Wayne County Nursing Home
October 9, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 9, 2018
Corrected date: December 9, 2018

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 #237) of two residents reviewed for transmission based precautions, the facility did not implement a person-centered care plan to reflect the needs of each resident. The issue involved the lack of care planning for a resident on isolation precautions for an infection. This is evidenced by the following: Resident #237 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/2/18, revealed the resident was cognitively intact. Record review revealed the resident was readmitted to the hospital on [DATE] following a fall and [MEDICAL CONDITION]. The Social Work note, dated 9/5/18, revealed that she was contacted by a family member who reported that the resident tested positive for [MEDICAL CONDITION] ([MEDICAL CONDITION], bacteria that causes diaherria and inflammation of the colon) and will need a private room. The resident was readmitted to the facility on [DATE], and [MEDICAL CONDITION] was added to the resident's [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The nursing admission note, dated 9/8/18, revealed the resident had loose stool but not [MEDICAL CONDITION]. A Nurse Practitioner note, dated 9/18/18, documented that the resident was found to have [MEDICAL CONDITION] on 9/5/18. The Comprehensive Care Plan (CCP), the Baseline Care Plan, and the Certified Nursing Assistant (CNA) Care Plan do not include any information regarding the resident having a [MEDICAL CONDITION] infection. During an observation on 10/4/18 at 9:21 a.m., the resident's door had a STOP before entering sign with instructions to report to the nurse before entering the room, contact precautions, gloves and gown required, remove before leaving room, and to use soap and water to wash hands before and after patient contact. A cart containing gloves, gowns and equipment was also in the hall by the door to the room. When interviewed at that time, the resident said she developed [MEDICAL CONDITION] in the hospital and was still having symptoms. When interviewed on 10/5/18 at 12:37 p.m., the charge Registered Nurse (RN) said the resident has [MEDICAL CONDITION] and is on isolation precautions. She said the RN Manager (RNM) completes the care plans. When interviewed on 10/5/18 at 12:53 p.m., the RNM said the resident's CCP should include the [MEDICAL CONDITION] infection, goals, and approaches. She said the CNA Care Plan should have a green star on it to show that the resident has an infection. After checking the CNA Care Plan, a green star was present. The RNM said the green star alerts the CNA that there is an infection, but not the type of infection or location. The RNM said that specific information regarding the infection should be on the CCP. When interviewed on 10/9/18 at 10:26 a.m., the RNM said two other RNs were learning to complete care plans and did not add the resident's [MEDICAL CONDITION] infection. She said the resident's [MEDICAL CONDITION] infection should have been added to the CCP. The facility policy for CCP, last revised (MONTH) (YEAR), includes the CCP committee will meet weekly and as needed to formulate a CCP for newly admitted residents. The CCP should have the needs and problems identified, including goals and approaches to reflect the relationship to the problem. (10 NYCRR 415.11(c)(1))

Plan of Correction: ApprovedOctober 25, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. For resident #237, the comprehensive care plan (CCP) was updated to reflect isolation precautions for [MEDICAL CONDITION].
B. A facility- wide sample audit will be conducted to assess the CCP for completeness and accuracy of the measureable objectives to meet resident?s medical, nursing and mental needs. RN will be assigned to review random samples of CCP. If an inaccuracy is found, the RN/MN/designee will correct the CCP.
C. Education Nurse will include CCP goals and objectives in the upcoming Education Fair. 12/9/2018
D. Education Nurse will conduct a monthly CCP audit for 3 months and report results at quarterly QA.
E. Completion Date: 12/9/18, Responsible Staff: Coordinator of Education

FF11 483.25(i):RESPIRATORY/TRACHEOSTOMY CARE AND SUCTIONING

REGULATION: § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 9, 2018
Corrected date: December 9, 2018

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 #86) of one resident reviewed for respiratory care, the facility did not provide proper respiratory treatments and/or care consistent with professional standards of practice. The issues involved an incomplete physician order [REDACTED]. Resident #86 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/1/18, revealed the resident had moderately impaired cognition and received oxygen therapy. The Comprehensive Care Plan, dated 8/14/18, revealed that the resident was at risk for hypoxic (lack of enough oxygen in tissues) episodes due to a history of pleural effusions (build-up of fluid between tissues that line the lungs and chest), and the need for oxygen supplement. The goal was to maintain oxygen saturation level at or over 92 percent, and for interventions the care plan directed to review the standing orders on the Treatment Administration Record (TAR) and Medication Administration Record. Physician orders, dated 7/26/18, included to obtain oxygen saturation levels every shift and if oxygen saturation levels were below 92 percent, apply oxygen via nasal cannula. There was no oxygen liter flow documented in the order. That order was scheduled for each shift. The oxygen was discontinued on 9/19/19\8 and reordered that same day, and included the previous order but was scheduled as needed versus every shift. A physician note, dated 8/16/18, revealed the resident's oxygen saturation levels were 96 percent on 2 liters of oxygen via nasal cannula. The (MONTH) (YEAR) TAR included to obtain oxygen saturation levels every shift and if the oxygen saturation level was below 92 percent, apply oxygen at liters via nasal cannula. There was no lifter flow documented. Staff signed off each shift through the morning of 9/19/18. The (MONTH) (YEAR) TAR, from 9/19/18 through 9/30/18, and the (MONTH) (YEAR) TAR included the same oxygen order but was scheduled as needed versus every shift and was not signed off as completed. Review of the Oxygen Saturation Levels Report, from 9/6/18 through 10/5/18, revealed that the levels were documented on four occasions on the day shift (9/10/18, 9/17/18, 9/24/18, and 10/1/18) and ranged between 94 percent and 99 percent. When observed intermittently on 10/2/18, 10/3/18, 10/5/18, and 10/9/18, the resident was receiving oxygen at 2 liters via nasal cannula continuously. During an interview on 10/5/18 at 1:43 p.m., a Licensed Practical Nurse (LPN) stated that if a resident uses oxygen, she would check oxygen saturation levels, monitor for shortness of breath, and monitor facial color and nail beds. The LPN said that monitoring oxygen saturation levels would require a physician order. She reviewed the resident's oxygen order, dated 9/19/18, and then stated the order was not transcribed correctly. The LPN said it was transcribed as needed and it should have been transcribed to check oxygen saturation level every shift routinely. When interviewed on 10/9/18 at 9:47 a.m., a Registered Nurse (RN) stated that the resident received oxygen continuously at 2 liters per minute. The RN that transcribed the physician order [REDACTED]. She stated that staff should observe the resident for shortness of breath, complaints of shortness of breath, and/or changes in the resident's color. She said that should all be included in the care plan. The RN reviewed the CCP and stated it did not include specific respiratory interventions. During an interview on 10/9/18 at 1:00 p.m., a Nurse Practitioner stated orders for oxygen should include the liter flow. She stated nurses should be checking and documenting oxygen saturation levels as ordered and monitoring the resident's respiratory status. (10 NYCRR 415.12(k)(6))

Plan of Correction: ApprovedOctober 25, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. For resident #86, updated physician orders [REDACTED].
B. A facility- wide sample audit will be conducted on all residents with oxygen orders; if an inaccuracy is found then corrections will be made at time of the finding.
C. Education Nurse will include obtaining oxygen orders, monitoring and documentation in the upcoming Education Fair. 12/9/2018
D. Education Nurse will conduct a monthly CCP audit for 3 months and report results at quarterly QA.
E. Completion Date: 12/9/2018, Responsible Staff: Coordinator of Education

Standard Life Safety Code Citations

K307 NFPA 101:AISLE, CORRIDOR, OR RAMP WIDTH

REGULATION: Aisle, Corridor or Ramp Width 2012 EXISTING The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5. 19.2.3.4, 19.2.3.5

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 9, 2018
Corrected date: December 9, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the Life Safety Code Survey, it was determined that for four of four resident sleeping wings, the facility did not maintain egress pathways. Specifically, furniture projected too far into the egress corridor or was not affixed to the floor or wall. The findings include: Observations conducted on 10/1/18 between 8:04 a.m. and 10:55 a.m. revealed furniture in the following locations that was not affixed to the floor or wall: In the Ontario Trail Wing: a. There were two armchairs in the corridor next to Resident room [ROOM NUMBER] on Salmon Run. In an interview at that time, the Facility's Director stated that he is just learning the furniture in the corridor requirements. b. There were two armchairs in the corridor next to Resident room [ROOM NUMBER]. In the Chimney Bluff Wing: a. There was one armchair and one reclining chair at the entrance to Lighthouse Lane next to Resident room [ROOM NUMBER]. b. There was an armchair at the entrance to Sand Bar Lane. In the Deer Run Wing: a. There was a love seat and armchair at the entrance to(NAME)Hollow Lane. b. There were two armchairs at the entrance to Blue Bird Lane. c. There was an armchair next to Resident room [ROOM NUMBER]. d. There was an armchair next to Resident room [ROOM NUMBER]. In the Barge Boulevard Wing: a. There was a love seat at the entrance to Bridge Lane. b. There was an armchair next to Resident room [ROOM NUMBER]. In the Erie Way Wing: a. There were two armchairs at the entrance to Drydock. b. There was one armchair at the computer work station on Drydock. c. There was an armchair at the computer work station next to Resident room [ROOM NUMBER]. In the Rose Ridge Wing: a. There were three chairs in the corridor of Peace Lane. b. There were three chairs in the corridor of Petal Lane. In the Herb Hollow Wing: a. There were three armchairs in the corridor of [MEDICATION NAME] Lane. b. There were four armchairs in the corridor of Peppermint Lane. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.3.4)

Plan of Correction: ApprovedNovember 1, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A.
In the Ontario Trail Wing:
a. There were two armchairs in the corridor next to Resident room [ROOM NUMBER] on Salmon Run. These two armchairs were removed.
b. There were two armchairs in the corridor next to Resident room [ROOM NUMBER].These two armchairs will be affixed to the wall.
In the Chimney Bluff Wing:
a. There was one armchair and one reclining chair at the entrance to Lighthouse Lane next to Resident room [ROOM NUMBER]. This armchair and recliner will be affixed to the wall.
b. There was an armchair at the entrance to Sand Bar Lane. The armchair will be affixed to the wall.
In the Deer Run Wing:
a. There was a love seat and armchair at the entrance to(NAME)Hollow Lane. The love seat and armchair will be affixed to the wall.
b. There were two armchairs at the entrance to Blue Bird Lane. The two armchairs will be affixed to the wall.
c. There was an armchair next to Resident room [ROOM NUMBER]. The armchair will be affixed to the wall.
d. There was an armchair next to Resident room [ROOM NUMBER]. The armchair will be affixed to the wall.
In the Barge Boulevard Wing:
a. There was a love seat at the entrance to Bridge Lane. The loveseat will be affixed to the wall.
b. There was an armchair next to Resident room [ROOM NUMBER]. This armchair will be removed.
In the Erie Way Wing:
a. There were two armchairs at the entrance to Drydock. The two armchairs will be affixed to the wall.
b. There was one armchair at the computer work station on Drydock. This chair will be replaced with a chair with no arm handles.
c. There was an armchair at the computer work station next to Resident room [ROOM NUMBER].This chair will be replaced with a chair with no arm handles.

In the Rose Ridge Wing:
a. There were three chairs in the corridor of Peace Lane. One chair will be removed and two will be affixed to the wall.
b. There were three chairs in the corridor of Petal Lane. One chair will be removed and two will be affixed to the wall.
In the Herb Hollow Wing:
a. There were three armchairs in the corridor of [MEDICATION NAME] Lane. One armchair will be removed and two armchairs will be affixed to the wall.
b. There were four armchairs in the corridor of Peppermint Lane. Three armchairs will be removed and one will be affixed to the wall.

B. Maintenance Director will conduct a facility-wide audit of all corridors to ensure all furniture is properly affixed and/or removed to meet exit access requirements. 12/2/2018
C. All staff will be educated on exit access requirements and newly created policy in the upcoming mandatory Education Fair. Facility policy will be created to ensure that staff is following the proper procedures when not using the chairs at the documentation stations. 12/9/2018
D. Maintenance Director/designee will conduct a monthly audit for 3 months of all corridors and report at quarterly QA.
E. Responsible Party: Maintenance Director. Date of Completion: 12/9/2018

K307 NFPA 101:HVAC

REGULATION: HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications. 18.5.2.1, 19.5.2.1, 9.2

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 9, 2018
Corrected date: December 9, 2018

Citation Details

Based on interviews and record reviews conducted during the Life Safety Code Survey, it was determined that for two of two resident sleeping floors, the facility did not maintain smoke and fire dampers. Specifically, the facility could not provide documentation of a damper inspection. The findings include: A review of facility records on 10/2/18 at 1:01 p.m. revealed no record of smoke or fire damper inspection. In an interview at that time, the Facility's Director stated that he was unable to find anything (damper inspection records). In an interview on 10/4/18 at 2:18 p.m., the Administrator stated that they were unable to find any damper inspection records. The 2012 Edition of NFPA 90A: Standard for the Installation of Air-Conditioning and Ventilating Systems states that fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. The 2010 Edition of NFPA 80: Standard for Fire Doors and Other Opening Protectives states that the test and inspection frequency shall then be every four years, except in hospitals, where the frequency shall be every six years. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.5.2.1, 9.2; 2012 NFPA 90 A: 5.4.8.1)

Plan of Correction: ApprovedOctober 24, 2018

a. Maintenance Director contacted licensed vendor on getting the inspections conducted on the smoke and fire dampers. Pricing and scope of work to be submitted to the facility by the licensed vendor. 10/26/2018
b. Maintenance Director and licensed vendor will conduct a facility wide review and inspection of all fire and smoke dampers. 12/9/2018
c. Maintenance Director will update current policies/procedures and department records to make sure fire and smoke dampers inspections are conducted every (4) years are required by NFPA.
d. Maintenance Director will report results at quarterly QA meeting.
e. Responsible Staff: Maintenance Director.
Date of Completion: 12/9/2018