Cold Spring Hills Center for Nursing and Rehabilitation
March 22, 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 22, 2024
Corrected date: April 18, 2024

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during an abbreviated survey (NY 869) initiated on [DATE] the facility failed to ensure that each resident receive treatment and care in accordance with professional standards of practice for 1 out of 5 residents (Resident #1). Specifically, on [DATE] at 6:05 PM Resident #1 experienced respiratory distress. At 7:55 PM Nurse Practitioner #1 assessed the resident and ordered the resident to be transferred to the hospital. Registered Nurse #1 did not follow the order to call for emergency medical transportation, instead Registered Nurse #1 called a non-emergency ambulance service. The company reported that it would take 2 hours for the ambulance to arrive. The resident's family intervened at approximately 9:00 PM and demanded that emergency services (911) be called. The Registered Nurse #1 did not call for emergency transportation via emergency services until 9:20 PM, causing a 1 hour and 33-minute delay in emergency transport treatment. Subsequently, Resident #1 expired while waiting for emergency transportation. This resulted in actual harm to Resident #1 with potential for serious harm for 426 other residents in the facility that is Immediate Jeopardy and Substandard Quality of Care. The facility's policy titled Resident Change in condition dated [DATE] documented when a significant change in a resident's condition is identified, the licensed nurse will immediately inform the charge nurse or nursing supervisor. The charge nurse or nursing supervisor will promptly assess the resident and initiate appropriate interventions. The medical provider and the resident's authorized representative will be notified about the change. The policy does not address if or when Emergency Medical Services should be notified. A Comprehensive Care Plan dated [DATE] titled Ventilator Dependent documented resident is on a mechanical ventilator secondary to inability to maintain adequate oxygen saturation. Interventions include evaluate for gurgling respirations, increase secretions and sputum, and inform medical doctor as indicated. The facility Administrator stated that when an emergency requires an ambulance there is no policy that indicates how staff are to determine which ambulance provider to contact. Resident#1 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) indicating severe impairment. A review of the facility's Transfer Form (form to be sent when a resident is going to the hospital dated [DATE] at 8:03 PM documented that Resident #1 was being transferred to the hospital for Respiratory Distress. A review of the Nurse Practitioner Progress note dated [DATE] at 8:49 PM documented at 7:55 PM Resident #1 was seen for [MEDICAL CONDITION](rapid heartbeat), profuse diaphoresis (excessive sweating), and tachypnea (fast breathing). Resident #1 was evaluated with the respiratory team present. Oxygen saturation desaturated to 89% with the ventilator setting set to 60% oxygen, (normal oxygen saturation is 95% or greater), the ventilator oxygen setting was increased to 100% by the respiratory team to maintain residents' oxygen at ,[DATE]%, heart rate ,[DATE] (normal heart rate ,[DATE] beats per minute). Resident was currently on intravenous fluids. status [REDACTED]. Resident #1 remains unchanged. Plan of care discussed with Medical Doctor. Transfer Resident #1 to the hospital for further evaluation. Discussed with nursing staff. The Nurse Practitioner #1 note dated [DATE] documented at around 9:00 PM Resident's family showed up and inquired as to why Resident #1 was still in the facility and not at the hospital. Resident's #1 family requested for emergency services to be called. Emergency services were called immediately. Resident #1 was unresponsive when Emergency Medical Services arrived, and they pronounced Resident #1 deceased . A review of Resident #1's Death Certificate dated [DATE] at 9:40 PM, documented the immediate cause of death as cardiorespiratory arrest due to [MEDICAL CONDITION]. A review of the Prehospital Care Report filled out by the emergency medical transport technician documented that Emergency Medical Services were notified on [DATE] at 9:20 PM that Resident #1 had breathing problems. Emergency services ambulance staff were at Resident #1's bedside at 9:33 PM. Resident #1 was found in semi-fowlers position (the head of the bed is elevated ,[DATE] degrees) in a hospital bed at the facility and was pulseless. Resident #1 is ventilator dependent, whom according to staff became [MEDICAL CONDITION] while being evaluated by nurse practitioner at 7:45 PM. Staff increased their ventilator settings, after no improvement called a private ambulance for transport to the hospital. After 1 hour waiting for a private ambulance, the staff decided to call 911. Resident #1 was pronounced deceased after an electrocardiogram (a test that records the hearts electrical activity) was attached to Resident #1 and was found to be in asystole (when the hearts electrical system fails entirely, which causes your heart to stop pumping). During a telephone interview on [DATE] at 4:35 PM, unit Registered Nurse # 1, who worked on the evening shift on [DATE], stated at 8:00 PM, Nurse Practitioner #1 stated to transfer Resident #1 to the hospital. Registered Nurse #1 stated they called the(NAME)County Ambulance at 7:50 PM-8:00 PM. Registered Nurse #1 stated they told Nurse Practitioner #1 that there was a 2-hour timeframe for the ambulance. They stated the Nurse Practitioner did not say anything. They stated that at around 9:00 PM the next of kin came and told them to call Emergency Medical Services. Emergency Medical Services came to the facility within 10 minutes. The Emergency Medical Services stated there was no reason to take Resident #1 because the resident had already died . During an interview with Nurse Practitioner #1 on [DATE] at 4:44 PM they stated they assessed Resident #1 and called the Medical Doctor. The Medical Doctor stated to transfer Resident #1 to the hospital. They stated the order was to be carried out right away. Resident #1 was diaphoretic and [MEDICAL CONDITION] and they wanted Resident #1 to go to the hospital for further evaluation. During a re-interview with Nurse Practitioner #1 on [DATE] at 10:46 AM they stated they expected their order to transfer Resident #1 to the hospital to be carried out immediately. They stated they were not informed that the ambulance would take 2 hours. They stated had they been aware they would have called Emergency Medical Services immediately. During an interview on [DATE] at 12:57 PM with Medical Director, who is also the attending physician for Resident #1, they stated Resident #1 was ventilator dependent and was experiencing respiratory distress and was [MEDICAL CONDITION]. The Medical Director stated they gave the order for Nurse Practitioner #1 to transfer Resident #1 to the hospital at approximately 7:55 PM. The Medical Director stated that Resident #1's transfer to the hospital was delayed. During an interview with the Director of Nursing on [DATE] at 7:15 PM, they stated on [DATE] in the evening, Resident #1 had a change in condition, but the staff felt Resident #1 was stable. The Director of Nursing stated they reviewed the record on [DATE], after Resident #1 expired and identified no issues. They stated Resident #1 was a chronic [MEDICAL CONDITION] resident. When the Nurse Practitioner and Registered Nurse assessed Resident #1 there was no need to call Emergency Medical Services. They stated they would not have called an ambulance because Resident #1 was stable, they would have called the regular(NAME)County ambulance ambulette. During an interview with the Administrator on [DATE] at 7:30 PM they stated on [DATE] in the evening, Resident #1 had a change in condition, but the staff felt Resident #1 was stable. The facility will develop a policy related to calling an ambulance for an immediate need for transfer. The facility will train all medical providers and licensed nursing staff related to an emergency transfer policy. 10 NYCRR 483.25

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 F684. 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]. 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]. 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]. 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]. 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]. 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]. 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, NPís, RNís, LPNís, 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.