., the RN Manager said that during the facility investigation, she only spoke with the involved nurses. She said that she did not speak with any CNAs to determine if anyone was aware of the open area. She said that she felt that the open area was there since 6/20/17. (10 NYCRR 415.12(c)(2))

Plan of Correction: ApprovedOctober 4, 2017

F 314
1.
Corrective action:
On 9/25/2017 a skin assessment was completed by the RN for resident #12. Preventative protective ointment added to care card twice daily. One to one education provided to nurses involved to complete nursing observation (which includes the skin assessment) upon admission.
Responsible Party:
Nurse Manager
Director of Nursing

Identification of other residents affected:
Confirmed all residents admitted since (MONTH) (YEAR) had a review of the nursing observation tool completed to include a skin assessments by an RN.
Responsible Party:
Director of Nursing
Completed by:
10/4/2017

Systemic changes:
Reeducate all nurses on the completion of the observation tool upon admission to include process of RN skin assessment.
Responsible Party:
Director of staff development
Completed by:
10/27/2017
Quality Assurance:
An audit of all new admissions will be conducted every month for 3 months for completion of the nursing observation tool, which includes RN skin assessment. Results will be reported at the QAA meeting monthly.
Responsible Party:
Director of Nursing
Director of Quality
First Audit will be complete by:
11/10/2017

F 314
#2
Corrective Action:
On 7/7/2017 the RN assessed and treated the open area. On 7/15/2017 a complete head to toe skin assessment was completed by the RN. Statements obtained from primary CNA's regarding resident #4 open area. Plan of care/care card updated to include protective ointment on buttocks twice daily.
As of 7/13/2017 skin observations are now completed for resident #4 while laying down in bed.
Responsible Party:
Nurse Manager
Identification of other residents affected:
An audit of current residents with pressure ulcers has been reviewed to ensure the skin assessment reflects the current skin issues.
Responsible Party:
Director of Nursing
Completed by:
9/27/2017
Systemic Changes:
An education plan has been created for nurses to address how to properly do a complete head to toe skin assessment.
Responsible Party:
Director of staff development
Complete by:
10/27/2017
Quality Assurance:
All residents with pressure ulcers will be reviewed monthly for three months for complete skin assessments.
A random audit of 6 investigations related to skin conditions per month will be reviewed for proper completion for three months. Results will be reviewed monthly at QAA.
Responsible Party:
Director of Nursing
Director of Quality
First audit to be complete by:
11/10/2017