Fort Hudson Nursing Center, Inc.
May 8, 2018 Complaint Survey

Standard Health Citations

FF11 483.20(a):ADMISSION PHYSICIAN ORDERS FOR IMMEDIATE CARE

REGULATION: §483.20(a) Admission orders At the time each resident is admitted, the facility must have physician orders for the resident's immediate care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 8, 2018
Corrected date: July 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during an abbreviated (Case # NY 083), the facility did not ensure that at the time each resident is admitted , the facility had physician orders for the resident's immediate care for 1 resident (Resident #3) of three residents reviewed. Specifically, for Resident #3's readmission to the facility following surgery for [REDACTED]. This is evidenced by: Resident #3: The resident was admitted to the facility on [DATE], and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. The Adaptive Medical Devices Policy and Procedure (undated), defined Medical Devices to include slings and immobilizers. All medical devices need an accompanying physician order that clearly stated what the device was to be used for, and when it was to be on or off. The hospital Transfer/Discharge Summary dated 8/31/17 at 2:30 pm, documented the resident had a brace to right lower extremity. The hospital General Discharge Orders and Instructions, dated 8/31/17 at 5:00 pm, documented a sling to right upper extremity (RUE) and a dry sterile dressing to the right hip daily. The admission orders [REDACTED]. A Physician's Order Note dated 9/1/17 at 10:22 am, written by RNUM #1, documented the Medical Doctor (MD) assessed the resident and reviewed the chart for readmission. No new orders were received. A Provider Illness Visit dated 9/11/17 at 9:09 am, written by the Nurse Practitioner (NP), documented the resident was wearing a KI, and noted a wound on the the lower portion of the back part of the resident's right leg. The wound (position) was located right over where one of the metal stays in the KI was. The upper portion of the right hip incision was slightly reddened around it and it had some purulent discharge (pus) that was to be cultured. The resident was started on an antibiotic. A Nurses Note dated 9/12/17 at 12:09 pm, written by RNUM #1, documented the RNUM assessed the resident's right heel and right lateral thigh area. The right thigh area had an open area consistent with the placement of a bar in the KI rubbing against it. The right heel had a fluid filled intact blister. The Orthopedic follow-up visit note dated 9/13/17, by MD #3 documented the resident had a deep pressure ulcer on the back of the right leg with dry, black skin. The KI was discontinued. The resident had some redness at the top of the surgical wound on the RLE and was on an antibiotic. Continue monitoring the [MEDICAL CONDITION] (the infection at the surgical wound site) and the prescribed antibiotic. During an interview on 3/8/18 at 11:41 am, RNUM #1 stated the resident had returned from the hospital on [DATE] with a leg brace following a femur fracture. RNUM #1 stated she usually looks at hospital records to have them ready for the MD. Nothing stood out about the KI. RNUM #1 did not catch the fact that the resident had an immobilizer in place, without orders or directions for care. RNUM #1 stated that another RN did the admission and she had not double checked the orders. Audits were done at night by the RNS. During an interview on 3/14/18 at 1:53 pm, RNUM #2 stated that upon admission or readmission of a resident from the hospital, the hospitals discharge summary, history and physical, consults, and labs were reviewed. RNUM #1 would look for any big questions. MD orders were needed for KI, slings, splints, etc. Orders need to have directions for the removal to provide care, and the frequency to be removed. She stated the 11:00 pm-7:00 am RNS did audits for admissions/readmission to check for completeness of orders and documentation. The results were provided to the RNUM and Director of Nursing (DON). During an interview on 3/15/17 at 2:29 pm, RNUM #1 stated there should have been an order for [REDACTED].#1 stated I missed it. RNUM #1 did not always review discharge orders from a facility because the RNS should be doing it, and again, the night RNS did audits. During an interview on 3/15/18 at 3:19 pm, the Assistant Director of Nursing (ADON) stated Nursing, PT and Occupational Therapy (OT) all missed that there was no order for the KI, the sling, or the dressing for the surgical wound. During an interview on 3/15/18 at 4:07 pm, the DON stated RNUM #1 took report from the hospital. The DON would expect the RNUM to check for orders. During an interview on 5/2/18 at 10:40 am, the Medical Director stated the facility should obtain as many records as possible from a transferring facility to reconcile care and medications. The MD writes the initial admission orders [REDACTED]. Frequently, the MD needs to get specific MD orders from the surgeons for resident post-operative care. The RN should have called the surgeon to clarify the orders, and once clarification was received, call the facility MD. Somebody should have clarified with the hospital. Many pieces for the resident's care were missed that led to the outcome. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance related to MD order for adaptive devices and was in substantial compliance at the time of this survey: - Facility audit of all residents with adaptive devices was conducted to ensure that an active order, care card and care plan were in effect; - The Admission/Re-Entry Checklist use by staff responsible for the admission of residents was revised to include the items required when admitting residents with adaptive devices (MD order, care plan/care card with instruction regarding the care of adaptive devices); - Reeducation of all RNs, PTs and Occupational Therapists (OT) on the facility policy/procedures for adaptive devices; - Auditing of all new/readmitted residents with adaptive devices for compliance with policies/ procedures by RNS on night shift. Audits result forward to QAPI committee on monthly basis for 6 months. 10 NYCRR 415.11

Plan of Correction: ApprovedJune 12, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #3 no longer resident at the facility. Remediation was completed with RNUM #1 and RNS.
2. Current residents admitted to the facility with a surgical wound, since 12/11/17 will have physicians orders audited to verify a treatment order was/is in place for immediate care of a surgical wound.
3. All RN Mgrs/Supervisors will be re-mediated on the purpose of the Admission/Re-Entry Checklist and what corrective actions are expected of them should they identify a discrepancy between discharge orders and the resident?s current physician orders.
4. All residents with a new surgical wound will have their chart audited for an active physician order [REDACTED].
Responsible Party: Director of Nursing Services

FF11 483.25(k):PAIN MANAGEMENT

REGULATION: §483.25(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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 8, 2018
Corrected date: July 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during an abbreviated survey (Case # NY 083), the facility did not 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 resident' goals and preferences for 1 (Resident #3) of 3 residents reviewed. Specifically, for Resident #3, who had severe cognitive impairment, the facility did not assess the resident for pain upon readmission on 8/31/17 post hospitalization for a fractured arm and surgical repair of a fractured leg. Additionally, the facility did not routinely evaluate or monitor for pain or the potential for pain. The Admission Note dated 8/31/17, Evaluations and Plans of treatment for [REDACTED]. This is evidenced by: Resident #3: The resident was admitted to the facility on [DATE], and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. The facility's Policy and Procedure for Pain Management (undated) documented that upon readmission a pain assessment will be completed, a care plan will be established when the assessment indicates a need for pain management and pain documentation will include the intensity, location, and level of relief following PRN (as needed) administration. The P&P documented that evaluations for pain staggered across all shifts were to be done weekly and the results documented on the Medication Administration Record (MAR). The Comprehensive Care Plan (CCP) initiated on 4/1/15 for the potential to demonstrate verbally abusive behaviors related to dementia, included an intervention revised on 3/27/17 to assess and anticipate the resident's needs. Evaluate for comfort level and pain. The CCP did not include a revision or update regarding the resident's comfort or pain upon readmission to the facility on [DATE]. The hospital Transfer Discharge Summary dated 8/31/17, documented [MEDICATION NAME] (Tylenol) 325 mg, 2 tablets every 4 hours as needed for mild pain or headache and [MEDICATION NAME] (narcotic pain medication), 5 mg every 4-6 hours as needed for moderate to severe pain. The admission orders [REDACTED]. The Admission Note dated 8/31/17 at 10:35 pm, written by the Registered Nurse Supervisor (RNS), documented the resident was readmitted to the facility at 7:15 pm and had discomfort only on movement. Review of the CCP's in the medical record did not include a care plan for pain or the potential for pain. The Medication Administration Record (MAR) dated 8/31/17, documented physician orders [REDACTED]. The MAR did not include documentation that as needed Tylenol was given. The Admission/Re-Admission Assessment form dated 8/31/17 at 10:55 pm, written by the Registered Nurse Supervisor (RNS), included a Section for completion of an assessment for pain. The pain assessment section was blank. The Medication Administration Record (MAR) dated 8/1/17-8/31/17 documented weekly pain evaluations staggered between the three shifts. The Occupational Therapy (OT) Evaluation and Plan of Treatment dated 9/1/17 at 5:14 pm, written by the OT, documented the resident had mild pain at rest, severe pain to the right arm when touched and right leg pain when the OT moved it. The pain assessment method used was based on the resident's behaviors and having cried out that it hurt. After a change in position the resident would state it was better. It documented the pain limited the resident's functional activities. The OT assessed the resident's ability to be aware of, and feel pain was intact. The Physical Therapy (PT) Evaluation and Plan of Treatment dated 9/1/17 at 5:24, written by the (PT), documented mild pain at rest, and severe pain with movement of the resident's right leg. The pain was described as sharp and quick. The MAR dated 9/1/17 - 9/30/17, documented the resident received 650 mg of [MEDICATION NAME] twice for pain on 9/1/17 at 6:28 am for a pain level of 7 and at 10:46 am for a pain level of 4. The MAR for the above time period did not include documentation that evaluations for pain staggered across all shifts were done. The Pain Assessment Interview section of the MDS dated [DATE], for the Indicators of Pain or Possible Pain for the past 5 days (9/2/17-9/7/17), documented the resident had vocal complaints of pain. A Nurses Note dated 9/21/18 at 4:31 pm, written by Licensed Practical Nurse (LPN) #3, documented the resident did not have pain on the weekly pain evaluation for the evening shift. During an interview on 4/30/18 at 11:41 am, the Physical Therapist (PT) stated the resident had behaviors, and pain could have made them worse. The resident's inability to fully cooperate with therapy could have been related to pain. During an interview on 3/14/18 at 1:53 pm, RNUM #2 stated pain assessments should be completed and documented when a resident is readmitted . Residents pain should be assessed every shift for seven days. During an interview on 3/15/18 at 3:19 pm, the Assistant Director of Nursing (ADON) stated a pain assessment was supposed to be done when a resident was readmitted . During an interview on 4/30/18 at 11:47 am, Registered Nurse Unit Manager (RNUM) #1 stated pain assessments were completed upon residents' admissions, readmissions, and quarterly. RNUM #1 stated she did not know why a pain assessment was not done when the resident was readmitted . The RNUM stated it was the responsibility of the RNUM to ensure admission/readmission assessments were completed. A pain assessment was to be done 48-72 hours after the resident arrived at the facility. Upon admission, residents were supposed to have pain assessments every shift for 7 days. There should have been a care plan for pain. During an interview on 5/1/18 at 10:32 am, the Director of Nursing (DON) stated a pain evaluation should be done at the time a resident is admitted or readmitted to the facility. She stated there should have been a Potential for Pain care plan implemented. During an interview on 5/2/18 at 10:40 am, the Medical Director stated pain could be difficult to assess in residents with dementia. Staff should be aware of changes in a resident's behaviors. During a phone interview on 5/2/18 at 2:01 pm, the DON stated the standing orders for pain evaluations was in the order section of the electronic medical record. The nurse must click on the box for the weekly pain evaluations. They must also click on the option for pain evaluations to be done every 4 hours for seven days for admissions and readmissions. The evaluations for a seven-day timeframe were done to establish a baseline for the residents' pain levels. The RNUM forgot to pull up the template to access the orders for the pain evaluations. 10 NYCRR 415.12

Plan of Correction: ApprovedJune 12, 2018

1. Resident #3 no longer resident at the facility.
2. All admissions within the last 6 months, who are still residents of the facility, will have their medical record reviewed to assure there was an initial pain assessment completed and an associated care plan established for pain, if indicated.
3. All admitting RN's will be re-educated regarding the policy to assess and care plan for identified pain upon admission and readmission.
4. All new admissions/re-admissions, per the Admission/Re-Entry Checklist, will be audited to ensure there is an order to assess for pain q 4 hours for 7 days and an associated care plan for pain if indicated by this assessment, 100% for 6 months. Results will be submitted to the QAPI Committee for review monthly; Auditing frequency may be amended by Committee after 6 months.
Responsible Party: Director of Nursing Services

FF11 483.25:QUALITY OF CARE

REGULATION: § 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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 8, 2018
Corrected date: July 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview during an abbreviated survey (Case #NY 083), the facility did not ensure that 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 to maintain the highest practicable physical well-being for one (Resident #3) of three residents reviewed. Specifically, upon Resident #3's readmission to the facility post hospitalization , the facility did not identify that the resident had a surgical wound, a knee immobilizer, and an arm sling. This resulted in a lack of treatment and care for the resident's surgical wound, knee immobilzer (KI) for repair of leg fracture and arm sling for fractured arm from 9/1/17-9/11/17. This is evidenced by: Resident #3: The resident was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. The Admission Policy and Procedure (P&P) revised on 6/15/12, documented the Registered Nurse (RN) would initiate an assessment that included the skin, pressure ulcer risk, pain, and cognition within 4 hours after the resident arrived at the facility. A care plan should be implemented based on the assessment findings. The policy and procedure (P&P), for Pressure Ulcer and Wound Care Policy (undated), documented the facility would ensure residents received wound care consistent with their needs and recognized standards of practice to promote optimal healing of wounds or prevent deterioration. The resident would be assessed weekly by a Registered Nurse (RN) and the assessment findings documented. The Adaptive Medical Devices P&P (undated), documented that medical devices included slings, braces, and immobilizers. The Comprehensive Care Plan (CCP) and/or Certified Nursing Assistant (CNA) Care Card should address the care of, maintenance for, and measures to prevent excessive pressure on body sites related to the medical device. The hospital General Discharge Orders and Instructions dated 8/31/17 at 5:00 pm, documented instructions to apply a dry sterile dressing to the right hip daily and that the resident had an arm sling. The admission orders [REDACTED]. An Admission Note dated 8/31/17 at 10:35 pm, written by the Registered Nurse Supervisor (RNS), documented the resident's right arm was in a sling, and the dressing to the right lower extremity (RLE) from the hip, to just below knee was dry and intact. Review of the medical record did not include a CCP for the resident's arm sling, surgical wound and knee immobilizer or a care plan following the discovery of an infection at the surgical site. Review of the resident's CCPs did not include a care plan for the resident's arm fracture with sling, surgical wound and KI. The CNA care card did not include instructions for the CNAs to follow to provide care for the resident's fractured arm and sling and immobilizer. A Provider Illness Visit dated 9/11/17 at 9:09 am, written by the Nurse Practitioner (NP), documented that the upper portion of the right hip incision was slightly reddened and had some purulent discharge (pus). A wound culture was ordered and the resident was started on an antibiotic. A Wound Tracking flowsheet was initiated on 9/11/17. The column on the flowsheet for surgical wound checks were blank. There were no other wound tracking flowsheets in the medical record. An orthopedic follow-up visit note dated 9/13/18, written by MD #3, documented to continue monitoring the [MEDICAL CONDITION] (skin infection) and the antibiotic for treatment of [REDACTED]. During an interview on 3/8/18 at 11:41 am, the RNUM #1 stated she did not double check orders when another RN did the readmission. The night RNS did audits for readmissions to ensure assessments, orders, etc. were complete. During an interview on 3/12/18 at 2:27 pm, CNA #1 stated approximately 10 days after the resident's return from the hospital, greenish-yellow drainage was noted on the pillow under the resident's right leg and the drainage was reported to the Licensed Practical Nurse (LPN) #2. During an interview on 3/15/17 at 2:29 pm, RNUM #1 stated there should have been an order for [REDACTED]. She did not always review discharge orders from a facility because the RNS should be doing it, and again, the night RNS did audits. During an interview on 3/15/18 at 4:07 pm, the Director of Nursing (DON) stated she expected that RNUM #1 would have reviewed the hospital discharge summary and instructions, obtain orders for the resident's care, and start a care plan. During an interview on 5/2/18 at 10:40 am, the Medical Director stated the facility should obtain records from a transferring facility to reconcile care and medications. The MD writes the initial admission orders [REDACTED]. Many pieces for the resident's care were missed that led to the outcome. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance related to MD order for adaptive devices and was in substantial compliance at the time of this survey: - Facility audit of all residents with adaptive devices was conducted to ensure that an active order, care card and care plan were in effect; - The Admission/Re-Entry Checklist use by staff responsible for the admission of residents was revised to include the items required when admitting residents with adaptive devices (MD order, care plan/care card with instruction regarding the care of adaptive devices); - Reeducation of all RNs, PTs and Occupational Therapists (OT) on the facility policy/procedures for adaptive devices; - Auditing of all new/readmitted residents with adaptive devices for compliance with policies/ procedures by RNS on night shift. Audits result forward to QAPI committee on monthly basis for 6 months. 10 NYCRR 415.12

Plan of Correction: ApprovedJune 12, 2018

1. Resident #3 no longer resident at the facility. Remediation was completed with RNUM #1 and RNS.
2. Current residents admitted to the facility with a surgical wound, since 12/11/17 will have care plan audited to verify a care plan was/is in place for immediate care of a surgical wound.
3. All RN Mgrs/Supervisors will be re-mediated on the purpose of the Admission/Re-Entry Checklist and what corrective actions are expected of them should they identify a discrepancy between discharge orders and resident plan of care.
4. All residents with a new surgical wound will have their chart audited for an active care plan, 100% for 6 months. Results will be submitted to the QAPI Committee for review monthly; Auditing frequency may be amended by Committee after 6 months.
Responsible Party: Director of Nursing Services

FF11 483.25(b)(1)(i)(ii):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER

REGULATION: §483.25(b) Skin Integrity §483.25(b)(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: Actual harm has occurred
Citation date: May 8, 2018
Corrected date: October 19, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview during an abbreviated survey (Case # NY 083), the facility did not ensure that based on the comprehensive assessment, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers (PU) and does not develop pressure ulcers for one (Resident #3) of three residents reviewed. Specifically, for Resident #3, the facility did not identify the resident's risk factors for the development of a pressure ulcer from the use of a medical device (knee immobilizer); Additionally, preventative interventions to reduce or remove the risk were not implemented upon the resident's readmission to the facility post hospitalization for a fractured leg. The knee immobilizer was not removed for 10 days from 8/31/17 through 9/11/17 resulting in an avoidable pressure ulcer. This is evidenced by: Resident #3: The resident was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. The Policy and Procedure (P&P) (undated) for Adaptive Medical Devices (sling, braces, splints, immobilizers) documented that medical devices must have a physician order that clearly states what the medical device is used for and when the device should be applied and removed. The Preventative Skin Care P&P dated as revised on 6/2012, documented the facility will maintain a system in which positioning devices (immobilizer) are routinely evaluated for pressure reduction/relief. The hospital Transfer/Discharge Summary dated 8/31/17 at 2:30 pm, documented the resident had a brace and mild swelling to the right lower extremity (RLE). admission orders [REDACTED]. A Nurses Note dated 8/31/17 at 10:54 pm, written by the Registered Nurse Supervisor (RNS), documented a brace was in place to the resident's right lower extremity (RLE). The Nursing Admission/Re-Admission Assessment skin assessment dated [DATE] at 10:55 pm, written by the RNS, did not include whether the skin under the KI had been assessed. A Nurses Note dated 9/1/17 at 2:57 am, written by Licensed Practical Nurse #1 (LPN), documented a leg immobilizer was in place on the right leg. The CNA (certified nursing assistant) Care Card dated 9/1/17, documented the resident had a knee immobilizer. The Comprehensive Care Plan (CCP) dated 10/30/14, documented that the resident has the potential for pressure ulcer development related to immobility. The care plan did not include a documented update to reflect a KI following the resident's readmission to the facility on [DATE]. A Provider Progress Note dated 9/1/17 at 3:33 pm, written by Medical Doctor (MD) #1, documented the resident's RLE was [MEDICAL CONDITION] (swollen) from the injury and surgery. A Provider Illness Visit dated 9/11/17 at 9:09 am, written by the Nurse Practitioner (NP), documented the resident had a KI on, and had a wound on the posterior (back part) lower portion of the right calf right over (the area) where one of the metal stays in the KI was. The ulcer measured 4.0 cm x 3.0 cm and had dry, necrotic (dead) material or slough (dead tissue) at the center. A Skin/Wound Note dated 9/11/17 at 10:08 am, written by the RNUM, documented the resident had a 4 cm x 3 cm area of eschar (dead tissue) on the posterior right calf, with no drainage/odor and consistent with the placement of a bar in the KI. The CCP created and initiated on 9/11/17, for the pressure ulcer on the posterior right calf did not include the KI on the resident's RLE. The CNA Care Card was revised on 9/11/17, did not include directions for the CNAs to provide care for the resident's KI. A Therapy Note dated 9/12/17 at 4:44 pm, written by the Physical Therapist (PT), documented that on 9/11/17, during the resident's therapy session, a red area was observed on the side of the resident's right shin. The KI was loosened to inspect the skin and a huge blackened area due to pressure from brace was found. The area was reported to the RNUM on 9/11/17. A Nurses Note dated 9/12/17 at 12:09 pm, written by RNUM #1, documented she was asked to assess the resident's right heel and right lateral thigh area. The right thigh area had a Stage 2 pressure ulcer that measured 1 cm x 1 cm. The area was consistent with placement of a bar in the KI rubbing against it. The right heel had a 4 cm x 4 cm fluid filled intact blister. An Orthopedic follow-up visit note dated 9/13/17, written by MD #3, documented the resident had a full thickness pressure ulcer on the posterior right leg with dry eschar. The knee immobilizer was discontinued. A Physician's Order Note dated 9/13/17 at 12:34 pm, written by the RNUM, documented the resident returned from an orthopedic appointment with a new order to discontinue the KI. A Nurses Note dated 9/20/17 at 12:22 pm, written by the RNUM, documented the resident had a 4 cm x 3 cm area of eschar on the posterior part of his right calf. The right lateral thigh wound was resolved. A Provider Progress Note dated 9/28/17 at 2:32 pm, written by MD #2, documented an open area with necrotic appearing tissue about 4.0 cm x 6.0 cm on the right lateral calf at the location of where a rod was located on the KI brace. An Orthopedic follow-up visit note dated 10/6/17, written MD #3, documented the resident had a deep pressure ulcer on his right leg, with lateral tendon and muscle exposed. The MD was sending the resident to the hospital to be evaluated by wound care and plastic surgery. Wound culture results from the resident's leg wound dated 10/9/17, documented [MEDICAL CONDITION] resistant Staphylococcus (MRSA) (bacterium with antibiotic resistance). A Plastic Surgery consult dated 10/7/17, written by the plastic surgeon, documented the resident had a stage 4 pressure ulcer to his right lateral lower leg. During an interview on 3/8/18 at 11:41 am with RNUM #1 regarding the resident's 8/31/17 readmission, the resident returned from the hospital with a leg brace following a femur fracture. It was true RNUM #1 did not identify the fact an immobilizer was in place without any orders or directions for care. The care plan and CNA Care Card were not updated, but should have been. RNUM #1 did not recall any CNAs questioning the immobilizer. If they had, RNUM #1 would have checked into it. RNUM #1 was unaware the resident had the KI until 9/11/17, when it was removed and there was a pressure area on the resident's right calf. The resident was seen by the NP. Had they been aware of the rod rubbing the calf area sooner, the pressure ulcer may have been prevented. During an interview on 3/12/18 at 2:27 pm, CNA #1 stated the resident had a KI. CNA #1 provided care by cleaning area around the immobilizer. There were no directions for how to care for the resident's KI, so CNA #1 did not remove it. During an interview on 3/14/18 at 3:18 pm, the RNS stated the resident's readmission skin assessment was completed however, the KI was not removed to inspect the skin under it. During an interview on 3/15/18 at 2:02 pm, MD #2 stated the location of the pressure ulcer on the resident's right calf was consistent with the location of a rod in the immobilizer. During an interview on 3/15/18 at 3:19 pm, the Assistant Director of Nursing stated Nursing, PT and Occupational Therapy (OT) all missed that there was no physician order for [REDACTED]. During an interview on 3/15/18 at 4:07 pm, the Director of Nursing stated RNUM #1 took report from the hospital. The resident returned to the facility on the 3:00 pm-11: pm shift. There were no orders from the hospital for the knee immobilizer. There should have been one obtained for the KI and the surgical wound dressing. The DON would expect the RNUM to check for orders. During an interview on 3/19/18 at 2:10 pm, the NP stated the ulcer was on the bottom of the right calf, right where one of the metal stays in the KI was. The NP would expect staff to open the immobilizer, check the skin, and clean the area. During an interview on 4/18/18 at 4:01 pm, MD #3 stated the resident was treated for [REDACTED]. On the 9/13/17 post-operative visit a severe pressure ulcer on the RLE was found. MD #3 expected that the nurse would have called him to clarify the use and instructions regarding the care of the KI. KIs were used for stability and to protect the surgical wound. Staff would need to check the skin under the KI at least daily. [MEDICAL CONDITION] in the RLE could have increased the risk for the development of the pressure ulcer. The resident's medical record did not include a documented history of [MEDICAL CONDITION] or arterial insufficiency (both conditions that can impair circulation and lead to wounds). The wound was consistent with a pressure ulcer and clinically avoidable if regular repositioning and skin checks had been done. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: - Facility audit of all residents with adaptive devices was conducted to ensure that an active order, care card and care plan were in effect; - The Admission/Re-Entry Checklist use by staff responsible for the admission of residents was revised to include the items required when admitting residents with adaptive devices (MD order, care plan/care card with instruction regarding the care of adaptive devices); - Reeducation of all RNs, PTs and Occupational Therapists (OT) on the facility policy/procedures for adaptive devices; - Auditing of all new/readmitted residents with adaptive devices for compliance with policies/ procedures by RNS on night shift. Audits result forward to QAPI committee on monthly basis for 6 months. NYCRR 415.12(c)(1)

Plan of Correction: ApprovedJuly 2, 2018

Past non-compliance. No P(NAME) required.