Fordham Nursing and Rehabilitation Center
February 2, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.20(g):ACCURACY OF ASSESSMENTS

REGULATION: §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 2, 2018
Corrected date: April 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility did not ensure that the comprehensive assessment accurately reflected the resident's medical diagnosis. Specifically, the Admission Minimum Data Set 3.0 (MDS) assessment and the 30-Day MDS did not document the resident's medical diagnosis. This was evident for 1 of 5 residents reviewed for Unnecessary Medications (Resident # 106). The finding is: Resident #106 is a resident, admitted on [DATE], with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] documented the resident had intact cognition and mood symptoms of sleep disturbance and moving slowly nearly every day. The MDS further documented the resident displayed behavior symptoms not directed towards others and rejection of care 1 to 3 days. The resident received antipsychotic medication for 6 days and hypnotic medication for 4 days. There were no psychiatric or mood disorders documented under active diagnoses. The 30-Day MDS dated [DATE] did not have any Psychiatric or Mood Disorders documented under active diagnoses. The Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] Drug Use Dated 12/3/17 documented that the resident received medication for [MEDICAL CONDITION] Disorder with [MEDICAL CONDITION]. The Psychiatric Consult dated 12/5/17 documented the resident was seen for anxiety and frustration. The resident had a history of [REDACTED]. The consult documented the resident had an Axis I [DIAGNOSES REDACTED]. The psychiatrist recommended the resident's [MEDICATION NAME] be increased from 100 milligrams (mg) to 125 mg HS (at bedtime). The Medication Administration Record (MAR) dated (MONTH) (YEAR) documented the resident was on [MEDICATION NAME] for [MEDICAL CONDITION]. The MAR documented [MEDICATION NAME] was increased to 125 mg on 12/6/17. On 2/2/18 at 11:03 AM, the RN (Registered Nurse) /MDS Nurse was interviewed and stated that to obtain the active Diagnoses, he checks the physician's orders [REDACTED]. The psychiatry consult usually has the [DIAGNOSES REDACTED]. He further stated he should also check the MAR and look for why the resident was given the [MEDICAL CONDITION] medications. The psychiatric disorders should have been marked off on Section I of the MDS as active diagnoses. She stated she could not figure out why it was not coded, especially since the Psychiatrist indicated the [DIAGNOSES REDACTED]. 415.11(b)

Plan of Correction: ApprovedMarch 1, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action:
1. The MDS Assessor who completed the discharged MDS and data entry error was counseled and re-educated on accurate coding of the MDS. Although the MDS Assessor documented the resident?s use of psychoactive medication, he inadvertently omitted the supporting [DIAGNOSES REDACTED].
2. The MDS Coordinator submitted a corrected assessment for this resident on 2/2/18.
3. Resident #106 has since been discharged from the facility on 1/6/18.
II. Identification of Other Residents:
1. The facility reviewed all its residents? most recent MDS records completed in the last 30 days to ensure coding accuracy. No other coding errors were noted.
2. Audits of MDS coding for all residents specific to a resident?s active [DIAGNOSES REDACTED].
III. Systemic Changes
1. The Director of Nursing reviewed the facility?s nursing policy for coding specific to active [DIAGNOSES REDACTED].
2. The MDS Department will be re-educated regarding accurate coding of the MDS.
3. A copy of the lesson plan and attendance will be filed for reference and validation.
IV. Quality Assurance Monitoring
1. The Director of Nursing developed an audit tool to track accurate coding in MDS assessments for active diagnosis.
2. This audit will be completed for 10% of all submissions weekly for the first month and monthly for the first quarter.
3. Audits with negative findings will have on site corrective actions implemented by the auditor.
4. Audit findings will be presented to the Quality Assurance Committee quarterly for evaluation and follow up as indicated.

Date of correction: 3/31/18
Responsible Party: MDS Coordinator

FF11 483.21(a)(1)-(3):BASELINE CARE PLAN

REGULATION: §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan- (i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 2, 2018
Corrected date: April 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, the facility did not ensure residents were provided with a summary of the baseline care plan. This was evident for 3 newly admitted residents out of 38 residents reviewed in the investigation sample (Resident #s 418, 416, and 419). The findings are: 1) Resident #418 was admitted to the facility on [DATE]. On 1/29/18 at 11:55 AM, the resident was interviewed and stated he did not have a care plan meeting yet. The resident further stated that he never received a summary of his baseline care plan. 2) Resident #416 was admitted on [DATE]. On 1/25/18 at 12:24 PM, the resident was interviewed and stated he attended a care planning meeting about two weeks after admission. He never received a written summary of his baseline care plan. The resident when through the drawers and told the surveyor he did not have it. 3) Resident #419 was admitted on [DATE]. On 1/26/18 at 11:14 AM, the resident was interviewed and stated he never received a baseline care plan in writing. He further stated that if he received a written summary, he would keep a copy in the drawer. On 2/1/18 at 12:50 PM, the Registered Nurse (RN) was interviewed and stated the nurse stated that she is responsible for the care planning meetings which take place 14 days after admission. The comprehensive care plan is a not a written summary, and the resident is not given a baseline care plan in writing. However, upon admission, the staff verbally inform the resident about discharge planning and appointments. In the care planning meeting, the staff discusses details about the resident's care. 415.11

Plan of Correction: ApprovedMarch 1, 2018

Immediate Corrective Action:
1. The baseline care plan developed for Residents #416, # 418 and #419 were printed immediately and provided by the Social Worker to the residents on ____

II. Identification of Other Residents:
Admissions from 11/28/17 up to 2/2/18 were reviewed to ensure a copy of the base line care plan was provided to the resident or representative. No other quality issues were identified.

III. Systemic Changes
? The Director of Nursing reviewed the facility?s policy and found the policy to be in compliance.
? The clinical staff were re-inserviced on the base line care plan completion and providing a copy of the care plan summary to the resident and their representative by the completion of the comprehensive care plan.
IV. Quality Assurance Monitoring
1. The Director of Nursing developed a Care Plan Summary Audit tool to monitor compliance to the requirement of F655.
Ten audits will be completed weekly for the first quarter.
2. Audits with negative findings will have on site corrective actions implemented by the auditor.
3. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up as indicated.

Date of correction: 3/31/18
Responsible Party: MDS Coordinator

FF11 483.40(d):PROVISION OF MEDICALLY RELATED SOCIAL SERVICE

REGULATION: §483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 2, 2018
Corrected date: April 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, during the Recertification survey, the facility did not provide medically related social services. Specifically, a resident was not assisted with obtaining clothing. This was evident for 1 of 38 residents in the investigation sample. (Residents #419) The finding is: Resident #419 is a resident, admitted [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had intact cognition and required the assist of one person for dressing. The MDS further documented it was very important for the resident to choose what clothing to wear under preferences. On 1/26/18 at 11:13 AM, the resident was observed wearing a hospital gown lying on the bed. The resident was interviewed and stated, I have no clothes as I came from the shelter to the hospital and then to the facility. I have been asking for clothes since I was admitted . This surveyor proceeded to look inside the resident's closet and there were no clothes. During a resident interview in the resident's room on 1/31/18, from 12:20 to 12:27 PM, the resident was lying in the bed wearing a hospital gown and black pants. The resident stated he had a doctor's appointment on Monday, (MONTH) 29th, and the nurse got him pants to wear because it was cold outside. He further stated that he borrowed a jacket from another resident. The resident stated he has been wearing the same pants since Monday. He felt bad because he did not want to eat lunch with the jacket on, and his chest gets cold in the hospital gown. He is not allowed to eat in the dining room wearing a hospital gown, so he must eat lunch in his room. The resident also stated he even asked the doctor to speak to the social worker because he needs clothes. The resident pointed to the jacket in the closet to show the surveyor the jacket he borrowed from another resident. The resident Inventory sheet dated 1/19/18 with the resident's name on top was blank. No personal belongings or clothing items were documented. The Certified Nursing Assistant (CNA) was interviewed on 1/31/18 at 1:13 PM and stated the resident has no clothes, but we got him the pants on Monday because he went to the Doctor. The coat was donated from another resident. She referred the resident to the Social worker, but she has not come to see him yet. The CNA stated she helps the resident with dressing, and all his meals are eaten in the room. She did not know why the resident always ate in the room, but she thought it was because he had an infection. The Licensed Practical Nurse (LPN) was interviewed on 1/31/18 at 12:05 PM and stated when the resident is admitted the Certified Nursing Assistant completes the inventory sheet. If the resident needs clothes, that CNA informs the nurse so they can make a request to the laundry for donated clothes and a social work referral. This should be documented in the progress notes. The CNA should document the resident has no clothes on the inventory sheet. This was not done. The residents can only eat in the dining room if they are wearing clothes. The LPN did not know why the resident went 13 days without clothes. The resident received the pants because of the doctor's appointment, and the coat was from another resident. On 1/31/18 at 3:13 PM, the Social Worker Director (DSW) was interviewed and stated she did not look for clothes for the resident because the resident did tell her that he did not have clothes. She further stated she did observe the resident wearing a hospital gown. 415.5(a)

Plan of Correction: ApprovedMarch 1, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action:
The Director of Nursing and Director of Social Services conducted a complete and thorough investigation into the care of Resident #419. Based on the investigation the following corrective actions were implemented:
? Resident #419 had just began tolerating the fabric touching his inflamed/hypersensitive scrotal area and was subsequently provided with donated clothing on 1/20/18,2/1/18,2/2/18. On 2/5/18 a family member bought in clothing.
? Inventory sheet for donated clothing indicated the dates Resident #419 was given donated clothing upon arrival from hospital. He had available shirts and pants despite initial intolerance to pants but was using the shirts underneath the hospital gown.
? Resident #419 was on contact isolation for scrotal drainage with ESBL/[DIAGNOSES REDACTED] Pneumonia which was not able to be contained by a dressing. The excessive wound drainage suggests an increased potential for extensive environmental contamination and risk of transmission that Resident #419 was served his meals in his private room. When the wound had improved and its drainage had decreased and was able to be contained by the dressing, the contact isolation was discontinued on 2/23/18. The resident is currently eating in the dining room.
? Resident was visited by the Social Worker on 1/31/18 to address the resident?s needs and requests.
II. Identification of Other Residents:
? A full house review of resident?s clothing needs was conducted.
? No other residents was affected by this deficiency and no additional quality issues were noted
III. Systemic Changes
1. The DNS and the Director of Social Services reviewed the Facility?s Policy on resident rights and promotion of resident dignity and found same to be compliant.
2. The In-service Coordinator re-in serviced all staff on the completion of personal belonging Inventory sheet on admission day, including documenting that resident did not have any clothing on admission.
3. An inventory sheet will be completed for any donated clothing provided by the facility to the resident.
IV. Quality Assurance Monitoring
1. The Social Service Director has created an audit tool to track compliance to F 550
2. The audits will be done weekly by Social Worker for all new admissions to the facility to ensure appropriate clothing is available for resident. Thereafter, random audits will be completed weekly over the next quarter.
3. Any negative findings will have corrective actions implemented as indicated
4. Audit findings will be presented to the QA
Committee quarterly for evaluation and follow up as needed.

Date of correction: 3/31/18
Responsible Party: Director of Social Service/designee

FF11 483.10(a)(1)(2)(b)(1)(2):RESIDENT RIGHTS/EXERCISE OF RIGHTS

REGULATION: §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 2, 2018
Corrected date: April 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, during the Recertification survey, the facility did not ensure that residents were cared for in a manner that enhanced their dignity. Specifically, a resident was observed dressed in hospital gowns throughout the day. This was evident for 1 of 38 residents in the investigation sample. (Resident #419) The finding is: The Facility's Welcome Booklet and Resident Information Guide documents, As a matter of resident's dignity, all residents should be properly attired while in the facility. Resident #419 is a resident, admitted [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had intact cognition and required the assist of one person for dressing. The MDS further documented it was very important for the resident to choose what clothing to wear under preferences. On 1/26/18 at 11:13 AM, the resident was observed wearing a hospital gown lying on the bed. The resident was interviewed and stated, I have no clothes as I came from the shelter to the hospital and then to the facility. I have been asking for clothes since I was admitted . This surveyor proceeded to look inside the resident's closet and there were no clothes. During a resident interview in the resident's room on 1/31/18, from 12:20 to 12:27 PM, the resident was lying in the bed wearing a hospital gown and black pants. The resident stated he had a doctor's appointment on Monday, (MONTH) 29th, and the nurse got him pants to wear because it was cold outside. He further stated that he borrowed a jacket from another resident. The resident stated he has been wearing the same pants since Monday. He felt bad because he did not want to eat lunch with the jacket on, and his chest gets cold in the hospital gown. He is not allowed to eat in the dining room wearing a hospital gown, so he must eat lunch in his room. The resident also stated he even asked the doctor to speak to the social worker because he needs clothes. The resident pointed to the jacket in the closet to show the surveyor the jacket he borrowed from another resident. The resident Inventory sheet dated 1/19/18 with the resident's name on top was blank. No personal belongings or clothing items were documented. The Certified Nursing Assistant (CNA) was interviewed on 1/31/18 at 1:13 PM and stated the resident has no clothes, but we got him the pants on Monday because he went to the Doctor. The coat was donated from another resident. She referred the resident to the Social worker, but she has not come to see him yet. The CNA stated she helps the resident with dressing, and all his meals are eaten in the room. She did not know why the resident always ate in the room, but she thought it was because he had an infection. The Licensed Practical Nurse (LPN) was interviewed on 1/31/18 at 12:05 PM and stated when the resident is admitted the Certified Nursing Assistant completes the inventory sheet. If the resident needs clothes, that CNA informs the nurse so they can make a request to the laundry for donated clothes and a social work referral. This should be documented in the progress notes. The CNA should document the resident has no clothes on the inventory sheet. This was not done. The residents can only eat in the dining room if they are wearing clothes. The LPN did not know why the resident went 13 days without clothes. The resident received the pants because of the doctor's appointment, and the coat was from another resident. 415.5(a)

Plan of Correction: ApprovedMarch 1, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action:
The Director of Nursing and Director of Social Services conducted a complete and thorough investigation into the care of Resident #419. Based on the investigation the following corrective actions were implemented:
? Resident #419 had just began tolerating the fabric touching his inflamed/hypersensitive scrotal area and was subsequently provided with donated clothing on 1/20/18,2/1/18,2/2/18. On 2/5/18 a family member bought in clothing.
? Inventory sheet for donated clothing indicated the dates Resident #419 was given donated clothing upon arrival from hospital. He had available shirts and pants despite initial intolerance to pants but was using the shirts underneath the hospital gown.
? Resident #419 was on contact isolation for scrotal drainage with ESBL/[DIAGNOSES REDACTED] Pneumonia which was not able to be contained by a dressing. The excessive wound drainage suggests an increased potential for extensive environmental contamination and risk of transmission that Resident #419 was served his meals in his private room. When the wound had improved and its drainage had decreased and was able to be contained by the dressing, the contact isolation was discontinued on 2/23/18. The resident is currently eating in the dining room.
? Resident was visited by the Social Worker on 1/31/18 to address the resident?s needs and requests.
II. Identification of Other Residents:
? A full house review of resident?s clothing needs was conducted.
? No other residents was affected by this deficiency and no additional quality issues were noted
III. Systemic Changes
1. The DNS and the Director of Social Services reviewed the Facility?s Policy on resident rights and promotion of resident dignity and found same to be compliant.
2. The In-service Coordinator re-in serviced all staff on the completion of personal belonging Inventory sheet on admission day, including documenting that resident did not have any clothing on admission.
3. An inventory sheet will be completed for any donated clothing provided by the facility to the resident.
IV. Quality Assurance Monitoring
1. The Social Service Director has created an audit tool to track compliance to F 550
2. The audits will be done weekly by Social Worker for all new admissions to the facility to ensure appropriate clothing is available for resident. Thereafter, random audits will be completed weekly over the next quarter.
3. Any negative findings will have corrective actions implemented as indicated
4. Audit findings will be presented to the QA
Committee quarterly for evaluation and follow up as needed.

Date of correction: 3/31/18
Responsible Party: Director of Social Service/designee

FF11 483.10(g)(2)(i)(ii)(3):RIGHT TO ACCESS/PURCHASE COPIES OF RECORDS

REGULATION: §483.10(g)(2) The resident has the right to access personal and medical records pertaining to him or herself. (i) The facility must provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically), or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays); and (ii) The facility must allow the resident to obtain a copy of the records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request and 2 working days advance notice to the facility. The facility may impose a reasonable, cost-based fee on the provision of copies, provided that the fee includes only the cost of: (A) Labor for copying the records requested by the individual, whether in paper or electronic form; (B) Supplies for creating the paper copy or electronic media if the individual requests that the electronic copy be provided on portable media; and (C)Postage, when the individual has requested the copy be mailed. §483.10(g)(3) With the exception of information described in paragraphs (g)(2) and (g)(11) of this section, the facility must ensure that information is provided to each resident in a form and manner the resident can access and understand, including in an alternative format or in a language that the resident can understand. Summaries that translate information described in paragraph (g)(2) of this section may be made available to the patient at their request and expense in accordance with applicable law.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 2, 2018
Corrected date: April 16, 2018

Citation Details

Based on interviews and record reviews during the recertification and abbreviated survey (Complaint #NY 713), the facility did not ensure that residents' representatives were provided with a copy of the residents health care records within 2 working days upon request for such records. Specifically, the HP (health care proxy) and family member of Resident #143 made a request for copies of the resident's record on 12/26/17 and again on 1/3/2018. At the time of the survey the facility had not complied with the request and not provided a copy of the record to the HP. This was evident for 1 resident reviewed for Access to Medical Records out of a sample of residents. The Finding is: Resident #143 has a nephew who is documented as the resident's HP. The nephew complained to the State Agency that he made 3 requests to the facility for a copy of the resident's medical record, and was never provided with a copy of the record. An internal facility email dated 1/5/18 was provided to the State Surveyor for review. The email documents that the facility acknowledged that on 12/26/17 the HP requested a copy of podiatry consultant reports, and on 1/3/17 he requested a copy of the entire medical record. The email documented that the HP was informed that he his request was not valid and that he needed to make corrections. On 2/2/18 the State Surveyor conducted an interview with the facility clerk who handles requests for medical records. The clerk stated that she spoke to the the resident's HP on two separate occasions; once on 1/4/18 and again on 1/5/18 in regards to his request for a copy of the resident's medical record. The facility clerk stated that his request was denied because he did not correctly complete the form titled Health Information Form Authorization. A review of the form revealed that there was not missing or incorrect information and that the form appeared to be complete and accurate, and signed by the HP. The facility had not provided the HP with a copy of the resident's medical record at the time the recertification/abbreviated survey. 415.3(c)(1)(iv)

Plan of Correction: ApprovedMarch 1, 2018

Immediate Corrective Action:
? The Medical Records Clerk reached out again to the resident?s nephew to complete the appropriate form as instructed by the facility?s legal department. A properly completed release form (Authorization for Release of Health Information Pursuant to HIPAA) now with box 13 filled out was submitted by the resident?s nephew on 2/20/18 and a copy of the resident?s medical record was provided to the resident?s nephew on 2/22/18.

II. Identification of Other Residents:
The facility respectfully states that no other residents was
affected by this deficiency.

III. Systemic Changes:
? The policy was revised to include Social Service involvement in explaining the proper completion of the Authorization for Release of Health Information Pursuant to HIPAA for any unforeseen reason for the request not to be valid and honored.
IV. Quality Assurance Monitoring
1. The Director of Nursing had developed an audit tool to track and validate the requirements of F573.
The audit tool will address:
? The validity of the request with the release form properly completed,
? Compliance to access to records within 24 hours of request (excluding weekends and holidays)
? Provision of a copy of medical record within 2 working days upon request for such records.

Date of correction: 3/31/18
Responsible Party: Director of Nursing

FF11 483.55(b)(1)-(5):ROUTINE/EMERGENCY DENTAL SRVCS IN NFS

REGULATION: §483.55 Dental Services The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(b) Nursing Facilities. The facility- §483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; §483.55(b)(2) Must, if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; §483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; §483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and §483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 2, 2018
Corrected date: April 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure routine dental services were provided in a timely manner. This was evident for 1 of 3 residents reviewed for Dental (Resident #416). The finding is: Resident #416 is a resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE], documented the resident had intact cognition and required the extensive assist of one personal hygiene. The MDS documented no dental concerns. On 1/25/18 at 12:28 PM, the resident was interviewed and stated, I want to go to a dentist but it is cold outside, and I do not believe the facility has a Dentist. On 2/1/18 at 10:54 PM, the resident was interviewed and stated that he found out the facility has a dentist after speaking wit the surveyor. The resident asked when he will have his appointment. He stated that it is important to him because his teeth are starting to break. The resident further stated, please help me. During the interview, the resident was observed with two teeth in the front and two teeth in the back. A Physician's (MD) order dated 12/30/17 documented an order for [REDACTED]. The list titled Schedule of Residents to be Seen By the Dentist dated 12/30/17 did not contain the resident's name. The Comprehensive Care Plan (CCP) for Dental dated 1/3/18 included interventions for dental consult annually and as needed and to monitor for missing, loose, or broken teeth. There was no documented evidence in the medical record that the resident received a dental consult. On 2/1/18 at 11:24 AM, the Licensed Practical Nurse (LPN) was interviewed and stated the Dentist comes every Monday, and she did not know why the resident was not seen by the dentist. On 2/1/18 at 12:50 PM, the Registered Nurse Supervisor Manager (RN) was interviewed and stated the dentist comes in every week, and there is a clinical coordinator who gives the dentist the consult forms. She further stated that since the order was made on 12/30/17, she is not sure why the resident is still waiting to be seen by the dentist. On 2/2/18 at 11:46 AM, the Clinical Coordinator (CC) was interviewed and stated the nurse puts in the order and fills out a form which is given to her so that she can put it in the Dental book. The consulting dentist also checks the list of residents to be seen. On 2/2/18 at 11:54 AM, the Secretary was interviewed and stated that all new admissions are put on the 24-hour census report, and the Dentist receives the 24-hour census report, the list of scheduled residents, and the forms. Once the forms are completed they are scanned and filed. On 2/2/18 at 1:30 PM, the Dentist was interviewed and stated he comes to the facility every Monday. He checks the 24-hour census report for new admissions and looks for the order in the computer. After the resident is examined, he keeps a card on file so he can ascertain the resident will be seen next year for the annual exam. Residents are usually seen within two weeks of admission, which is why he checks the 24-hour census report. The Dentist further stated that the fact that the resident was not seen was an oversight, but he saw the resident today. The Dentist stated the resident is missing several teeth, and the resident is in pain probably due to his [DIAGNOSES REDACTED]. 415.17

Plan of Correction: ApprovedMarch 1, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Director of Nursing investigated the case of the involved resident #416 due to the deficiency. Subsequently the following actions were taken:
1. Resident #416 was evaluated by the dentist on 2/2/18 and the dentist believed that the resident?s discomfort was secondary to [MEDICAL CONDITION] diagnosis.
2. A follow up Oral Surgical consult was recommended and scheduled for resident #416.
II. Identification of Other Residents:
1. The facility respectfully acknowledges that all residents were potentially affected by this deficiency.
2. A full house review of all residents was conducted. All current residents have an admission and/ or an annual dental consults/evaluations completed. All findings or recommendations were followed through. No other negative issues were noted from this review.
III. Systemic Changes
1. The Director of Nursing and Medical Director reviewed the facility?s policy on dental services, including resident notification of the availability of dental services and found the policy to be compliant with the regulations.
2. Staff were re-inserviced regarding follow up on all consults.
3. The Clinic Coordinator will also review the daily 24 hour census to make certain that all new admissions are added to the dentist?s list.
IV. Quality Assurance Monitoring
1. The Director of Nursing developed a Consult Audit form to monitor the Dental consults completed.
2. Weekly audits of 100% of dental consults for the first three months, then 10% of dental consults monthly thereafter.
3. Audits with negative findings will have on site corrective actions implemented by the auditor.
4. Audit findings will be presented to the Quality Assurance Committee quarterly for evaluation and follow up as indicated.
Responsible Party: Director of Nursing
Date of correction: 3/31/18

Standard Life Safety Code Citations

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 2, 2018
Corrected date: February 22, 2018

Citation Details

Based on emergency preparedness documentation review and staff interview, the facility did not ensure that its emergency preparedness (EP) program addressed waiver requirements. Reference is made to the lack of documentation. The Finding is: On (MONTH) 12 (YEAR), during the life safety recertification survey, the EP plan was thoroughly reviewed and the following components were not included: The role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. There was no documentation provided to address the missing components. On (MONTH) 12 (YEAR), at approximately 1:45 pm, the Administrator and CEO stated that the 1135 waiver plan will eventually be part of the EP plan.

Plan of Correction: ApprovedFebruary 22, 2018

The deficient practice was immediately corrected. The policy had been written and was located. We submit that no residents were negatively impacted by this citation.
Since the Policy was in place already, no other residents were impacted by this citation.
The Policy will be reviewed and approved annually as part of our safety meeting. Safety meeting minutes are reported to QA quarterly.
The completion of the approved emergency policies will be annual and will be the responsibility of the administrator to ensure compliance.