Monroe Community Hospital
August 2, 2018 Complaint Survey

Standard Health Citations

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 2, 2018
Corrected date: September 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Abbreviated Survey (complaint #NY 325) completed on 8/2/18, it was determined that for one (Resident #3) of four residents reviewed for accidents, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the Certified Nursing Assistant (CNA) Care Plan was not updated to reflect that the resident required the assistance of two staff members for bed mobility resulting in a serious injury when the resident slipped off the bed to the floor with the assistance of one staff member for cares. This is evidenced by the following: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] after a hospital stay due to cervical spine fractures (C6-C7) which required surgical spinal fusion repair. The Minimum Data Set (MDS) Assessment, dated 6/1/18, included that the resident was cognitively intact and required the total assistance of one person with bed mobility. Review of the Physical Therapy (PT) Screen, dated 12/8/17, revealed that the resident remained dependent for all bed mobility and required the maximal assistance of two staff members for bed mobility. The Comprehensive Care Plan (CCP), dated 12/12/17, revealed that the resident required total care, assistance of two staff members for any positioning or hygiene issues that require lifting or repositioning, including turning and changing the resident's incontinence brief. Review of the Resident Care Summary Assessment, dated 7/17/17, revealed total dependence for mobility but does not specify the number of staff members to assist. The Falls Risk Assessment, dated 5/29/18, concluded that the resident was at high risk for falls with a score of 14 (high risk if score of 10 or above). Review of the Incident/Accident Report, dated 7/12/18, revealed that at approximately 12:10 a.m., one CNA was performing incontinence cares when the resident slipped off the bed between the CNA and the bed onto the floor. The resident was sent to the Emergency Department twice, and on the second visit she was admitted with a C6-C7 cervical fracture. The resident underwent [REDACTED]. The facility investigation concluded that there was a discrepancy between the CCP and the Resident Care Summary Assessment which persisted through multiple quarterly updates and may have contributed to the resident's injury. When observed on 8/1/18 at 10:28 a.m., the resident had dark purple bruising on her chin and the front of her neck. A hard neck collar was applied to the resident's neck, and she was given care with the assistance of two staff without any issues. Interviews conducted on 7/31/18 included the following: a. At 1:55 p.m., CNA #1 said she has been providing incontinence care for the resident alone as long as she can remember. b. At 2:03 p.m., CNA #2 stated that the resident was care planned as a one person assist for incontinence care. c. At 2:30 p.m., the Registered Nurse Manager stated that she was responsible for the care planning and that the CCP included a two person assist for any hygiene, lifting, or repositioning. She said the Resident Care Summary Assessment that the CNAs refer to was not updated nine months ago to include a two person assist. She said when the facility switched to computer programs, the information was not updated correctly. She stated that she was disciplined for that incident to ensure in the future that the CCP and the Resident Care Summary Assessment match. Interviews conducted on 8/1/18 included the following: a. At 8:00 a.m., CNA #3 said that the resident was care planned as a one person assist with cares. She said on 7/12/18 at about 12:00 a.m., she provided incontinence care for the resident alone. CNA #3 said she turned the resident towards her, the resident requested that she check a boil on her thigh, so she turned the resident further, and the resident slipped between her body and the bed onto the floor. CNA #3 said the resident landed on her back and was howling out saying, Get out of here, I need to go to the hospital, and, Do not touch me. CNA #3 said she notified the nurse right away. b. At 10:00 a.m., the Director of Rehabilitation stated that when the resident was evaluated by physical therapy on 12/8/17, the bed mobility did not change, it was maintained with maximum assistance of two staff members. He said the CCP and the Resident Care Summary Assessment should include two staff members for assistance with bed mobility because the primary motion during care is rolling. c. At 10:28 a.m., the resident stated that she had been receiving incontinence care with the assistance of one staff member. She said that when she fell , it was an accident, and she does not know how it happened. d. At 10:35 a.m., the Director of Nursing stated the CCP, Resident Care Summary Assessment, and the MDS Assessment should all be the same, and in this case they were not. He said the computer system does not transfer the information from the CCP to the Resident Care Summary Assessment so they have to rely on the staff to do it correctly. (10 NYCRR 415.12(h)(2))

Plan of Correction: ApprovedAugust 21, 2018

F689
In direct response to the questions listed in the correspondence from NYSDOH dated (MONTH) 15, (YEAR) and received by the Facility via DOH HCS Portal Link transmittal on (MONTH) 15, (YEAR), along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The resident will be re-assessed to determine whatever staff assistance she may need for care delivery and her plan of care and CNA care card (Resident Care Summary Assessment) will be adjusted accordingly. Additionally, the plan of care, CNA care card, and MDS will be reviewed to insure they correspond to the findings of the clinical staff?s assessments.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Any resident with a plan of care and CNA care card that do not match has the potential to be adversely affected.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Clinical Nurse Manager is the person responsible for insuring all plans of care are accurate and that CNA care cards match the plans of care. In-service education will be provided to the Clinical Nurse Managers regarding the importance of insuring plans of care, CNA care cards, and the MDS match. The Clinical Nurse Managers will conduct an audit of all resident plans of care, CNA care cards, and the MDS to insure they match. Discrepancies will be noted, will be reported to the Assistant Directors and Director of Nursing and corrected accordingly. Such audits shall be conducted monthly for a quarter and quarterly thereafter.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Quality Assurance and Improvement Coordinator shall appoint a committee of at least three persons, at least one of whom shall be a licensed nurse and one of whom shall be a CNA, to conduct audits to insure that the audits conducted by the Clinical Nurse Managers (see #3 above) are completed in a timely fashion and that discrepancies have been reported and corrected accordingly. Such audits shall coincide with the Clinical Nurse Manager audits; i.e., monthly for a quarter and quarterly thereafter. The results of the audits will be presented at the monthly Quality Assurance Committee meetings.
5. The date for correction action and the title of the person responsible for correction of this deficiency.
September 25, (YEAR)
Director of Nursing