Beacon Rehabilitation and Nursing Center
October 16, 2017 Certification Survey

Standard Health Citations

FF10 483.25(e)(1)-(3):NO CATHETER, PREVENT UTI, RESTORE BLADDER

REGULATION: (e) Incontinence. (1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. (2)For a resident with urinary incontinence, based on the resident?s comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident?s clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident?s clinical condition demonstrates that catheterization is necessary and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. (3) For a resident with fecal incontinence, based on the resident?s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2017
Corrected date: December 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a recertification survey, the facility did not ensure that care and services were provided for 1 of 3 residents (#181) reviewed for pressure ulcers from a total Stage 2 sample of 31 residents. Specifically, the attending physician was not informed in a timely manner of the results of a pelvis ultrasound (used to determine the amount or volume of residual urine in the bladder) in order to provide timely treatments, including insertion of an indwelling Foley catheter to relieve [MEDICAL CONDITION]. The finding is: Resident #181 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/15/17 Admission Minimum Data Set (MDS) assessment documented the resident's Brief Interview for Mental Status (BIMS) score as 12 out of 15, which indicated the resident had moderate cognitive impairment. This MDS originally documented that the resident either had a urinary catheter, urinary ostomy, or no urine output for the prior 7 days. The Registered Nurse (RN) MDS Coordinator was interviewed on 10/13/2017 at 10:45 AM and stated at the time of the MDS assessment the resident did not have a urinary catheter and the resident was incontinent. She stated the MDS was an error. The attending physician's progress note dated 9/8/2017 documented the resident had a history of [REDACTED]. The Physician documented that the resident was voiding but the post-void residual urine was not checked. The attending physician further documented that the resident may need a Foley catheter and planned for a bladder sonogram to check for post-void residual urine. The physician's orders [REDACTED]. A note in the order required the use of a portable ultrasound due to the resident's physical or mental limitations to be transported from the facility. The initial nursing progress note written by the unit Registered Nurse (RN) Supervisor #1 dated 9/13/2017 at 1:01 PM documented the pelvis ultrasound was done during the shift and the result was pending. The ultrasound report was uploaded to the facility's computer system on 9/15/17 at 12:00 PM. The report documented the date of service was 9/13/17 and the pre-void volume was 1,285 cc. The report documented that post-void residual was not documented. The Attending Physician saw the resident on 9/16/17. A Physician's progress note dated 9/16/17 at 11:53 PM documented that the bladder appeared to be distended. Bladder sonogram and [MEDICAL CONDITION] (GU) consults for Foley catheter placement was ordered and report was pending. Further review of the physician's orders [REDACTED]. The computer documentation showed that the physician reviewed and signed-off on the report on 9/17/17 at 7:07 AM, four days after the bladder sonogram was done. A nursing progress note dated 9/17/2017 at 7:29 AM written by the overnight RN Supervisor #2 documented that a Foley catheter was inserted. The urine output from the catheter on 9/17/17 at 7:20 AM was documented as 700 cc. The Comprehensive Care Plan (CCP) dated 9/18/2017 titled Urine Incontinence/and Indwelling Catheter documented that the resident has a history of retention. The bladder sonogram revealed pre-void volume of 1,285 cc and an order obtained to insert Foley catheter secondary to [MEDICAL CONDITION] and the urology consult was pending. A representative from the diagnostic company that performed the ultrasound was interviewed on 10/13/17 at 11:10 AM and stated the portable ultrasound was done at the facility on 9/13/17. The technician immediately notified the unit RN Supervisor #1 of severe [MEDICAL CONDITION] of 1,300 cc pre-void and 1,300 cc post-void. The representative stated that official report was faxed to the facility on [DATE] at 12 PM and uploaded the report to the facility's computer system on 9/15/17 at 12 PM. She stated that the facility was not called regarding the results. RN Supervisor #1 was interviewed on 10/13/17 at 11:42 AM and she stated she did not recall the technician reporting the results of the bladder ultrasound to her. Regarding the ultrasound report that was uploaded to the computer system on 9/15/2017, she stated that the section of the computer that it was uploaded to, is the physician's section and she did not review it or receive notification that the report was there. RN Supervisor #1 further stated the resident was urinating and she did not follow up with the diagnostic company for the results because the test was routine. The Director of Nursing Services (DNS) was interviewed on 10/13/17 at 12:33 PM and she stated that the fax number the diagnostic company had was wrong and therefore the faxed report was not received by the facility. She stated the report that was uploaded to the computer was to notify the physician and was unclear if the nurse's received notification. The DNS stated that it was not routine policy for the nurse's to follow up with the diagnostic company. Review of the Resident Bowel and Bladder by Shift Chart documented by the Certified Nursing Aides revealed that between 9/13/17 and 9/17/17, the resident had one incontinent episode per shift, with the exception of 9/15/2017 during the 11 PM - 7 AM shift, when the resident had two incontinent episodes. The nursing progress notes between 9/13/17 and 9/18/17 did not reveal any urinary assessments. A call was placed to the Attending Physician on 10/16/17 at 10:06 AM. The Physician was not available for an interview. 415.12(d)(2)

Plan of Correction: ApprovedNovember 3, 2017

Plan of Correction: F315
I. Immediate Corrective Action
Resident #181 was seen and examined by the primary physician and determined that the resident suffered no ill effect. The Director of Nursing contacted the ultrasound company to formulate a system where all preliminary bladder ultrasound results would be reported by the technician to the nursing supervisor immediately after test completion
II. Identification of other Residents
The facility respectfully states that all Residents were potentially affected by this deficient practice.
III. Systemic Changes
The Assistant Director of Nursing and the ultrasound company met and developed a written tool that the technician would give to the nursing supervisor, after the bladder ultrasound is completed. The Nursing Supervisor would report all abnormal results to the primary physician for further interventions, if needed.
The Director of Nursing reviewed and revised the Policy and Procedure for receiving and reporting ultrasound results, after test completion. The revised policy includes standard procedure on reporting any abnormal results to the physician on the same day as the test completion. This, thereby, would ensure that there will not be any delay in care.
IV. Quality Assurance
The Director of Nursing/designee will perform a monthly audit on all residents who received bladder ultrasounds to ensure that any abnormal bladder ultrasound results were addressed by the physician on the same day as the ultrasound completion. The audit will be done monthly x 3 and quarterly thereafter. The audits will be submitted to the QAPI Committee and for review, quarterly.
V. The DNS/Designee will be responsible for this FTag.

Standard Life Safety Code Citations

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: October 16, 2017
Corrected date: November 17, 2017

Citation Details

2012 NFPA 99: 11.3.4 Signs 2012 NFPA 99: 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 2012 NFPA 99: 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING 2012 NFPA99: 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. 2012 NFPA99: 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. Based on observation and staff interview, oxygen storage rooms lacked required signage. This was noted on three of three floors. The findings are: On 10/10/17 between 9:30am- 2:00pm during the recertification survey, the following was noted for oxygen storage rooms: 1) The required signage for oxygen storage was not provided on the 1st, 2nd and 3rd floors. The provided signage indicated only Danger. Oxygen In Use. No Smoking Matches or Open Flame. 2) Oxygen storage rooms lacked signage within the room to indicate the empty cylinders. Examples are: a. A storage rack with four E tanks was observed as empty but the signage was not provided. This was noted in the 2nd floor oxygen storage room that also contained full E tanks within. b. A mix of full E tanks and empty E tanks were observed within the same storage carts in the 1st floor main oxygen storage room. There was no signage provided to indicate the empty cylinders. In an interview on 10/10/17 at approximately 11:30am, the Director of Building Services stated that he would address the issue immediately. 2012 NFPA 99: 11.3.4, 11.3.4.1, 11.3.4.2, 11.6.5.2, 11.6.5.3 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedNovember 1, 2017

Plan of Correction: K923
I. Immediate Corrective Action
The Director of Maintenance placed signage stating ?Oxidizing gas(es) stored within. No smoking? outside the 1st, 2nd and 3rd floor oxygen storage rooms., The Director of Maintenance segregated the oxygen tanks, located in the 1st floor oxygen storage room between empty and full tanks. ?Empty? signage was placed to identify the segregation on the 1st, 2nd and 3rd floors oxygen storage rooms.
II. Identification of other Residents
The facility respectfully states that all Residents where potentially affected by this deficient practice.
III. Systemic Changes
The Director of Maintenance conducted facility wide rounds to ensure that: all oxygen tanks were segregated between empty and full tanks; that ?empty? signage was placed in the 1st, 2nd and 3rd floors oxygen storage rooms; and that ?Oxidizing gas(es) stored within. No smoking? signage was placed outside the 1st, 2nd and 3rd floor oxygen storage rooms
IV. Quality Assurance
The Director of Maintenance/designee will perform weekly audits, during environmental rounds, to ensure that all signage is appropriately affixed on the 1st, 2nd, and 3rd floors oxygen storage rooms and that oxygen tanks, on the 1st floor, are segregated between full and empty. The results of this will be presented to the administrator and to the QAPI committee, quarterly, for review.
V. The Person Responsible for this KTag
The Director of Maintenance is responsible for correcting this KTag deficiency.

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 16, 2017
Corrected date: November 17, 2017

Citation Details

2012 NFPA 101: 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25: 6.2.1 Components of standpipe and hose systems shall be visually inspected annually or as specified in Table 6.1.1.2. 2011 NFPA 25: Table 6.1.1.2 Summary of Standpipe and Hose Systems Inspection, Testing, and Maintenance. Test Item Frequency Reference Hose 5 years/ 3 years NFPA 1962 2008 NFPA 1962: 4.3.2 In-service hose designed for occupant use only shall be removed and service-tested as specified in Chapter 7 at intervals not exceeding 5 years after the date of manufacturer and every 3 years thereafter. This requirement is not met as evidenced by: Based on observation, staff interview and documentation review during the recertification survey, the facility did not ensure that the fire hoses installed within 2 of 2 emergency exit stairwells were maintained as per NFPA 25 & NFPA 1962. This was noted on 3 of 3 resident floors. The findings are: During the Life Safety Code Survey conducted on 10/10/17 between 9:00am and 1:00pm, it was noted that the stamped manufacturer's dates on the fire hoses within the stairwells indicated dates between 10/01-01/11. The facility did not provide documentation for the testing of the fire hoses as per NFPA 25 & NFPA 1962. Examples include but are not limited to fire hoses within Stairs A, and B on floors 1-3. In an interview on the same day at approximately 10:15am, the Director of Building Services stated that he would check for the documentation of the fire hose tests and provide them if necessary. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 5.3.2.1, 5.4.1.4, 5.4.1.4.1, 6.2.1, 6.1.1.2, 13.4.4.2.2, 13.4.4.2.2.2 2008 NFPA 1962: 4.3.2 NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedNovember 1, 2017

Plan of Correction: K035
I. Immediate Corrective Action
The Director of Maintenance contacted the vendor to replace the fire hoses within 2 of 2 emergency exit stairwells on 3 of 3 resident?s floors.
II. Identification of other Residents
The facility respectfully states that all Residents where potentially affected by this deficient practice which has been corrected.
III. Systemic Changes
The fire hose installation vendor replaced all the fire hoses within Stairwells A, B, and C on floors 1, 2 and 3 and basement, as per NFPA 25 & NFPA 1692 regulations.
IV. Quality Assurance
The fire hoses will be visually monitored and inspected, monthly, by the Director of Maintenance/designee. All findings will be brought to the administrator and the QAPI committee, quarterly, for review.
V. The Person Responsible for this KTag
The Director of Maintenance is responsible for correcting this KTag deficiency.