New Vanderbilt Rehabilitation and Care Center, Inc
February 6, 2017 Certification Survey

Standard Health Citations

E3BP 402.7(a)(2)(i):DEPARTMENT CRIMINAL HISTORY REVIEW

REGULATION: Section 402.7 Department Criminal History Review. (a) After reviewing a criminal history record of an individual who is subject to a criminal history record check pursuant to this Part, the Department and the provider shall take the following actions: ...... (2) Where the criminal history information of a prospective employee reveals a felony conviction at any time for a sex offense, a felony conviction within the past ten years involving violence, or a conviction for endangering the welfare of an incompetent or physically disabled person pursuant to section 260.25 of the Penal Law, or where the criminal history information concerning such prospective employee reveals a conviction at anytime of any class A felony, a conviction within the past ten years of any class B or C felony, any class D or E felony defined in articles 120, 130, 155, 160, 178 or 220 of the Penal Law or any crime defined in sections 260.32 or 260.34 of the Penal Law or any comparable offense in any other jurisdiction, the Department shall propose disapproval of such person's eligibility for employment unless the Department determines, in its discretion, that the prospective employee's employment will not in any way jeopardize the health, safety or welfare of patients, residents or clients of the provider. (i) The Department shall provide to the provider and the prospective employee, in writing, a summary of the criminal history information along with the notification identified in this paragraph. Upon the provider's receipt from the Department of a notification of proposed disapproval of eligibility for employment, the provider shall not allow the prospective employee to provide direct care or supervision to patients, residents, or clients of such provider until receipt of a final determination of eligibility for employment from the Department.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2017
Corrected date: April 3, 2017

Citation Details

Based on record review and interview, the facility did not ensure that an employee with a negative determination letter in the Criminal History Record Check (CHRC) system was immediately removed from direct care of residents. This was evident for 2 of 5 employees reviewed for negative determination letters (Employee #3 and #4). The findings are: 1) Employee #3 was hired 4/12/16 as a Resident Transporter. The facility received a Pending Denial letter dated 5/12/16 from the CHRC system. The employee's Time Card Report covering 5/1/16 to 7/1/16 documented the employee worked in the facility until 5/17/16. The employee was not immediately removed from direct care of residents. 2) Employee #4 was hired as transporter on 2/16/16. The facility received a Pending Denial letter dated 4/25/16 from the CHRC system. The Time Card Report covering 5/1/16 to 7/1/16 documented the employee worked at the facility until 5/18/16. The employee was not immediately removed from direct care. On 2/6/17 at 4:10 PM, the Human Resources Coordinator was interviewed and stated that she knew that she should remove people from direct care with Hold in Abeyance letters, but she did not know they also should be removed for Pending Denial Letters. She stated that the two employees in question were transporters and escorted residents to medical appointments. She stated that she discussed the Pending Denial letters with them, but she thought they had 30 days to clear up the issues and could continue working while the final decision was pending.

Plan of Correction: ApprovedMarch 6, 2017

R808
I. Immediate corrective action
No individual residents were found to be affected by the deficient practice.
1. Employee #3 has been terminated from employment, effective 5/17/16
2. Employee #4 has been terminated from employment, effective 5/18/2016
II. Identification of other Residents
The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.
The Human Resources Coordinator conducted a thorough search through all newly hired employees and ascertained that there were no employees involved in direct patient care with a negative determination by the CHRC system.

III. Systematic Changes
The facility has updated policies and procedures regarding all negative determination letters by the CHRC system. In the event that such a letter is sent, the prospective employee will immediately be removed from direct patient care until a final determination of eligibility is completed.
IV. Q/A Monitoring
1. The HR coordinator will conduct monthly audits over the next quarter.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly, for evaluation and follow up.
V. All corrective actions will be completed by the Human Resources Coordinator by 4/3/2017

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2017
Corrected date: April 3, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure that the resident's drug regimen was free of unnecessary medications. Specifically, a resident diagnosed with [REDACTED]. In addition, the medication and plan of care did not specify which behaviors were being treated by the use of antipsychotic medication, and there was no documented evidence of behaviors to support the ongoing use of antipsychotic medication. This was evident for 1 of 5 residents reviewed for Unnecessary Medication (Resident #168). The finding is: Resident #168 is a [AGE] year-old, admitted [DATE], with [DIAGNOSES REDACTED]. The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition, and the resident is rarely/never understood. The MDS further documented the resident displayed no physical or verbal behavioral symptoms directed to self or others, and the resident received antipsychotic medication. The MDS documented the resident required limited assist of one person for bed mobility, transfer, eating, and locomotion on the unit. The resident required extensive assist of one person for locomotion off the unit, toileting, and personal hygiene. The MDS documented the resident had [DIAGNOSES REDACTED]. On 2/2/17 at 10:08 AM the resident was observed in the day room sitting in his wheelchair watching television. No behaviors were observed. On 2/3/17 at 11:00 AM, the resident was observed in the day room while a recreational activity (Chutes and Ladders was in progress). Resident was sitting in his chair listening to the Activity therapist On 2/6/17 at 2:00 PM, the resident was observed in the day room with his wife during (TV time ), resident appeared to be good spirits and happy to be with his wife. On 2/2/17 at 10:30 AM, the resident's wife was interviewed and stated that for the last year her husband has been quieter than he used to be, but when he does talk, he speaks much clearer than other days. She reported that she visits the resident every other day in the afternoon between 1:30 PM and 2:00 PM. The resident's wife admitted that she is not familiar with his medication, but she feels that whatever he is on is making him sleepy. She stated she had not seen or spoken to the primary Physician (MD) in a few months, but she sees no real change in the resident. The Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] Drug Use dated 11/25/16 documented the resident was receiving [MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION] and agitation. The CCP further documented the goals to have no side effects, be free of accidents, reduce drug dosage, and decrease episodes of agitation. The interventions included: Administer [MEDICATION NAME] (an antipsychotic medication) as ordered by MD; Monitor for drug effectiveness; Monitor for drug toxicity or drug related side effects; Monitor for any changes in mood/behavior; Psychiatry evaluation & follow-up; Monitor lab results as ordered; Provide verbal reminder of available activities; Monitor weights and appetite; Always approach resident calmly and unhurriedly; Encourage family to visit; and Anticipate needs. The Psychiatry Consult dated 4/4/16 documented the resident continued to be on [MEDICATION NAME] 50 mg (milligrams) HS (at bedtime) and 25 mg BID (twice per day) for Senile Dementia with Behavioral Disturbances and [MEDICAL CONDITION] NOS (Not Otherwise Specified). The consult further documented the resident's general behavior has been manageable, and his agitated/aggressive/disruptive behavior was improved. The consult documented the resident did not present with suicidal/homicidal ideation, no paranoia, no delusions, and no hallucinations. The Psychiatry Consults dated 5/20/16 and 6/6/16 documented the resident was still on [MEDICATION NAME] 50 mg HS and 25 mg BID and for [MEDICAL CONDITION] NOS (not otherwise specified). The consults documented the resident's behavior had been manageable and aggressive behaviors were improved. The consult dated 6/6/16 documented the resident had no suicidal/homicidal ideation, no paranoia, no delusions, and no hallucinations. The Psychiatry Consults dated 6/17/16, 8/18/16, 9/15/16, 10/22/16, 11/8/16, and 12/10/16 documented the resident continued to be treated with [MEDICATION NAME] 50 mg HS and 25 mg BID and for Alzheimer's Dementia with a history of [MEDICAL CONDITION]. All of the referenced Psychiatry consults documented that no dosage reduction was attempted because the resident had no behavior issues and no [MEDICAL CONDITION] on the current medications. The Physician's (MD) Orders dated 1/23/17 documented the resident was prescribed Quetiapine ([MEDICATION NAME]) 25 mg BID and Quetiapine 50 mg HS. The order further documented the Quetiapine was originally ordered on [DATE] in the system. The Medication Administration Record [REDACTED]. The Psychiatry Consultation dated 1/16/17 documented the recommendation to continue [MEDICATION NAME] 25 mg BID and [MEDICATION NAME] 50 mg HS. The consult documented that there was no dose reduction was attempted in the last 4 to 6 months because the patient is on a low dose. The consult documented the resident had no behaviors and no side effects. The Physician Assessment Form, written by the Primary MD, dated 1/23/17 documented the resident's mental status was awake and demented. The assessment documented the resident had Alzheimer's, and the plan of care for the Alzheimer's was Quetiapine ([MEDICATION NAME]). The Interdisciplinary Notes from (MONTH) (YEAR) to (MONTH) (YEAR) were reviewed. There were no documented incidents of behavior problems. There was no documented evidence in the Medical Record that a Gradual Dose Reduction (GDR) was attempted for [MEDICATION NAME] in the last year. The Psychiatry Consult dated 2/3/17 documented specific behavior to be addressed is neuro cognitive and [MEDICAL CONDITION]. Resident is on low dose of psychiatric meds and has no side effects and is doing well. No dosage reduction attempted in the last 4-6 months because resident is on a low dose of [MEDICATION NAME]. On 2/6/17 at 10:45 AM, the Certified Nursing Assistant CNA was interviewed and confirmed that she has been taking care of resident for almost a year and expressed that Resident (168) is pleasant but sometimes yells when he becomes frustrated. The CNA was asked about his sleeping habits but she states that she is not aware of his sleeping habits because she works during the day shift but as far she knows his sleeping habits are okay. The resident has no problems eating, has a good appetite and when his wife comes he is in a much better mood. The CNA stated she is not too familiar with what medications the resident is taking. She stated that resident stays in the day room until the end of her shift. On 2/6/17 at 4:33 PM, the Psychiatrist was interviewed on the telephone. The Psychiatrist confirmed that the resident has been on [MEDICATION NAME] 25 mg BID and [MEDICATION NAME] 50 mg at bedtime and has a [DIAGNOSES REDACTED]. The Psychiatrist further stated that he was recently at the facility on Friday, 2/3/17, when he saw the resident trying to come out of his room without clothes on. The resident's behavior happens sporadically, and the behavior becomes aggressive. The Psychiatrist also stated he is a consultant for the facility and is on site two to three times per week. He stated that he had planned to do a Gradual Dose Reduction but doesn't want the resident to act out towards any of the CNAs. The only non- pharmacological interventions he tried was putting the resident in the day room so he can become involved in daily activities. He stated he is very cautious because of the resident's [MEDICAL CONDITION] and history of [MEDICAL CONDITION]. The Psychiatrist also stated that the resident has [MEDICAL CONDITION], which indicates the resident has problems sleeping and becomes agitated at times, and he did not taper down the medication yet due to many factors. He stated that the resident is on a low dose for his body size, and the medication should be tapered off slowly. He then explained that [MEDICAL CONDITION] is different from Alzheimer's, and [MEDICAL CONDITION] is hard to treat because sometimes the residents become violent and act out for no reason while [MEDICAL CONDITION] occurs mostly in older residents. The Psychiatrist stated that Resident #168 is a young guy with [MEDICAL CONDITION], so he prescribed [MEDICATION NAME] for sedation and to get the edge off so the resident would be in control but not drowsy. The surveyor reminded the Psychiatrist that he documented the resident has [MEDICAL CONDITION] and is 84-years-old during the conversation. The Psychiatrist said he monitors the resident's progress by getting feedback from the resident's wife and the CNAs from different shifts. On 2/6/17 4:59 PM, the Attending Physician (MD) was interviewed and stated he has been the primary doctor for 2 years. He is responsible for the resident's care and he completes the monthly evaluations which include medication review. He further stated when he took over the case, the resident wife complained to him that the resident was on too many psychiatric meds, and he reduced his which resulted in the resident becoming more alert. He also stated that as his Doctor overall he is there for an emergency or if there is something wrong with the resident, but he does not review the [MEDICAL CONDITION] medications monthly for a possible Gradual Dose Reduction (GDR). The MD also stated that if the Psychiatrist does not reduce the medications, he assumes it is because it cannot be done. He stated he is aware of the guidelines for GDR attempts, but he assumes the Psychiatrist is doing the right thing, and he believes that a [MEDICATION NAME] reduction was attempted in the past but was unsuccessful , because the resident became aggressive. He stated that he believes the reduction was done at least a year ago or more. The Psychiatry Consult dated 12/31/15 documented the resident was on [MEDICATION NAME] 50 mg HS (at hour of sleep) and 25 mg BID (twice a day) as well as [MEDICATION NAME] (natural sleep supplement ). The consult documented the resident was declining behaviorally and cognitively. The consult further documented that the resident's aggressiveness and agitated behavior had improved. The [DIAGNOSES REDACTED]. The consult further documented the resident had no suicidal ideation, paranoia, or visual or auditory hallucinations. Resident #168 has been on [MEDICATION NAME] 50 mg and [MEDICATION NAME] 25mg since 11/9/2015 without a Gradual Dosage Reduction attempt. The [MEDICATION NAME] was used to treat Senile Dementia with Behavioral Disturbances, [MEDICAL CONDITION], and Alzheimer's Dementia. The resident was given the [DIAGNOSES REDACTED]. Senile Dementia and Alzheimer's Dementia are not appropriate indications for the use of [MEDICATION NAME], and there was no documented evidence in the medical record that the resident was having ongoing behaviors that made him a danger to himself or others. There was no documented evidence in the medical record that the resident had symptoms of [MEDICAL CONDITION]. In addition, the Primary Physician stated that he does not oversee the monitoring of the [MEDICATION NAME], relying on the Psychiatry consultant. The Psychiatry consultant's explanation for the use of the [MEDICATION NAME] did not reflect the [DIAGNOSES REDACTED]. The Psychiatrist stated the [MEDICATION NAME] was used due to the resident's history [MEDICAL CONDITIONS], but the resident does not have either of these [DIAGNOSES REDACTED]. 483.45

Plan of Correction: ApprovedMarch 3, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** P(NAME) New Vanderbilt
F329
(I. Immediate Correction:)

1) On 02/09/17 resident # 168 was assessed by the Psychiatrist and a Gradual Dose Reduction (GDR) was recommended.
2) The PMD reviewed the Psychiatry consult and ordered the GDR on 2/9/17 and updated plan of care in the medical record.
3) On 02/10/17 the IDT team reviewed and revised the CCP to reflect the updated plan of care.
4) On 02/13/17 the Medical Director conducted an educational counseling with the PMD for not conducting a review of [MEDICAL CONDITION] medication assessment with each monthly visit

(II.Identification of Others:)
1) On 02/20/17 the DNS in conjunction with the Medical Director obtained a list of all residents receiving an antipsychotic medication to ascertain if any other residents with the Dx of dementia was receiving an antipsychotic medication without an indication for use and/or attempts at a GDR. Any identified issues were immediately corrected.
(III. Systemic Changes:)
1) On 02/13/17 the Medical Director in conjunction with the DNS reviewed/revised the facility P/P for Antipsychotic medication administration. This P/P will be in serviced to all physicians, licensed nurses and pharmacy consultants by Inservice Coordinator as of 02/24/17.The lesson plan will focus on:
? Federal Requirements and Regulatory provisions pertaining to care of residents with dementia and the use of Antipsychotic medications.
? All residents will be evaluated by psychiatrist for the appropriate clinical indication and [DIAGNOSES REDACTED].
? The psychiatrist will complete consultation form indicating resident diagnosis, clinical justification for medication usage and attempts at gradual dose reduction at a minimum of every three months or as resident clinical condition indicates.
? The PMD will review psychiatric consultation and order recommendations as needed or document rationale for not initiating recommendations.
? The PMD will review the use of antipsychotic medication at each monthly visit and as needed.
? A copy of all psychiatry consultations will be provided to the DNS and Director of SS.
? The IDT Team will develop an individualized CCP for the use of antipsychotic medications including clinical indication, Dx and all non-pharmacological interventions to be implemented and attempts and results of GDR (gradual dose reduction) including residents response. The CCP will be reviewed and revised a minimum of quarterly and as indicated by individual resident?s condition.
? The pharmacy consultant will conduct DRR (drug regime review) monthly and upon request documenting recommendations regarding medication usage, potential adverse reactions and contraindications.
? The PMD will review all pharmacy consultant recommendations documenting any changes or rationale for not following recommendations in medical record.
? The DNS and Medical Director will ensure all DRR recommendations are addressed by PMD.
(IV. Quality Assurance)
1) On 03/01/17 the Medical Director developed an audit tool to monitor the facility?s compliance with ensuring residents receiving antipsychotic medication are assessed for appropriate clinical indications, Dx and gradual dose reductions as indicated. This audit will be conducted by Medical Director/designee for 4 residents receiving antipsychotics weekly x 4 weeks followed by 4 residents monthly x 12 months. Any issues will be reported to QA Committee for follow up and input as indicated.
2) Findings of the audit requiring immediate attention will be brought to the Morning QI meeting for follow up.
(V. Responsible Party:)
The DNS and Medical Director are responsible for this FTag.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2017
Corrected date: April 3, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure that the physician reviewed the resident's total plan of care. Specifically, the Physician did not ensure that a resident on an antipsychotic medication for an unapproved indication received adequate monitoring and was evaluated for Gradual Dose Reduction. This was evident for 1 of 5 residents reviewed for Unnecessary Medication (Resident #168). The finding is: Resident #168 is a [AGE] year-old, admitted [DATE], with [DIAGNOSES REDACTED]. The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition, and the resident is rarely/never understood. The MDS further documented the resident displayed no physical or verbal behavioral symptoms directed to self or others, and the resident received antipsychotic medication. The MDS documented the resident required limited assist of one person for bed mobility, transfer, eating, and locomotion on the unit. The resident required extensive assist of one person for locomotion off the unit, toileting, and personal hygiene. The MDS documented the resident had [DIAGNOSES REDACTED]. On 2/2/17 at 10:08 AM the resident was observed in the day room sitting in his wheelchair watching television. No behaviors were observed. On 2/3/17 at 11:00 AM, the resident was observed in the day room while a recreational activity (Chutes and Ladders was in progress). Resident was sitting in his chair listening to the Activity therapist On 2/6/17 at 2:00 PM, the resident was observed in the day room with his wife during (TV time ), resident appeared to be good spirits and happy to be with his wife. On 2/2/17 at 10:30 AM, the resident's wife was interviewed and stated that for the last year her husband has been quieter than he used to be, but when he does talk, he speaks much clearer than other days. She reported that she visits the resident every other day in the afternoon between 1:30 PM and 2:00 PM. The resident's wife admitted that she is not familiar with his medication, but she feels that whatever he is on is making him sleepy. She stated she had not seen or spoken to the primary Physician (MD) in a few months, but she sees no real change in the resident. The Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] Drug Use dated 11/25/16 documented the resident was receiving [MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION] and agitation. The CCP further documented the goals to have no side effects, be free of accidents, reduce drug dosage, and decrease episodes of agitation. The interventions included: Administer [MEDICATION NAME] (an antipsychotic medication) as ordered by MD; Monitor for drug effectiveness; Monitor for drug toxicity or drug related side effects; Monitor for any changes in mood/behavior; Psychiatry evaluation & follow-up; Monitor lab results as ordered; Provide verbal reminder of available activities; Monitor weights and appetite; Always approach resident calmly and unhurriedly; Encourage family to visit; and Anticipate needs. The Psychiatry Consult dated 12/31/15 documented the resident was on [MEDICATION NAME] 50 mg HS (at hour of sleep) and 25 mg BID (twice a day) as well as [MEDICATION NAME] (natural sleep supplement ). The consult documented the resident was declining behaviorally and cognitively. The consult further documented that the resident's aggressiveness and agitated behavior had improved. The [DIAGNOSES REDACTED]. The consult further documented the resident had no suicidal ideation, paranoia, or visual or auditory hallucinations. The Psychiatry Consult dated 4/4/16 documented the resident continued to be on [MEDICATION NAME] 50 mg (milligrams) HS (at bedtime) and 25 mg BID (twice per day) for Senile Dementia with Behavioral Disturbances and [MEDICAL CONDITION] NOS (Not Otherwise Specified). The consult further documented the resident's general behavior has been manageable, and his agitated/aggressive/disruptive behavior was improved. The consult documented the resident did not present with suicidal/homicidal ideation, no paranoia, no delusions, and no hallucinations. The Psychiatry Consults dated 5/20/16 and 6/6/16 documented the resident was still on [MEDICATION NAME] 50 mg HS and 25 mg BID and for [MEDICAL CONDITION] NOS (not otherwise specified). The consults documented the resident's behavior had been manageable and aggressive behaviors were improved. The consult dated 6/6/16 documented the resident had no suicidal/homicidal ideation, no paranoia, no delusions, and no hallucinations. The Psychiatry Consults dated 6/17/16, 8/18/16, 9/15/16, 10/22/16, 11/8/16, and 12/10/16 documented the resident continued to be treated with [MEDICATION NAME] 50 mg HS and 25 mg BID and for Alzheimer's Dementia with a history of [MEDICAL CONDITION]. All of the referenced Psychiatry consults documented that no dosage reduction was attempted because the resident had no behavior issues and no [MEDICAL CONDITION] on the current medications. The Physician's (MD) Orders dated 1/23/17 documented the resident was prescribed Quetiapine ([MEDICATION NAME]) 25 mg BID and Quetiapine 50 mg HS. The order further documented the Quetiapine was originally ordered on [DATE] in the system. The Medication Administration Record [REDACTED]. The Psychiatry Consultation dated 1/16/17 documented the recommendation to continue [MEDICATION NAME] 25 mg BID and [MEDICATION NAME] 50 mg HS. The consult documented that there was no dose reduction was attempted in the last 4 to 6 months because the patient is on a low dose. The consult documented the resident had no behaviors and no side effects. The Physician Assessment Form, written by the Primary MD, dated 1/23/17 documented the resident's mental status was awake and demented. The assessment documented the resident had Alzheimer's, and the plan of care for the Alzheimer's was Quetiapine ([MEDICATION NAME]). The Interdisciplinary Notes from (MONTH) (YEAR) to (MONTH) (YEAR) were reviewed. There were no documented incidents of behavior problems. There was no documented evidence in the Medical Record that a Gradual Dose Reduction (GDR) was attempted for [MEDICATION NAME] since (MONTH) (YEAR). The Psychiatry Consult dated 2/3/17 documented specific behavior to be addressed is neuro cognitive and [MEDICAL CONDITION]. Resident is on low dose of psychiatric meds and has no side effects and is doing well. No dosage reduction attempted in the last 4-6 months because resident is on a low dose of [MEDICATION NAME]. On 2/6/17 4:59 PM, the Attending Physician (MD) was interviewed and stated he has been the primary doctor for 2 years. He is responsible for the resident's care and he completes the monthly evaluations which include medication review. He further stated when he took over the case, the resident wife complained to him that the resident was on too many psychiatric meds, and he reduced his which resulted in the resident becoming more alert. He also stated that as his Doctor overall he is there for an emergency or if there is something wrong with the resident, but he does not review the [MEDICAL CONDITION] medications monthly for a possible Gradual Dose Reduction (GDR). The MD also stated that if the Psychiatrist does not reduce the medications, he assumes it is because it cannot be done. He stated he is aware of the guidelines for GDR attempts, but he assumes the Psychiatrist is doing the right thing, and he believes that a [MEDICATION NAME] reduction was attempted in the past but was unsuccessful , because the resident became aggressive. He stated that he believes the reduction was done at least a year ago or more. . 415.15(b)(2)(iii)

Plan of Correction: ApprovedMarch 3, 2017

F386
(I. Immediate Correction:)
1) On 02/09/17 the PMD
reviewed the Resident # 168 total plan of care including the use of antipsychotic medication FACILITY Review: and a GDR was initiated and documented in medical record.
2) On 02/13/17 the Medical Director issued an educational counseling to the PMD responsible for the care of Resident # 168.
(II.Identification of Others:)
1) The facility respectfully states that all residents were potentially affected by the deficient practice.
(III.Systemic Changes:)
1) On 02/22/17the Medical Director in conjunction with the DNS reviewed/revised the facility Policy/Procedure for Physician Visits. The P/P will be in serviced to all Physicians/Nurse Practitioners/licensed nurses by Inservice Coordinator as of 02/24/17. The lesson plan will focus on:
? At each monthly visit the primary physician will review the individual residents plan of care including all resident Dx,medications, treatments, weights and labs documenting resident status and any changes to plan of care in medical record.
? The PMD will review all consults and consultant recommendations documenting the rationale for not following consultant recommendations as indicated.
? The PMD will sign, date, all orders and progress notes at each visit.
(IV.Quality Assurance:)
1) On 03/01/17 the Medical Director developed an audit tool to monitor the facility?s compliance with ensuring physician visits are conducted to review residents total plan of care. This audit will be conducted by the Medical Director for 4 residents weekly x 1 month followed by 4 residents monthly x 12 months. All findings will be forwarded to QA Committee for follow up.
(V. Person Responsible for this Ftag:)
Medical Director

Standard Life Safety Code Citations

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2017
Corrected date: May 11, 2017

Citation Details

Based on observation and interview, it was determined that the facility did not ensure that all areas of the facility were protected by an automatic sprinkler system in accordance with section 9.7 (NFPA 101) 13, 5-13.6.2. Reference is made to the Air-Handling closet located in the basement. The Finding is: On (MONTH) 01, (YEAR) at approximately 10:15 a.m during the life safety code recertification survey, it was observed that inside the air handler closet located in the basement, sprinkler head protection was not provided. In an interview with the Maintenance Director on (MONTH) 01, (YEAR) at approximately 10:15 a.m, he stated that sprinkler head(s) will be provided in this location. NFPA 101 2012 and NFPA 13, 5-13.6.2, 711.2 (a) (1)

Plan of Correction: ApprovedMarch 29, 2017

K351
I. Immediate Corrective Action
No individual residents were found to be affected by the deficient practice.
The Director of Maintenance Services contacted the facility?s sprinkler maintenance company and scheduled the installation of the identified sprinkler head.
The Director of Maintenance Services along with a licensed sprinkler installer has reviewed all other areas for proper sprinkler coverage and found no other required sprinklers missing.
II. Identification of other Residents
The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.
2. The Director of Maintenance Services inspected all other sprinkler heads and found them to be in reliable operating condition.
3. No additional quality issues were identified.
III. Systematic Changes
1. The sprinkler maintenance company will add inspection of the sprinkler heads to their preventive maintenance inspection/ testing. Any sprinkler heads identified will be immediately replaced. Monthly inspections of the system and facility shall be conducted by the certificated person and records maintained accordingly. The Facility will have quarterly inspection completed by a licensed sprinkler company for appropriate heads and proper coverage.
2. The Director of Maintenance Services has developed an audit tool to use for monthly inspection of the sprinkler heads in the affected areas.
3. The required suppression system shall be added to the facility PM program and all scheduled maintenance shall be accomplished with appropriate NFPA guidelines.
4. Maintenance staff will be in serviced by the Director of Maintenance Services on monthly inspection of the system.
5. A copy of the lesson plan and attendance records will be kept on file for reference and validation.
IV. Q/A Monitoring
4. The Director of Maintenance Services will conduct monthly audits over the next quarter.
5. Audits of negative findings will have immediate corrective actions implemented.
6. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Maintenance Services by 4/06/2017

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2017
Corrected date: May 11, 2017

Citation Details

Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. Based on observation and interview, it was determined that the facility did not ensure that vertical openings were sealed with a fire resistance rating of at least one hour. Reference is made to the observation of a rectangular opening on the ceiling above the suction machine compressor located in the basement. This was found in 1 out of 9 floors. The finding is: On (MONTH) 01, (YEAR) between the hours of 09:30 a.m and 11:00 a.m during the life safety code recertification survey, it was observed that an approximately 6 feet by 4 feet section of ceiling was observed missing above the suction machine compressor in the basement storage area. In an interview with the maintenance director on the same day after the finding, he stated that this concern would be sealed. NFPA 101 19.3.1.1 through 19.3.1.6

Plan of Correction: ApprovedFebruary 27, 2017

K311
I. Immediate corrective action
No individual residents were found to be affected by the deficient practice.
The Director of Maintenance Services along with maintenance staff completed installation of the missing ceiling system.
II. Identification of other Residents
The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.
1. The Director of Maintenance Services inspected all vertical openings for complete closure and found none to be out of compliance.
No additional quality issues were identified.
III. Systematic Changes
The facility has updated policies about repair and construction to include complete closure of any openings upon completion of work.
IV. Q/A Monitoring
1. The Director of Maintenance Services will conduct monthly audits over the next quarter.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Maintenance Services by 4/3/2017