Woodbury Heights Nursing and Rehabilitation Center
March 29, 2024 Complaint Survey

Standard Health Citations

FF14 483.25:QUALITY OF CARE

REGULATION: § 483. 25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: March 29, 2024
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey dated 06/04/2024 through 06/12/2024, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan did not include provisions detailing their role for the care and treatment of [REDACTED]. This is evidenced as follows: There was no documented evidence that the facility emergency preparedness plan included provisions for the care and treatment of [REDACTED]. During an interview on 06/12/2024 at 11:10 AM, Administrator #1 stated that they would consult with thier county emergency preparedness officials and develop a plan for the care and treatment of [REDACTED]. 10 New York Codes, Rules, and Regulations 415. 26 42 Code of Federal Regulations: 483. 73(b)(8)

Plan of Correction: ApprovedApril 23, 2024

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or the conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. This plan of correction is the facility allegation of compliance: As recommended, a consultant has developed a directed plan of action. The facility retained the services of a consultant to assist with a Directed Plan of Correction and education for F 684. 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? 1. The facility took the following actions to address the citation and prevent additional residents from the deficient practice 2. Resident #1 expired. Immediately on [DATE], the facility initiated a record audit of all residents potentially affected by this practice to ensure no additional residents were affected. 3. The Director of nursing educated and suspended RN Nurse #1 on ,[DATE]- 24. 4. RN Nurse #1 was aware of a significant change but did not call 911 or notify the physician. The RN #1 was terminated from the facility on ,[DATE]- 24. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. 1. Following the occurrence, the facility immediately retained the services of a consultant on ,[DATE]/ 24. 2. The facility conducted a comprehensive audit and concluded that the deficient practice harmed no other resident. However, the potential exists for all residents who require emergency transport. 3. On [DATE], the RN Consultant developed an in-service lesson plan and post-test that addressed the following: a. To educate all medical and nursing staff on timely, effective, and consistently identifying the level of medical urgency and timely and effective implementation of medical orders to prevent a delay in a medical emergency. 4. The facility QAPI was conducted on [DATE] to develop a plan to review all 426 affected residents who would potentially be affected. An audit of all 426 residents was completed on ,[DATE]/ 24. b. The revised change in condition policy on [DATE] includes a life-threatening situation, a critical medical condition, or rapid worsening of a clinical situation; the nurse will call 911 and notify the physician. 5. RN Nurse #1 was aware of a significant change but did not upgrade transport to a more immediate transport nor notified the physician. The RN#1 was terminated from the facility on ,[DATE]- 24. 6. On [DATE], in-services for all staff members will begin on the change in condition policies. All staff members will be required to take a post-education test with 100% compliance. In-services completed on ,[DATE]/ 24. 3. What measures will be taken or systemic changes will you make to ensure that the deficient practice does not recur? 1. The facility with the consultant updated the policy & procedures regarding changes in condition to include a life-threatening situation, a critical medical condition, or rapid worsening of a clinical situation; the nurse will call 911 and notify the physician on [DATE] 2. The education plan was directed to all licensed staff: Physicians, NP's, RN's, LPN's, Respiratory, PT/OT and Social Work, on the updated change of condition policy and procedures and physician notification regulations. 3. The facility QAPI was conducted on [DATE] to develop a plan to review all affected residents who would potentially be affected. 4. The licensed staff are not permitted to work a shift until education is completed. 5. New hires and licensed staff will be educated on significant changes in condition and how to call 911 for a life-threatening or critical medical situation. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice. 1. In coordination with the QAPI committee, the RN Consultant initiated a change in the condition compliance audit tool to ensure compliance with the newly revised policy to be completed by the nursing supervisor with a focus on physician notification of significant changes. The DON/designee will also complete chart audits of residents with significant or life-threatening changes. For residents whose conditions change, audits will be conducted weekly for three months, then monthly for three months, and quarterly for one year. 3. Any negative findings identified during the audits will have immediate corrective action and be reported to the Administrator for follow-up. 4. The monthly QA/QI committee will review the results of the audit tools to identify trends and actions taken, determine the need for and/or frequency of continued monitoring, and make recommendations for continued compliance. 5. The correction date is (MONTH) 22, 2024. The facility Director of Nursing will be responsible for compliance.