St Luke Residential Health Care Facility Inc
August 1, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.80(a)(1)(2)(4)(e)(f):INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility?s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 1, 2017
Corrected date: September 29, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, the facility did not maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of disease and infection for 4 of 5 sampled residents (Residents #3, 18, 21 and 23) and 2 additional residents (Residents #30 and 31) observed for blood glucose monitoring. Specifically, for Residents #3, 18, 21, 23, 30 and 31 the licensed practical nurses (LPNs) obtained blood samples for blood glucose monitoring using a glucometer (device used to measure blood glucose) and the device was not placed on a barrier after use and prior to disinfection to prevent surface contamination. Findings include: 1) Resident #18 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had moderate cognitive impairment. Physician orders [REDACTED]. Fingerstick blood glucose monitoring was observed for the resident on [DATE] at 7:38 AM. Licensed practical nurse (LPN) #2 obtained the resident's blood glucose with the glucometer, discarded the test strip and lancet in the sharps container and placed the glucometer directly on top of the medication cart. She then disinfected the glucometer with a sani-wipe and placed it on a towel on top of the medication cart and did not disinfect the surface of the cart. An attempt to interview LPN #2 via telephone was unsuccessful on [DATE] at 9:02 AM. The Infection Control Nurse was interviewed on [DATE] at 11:55 AM. She stated whenever a glucometer was placed on any surface there should be a barrier between the glucometer and the surface. 2) Resident #21 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Fingerstick blood glucose monitoring was observed for the resident on [DATE] at 4:40 PM. Licensed practical nurse (LPN) #1 obtained the resident's blood glucose with the glucometer and placed the glucometer on top of the medication cart without a barrier. She proceeded to disinfect the glucometer, return it to the drawer in the medication cart and did not disinfect the surface of the medication cart. During a telephone interview with LPN #1 on [DATE] at 10:40 AM she stated after obtaining a fingerstick with the glucometer she would sanitize it with the sani-wipes while holding it in her freshly gloved hand. It she had to set the glucometer down at any time she would place a barrier such as a paper towel. She did not realize she had placed the glucometer on top of the medication cart without a barrier during the observation. The Infection Control Nurse was interviewed on [DATE] at 11:55 AM. She stated whenever a glucometer was placed on any surface there should be a barrier between the glucometer and the surface. 3) Resident #30 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Fingerstick blood glucose monitoring was observed for the resident on [DATE] at 7:45 AM. Licensed practical nurse (LPN) #3 obtained the blood sample from the resident and placed it on the test strip in the glucometer. The batteries malfunctioned during the reading and LPN #3 placed the glucometer on top of the medication cart without a barrier while she checked the batteries. She proceeded to retest the glucose, disinfect the glucometer with a sani-wipe and placed the glucometer on a paper towel on top of the medication cart. The surface of the medication cart was not disinfected during the observation. LPN #3 was interviewed on [DATE] at 10:20 PM. She stated after obtaining a blood glucose reading she would wipe the glucometer with a sani-wipe while holding it in her hand and then set it down on a clean napkin on top of the cart. If she had to set the glucometer down before cleaning, she would place it on a napkin. She realized what she had done during the observation but when the glucometer batteries had died she had become flustered. The Infection Control Nurse was interviewed on [DATE] at 11:55 AM. She stated whenever a glucometer was placed on any surface there should be a barrier between the glucometer and the surface. 10NYCRR 415.19(a)(,[DATE])

Plan of Correction: ApprovedSeptember 1, 2017

PLAN OF CORRECTION
ST. LUKE HEALTH SERVICES
SURVEY EXIT DATE: 8/1/2017
F441 483.80 INFECTION CONTROL, PREVENT, SPREAD, LINENS
Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility?s credible allegation of compliance.
1. Corrective action(s) will be / have been accomplished for those residents found to be affected by the deficient practice:
RESIDENT #18: LPN #2 was educated on the revised Glucometer True Meter Policy and Procedure on 8/24/2017. Blood glucose checks have been properly administered using appropriate infection control techniques. Completion date: 8/25/2017
RESIDENT #21: LPN #1 was educated on the revised Glucometer True Meter Policy and Procedure on 8/24/2017. Blood glucose checks have been properly administered using appropriate infection control techniques. Completion date: 8/25/2017
RESIDENT #30: LPN #3 was educated on the revised Glucometer True Meter Policy and Procedure on 8/24/2017. Blood glucose checks have been properly administered using appropriate infection control techniques. Completion date: 8/25/2017
RESIDENT #3: Blood glucose checks have been properly administered using appropriate infection control techniques. Completion date: 8/25/2017
RESIDENT #31: Blood glucose checks have been properly administered using appropriate infection control techniques. Completion date: 8/25/2017
2. Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
The Glucometer True Balance Policy and Procedure was revised to include when placing the glucometer down on a surface there must be a barrier between the surface and the glucometer. Completion Date: 8/25/2017.
The Infection Control Nurse and Unit Managers will complete random rounds to monitor staff to ensure they are properly following the Glucometer True Balance policy and procedure to ensure a barrier is being used when placing the glucometer down. Completion Date: 9/29/2017 and ongoing
3. Measures put in place to ensure that the deficient practice does not recur:
All Nursing staff will be in-serviced by the In-Service Coordinator regarding the revised policy and procedure for Glucometer True Balance to ensure a barrier is being put down when placing the glucometer on a surface. Completion Date: 9/29/2017 and ongoing
The revised policy revised Glucometer True Balance Policy has been posted on all nursing units for the licensed nursing review. 8/25/2017 and ongoing.
4. How the Corrective Actions will be monitored by to ensure the practice will not recur:
A QA monitor will be implemented to ensure staff are placing a barrier between the surface and the glucometer when doing blood glucose monitoring. The audit will be done monthly for three months, then quarterly for six months by Infection Control Nurse / Designee with further frequency of monitoring to be determined by the QA committee. Threshold: An expected compliance will be 85%. Completion date: 9/29/2017 and ongoing.
5. Date for Correction: 9/29/2017 and ongoing
6. Person Responsible for Correction: Director of Nursing / Designee

FF10 483.12(a)(3)(4)(c)(1)-(4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: 483.12(a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 1, 2017
Corrected date: September 29, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated for 3 of 29 residents (Residents #6, 13 and 14.). Specifically, there was no documentation that investigations were thorough and complete to rule out abuse, neglect, or mistreatment when Resident #6 sustained a bruise and a skin tear of unknown origin; when Resident #13 sustained skin tears; and when Resident #14 sustained skin tears and had several falls. Findings include: 1) Resident #14 was admitted [DATE] and had [DIAGNOSES REDACTED]. The 6/16/2017 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, transferred and ambulated with supervision and a walker, and had no falls or skin tears. The comprehensive care plan (CCP) initiated 11/2/2016 documented the resident was at risk for falls and skin breakdown. Interventions included to assess for environmental safety, remove sharp objects from environment, and staff to provide 1 on 1 as needed (prn). A Resident Incident Report on 7/1/2017 at 1:12 AM documented the resident wandered into another resident's room and was observed sitting on the floor. It was documented the resident frequently wandered and was non-compliant using her walker. There were no obvious injuries and the resident was medicated for knee pain with effect. An interdisciplinary progress note dated 7/1/2017 documented prior to the incident, the resident was observed exiting the elevator on another floor. She was returned to the unit and was observed crying and stating she didn't want to go to bed. It was documented the CNA then encouraged the resident to lie down in her bed. The 7/1/2017 investigation was not thorough as there was no documented evidence the facility determined if interventions were implemented when the resident was exhibiting exit seeking behavior and crying prior to the incident. After the incident occurred, there was no documented evidence the environment was investigated to determine possible factors contributing to the fall. A Resident Incident Report on 7/2/2017 at 9:00 PM documented the resident was observed lying on her side in the hallway. It was documented the resident had previously been ambulating with an unsteady gait. There were no obvious injuries and the resident was assisted into a wheelchair. The 7/2/2017 investigation was not thorough to determine root cause and rule out abuse, neglect or mistreatment when there was no documented evidence the cause of the unsteady gait was investigated and what interventions were implemented after the resident was assisted into a wheelchair A Resident Incident Report on 7/19/2017 at 8:00 PM documented the resident was observed to have 2 skin tears to the right wrist and lower forearm during bedtime (HS) care. It was documented the resident was combative at times and non-compliant. The cause of the skin tears was unknown and the areas were treated. The 7/19/2017 investigation was not thorough as there was no documented evidence interventions were initiated earlier in the shift prior to the incident when the resident was acting out and crying to leave. A Resident Incident Report on 7/20/2017 at 8:30 PM documented the resident was observed lying prone on the floor in her room with a pillow beneath her upper body and face. It was documented the resident was agitated, non-compliant, and there was decreased lighting in the room. There were no obvious injuries. HS care was provided and the resident was brought to the common area for a snack. The 7/20/2017 investigation was not thorough as there was no documented evidence interventions were initiated when decreased lighting was noted as a possible contributing factor to the fall, or if it was determined how long the resident's lighting had been poor and if staff had reported it timely to prevent falls. During an interview with certified nurse aide (CNA) #7 on 8/1/2017 at 12:05 PM, she stated if she observed a bruise or skin tear on a resident she would notify the charge nurse. During an interview with registered nurse (RN) Unit Manager #19 on 8/1/2017 at 12:45 PM, she stated she signs off on resident incident reports and updates the care plans and Resident Care Records (RCR, care instructions). 2) Resident #6 was admitted [DATE] and had [DIAGNOSES REDACTED]. The 4/9/2017 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, transferred and ambulated with a total assist of two and a full Hoyer lift, (mechanical patient lift). The resident had a history of [REDACTED]. The Resident Care Record (RCR, care instructions) dated 7/21/2016 documented the resident was at risk for falls and skin breakdown. Interventions included low bed with mats, alternating pressure mattress and coccyx cut out cushion and leg supports for wheelchair. Resident incident reports documented the following: - On 7/18/2017 at 6:15 AM the resident was found to have a bruise and small cut on his right eyebrow by certified nurse aide (CNA) #11 while performing AM care. RN Nurse Manager #5 documented the resident's hand could have been up by his face with positioning. - On 7/19/2017 at 12:30 PM the resident was found to have a small skin tear to the right elbow. It documented possible wheelchair arm rest causing the skin tear. Blood was also noted between the left third and fourth digit with a small scratch related to the resident scratching. The investigations were not thorough to determine root cause and rule out abuse, neglect or mistreatment when the resident was noted with contractures (shortening/hardening of muscles/joints) and the investigation did not document how it was determined the resident could have his hand by his face causing a skin tear. On 7/27/17 the resident was noted to be sitting up in a high back wheel chair with legs and arms contracted. At 6:01pm during the dinner meal the resident attempted to feed himself and was unable to pull his hands up to his mouth to feed himself. On 8/1/2017 at 9:40 AM during an interview with certified nurse aide (CNA) #11, she stated if she found a bruise or cut she would notify the charge nurse who would start an incident report. The nursing supervisor would fill them out and we give a statement. CNA #11 verified the resident was transferred via a full Hoyer lift with two staff at all times. She went on to state she was doing AM care and noted a bruise and cut over the resident's right eye. She notified the charge nurse to begin the investigative process. When asked what she thought could have caused it, she stated, It looked like he got hit with the Hoyer, and, He is unable to pull his hand up that high. On 8/1/2017 at 10:57 AM during an interview with RN Unit Manager #5, she stated if someone found a cut or bruise they were expected to go to the charge nurse who would contact the RN or shift supervisor who would begin the investigation. She stated an assessment would be completed and a progress note written. She stated they would make every attempt to see if the wound lined up with equipment like a Hoyer lift. She stated that the Hoyer lift was always operated using two staff. When asked about the resident's ability to reach up and scratch himself, she stated that the resident was rigid and had spastic movements but could lift his hand to reach his eye. She stated she remembered the incident and she believed the investigation was complete. On 8/1/2017 at 12:00 PM during an interview with Assistant Director of Nursing (ADON) who had signed both incident reports, she stated that incident reports were started for any unusual resident issues including falls or skin tears. She stated all mechanical lifts were done with two staff at all times. She reviewed both incident reports and stated the investigations had been completed and no one knew what happened. On 8/1/2017 at 2:27 PM during a phone interview with licensed practical nurse (LPN) #12, she was asked specifically about the incident on 7/18/2017. She stated she remembered finding the cut over the resident's right eye. LPN #12 stated she was not sure how the resident was injured. She cleansed the area and applied [MEDICATION NAME] and covered the wound. When asked what the procedure was for incident reports she stated if an incident was reported to her or if she found an issue she would notify the supervisor. When asked about the procedure for mechanical lifts, she stated there were two staff at all times when a mechanical lift was used. 3) Resident #13 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 7/19/2017 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and and had skin tears. The CCP initiated 7/10/2017 documented the resident was at high risk for skin breakdown. Interventions included to observe for breakdown and immediately report skin breakdown to charge nurse or unit manager. Resident incident reports documented the following: - On 7/16/2017 at 9:00 AM, the resident was observed to have 2 skin tears on his left forearm/elbow. The resident stated he did it on the rails when he was going down the hall in his wheelchair. It was documented the resident had decreased safety awareness and dementia. There was no documented evidence the environment, specifically, handrails were investigated to determine possible factors contributing to the skin tears and what interventions were initiated to prevent reoccurrence. - On 7/31/2017 at 9:30 PM, the resident was observed to have a skin tear on his left arm. The resident stated he had scratched himself and that his arm was itchy. There was no documented evidence the resident's skin was assessed to determine the cause of the itchiness and his fingernails assessed to determine the length of his nails; and that interventions were initiated to prevent reoccurrence. An interdisciplinary progress note dated 7/21/2017 documented the resident walked into railing, sustained a skin tear on his left forearm, and the nursing staff and unit manager were notified. There was no documented evidence an incident report was completed and the incident was investigated and interventions were initiated to prevent reoccurrence. Interdisciplinary progress notes documented the following: - On 7/25/2017 at 3:00 PM, the resident re-opened the skin tear on the left elbow and [MEDICATION NAME] (antibiotic ointment) was applied. - On 7/28/2017 at 8:00 AM, the resident re-opened the skin tear on the left forearm and steri-strips (type of skin closure) were applied. During an interview with certified nurse aide (CNA) #18 on 8/1/2017 at 12:40 PM, she stated if she observed a skin tear on a resident, she would notify the charge nurse. During an interview with registered nurse (RN) Unit Manager #19 on 8/1/2017 at 12:45 PM, she stated she signs off on resident incident reports and updates the care plans and RCRs. 10NYCRR 415.4(b)(2)


Plan of Correction: ApprovedSeptember 1, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** PLAN OF CORRECTION
ST. LUKE HEALTH SERVICES
SURVEY EXIT DATE: 8/1/2017
F 225 483.12 ? INVESTIGATE/REPORT ALLEGATIONS/INVIVIDUALS
Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility?s credible allegation of compliance.
1. Corrective action(s) will be / have been accomplished for those residents found to be affected by the deficient practice:
Resident #6: A complete and thorough investigation of the 7/18/2017 incident was completed by the Unit Manager and it was determined that no abuse / neglect had occurred. Staff interviews were completed regarding the Hoyer use, the resident?s spastic movements and a room environmental review was completed. It was determined that the injury was most likely as a result of jerking movement hands toward his face and sharp nails. Resident has been assessed and nails are currently as short as practical. Care plan has been reviewed and revised. Completion date: 8/25/2017

A complete and thorough investigation of the 7/19/2017 incident was completed by Unit Manager and it was determined that no abuse / neglect had occurred. After staff interviews, an interview with the Health Care Agent, and an examination of the wheelchair, it was determined the resident?s nails had caused the skin tear as the resident does have jerking movements. The Health Care Agent does not want derma-sleeves applied at this time. Nails are currently as short as practical. Care Plan reviewed and revised. Completion date: 8/25/2017
Resident #13: A complete and thorough investigation of the 7/16/2017 incident was completed by the Unit Manager/Designee and it was determined that no abuse / neglect had occurred. Staff interviews were completed. The hand rails throughout the entire unit were checked for irregularities that could cause skin tears, no sharp or rough areas noted. The resident?s room including furniture, heater, doorways, w/c and doorknobs were checked, no sharp or rough areas were noted. It was determined resident self-inflicted skin tear when he hit the handrail. Resident was educated regarding not wheeling too close to the hand rails due to safety reasons. Derma-sleeves instituted as protective measure and d/c?d 8/18/2017due to improvement in condition. Care plan reviewed and revised. Completion date: 8/25/2017
A complete and thorough investigation of the 7/31/2017 incident was completed by the Unit Manager/Designee and it was determined that no abuse / neglect had occurred. On assessment the resident?s hands are clean, neatly manicured with short smooth edged nails. Skin is noted to be thin, frail and dry. Dry skin is treated with stock lotion PRN with positive effect. Derma sleeves instituted as a protective measure and d/c?d 8/18/2017 due to improvement in condition. Care plan review and revised. Completion date: 8/25/2017
A complete and thorough investigation of the 7/21/2017incident was completed by the Unit Manager/Designee and it was determined that no abuse / neglect had occurred. Staff statement obtained. Staff person was educated on the need to monitor the path for obstacles while ambulating with the resident. Also reviewed was the need to ensure there was an adequate distance between the resident and immovable objects such as handrails in hall. Resident received treatment for [REDACTED].
Resident #14: A thorough investigation of the 7/1/2017 incident was completed by the Unit Manager and it was determined that no abuse / neglect had occurred. Staff interview completed. Resident has a wanderguard in place and is in working order. Environment reviewed, there was no substance on the floor or tripping hazards and no slippery surfaces. The lighting was dim due to time of the incident. Night lights were in working condition. Resident had non-skid slipper socks on. Resident had complained of pain. Resident had spit out 2200 meds despite attempts to re-medicate her. At 1:43 pm resident received [MEDICATION NAME] with positive effect for knee pain. Resident was returned back to bed after the incident and checked on frequently. Resident was seen by the Tele-Psychiatrist on 8/21/2017. Medication adjustment completed with no behaviors reported today, 8/25/2017. She will be followed by the Tele-Physiatrist. Care plan reviewed and revised. Completion date: 8/25/2017
A complete and thorough investigation of the 7/2/2017 incident was completed by the Unit Manager and it was determined that no abuse / neglect had occurred. Staff interview completed. Resident was assisted to a chair next to the birds and offered a snack which she had declined. Resident was medicated with routine [MEDICATION NAME] at 10:17 p.m. which was the next scheduled dose. Review of the environment was completed and there was no substance on the floor or tripping hazards. Resident was seen by the Tele-Psychiatrist on 8/21/2017. Medication adjustment completed with no behaviors reported today, 8/25/2017. She will be followed by the Tele-Psychiatrist. Care plan reviewed and revised. Completion date: 8/25/2017
A complete and thorough investigation of the 7/19/2017 incident was completed by the Unit Manager and it was determined that no abuse / neglect had occurred. Staff interviews completed. Resident is independent with ambulation and frequently walks the unit. Staff will continue to allow the resident to self-ambulate and monitor her safety. The hand rails and doorway throughout the entire unit were checked for irregularities that could cause skin tears, no sharp or rough areas noted. The resident?s room including furniture, heater, doorways, w/c and doorknobs were checked, no sharp or rough areas were noted. The resident receives frequent 1:1?s with the staff. Resident was seen by the Tele-Psychiatrist on 8/21/2017. Medication adjustment completed with no behaviors reported today, 8/25/2017. She will be followed by the Tele-Psychiatrist. Care plan reviewed and revised Completion date: 8/25/2017
A complete and thorough investigation of the 7/20/2017incident was completed by the Unit Manager and it was determined that no abuse / neglect had occurred. All lighting in the resident?s room was checked in and it is working order. Lighting was off at the time as the resident was sitting at the nurse?s desk and not in the room. The care plan was revised to leave night light on when the resident is out of the room. Care Plan reviewed and revised. Completion date: 8/25/2017

2. Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
RN Clinical Nurse / Designee will review all incident reports of residents who have had bruises, skin tears and repeated falls since 8/1/2017 to ensure a thorough investigation has been completed to rule out abuse, neglect or mistreatment. Completion date: 9/29/2017 and ongoing
3. Measures put in place to ensure that the deficient practice does not recur:
RN?s will be re-in serviced by the In-service Coordinator regarding the Quality Assurance Incident Report Policy and Procedure. This includes performing route cause so that abuse, neglect or mistreatment can be ruled out. Completion Date: 9/29/2017 and ongoing
All licensed nursing staff will be in-serviced by the In-service Coordinator on completing incident reports on all residents who sustained a skin tear of unknown origin, bruise and repeated falls so that a complete and thorough investigation can be completed to ensure abuse, neglect or mistreatment can be ruled out. Completion date: Completion date: 9/29/2017 and ongoing
All licensed staff will be in-serviced by the In-service Coordinator regarding the Quality Assurance Incident Reports Policy and Procedure as it relates to completing a complete and thorough investigation as well as ruling out abuse, neglect, and mistreatment. Completion Date: 9/29/2017 and ongoing
All nursing and therapy staff will be educated by the In-Service Coordinator on the need to monitor the path for obstacles while ambulating with residents. It will include the need for adequate distance between the resident and immovable objects such as handrails in hall. Completion date 9/29/2017 and ongoing
The Interdisciplinary Team will discuss at the weekly team meeting all repeated falls, skin tears of unknown origin and bruises of unknown origin to ensure the appropriate care plan interventions are in place. Completion date: 9/29/2017 and ongoing.
The Building Engineer will place handrails and doorways on a quarterly preventive monitoring schedule to ensure they are in proper repair. Completion date: 9/29/2017 and ongoing

4. How the Corrective Actions will be monitored by to ensure the practice will not recur:
A QA monitor will be implemented to ensure incident reports are thorough and complete to rule out abuse, neglect or mistreatment as it relates to bruises, skin tears of unknown origin and repeated falls. The audit will be done monthly for three months, then quarterly for six months by RN Clinical Nurse with further frequency of monitoring to be determined by the QA committee. Threshold: An expected compliance will be 85%. Completion Date: 9/29/2017 and ongoing.
5. Date for Correction: 9/29/2017 and ongoing
6. Person Responsible for Correction: Director of Nursing

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: August 1, 2017
Corrected date: September 29, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview conducted during the recertification and abbreviated (NY 827) surveys, the facility did not ensure residents were provided with the necessary services to maintain optimal physical well-being for 1 of 17 residents reviewed for quality of care (Resident #1). Specifically, Resident #1's anticoagulation status was not rechecked in a timely manner and the resident experienced a stroke. In addition the facility did not ensure Resident #1's anticoagulation status remained appropriate for his condition after re-admission to the facility. Findings include: Resident #1 was admitted [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/31/2017 Minimum Data Set (MDS) assessment documented the resident's cognition was moderately impaired, was independent with transfers and required supervision for dressing and limited assistance for bathing. The comprehensive care plan (CCP) dated 2/8/2017 documented the resident was at risk for blood clots related to a-fib and [MEDICATION NAME] (anticoagulant/thins the blood) therapy. PT/INR The [MEDICATION NAME] log sheet documented the following INRs (international normalized ratio, blood test with a therapeutic range of 2.0-3.0 for people on [MEDICATION NAME] for a-fib): - On 11/22/2016 the INR was 2.1 with no changes to the [MEDICATION NAME] dose and the next INR to be checked on 12/6/2017. - On 12/6/2016 the INR was 2.2 with no changes to the [MEDICATION NAME] dose and the next INR to be checked on 12/20/2017. - On 12/20/2016 the INR was 2.1 with no changes to the [MEDICATION NAME] dose and the next INR to be checked on 1/3/2017. - On 1/3/2017 the INR was 2.4 with no changes to the [MEDICATION NAME] dose and the next INR to be checked on 1/17/2017. - On 1/17/2017 the INR was 2.8 with no changes to the [MEDICATION NAME] dose and the next INR to be checked on 2/7/2017. - On 2/7/2017 the INR was 2.2 with no changes to the [MEDICATION NAME] dose and the next INR to be checked on 2/28/2017. - On 2/28/2017 the INR was 1.9 with no changes to the [MEDICATION NAME] dose and the next INR to be checked on 3/21/2017. - On 3/21/2017 the INR was 1.6 with no changes to the [MEDICATION NAME] dose and the next INR was to be rechecked on 4/10/2017. A nursing progress note dated 3/30/2017 documented the resident went out of the facility at 5:10 PM with his family. At 9:15 PM the facility received a phone call from the resident's family member who reported the resident was experiencing some weakness and numbness on his left side and he wanted to go to the emergency room . The family was encouraged to have resident evaluated. A hospital discharge summary dated 4/6/2017 documented on 3/30/2017 the resident was admitted to the hospital for sudden onset of left-sided weakness, in which he received t-PA (alteplase/treatment for [REDACTED]. Physician orders dated 4/6/2017 included the resident's INR and [MEDICATION NAME] dosing would be managed by the resident's cardiology office. The admission history and physical dated 4/7/2017 documented the resident had a recent stroke with left-sided weakness and would receive physical therapy for strengthening. The 4/18/2017 MDS documented the resident's cognition was moderately impaired, was limited assistance for transfers, and extensive assistance for dressing, personal hygiene and bathing. During an interview with a nurse from the resident's cardiology office on 7/28/2017 at 1:20 PM she stated the resident's expected INR therapeutic range was between 2.0-3.0, and an INR less than that placed the resident at risk for a stroke. She stated she reviewed the resident's record and on 3/9/2017 the office was told the nursing home would be managing his INR and [MEDICATION NAME]. On 4/10/2017 the cardiology office was again managing the resident's INR and [MEDICATION NAME] and she did not know why. During an interview with registered nurse (RN) Unit Manager #8 on 7/28/2017 at 1:45 PM, she stated the resident's INR should be from 2.0-3.0 to prevent the blood from clotting. She stated the resident's INRs and [MEDICATION NAME] dosing was managed by his cardiology office per family request and she could not recall why the family had requested that. During an interview with the nurse practitioner (NP) on 7/31/2017 at 8:30 AM, she stated the therapeutic INR range for residents on [MEDICATION NAME] for a-fib was 2.0-3.0, and if they were subtherapeutic they would be at risk for a stroke. She stated if the resident's INRs were stable and they started to trend down she would review the resident's Medication Administration Record [REDACTED]. She stated she may not necessarily change the [MEDICATION NAME] dose and she would normally recheck the INR again in a couple of days. She stated for Resident #1 she did not change the frequency of his INR schedule of every two weeks as his INR was only 1.6 one time, on 3/21/2017. During an interview with the resident's attending physician #9 on 7/31/2017 at 12:00 PM, he stated the normal range of INRs for anticoagulant residents with a-fib was 2.0-3.0. If the resident's INRs were stable and they trended down he would keep a close eye on it and rechecking sooner than 2 weeks would be a good idea. DISCHARGE ORDERS The hospital discharge summary documented the resident was treated for [REDACTED]. The Aspirin needs to be discontinued once his INR is therapeutic. Please make sure that once the INR is therapeutic the patient is ONLY ON [MEDICATION NAME] AND [MEDICATION NAME]. Discharge instructions included to obtain daily INR (international normalized ratio, blood test with a therapeutic range of 2.0-3.0 for people on [MEDICATION NAME] for a-fib) levels to ensure that [MEDICATION NAME] dosage was appropriate. The hospital medication reconciliation form dated 4/6/2017 documented Aspirin 81 milligrams (mg) and to discontinue once INR was in therapeutic range. The admission physician orders dated 4/6/2017 documented Aspirin 81 mg daily. The order did not contain instructions to discontinue once INR was therapeutic. The orders included to check the INR on 4/10/2017. The physician orders documented the medications were reviewed by licensed practical nurse (LPN) #3; there was a check mark next to LPN #10's initials; and noted was documented next to registered nurse (RN) Unit Manager #8's name. The orders were signed by the physician on 4/7/2017. The admission history and physical dated 4/7/2017 documented the resident would continue with the [MEDICATION NAME] and Aspirin. The Aspirin would be discontinued once the [MEDICATION NAME] level was therapeutic, per the discharge instructions. The 4/26/2017 comprehensive care plan (CCP) documented the resident was at risk for falls as he had a history of [REDACTED]. Interventions included to protect from injury as able. The [MEDICATION NAME] log sheet documented INR's were completed: - On 4/10/2017 with result of 1.9. - On 4/11/2017 with result of 1.7. - On 4/17/2017 with result of 1.9. - On 4/24/2017 with result of 1.8. - On 5/2/2017 with result of 1.7. - On 5/8/2017 with result of 2.0. - On 5/22/2017 with result of 1.8. - On 5/30/2017 with result of 2.0. - On 6/6/2017 with result of 2.3. - On 6/13/2017 with result of 2.3. - On 6/7/2017 with result of 2.1 and - On 7/11/2017 with result of 2.1. There was no documented evidence the Aspirin was discontinued when the resident reached a therapeutic (2.0) INR level. Physician orders reviewed by the surveyor on 7/28/2017 included Aspirin 81 mg daily, [MEDICATION NAME] 75 mg daily and [MEDICATION NAME] 4 mg daily. The Medication Administration Record [REDACTED]. The resident was observed on 7/28/2017 at 11:15 AM sitting in a wheelchair in his room by himself. At 12:15 PM he was observed in bed sleeping with his wheelchair sitting directly next to his bed. During an interview with RN Unit Manager #8 on 7/28/2017 at 1:45 PM, she stated admission orders [REDACTED]. The orders were then given to the Unit Manager who reviewed them to ensure they were correct with the medication list and discharge summary, and the RN would call the physician to review orders with him. The third check was completed by the night nurse and she would place a check mark next to her initials indicating the orders were checked with the physician orders and ensure they were inputted into the computer accurately. When the physician came in to evaluate the resident, he would sign the physician orders and the RN or LPN would then place noted next to their name indicating the orders were correct and ensure any additional physician orders were implemented. She stated she was not aware of the instructions regarding the Aspirin and INRs as she was not the Unit Manager at the time of Resident #1's admission. She stated she did note the orders after the physician had evaluated the resident and signed the orders. During an interview with LPN #3 on 7/28/2017 at 2:00 PM, she stated when a resident was admitted the LPN would look at the discharge summary and medication list from the hospital and input the orders on the physician order sheet. The RN Unit Manger would do the second check, comparing the orders to the discharge summary and medication list to ensure they were accurate and call the physician to review the orders with him. The LPN stated stated she remembered questioning the instructions regarding the Aspirin and daily INRs for this resident and she did not input the Aspirin on the order sheet. She stated when she gave the orders to the Unit Manager, who no longer worked at the facility, she informed her there were specific instructions that she needed to look at regarding the Aspirin and the INRs. During an interview with physician #10, the resident's attending physician, on 7/31/2017 at 12:00 PM, he stated the normal INR range for a resident with a-fib was 2.0-3.0 seconds. He stated he would review discharge instructions for every resident admitted or readmitted and it was ultimately his responsibility to ensure Resident #1's Aspirin was discontinued once the INR was in therapeutic range. 10NYCRR 415.15(b)(2)(ii)

Plan of Correction: ApprovedSeptember 1, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** PLAN OF CORRECTION
ST. LUKE HEALTH SERVICES
SURVEY EXIT DATE: 8/1/2017
F386 483.30 PHYSICIAN VISITS ? REVIEW CARE / NOTES / ORDERS
Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility?s credible allegation of compliance.
1. Corrective action(s) will be / have been accomplished for those residents found to be affected by the deficient practice:
RESIDENT #1: Aspirin was discontinued 7/28/2017. Resident continues to receive [MEDICATION NAME] and [MEDICATION NAME]. Attending physician assessed the resident?s recent INR level and determined the resident?s condition to be well and stable on current does of [MEDICATION NAME] 6mg 2x week and 4 mg 5x week on 8/25/2017. Will repeat INR on 8/29/2017. Completion date: 8/25/2017
2. Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
All residents on [MEDICATION NAME] will be reviewed by the Medical Department to insure their INR is within therapeutic range. If the resident is not in their therapeutic range, there will be medical documentation as to the course of treatment for [REDACTED]. 9/29/2017and ongoing.
The Policy and Procedure for Ordering Laboratory Tests has been revised. [MEDICATION NAME] therapy monitoring will be managed by the facility attending physicians / NP?s. All other physicians will be considered consultants. Any recommendations from the consultants must be reviewed and approved by the attending physician / NP as it relates to [MEDICATION NAME] orders and follow-up lab testing. Any deviation from the resident?s therapeutic range without a [MEDICATION NAME] adjustment will have the rationale documented in the medical record by the MD/NP. Repeat labs will be drawn at the discretion of the MD / NP. Completion Date: 8/25/2017 and ongoing
All residents who were admitted / readmitted from the hospital since 8/1/2017 will have the Interact Medication Reconciliation Worksheet for Post-Hospital Care completed to ensure there were no discrepancies with their medication orders. Any discrepancies will be clarified with the MD / NP. Completion Date: 9/29/2017 and ongoing
3. Measures put in place to ensure that the deficient practice does not recur:
Medical Staff will be in-serviced by the Medical Director on the revised policy and procedure for Ordering Laboratory Tests by 9/29/2017 and ongoing.
All RN?s and licensed nursing staff will be in-serviced by the In-Service Coordinator on the revised policy and procedure for Ordering Laboratory Tests by 9/29/2017 and ongoing.
All licensed staff will be re-educated on the Interact Medication Reconciliation Worksheet for Post-Hospital Care by the In-Service Coordinator / Designee by 9/29/2017 and ongoing.
4. How the Corrective Actions will be monitored by to ensure the practice will not recur:
A QA monitor will be implemented to ensure any resident on [MEDICATION NAME] is maintained within their specified therapeutic range based on the results of the INR lab test. If the INR is not within therapeutic range, and there has been no change to the [MEDICATION NAME] order there is documentation from the medical department as to their rational in the medical record as well as what the follow up monitoring will be. The audit will be done monthly for three months, then quarterly for six months by Medical Director / Designee with further frequency of monitoring to be determined by the QA committee. Threshold: An expected compliance will be 85%. Completion Date: 9/29/2017 and ongoing.
A QA monitor will be implemented to ensure a RN Unit Manager has notified MD/NP any INR results that are not within the specified therapeutic range. The audit will be done monthly for three months, then quarterly for six months by RN Clinical Nurse with further frequency of monitoring to be determined by the QA committee. Threshold: An expected compliance will be 85%. Completion Date: 9/29/2017 and ongoing.
A QA monitor will be implemented to ensure those residents who have been admitted / readmitted from the hospital have the Interact Medication Reconciliation Worksheet for Post-Hospital Care completed and any meds needing clarification have been clarified with the MD/NP. The audit will be done monthly for three months, then quarterly for six months by RN Clinical Nurse with further frequency of monitoring to be determined by the QA committee. Threshold: An expected compliance will be 85%. Completion Date: 9/29/2017 and ongoing.
5. Date for Correction: 9/29/2017 and ongoing
6. Person Responsible for Correction: Medical Director