Boro Park Center for Rehabilitation and Healthcare
December 6, 2017 Complaint Survey

Standard Health Citations

FF10 483.10(g)(14):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)

REGULATION: (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2017
Corrected date: January 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during an abbreviated survey (Complaint #NY 153), the facility did not ensure that a resident representative was notified of a change in status for 1 out of 5 residents reviewed (Resident #1). Specifically, Resident #1's tube feeding formula rate was lowered due to a leaking jejunostomy feeding tube (J tube). Intravenous Fluid (IVF) was ordered and recommendations were made by a physician (MD #2) during the late evening on [DATE] to transfer Resident #1 to the hospital. Resident #1's next of kin was not notified. Resident #1 passed away in the facility on [DATE] at 4:48 PM as indicated on the Certificate of Death. The findings include: The Facility Policy on Transfers dated ,[DATE] documented that a resident may be transferred to the hospital, emergency department if their needs cannot be met on site. Nurse's instructions in the policy included that the nurse would verify and obtain an order from the physician that the resident was to be transferred out of the facility and to notify family of resident's change in condition and verify the decision to transfer resident to the hospital. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS, an assessment tool) dated [DATE], the resident had a BIMS (Brief Interview for Mental Status used to determine attention, orientation and ability to recall information) score of 9 out of 15, associated with moderate impairment (,[DATE] Severe impairment, ,[DATE] Moderate impairment & ,[DATE] Cognitively intact). According to the resident's medical record face sheet, a family representative was designated as the primary contact for the resident. A doctor's progress note dated [DATE] at 11:27 AM documented that Resident #1 was examined at the bedside with episodes of confusion, the tip of the J tube noted to be leaking and universal adapter was attached to the tip of the tube. A nurse's note dated [DATE] at 6:23 PM documented upon starting the tube feeding, the J tube was leaking at the base. Medical Doctor #2 (MD #2) notified, and ordered the feeding rate lowered. MD #2 to follow up. A nurse's note dated [DATE] at 9:54 PM documented J tube leaking upon administering water as ordered. The RNM (Registered Nurse Manager) notified MD #2 who again ordered the feeding rate lowered and to apply absorbent dressing until seen by him (MD #2). An Order Listing Report dated [DATE] documented on order to provide IV fluids used to maintain minerals and electrolytes. Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC), Urine Analysis and Urine Culture ordered for Altered Mental Status. A nurse's note dated [DATE] at 11:31 PM documented that Resident #1's gown and bed linen were wet from the leaking tube feeding. The tube was leaking from the insertion site. The RNM and MD #2 were on the unit at 11:30 PM and were aware. Intravenous Fluid (IVF) started as per ordered. A nurse's note dated [DATE] at 11:38 PM documented that Resident #1 was observed sleeping in bed with the J tube leaking at the suture line (at the abdominal insertion site) and that MD #2 examined Resident #1. The nurse also documented Awaiting approval for transfer to the hospital from the Medical Director. A Transfer to Acute Hospital Form dated [DATE] documented that the reason for the transfer was gastrostomy status and evaluation. A Change In Medical Condition - SBAR document dated [DATE] documented that MD #3 was informed of some leakage around the stoma site (at the abdominal opening). An order was given to transfer Resident #1 to the emergency room (ER) with diagnosis gastrostomy status. The nurse also documented that MD #3 visited and held the transfer order. A General Documentation Note dated [DATE] at 8:33 AM documented that Resident #1 in bed appeared weak. IV fluids were infusing. The tube feeding was held due to leakage around the stoma. As per ongoing nurse, MD #3 was notified and assessed Resident #1, no leakage noted and ordered to resume feeding. A Comprehensive Care Path note dated [DATE] at 10:55 AM documented that Resident #1 was alert and verbally responsive, but continued to appear weak. MD #3 aware. An Order Listing Report dated [DATE] documented that CBC and CMP lab tests were ordered. There was no documented evidence that a designated representative was notified of the changes in Resident #1's status and associated treatment plan. Lab results dated [DATE] documented the following (Ref Range): White Blood Cells 15.7 (4XXX,[DATE].8), Hemoglobin 10.7 (13XXX,[DATE].0), Hematocrit 36 (,[DATE]), Blood Urea Nitrogen (BUN) 133 (,[DATE]), Creatinine 2.01 (0XXX,[DATE].50) and Sodium 159 (,[DATE]). (Elevated BUN, Creatinine and Sodium values can be indicative of compromised hydration and/or kidney function). A General Documentation Note dated [DATE] at 5:07 PM documented Resident #1's companion reported that Resident #1 does not look well. Resident #1 was observed with absence of vital signs. Code Blue was announced, Cardiopulmonary Resuscitation CPR) initiated and 911 called. Resident #1 was pronounced dead at 5:05 PM. The Director of Nursing Service (DNS) was interviewed on [DATE] at 2:23 PM, she stated that Resident #1's next of kin should have been notified of the changes in status. She further stated that the nursing supervisor could have called the family or delegated the responsibility to another nurse to call and inform the family. 415.15(b)(2)(iii)

Plan of Correction: ApprovedJanuary 2, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. The facility cannot retroactively correct this deficiency due to resident #1 no longer at facility.

MD #2 was in-serviced on notifying family representative of resident?s change in condition
2. All resident with change in condition have the potential of being affected by this deficient practice
A review was initiated from [DATE], (YEAR) and is on-going to identify residents with change in condition, documentation and notification of resident representative to ensure notification of change in status.
Any findings will be immediately addressed.
3. The policy and procedure titled ?Change in Resident?s Condition or Status? which references the practice of Family notification with changes in resident?s medical/mental condition and/or status was reviewed and no changes were necessary.
Education for all Licensed staff on the policy and procedure ?Change in Resident?s Condition or Status was initiated and is on-going.
License staff will initiate a new order note for any new order obtained relating to change in condition and resident will be placed on the communication report.
4.DON or designee will conduct audits on 30% of residents who have experienced a change in condition weekly x 2 weeks, then bi-weekly x 4 weeks, then monthly x3.
The results of the audits with corrective actions will be reported at the QA meeting monthly.

5. Person Responsible - DNS

FF10 483.30(b)(1)-(3):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDERS

REGULATION: (b) Physician Visits The physician must-- (1) Review the resident?s total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; (2) Write, sign, and date progress notes at each visit; and (3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2017
Corrected date: January 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated survey (Complaint # NY 153), the facility did not ensure that a physician supervised medical care in the absence of an attending physician and provided orders for immediate care, including transfer to a hospital, and wrote, signed and dated progress notes at each visit, for 1 of 5 residents sampled (Resident #1). Specifically, Medical Doctor #2 (MD #2), examined Resident #1 on two occasions and did not document resident status or MD recommendations in Resident #1's medical record. In addition, MD #2 recommended transfer of Resident #1 to the hospital. MD #2 did not write a doctor's order for transfer, did not direct staff to transfer the resident and did not take necessary steps to accomplish transfer of the resident to the hospital. The findings include: The Facility Policy on Charting and Documentation with a revised date of (MONTH) 2008 stated that all observations and services performed must be documented in the resident's clinical record. The Facility Policy on Transfers dated 08/2016 documented that a resident may be transferred to the hospital, emergency department if their needs cannot be met on site. The policy included nurse's instructions for the nurse to verify and obtain an order from the physician that the resident is to be transferred out of the facility and to notify family of resident's change in condition and verify the decision to transfer the resident to the hospital. The policy also documented that the physician will order the transfer to an acute hospital or emergency department. Document assessment, probable diagnosis, treatment plan, resident response to treatment and the reason for the transfer. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS an assessment tool) dated 10/12/2016, Resident #1 had a BIMS (Brief Interview for Mental Status used to determine attention, orientation and ability to recall information) score of 9 out of 15, associated with moderate impairment (00-07 Severe impairment, 08-12 Moderate impairment & 13-15 Cognitively intact). A physician's note written by MD #1, the resident's attending physician, dated 10/06/2016 at 9:12 AM documented that MD #2 (a [MEDICATION NAME] (GI)), examined Resident #1 for a leaking J tube (jejunostomy feeding tube surgically inserted through the abdomen). Recommendations were made for lab tests and to consider CT scan of the abdomen and pelvis. There was no documented evidence, and the facility provided no evidence, that MD #2 documented progress notes for the visit. A General Documentation nurse's note dated 10/13/2016 documented that MD #2, who was the physician covering the resident's care in the absence of MD #1, ordered lab tests including Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP). There was no documented evidence that MD #2 completed progress notes to address the indication for, or further recommendations based on, the ordered lab tests. A General Documentation nurse's note dated 10/14/16 at 6:23 PM documented that, upon starting tube feeding, the J tube was noted to be leaking at the base. MD #2 was notified, ordered the feeding rate to be lowered and will follow up. There was no documented evidence that MD #2 completed progress notes to address the issue or the intervention ordered. A Comprehensive Care Path nurse's note dated 10/14/2016 at 11:31 PM documented that formula was infusing by the feeding tube and Resident #1's gown and bed linens were wet from the leaking tube feeding. The tube was leaking from the insertion site. The Registered Nurse Manager (RNM) and MD #2 were on the unit at 11:30 PM and were aware. Intravenous Fluid (IVF) started per order. A General Documentation Note written by the RNM dated 10/14/2016 at 11:48 PM documented that Resident #1 was observed sleeping in bed with leaking J tube at the suture line and that MD #2 examined Resident #1. The RNM documented that, Awaiting approval for transfer to the hospital from Medical Director. There was no evidence that MD #2 documented examination findings, interventions, recommendations or an order to transfer the resident to the hospital. A Transfer to Acute Hospital Form dated 10/15/2016 was completed by an RN and documented to transfer to the hospital for gastrostomy tube status and to evaluate. The resident was not transferred to the hospital. A Change In Medical Condition - SBAR document dated 10/15/2016 and entered at 10:28 AM was completed by an RN and documented that MD #3 was informed of some leakage around the stoma (abdominal opening) site. An order was given to transfer Resident #1 to the emergency room (ER) with [DIAGNOSES REDACTED].#3 visited and held the transfer order. Order Listing Reports from 10/14/2016 through 10/15/2016 revealed that an order was not written for the transfer on 10/14/2016 or 10/15/2016 and an order was not written to hold the transfer on 10/15/2016. MD #2 was interviewed on 07/10/2017 at 12:27 PM via telephone. He stated that he covered for MD #1 for a few days. He affirmed that on 10/06/2016 MD #1 asked him to come see Resident #1. He stated that he examined Resident #1 on 10/06/2016 and the J tube was leaking and not working well. He verbalized that the J tube was beyond the scope of his expertise, not a tube for a GI doctor. MD #2 stated that, I don't deal with a J tube often. He also stated that he recommended that Resident #1 be evaluated by radiology or surgery. He stated that he adjusted the feeding to 30cc/hr. MD #2 responded to a question regarding the documentation of his examination and recommendation. He stated that he did not document in Resident #1's medical record. MD #2 responded to a question regarding his examination and recommendation of Resident #1 on 10/14/2016. He stated that he examined Resident #1 for the leaking tube and recommend transfer to the hospital. He further stated that he spoke with the RNM instructing her to call the Medical Director or the on-call physician for a decision. Upon inquiry, MD #2 stated I was the covering physician, I am not required to write a doctor's order. When MD #2 was asked if he had documented his examination and recommendation in Resident #1's medical record, he stated, No. The RNM was interviewed on 07/11/2017 at 2:04 PM via telephone. She stated that on 10/14/2016 (she did not remember the time) MD #2 examined Resident #1 for the leaking J tube and verbalized that that the tube needs to be fixed in the hospital. She further stated that MD #2 verbalized that he was not able to do anything for the tube. She affirmed that MD #2 stated that Resident #1 needed to be transferred to the hospital, but that MD #2 did not write an order to transfer Resident #1. The RNM also stated that the Medical Director has the final call. She also stated that MD #2 stated that he tried to contact the Medical Director, but the Medical Director did not respond. She stated at approximately 11:00 PM on 10/14/2016, she called the Medical Director, but he did not respond. She added at approximately 11:30PM she informed the Registered Nurse Supervisor (RNS) that the feeding tube was leaking and that she wanted to transfer Resident #1, but she was waiting for the Medical Director to call back. MD #1 was interviewed on 10/30/2017 at 5:54 PM. via telephone. MD #1 stated that he asked MD #2 to look at Resident #1 and MD #2 evaluated Resident #1 on 10/06/2016 at the bedside. MD #1 responded to a question regarding the responsibilities of a covering physician. He stated that the covering physician is responsible for the total care of the residents. He further stated that the covering physician can write or give telephone orders and transfer a resident to the hospital if needed. MD #3 was interviewed on 10/26/2017 at 6:00 PM via telephone. She stated that she no longer worked at the facility, did not recall the resident and could not give any information. The former Medical Director, who was the Medical Director on 10/14/2016 and 10/15/2016, was interviewed on 10/26/17 at 10:26 AM. He responded to a question regarding the responsibilities of the covering physician and the attending primary physicians. He stated that a covering physician is responsible for the total care of the resident which includes writing a doctor's order to transfer a resident to the hospital. He further stated that he was available to the physicians to discuss resident care including transfers to the hospital. He added that a physician does not need to wait for a response from him to transfer a resident to the hospital. He stated that it is up to the physician or covering physician to transfer a resident. He stated that he would like to know when a resident is being transferred out of the facility. The Medical Director also stated that it is standard medical practice for a physician to document their examination and interventions performed in a resident chart. He stated that he was not aware MD #2 was not documenting in Resident #1's medical record. He stated that MD #2 or MD #3 could have written the transfer order. 415.15(b)(2)(iii)

Plan of Correction: ApprovedJanuary 2, 2018

1. The facility cannot retroactively correct this deficiency due to resident #1 no longer being in the facility.
The MD #2 was in-serviced on:
Initiating a progress note to reflect physician visit and the plan of care for the resident.
Writing a physician?s order to reflect intended plan of care
2. All residents have the potential to be affected by this deficient practice.
Audits were initiated for the month of (MONTH) (YEAR) for all residents on attending and covering physician?s documentation and orders in the resident?s chart reflecting each visit and or change in the resident?s plan of care. These audits are ongoing.
All findings will be immediately addressed.
3. The Policy and procedure titled, ?Attending Physician Responsibility?, which reviews covering MD, Consults, and doctors? orders was reviewed and no changes were necessary.
The policy and procedure titled ?Orders for Consultants? was reviewed and no changes were necessary.
Education was initiated and is on-going for all medical staff regarding
? Documenting a progress note reflecting resident?s status and medical recommendation orders for each patient visit.
? Content of the Policy and Procedures, Attending Physician Responsibility.
4. The Medical Director will audit 25% of residents medical visits for documentation of visit and the writing of orders for recommendations when applicable weekly x 2 weeks, then bi-weekly x4 weeks, then monthly x 4 months
The Medical Director or designee will report findings of audit to the QA committee monthly
5. Person Responsible - DNS

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: Actual harm has occurred
Citation date: December 6, 2017
Corrected date: January 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated survey (Complaint # NY 153), the facility did not ensure that services were provided in accordance with professional standards of quality, nursing and medical practice in order to prevent potential delay in [DIAGNOSES REDACTED].#1). Specifically, Resident #1 had multiple Doctor's Orders that were not carried out including orders for lab tests of blood and urine and scheduling for an outpatient surgical appointment. Additionally, Medical Doctor #2 (MD #2), examined Resident #1 on two occasions and did not document resident status or MD recommendations in Resident #1's medical record. MD #2 also recommended transfer of Resident #1 to the hospital. MD #2 did not write a doctor's order for transfer, did not direct staff to transfer the resident and did not take necessary steps to accomplish transfer of the resident to the hospital. The findings include: Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS, an assessment tool) dated 10/12/2016, the resident had a BIMS (Brief Interview for Mental Status used to determine attention, orientation and ability to recall information) score of 9 out of 15, associated with moderate impairment (00-07 Severe impairment, 8-12 Moderate impairment & 13-15 Cognitively intact). A physician's note written by MD #1, the resident's attending physician, dated 10/06/2016 at 9:12 AM documented that MD #2 (a [MEDICATION NAME] (GI)), examined Resident #1 for a leaking J tube (jejunostomy feeding tube surgically inserted through the abdomen). Recommendations were made for lab tests and to consider CT scan of the abdomen and pelvis. There was no documented evidence, and the facility provided no evidence, that MD #2 documented progress notes for the visit. An Order Listing Report dated 10/10/2016 documented that an appointment for outpatient surgery clinic, for a [DIAGNOSES REDACTED]. There was no documented evidence, and the facility provided no evidence, that the appointment was scheduled. A General Documentation nurse's note dated 10/13/2016 documented that MD #2, who was the physician covering the resident's care in the absence of MD #1, ordered lab tests including Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP). An Order Listing Report dated 10/13/2016 documented that lab tests for Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) were ordered. There was no documented evidence, and the facility provided no evidence, that the blood tests were performed. There was no documented evidence that MD #2 completed progress notes to address the indication for, or further recommendations based on, the ordered lab tests. An Order Listing Report dated 10/14/2016 documented that CBC, CMP, Urine Analysis and Urine Culture were ordered for a [DIAGNOSES REDACTED]. There was no documented evidence, and the facility provided no evidence, that the blood and urine lab tests were performed. A General Documentation nurse's note dated 10/14/16 at 6:23 PM documented that, upon starting tube feeding, the J tube was noted to be leaking at the base. MD #2 was notified, ordered the feeding rate to be lowered and will follow up. There was no documented evidence that MD #2 completed progress notes to address the issue or the intervention ordered. A Comprehensive Care Path nurse's note dated 10/14/2016 at 11:31 PM documented that formula was infusing by the feeding tube and Resident #1's gown and bed linens were wet from the leaking tube feeding. The tube was leaking from the insertion site. The Registered Nurse Manager (RNM) and MD #2 were on the unit at 11:30 PM and were aware. Intravenous Fluid (IVF) started per order. A General Documentation Note written by the RNM dated 10/14/2016 at 11:48 PM documented that Resident #1 was observed sleeping in bed with leaking J tube at the suture line and that MD #2 examined Resident #1. The RNM documented that, Awaiting approval for transfer to the hospital from Medical Director. There was no evidence that MD #2 documented examination findings, interventions, recommendations or an order to transfer the resident to the hospital. A Transfer to Acute Hospital Form dated 10/15/2016 was completed by an RN and documented to transfer to the hospital for gastrostomy tube status and to evaluate. The resident was not transferred to the hospital. A copy of all the lab tests that were conducted for Resident #1 was received from the Diagnostic Company on 07/13/2017. There was no evidence of lab tests done on 10/13/2016 and 10/14/2016 as ordered. The Administrative Assistant at the Diagnostic Company was interviewed via telephone on 07/18/2017 at 2:45PM. She stated that the company performed no lab tests on 10/13/2016 or 10/14/2016 for Resident #1 and no test were requested for the resident on those dates. Upon request on 04/03/2017 between 1:30 PM and 2:30 PM during an onsite visit, the Director of Nursing Service (DNS) found no evidence of test results for the labs ordered for 10/13/2016 and 10/14/2016 in Resident #1's electronic medical record or elsewhere in the facility's computer system. The DNS also found no evidence that the 10/10/2016 appointment for outpatient surgery clinic ordered on [DATE] was scheduled or completed. A subsequent telephone interview was conducted with the Director of Nursing Service on 11/14/2017 at 2:23 PM. She responded to a question regarding the procedure for outside appointment. She stated that the nurse who picked up the doctor's order should have printed the lab slips and written the consult (written request for consultation appointment). The consult is placed in an inbox on the unit and someone from the transportation department comes to the unit and picks up the consult, makes the appointment and transportation arrangements and then returns the consult to the unit. The Transportation Coordinator, who is responsible for making appointments and transportation arrangements, was interviewed on 07/13/2017 via telephone. The Transportation Coordinator stated that she goes to the units daily and collects the consults, makes the appointments and transportation arrangements. Then she takes the consults with the residents' Face Sheets back to the units and she puts the information back in the box on the unit. She checked the computer (as she was being interviewed) and observed a doctor's order dated 10/10/2016 for an outpatient surgical appointment. She stated that she did not receive a consult for the appointment and that she did not schedule any appointment for Resident #1. MD #1 was interviewed on 10/30/2017 at 5:54 PM via telephone. MD #1 stated that MD #2 was covering, as he was away at a conference, from 10/13/2016 to 10/15/2016. He stated that the covering physician is responsible for the total care of the residents. He further stated that the covering physician can write or give telephone orders and transfer a resident to the hospital if needed. MD #1 also stated that he was not aware that the outpatient appointment was not scheduled and that the staff would not have informed him that the appointment was scheduled. MD #2 was interviewed on 07/10/2017 at 12:27 PM via telephone. He stated that he covered for MD #1 for a few days. He affirmed that on 10/06/2016 MD #1 asked him to come see Resident #1. He stated that he examined Resident #1 on 10/06/2016 and the J tube was leaking and not working well. He verbalized that the J tube was beyond the scope of his expertise, not a tube for a GI doctor. MD #2 stated that, I don't deal with a J tube often. He also stated that he recommended that Resident #1 be evaluated by radiology or surgery. He stated that he adjusted the feeding to 30cc/hr. MD #2 responded to a question regarding the documentation of his examination and recommendation. He stated that he did not document in Resident #1's medical record. MD #2 responded to a question regarding his examination and recommendation of Resident #1 on 10/14/2016. He stated that he examined Resident #1 for the leaking tube and recommend transfer to the hospital. He further stated that he spoke with the RNM instructing her to call the Medical Director or the on-call physician for a decision. Upon inquiry, MD #2 stated I was the covering physician, I am not required to write a doctor's order. When MD #2 was asked if he had documented his examination and recommendation in Resident #1's medical record, he stated, No. The Registered Nurse Manager (RNM) was interviewed on 07/11/2017 at 2:04PM via telephone. She stated that she oversees the residents on the unit and the unit staff. She stated that she did not see lab test orders for 10/13/2016 and 10/14/2016. She further stated that the nurse who picks up the order is responsible for making out the lab slip and putting the slip in the lab book. The RNM also responded that she did not recall seeing a 10/10/2016 order for an out-patient appointment for Resident #1. She stated that the nurse who picked up the order should have written up a consult. The RNM also stated that on 10/14/2016 (she did not remember the time) MD #2 examined Resident #1 for the leaking J tube and verbalized that that the tube needs to be fixed in the hospital. She affirmed that MD #2 stated that Resident #1 needed to be transferred to the hospital, but that MD #2 did not write an order to transfer Resident #1. The RNM also stated that the Medical Director has the final call. She also stated that MD #2 stated that he tried to contact the Medical Director, but the Medical Director did not respond. She stated at approximately 11:00 PM on 10/14/2016, she called the Medical Director, but he did not respond. She added at approximately 11:30PM she informed the Registered Nurse Supervisor (RNS) that the feeding tube was leaking and that she wanted to transfer Resident #1, but she was waiting for the Medical Director to call back. The former Medical Director, who was the Medical Director on 10/14/2016 and 10/15/2016, was interviewed on 10/26/17 at 10:26 AM. He responded to a question regarding the responsibilities of the covering physician and the attending primary physicians. He stated that a covering physician is responsible for the total care of the resident which includes writing a doctor's order to transfer a resident to the hospital. He further stated that he was available to the physicians to discuss resident care including transfers to the hospital. He added that a physician does not need to wait for a response from him to transfer a resident to the hospital. He stated that it is up to the physician or covering physician to transfer a resident. He stated that he would like to know when a resident is being transferred out of the facility. The Medical Director also stated that it is standard medical practice for a physician to document their examination and interventions performed in a resident chart. He stated that he was not aware MD #2 was not documenting in Resident #1's medical record. 415.21(a)

Plan of Correction: ApprovedJanuary 2, 2018

1. The facility cannot retroactively correct this deficiency due to resident #1 no longer being in the facility.
The RNM involved in Resident?s #1 care was in- serviced on :
1. Policy relating to written consults, ?Orders for Consultants?
2. Initiating and following through with Doctors? orders
MD #2 was in-serviced on:
Documenting all physician visits with the resident with an emphasis on residents? status and plan of care.
Writing orders for recommendations regarding intended plan of care.
2. An audit was initiated for all residents? laboratory orders for (MONTH) (YEAR) to ensure order was executed as ordered by the physician.
A review of all residents that were scheduled for out-patient appointments in (MONTH) (YEAR) were reviewed for completion.
Any findings will be immediately addressed.
A review of all residents for recommendations of transfer to the hospital was initiated for the month of (MONTH) (YEAR) is being reviewed for order completion.
All audits are ongoing.
All findings will be immediately addressed.

An audit was initiated for residents for the month of (MONTH) (YEAR) is being reviewed for Doctors? visits having appropriate documentation / progress notes.
All findings will be immediately addressed.
3. The Policy and procedure titled, ?Attending Physician Responsibility?, which reviews covering MD, Consults, and doctors? orders was reviewed and no changes were necessary.
The policy and procedure titled ?Orders for Consultants? was reviewed and no changes were necessary.
In-service initiated for all licensed staff on Initiating and following through with MD orders is on-going.
Education for all MD?s were initiated and is on-going:
? Documentation upon medical visit with resident with an emphasis on residents? status.
A triple check has been implemented to ensure that all orders are confirmed and completed as per MD order.
4. The DON or designee will conduct random audits for 25% of resident ?s MD orders specifically as it relates to labs and consults weekly x 2 weeks, then bi-weekly x4 weeks, then monthly x3, to ensure that all MD orders regarding labs and consults were obtained/implemented as ordered.
The medical director will audit 20% of residents medical visits for documentation of visit and the writing of orders for recommendations when applicable weekly x 4 weeks, then bi-weekly x4 weeks, then monthly x 4
The Don or designee will report finding of audit to the QA committee monthly.
5. Person Responsible - DNS

FF10 483.70(i)(1)(5):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident?s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician?s, nurse?s, and other licensed professional?s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2017
Corrected date: January 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review conducted during an abbreviated survey (NY 153), the facility did not maintain clinical record documentation in accordance with accepted professional standards and practices for 1 of 5 residents reviewed (Resident # 1). Specifically, Resident #1's weight was not accurately documented as required for establishing a weight pattern and timely interventions. The findings include: The facility policy Residents Weighing System dated 05/23/2016 documented the following responsibility for staff nurse: Immediately after being notified by the CNA that the weighing is done, review the weights as recorded on the weight/vitals portal in Point Click Care (PCC). Notifies the Registered Nurse Manager and the unit dietician if the re-weigh confirms the weight change (gain or loss of 4 pounds). The facility policy Charging Errors and/or Omissions documented that if it is necessary to change or add information in the residents' medical record, it shall be completed by means of an addendum and signed and dated by the person making such change or addition. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS an assessment tool) dated 10/12/2016, the resident had a BIMS (Brief Interview for Mental Status used to determine attention, orientation and ability to recall information) score of 9 out of 15, associated with moderate impairment (00-07 Severe impairment, 8-12 Moderate impairment & 13-15 Cognitively intact). Hospital Discharge Instructions dated 10/05/2016 documented that Resident #1's discharge weight was 54.42kg (119.9lbs). A facility dietary note dated 10/06/2016 at 4:52 PM documented that Resident #1's hospital discharge weight was 135lbs. A Weights and Vitals Summary Report documented the resident's weight on 10/06/2016 as: 10/6/16 at 10:06 135lb (bed). A Dietary Comprehensive Care Plan (CCP) dated 10/06/2016, documented that Resident #1 requires tube feeding related to [DIAGNOSES REDACTED] bulb ulcer. Under Goal documented that Resident #1 will maintain current weight of 135lbs +/- 2-4lbs through review date of 10/20/2016. The interventions included to monitor caloric intake, estimate needs and make recommendations for changes to tube feeding as needed. An Order Listing Report dated 10/06/2016 documented daily weight one time a day for [MEDICAL CONDITION], daily weight times five then weekly weight times four one time a day. The Weights and Vitals Summary Report dated 10/06/2016 through 10/15/2016 further documented the following: 10/6/16 at 10:06 135lb (bed). 10/7/16 at 13:22 135lb (Hoyer Lift). A straight line is drawn through the documentation. 10/7/16 at 14:46 112.1lb (wheelchair). 10/8/16 at 8:00AM 135lb (wheelchair). 10/9/16 at 12:18 136.5lb (Hoyer Lift). A straight line is drawn through the documentation. 10/10/16 at 9:12AM 135.9lbs (wheelchair). A straight line drawn through the documentation. 10/10/16 at 11:32AM 135.6lb (wheelchair). A straight line drawn through the documentation. 10/11/16 at 14:00 135lbs (wheelchair). A straight line is drawn thought the documentation. 10/12/16 at 12:25PM 135lb (wheelchair). A straight line is drawn through the documentation. 10/13/16 at 10:38AM 135lb (wheelchair). A straight line is drawn through the documentation. 10/14/16 at 6:25AM 112lb (wheelchair) 10/15/16 at 7:51 AM 102.6lb. All of the documented weights with a straight line drawn through, had notations of incorrect documentation written by the Registered Nurse Manager (RNM) on 10/14/2016. Based on the hospital discharge weight of 119.9lbs on 10/05/2016, and the documented weight of 102.6 pounds on 10/15/2016, this would indicate that Resident #1 lost 16.9lbs in 10 days, with a 9.5 pound loss in one day from 10/14/2016 to 10/15/2016. A nurse's note dated 10/14/2016 at 9:01AM documented that Resident #1 had a weight discrepancy. An abnormally lower value than previously documented. The Dietitian and the Nursing Supervisor were both notified. A weight warning note dated 10/14/2016 at 12:58 PM documented that Resident #1 had an abnormal weight loss since admission. Daily weights times 14 days was recommended to determine Resident #1's weight pattern. A dietary note dated 10/14/2016 at 5:19 PM documented the dietitian spoke with Resident #1's family regarding order changes. The note also documented that Resident #1's family reported that Resident #1's usual body weight was 119lbs. The note further documented that Resident #1's current body weight was 112lbs and that the weight of 135lbs may be due to scale error. Medical Doctor #1 (MD #1) was interviewed on 04/03/2017 at 12:30 PM. He responded to a question regarding weight discrepancy and weight loss for Resident #1. He stated that when he checked Resident #1's weight in the computer, the weight was stable and Resident #1 did not have a weight loss. He stated that on 10/07/2016 he ordered labs and that the lab result was fine. He also stated that he became aware, after 10/15/2016, that the Registered Nurse Manager (RNM) went back in Resident #1's weight record on 10/14/2016 and struck a line through the weights. The RNM was interviewed on 07/11/2017 at 2:04PM. She stated that she became aware of the weight discrepancy on 10/14/2016 when the dietitian brought it to her attention. She also stated that the dietitian instructed her to go back to the previous weights and strike a line through all the weights of 135lbs. She verbalized going back in the weight record on 10/14/2016 and striking a line through the weights with 135lbs. She added that she missed striking a line through 10/06/2016 and 10/08/2016 weights of 135lbs. Licensed Practical Nurse #1 (LPN #1) was interviewed via telephone on 07/12/2017 at 2:30PM. He stated that he witnessed Resident #1's weight of 112lbs on 10/07/2016. LPN #1 responded to a question regarding the resident's weight discrepancy. He stated that he was not aware of a weight discrepancy. He further stated, I am held accountable for the day's weight. The dietitian is responsible for following up with the residents' weights. If there is a discrepancy, the dietitian would let nursing know. Certified Nursing Assistant #1 (CNA #1) who weighed Resident #1 on 10/05/2016 was interviewed on 07/17/2017 at 11:39AM via telephone. She stated that she weighed Resident #1 with the Hoyer Lift on 10/05/2016 at 119lbs. In addition, she stated that Resident #1's family member was present at the time the weight was being taken. She also stated that Resident #1 family member asked about Resident #1's weight and she told the family member that the weight was 119lbs. The CNA responded to a question regarding recording of Resident #1's weight. She stated that she wrote the weight on a piece of paper and gave it to the nurse for recording. The CNA stated that she does not remember the nurse's name and that the nurse no longer employed at the facility. CNA #2 who took Resident #1's weight on 10/07/2016 with the wheelchair was interviewed via telephone on 07/17/2017 at 10:32AM. He stated that he first weighed the wheelchair and then he weighed Resident #1 sitting in the wheelchair. He stated that he does not recall what the total weight was, but that he subtracted the weight of the chair from the total weight and the balance of 112.1lbs was Resident #1's weight. He does not know who also took Resident #1's weight on 10/07/2016 and documented 135lbs. The Medical Director in place throughout the time of the resident's stay at the facility was interviewed on 10/26/2017 at 10:26 AM via telephone. He stated that he was familiar with Resident #1, but was not involved in Resident #1's daily care. He further stated that Resident #1's family member approached him prior to 10/14/2016, stating that Resident #1 was losing weight. He stated that he checked the computer and noted that Resident #1's weight was stable. He also stated that he contacted MD #1 regarding the family member concerns and that MD #1 informed him that Resident #1's weight was stable. He added that he became aware of the weight discrepancy one week after it was discovered. The Director of Nursing Service (DNS) was interviewed on 11/03/2017 at 12:15 PM. She stated that she became aware of the weight discrepancy after 10/15/2016. She saw that the weights were struck out and she asked the nurse about the weights. The DNS stated that the nurse informed her that the weights were incorrect and that was the reason the weights were struck out. The DNS responded to a question regarding the time frame in which the nurse went back in the record and struck out the weights. She stated that the nurse should not have gone back and struck out the weights as it was too far gone. The DNS responded to a question regarding the timeframe. She stated that the nurses can go back and make corrections or addendum no more than 24 hours. The facility policy Charting Errors and/or Omissions did not specify that staff can go back and make corrections no more than 24 hours. 415.22(a)(1-4)

Plan of Correction: ApprovedJanuary 2, 2018

1. The Licensed nurse involved and the C.N.A. involved in Resident #1 care were in-serviced on the policy and procedure as it relates to obtaining and verifying residents? weights upon admission and as ordered.
2. All residents have the potential to be affected by this deficient practice.
A full house audit was completed for the month of (MONTH) (YEAR) on residents? weights to ensure that they were accurate and appropriately documented. There were no identified deficiency. These audits are ongoing.
3.The policy and procedures titled Weight Assessment and Intervention and Charting Errors and Omissions were reviewed. No amendments were made.
In-service on obtaining resident?s weight/ensuring accuracy was initiated and is on-going for all licensed staff and C.N.As as per the policy and procedure.
? Weighing resident upon admission and the next two consecutive days.
? The Nurse and or dietitian will check the previous weight prior to entering weight in PCC portal.
Verifying any weight discrepancy with nursing and or unit dietitian on said day.
? Facility dietitians were educated of documenting admission weights obtained from facility.
? Facility Dietitians educated to utilize transfer record weights as reference and not as admitting weights.
4.DON or designee will audit admission weights on all admissions, daily. 25% of Residents on weekly weights will be randomly audited for x 1 month.
25% of residents on monthly weights will be randomly audited monthly x 6 months and findings reported to the QA committee
5. Person Responsible - DNS

FF10 483.10(g)(2)(3):RIGHT TO ACCESS/PURCHASE COPIES OF RECORDS

REGULATION: (g)(2) The resident has the right to access personal and medical records pertaining to him or herself. (i) The facility must provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically), or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays); and (ii) The facility must allow the resident to obtain a copy of the records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request and 2 working days advance notice to the facility. The facility may impose a reasonable, cost-based fee on the provision of copies, provided that the fee includes only the cost of: (A) Labor for copying the records requested by the individual, whether in paper or electronic form; (B) Supplies for creating the paper copy or electronic media if the individual requests that the electronic copy be provided on portable media; and (C)Postage, when the individual has requested the copy be mailed. (3) With the exception of information described in paragraphs (g)(2) and (g)(11) of this section, the facility must ensure that information is provided to each resident in a form

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2017
Corrected date: January 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated survey (Complaint # NY 153), the facility did not ensure that a resident representative received a copy of a resident medical record in a timely manner for one of five residents reviewed (Resident #1). The findings include: The facility Policy for Request for Medical Records dated 08/2015 stated that the Administrator will be notified of all requests for the release of medical records. The Administrator will ensure that written authorization for the release of medical records is received and will notify the Director of Nursing Service of the request for medical records. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS, an assessment tool) dated 10/12/2016, Resident #1 had a BIMS (Brief Interview for Mental Status used to determine attention, orientation and ability to recall information) score of 9 out of 15, associated with moderate impairment (00-07 Severe impairment, 08-12 Moderate impairment & 13-15 Cognitively intact). According to the resident's medical record face sheet, a family representative was designated as the primary contact for the resident. A letter dated 10/19/2016, addressed to the Facility's Administrator, directed that a request was being made by the resident representative for a copy of Resident #1's complete medical record. A Certified Mail Receipt dated 10/19/2016 revealed that an item was mailed to the Facility's Administrator (the administrator's name and facility address were noted on the receipt). A United States Postal Service (USPS) Product and Tracking Information slip dated 10/20/2016, showed that an item was delivered on 10/24/2016 at 1:57 PM to the facility's address and signed for by a facility staff member (the Director of Admissions) as indicated on the back of the USPS slip. The Administrator was interviewed via telephone on 06/02/2017 at 12:22 PM regarding the certified letter from the resident representative. He stated that he did not recall receiving a letter from the resident representative. The Director of Admissions was interviewed via telephone on 07/17/2017 at 2:24 PM. She responded to a question regarding the certified letter addressed to the administrator that had her printed name and signature on the delivery receipt dated 10/24/2016 at 1:57 PM. She stated that she signs for letters if no one is in the finance department and that she leaves the letters in the finance department on the Finance Coordinator's desk. She also stated that she did not remember signing for a letter from the resident representative. The Finance Coordinator was interviewed via telephone on 07/17/2017 at 2:37 PM. She stated that she did not remember the letter, but that she gave the administrator every letter that came for him or she leaves the letter on his desk. The Clerk in the Medical Record Department was interviewed on 11/21/2017 at 9:43 AM via telephone. She stated that she had not received a medical record request from the resident representative until 06/07/2017, after the date the Administrator was interviewed. 412.3 (iv)

Plan of Correction: ApprovedJanuary 2, 2018

1. The facility cannot retroactively correct this deficiency.
Resident#1 representative was issued a copy of the medical record as requested.
2. All residents have the potential to be affected by this deficient practice.
A review of all outstanding facility complaints was completed to see if there were any complaints regarding outstanding request for medical records by residents or resident representative. There were no other family/residents? complaints outstanding requests for medical records.
3. The policy and procedure, ?Requests for Medical Records? which covers the provision of requested medical records for residents? representative was reviewed. There were no changes made.
The facility implemented a log-in system at the executive office front desk to ensure all request for medical records that is delivered is documented and can be expedited in a timely manner.
All licensed and clerical staff were in-service with focus on
Timely expedition of medical records as it relates to Federal guidelines/policy.
4. DON or designee will audit the log and mailed request for medical records daily to ensure compliance.
The DON or designee will report findings of audit to the QA committee monthly.
5. Person Responsible - DNS

FF10 483.21(b)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2017
Corrected date: January 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated survey (Complaint # NY 153), the facility did not ensure that services were provided in accordance with professional standards of quality, nursing and medical practice in order to prevent potential delay in [DIAGNOSES REDACTED].#1). Specifically, Resident #1 had multiple Doctor's Orders that were not carried out including orders for lab tests of blood and urine and scheduling for an outpatient surgical appointment. Additionally, Medical Doctor #2 (MD #2), examined Resident #1 on two occasions and did not document resident status or MD recommendations in Resident #1's medical record. MD #2 also recommended transfer of Resident #1 to the hospital. MD #2 did not write a doctor's order for transfer, did not direct staff to transfer the resident and did not take necessary steps to accomplish transfer of the resident to the hospital. The findings include: Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS, an assessment tool) dated 10/12/2016, the resident had a BIMS (Brief Interview for Mental Status used to determine attention, orientation and ability to recall information) score of 9 out of 15, associated with moderate impairment (00-07 Severe impairment, 8-12 Moderate impairment & 13-15 Cognitively intact). A physician's note written by MD #1, the resident's attending physician, dated 10/06/2016 at 9:12 AM documented that MD #2 (a [MEDICATION NAME] (GI)), examined Resident #1 for a leaking J tube (jejunostomy feeding tube surgically inserted through the abdomen). Recommendations were made for lab tests and to consider CT scan of the abdomen and pelvis. There was no documented evidence, and the facility provided no evidence, that MD #2 documented progress notes for the visit. An Order Listing Report dated 10/10/2016 documented that an appointment for outpatient surgery clinic, for a [DIAGNOSES REDACTED]. There was no documented evidence, and the facility provided no evidence, that the appointment was scheduled. A General Documentation nurse's note dated 10/13/2016 documented that MD #2, who was the physician covering the resident's care in the absence of MD #1, ordered lab tests including Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP). An Order Listing Report dated 10/13/2016 documented that lab tests for Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) were ordered. There was no documented evidence, and the facility provided no evidence, that the blood tests were performed. There was no documented evidence that MD #2 completed progress notes to address the indication for, or further recommendations based on, the ordered lab tests. An Order Listing Report dated 10/14/2016 documented that CBC, CMP, Urine Analysis and Urine Culture were ordered for a [DIAGNOSES REDACTED]. There was no documented evidence, and the facility provided no evidence, that the blood and urine lab tests were performed. A General Documentation nurse's note dated 10/14/16 at 6:23 PM documented that, upon starting tube feeding, the J tube was noted to be leaking at the base. MD #2 was notified, ordered the feeding rate to be lowered and will follow up. There was no documented evidence that MD #2 completed progress notes to address the issue or the intervention ordered. A Comprehensive Care Path nurse's note dated 10/14/2016 at 11:31 PM documented that formula was infusing by the feeding tube and Resident #1's gown and bed linens were wet from the leaking tube feeding. The tube was leaking from the insertion site. The Registered Nurse Manager (RNM) and MD #2 were on the unit at 11:30 PM and were aware. Intravenous Fluid (IVF) started per order. A General Documentation Note written by the RNM dated 10/14/2016 at 11:48 PM documented that Resident #1 was observed sleeping in bed with leaking J tube at the suture line and that MD #2 examined Resident #1. The RNM documented that, Awaiting approval for transfer to the hospital from Medical Director. There was no evidence that MD #2 documented examination findings, interventions, recommendations or an order to transfer the resident to the hospital. A Transfer to Acute Hospital Form dated 10/15/2016 was completed by an RN and documented to transfer to the hospital for gastrostomy tube status and to evaluate. The resident was not transferred to the hospital. A copy of all the lab tests that were conducted for Resident #1 was received from the Diagnostic Company on 07/13/2017. There was no evidence of lab tests done on 10/13/2016 and 10/14/2016 as ordered. The Administrative Assistant at the Diagnostic Company was interviewed via telephone on 07/18/2017 at 2:45PM. She stated that the company performed no lab tests on 10/13/2016 or 10/14/2016 for Resident #1 and no test were requested for the resident on those dates. Upon request on 04/03/2017 between 1:30 PM and 2:30 PM during an onsite visit, the Director of Nursing Service (DNS) found no evidence of test results for the labs ordered for 10/13/2016 and 10/14/2016 in Resident #1's electronic medical record or elsewhere in the facility's computer system. The DNS also found no evidence that the 10/10/2016 appointment for outpatient surgery clinic ordered on [DATE] was scheduled or completed. A subsequent telephone interview was conducted with the Director of Nursing Service on 11/14/2017 at 2:23 PM. She responded to a question regarding the procedure for outside appointment. She stated that the nurse who picked up the doctor's order should have printed the lab slips and written the consult (written request for consultation appointment). The consult is placed in an inbox on the unit and someone from the transportation department comes to the unit and picks up the consult, makes the appointment and transportation arrangements and then returns the consult to the unit. The Transportation Coordinator, who is responsible for making appointments and transportation arrangements, was interviewed on 07/13/2017 via telephone. The Transportation Coordinator stated that she goes to the units daily and collects the consults, makes the appointments and transportation arrangements. Then she takes the consults with the residents' Face Sheets back to the units and she puts the information back in the box on the unit. She checked the computer (as she was being interviewed) and observed a doctor's order dated 10/10/2016 for an outpatient surgical appointment. She stated that she did not receive a consult for the appointment and that she did not schedule any appointment for Resident #1. MD #1 was interviewed on 10/30/2017 at 5:54 PM via telephone. MD #1 stated that MD #2 was covering, as he was away at a conference, from 10/13/2016 to 10/15/2016. He stated that the covering physician is responsible for the total care of the residents. He further stated that the covering physician can write or give telephone orders and transfer a resident to the hospital if needed. MD #1 also stated that he was not aware that the outpatient appointment was not scheduled and that the staff would not have informed him that the appointment was scheduled. MD #2 was interviewed on 07/10/2017 at 12:27 PM via telephone. He stated that he covered for MD #1 for a few days. He affirmed that on 10/06/2016 MD #1 asked him to come see Resident #1. He stated that he examined Resident #1 on 10/06/2016 and the J tube was leaking and not working well. He verbalized that the J tube was beyond the scope of his expertise, not a tube for a GI doctor. MD #2 stated that, I don't deal with a J tube often. He also stated that he recommended that Resident #1 be evaluated by radiology or surgery. He stated that he adjusted the feeding to 30cc/hr. MD #2 responded to a question regarding the documentation of his examination and recommendation. He stated that he did not document in Resident #1's medical record. MD #2 responded to a question regarding his examination and recommendation of Resident #1 on 10/14/2016. He stated that he examined Resident #1 for the leaking tube and recommend transfer to the hospital. He further stated that he spoke with the RNM instructing her to call the Medical Director or the on-call physician for a decision. Upon inquiry, MD #2 stated I was the covering physician, I am not required to write a doctor's order. When MD #2 was asked if he had documented his examination and recommendation in Resident #1's medical record, he stated, No. The Registered Nurse Manager (RNM) was interviewed on 07/11/2017 at 2:04PM via telephone. She stated that she oversees the residents on the unit and the unit staff. She stated that she did not see lab test orders for 10/13/2016 and 10/14/2016. She further stated that the nurse who picks up the order is responsible for making out the lab slip and putting the slip in the lab book. The RNM also responded that she did not recall seeing a 10/10/2016 order for an out-patient appointment for Resident #1. She stated that the nurse who picked up the order should have written up a consult. The RNM also stated that on 10/14/2016 (she did not remember the time) MD #2 examined Resident #1 for the leaking J tube and verbalized that that the tube needs to be fixed in the hospital. She affirmed that MD #2 stated that Resident #1 needed to be transferred to the hospital, but that MD #2 did not write an order to transfer Resident #1. The RNM also stated that the Medical Director has the final call. She also stated that MD #2 stated that he tried to contact the Medical Director, but the Medical Director did not respond. She stated at approximately 11:00 PM on 10/14/2016, she called the Medical Director, but he did not respond. She added at approximately 11:30PM she informed the Registered Nurse Supervisor (RNS) that the feeding tube was leaking and that she wanted to transfer Resident #1, but she was waiting for the Medical Director to call back. The former Medical Director, who was the Medical Director on 10/14/2016 and 10/15/2016, was interviewed on 10/26/17 at 10:26 AM. He responded to a question regarding the responsibilities of the covering physician and the attending primary physicians. He stated that a covering physician is responsible for the total care of the resident which includes writing a doctor's order to transfer a resident to the hospital. He further stated that he was available to the physicians to discuss resident care including transfers to the hospital. He added that a physician does not need to wait for a response from him to transfer a resident to the hospital. He stated that it is up to the physician or covering physician to transfer a resident. He stated that he would like to know when a resident is being transferred out of the facility. The Medical Director also stated that it is standard medical practice for a physician to document their examination and interventions performed in a resident chart. He stated that he was not aware MD #2 was not documenting in Resident #1's medical record. 415.21(a)

Plan of Correction: ApprovedJanuary 2, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. The facility cannot retroactively correct this deficiency due to resident #1 not in facility.
The RNM involved in Resident?s #1 care was in- serviced on:
1. Policy on implementing Physician orders [REDACTED].
2. Completing Doctors? orders
The MD #2 was in-serviced on:
? Documentation upon medical visit with resident with an emphasis on residents? status.
? Writing order for recommendations when applicable.

2. All residents have the potential to be affected by this deficiency.
A review for completion of residents? laboratory ordered was initiated from [DATE] and is on-going.
Any findings will be immediately addressed.
A review residents with out-patient appointments from (MONTH) (YEAR) were reviewed for completion.
Any findings will be immediately addressed.

An audit was completed for residents with orders and or recommendations for transfers to the hospital in (MONTH) (YEAR) was completed.
Any findings will be immediately addressed.
An audit was completed for residents with change in condition / SBAR in (MONTH) (YEAR) to ensure that appropriate documentation was completed by the physician.
Any findings will be immediately addressed.
All audits are ongoing.
3. Education for all licensed staff was immediately initiated and is on-going ?
? Initiating and following up with MD?s orders

? Education for all MD?s was initiated and is on-going on:-
? Documentation upon medical visit with residents with an emphasis on resident?s status
? Writing orders for recommendations where applicable
4. The DON or designee will conduct random audits totaling 25% of resident ?s with MD orders specifically as it relates to labs and consults weekly x 2 weeks, then bi-weekly x4 weeks, then monthly x3, to ensure that all MD orders regarding labs and consults were obtained/implemented as ordered.
The Medical Director will audit 25% residents medical visits for physician documentation of visit and the writing of orders/progress notes for recommendations weekly x 2 weeks, then bi-weekly x4 weeks, then monthly x3
The Don or designee will report finding of audit to the QA committee monthly.
5. Person Responsible - DNS