Park Ridge Nursing Home
May 16, 2017 Certification Survey

Standard Health Citations

FF10 483.60(i)(1)-(3):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 16, 2017
Corrected date: July 12, 2017

Citation Details

Based on observations, interviews, and record reviews, conducted during the Recertification Survey, it was determined that for one (Cottage #100) of four residential cottages, the facility did not store and prepare food under sanitary conditions. Specifically, food items were not hot-held at an appropriate temperature. This is evidenced by the following: Observations on 5/15/17 at 12:15 p.m. revealed a plate of chicken patties on the counter next to the range in the kitchen of Cottage #100. In an interview at that time, a Cook/Kitchen Worker (CKW) stated that she had taken the chicken patties out of the oven about five to ten minutes ago. She said the chicken patties are going to be served for lunch. The CKW stated that the lunch service does not start until 12:30 p.m. The surveyor then asked the CKW to take the temperature of the patties. The dial-type thermometer showed 125 degrees Fahrenheit. The CKW said she was not sure about hot holding temperatures. She stated that she was not instructed or told about hot holding temperatures. (10 NYCRR 415.15(h), 14-1.40(a))

Plan of Correction: ApprovedJune 9, 2017

F371 483.60 (i)(1)-(3) Food Procure, Store/Prepare/Serve ? Sanitary
1. Identified staff member and all current front line staff members responsible for the cooking and serving of food in this cottage were immediately re- educated on cooking and food preparation process and the Food Temperature Policy.
Responsible Party: Food/Dining Manager or Designee
Date: 5/15/2017
2. All other cottages were reviewed by the Food/Dining Manager for accurate and proper hot-held procedures. This review did not identify any areas out of compliance, however, all staff responsible for cooking and serving of food will receive mandatory re-education.
Responsible Party: Food/Dining Manager or Designee
Date: 6/17/2017
3. The Food Temperature Policy was reviewed. The Daily Food Production logs were revised to include hot-held temperature range. All staff responsible for cooking and serving of food will be educated on the Food Temperature Policy, which includes hot holding procedures and the addition of the recommended hot held temperature range to the Daily Food Production logs.
Responsible Party: Food/Dining Manager or Designee
Date: 6/17/2017
4. On a weekly basis a random audit during scheduled mealtimes within all four cottages will be completed to ensure compliance with proper hot-holding temperatures.
Responsible Party: Food/Dining Manager or Designee
Date: 7/12/2017
5. Compliance will be monitored utilizing the quality audit process review. Results of the weekly audit will be submitted to the QIE (Quality, Infection Control and Education) RN who will review the results, evaluate, and address any variation to compliance and ensure continued adherence to the established policies. Results will be reported to the PRLC QAPI Committee for a minimum of 6 months. The QAPI Committee will determine the scope and duration of the audits based on the results of the findings.
Responsible Party: QIE RN/designee
Date: 7/12/2017

FF10 483.10(d)(3)(g)(1)(4)(5)(13)(16)-(18):NOTICE OF RIGHTS, RULES, SERVICES, CHARGES

REGULATION: (d)(3) The facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. §483.10(g) Information and Communication. (1) The resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. (g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including: (i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes - (A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section; (B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act. (C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and (D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.) [§483.10(g)(4)(ii) will be implemented beginning November 28, 2017 (Phase 2)] (iii) Information regarding Medicare and Medicaid eligibility and coverage; [§483.10(g)(4)(iii) will be implemented beginning November 28, 2017 (Phase 2)] (iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program; [§483.10(g)(4)(iv) will be implemented beginning November 28, 2017 (Phase 2)] (v) Contact information for the Medicaid Fraud Control Unit; and [§483.10(g)(4)(v) will be implemented beginning November 28, 2017 (Phase 2)] (vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives: (i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and (ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community. (g)(13) The facility must display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. (g)(16) The facility must provide a notice of rights and services to the resident prior to or upon admission and during the resident?s stay. (i) The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. (ii) The facility must also provide the resident with the State-developed notice of Medicaid rights and obligations, if any. (iii) Receipt of such information, and any amendments to it, must be acknowledged in writing; (g)(17) The facility must-- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in paragraphs (g)(17)(i)(A) and (B) of this section. (g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident?s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility?s per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility?s per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident?s date of discharge from the facility. v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: May 16, 2017
Corrected date: June 9, 2017

Citation Details

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #4) of three closed records reviewed for resident rights, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries in order to notify them of their appeal rights under the regulation. Specifically, the facility did not issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or denial letter at the termination of the Medicare Part A benefits. This is evidenced by the following: Resident #4 was discontinued from Medicare Part A services on 12/29/16 and continued to remain in the facility under custodial care. There is no evidence that a SNFABN or denial letter was provided to the resident or their representative informing them of their potential liability for payment. During a telephone interview on 5/15/17 at 1:45 p.m., the representative from the Patient Billing Department stated that she was unable to find evidence that the resident or representative had received a SNFABN or denial letter notifying them of their rights to appeal Medicare non-coverage. (10 NYCRR 415.3(g)(2)(i))

Plan of Correction: ApprovedJune 9, 2017

F156 483.10(d)(3)(g)(1)(4)(5)(13)(16)-(18) Notice of rights, rules, services, charges
1. Resident received Notice of Medicare Non-coverage (NOMNC) on 12/27/16 when determined her discharge date was to be on 12/29/16 to home with services. On 12/28/16 the home care agency determined they could not provide adequate home services and declined services. At that time determination was made that the resident would remain in the TCC with Medicaid as the primary payor source. The resident did not receive the Advance Beneficiary Notice (ABN) at this time; however the resident was not liable for charges due to primary payor source being Medicaid. There were no negative consequences to the resident.
Responsible Party: MDS Coordinator
Date: 5/15/17
2. The facility has identified residents with a Medicare Part A stay could potentially be impacted by this deficient practice. All current residents on Medicare Part A with a discharge date were reviewed for appropriate liability and appeal notices. There were no other findings of missing liability and appeal notices. Process for issuing liability and appeal notices was reviewed with Social Work and MDS Nurses.
Responsibility: MDS Coordinator
Date: 5/17/17
3. Medicare Notice of Non-Coverage Policy and Procedure reviewed to assure applicability. Social Work and MDS staff will be re-educated using the current policy and procedure which includes the issuing of the Advanced Beneficiary Notice to patients 48 hours prior to discharge.
Responsible Party: MDS Coordinator
Date: 7/10/17
4. Residents with Medicare A coverage will be audited for proper issuing of the NOMNC (Notice of Medicare Non-Coverage) and ABN (Advanced Beneficiary Notice) within the required time. This audit will be completed on a weekly basis by the MDS Coordinator.
Responsible Party: MDS Coordinator or designee
Date: 7/1/17 and ongoing
5. Compliance will be monitored utilizing the quality audit process review. Results of the weekly audit will be submitted to the QIE (Quality, Infection control and Education) RN who will review the results, evaluate, address any variation to compliance and ensure continued adherence to the established policies. Results will be reported to the PRLC QAPI Committee for a minimum of 6 months. The QAPI Committee will determine the scope and duration of the audits based on the results of the facility and MDS Coordinator findings.
Responsible Party: MDS Coordinator and QIE (Quality Infection Control and Education) Nurse
Date: 7/12/17 and ongoing

FF10 483.24, 483.25(k)(l):PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 16, 2017
Corrected date: July 12, 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 #295) of one [MEDICAL TREATMENT] resident reviewed for quality of care, the facility did not provide the necessary interventions to attain or maintain the resident's highest practicable well- being. The issues involved the lack of fluid monitoring and a thorough daily care assessment of the fistula. This is evidenced by the following: Resident #295 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current Comprehensive Care Plan (CCP) documented that the resident is on a 1,200 cubic centimeter (cc) fluid restriction, and to check the fistula every shift for bruit and thrill (sounds used to evaluate patency of tube). Review of the Medication/Treatment Administration Record (MAR/TAR), dated 4/15/17 through 5/25/17, included an entry to check the left arm fistula bruit and thrill every shift and a 1,200 cc fluid restriction. The resident's fluid intake was not recorded on the MAR/TAR. Review of the Intake and Output Records, dated 4/25/17 through 5/12/17, revealed that the resident's fluid intake was recorded at meals (breakfast, lunch and dinner). Physician orders dated 4/27/17 included a 1,200 cc fluid restriction orally. Review of the Nursing Progress Notes, dated 5/1/17 through 5/15/17, documented that the bruit and thrill checks were completed. A Nursing Progress Note, dated 5/15/17, documented that the resident's band aid was reapplied to the fistula [MEDICAL TREATMENT] needle site due to leaking when removed. The Minimum Data Set Assessment, dated 5/2/17, revealed that the resident is cognitively intact. During an observation on 5/12/17 at 8:02 a.m., a sign posted by the resident's door read, Fluid restriction and to check with the nurse. At 2:09 p.m., a large Styrofoam cup with liquid, an unopened soda (Sunkist), and a plastic cup with Jello were observed on the resident's bedside table. Interviews conducted on 5/12/17 included the following: a. At 2:14 p.m., a Licensed Practical Nurse (LPN) stated the resident did not have a fluid restriction. She stated the resident's fistula was checked every day for bruit/thrill. The LPN said she would ensure the resident's fistula site was not bulging the day after a [MEDICAL TREATMENT] treatment. The LPN said she did not know how long the dressing to the fistula site should stay in place after a [MEDICAL TREATMENT] treatment. The LPN stated there would be a physician order for [REDACTED]. After review of the MAR, the LPN stated the resident is on a fluid restriction. She said fluids consumed by the resident would be entered into the electronic record. b. At 2:48 p.m., the Registered Nurse Manager (RNM) stated when a resident is on a fluid restriction, dietary determines the amount of fluids to be allotted on the meal trays and the amount of fluids allotted for nursing. She said dietary monitors the resident's fluid intake. She said the nurses should report shift to shift on the amount of fluids the resident consumed and the amount remaining. c. At 2:55 p.m., the Registered Dietician (RD) stated that the facility has a policy on fluid restrictions. She said dietary provides 75 percent of the allowed fluids and nursing 25 percent. The RD said she monitored the fluids provided by dietary. Interviews conducted on 5/15/17 included the following: a. At 8:55 a.m., the resident stated she was keeping track of the fluids she drank. b. At 12:57 p.m., the RN stated the fistula site should be monitored for signs of infection and bleeding after [MEDICAL TREATMENT]. The RN stated that when the resident returns from [MEDICAL TREATMENT], the dressing to the fistula site remains in place for 48 hours. She stated that the [MEDICAL TREATMENT] nurse instructed the nursing staff when to remove the dressing and there should be an entry on the TAR. After review of the TAR, the RN stated there is no entry for the dressing removal. The RN said that monitoring the fistula site for bleeding, signs of infection and removal of the dressing should be part of the resident's plan of care. The RN stated that dietary informs nursing of the amount of allowed fluids. The RN said she did not know who was responsible for assigning the allotted nursing fluids to each shift. She stated the resident's assigned nurse should monitor fluids in the care tracker (electronic documentation) and communicate to the next shift the resident's fluid intake and the amount of fluids remaining for consumption. c. At 1:16 p.m., the [MEDICAL TREATMENT] Director of Nursing stated residents receiving [MEDICAL TREATMENT] are on fluid restrictions. She said the expectation is that the facility is monitoring fluid intake. She said the fistula site dressing is removed 24 hours after a [MEDICAL TREATMENT] treatment. She said the facility should be following their policy for care of the fistula site. Review of the facility policy, Standards of Calculations and Definitions, dated (MONTH) (YEAR) for fluid restrictions, revealed that a provider order is written for fluid restrictions unless otherwise specified, nursing is allotted 25 percent of the allowed fluids and the Dietary Department is allotted the other approximate 75 percent. Nursing records the resident's consumption of fluids in Care Tracker, and RD or Diet Technician reviews the information during follow up assessments. Review of the undated facility policy, [MEDICAL TREATMENT], revealed that when the resident arrives back to the facility after [MEDICAL TREATMENT], the RN or LPN must take vital signs, check the [MEDICAL TREATMENT] and document appropriately. Bandages need to be removed from the fistula site 24 hours after a [MEDICAL TREATMENT] treatment to decrease the risk for infection to the fistula site. Nurses must check and document the [MEDICAL TREATMENT] dressing every shift and document appropriately. The policy revealed all [MEDICAL TREATMENT] residents will be on a fluid restriction unless otherwise noted. Nurses and Certified Nursing Assistants are to document all fluids given to a [MEDICAL TREATMENT] resident in the electronic documentation system. (10 NYCRR 415.12)

Plan of Correction: ApprovedJune 9, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F309 483.24, 283.25 (k)(l)Provide Care/Services for Highest Well Being
1. Identified TCC resident?s plan of care was reviewed to determine appropriate documentation of fluid restrictions and fistula site checks to assure that interventions were initiated. The following interventions were clarified: every day documentation of fistula site to include bruit, thrill and appearance of site; fluid intake to be completed on a hard copy intake and output form and placed in the red book (plan of care) in resident?s room; careplan and treatment administration record updated to reflect changes.
Responsible Party: TCC Nurse Manager
Date: 5/15/17
2. All residents on fluid restriction or [MEDICAL TREATMENT] were reviewed for accurate documentation of fluid restrictions (intake) and/or fistula. One resident was identified as having a [MEDICAL TREATMENT] fistula and three residents were on fluid restrictions. Each of these residents care plans were reviewed and revised to accurately reflect care needs.
Responsible Party: TCC Nurse Manager
Date: 5/16/2017
3. Current [MEDICAL TREATMENT] Policy reviewed and revised to include detailed fistula site care and required documentation. All licensed nursing staff to be educated on [MEDICAL TREATMENT] policy. In addition, preprinted treatment sheets will be implemented for [MEDICAL TREATMENT] patients.
Current fluid restriction guidelines noted in the Diet Manual were reviewed with clinical dietician. Determination made that fluid monitoring policy specific to clinical staff is established. All licensed clinical staff and certified nursing assistants to be educated on fluid monitoring policy.
Responsible Party: Director of Nursing,/Quality, Infection, Education Coordinator (QIE) or designee
Date: 7/16/17
4. On a monthly basis an audit of all [MEDICAL TREATMENT] residents will be completed to ensure compliance of [MEDICAL TREATMENT] and fluid monitoring procedures to include fistula site assessment and documentation; fluid intake and documentation are compliant with policy.
Responsible Party: Director of Nursing/Nurse Manager/designee
Date: 7/1/17 and ongoing
5. Compliance will be monitored utilizing the quality audit process review. Results of the monthly audit will be submitted to the QIE (Quality, Infection control and Education) RN who will review the results, evaluate, address any variation to compliance and ensure continued adherence to the established policies. Results will be reported to the PRLC QAPI Committee for a minimum of 6 months. The QAPI Committee will determine the scope and duration of the audits based on the results of the facility and Nurse Manager findings.
Responsible Party: Quality, Infection, Education Coordinator (QIE) /designee
Date: 7/12/17 and ongoing

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 16, 2017
Corrected date: June 9, 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 #105) of one resident reviewed for bowel incontinence, the facility did not ensure care was provided in accordance with the resident's written plan of care. Specifically, physician orders [REDACTED]. This is evidenced by the following: Resident #105 has [DIAGNOSES REDACTED]. A Minimum Data Set Assessment, dated 4/21/17, revealed that the resident is cognitively intact, dependent on staff for toileting and incontinent of bowels. Physician orders, dated 4/25/17, included [MEDICATION NAME]-S (a combination stool softener and laxative) two tablets every evening for constipation. Additionally, to follow a bowel protocol if the resident goes 9 shifts (72 hours) with no bowel movement. The bowel protocol includes to give [MEDICATION NAME] (laxative) 30 milliliters by mouth times one. If no results after eight hours or if resident refuses, give [MEDICATION NAME] 10 milligrams suppository times one rectally. If no results in two hours or resident refuses, then give a saline enema, and if no results then notify the physician or Nurse Practitioner (NP). The Nursing Care Plan, dated 2/25/17, included that the resident is at risk for altered hydration status related to irregular bowel movement patterns at times and a [DIAGNOSES REDACTED]. The Care Plan does not include any history of resident refusals of medically prescribed medications or treatments. Review of the Point of Care Bowel Movement Report and the Medication Administration Records revealed that from 3/16/17 through 5/14/17, the resident had five episodes of no documented bowel movements for greater than 9 shifts (72 hours) and the bowel movement protocol was not started. These included the following: a. From 3/18/17 to 3/22/17, the resident did not go within 12 shifts (96 hours). b. From 3/22/17 to 3/26/17 and 3/27/17 to 3/31/17, the resident did not go within 13 shifts (104 hours). c. From 4/15/17 to 4/21/17, the resident did not go within 19 shifts (152 hours). d. From 4/27/17 to 5/2/17, the resident did not go within 15 shifts (120 hours). Review of the Interdisciplinary Progress Notes and the No Bowel Movement Report for the same time periods, revealed that on 4/18/17 and 4/21/17, the resident refused the [MEDICATION NAME] as documented by the Licensed Practical Nurse (LPN). There was no documentation of any suppository or enema offered or that the medical team was notified on any of the occasions of refusals. The most recent Medical Progress Note, dated 4/17/17 and signed by the NP, includes a [DIAGNOSES REDACTED]. Interviews conducted on 5/15/17 included the following: a. At 12:11 p.m., the Certified Nursing Assistant stated that the resident is totally dependent on staff for toileting and is incontinent of bowels. She added that sometimes the resident goes days without a bowel movement. b. At 1:31 p.m., the LPN stated that every morning staff are to print a No Bowel or Small Bowel Movement in Last 9 Shifts (72 Hours) Report and initiate the bowel protocol. She said if the resident still does not go, then the NP is notified. She said that the resident sometimes refuses the [MEDICATION NAME] and staff are to document this in a Progress Note. c. At 2:23 p.m., and again on 5/16/17 at 8:24 a.m., the Registered Nurse Manager stated that she expects staff to re-approach a resident if they refuse or try a different caregiver. She said if neither approach works then the NP should be notified. She said that the resident is incontinent and does not always know when she needs to go. Review of the current facility policy, Bowel Management Protocol, includes that if a resident has not had a bowel movement in the last 9 shifts (72 hours) , as per the No Bowel Movement Report, the evening nurse will administer the laxative as ordered and the day staff will follow up on the results. If no results, the medical team will be notified. (10 NYCRR 415.11(c)(3)(ii))

Plan of Correction: ApprovedJune 9, 2017

F282 483.21(b)(3)(ii)Services by qualify persons/per care plan
1. Identified Resident in cottage 400 was assessed and Nurse Practitioner was notified to review current individual bowel protocol. Based on medical review and history of refusing prescribed bowel protocol, assessment and interview of Resident, Nurse Practitioner discontinued current bowel protocol in order to individualize her preference and normal bowel routine. Resident?s plan of care was updated to reflect changes to bowel regime.
Responsible Party: Cottage Nurse Manager
Date: 5/15/17
2. All residents were reviewed to identify acceptance of prescribed bowel protocol. This review did not identify any further residents out of compliance with the bowel protocol. Upon further investigation, determination was made that this was an isolated incident related to Resident making choices to fit her preference of bowel management.
Responsible Party: Cottage Nurse Manager
Date: 5/15/17
3. Medication Administration Policy and Bowel Management Protocol reviewed. Bowel Management Algorithm reviewed and revised to include ?If resident refuses bowel protocol, document in medical record and notify provider of refusal.? In addition, Bowel Management Algorithm will be added as an attachment to the Bowel Management Protocol. All nursing staff will be educated using the revised Bowel Management Protocol and Algorithm.
Responsible Party: Director of Nursing /Quality, Infection Control, Education (QIE) Coordinator
Date: 7/12/17
4. On a weekly basis a random audit of 10% of census will be completed to ensure compliance of bowel protocol to include BM monitoring report, refusal of BM protocol and documentation of bowel protocol results.
Responsible Party: Nurse Managers/QIE/designee
Date: 7/12/2017
5. Compliance will be monitored utilizing the quality audit process review. Results of the weekly audit will be submitted to the QIE (Quality, Infection control and Education) RN who will review the results, evaluate, address any variation to compliance and ensure continued adherence to the established policies. Results will be reported to the PRLC QAPI Committee for a minimum of 6 months. The QAPI Committee will determine the scope and duration of the audits based on the results of the facility and Nurse Manager findings.
Responsible Party: QIE RN/designee
Date: 6/17/17 and ongoing