Iroquois Nursing Home Inc
July 21, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.60(g):ASSISTIVE DEVICES - EATING EQUIPMENT/UTENSILS

REGULATION: (g) Assistive devices The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 21, 2017
Corrected date: September 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure 1 of 14 residents (Resident #8) reviewed for assistive devices, were provided assistive devices for eating as planned. Specifically, Resident #8 was not provided with a specialized lip plate in accordance with her plan of care. Resident #8 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 6/15/2017 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, required supervision with one person physical assist with eating, and had severe visual impairment. The comprehensive care plan (CCP) updated 6/13/2017 documented a lip plate and a scoop dish were implemented. A 6/13/2017 certified occupational therapy assistant (COTA) progress note documented the resident would benefit from a scoop dish, and ordered the assistive device. A 6/21/2017 occupational therapy (OT) progress note documented the resident was provided with feeding skills training with use of an inner lip plate to improve feeding self and ease of care provided by nursing staff. The resident was to continue to address this goal area in order to improve consistency in performance. A 6/23/2017 COTA progress note documented the resident was seen during lunch in order to reassess self-feeding skills and promote maximum independence during meal time. The resident had a scoop dish, a sandwich and pudding. The resident was able to continue task with minimum verbal cues. A 6/29/2017 OT discharge progress note documented the resident was able to feed self utilizing inner lip plate for 50% of meal requiring minimum to maximum assist. The resident was provided with feeding skills training with use of an inner lip plate to improve feeding self and ease of care provided by nursing staff. The resident's feeding skills had declined and required a short term goal to be added to the plan of care. The resident's abilities had fluctuated between minimum to maximum assist of 1 for feeding. The 7/20/2017 certified nurse aide (CNA) care instructions had no documentation the resident was to have adaptive equipment in place at meals. On 7/20/2017 at 5:30 PM, lip plate was observed to be documented on the resident's diet slip (meal ticket). On 7/20/2017 at 8:50 AM and 1:06 PM, and on 7/21/2017 at 8:35 AM, the resident was observed eating her meals without the use of a lip plate. During an interview with physical therapist (PT) #23 on 7/20/2017 at 4:00 PM, he stated when assistive devices for eating were recommended by his department, an electronic message was sent to the nursing and dietary departments to inform them of the changes made. Residents were reassessed quarterly and as needed thereafter. He then verified the resident's plan of care to include a lip plate. During an interview with CNA #24 on 7/21/2017 at 10:30, she stated if a resident needed adaptive equipment for eating, it was on the CNA care instructions and the meal ticket. During an interview with registered nurse (RN) #17 on 7/21/2017 at 12:20 PM, she stated the resident was being evaluated for continued use of the lip plate as the resident required extensive assistance with eating. She then stated the lip plate was discontinued that morning at 8:15 AM. 10NYCRR 415.14(g)

Plan of Correction: ApprovedAugust 18, 2017

F-369 ASSISTIVE DEVICES ? EATING EQUIPMENT/UTENSILS
I. The following actions were accomplished for the residents identified in the sample:
? Resident #8 ? was evaluated by Occupational Therapy on 7/20/17 with a resulting determination that resident is now fed and no longer benefits from a lip plate. Lip plate discontinued.

II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice:
? A full house audit has been completed to identify all residents who require adaptive equipment for eating per the individualized comprehensive care plan
? For all residents identified as requiring adaptive equipment, the care plan, CNA instructions and Eating icon have been reconciled
III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility?s guidelines ensure that:
? When a resident requires adaptive equipment for eating
1. Therapy will send an OUTLOOK message to the THERAPY UPDATE group.
2. The individualized comprehensive care plan and Nursing instructions will be updated
3. The newly created icon for eating will be activated
4. The diet tech will add the adaptive equipment to the resident meal profile/ticket.
5. The dietary supervisor will ensure ordered adaptive equipment is sent to the unit with each meal
6. The CNA will place the adaptive equipment (as indicated on the meal ticket) at the meal
? All staff have been educated on the new system

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
? An audit tool has been developed to review all residents requiring adaptive equipment for eating
? QA monitoring will be conducted weekly by the DON/ADON for 3 months until such time that 100% compliance is achieved.
? Findings and actions taken will be reported to the Quality Assurance Committee monthly. Frequency of on-going audits will be determined by the Committee based on audit results.


Completion Date: (MONTH) 8, (YEAR)
Responsibility: Director of Nursing

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 21, 2017
Corrected date: September 8, 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 ensure all residents were free from unnecessary drugs for 1 of 2 residents (Resident #2) reviewed for anti-anxiety/hypnotic medications. Specifically, Resident #2 was administered an as needed (prn) anti-anxiety medication without consistent documentation of supportive rationale or of individualized non-pharmacological interventions attempted prior to administration. Findings include: Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, inattention and disorganized thinking were continually present and the resident had trouble falling or staying asleep. She required extensive assistance to total dependence with activities of daily living, had an anxiety disorder and received an anti-anxiety medication 5 of the previous 7 days. The comprehensive care plan (CCP) effective 2/15/2017 documented the resident was on an anti-anxiety medication with a goal to have symptoms of anxiety well controlled. Interventions included to document the onset, duration and characteristics of all symptoms of anxiety and assess for the effectiveness of medication. The CCP documented the resident would make repetitive verbalizations related to her [MEDICAL CONDITION] (difficulty expressing language) and she became combative with care. Interventions included to use a calm, reassuring manner, reapproach as needed and administer medications per physician order. There was no documentation of individualized non-pharmacological interventions to use when the resident was agitated, restless or anxious. A physician order [REDACTED]. A social services progress note dated 5/3/2017 at 6:54 AM documented the resident had repeated verbalizations and responded to music and enjoyed listening to it in her room. She would sing along to the music and would fold towels etc. Those activities acted as a diversion and calming influence. Physician orders [REDACTED]. Nursing progress notes documented the resident was administered [MEDICATION NAME] 1 mg on: - 5/8/2017 at 3:31 PM, for increased agitation; - 5/9/2017 at 6:01 AM for repetitive verbalizations; - 6/23/2017 at 4:17 AM and on 6/24/2017 at 4:00 AM, the resident was up and using a loud voice talking nonsense; - 6/25/2017 at 1:59 PM for increased agitation; - 6/26/2017 at 2:15 PM, the resident had been up most of the night and resisted a nap; - 6/27/2017 at 1:35 PM, the resident displayed periods of increased agitation and did not sleep more than 3 hours; - 6/28/2017 at 10:00 AM, the resident was awake and talking with a loud voice; and - 6/29/2017 at 6:12 AM, the resident was calling out in a loud voice, speaking nonsense. There was no documentation if individualized interventions were attempted prior to administration of [MEDICATION NAME]. The resident was observed sitting in her wheelchair, smiling and repeating the same words over on: - 7/19/2017 at 9:55 AM, 10:10 AM and 10:45 AM; and - 7/20/2017 at 9:30 AM and 9:55 AM. Certified nurse aide (CNA) #4 was interviewed on 7/20/2017 at 2:00 PM. She stated the resident constantly repeated the same words over and over. Sometimes other residents would become bothered and tell her to stop. She had never seen the resident become agitated. She tried to keep the resident occupied by folding laundry or other activities. CNA #5 was interviewed on 7/20/2017 at 2:10 PM. She stated when the resident would become restless she would check to make sure she was toileted or wanted to rest. She would give her activities to keep busy. The resident was easy to redirect when she became restless. The resident would repeat the same words over and over again and it did not seem to bother her. Redirection would usually work for the resident. Licensed practical nurse (LPN) #6 was interviewed on 7/20/2017 at 2:30 PM. He stated the resident was very repetitive with particular words. The resident would become very loud and would disturb other residents. The charge nurse would call the physician for a one time dose of [MEDICATION NAME]. Before administering [MEDICATION NAME] he would always try to redirect the resident and chemical intervention would always be the last resort. He would document the medication was given, tell the Unit Manager and she would document in a progress note. LPN #2 was interviewed on 7/20/2017 at 3:07 PM. She stated the resident would repeat the same word over and over again and would not be agitated. She was going through a period of adjustment as she had been on a few different floors since she was admitted . Licensed Master Social Worker (LMSW) Unit Manager #1 was interviewed on 7/20/2017 at 3:45 PM. She stated the resident had no behaviors which would be considered distressful to the resident. She repeated the same word over and over and it did not appear to bother her or other residents. If it did, she would expect staff to attempt to move the resident to a different area, and provide diversions such as aromatherapy, music, or tactile stimulation. The nurse practitioner was interviewed on 7/20/2017 at 3:50 PM. She stated [MEDICATION NAME] would be ordered for residents with a history of anxiety and residents who were at high risk for aggression. She would not usually order a one-time dose. Registered Nurse (RN) Unit Manager #17 was interviewed on 7/21/2017 at 10:45 AM. She stated the resident was very restless and had repetitive speech. She would wake up during the night and would not get back to sleep and she was exhausted. When the resident got to that point she would call the physician and he would order a one-time dosage of [MEDICATION NAME] to aid with sleep. She would not request [MEDICATION NAME] if the resident was being repetitive as that was her baseline behavior. During an interview with physician #29 on 7/21/2017 at 11:15 AM, he stated medical symptoms should be ruled out and non-pharmacological interventions should have been attempted before an anti-anxiety medication was administered to a resident. 10NYCRR 415.12(l)(1)

Plan of Correction: ApprovedAugust 18, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-329 DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS
I. The following actions were accomplished for the residents identified in the sample:
? Resident #2 ? order for PRN [MEDICATION NAME] was discontinued on 7/10/17
? Resident has been transferred to the dementia unit
? Care plan has been updated to include non-pharmacological interventions for anxiety. Including but not limited to: aroma therapy, music and memory program, weighted blanket, hand massage

II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice:
? A full house audit will be completed to identify all residents who have active PRN orders for anti-anxiety medications
? Any resident identified as having a PRN anti-anxiety medication will have a medication review by MD to determine appropriateness of the medication to treat his or her specific condition as diagnosed
? An assessment has been created in SigmaCare that must be completed prior to PRN [MEDICAL CONDITION] medication administration. The assessment includes all non-pharmacological interventions attempted prior to the administration of the medication.
? If non-pharmacological interventions are attempted and are not effective and a PRN medication is administered, the IDCT team will be notified through the PRN Medication Group and will review and update the care plan as appropriate.

III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility?s guidelines ensure that:
? An order set has been developed to require acknowledgement that all non-pharmacological interventions per individualized care plan have been attempted and unsuccessful prior to administering a PRN anti-anxiety medication
? All nurses will be educated on the new order set and process for administering a PRN anti-anxiety medication
IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
? An audit tool has been developed to review that non-pharmacological interventions have been attempted prior to the administration of a PRN anti-anxiety medication
? QA monitoring will be conducted weekly by the DON/ADON for 6 months until such time that 100% compliance is achieved.
? Findings and actions taken will be reported to the Quality Assurance Committee monthly. Frequency of on-going audits will be determined by the Committee based on audit results.

Completion Date: (MONTH) 8, (YEAR)
Responsibility: Director of Nursing

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: July 21, 2017
Corrected date: September 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated for 1 of 14 residents (Resident #3). Specifically, there was no documentation that investigations were thorough and complete to rule out abuse, neglect, or mistreatment when Resident #3 sustained a fall, a facial laceration and bruising to his legs. Findings include: Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required extensive assistance for bed mobility, dressing, toilet use and limited assistance for transfers. The resident was always incontinent of urine and bowel and had not had any falls since the prior assessment. FALLS: The comprehensive care plan (CCP) dated 10/27/2016 documented the resident was at risk for falls and interventions included a merry walker (an ambulation device) for ambulating around the unit, high-low bed to floor and mats at bedside. The resident had a fall without injury on 06/30/2017 and interventions included sleep hygiene. An incident report dated 06/30/2017 at 11:55 PM documented the resident was found in his room kneeling on the mat next to his bed. The fall was unwitnessed. The resident's head did not touch the floor and neuro checks were not implemented. The resident was incontinent when found. An interview was conducted with the staff member who found the resident on the floor. There was no documented evidence the facility investigated possible root causes to determine what led to the fall. During an interview on 07/20/2017 at 3:30 PM, Licensed Master Social Worker (LMSW) Unit Manager #1 stated that on 06/30/2017, the resident had a low bed and mats. A light was left on and they believed the resident was confused and thought it was time to get up. Staff were educated on sleep hygiene and included dim lights and aromatherapy. During an interview with certified nurses aide (CNA) #8 on 7/20/2017 at 3:00 PM, she stated she found the resident on the floor and the bed was in the low position, mats were on both sides of the bed and the resident was found kneeling with his head resting on the bed. He frequently slept at the edge of his bed and he just rolled over. She notified the charge nurse who notified the nursing supervisor. INJURIES OF UNKNOWN ORIGIN: A physician order [REDACTED]. The CCP dated 7/06/2017 documented the resident was at risk for skin impairment and on 6/6/2017 the resident had two right hip bruises. The CCP documented treatment per physician orders [REDACTED]. Resident nursing instructions dated 3/31/2017 documented the resident attempted to ram his merry walker into exit doors. The resident was observed leaning forward and resting his head on the crossbar of his merry walker, with a cushion on the crossbar, on 7/18/2017 at 11:45 AM and on 7/19/2017 at 8:20 AM. During an observation on 7/20/2017 at 11:10 AM the merry walker had a PVC pipe which was smooth and free of sharp edges. There was a cushion on the bar where the resident rested his head. An incident report dated 6/06/2017 at 11:00 AM documented two bruises to the right thigh. One to the front right thigh and the other to the back right thigh. A staff interview with the certified nurse aide (CNA) who found the bruises during a shower was included with the report. There was no documented evidence the facility investigated possible root causes to determine the origin of the bruises. During an interview on 7/20/2017 at 2:05 PM with CNA #4 she stated she did not know what happened to cause the bruise. She had noticed the bruising during the shower. She was aware of the laceration to the bridge of his nose and she thought he had hit it on his merry walker. Cushions had been added to his walker and he was known to take it off. During an interview on 7/20/2017 at 3:30 PM, Licensed Master Social Worker (LMSW) Unit Manager #1 stated the laceration occurred while the resident was leaning forward and resting his head on the cross bar of the merry walker. They had obtained an extra cushion so they could be sure the cross bar was covered at all times to prevent further injury. She would have to look at progress notes to determine what had been determined about the bruises as an RN would have done the assessment. During an interview with licensed practical nurse (LPN) #2 on 7/20/2017 at 3:07 PM, she stated if there was a fall or injury, staff would call the supervisor, stay with the resident and make them comfortable until the Nursing Supervisor arrived to assess them. She did not know what caused the laceration on the bridge of the resident's nose, but did remember putting skin prep on the area as ordered. During an interview with the Director of Nursing (DON) on 7/21/2017 at 11:30 AM, she stated she was aware of the fall, the laceration and the bruising. She had investigated all incidents including speaking to other staff and re-creating/ lining up the thigh bruise with the dining room table. She had no documentation of interviews with staff regarding the incidents or of the re-creation. The DON stated the bruise lined up with the dining room table and the laceration lined up with the round PVC pipe on his merry walker. The DON stated the laceration to the bridge of the nose was not significant and that was why an incident report was not initiated. 10NYCRR 415.4(b)(2)

Plan of Correction: ApprovedAugust 18, 2017

F-225 INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS
I. The following actions were accomplished for the residents identified in the sample:
? Resident #3 ?
o The investigation for the identified fall was completed on 7/3/2017 and the investigation for the bruising to his legs was completed on 6/9/2017. An investigative summary has been completed for both. Abuse and neglect have been ruled out.
o An investigation for the facial laceration was completed on 7/21/17, and an investigative summary has been completed. Abuse and neglect have been ruled out.

II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice:
? A full house audit has been completed for all incidents identified since 7/21/17.
? Each incident identified has been thoroughly investigated, and an Incident Documentation Tool has been completed with an investigative summary ruling out evidence of abuse or neglect.
III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility?s guidelines ensure that:
? Investigative reporting policy has been reviewed and revised to include: all incidents will have an Incident Documentation Tool with an investigative summary completed to rule out abuse and neglect.
? The investigative summary will be documented under ?Statement? section in the A&I module of SigmaCare.
? All staff will be educated on the new procedure and process.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
? An audit tool has been developed to review that an Incident Documentation Tool along with the Investigative Summary ruling out abuse and neglect has been completed for each incident.
? Performance Improvement Director will conduct quality assurance monitoring audits of staff practice relative to the completion of the Incident Documentation Tool along with the Investigative summary ruling out abuse and neglect for each completed incident.
? QA monitoring will be conducted weekly for 3 months until such time that 100% compliance is achieved.
? Findings and actions taken will be reported to the Quality Assurance Committee monthly. Frequency of on-going audits will be determined by the Committee based on audit results
Completion Date: (MONTH) 8, (YEAR)
Responsibility: Director of Nursing

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 21, 2017
Corrected date: September 8, 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 ensure each resident received services provided by qualified persons in accordance with each resident's written plan of care for 2 of 24 residents reviewed (Residents #8 and 20). Specifically, Resident #8 was not consistently provided care-planned interventions to prevent falls and skin tears, and Resident #20's interventions to prevent recurrent falls were not consistently updated in the comprehensive care plan (CCP). Findings include: 1) Resident #8 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 6/15/2017 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, had sustained skin tear(s) and a fall, and required extensive assistance with bed mobility, dressing and transfers, and limited assistance with ambulation. SKIN TEARS: Accident and Incident Reports documented: - On 6/18/2017, the resident sustained [REDACTED]. - On 6/19/2017, the resident sustained [REDACTED]. The corrective measure included to add tubi-grips to the resident's arms. - On 7/8/2017, the resident sustained [REDACTED]. The comprehensive care plan (CCP) updated on 6/19/2017 documented the resident was at risk for impaired skin integrity and interventions included tubi-grips (elastic bandages) to arms and legs, on in AM, and off at HS (bed time). The certified nurse aide (CNA) care instructions were updated on 6/20/2017 to include tubi-grips to arms and legs. A 6/22/2017 registered nurse (RN) progress note documented the interdisciplinary team met to discuss the resident's skin tears sustained on 6/18 and 6/19/2017. The current care plan interventions were reviewed and interventions in place were followed. The interdisciplinary team would add tubi-grips to arms and legs for protection. A 7/14/2017 RN progress note documented the interdisciplinary team met to discuss the resident's skin tear to the left wrist sustained on 7/8/2017. The current care planned interventions were reviewed and interventions in place were followed. The interdisciplinary team would add tubi-grip to both arms as a new intervention to prevent further re-occurrence. On 7/19/2017 at 5:21 PM, on 7/20/2017 at 10:00 AM, and on 7/21/2017 at 10:40 AM the resident was observed without tubi-grips on her arms. The CNA Documentation Record documented the CNAs completed/provided the resident's total program of care from 7/19-7/21/2017. The CNA was interviewed again on 7/21/2017 at 2:30 PM and she stated the resident did not have tubi-grips on her arms because she couldn't find any and she would have to ask a nurse. The tubi-grips may have been in the laundry and never came back. During an interview with CNA #28 on 7/20/2017 at 4:20 PM, she pointed out the tubi-grips on the resident's legs. There were no tubi-grips observed on the resident's arms. The CNA was interviewed again on 7/21/2017 at 2:30 PM and she stated the resident did not have tubi-grips on her arms because she couldn't find any and she would have to ask a nurse. The tubi-grips may have been in the laundry and never came back. FALLS: The 4/4/2017 CCP documented the resident was at risk for falls. The CCP was updated on 7/17/2017 to include Dycem (non-slip material) on top of the recliner cushion. A 7/9/2017 Accident and Incident report documented the resident had a fall out of the recliner chair in her room. The interdisciplinary team met and the resident's plan of care would be updated to include a Dycem on top of recliner cushion to prevent further re-occurrence. The CNA instructions updated on 7/17/2017 documented the resident used a wheelchair for ambulation on and off the unit, transferred with a walker and a gait belt. On 7/17/2017 the instructions were updated to include Dycem on top of the recliner cushion. On 7/21/2017 at 10:40 AM, the resident was observed sitting in her recliner without the Dycem in place. During an interview with registered nurse (RN) #17 on 7/21/2017 at 12:20 PM, she stated she updated the care plan and the CNA instructions when changes occurred. She verbally told staff when changes occurred and reminded staff to look for updates. The CNA signature indicated all care on the CNA assignment had been provided. 2) Resident #20 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 5/10//2017 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assist of 2 for transfers, and limited assist of 1 for locomotion in a scoot chair (chair that facilitates independent mobility using resident's feet), and was non-ambulatory. On 10/25/2016 the Resident Nursing Instructions (care instructions) documented the resident was able to self-propel in a scoot chair with right lateral support and pommel cushion (cushion to prevent sliding). The comprehensive care plan (CCP) dated 10/31/2016 documented the resident required extensive assist of 2 with mechanical lift for transfers, limited assist of 1 in a scoot chair with right lateral support cushion with Dycem, and the resident was non-ambulatory. The 11/18/2016 CCP documented the resident was at risk for falls. Interventions included nonskid socks at HS (bedtime) and a scoot chair with lateral support. The occupational therapy (OT) discharge plans and instructions dated 12/1/2016 documented the resident was to continue right lateral support and a new scoot chair was provided. The pommel was removed and the resident was sitting on a wedge to maintain sitting balance and reduce lateral lean. There was no documented evidence the CNA care instructions and care plan had been updated to reflect OT recommendations. During an interview with CNA #27 on 7/21/2017 at 11:40 AM, she stated the resident no longer had a pommel cushion and she now used a cushion with Dycem and a lateral arm support. During an interview with registered nurse (RN) #17 on 7/21/2017 at 12:20 PM, she stated she updated the care plan and the CNA instructions when changes occurred. She verbally told staff when changes occurred and reminded staff to look for updates. The CNA signature indicated that all care on the CNA assignment had been provided. She stated the resident's pommel cushion must have gotten lost in the shuffle. 10NYCRR 415.12(h)(1)

Plan of Correction: ApprovedAugust 18, 2017

F-282 SERVICES BY QUALIFIED PERSONS/PER CARE PLAN
I. The following actions were accomplished for the residents identified in the sample:
? Resident #8 ? Tubi-grips have been obtained from the laundry and placed on the resident?s upper extremities per care plan.
? Resident #20 ? The care plan and CNA instructions have been updated to reflect the OT recommendation.

II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice:
All residents have the potential to be affected by this practice:
? An audit has been completed for all residents to verify fall and skin related interventions are being implemented per individualized comprehensive care plan.
? A full house audit has been completed to identify all residents who have a Positioning device / Specialized Cushion as outlined by their individualized comprehensive care plan.
o Care plans, CNA instructions, and icons have been reconciled for all residents who were identified as requiring a Positioning device / Specialized Cushion.

III. The following system changes will be implemented to assure continuing compliance with regulations:
The facility?s guidelines ensure that:
? Protective equipment
o Every resident care planned for tubi grips will be issued 2 sets
? Positioning devices / Specialized cushions
o When a resident requires a positioning device (including specialized cushions)
1. Therapy will send an OUTLOOK message to the THERAPY UPDATE group.
2. The individualized comprehensive care plan and Nursing instructions will be updated
3. The newly created icon for Positioning device / Specialized Cushion will be activated
? All staff have been educated on the process
? An weekly audit tool will be developed to review all residents who have fall and skin related interventions are updated in the care plan, CNA instructions and physically implemented.

IV. The facility?s compliance will be monitored utilizing the following quality assurance system:
? Utilizing the newly revised audit tool, the DON/ADON will conduct a quality assurance audit of 2 residents per unit per week to ensure that fall and skin related interventions are being implemented.
? QA monitoring will be conducted weekly for by the DON/ADON for 3 months until such time that 100% compliance is achieved.
? Findings and actions taken will be reported to the Quality Assurance Committee monthly. Frequency of on-going audits will be determined by the Committee based on audit results.


Completion Date: (MONTH) 8, (YEAR)
Responsibility: Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:AISLE, CORRIDOR, OR RAMP WIDTH

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 7, 2017
Corrected date: September 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, the facility did not maintain the required 4 foot corridor width to the ends of the corridors on each of the 4 units, which primarily affected 8 of the 96 resident rooms in the facility (resident rooms #110, 122, 210, 222, 310, 322, 410, and 422). Specifically, the corridor width was restricted to approximately 4 feet in clear width between the end room on each corridor wing, and the remainder of the nursing unit. Findings include: A letter from a registered architect dated 8/7/2017 documented an FSES (Fire Safety Equivalent System) analysis was done in 8/2017, and it was determined the facility was deemed compliant by passing the FSES. Due to the original construction, which included an unusual design in the corridors at the ends of each corridor wing, there was a [MEDICATION NAME] at the end of each corridor wing, which reduced the corridor width to less than four feet. These areas were located outside resident rooms #110, 122, 210, 222, 310, 322, 410, and 422. The surveyor observed the narrow corridor areas outside rooms as follows: - rooms [ROOM NUMBERS], on 8/7/2017 between 10:29 AM and 10:43 AM; - rooms [ROOM NUMBERS], on 8/7/2017 between 10:05 AM and 10:29 AM; - rooms [ROOM NUMBERS], on 8/7/2017 between 9:46 AM and 10:05 AM; and - rooms [ROOM NUMBERS], on 8/7/2017 between 9:15 AM and 9:46 AM. During an interview on 8/7/2017 at 2:40 PM, the Maintenance Director stated the facility, related to the issue with the narrow corridor at each end of the wings, had passed the FSES. The Centers for Medicare & Medicaid Services recognizes the 2013 edition of NFPA 101A, Guide on Alternative Approaches to Life Safety, (also known as the Fire Safety Equivalent System, or FSES). This standard provides alternative approaches to life safety based on equivalent safety concepts. A building determined to have equivalent safety to the requirements of the NFPA 101, Life Safety Code, is deemed to be compliant for the identified deficient requirement. In the event the facility would like to continue to be deemed compliant via the FSES, the Plan of Correction should request a continuation of the FSES. 2012 NFPA 101 19.2.3.4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedAugust 23, 2017

1) Request for continuation of FSES.
1) Request for continuation of waiver.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 7, 2017
Corrected date: September 15, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure that 4 of 4 smoke/fire barriers observed were constructed to a 1 hour fire resistance rating (fourth floor A side barrier, fourth floor B side barrier, third floor C side barrier, and second floor A side barrier). Specifically, these smoke/fire barriers had unsealed penetrations. Findings include: On 8/7/2017, between 2:27 PM and 2:38 PM, a surveyor observed the following 1 hour fire rated smoke/fire barriers had unsealed penetrations: - the fourth floor A side smoke/fire barrier had an unsealed conduit with fire alarm wires passing through it and the inside of the conduit was not sealed; - the fourth floor B side smoke/fire barrier had an unsealed conduit with fire alarm wires passing through it and the inside of the conduit was not sealed; - the third floor C side smoke/fire barrier had an unsealed conduit with fire alarm wires passing through it and the inside of the conduit was not sealed; and- the second floor A side smoke/fire barrier had an unsealed conduit with fire alarm wires passing through it and the inside of the conduit was not sealed. During an interview on 8/7/2017 at 2:40 PM, the Maintenance Director stated he was not aware of the unsealed penetrations in the observed smoke/fire barrier walls. He stated the fire alarm wires were installed approximately 7 months ago as part of fire alarm upgrade. 2012 NFPA 101: 19.3.7.3 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedAugust 31, 2017

1)
A. 4th floor A smoke/fire barrier will be sealed.
B. 4th floor B smoke/fire barrier will be sealed.
C. 3rd floor C smoke/fire barrier will be sealed.
D. 2nd floor A smoke/fire barrier will be sealed.
2) Fire alarm company will conduct a full building smoke barrier audit on all new fire alarm penetrations.
3) The facility Maintenance Director will conduct a monthly walk through using a standardized and uniform Quality Assurance tool, to inspect the facility smoke barrier components and check for penetrations which will include future renovations and/or additions until such time that 100% compliance is achieved.
4) The facility Maintenance Director will report any non-compliance findings to the Safety Committee. Safety Committee will track and trend the findings and report to the quarterly QAPI committee for 9 months with ongoing frequency to be determined by the committee.
Responsibility: Director of Maintenance