Glendale Home-Schdy CNTY Dept Social Services
June 1, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and (ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident?s medical record. (iv)In consultation with the resident and the resident?s representative (s)- (A) The resident?s goals for admission and desired outcomes. (B) The resident?s preference and potential for future discharge. Facilities must document whether the resident?s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 1, 2017
Corrected date: July 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification and abbreviated survey (Case #NY 476), it was determined the facility did not ensure a comprehensive care plan (CCP) was developed for each resident to meet medical, nursing, and psychosocial needs identified in the comprehensive assessment for four (Resident #'s 49, 65, 186, and #201) of 30 residents reviewed Specifically, the facility did not ensure: for Resident #186, there was a CCP addressing the use of a continuous positive airway pressure ([MEDICAL CONDITION]) machine or oxygen use; for Resident #49 and #65, there was a CCP addressing the use of psychoactive medications, for Resident #201, the facility did not ensure that a comprehensive care plan for stage 2 and unstageable pressure ulcers. This is evidenced by: A review of the Policy & Procedure (P&P) titled Care Plans-Comprehensive, dated [DATE] documented: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each Resident's comprehensive care plan is designed to: incorporate identified problem areas; incorporate risk factors associated with identified problems, build on the resident's strengths; reflect the resident's expressed wishes regarding care and treatment goals; reflect treatment goals, timetables and objectives in measurable outcomes; identify the professional services that are responsible for each element of care; aid in preventing or reducing declines in the resident's functional status and/or levels; enhance the optimal functioning of the resident by focusing on a rehabilitative program; and reflect currently recognized standards of practice for problem areas and conditions. Resident #65: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of [DATE], assessed that the resident rarely understands, was rarely understood, and had severely impaired cognitive ability. It also documented the resident had verbal and other behavior on ,[DATE] of 7 days prior. It identified the resident received antipsychotic and antidepressant medication for the 7 days prior. Physician admission orders [REDACTED]. The Medication Administration Record [REDACTED]. The (MONTH) and (MONTH) MARs also documented [MEDICATION NAME] given as ordered including the PRNs. A CCP initiated on [DATE], for [MEDICAL CONDITION] Medication Use documented the following goal: The resident will maximize functional potential and well-being while minimizing use of medication. The CCP did not include interventions to accompolish the goals. The CCP did not include specific interventions for staff to utilize prior to administering PRN [MEDICATION NAME]. During interview on [DATE] at 2:56 pm, the Registered Nurse Manager looked in the computer for the resident's CCP for psychoactive medications. She stated she did not initiate the CCP. The person who did, did not put the interventions in. She stated she was not aware, when she puts notes about medications in the CCP, she puts them under the Mood CCP. Resident #186: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of [DATE], assessed that the resident is understood, usually able to understand, and has moderately impaired cognitive ability. physician's orders [REDACTED]. Review of CCP's did not include a CCP that addressed the use of the [MEDICAL CONDITION] or oxygen. During an interview on [DATE], the Registered Nurse Manager (RNM) reported the resident should have Care Plans addressing the use of oxygen and [MEDICAL CONDITION] and she did not. The RNM reported the resident was transferred from the Rehabilitation Unit and during the Care Plan audit she should have recognized the missing Care Plans. Resident #201: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident was cognitively intact, and could understand others and make himself understood. The resident expired on [DATE]. A review of the Push Tool forms (The Pressure Ulcer Scale for Healing, was developed by the National Pressure Ulcer Advisory Panel (NPUAP) as a quick, reliable tool to monitor the change in pressure ulcer status over time.) dated weekly from [DATE] through [DATE], revealed that on [DATE], the resident had two pressure ulcers (pu) with no date of discovery, one on the left ischial 1.6 centimeters (cm) x 1 cm x 0 cm, and one on the left buttock 2 cm x 0.4 cm x 0 cm. On [DATE], the Push Tool documented a pu (unstageable deep tissue injury(pressure-related injury to subcutaneous tissues under intact skin) 7 cm by 5 cm. A Nursing progress note dated [DATE], documented right heel with purple area 7 cm x 5 cm deep tissue injury. Skin prep applied, bilateral heels off loaded from bed. Order sent for heel cushions X 2. Patient educated on pressure injuries and skin breakdown, MD notified via documentation. On [DATE], the Push Tool documented a pu to the right heel 7cm x 5cm x 0.1cm, one to the left buttock 6cm x 3cm x 0.1cm, right buttock 10cm x 3cm x 0cm, and the coccyx 5cm x 3cm x 0cm. There was no documentation of a second pu to the left buttock which was documented the previous week. A review of the Comprehensive Care Plan (CCP) revealed a care plan titled Skin integrity, at risk for skin breakdown dated [DATE], documented; at high risk for skin breakdown related to Braden Scale score, decreased mobility, incontinence, [MEDICAL CONDITIONS], or malnourishment. During an interview on [DATE] at 9:25 am, the Registered Nurse Manager (RNM) stated an actual pressure sore care plan should be initiated with any new wound, and updated with any additional wounds or interventions. The RNM stated she did not know why there was not a care plan for wounds that started in (MONTH) or (MONTH) (YEAR). During an interview on [DATE] at 3:10 pm, the Director of Nursing (DON) stated all the residents should have a skin integrity care plan. If there is presence of a pressure sore, there should be specific care plan for that, with any new interventions added to care plan. 10 NYCRR 415.11(c)(1)

Plan of Correction: ApprovedJune 27, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element # 1 Residents # 49, #65, and #186 who were found to not have a comprehensive care plan developed to meet their medical, nursing and psychosocial needs have been reviewed using the RAI process and the care plans have been updated as needed They are unaffected and their present care plan reflects the services which are furnished to attain or maintain the resident?s highest practicable physical , mental and psychosocial wellbeing. Resident # 201 is deceased .
Element # 2 All residents have a potential to be affected. A full house audit will be completed to ensure that each resident has a care plan related to the services provided, their diagnoses, and to meet medical, nursing and psychosocial needs.
Element # 3 All registered nurses will receive education related to care planning and the need to initiate new care plans as the resident?s needs change. An EMR review will be conducted at least weekly to ensure the initiation of a care plan related to new physician orders, new [DIAGNOSES REDACTED]. The day supervisor or designee will run a report on new or changed orders to monitor for care plans needed on a daily basis.
Element # 4 An audit will be conducted weekly for new [DIAGNOSES REDACTED].?s medical, nursing and psychosocial needs, with results to the QA committee who will determine the frequency thereafter.
Responsible Party: DON or designee

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 1, 2017
Corrected date: July 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey, the facility did not ensure that each resident's drug regimen remained free from unnecessary drugs for 4 of 30 residents reviewed. Specifically: For Residents #'s 65, 73, and #144 there was a lack of consistant indications for the use of PRN (as needed) psychoactive medication as well as lack of consistant documentation of effectiveness of the PRN medication; For Residents #s 81 and 144, the facility did not ensure that the resident's pain was adequately monitored to determine the effectiveness of the medication and the need for their continued use. In addition for Resident #144, the facility did not ensure that non pharmaceutical interventions were attempted prior to administration of the narcotic and [MEDICATION NAME]. This is evidenced by: A facility Policy titled Antipsychotic Medication Use dated 5/12/17, documented the nursing staff will document in detail an individual's target symptoms and the staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions including antipsychotic medications. A Pain Rating Scale shall be completed and documented to identify and monitor the level of pain and/or the effectiveness of treatment modalities until the resident achieves consistent pain relief control AHRQ, National Guideline Clearinghouse. Health Care Association of New Jersey (NCANJ): (MONTH) 18.23. Resident #73: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set of 5/11/17, assessed the resident rarely understands, was sometimes understood, and had severely impaired cognition. It documented the resident had physical and other types of behaviors for 1-3 of the previous 7 days. A physician order [REDACTED]. The Medication Administration Record (MAR) for (MONTH) (YEAR) documented: PRN [MEDICATION NAME] given on 3/10, 3/11, 3/12, 3/18, 3/22, 3/25, 3/26, 3/27, 3/31/17. The MAR did not document why the PRN was given or the effectiveness of the PRN medication. Progress Notes for (MONTH) documented: 3/10/17 at 10:59 am increased agitation, calling for her husband repeatedly, going to other residents stating they were her husband. Unable to redirect. PRN [MEDICATION NAME] ([MEDICATION NAME]) given with positive effects. 33/12/17 at 12:16 pm given PRN at 10:30 am for increased agitation, grabbing at staff and calling out. Given with good effect. 3/18/17 no note about the PRN being given. 3/22/17 at 2:54 pm PRN [MEDICATION NAME] given for weepiness and anxiety, will monitor for effect. 3/26/17 at 6:55 pm PRN [MEDICATION NAME] given at 4:00 pm for increased anxiety and crying. Positive effect. 3/11, 3/25, 3/27, 3/31/17 documented appropriate indications for use and effectiveness. The MAR for (MONTH) (YEAR) documented: the PRN [MEDICATION NAME] given on 4/1, 4/7, 4/8, 4/9, 5/15, 4/23, and 4/24/17. This MAR did not include documentation regardng the reason the PRN was given or the effectiveness of the PRN medication. Progress notes for (MONTH) documented: 4/1/17 at 10:32 pm increased agitation, stating she needed to find her mother and husband, almost running over other residents and staffs feet. Attempted to redirect to quiet area, but resident just returned and repeated the same. PRN [MEDICATION NAME] given with effective results. 4/8/17 at 10:31 am some agitation noted today, received PRN [MEDICATION NAME] with very little effect. 4/9/17 no progress note about the PRN given 4/15/17 at 2:08 pm resident walking down the hall way without asistance, walked from her room to the nurses station. Non compliant, refused to sit in wheel chair or unit furniture. Continually attempting to stand/walk without assistance. PRN [MEDICATION NAME] given. 4/23/17 at 2:16 pm PRN given at 10:50 am due to crying out repeatedly for family, and trying to get out of bed without assistance. PRN effective, resident in bed asleep. 4/7 and 4/24/17 had appropriate indications for use and effectiveness. The MAR for (MONTH) (YEAR), documented the PRN [MEDICATION NAME] given on 5/2, 5/10, 5/11, 5/17 x 2, 5/18, and 5/20/17. This MAR did not include documentation regarding the reason the PRN was given and documented E for effectiveness of the PRN medication. 5/2/17 at 2:32 pm resident very combative today, hitting staff, yelling she wanted her mother, PRN [MEDICATION NAME] given with positive effect. 5/10/17 at 2:42 pm PRN [MEDICATION NAME] (? meant [MEDICATION NAME] since that is what was documented on the MAR) given at 1:40 for increased anxiety and increased restlessness, unable to redirect or quiet down,will monitor per policy. 5/17/17 at 2:01 pm received PRN [MEDICATION NAME], very anxious, grabbing at others, crying. Resident was just toileted. Unable to verbally calm. At 3:20 PRN had some effect. 5/17/17 at 9:01 pm PRN [MEDICATION NAME] given for increased anxiety. staff unable to redirect. 5/18/17 no progress note about the PRN given. 5/20/17 at 10:01 am [MEDICATION NAME] given at 10:00 am for anxiety. Resident standing up, taking belt off, walking, having near fall x 2. Resident weepy, crying for husband, father, mother, sister. Unable to console. At 11:08 am PRN effective. During interview on 5/31/17 at 2:29 pm, an LPN (Licensed Practical Nurse), who gave medications to the resident, stated that before giving a PRN you would try things like a snack, toileting, etc. and document it. If they did not work you give the PRN. The LPN stated that you have to document the reason why the PRN was given, includes what the resident was doing, it needs to be descriptive. The word anxious is not enough. Then she tries to document the effectiveness within the hour. The LPN stated that she uses the effectiveness button in the computer and does a follow up note. If effective she would say things like, sleeping, calm and if not effective would say what they were still doing. During interview on 5/31/17 at 2:55 pm, the Registered Nurse Manager (RNM) was asked about the PRN [MEDICATION NAME]. She stated that progress notes should say what the behaviors the resident is displaying are ( i.e rolling over toes, goes very fast. Then should document the interventions were that were tried before giving the PRN. If they did not work then give the PRN. Then you would document if the behaviors subsided. Resident #81: The facility did not ensure that PRN pain medications prescribed were adequately monitored to determine the effectiveness of the medications and the need for their continued use. This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had moderately impaired cognition and was sometimes able to understand others and was rarely/never understood. The Comprehensive Care Plan (CCP) for Pain related to turning and positioning, secondary to OA with an effective date of 3/01/16 documented a goal of resident will exhibit a decrease in nonverbal signs and symptoms of pain as evidenced by normal breathing, no moaning, no calling out, no facial grimacing, no distressed appearance or inability to console. The MDS under Section J, Health Conditions dated 4/26/17, documented under staff assessment for pain, vocal complaints of pain. Frequency of indicator of pain or possible pain in the last 5 days coded pain observed 1 to 2 days. A physician's orders [REDACTED]. The Electronic Administration Medication Record (EMAR) dated 4/2017, documented the resident received PRN [MEDICATION NAME]-[MEDICATION NAME] on 27 occasions. For each administration, the resident's pre-medication pain level was not documented. The reason for giving the PRN pain medication and the post-medication pain scale was not documented. The EMAR dated 5/2017, documented the resident received PRN [MEDICATION NAME]-[MEDICATION NAME] on 26 occasions. For each administration, the resident's pre-medication pain level was not documented. The reason for giving the PRN pain medication was not documented. Post-medication pain scale on 8 occasions documented not collected. Post-medication pain scale on 18 occasions was not documented. The nursing progress notes dated 4/2017, documented the effectiveness of giving PRN pain medication using the words some, good, positive or not effective on 12 occasions. Nursing progress notes documented that the PRN pain medication was given on 4 occasions with no documented evidence of the effectiveness. The nursing progress notes dated 5/2017, documented effectiveness of giving the PRN pain medication using the words, good, positive and effective on 11 occasions. Nursing progress notes documented the PRN pain medication was given on 2 occasions with no documented evidence of effectiveness. During an interview on 5/31/17 at 9:25 am, LPN #2 reviewed the 5/2017 eMAR for PRN [MEDICATION NAME] for right foot pain and could not find a drop down box entered into the eMAR. LPN #2 stated the nurse who initially entered the PRN pain medication into the computer was the person responsible for also modifying the pop up pain scale into the computer. She stated if there was a drop down box, this is where the nurses should enter a pain scale number. LPN #2 stated the nurses should be charting on every PRN medication being given either in the nurses notes or in the eMAR. If the medication is not effective, the physician should be called. She stated the effectiveness of the medication should be put in the nurses notes if there is no drop down box. During an interview on 5/31/17 at 11:45 am, RNM #1 stated the numeric pain scale should be used prior to giving and after the resident received PRN pain medication if the resident is able to verbalize their pain level using a numeric scale. This resident has dementia and a pain AD scale is supposed to be used which gives numeric pain level depending on intensity and type of non-verbal signs of pain. The RNM stated this pain scale is generated from the answers given using the pain AD scale. These are the only two types of pain scales the nurses are supposed to be using each time a PRN pain medication is given. The RNM stated using the words effective or ineffective are to be used only when giving a PRN anti-anxiety medication and not when giving a PRN pain medication. The RNM stated that every time a PRN medication is given, a nurses note should be written by the nurse. The RNM stated any any nurse can add the pop up to the eMAR if she sees it hasn't be entered or she can tell the RNM and she will enter it into the computer. Resident #144: The facility did not ensure that the residents pain level was adequately and appropriately monitored to evaluate the effectiveness of [MEDICATION NAME], a narcotic/ copied pain medication and [MEDICATION NAME], a non steroid noninflammable drug used for the relief of pain and inflammation. In addition the facility did not ensure that the antianxiety drug, [MEDICATION NAME], which was administered on a PRN basis was monitored for effectiveness and that non pharmaceutical interventions were attempted before administering [MEDICATION NAME]. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident also sustained a non displaced [MEDICAL CONDITION] humerus on 3/5/17. The Minimum Data Set ((MDS) dated [DATE], assessed the resident usually understands, is understood, and has severe cognitive impairment. A physician order [REDACTED]. The Medication Administration Record (MAR) for (MONTH) (YEAR), documented the resident received [MEDICATION NAME] 0.25 mg po q 6 hr prn on 3/14/ 17 and 3/21/17. There was no documentation regarding the effectiveness on the MAR or in the nursing progress notes. The MAR for (MONTH) (YEAR), documented that on 4/30/17, the resident received PRN [MEDICATION NAME] for increased agitation. There was no documentation on the MAR or nursing progress notes regarding it's effectiveness. The MAR for (MONTH) (YEAR), documented that the resident received the PRN [MEDICATION NAME] on 5/11/17, but there was no documentation regarding the reason for administering the [MEDICATION NAME] and for it's effectiveness on the MAR or in the nurses notes. A nursing progress note dated 4/22/17, documented that an attempt to redirect the resident was unsuccessful. This was the only documentation noted regarding interventions attempted prior to administering the PRN [MEDICATION NAME] during the months of March, (MONTH) and (MONTH) (YEAR). A physician's orders [REDACTED]. The MAR for (MONTH) (YEAR), documented [MEDICATION NAME] 5 mg capsule give 1 capsule (5 Mg) by oral route every 4 hrs as needed for pain related to fractured arm , MDD 6 doses. The MAR documented that the resident received doses on 3/6/17, 3/7/17, 3/8/17 and 3/9/17 for a total of 8 doses . There was no documentation on the MAR regarding the numeric pain scale at the time the resident was medicated and the follow up pain scale for these 8 doses. A physician's orders [REDACTED]. The MAR for the month of (MONTH) (YEAR), documented that the resident had received a total of 17 doses of [MEDICATION NAME] 200 mg po every 4 hrs as needed on 5/1/17, 5/3/17, 5/4/17, 5/6/17, 5/7/17, 5/9/17, 5/11/17, 5/12/17, 5/14/17, 5/15/17, 5/16/17,5/17/17, 5/19/17 5/29/17,and 5/30/17 . There was no documentation on the MAR regarding the resident's pre medication pain scale or a follow up post medication pain scale. During an interview with the Director of Nursing (DON) on 5/31/17 at 4:00 pm, the DON stated that the nurse is supposed to assess and document the level of pain per the numeric pain scale prior to administration of the pain medication and reassess the resident's pain level as a follow up to determine the effectiveness. The DON also stated that the nurses are to document reason and symptoms for administering the antipsychotic and do a follow up reassessment to evaluate the effectiveness During an interview with a Licensed Practical Nurse (LPN) #1 on 6/1/17 at 12:45 pm, LPN #1 stated that when a nurse is to medicate a resident for pain, the nurse is to ask the resident their numeric pain level on a scale of 1-10, with 10 being the worst and then as a follow up ask the resident their pain level to determine if the medication was effective. LPN #1 also stated that when medicating a resident with a prn antidepressant, antianxiety drug, or an antipsychotic, the nurse is to document in the computer the reason that the resident is being medicated and follow up with a notation of whether the medication was effective. In addition, LPN #1 stated that non pharmaceutical interventions are to be attempted and documented and if effective the resident does not need to be medicated. 10NYCRR415.12(I)(1)

Plan of Correction: ApprovedJune 27, 2017

Element # 1 Residents #65, #73, #81 and # 144 have been reviewed for administration of unnecessary drugs as evidenced by no adequate monitoring and no adequate indications for usage. The residents all remain stable and on appropriate medication regimen with adequate monitoring and adequate indications of use. The nurses who gave the medication without adequate indication for use and/or without adequate monitoring will be immediately re-education on interventions to try before medicating and following up effects of medication.
Element # 2 A full house audit of all residents receiving prn medication will be conducted to ensure that any resident receiving prn medication have the appropriate interventions offered before medicating and have the appropriate effectiveness monitoring completed.
Element # 3 All nurses will receive education on correctly administering prn medication regarding indications for use, trying and documenting non-pharmacological interventions, and documenting effectiveness after administration. A pop up will be placed in the EMR to prompt nurses to try non-pharmacological interventions before medicating.
Element # 4 A weekly audit will be conducted for 6 months to ensure that all prn medication have indications for use and effectiveness documented, with results to the QA committee who will determine the frequency thereafter.
Responsible party: DON or designee

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 1, 2017
Corrected date: July 31, 2017

Citation Details

Based on observation, record review, and staff interview during the recertification survey, it was determined that the facility did not adhere to generally accepted food sanitation practices. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Chapter 1 Subpart 14 State Sanitary Code, the community standard for food service establishments operating in New York State both state that automatic dishwashing machines are to function in accordance with the manufacturer instructions and chemicals used in food equipment sanitizing to kill bacteria are to be at the correct concentration. Specifically, the automatic dish washing machine was not rinsing in accordance with the manufacturer's instructions and the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than that required by the manufacturer. In addition, the facility did not ensure that the food on the residents trays were covered when trays were distributed from the steam cart located in the unit's dining room to the residents rooms. This is evidenced as follows. Finding #1: The facility did not ensure the automatic dish washing machine was rinsing in accordance with the manufacturer's instructions. The concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than that required by the manufacturer. The Main Kitchen was inspected on 05/25/2017 at 8:30 am. The automatic dish washing machine was rinsing at 180 degrees Fahrenheit and 15 pounds per square inch (psi) water flow pressure. The automatic dish washing machine instructions were reviewed on 05/25/2017. These instructions state that the final rinse flow pressure is to be between 20 and 25 psi. Equipment washing and sanitizing was taking place in the large 3-compartment sink. A sample of the QAC used in the sanitizing rinse sink, the third sink, was found to be less than 150 parts per million (ppm) when measured at 75 F. The manufacturer's label directions stated the concentration is to be between 150 ppm and 400 ppm when the solution is measured between 65 F and 75 F. The Food Service Director stated in an interview conducted on 05/25/2017 at 9:20 am, that the automatic dishwashing machine finial rinse pressure frequently needs adjustments and a Food Service Worker added cold water to the QAC solution to lower the temperature of the water. Finding #2: The facility did not ensure that the food on the residents trays were covered when trays were distributed from the steam cart located in the unit's dining room to the residents rooms. During observation of lunch on 5/25/17 at 12:00 pm, on the Dutch Hollow Unit, the staff was observed placing the uncovered individual bowls of fruit cocktail and uncovered individual bowls of salad on the residents trays and carrying the trays down the halls to the residents rooms. On 5/25/17 at 12:30 pm, Certified Nursing Assistant (CNA) #1 was observed placing an uncovered bowl of fruit cocktail on the resident's tray and carrying the tray with the uncovered fruit cocktail down the hall to the resident's room. During an interview on 5/25/17 at 2:40 pm, CNA #1 stated that all food should be covered when taking the tray from the steam cart to the resident's room. CNA #1 also stated she did not know why the facility does not have covered bowls for the fruit cocktail. On 5/25/17 at 12:40 pm, CNA #2 was observed placing salad in an individual salad bowl and placing the uncovered salad bowl on a resident's food tray and then carrying the food tray with the uncovered salad bowl from the steam table down the hall to the resident's room . During an interview on 5/25/17 at 2:50 pm, CNA #2 stated that all food on a tray should be covered when being delivered to a resident's room . 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.110

Plan of Correction: ApprovedJune 27, 2017

Element # 1 No residents were affected. Immediate correction to 3 bay sink.
Element #2 All residents have the potential to be affected by this. All pots and pans were rewashed and sanitized. Staff were educated.
Element # 3 Facility will use sanitizing strips and log twice daily as bay sink used to assure proper PPM. Daily observation documentation of PSI on dish machine with new valve when installed. Staff will be educated on policy and procedure related to water temperatures and related procedures.
Element # 4 Audits of sanitizing logs conducted daily for three months. Daily monitoring of pressure in dish machine audited for three months. Results of audits to present to QA to determine frequency thereafter.
Responsible person: Director of Food Service
Finding # 2
Element #1 Staff immediately corrected to ensure all foods covered when leaving dining room area.
Element # 2 Any tray that leaves the dining room will have all food items covered to ensure compliance.
Element # 3 New bowls and lids ordered for foods that leave the dining area. Staff education will be provided on importance of covering food when transporting out of dining area.

Element # 4 Monitor daily by food service, alternating meals for compliance to recorded on audit sheet, and report to QA monthly for three months. QA will determine frequency thereafter.
Responsible Party: Food Service Manager or designee

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 1, 2017
Corrected date: July 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey, the facility did not establish and 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 determined for 2 of 8 dressing changes observed. Specifically, for Resident #'s 36 and 88, the facility did not ensure proper precautions were maintained during dressing changes. This is evidenced by: Resident #36: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with a Brief Inventory for Mental Status (BIMS) score of 5; indicative of severe cognitive impairment, usually understands and sometimes is understood. A physician's orders [REDACTED].) treatment (Negative-pressure wound therapy (NPWT) is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds) to sacral decubitus 125 mm HG (A millimeter of mercury is a manometric unit of pressure, formerly defined as the extra pressure generated by a column of mercury one millimeter high. It is denoted by the symbol mmHg.) change three times a week and as necessary (prn) use black foam (wound vac. dressing material). During an observation of the wound vac dressing change to the resident's sacral decubitus on 5/31/17 at 10:10 am, the Registered Nurse Manager (RNM) began by washing her hands, gathering supplies and assisting a Registered Nurse (RN) and Certified Nurse Assistant (CNA) to position the resident onto his left side. The RN and CNA washed their hands prior to donning clean gloves to position the resident. The wound vac and tubing were on the floor; without a protective bag or covering. During positioning, the wound vac and tubing were placed directly on the bed sheets, approximately 14 inches from the wound. After positioning, the RNM washed her hands, sanitized the over the bed table and opened two sterile fields; one on the overbed table with the wound vac dressing material and another sterile field on the bed for wound irrigation (cleansing). After irrigating the wound with the irrigation set on the bed, the RNM picked up the irrigation sterile field to dispose of in the garbage, unaware that the paper field had folded over onto itself contaminating her sterile glove on her left hand. The RNM did not change her gloves, after contaminating them. While preparing the black foam for the wound area, the RNM realized she did not have sterile scissors on her sterile field and asked the CNA to leave the room and retrieve sterile scissors. The CNA removed her gloves and left the room without washing her hands and returned with the sterile scissors. The RNM removed her sterile gloves and opened the sterile scissors onto the sterile field. The RNM donned sterile gloves and completed the dressing change. During an interview with the RNM on 6/1/17 at 12:30 pm regarding the dressing change, the RNM stated she did not realize she had contaminated her left hand. She acknowledged that the CNA did not wash her hands after removing her gloves. She stated in the future she would not allow the wound vac or tubing to touch the floor and would place a barrier on the bed before placing the wound vac on the bed. Resident #88: This resident was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severely impaired cognition, sometimes could understand others and could rarely be understood. The MDS dated [DATE], documented under Section G, Functional Status, the resident required extensive assist for bed mobility. A Medical Progress Note dated 3/03/17, documented the resident had a rigid posture, her bilateral legs were rigid and spasmed upon movement. The resident's past medical history included peripheral vascular disease (PVD), non healing wounds to her left lower leg and spinal stenosis. Resident's skin exam dated 5/03/17, documented the resident had a wound on her left inner knee 1 cm x 1 cm x 0.1 cm unstageable deep tissue injury; pressure ulcer to the resident's right inner knee 1 cm x 1 cm x 0 cm unstageable deep tissue injury; and left ear unstageable deep tissue injury 4 cm x 0.3 cm x 0 cm. A physician's orders [REDACTED]. A physician's orders [REDACTED]. During an observation of dressing changes to the resident's left ear and left and right inner knees on 5/30/17 at 10:45 am, LPN #1 was not observed to wash the bedside table. The LPN stated she had just washed it. The dressing supplies were placed directly on the table. LPN #1 did not wash her hands prior to putting on a glove to her right hand and opening the gauze to be used to cover the resident's left ear. The LPN removed the old dressing to resident's left ear by holding the resident's ear with an ungloved left hand and removing the dressing with the gloved right hand. The LPN then washed and dried the wound and applied [MEDICATION NAME] to the resident's left ear pressure sore. The LPN then opened the drawer to the resident's bedside table to look for a comb, went into the resident's bathroom and returned with a comb. The LPN combed the resident's hair away from her ear, placed the gauze barrier to resident's left ear, removed the glove and washed her hands. The LPN then opened two packages of border gauze and initialed and dated them. The LPN removed the dressings to both the resident's left and right knee. The LPN then washed the left and right knee wounds with normal saline. The LPN used a small gauze pad to dry the left knee wound, turned the same gauze pad to the dry side and dried the right knee wound stating, this side is still good. The LPN applied santyl gel using a cotton tipped applicator to the right knee wound and covered the wound. Then applied santyl gel using a cotton tipped applicator to the left knee wound and applied a gauze covering. The LPN was not observed to wash her hands or change gloves during the two inner knee dressing changes. The LPN did not treat the wounds as two separate wounds as she did not complete one dressing change to the inner knee, wash her hands and change gloves and then proceed to the next inner knee dressing change. During an interview on 5/30/17 at 11:00 am, LPN #1 stated she thought she was washing her hands and changing gloves between dressing changes. During an interview on 5/30/17 at 11:10 am, the Registered Nurse Manager (RNM) stated the LPN should have washed her hands and changed her gloves between dressing changes. She stated the two knee wounds were two separate wounds and the LPN should have changed her gloves after doing one knee and should not have used the same gloves for both knee dressing changes. The RNM stated the LPN should not have used the same gauze pad to dry both wounds. She should have completed the dressing change to one knee wound before starting the other. She stated infection control measures should be followed during a dressing change. The NM stated the LPN should wear gloves on both hands during a dressing change. 10NYCRR 415.19(a)(1-3)

Plan of Correction: ApprovedJune 27, 2017

Element # 1 Residents # 36 and # 88 records were reviewed and are unaffected. Both nurses involved in dressing changes of resident # 36 and # 88 have been in-serviced in infections control and sterile dressing technique.
Element # 2 All residents have the potential to be affected and a whole house in-service will be conducted on infection control and sterile technique
Element # 3 After the completion of in-servicing on infection control and sterile dressing technique, the in-service will be conducted upon hiring and annually thereafter for all nurses.
Element # 4 A weekly audit on alternating dressing changes, will be done to ensure sterile technique and infection control, via visual monitoring to ensure measures are being implemented. This audit will continue for 6 months and will be reported to QA. QA will determine the frequency of said audits thereafter.
Responsible party: DON or 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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 1, 2017
Corrected date: July 31, 2017

Citation Details

Based on record review, staff interview, and Administrative Policy review during the recertification survey, it was determined that the facility did not conduct the minimum required background checks on new employees. Facilities must not employ individuals with an indication of unfitness for service as a licensed staff person. Specifically, a NY State Department of Health Bureau of Examiners of Nursing Home Administrators verification check was not conducted for 1 of 1 licensed new employees. This is evidenced as follows. The personnel file for the Administrator was reviewed on 05/30/2017. This record review revealed that the facility had not conducted a licensure verification check on this person prior to hire. The Senior Payroll Audit Clerk stated in an interview conducted on 05/30/2017 at 2:00 pm, that she can find no record the Administrator's license was verified as being valid prior to his being hired and that she thinks the responsibility for this check may be with the Schenectady County Human Resources Department. The facility policy Policy and Procedure for New Employee Applicants was reviewed on 05/31/2017. This policy states that for licensed professionals, an Office of Professional Discipline check will be conducted prior to hire, but is silent on checking the appropriate licensing authority. 483.13(c)(1)(ii)

Plan of Correction: ApprovedJune 23, 2017

Element # 1 Administrators license was verified on 1/3/17 as active. Re-verified on 6/21/17.
Element # 2 No other employees are included in this job category.
Element # 3 Schenectady County Human Resources under the County Manager will continue to assume the responsibility of verifying administrators license.
Element # 4 All newly employed licensed nursing home administrators license will be reported to the QA committee prior to start date of employment.
Responsible person: HR manager or designee

FF10 483.25(g)(1)(3):MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

REGULATION: (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident?s comprehensive assessment, the facility must ensure that a resident- (1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident?s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 1, 2017
Corrected date: July 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and observation the facility did not ensure it maintained acceptable parameters of nutrition, such as usual body weight, for 2 ( Resident #'s 54, and 79) of three residents reviewed for weight loss during the recertification survey. Specifically: the facility did not ensure that reweighs were done timely and that accurate weights were obtained. This is evidenced by: The facilities Weight Policy and Procedure dated 2/22/17, documented that Routine weights are monthly and are obtained by the seventh of the month. Under Procedure documented: #9. The CNA (Certified Nurse Aid) will inform the nurse of the weight result. The nurse will enter the weight book. The RD's Diet Techs will be responsible to enter into the EMR (electronic medical record). The nurse will then compare to the previous weight and if there is a discrepancy of 5 or more pounds a re-weight will be done by the following day; #18. Residents who have active [MEDICAL CONDITIONS] will be weighed three times weekly ( Monday, Wednesday, and Friday). Any weight gain of 5 lbs or more must be reported to the physician. Resident #54: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 5/4/17, assessed that the resident rarely understands or was understood and had severely impaired cognitive ability. The resident's computerized weight record documented: 11/7/16=192.3 lbs., 12/8/16= 175.7 lbs., 12/27/16=193.9 lbs. (written next to the weight reweight written in weight book, added to computer) 1/3/17= 194.7 lbs., 2/5/17 = 191.7 lbs., 3/7/17= 164.1 lbs. (no reweigh), 3/24/17= 183 lbs., 3/25/17= 190.2 lbs, 3/29/17=192.1 lbs., 4/5/17= 190 lbs., 5/2/1= 188.9 lbs. A Nutrition assessment dated [DATE], documented a weight of 191.7 lbs. and that the weight was stable for the last 6 months. The resident remained above DWR (desirable weight range), weight is stabilized and resident is tolerating Consistent Carbohydrate diet. There was no mention of the inconsistent weight of 12/8/16. A Dietary progress note dated 3/24/17, documented (MONTH) weight of 164 lbs., down from Feb. weight of 192 lbs. Per weight history the past 6 months, the resident's weight fluctuates substantially from month to month. Jan. weight 195 lbs, Dec. weight 176 lbs., Nov. weight 194 lbs. Sept. weight 189 lbs. Will continue to follow resident's progress, she has been placed on weekly weights x 2 weeks since last week for closer monitoring. Gradual, slow weight loss desired, but large losses month to month are discouraged. A Dietary note dated 3/27/17, documented an addendum fro the above note. Weight recorded as (MONTH) weight (164 lbs) was erroneous. Actual weight obtained 3/25/17 noted to be 190.8 lbs which is in line with Feb. weight. Resident will be weighed this week. If weight is similar to Feb. and (MONTH) weights, will resume monthly weights, otherwise may extend weekly weights to monitor weights more closely until stabilization occurs. A Dietary note dated 4/13/17 documented (MONTH) weight reported to be 190 lbs. which is in line with weights prior to (MONTH) weight. Due to likely erroneous weight recorded in March. Resident was on weekly weights in March, no other weight was as low as the 164 lbs at the beginning of the month. Will continue to follow progress. The resident has no changes in intake or medical condition lately. During interview on 6/1/17 at 9:29 am the Diet Technician (DT) stated they have been without a second DT for the past 3 months. He was asked about the resident's weight in Dec of 175.7 lbs. He stated a reweigh was done 12/27/16. He was asked about the weight policy nursing follows. he said that the policy was that nursing would do a reweight if a resident's weight changed up or down 5 lbs. He said the Dec. reweigh was not done in the time it should have been. He said they have had issues with reweighs. During interview on 6/1/17 at 9:50 am the Registered Dietitian (RD) she stated that a weight change of 5 lbs up or down needed a reweigh which would be done the next day. She said that nursing did not need to be notified that a reweigh was needed, it was policy. The RD stated that hat the first weight change (Dec) was before her time there. She was asked about the (MONTH) weight of 164 lbs. She said she would have asked for a reweigh to be done but could no say when that was it was not documented. She said that waiting til the 24th was an exorbitant amount of time to wait for a reweigh. The RD stated there had been problems getting accurate weights. Just recently the County Weights and Measures came to look at the scales. They said to contact the scale company. She was asked why it took so long for a dietary note about the 164 lb weight. She said she was waiting to get an accurate weight. Resident #79: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set of 5/11/17, assessed that the resident sometimes understands, was sometimes understood, and had a BIMS of 3/15 or severely impaired cognitive ability. The resident's computerized weight record documented: 3/1/17 =130.3 lbs., 3/3/17 = 126.5 lbs., 3/8/17 =128.6 lbs., 3/15/17 =130.3 lbs., 3/17/17 =124.4 lbs., 3/20/17= 132.6 lbs., 3/22/17 =130.9 lbs., 3/24/17 = 131 lbs., 3/27/17 =130.2 lbs., 3/29/17 =130.2 lbs., 3/31/17 =130 lbs., 4/3/17 =131.3 lbs., 4/7/17 =124.5 lbs., 4/10/17 = 127.1 lbs., 4/12/17 =125.1 lbs., 4/14/17 =127.5 lbs., 4/17/17 =128 lbs., 4/19/17 = 130.4 lbs., 4/21/17=127.9 lbs., 4/24/17 = 126.7 lbs., 4/26/17 = 124.8 lbs., 4/28/17 = 125.1 lbs., 5/1/17 = 124.8 lbs., 5/5/17 = 124.8 lbs., 5/8/17= 120.2 lbs., 5/10/17 = 120.2 lbs., 5/12/17 = 121.7 lbs., 5/15/17 = 121 lbs., 5/17/17 = 120.7 lbs., 5/19/17 =120 lbs., 5/22/17 = 118.1 lbs., 5/24/17 =118.2 lbs. with reweigh of 120.9 lbs. During interview on 6/1/17, at approximately 3:00 pm, the RNM (Registered Nurse Manager) was asked about the resident's weights. She stated the resident is on [MEDICAL CONDITIONS] protocol which means she is weighed every Monday, Wednesday and Friday. She stated she was not sure of the accuracy of the weights. She said she discovered the Pharmacy scale was calibrated but the unit scales were not routinely calibrated. She stated she wrote the Administrator and e-mail about her concern with the accuracy of the weights. She stated maintenance checked the scale by weighing himself and thought it was ok because it was within normal limits. Then the Adminstator asked for the County Weights and Measures to come check the scales. They said to have the scale company look at them. It is scheduled for (MONTH) 5th. She looked at the resident's weights and said some don't seem accurate. The resident is on [MEDICATION NAME] (diuretic medication) but there has not been a dose change since she came in. The RNM said that yesterday the weight was 116 lbs. in the morning and later in the afternoon it was 119.9 lbs. She said the resident is on supplements for her weight. 10NYCRR415.12(i)(1)

Plan of Correction: ApprovedJune 27, 2017

Element # 1 Weight discrepancies were identified for residents # 54 and # 79 and discussed at QA meetings in (MONTH) and April. The discrepancies were also reviewed at Nutrition at Risk committee meeting initiated by CNM/RD in (MONTH) (YEAR).
Element # 2 Residents having the potential to be affected by the same deficient practice will be identified by a +- 5# weight change. They will then be reweighed within 24 hours to verify or dispute the weight in question. If necessary, based on the professional judgment of the CMN/R, residents will be placed on frequent weight monitoring such as weekly weighting for a period of time designated by the CNM/RD.
Element # 3 The RD and head nurses will discuss any discrepancies at morning report on a daily basis. The clinical nutrition team will determine which residents need to be on the weekly weights list and the duration of weekly weights resident noted to require closer monitoring. The Nutrition at Risk committee meetings will continue on a monthly basis as a regular QA practice.
Element # 4 The RD will report any significant weight changes at QA on a monthly basis. A summary of the monthly NAR meeting minutes will be presented as part of the QA report. Weekly weight audits will be done on all residents using a weight audit tool for a total of six months. QA to determine the frequency thereafter.
Responsible party: Registered Dietician Manager
Element # 4

FF10 483.25(b)(1):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES

REGULATION: (b) Skin Integrity - (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual?s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 1, 2017
Corrected date: July 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey and abbreviated survey (Case #NY 476) it was determined the facility did not ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing for 2 (Resident #201, and #203) of 8 residents reviewed. Specifically: For Resident #201, the facility did not ensure that the weekly documentation for stage 2 pressure ulcers was accurate, that there was a comprehensive care plan (CCP) in place for the pressure ulcers, that turn & positioning documentation was complete, and that the resident received treatments for pressure ulcers from [DATE] through [DATE]; For Resident #203, the facility did not ensure timely and consistent pressure ulcer tracking and did not ensure the care plan addressed the actual alteration in skin integrity (pressure ulcers). This was evidenced by: A review of the Policy & Procedure (P&P) titled Pressure ulcer protocol, Overview dated ,[DATE] documented, a pressure ulcer protocol is administered through an interdisciplinary team at the facility towards the goal that a resident does not develop a pressure ulcer while in the facility unless assessment indicates risk is high and may be unavoidable. Documented under responsibility, preventive interventions are implemented promptly upon identification of risk upon admission, readmission change in condition. The HRN/Charge nurse directs licensed staff, educated to facility goals, per an individualized pressure ulcer protocol and prevention plan of care. Nursing provides prevention and therapeutic intervention measures per individual risk assessment and department process. A review of the P&P titled Pressure ulcer protocol documentation dated ,[DATE] documented, documentation following discovery of skin breakdown is provided to support that aggressive and appropriate care was provided with follow up as indicated. Documented under heading Pressure ulcer/vascular ulcer development MD progress note, weekly skin assessment sheet at onset of stage 1 or greater and weekly thereafter until healed. Resident #201: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, and able to understand others and make himself understood. The resident expired on [DATE]. A review of the Push Tool forms (The Pressure Ulcer Scale for Healing, was developed by the National Pressure Ulcer Advisory Panel (NPUAP) as a quick, reliable tool to monitor the change in pressure ulcer status over time.) revealed the tool documented the day of completion of the assessment on the top of the form, middle of the form is an anterior and posterior body sketch. The bottom portion of the form documented each pressure ulcer with the date identified, location, size, exudate (drainage), tissue type, stage, appearance and treatment. The date identified (date wound was discovered) on the push tools was documented as the date of wound assessment. A review of the Push Tools dated weekly from [DATE] through [DATE], revealed that on [DATE] through [DATE] the resident had two pressure ulcers (pu) with no date of discovery, one on the left ischial 1.6 centimeters (cm) x 1cm x 0cm, and one on the left buttock 2cm x 0.4cm x 0cm. The facility did not ensure the care plan addressed the actual alteration in skin integrity (pressure ulcers). Finding #1: The facility did not ensure the care plan addressed the actual alteration in skin integrity (pressure ulcers). A review of the Comprehensive Care Plan (CCP) included a care plan titled Skin integrity, at risk for skin breakdown dated [DATE]. The care plan documented; at high risk for skin breakdown related to Braden Scale score, decreased mobility, incontinence, [MEDICAL CONDITIONS], or malnourishment. Resident digs at own skin (particularly on arms). Finding #2: The facility did not ensure that the weekly documentation for stage 2 pressure ulcers was accurate. The Push Tool documented: On [DATE] documented pu left buttock, and right cheek (buttock). On [DATE] documented a pu left buttock and left lower buttock. On [DATE] documented a new discovery of pu (unstageable deep tissue injury(pressure-related injury to subcutaneous tissues under intact skin) 7 cm by 5 cm right heel. On [DATE], documented a pu on the right heel, the left lower buttock, and the right cheek. On [DATE], documented a pu on the right heel, left buttock, and the right cheek. On [DATE], documented a pu on the right heel, left lower buttock, right cheek. On [DATE], documented a pu right heel, left buttock, right cheek. On [DATE], documented a pu to the right heel, two to the left buttock, the coccyx. On [DATE], documented a pu to the right heel, left lower buttock, right buttock, and coccyx On [DATE] and [DATE], the Push Tool documented a pu on the left buttock 1 cm x 1 cm x 0.1cm, and the left ischeal 1 cm x 1 cm x 0.1 cm. On [DATE], the Push Tool documented a pu on the left buttock 3cm x 2cm x 0.1cm, and the left ischial 2cm x 0.5cm x 0.2cm. Finding #3: The facility did not ensure the resident received treatments for pressure ulcers from [DATE] through [DATE]. A review of the Treatment Administration Records (TARs) for (MONTH) and (MONTH) (YEAR) documented: [DATE] through (MONTH) 5 (YEAR); The TAR documented treatments were completed from [DATE] through [DATE]. On [DATE] the TAR documented [MEDICATION NAME] AG wound dressing to left lower buttock and right lower buttock change daily and prn. The TAR did not include treatments to the buttock areas from . A review of physician orders did not include an order to discontinue the dressing changes on [DATE]. Finding #3: The facility did not ensure that turn & positioning documentation was complete. A review of the Turn and Position (T&P) documentation in the electronic medical record (EMR) under the column scheduled from [DATE] through [DATE], revealed the T&P was scheduled for every three hours 12:00 am, 3:00 am, 6:00 am, 9:00 am, 12:00 pm, 3:00 pm, 6:00 pm and 9:00 pm. The T&P documentation revealed that on 22 of the 87 days T&P was performed all three shifts, on the remainder of the 87 days T&P was documented sporatically. A physician order dated [DATE], documented turn and reposition every 2 hours, use wedge cushion keep on side. A review of the T&P documentation in the EMR under the column scheduled from ,[DATE] through [DATE] revealed the scheduled times for T&P varied from 34 minutes apart to 2 hours and 54 minutes apart. The column documentation revealed that 6 of the 6 days T&P was documented sporatically. Interviews: During an interview on [DATE], the RN, MDS Coordinator stated that in the CNA documentation and T&P schedule that inactive means the task is shut off and cannot be signed. During an interview on [DATE] at 9:25 am, the Registered Nurse Manager (RNM) stated the Push Tool wound assessment is done weekly. Discovery of a new wound is reported to a Registered Nurse (RN) who would do an initial assessment. The physician would give a treatment order and the RN should notify the family. This should all be written in the progress notes and a Push Tool should be done. The RNM reviewed the Push Tool dated [DATE], as the date identified and stated that to determine when the wound started would have to compare the first Push Tool to the nursing progress notes and if there was no initial note for the wound would have to keep looking back in the notes, that would be a lot of work. The RNM stated that wound tracking could be done a lot better, it is confusing how a new wound appears and a previous wound drops off week to week. When a weekly Push Tool is done the nurse is supposed to look at the previous week's Push Tool. The RNM had no idea how this documentation happened, any wound that does heal was supposed to be followed and documented on the Push Tool for 4 weeks. The RNM reviewed Resident #201 in the computer and stated there should been an actual wound care plan initiated when the wound was discovered, she could only find a care plan for potential for skin breakdown. The RNM stated the resident should have been T&P every ,[DATE] hours, and after the physician order on [DATE], he should have been T&P every 2 hours. The RNM was not sure what inactive meant in the T&P documentation. During an interview on [DATE] at 2:00 pm, the RN, MDS Coordinator (MDSC) stated she collects the pressure ulcer Push Tools for data collection to see the progress of the wounds. There are issues with the Push Tool, they have been used in the facility for about a year. The documentation on the bottom portion of the Push Tool should have the date the wound was identified documented not the date of the assessment. The MDSC did have a memory of the discrepancy in the week to week documentation for Resident #201, she stated when she saw a discrepancy she would send the documentation back and ask for a correction. The MDSC stated that each discipline starts their own care plans. If the MDS assessment triggers for skin the MDSC would let the RNM know to do a care plan. There should be a care plan for Resident #201 that included the pressure areas and stages, and any devices should be part of the care plan and on the care card. The physician order for [REDACTED]. During an interview on [DATE] at 3:10 pm, the Director of Nursing (DON) stated that the facility will be doing away with the Push Tools, the new protocol needs the prior wound rounds printed out and then document the new wound rounds. All residents with pressure ulcers should have a pressure ulcer care plan, and any new interventions should be on the care plan. The DON stated that the facility policy was to T&P every 2 hours unless otherwise stated in the resident's care plan. Resident #203: The facility did not ensure timely and consistent pressure ulcer tracking and did not ensure the care plan addressed the actual alteration in skin integrity (pressure ulcers). The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with severe cognitive impairment. The MDS also assessed that the resident is sometimes able to understand others and is sometimes able to be understood by others. The Braden Scale dated [DATE], documented that the resident scored a 14, indicating the resident was at moderate risk for development of a pressure ulcer. The Braden Scale dated [DATE], documented the resident scored a 14, indicating the resident was at moderate risk for development of a pressure ulcer. The PUSH Tool (The Pressure Ulcer Scale for Healing), document identified by staff as pressure ulcer tracking documentation, documented the following: [DATE] pressure ulcer to right buttock, identified [DATE], location right buttock, length 0.2 centimeters(cm) wide, 0.1 cm wide, closed Stage 1. [DATE]- #1 pressure ulcer site: right buttock identified [DATE] location to right buttock, length 2.1 cm : width 0.8 cm: and depth 0.1 cm. Stage 2, treatment consisting of [MEDICATION NAME] gentle dressing, Description : the wound bed is red and edges are pink. Superficial Stage 2. - #2 pressure ulcer site: left buttock identified [DATE]. location left buttocks. Length 1.1 cm: Width 1.0 cm: Depth 0.1 cm. Type:2 closed Stage 2. Wound appearance granulating. Treatment [MEDICATION NAME] dressing . Wound bed is red and edges are pink. Superficial stage 2. - #3 pressure ulcer site. Site coccyx, date identified [DATE]. Location coccyx. Length 0.3 cm. Width 0.3 cm., Depth 0.1 cm. Tissue type: granulation tissue, Stage 2. Description: wound bed is red, edges are pink, superficial Stage 2. [DATE] - #1 pressure ulcer site. Left buttocks. length, date identified [DATE], location left buttock. Length 0.3 cm, Width 0.3, and Depth 0.1 cm Stage 2. Wound bed is red, edges are pink , area is improving. -#2 pressure ulcer site. Coccyx. Closed stage 2 area is resolved. -#3 pressure ulcer site. Right Buttock identified [DATE]. Length 1.3 cm., Width 0.5 cm, Depth 0.1 cm. Stage 2. Wound bed is red, edges are pink, and wound is improving. [DATE] - pressure ulcer site. Right leg calf interior aspect. Stage 2. [DATE] - pressure ulcer site. right lower leg, right leg calf interior aspect. Length 0.4 cm., width 0.3 cm, and depth 0.01 cm. Stage 2. No PUSH tool information for wound tracking was available after [DATE] for pressure ulcers to the left and right buttock. Review of Progress Notes documented: [DATE] - documented that the resident was seen and examined by the Nurse P:practitioner for report of open area on right buttock. Stage 1 area identified by NP, skin is intact. No need for dressing at this time, continue triple cream. [DATE] - documented by the Nurse Practitioner identifies the inner right buttock with 2 cm x 3cm intact blanchable area. Under the assessment/plan the progress note identified a Stage 1 to the inner right buttock, continue with 3 part cream, turn and check every 2 hours and as needed, and off load. [DATE] - documented that the resident's buttocks were previously reddened and treated with triple cream. Three superficial stage 2 areas evident today ([DATE]) to left buttock, right buttock, and coccyx. The Nurse Practitioner was notified with new order to apply [MEDICATION NAME] gentle dressing every 3 days and as needed. [DATE] - the Licensed Practical Nurse (LPN) reported open areas to the right leg exterior calf and to the right leg anterior calf. There were no progress notes documenting pressure areas and tracking of the wounds to the left and right buttock after [DATE]. The Care Plan Activity Report effective date [DATE], documented Skin Integrity: At Risk for Skin Breakdown as the care plan for skin integrity issues to the resident. There was no Care Plan for actual skin integrity. During interview on [DATE] at 2:00 pm with the Director of Nursing (DON), the DON stated that the PUSH tool has been the facility's tool tracking pressure ulcers. The DON stated the PUSH tool in use for Resident #203 from [DATE] to [DATE] was missing information to provide accurate and consistent pressure ulcer tracking. The DON stated that no tracking of the pressure ulcers to the resident's right and left buttock was available after [DATE]. The DON stated that the care plan for residents with potential for skin breakdown must be listed as residents with actual skin breakdown issues if the resident experiences actual skin breakdown. 10NYCRR 415.12(c)(2)

Plan of Correction: ApprovedJune 27, 2017

Element # 1 Resident #201 expired in the hospital
Resident # 203 is expired
Element # 2 A full house audit will be completed to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure injuries and does not develop pressure injury unless the individual?s clinical condition demonstrates that they were unavoidable, and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. A full house audit will be conducted to ensure every resident with a pressure area will have a separate CCP in place to address said ulcer, and that weekly documentation is occuring, proper turning and positioning is being documented. treatments to pressure areas are being done according to MD orders.
Element # 3 The PUSH tool will be replaced by a paper pressure ulcer tracking tool to be completed weekly by a Registered Nurse. All registered nurses will be in-serviced In using the new tool. A house wide inservice for all medical staff will be conducted on documentation of both resident care and treatments.
Element #4 A weekly audit will be conducted for a total of 6 months to ensure push tools are being completed weekly, CNA documentation is reflecting turning and positioning as per CCP, treatments are being done and signed for as per MD orders. Results will be presented to the QA committee who will determine the frequency thereafter.
Responsible party: DON or designee

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDOR - DOORS

REGULATION: Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 1, 2017
Corrected date: July 31, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that corridor doors were not free of impediments to closing the doors in the event of a fire emergency. NFPA 101 Life Safety Code 2012 edition section 19.3.6.3.10 requires that corridor doors shall not be held open by devices other than those that release when the door is pushed or pulled. Specifically, five corridor doors in resident areas were kept open with devices that required more than a push or pull to close the door. This is evidenced as follows. Corridor doors were inspected on 05/25/2017 at 2:00 pm and again on 05/31/2017 at 1:30 pm. Door wedges were used to hold open the doors to rooms C-216, C-219, C-123, C-301, and SC-209. The Facility Supervisor stated in an interview conducted on 05/31/2017 at 2:15 pm, that the facility does not supply door wedges, staff probably bring in their own door wedges, and door wedges are removed when seen but routine audits are conducted. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.6.3.10; 2000 NFPA 101 19.3.6.3; 10 NYCRR 415.29, 711.2(a) (1)

Plan of Correction: ApprovedJune 27, 2017

Element # 1 Door wedges were immediately removed from rooms C216, C219, C123, C301, SC209.
Element # 2 Staff was educated to not prop doors open.A whole house audit will be conducted for presence of door wedges.
Element # 3 Monitoring will be conducted on monthly environmental safety rounds.
Element # 4 Results will be addressed at monthly QA. Frequency to be determined by QA there after.
Responsible Person: Maintenance Manager

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 1, 2017
Corrected date: July 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, it was determined that the facility did not utilize extension cords in accordance with adopted regulations. NFPA 70 National Electrical Code 2011 Edition Article 590 section 590.3 (D) requires that temporary wiring, such as extension cords, shall be removed immediately upon completion of construction or purpose for which the wiring was installed. Specifically, extension cords were used to power non-patient care electrical devices in 2 of 16 resident rooms checked. This is evidenced as follows. A selection of resident rooms was inspected for the use of extension cords on 05/31/2017 at 1:30 pm. An extension cord was used to power a microwave oven in resident room [ROOM NUMBER]. An extension cord was plugged into the wall receptacle in resident room [ROOM NUMBER] with no appliance attached. The Facility Supervisor stated in an interview conducted on 05/31/2017 at 2:15 pm that resident families probably bring in extension cords and the facility should do better checks to prevent their use. 42 CFR 483.70 (a) (1); 2011 NFPA 70 590.3(D); 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 70 527.3(D)

Plan of Correction: ApprovedJune 27, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element # 1 Extension cords were removed immediately from rooms [ROOM NUMBERS].
Element # 2 Residents and families were educated that power strips and extension cords are not allowed via mailings, posting throughout the facility and admission information. A whole house will be conducted for presence of power strips and extension cords.
Element # 3 Housekeepers have been educated to inform their supervisor if above items are discovered when doing their daily cleaning.
Element # 4 Daily observation by housekeepers and monitoring conducted on monthly environmental rounds for six months. Findings to be brought to QA monthly and QA to determine length of time thereafter.

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 1, 2017
Corrected date: July 31, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not store pressurized oxygen cylinders in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.6.5.3 requires that empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner, and section 5.1.3.3.2(4) requires that pressurized oxygen storage locations greater than 3000 cubic feet shall be constructed with doors that are of a minimum 1-hour fire resistance rating. NFPA 80 Standard for Fire Doors and Other Opening Protectives 2010 Edition section 7.4.1.1 requires sheet metal fire doors to be equipped with self-closing or automatic-closing devices. Specifically, an empty cylinder was not marked in 1 of 5 resident unit oxygen storage areas, and the door to the Main Oxygen Storage Room was not self-closing. This is evidenced as follows. The Main Oxygen Storage Room and the resident area oxygen storage areas on the first, second, and third floors were inspected on 05/31/2017 at 1:30 pm. An empty oxygen cylinder in room C-245 was not marked. The Main Oxygen Storage Room stored greater than 3000 cubic feet of oxygen and the fire-rated door was not self-closing. The Facility Supervisor stated in an interview conducted on 05/31/2017 at 2:15 pm, that the empty cylinder should have been put in the empty cylinder area and the person assigned did not install the closing mechanism on door to the main oxygen storage room. 42 CFR 483.70 (a) (1); 2012 NFPA 99 5.1.3.3.2(4), 11.6.5.3; 2010 NFPA 80 7.4.1.1; 10 NYCRR 415.29, 711.2(a)(26); 1999 NFPA 99 4-5.5.2.2(b)2

Plan of Correction: ApprovedJune 27, 2017

Element # 1 Oxygen storage racks have been ordered and will be marked empty cylinders only.
Element # 2 All staff and residents have the potential to be affected.
Element # 3 Staff will be educated to place empty cylinders in the proper racks.
Element # 4 Monitoring will be conducted on monthly safety rounds for 6 months. Results will be discussed in monthly QA meetings. QA to determine frequency thereafter.
Responsible Person: Maintenance Supervisor




Part 2
Element #1 and 2 The self closer was re-installed on the door.
Element # 3 Maintenance staff were directed to not remove the self closing device.
Element # 4 Monitoring will be conducted on monthly environmental rounds. Results will be reported to QA with QA determining frequency thereafter.
Responsible Person: Maintenance Supervisor

K307 NFPA 101:GAS EQUIPMENT - QUALIFICATIONS AND TRAINING

REGULATION: Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 1, 2017
Corrected date: July 31, 2017

Citation Details

Based on observation, staff interview, and record review during the recertification survey, it was determined that the facility did manage pressurized oxygen cylinders in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.5.2.1 requires that personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained and receive continuing education on the usage requirements and the risks associated with their handling and use. Specifically, staff were not handling medical oxygen cylinders safely and the facility did not provide continuing education associated with the handling medical oxygen cylinders. This is evidenced as follows. On 05/31/2017 at 2:20 pm, Licensed Practical Nurse #1 was observed carrying an oxygen cylinder free-hand and not in a cylinder cart. The Staff Development Supervisor stated in an interview conducted on 06/01/2017 at 10:10 am, that training on the risks and use of oxygen cylinders was conducted periodically when in the old building but had not been continued once the facility moved into the new building. The facility policy Oxygen Tank Storing and Handling was reviewed on 06/01/2017. This policy requires that all oxygen cylinders must be secured for transport in a cylinder cart, wheelchair carrier, strapped to a hand truck, or strapped securely in an vehicle in which they are placed. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.5.2.1

Plan of Correction: ApprovedJune 27, 2017

Element # 1 Nurse was immediately stopped and re-educated on how to transport oxygen.
Element # 2 Staff and residents are at risk.
Element # 3 All nursing staff will be educated on the proper handling of oxygen cylinders. Training on safety and proper handling of 02 will be done annually and on hiring.
Element # 4 Monitoring will be conducted by the inservice supervisor weekly for 60 days. Results will be presented to QA. QA will determine length of time thereafter.
Responsible Person: Maintenance Supervisor

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 1, 2017
Corrected date: July 31, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that exits were maintained in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 7.1.10.1 requires that means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Specifically, 1 of 4 exits from the Mohawk Trail Unit was obstructed. This is evidenced as follows. The Mohawk Trail Unit exits were inspected on 05/25/2017 at 10:20 am. The main exit was obstructed with a large 3-section plastic cardboard barrier that extended the width of the corridor leading to the exit. The Facility Supervisor and Pharmacy Aide #1 stated in an interview conducted on 05/25/2017 at 10:20 am, that this barrier was first placed in front of this exit several months ago as a deterrent to wandering residents from continually activating the audible elopement control system, thereby requiring staff to frequently reset the alarm. 42 CFR 483.70 (a) (1); 2000 NFPA 101 7.1.10.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 7.1.10.1

Plan of Correction: ApprovedJune 27, 2017

Element #1 The barrier was immediately removed on 5-25-17 at 1020 am.
Element # 2 Staff was educated on not to block the path of egress.
Element # 3 Monitoring will be conducted on monthly environmental safety rounds
Element # 4 Report finds to QA monthly for six months QA will determine frequency thereafter.
Responsible Person: Maintenance Manager