Parker Jewish Institute for Health Care & Rehab
March 5, 2019 Certification Survey

Standard Health Citations

FF11 483.25(c)(1)-(3):INCREASE/PREVENT DECREASE IN ROM/MOBILITY

REGULATION: §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 5, 2019
Corrected date: May 1, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the re-certification survey, the facility did not ensure a resident with limited range of motion (ROM) and mobility received appropriate treatment and services to increase range of motion and or to prevent further decrease in range of motion. Specifically, a hand roll and a splint device were not provided to the resident as per physician order. This was evident in 1 of 2 residents reviewed for ROM care and services (Resident #87). The finding is: The facility policy and procedure titled Adaptive Devices dated 07/2018 documented the following: Adaptive devices are provided when necessary to prevent a decline in a resident's range of motion or to maintain a resident's proper positioning in bed or in a chair. The nursing staff will provide or apply the devices to the resident as per the instructions provided and schedule determined on the CNA instructions. Resident #87 was admitted to the facility with [DIAGNOSES REDACTED]., and Depression. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented that the resident had moderately impaired cognition. The MDS further documented that the resident required total assistance for all Activities of Daily Living (ADLs) and had impairments on both sides of upper and lower extremities. In addition, resident used a pressure reducing device for chair and bed. On 02/26/2019 at 12:18 PM, the resident was observed in the dining room asleep in a gerichair. The resident had contractures of bilateral upper and lower extremities. There was no device placed on either hand. A blue hand roll was observed resting on the resident's lap. A hand roll was also observed on a resident's night stand in the room. On 02/27/19 between 10:05 AM and 11:25 AM, the resident was observed seated in the gerichair in the lobby with no hand roll and no hand splint in place. On 02/27/19 at 12:35 PM, the resident was observed in the dining room with no hand roll or splint in place. Occupational Therapy (OT) progress note dated 12/13/2017 documented resident seen by OT as per nursing request due to tightness noted, decreased ROM in bilateral hands and right elbow. Nursing staff with noted difficulty on/off bilateral hand splints. Upon OT assessment, resident would benefit from restorative OT for proper splint management & fitting. CCP updated OT progress note dated 02/14/2019 documented OT re-evaluation and treatment in progress, P(NAME) established. Resident referred for OT services secondary to increased tightness, decreased PROM (Passive Range Of Motion) and overall difficulty applying splints to B/L (bilateral) UE's (upper extremities). physician's orders [REDACTED]. Adaptive Device: Right elbow splint to be worn 3 hrs BID (twice daily). Remove for skin check and hygiene from 7 AM to 3 PM and 3 PM to 11 PM. Right hand grip splint and left hand roll to be worn for 4 hours BID from 7 AM to 3 PM and 3 PM to 11 PM. Active Certified Nursing Assistant (CNA) instructions documented right hand grip splint, left hand roll BID, remove for skin check/hygiene. Right elbow splint 3 hours BID. On 03/04/19 at 10:03 AM, an interview was conducted with Certified Nursing Assistant (CNA#1). CNA #1 stated resident is positioned every 2 hours when in bed, and range of motion is done during dressing for upper and lower extremities. Hand splint is put on the right hand and hand roll on the left hand. The splint and hand roll are placed on the resident at about 10 AM when resident is taken out of bed and removed at about 2 PM after lunch when he is transferred back to bed. The hand rolls and the splint are removed regularly for skin check. On 03/04/19 at 11:47 AM, an interview was held with the Unit Manager /Registered Nurse (RN #1). RN #1 stated that the nurse on the unit is responsible for placing the devices and documenting the time the splint and hand roll is placed on the resident daily in order to monitor the time the devices are to be removed. There no specific times for placement of the device indicated in the physician's orders [REDACTED]. On 03/04/19 at 11:55 AM, an interview was held with the Registered Nurse (RN #2) who was on duty on the 7 AM to 3 PM shift on 2/26/19 and 2/27/19. RN #2 stated the order is checked for the timeframes to apply and to remove the devices. RN #2 also stated that the nurses are supposed to apply the devices, remove them and document as per order. The CNA's are instructed to monitor and ensure that the resident has the devices in place. No fixed time is assigned but the devices are always applied when the resident is taken out of bed and then removed after the stipulated time period has passed. On 03/04/19 at 12:34 PM, an interview was conducted with the Occupational Therapist (OT). The OT stated when the device is recommended, OT provides the device, places an order, initiates the care plan, in-services the CNA/Nurses, and updates the CNA profile The OT further stated that a screen is completed and they make rounds on the unit to see devices are properly placed. If there is a complaint with any device, there is communication between the nursing and the rehab to address the problem. The OT also stated that the time the device is placed is not specified by the rehab, they only specify the daily duration of the placement. The nursing staff determine the timing based on when the device is applied. 415.12(e)(2)

Plan of Correction: ApprovedMarch 25, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The following Plan of Correction is submitted in accordance with applicable law and regulation for continued Medicare / Medicaid certification. The facility reserves the right to contest any of the findings or deficiencies set forth in the Statement of Deficiencies.

F- 688
I. The following actions were accomplished for the residents identified in the sample:
Resident #87
The IDCPT, including the Occupational Therapist, reviewed the resident?s plan of care related to the prevention of a decrease in ROM and determined that the use of the hand roll and splint devices remained appropriate. The RN Manager reviewed the physician orders [REDACTED]. The RN Manager reviewed the CNA assignment to ensure that the hand roll and splint were included on the assignment and determined that there was no need to revise the assignment. The RN Manager reviewed the plan of care related to the use of the hand roll and splint with the responsible unit staff.
The Nurse Manager reeducated the RNs and CNAs responsible for the care of this resident on the adaptive device policy, including the use and placement of ordered devices as per practitioner order.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
The RN Managers and Rehabilitation staff identified all residents with orders for an adaptive device.
The Director of Rehabilitation conducted a full house audit of all identified residents to ensure that the orders are correct and are part of the resident?s care plan. The RN Managers reviewed and revised, as needed, the CNA assignment for each identified resident and reviewed the plan of care with the responsible unit staff.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The Administrator, Medical Director, and Directors of Nursing and Rehabilitation reviewed the policy and procedures for ROM/Mobility and use of Adaptive Devices, including hand rolls and splints, and determined that there was no need to revise the policy.
The Director of Rehabilitation, in conjunction with the Staff Educator/designee, will reeducate the nursing staff on the facility policy and procedure titled Adaptive Devices, including application of the devices per the plan of care and practitioner order and completing required documentation
The RN Managers/designee will monitor for compliance of adaptive devices being utilized as per practitioner order and the plan of care during routine and random rounds. Immediate corrective action, including staff education or application/removal of a device, will be implemented as indicated.
IV. Quality Assurance Monitoring:
The facility will develop an audit tool to monitor compliance with the facility?s protocol for use of adaptive equipment to increase/prevent a decrease in ROM/Mobility.
The Director of Rehabilitation/designee will audit 20% of those residents with a plan of care related to increasing/preventing a decrease in ROM/Mobility monthly for 3 months and then quarterly for an additional 3 quarters. Residents with orders for use of a hand roll or splint will be included in the audit sample. The Director of Rehabilitation will report and ROM/Mobility and use of adaptive devices audit findings to the Administrator and Director of Nursing monthly for 3 months and then quarterly for an additional 3 quarters. Corrective actions, such as updating the plan of care or staff reeducation, will be implemented as indicated.
The Director of Rehabilitation will report all ROM/Mobility and use of adaptive devices audit findings to the QAPI Committee monthly for 3 months and then quarterly for an additional 3 quarters for discussion and follow-up. At the end of the 4th quarter, the Committee will make a determination regarding the need for ongoing auditing and the frequency of such auditing.
V. Completion Date: 5/1/19
VI. Responsibility: VP of Patient Care Services

FF11 483.10(i)(1)-(7):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: March 5, 2019
Corrected date: N/A

Citation Details

Based on observations and staff interviews during the re-certification survey, the facility did not ensure resident equipment were maintained in a safe, functional manner. Specifically, the pole used for a resident's tube feeding pump was observed to be bent and not properly secured to the base (Resident #334). This was evident during multiple observations on the 3rd Floor. The finding is: On 02/26/19 at 09:56 AM and at 10:05 AM, Resident #334 room was observed with a tube feeding (TF) pump loosely hung on a tilted bent feeding pump pole and subsequently on the second observation the pole was tied to the oxygen gauge on the wall with a white rolled gauze bandage. On 02/27/19 at 09:10 AM, Resident #334 TF pump was again observed loosely hung on the tilted bent feeding pump pole and was tied to the oxygen gauge with white rolled gauze bandage. On 02/27/19 at 04:15 PM and on 02/28/19 at 09:18 AM, Resident #334 TF pump was observed hanging loosely from the tilted bent pole. On 03/01/19 at 12:13 PM, an interview was conducted with the Certified Nursing Assistant (CNA#2). CNA#2 stated the feeding pump is sometimes on and running when she comes at 7 am, and it is usually finished around 8:30 am. The nurse is called in to stop the feeding before care is provided to the resident and put on when care is finished, resident's head is always elevated in bed when the feed is running. CNA#2 stated that she did not notice that the feeding pole was attached to the oxygen gauge on the wall but only noticed that the pump is lower on the pole. On 03/01/19 at 12:22 PM, an interview was conducted with the Registered Nurse (RN #7). RN#7 stated that the feeding is started on the evening shift and is completed on her tour, day shift. When the feed is completed the bottle is removed. RN#7 stated that the pump was noted hanging on the tilted pole yesterday (2/28/19), but she does not normally touch the pole because the feeding is always hung by the evening nurse. She stated that she was asked by the Nurse Manager to collect another pump yesterday when the other pole was noted bent, and that the pump was fine its only the pole that was bent. RN#7 further stated she only noticed the bent pole yesterday when she was asked to go for another one. On 03/01/19 at 12:35 PM, an interview was conducted with the Nurse Manager/Registered Nurse (RN #3). RN#3 stated she noticed the pump was leaning yesterday and called for another pole and pump to replace it. RN#3 also stated nobody brought it to her attention the pole is bent but only noticed it yesterday when she went to the room to answer the call light for the resident's room mate who had called for assistance. It was then she observed the pole was bent over and immediately called for a new pump and pole because the screw connecting the pump to the pole was also noted to be loose and difficult to tighten. RN#3 further stated when she makes daily rounds, she checks on the residents, but does not normally go in to every room to check the equipment unless there is an issue to be taken care of, or if a resident calls for attention, as she also covers other units. On 03/04/19 at 09:22 AM, an interview was held with the Unit Charge Nurse/Registered Nurse (RN #4) who was in charge on 2/26/19. RN#4 stated that she has been working on the 3rd floor units for 4 years, most of the time on the 3 NW, but also oversees the East side if there is any urgent issues that requires RN attention like if there is a fall, or if any resident needs IV to be inserted. RN #4 stated that she takes the reports in the morning and makes rounds on the West side while the LPN assigned to the East unit makes round of the residents on the unit and report any abnormal findings to her if noted. RN#4 stated that no one ever reported that the pump in the resident's room is bent or needed to be replaced. On 03/04/19 at 02:15 PM, an interview was held with the Licensed Practical Nurse (LPN #2), who worked 7 AM to 3 PM on the unit on 2/26/19. LPN stated that the pump was noted to be shaky but did not think that the pump needed to be changed as it was still functioning well. LPN #2 stated that she cannot recall how long the pole and the pump had been like that. She stated that the feeding is normally hung by the 3-11 nursing staff, and she only removes the bottle and flushes resident's feeding tube in the morning after the feed is completed. On 03/04/19 at 02:54 PM, a telephone interview was held with the Registered Nurse (RN #5) who worked 11 PM to 7 AM on the unit on 2/26/2019 and 2/27/2019. RN #5 stated that he could not remember seeing the pump loosely hung on the bent feeding pole or tied to the oxygen gauge. RN#5 stated that resident gets medication via feeding tube and that treatment is also done for the resident during his tour. He stated that he was off for some days and just came back and did not really observe that the pump was bent but noticed that a new pump was there last night (2/28/19) when he worked. 415.5(h)(2)

Plan of Correction: ApprovedApril 1, 2019

A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message.

Standard Life Safety Code Citations

K307 NFPA 101:HORIZONTAL SLIDING DOORS

REGULATION: Horizontal-Sliding Doors Horizontal-sliding doors permitted by 7.2.1.14 that are not automatic-closing are limited to a single leaf and shall have a latch or other mechanism to ensure the door will not rebound. Horizontal-sliding doors serving an occupant load fewer than 10 shall be permitted, providing all of the following criteria are met: o Area served by the door has no high hazard contents. o Door is operable from either side without special knowledge or effort. o Force required to operate the door in the direction of travel is less than or equal to 30 lbf to set the door in motion and less than or equal to 15 lbf to close or open to the required width. o Assembly is appropriately fire rated, and where rated, is self-closing or automatic-closing by smoke detection per 7.2.1.8, and installed per NFPA 80. o Where required to latch, the door has a latch or other mechanism to ensure the door will not rebound. 19.2.2.2.10

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: March 5, 2019
Corrected date: N/A

Citation Details

The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes that waiver(s) to be continued. Include your request for renewal of this waiver, or plan of correction in the space provided on this form. K224, S/S=B The facility has not provided evidence that the horizontal sliding doors to resident family lounge are compliant NFPA [PHONE NUMBER]: 7.2.1.14, 7.2.1.8, 19.2.2.2.10 NYCRR 711.2(a)(1), 483.70(a)

Plan of Correction: ApprovedMarch 15, 2019

K224
The Facility respectfully requests a continuation of this waiver.
Physical conditions have not changed since last survey.