Central Park Rehabilitation and Nursing Center
September 14, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 17, 2018
Corrected date: October 31, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview during the recertification survey the facility did not ensure a thorough and complete investigation was conducted for 1 of 6 residents (Resident #25) reviewed for abuse. Specifically, Resident #25 was found with a fracture of unknown origin and the facility did not complete a thorough investigation to rule out abuse, neglect or mistreatment. Findings include: Resident #25 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 04/19/18 Minimum Data Set (MDS) assessment documented the resident required total dependence for all activities of daily living and had impairment to both upper and lower extremities. The resident had no falls in the previous quarter. The 06/29/18 quarterly MDS documented the resident had a fall with major injury and was receiving pain medications. The 04/20/18 comprehensive care plan (CCP) documented the resident was unable to speak and was severely cognitively impaired. The resident was at risk for falls and was to have bilateral side supports in her gerichair (reclining chair). The resident required two staff at all times for all care, was non-ambulatory, and required a mechanical lift with two people for transfers. The CCP was updated on 06/23/18 to include the displaced oblique fracture to the proximal humerus shaft (fracture out of place in the upper part of the upper arm). Nursing progress notes: - On 06/15/18 at 06:00 PM, the registered nurse (RN) assessment documented the resident fell from her gerichair after leaning to the side and had a head abrasion. RN #17 documented that the resident had no pain at that time. - On 06/16/18 at 05:30 AM, RN #6 documented the resident had an abrasion to the forehead and a bruise to a wrist, no ill effects or further injuries form the fall, and Tylenol was given for a low-grade temperature. - On 06/16/18 at 10:40 PM and on 06/17/18 at 03:45 PM, the nursing progress documented the resident had no signs of pain. - On 06/18/18 at 04:00 PM, RN Unit Manager #10 documented the resident had a few small scattered areas of faint bruising on her right arm which were light purple and yellow in color and appeared superficial. The resident had no signs or symptoms of pain and her range of motion remained within normal limits for the resident. - On 06/18/18 at 11:36 PM, 06/19/18 at 07:54 AM and 11:26 PM, 06/20/18 at 10:58 PM, and 06/21/18 at 09:37 PM, the nursing notes documented the resident had no pain. - On 06/22/18 at 01:35 PM, licensed practical nurse (LPN) #15 documented the resident had bruising on her right arm which was purple/red in color, had swelling, and the resident had a facial grimace with movement to her right upper arm. The nurse practitioner (NP) was called and an order for [REDACTED]. - On 06/22/18 at 03:12 PM, RN #14 documented the resident had bruising from the right axilla (armpit) extending and throughout the upper inner arm. The right upper and lower arm had [MEDICAL CONDITION] (swelling), the resident showed facial grimacing when range of motion was attempted, and the extremity was warm to the touch. - On 06/22/18 at 07:00 PM, the RN documented the x-ray showed a humerus displaced oblique fracture proximal shaft. The resident had bruising to her right upper arm. A 06/15/18 at 06:00 PM investigation documented the resident had a witnessed fall from her chair to the floor and she obtained an abrasion on her head. The investigation documented that all staff who witnessed the fall wrote statements. The resident was to be seen by physical and occupational therapy. The 06/18/18 Physical Therapy Plan of Care documented the resident was referred for a recent fall out of her geri chair. Positioning, transferring from bed to chair, and bed mobility was to be addressed. The resident required maximum assistance for bed mobility and transferring, and assistance with two people for positioning. The 06/19/18 Occupation Therapy Plan of Care- Evaulation Only documented the resident was referred after a fall from her chair after an unexpected movement and physical therapy was addressing positioning and bed mobility. The resident had profound cognitive impairment, required 100% assist for all activities of daily living, and required assistance with two people for positioning. The 06/22/18 portable x-ray report documented a displaced oblique fracture proximal shaft (fracture out of place in the upper part of the upper arm), no shoulder dislocation, and intact clavicle on the right clavicle/shoulder/humerus view. The 06/22/18 synopsis completed by the Director of Nursing (DON) of the resident fall and fracture the documentation from the 06/15/18 accident and incident report. The synopsis determined the fracture was related to the 06/15/18 fall. The synopsis did not include interview statements surrounding the 06/22/18 fracture. The 06/29/18 Physical Therapy (PT) Therapist Progress and Discharge summary documented the resident was seen for range of motion (ROM) exercise and geri chair positioning. The discharge summary documented ROM was performed on the resident's bilateral lower extremities. The resident was observed in a gerichair leaning to the right side on 09/13/18 at 01:21 PM, on 09/14/18 at 12:01 PM and 1:40 PM. On 09/17/18 at 10:28 AM, LPN #13 stated in interview when a fracture without a known cause occurs, all employees on the shift and the shift before are required to write statements. The LPN witnessed the resident fall on 06/16/18. The LPN said she checked the resident daily and she had no bruises, no facial grimacing, and no signs of pain in the days following the fall. When the bruise presented, it wasn't bad but it got darker over a few days. On 09/17/18 at 10:56 AM, RN Unit Manager #10 stated in interview accident and incident reports were to be completed on falls and new skin issues including bruises. Investigations were to be initiated immediately and were to be done on each individual incident. The RN stated that if a resident fell on a Monday and a new bruise was discovered Wednesday, a follow up incident report would be initiated to determine if the bruise aligned with the prior incident as an example. For new bruises, they interviewed staff from the previous 48 hours. The RN remembered the fall happening on 06/15/18 when the resident had a spastic movement, tipped over the side of her chair, and fell on her right arm. The RN stated the resident had no issues with range of motion following the fall and physical therapy started working the resident. The bruise was noticed on 06/22/18 on the right arm. On 09/17/18 at 11:49 AM, the DON stated in interview the resident fell on [DATE] and started therapy on 06/18/18. When the bruise was found, RN #10 completed an assessment which documented the resident had baseline contractures and no pain was evident. A couple days later, the bruise had progressed and the resident had no pain. On 06/22/18, the bruise was thicker and an x-ray was obtained that showed a fracture. The DON stated that the nursing notes all along documented no signs of pain and no facial grimacing. A second accident and incident report was not completed as the fracture was attributed to the fall on 06/15/18, nursing had been documenting right along following the progression, and was on the same arm resident fell on . The DON stated she did not complete staff interviews following the fracture. A synopsis was completed to tie the fracture to the fall and the facility provided education on abuse with a focus on reporting changes in condition. The DON stated the date on the sypnosis is not the date it was initated and not the date it was completed. The DON stated the bruising may have been exacerbated from physical therapy. 10NYCRR 415.4(b)

Plan of Correction: ApprovedOctober 15, 2018

F610 Investigate/Prevent/Correct Alleged Violation

Immediate Corrective Actions:
Investigation re-opened and expanded related to the fracture/bruising of resident #25.

Identification of Other Residents Potentially Affected:
A review of all resident incident reports in the past 30 days was conducted to determine if further investigation was needed to determine if abuse, neglect, or mistreatment occurred ? none noted.

Systematic Changes:
All unwitnessed injuries will be considered as unknown origin and an investigation will be conducted to identify root cause and rule out resident abuse. The facility has implemented an accident/incident log for all incidents that result in an injury. All incidents logged will be audited weekly to ensure for a thorough investigation to include witness statements and thoroughly completed accident/incident reports to determine if abuse, neglect or mistreatment occurred. All staff will be in-serviced on incident reporting and facility abuse prevention program including investigations and reporting resident changes in condition. Any investigation pertaining to a potential injury of unknown origin will include an accident/incident report along with statements going back 24 hours of the reported incident.

QA Monitoring:
The facility will audit all accident/incident reports that result in injury to ensure a thorough investigation is completed. This audit will be conducted weekly for 4 weeks and then monthly thereafter until determined otherwise by the monthly Quality Assurance and Performance Improvement Committee. The results will be reported to the monthly Quality Assurance and Performance Improvement Committee for review. The Assistant Director of Nursing (ADON) will be responsible for oversight of the audits. Goal is 100% compliance with injuries of unknown origin to have an investigation for root cause and rule out resident abuse. In the event there is an injury of unknown origin without an investigation, the Director of Nursing will be notified immediately to conduct an investigation.

Responsible Person: Assistant Director of Nursing
Completion Date: (MONTH) 31, (YEAR) and ongoing

FF11 483.45(a)(b)(1)-(3):PHARMACY SRVCS/PROCEDURES/PHARMACIST/RECORDS

REGULATION: §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who- §483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 17, 2018
Corrected date: October 31, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey the facility did not maintain drugs and biologicals stored and labeled in accordance with currently accepted professional standards, and the expiration date when applicable for 1 of 4 nursing units (Unit 2) inspected. Specifically, inspection of medication rooms revealed Unit 2 had a [MEDICAL CONDITION] test multi-dose vial that was expired or outdated beyond the opened expiration date in the medication refrigerator. Findings include: The revised [DATE] Administering Medication policy documented when opening a multi-dose container, the date shall be recorded on the container. The policy documented the expiration date on the medication label must be checked prior to administering. The revised [DATE] Storage of Medications policy documented the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. The policy documented all such drugs shall be returned to the dispensing pharmacy or destroyed. The policy stated nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. On [DATE] at 12:46 PM during a Unit 2 medication room inspection with licensed practical nurse (LPN) #16, there was a [MEDICAL CONDITION] test multi-dose vial labeled lot # 4 manufacture expiration date ,[DATE]. A date handwritten on the open box was [DATE]. When interviewed on [DATE] at 01:15 PM, LPN #16 stated there were 2 vials of [MEDICAL CONDITION] test in the medication room fridge yesterday, and she did not know what happened to them as they were not there now. She stated that nurses were to write the date they opened the vials when first accessing the vials. She was not sure if anyone was designated to check vial expiration dates on a routine basis, and that the nurse giving the medication should check the expiration date of the medication prior to each administration. Once a vial was opened, it was good for 30 days for the [MEDICAL CONDITION] test. She stated the vial should have been discarded as it was dated opened on [DATE] and was expired. When interviewed on [DATE] at 01:27 PM, registered nurse (RN) Unit Manager #17 stated staff threw the vials of [MEDICAL CONDITION] test away yesterday. The expired vial was brought to the unit from another unit yesterday. She stated the nurses and pharmacy were responsible for checking expiration dates of medications, and that the pharmacy checked them monthly. She stated only the LPNs on each unit had keys to the unit medication room refrigerator, the nurse opening the vial was to date it when opened, and it expired 30 days from that date. The night shift was responsible for checking the temperature and expiration dates of the medication room refrigerator medication nightly. Also, the nurse administering the medication was responsible for checking expirations of that medication prior to administration. One of the vials in the medication room was expired and should have been disposed of by placing it in the SHARPS container due to the vial being glass. She stated there was no form that the night shift nurse documented they checked the expiration dates but it was an implied duty when they checked and signed for refrigerator temperatures. When interviewed on [DATE] at 10:24 AM, the Director of Nursing (DON) stated purchasing staff checked and delivered the stock medications, to include expiration dates. She expected the nurses to date each stock multi-dose vial when opened, and there was no designated person to check expiration dates. Each nurse was responsible for checking expiration dates prior to administering the medication and not give an expired medication, per standard of practice. She expected a vial dated as opened [DATE] to be discarded after 30 days, and the expired vial should have been discarded. She stated all the nurses were aware of storage of medication and medication expiration policies. 10NYCRR 415.18

Plan of Correction: ApprovedOctober 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F755 Pharmacy Services/Procedures/Pharmacist/Records

Immediate Corrective Actions:
The [MEDICAL CONDITION] test multi-dose vial in the medication refrigerator on unit 2 was disposed of immediately.

Identification of Other Residents Potentially Affected:
The facility conducted a full-house audit of all unit medication rooms including medication refrigerators for outdated or expired medications and multi-dose vials. No issues identified.

Systematic Changes:
Designated nursing staff will conduct and document weekly audits of all medication rooms including medication refrigerators for outdated or expired medications and multi-dose vials. All licensed nursing staff to be in-serviced on checking the expiration date on all medications prior to administering the medication and properly discarding any medications that are outside the expiration date.

QA Monitoring:
The Unit Managers will monitor the ongoing weekly audits of all medication rooms including medication refrigerators for outdated or expired medications and multi-dose vials. This audit will be conducted weekly for four weeks with a target threshold of 90%. Once this is met, the audit will be conducted monthly thereafter. The results will be reported to the monthly Quality Assurance and Performance Improvement Committee for review. The Assistant Director of Nursing (ADON) will be responsible for oversight of the audits and corrective measures. If a problem is identified, the Director of Nursing will be notified immediately for proper follow up.

Responsible Person: Assistant Director of Nursing
Completion Date: (MONTH) 31, (YEAR) and ongoing

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 14, 2018
Corrected date: October 31, 2018

Citation Details

Based on observation and interview conducted during the Life Safety Code survey, the facility did not ensure the building was protected throughout by an approved automatic sprinkler system for 1 isolated area (stairwell 1 east) in accordance with National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems section 8.3.3.2. Section 8.3.3.2 states: Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3. Specifically, stairwell 1 east contained both quick response and standard response sprinkler heads. Findings include: On 9/12/2018 at 11:30 AM, a surveyor observed stairwell 1 east contained 1 quick response sprinkler head and 2 standard response sprinkler heads. During an interview on 9/12/2018, between 11:30 AM and 12:04 PM, the Maintenance Director stated he was not aware that stairwell 1 east contained both quick response sprinkler heads and standard response sprinkler heads. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.3.3.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedOctober 1, 2018

K 351 NFPA 101 Sprinkler System ? Installation

Immediate Corrective Actions:
The automatic sprinkler heads in the East stairwell were changed and installed with all quick response sprinkler heads so all sprinkler heads were matching within the compartment.

Identification of Other Residents Potentially Affected:
The facility recognizes all residents as having the potential to be affected. A facility wide inspection of all sprinkler heads was completed by the maintenance department to ensure there are matching sprinkler heads within a compartment or area. No issues identified.

Systematic Changes:
Maintenance Director or designated personnel will audit sprinkler heads semi-annually to ensure cleanliness and make sure there is no foreign material on the head and ensure it is unobstructed.

QA Monitoring:
The Director of Maintenance will monitor the documentation and completion of sprinkler head auditing. The Maintenance Director will report monthly at the Quality Assurance (QA) Committee meeting that the facility is up to date and in compliance.

Responsible Person: Director of Maintenance
Completion Date: (MONTH) 31, (YEAR) and ongoing

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 14, 2018
Corrected date: October 31, 2018

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility did not ensure 2 of 2 fire barriers observed were constructed to a 1-hour fire resistance rating (second floor fire barrier, and first floor fire barrier). Specifically, the fire barriers referenced above had unsealed penetrations. Findings include: On 9/14/2018, between 11:34 AM and 12:05 PM, a surveyor observed the following 1-hour fire rated fire barriers had unsealed penetrations: - The second floor fire barrier had a pipe conduit passing through it and the outside of the pipe was partially sealed. There were four cables running through the outer annular space of the pipe conduit, and this area was not sealed. - The first floor fire barrier had an unsealed 1 inch bundle of data wires passing through it. During an interview on 9/14/2018, between 11:34 AM and 12:05 PM, the Maintenance Director stated he was not aware of the unsealed fire barrier penetrations found during survey. 2012 NFPA 101: 19.3.7.3 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedOctober 5, 2018

K 372 NFPA 101 Subdivision of Building Spaces ? Smoke Barrier Construction

Immediate Corrective Actions:
Unsealed penetrations in the first floor and second floor fire barriers were all sealed with fire rated material.

Identification of Other Residents Potentially Affected:
The facility recognizes all residents as having the potential to be affected. A facility wide inspection was completed by the maintenance department. Any openings/penetrations identified were sealed with fire rated material.

Systematic Changes:
Maintenance Director will be educated via educational seminar on fire stopping requirements, systems and techniques prepared by the International Firestop Council (IFC). Maintenance Director or designated maintenance worker will inspect all construction and work of outside vendors on a daily basis throughout the entirety of the project to ensure there is no unsealed openings/penetrations. Any identified unsealed penetrations will be sealed with fire rated material.

QA Monitoring:
The Director of Maintenance will monitor construction or any other outside vendor work performed in the facility to ensure there is no unsealed openings/penetrations. The Maintenance Director will report monthly at the Quality Assurance (QA) Committee meeting any work that was completed by outside vendors or companies and that the work was inspected thoroughly after the vendors were finished.

Responsible Person: Director of Maintenance
Completion Date: (MONTH) 31, (YEAR) and ongoing