Chemung County Health Center-Nursing Facility
November 5, 2018 Certification Survey

Standard Health Citations

FF11 483.24(a)(1)(b)(1)-(5)(i)-(iii):ACTIVITIES DAILY LIVING (ADLS)/MNTN ABILITIES

REGULATION: §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 3, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #9) of one resident reviewed for rehabilitation and restorative care, the facility did not provide the treatment and services in the resident's plan of care to maintain functional ability. Specifically, the resident was not consistently ambulated by staff per the resident's individualized plan of care. This is evidenced by the following: Resident #9 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/12/18, revealed the resident had severely impaired cognition and required the limited assist of one staff member to walk in her room but did not walk in the corridor at all during the period assessed from 10/6/18 through 10/12/18. Review of the Physical Therapy discharge summary, dated 11/3/17, revealed that the resident was able to ambulate greater than 150 feet, that caregiver training included safety precautions, the use of an assistive device (walker) to facilitate improved functional ability, and for staff to continue to encourage transfers and ambulation for safety. The current Comprehensive Care Plan revealed that the resident had an Activity of Daily Living (ADL) performance deficit and was at risk for falls due to dementia, non-compliance in asking for assistance, poor safety awareness and a history of falls. Interventions included, but were not limited to, ambulate the resident to the dining room at lunch and dinner. The current Certified Nursing Assistant (CNA) Bedside Kardex included to transfer the resident with one assist and a walker, to keep the resident in a populated area and to remove the wheelchair foot pedals as the resident attempts to get up unassisted. The Kardex did not include instructions for ambulating the resident. An undated sign posted in the nursing station included a list of residents, including Resident #9, who were to be ambulated to the dining room (approximately 80 feet) and back for lunch and dinner. Review of the ADL response history in the electronic medical record (system used by staff to record resident's daily ADLs) for the past 30 days revealed documentation that the resident was able to ambulate in her room on 22 of 30 days but ambulated in the hallway on just one day for the past 30 days. Review of the Resident Incident Investigations revealed that the resident had three falls in the past month while attempting to get up unassisted. The most recent Fall and Investigation Report, dated 10/20/18, resulted in an abrasion and a visit to the emergency room to rule out a fracture due to complaints of pain. The physician progress notes [REDACTED]. A Rehabilitation Referral for Therapy Services, dated 10/21/18 and signed by the Licensed Practical Nurse, included that the resident needed more assist with ADLs. During multiple observations daily from 10/29/18 through 11/2/18, the resident was sitting in a wheelchair in the hall outside her room. At no time was the resident observed ambulating. In an interview on 10/29/18 at 11:08 a.m., a visiting family member stated that the resident used to walk but the resident had recently gone downhill and the visitor did not think that staff walked the resident anymore. Interviews conducted on 10/31/18 included the following: a. At 12:23 p.m., the day shift CNA stated that the resident can walk from the bed to the toilet but no further. She said that if she has time she will walk the resident in the afternoon but most days it is just back and forth to the bathroom. She said she does not walk the resident to the dining room. b. At 3:33 p.m., the Director of Physical Therapy stated that the most recent therapy note was when the resident was discharged from therapy on 11/3/17. When asked if he had any other screens or evaluations for the resident since that time, the Director stated no. c. At 3:35 p.m., the evening shift CNA stated that the resident walks but not much since her fall a few weeks ago. She said the resident was too weak and walks a few feet from bed to chair or toilet but not more. Interviews conducted on 11/2/18 included the following: a. At 8:42 a.m., the Registered Nurse Manager stated that if staff are unable to complete tasks on the care plan they should notify the team leader. She said the resident was referred to therapy after the last fall but they were not able to see her until that week (after surveyor intervention). b. At 8:47 a.m., the Director of Physical Therapy said that therapy received the evaluation but had not been able to get to it until recently due to staffing issues. He said that the resident will be picked up for daily Physical Therapy, but he could not say if her decline was functional or due to her dementia. (10 NYCRR 415.12(a)(1)(ii))

Plan of Correction: ApprovedNovember 30, 2018

1. Residents and Areas Affected by Deficiency: Resident #9 was screened and placed on physical therapy during survey. Resident?s Comprehensive Care Plan was updated to reflect resident?s condition change.
2. Identifying Other Residents/Areas: All residents who are care planned to ambulate will be reviewed to ensure that they are meeting their ambulation goal. All residents who had a therapy referral in place have been reviewed to ensure that therapy had completed a screen. All residents who had a referral, were found to have been screened in an appropriate time frame by therapy.
3. Measures and Systemic Changes:
A) A Therapy Referral Log has been created to track all referrals. This log is sent to the Administrator on a weekly basis to review.
B) A Resident Walk Program and Policy will be developed and implemented to address resident?s meeting their ambulation goals. The program will address residents who have been designated to walk or who are at risk for decreased function in their activities of daily living.
C) Tasks will be assigned in electronic medical record for CNA's with specific instructions for ambulation. If the task has not been completed, and alert will be sent to the nursing staff on the unit.
4. Quality Assurance Program:
A) The Assistant Director of Nursing or designee will audit 10 residents monthly who have been designated to ambulate. Audits shall reflect appropriate care plan, Kardex instructions and documentation in electronic medical record. A report of the audits shall be prepared for presentation to the QAPI Committee monthly for a period of three months. If 100% compliance in accuracy of audits is achieved, the frequency of audits will be reduced to quarterly for two consecutive quarters. If 100% compliance in accuracy is attained in consecutive quarters, the QAPI Committee may discontinue the quarterly reports.

Person Responsible for Completion: Assistant Director of Nursing

FF11 483.25(e)(1)-(3):BOWEL/BLADDER INCONTINENCE, CATHETER, UTI

REGULATION: §483.25(e) Incontinence. §483.25(e)(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. §483.25(e)(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. §483.25(e)(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: November 5, 2018
Corrected date: January 3, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #131) of two residents reviewed for indwelling urinary catheters, the facility did not ensure that the residents with a urinary catheter received the treatment and services needed to prevent infections to the extent possible. Specifically, the resident's indwelling catheter was not secured to prevent tension on the insertion site, and the tubing and drainage bag were observed on several occasions in a manner that could potentially predispose the resident to an infection. This is evidenced by the following: Resident #131 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/14/18, revealed that the resident had severely impaired cognition and was always incontinent of urine. The resident did not have a catheter at that time. The facility policy, dated as last reviewed (MONTH) 2012, Catheterization/Peri care, under guidelines included, but was not limited to, that the catheters must be ordered by a physician and include catheter and balloon size, that drainage bags need to have a blue drainage bag holder when in bed if the resident is in a high low bed, that the bag and tubing must not drag on the floor, must be free of kinks, and to secure the catheter by using a 'Cath-secure' band. The current Certified Nursing Assistant (CNA) Bedside Kardex included that the resident had a catheter, to position the bag and tubing below the level of the bladder and away from the room door entrance (for privacy), and to monitor for discomfort. It did not include the use of a leg strap. The current Comprehensive Care Plan did not include that the resident had an indwelling urinary catheter. Review of the nursing progress note, dated 9/29/18 and signed by the Licensed Practical Nurse, revealed that the resident did not void that shift, that a bladder scan was done revealing 350 cubic centimeters (ccs) of urine, and an indwelling catheter was inserted. Review of medical orders, dated 9/29/18, revealed an order for [REDACTED]. Observations conducted included the following: a. On 10/29/18 at 2:00 p.m., the resident was being wheeled in a geriatric chair. The catheter tubing was caught between the spokes of the wheel pulling back and forth as she was wheeled. b. On 10/30/18 at 9:24 a.m., the catheter drainage bag was on the floor uncovered, lying under a dirty fall mat, and was not secured to the bed or linens to prevent tension. c. On 11/1/18 at 8:58 a.m., the catheter drainage was attached to the resident's bed frame, was on the floor, uncovered, and able to be seen from the hallway. d. On 11/1/18 at 10:00 a.m. during incontinence and wound care, the drainage tubing was not secured to anything to prevent tension as the resident was turned back and forth several times for care with the tubing pulled across the body several times. Interviews conducted on 11/1/18 included the following: a. At 10:15 a.m., the Registered Nurse (RN) stated that the resident had not had a leg strap on to secure the catheter for several days. b. At 1:52 p.m., the CNA stated that the drainage bag should not be on the floor. She said the drainage should be in a protector bag and that the resident should have a leg strap on. c. At 2:19 p.m., the RN Nurse Manager stated that the catheter bag should never be on the floor. She said the resident should always have a strap on to secure the Foley. She said that the catheter was placed on 9/29/18 which was a weekend, but the complete orders were not written until several weeks later when it was noticed that there was no care guidelines and/or size ordered. (10 NYCRR 415.12)

Plan of Correction: ApprovedNovember 29, 2018

1. Residents and Areas Affected by Deficiency: Resident #131?s Comprehensive Care Plan was reviewed and updated to reflect resident?s indwelling urinary catheter. The resident?s catheter has been checked to ensure it has been properly placed in a way that would prevent potential infection.
2. Identifying Other Residents/Areas: A review of all other resident?s with a indwelling urinary catheter has been completed to ensure that there is a matching physicians order, care plan, and that each catheter is appropriately placed.
3. Measures and Systemic Changes:
A) In-service education will be provided to all CNA?s, LPN?s, and RN?s on proper placement of leg straps and utilization of catheter bag.
B) A template for indwelling urinary catheters has been created in the electronic medical record. The template provides instruction for nursing staff on proper use of leg straps and placement of catheter bag.
4. Quality Assurance Program:
A) An audit will be conducted for all residents that require an indwelling urinary catheter. Audits shall reflect appropriate care plan, Kardex instructions, physicians order, and proper placement of leg straps and utilization of catheter bag. This audit will be conducted by the Assistant Director of Nursing or designee once per month. A report of the audits shall be prepared for presentation to the QAPI Committee monthly for a period of three months. If 100% compliance in accuracy of audits is achieved, the frequency of audits will be reduced to quarterly for two consecutive quarters. If 100% compliance in accuracy is attained in consecutive quarters, the QAPI Committee may discontinue the quarterly reports.
Person Responsible for Completion: Infection Prevention Coordinator

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 3, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for 5 of 35 residents reviewed for care planning, the facility did not develop and/or implement a plan of care for each resident that included measureable objectives and interventions to address the residents' medical, physical, mental and psychosocial needs. The issues involved the lack of a care plan with person centered approaches for behaviors (Residents #98 and #42), the lack of a care plan for impaired vision (Resident #183), the lack of a plan of care for Tubi-grips (Resident #117), and the lack of following the plan of care for feeding strategies (Resident #56). This evidenced by, but not limited to, the following. Review of the facility policy, Comprehensive Care Plan (CCP), dated 7/31/17, revealed that an individualized CCP included measurable goals, objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident and will always be reflective of the resident's status. 1. Resident #98 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 8/31/18, revealed the resident had severely impaired cognition and exhibited rejection of care daily during the look back period. Review of the CCP, dated 9/12/18, revealed that the resident had the potential for behaviors, and the family reported that the resident had sundowner's symptoms which occurred between 2:00 p.m. and 5:00 p.m., and had a history of [REDACTED]. The current bedside Kardex documented in the behaviors and mood section to analyze circumstances and triggers and alter if able, if resident becomes angry or agitated intervene before escalation by engaging in calm conversation, guide away from the source of distress, and leave and reapproach if the resident is upset or resistive. When interviewed on 11/1/18 at 4:04 p.m., Certified Nursing Assistant (CNA) #1 stated she would check the resident's Kardex for behaviors. She stated if a resident had behaviors and was aggressive, she would reapproach the resident and report the behavior to the nurse. CNA #1 stated the facility had a book that included interventions that were general approaches but not resident specific. Duning an interview on 11/1/18 at 4:15 p.m., Licensed Practical Nurse (LPN) #1 stated the resident was typically very anxious at the start of the shift. She stated the resident would pace, fidget with his clothes, bend over trying to pick up things from the floor that were not there, and sometimes make and remake his bed. LPN #1 stated on occasion the resident would go into another resident's room and would be redirected. LPN #1 stated diversional activities would include giving the resident a magazine or trying standard things. She stated that walking with the resident was an effective intervention. LPN #1 stated that therapeutic communication means trying to comfort the resident. She stated the resident becomes anxious over money and needs reassurance that expenses are taken care of. LPN #1 stated these interventions should be on the CCP and the Kardex. LPN #1 reviewed the resident's Kardex and then stated the interventions were not specific to the resident. She stated the diversional activities contained in the diversional activity book were not resident specific. When interviewed on 11/2/18 at 10:48 a.m., the Registered Nurse Manager stated she developed the care plan addressing the resident's behaviors. After review of the resident's CCP, she stated the interventions were approaches utilized for all residents. She stated the CCP should include interventions specific to the resident. 2. Resident #183 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The comprehensive MDS Assessment, dated 1/22/18, documented in the Care Area Assessment section that visual function was addressed in the CCP. The MDS Assessment, dated 10/2/18, revealed the resident had moderately impaired cognition, impaired vision, and glasses were used. The optometry consult, dated 12/11/17, revealed the resident was seen as requested and a new prescription for glasses was filled. The CCP, dated 7/18/18, revealed the resident's risk for falls included poor vision, and the current Kardex revealed the resident's preference was watching television. During an observation and interview on 10/29/18 at 10:45 a.m., the resident was not wearing glasses. A family member applied the glasses and stated the staff do not put the resident's glasses on. During an observation on 11/1/18 at 9:02 a.m., the resident was sitting up in bed, the television was on, and a pair of glasses were lying folded on the overbed table out of the resident's reach. A CNA entered the room and offered to put the resident's head down. When interviewed on 10/31/18 at 3:28 p.m., CNA #2 stated the resident wore glasses, and it should be on the Kardex. During an interview on 11/1/18 at 11:15 a.m., Unit Manager #2 stated if a resident wears glasses it should be on the CCP and Kardex. She stated the family had expressed concern about the glasses not being applied. 3. Resident #117 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assesment, dated 9/7/18, revealed that the resident was cognitively intact and required extensive assistance with dressing. The current physician orders (with a start date of 7/3/18) included Tubi-grip stockings for legs, apply a double layer on in the morning and a single layer on at bedtime. Review of the (MONTH) (YEAR) through (MONTH) (YEAR) Treatment Administration Records (TAR) revealed entries for the Tubi-grip stocking as ordered and was signed as completed The current CCP revealed that the resident had bliateral leg [MEDICAL CONDITION] with complaints of discomfort. Interventions included a double layer of Tubi-grip stockings during the day and a single layer of Tubi-grip stockings at bedtime. The resident was non-compliant with transfer and toileting assistance. Review of the Integrated Progress Notes, from 7/3/18 through 11/1/18, revealed no documentation that the resident had refused to wear a double layer of Tubi-grips. During an observation and interview on 10/30/18 at 3:00 p.m., the resident was wearing one layer of Tubi-grips and one pair of stockings. The resident said that she was supposed to wear a double layer of Tubi-grips but prefers one pair of Tubi-grips and a pair of stockings. On 10/31/18 at 3:50 p.m. and on 11/1/18 at 10:01 a.m., the resident was sitting in her chair and was wearing one layer of Tubi-grips and stockings. When interviewed on 11/1/18 at 1:00 p.m., the LPN said that the CNA was responsible to put on the resident's Tubi-grips, and the nurses sign off on the TARs that she is wearing them. The LPN stated she wrote a note that the resident refused to wear a double layer of Tubi-grips. She said the resident will only wear one layer and everybody knows, including the Nurse Manager. The LPN said she assumed the Nurse Manager would discuss with the physician the resident's refusal to wear the two layers of Tubi-grips. When interviewed on 11/1/18 at 4:29 p.m., the RN Manager said it was an oversite and it should have been done. 4. Resident #56 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 8/13/18, revealed the resident had severely impaired cognition, required supervision after set-up for eating, and had a mechanically altered and therapeutic diet. The current physician orders for diet are no added salt and pureed texture with regular consistency. Recommend all meal items in separate bowls. To ensure safety and a low rate of intake, recommend staff and/or family provide one meal item at a time. The CCP for nutrition includes to follow Speech Therapist recommended feeding strategies per the 9/7/17 swallow evaluation which includes to recommend all meal items in separate bowls to ensure safety and slow rate of intake. Also, recommend staff and/or family provide one meal item and one drink at a time and provide distant supervision. During an observation of the lunch meal on 10/29/18 at 12:41 p.m., the resident was served his entire lunch tray with pureed items in separate bowls. The resident quickly emptied each bowl either by drinking the contents from the bowl and/or with a spoon. On 10/31/18 at 12:44 p.m., the resident was served his entire tray that included five bowls with pureed solids and regular liquids including apple juice and milk from a carton. All items were left on the tray for the resident to eat himself. The resident was alternating bites and sips on his own. The resident ate his meal and then got up to leave the dining room. A staff member said to the resident are you done and then documented what the resident ate as he left the dining room. When interviewed on 11/1/18 at 1:19 p.m., the resident's assigned CNA said that the resident required set up for meals. She said that she removes covers and opens everything and then the resident eats on his own. The CNA said that the resident required supervision due to eating so fast. After reviewing the resident's care Kardex, the CNA said that the resident does not like to be given one bowl at a time and will get up and leave the dining room if the tray is served that way. The CNA said that the resident gets his meal tray first because he will get mad and leave if he has to wait. When asked if nursing had been made aware of the resident's refusal to accept one meal item at a time, the CNA responded that all of the nurses are aware that the resident is supposed to receive one meal item at a time and that the resident will leave the dining room if served one item at a time. During an interview on 11/2/18 at 10:38 a.m., the Director of Nursing stated that her expectation would be that nursing staff would notify Speech Therapy and the physician, and update the physician's order and the CCP. (10 NYCRR 415.11(c)(1)(2)(ii))

Plan of Correction: ApprovedNovember 30, 2018

1. Residents and Areas Affected by Deficiency: Resident #42?s Care Plan was reviewed and revised to include person centered approaches for her specific behaviors. Resident #98?s Care Plan was reviewed and revised to include person centered approaches for his specific behaviors. Resident #183?s Care Plan and Kardex was updated to include her use of glasses. Resident #117?s Care Plan was updated to accurately reflect her receiving one layer of tubi-grips. Resident #56 now receives his meal as originally care planned.
2. Identifying Other Residents/Areas: All residents who were care planned for behaviors were reviewed to ensure a person centered approach was in place and being followed. All residents care planned for glasses and tubi grips were reviewed for accuracy and ensuring proper implementation. A review of all residents requiring special feeding instructions will be completed to ensure that all recommendations are being fully implemented.
3. Measures and Systemic Changes:
A) In-service education will be provided to all clinical staff for person-center approaches to behaviors and dementia.
B) A Behavior Meeting will be implemented and held on a bi-weekly basis. Behavior Meetings will be overseen by Social Services with an interdisciplinary team approach to review interventions in the care plans. Person-centered approaches to care will be implemented to assure the care is consistent with the resident?s needs and choices.
C) A new ?Resource Binder? will be created for each nursing unit. The binder will be updated daily and provide staff with an accurate list of each resident?s needs. The binder will track resident?s who require glasses and tubi-grips among other items. Each nursing staff member will be educated on the location and purpose of this binder.
4. Quality Assurance Program:
A) Audits of four Comprehensive Care Plans will be conducted by the Director of Social Work or designee monthly for one quarter. Audits shall review CCP?s to ensure that appropriate person-centered care plan is in place when a resident with behaviors has been identified. A report of the audits shall be prepared by the Director of Social Services for presentation to the QAPI committee. If 100% compliance is recorded after the first three months, the audit may be reduced to once quarterly for two consecutive quarters. If 100% compliance is achieved, the QAPI committee may choose to discontinue the audit.
B) Audits of 5 residents per month for three months will be conducted by the Assistant Director of Nursing or designee to review accuracy of care plan, Kardex instructions, and appropriate doctor?s orders for residents wearing glasses and/or requiring tubi-grips. The QAPI committee will implement any new recommendations after the first three months and may discontinue quarterly reports when it's deemed appropriate.
Person Responsible for Completion: Director of Nursing

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: November 5, 2018
Corrected date: January 3, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #48) of one resident reviewed for a death in the facility, the facility did not provide medically related social services to attain or maintain the highest practical, mental and psychosocial well-being of each resident. Specifically, there was a lack of social services for a resident and family during end of life care and related family interactions prior to the resident's death in the facility. This is evidenced by the following. Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated [DATE], revealed that the resident had severely impaired cognition, was totally dependent on staff for all activities of daily living and had occasional behaviors such as hitting and kicking. The resident expired in the facility on [DATE]. The current Comprehensive Care Plan included that the resident had a communication problem due to [MEDICAL CONDITION] (difficulty speaking) from a stroke, a cognitive loss due to dementia, and that the resident can be physically aggressive as evidenced by attempts to hit staff and family. Interventions included, but were not limited to, to anticipate and meet all needs and assist the spouse in addressing any concerns. The care plan did not include difficult family interactions and special visiting instructions that were in place for the resident's spouse. In an interview on [DATE] at 1:47 p.m., the resident's spouse stated that she was not allowed to visit her husband in his room for the past two months because she yelled at him a few times when he was attempting to hit her. She stated that they had been married for [AGE] years and that when she told him to stop hitting her and he realized who she was he was fine. She said the Social Worker told her she had to call ahead of time prior to her visits so staff could get the resident out of bed. The resident's spouse said she was told she could only visit with him in the hallway, including after he went on comfort care. She said sometimes he was up and sometimes he was not causing her visit to be cut short due to her transportation arrangements. She said she did not think the resident would be able to tolerate getting up much longer and her time with him was coming to an end. The resident's spouse said she asked if someone could be in the resident's room when she visited, and she was told no. The resident's spouse said she told the previous Director of Nursing (DON) about her concerns but nothing was changed, and she was not allowed private time prior to his death and that upset her. Review of the resident's electronic medical record revealed the following: a. The resident's spouse was listed as Health Care Proxy, Power of Attorney, Executer and primary emergency contact. b. Interdisciplinary progress notes from [DATE] through [DATE] revealed multiple notes of aggressive behavior of the resident towards staff that were sometimes re-directed with a calm approach and explanations. The notes also included that the resident's spouse was notified of any changes in the resident's condition. c. The most recent Social Work note, dated [DATE], included information related to a Medicaid application. There were no Social Work notes in the medical record related to visiting instructions for the spouse and/or support related to end of life care. d. Review of a physician progress notes [REDACTED]. e. Review of a progress note, dated [DATE] and signed by the Registered Nurse Manager (RNM), revealed that the RNM and the Social Worker met with the resident's spouse to discuss comfort care. Hospice services were offered and declined, and comfort care guidelines worksheet was filled out and initiated at that time. A summary signed by the Administrator, dated [DATE], revealed that on [DATE] the Administrator was notified that the resident's spouse was overheard being inappropriate and that the spouse was agreeable to a visitation plan. After an investigation, it was determined that there was no abuse, neglect or mistreatment and that the plan will be re-evaluated as needed. Interviews conducted on [DATE] included the following: a. At 8:51 a.m., the RNM stated that there were multiple issues with the family. She said other members of the family requested the visits be monitored due to concerns related to verbal abuse and so that plan was initiated. She stated she had a good rapport with the resident's spouse, that she was really trying and that she was not aware that the spouse was unhappy about visiting the resident only in the hallway. b. At 11:26 a.m., the Social Work stated that she received a call from another family member who was concerned with verbal aggression a few months ago. She stated she requested the spouse to meet with the resident in the hallway and that she thought she was ok with the plan. The Social Worker said that she had no documentation related to the issue and or the visitation rules that the facility set up. The Social Worker said that she had no further documentation since the [DATE] note and the [DATE] comfort care worksheet that she completed. In an interview on [DATE] at 11:30 a.m., the Administrator and the Director of Nursing stated that there was no formal investigation conducted or documented to rule out verbal abuse as it was just an informal discussion by staff and that they did not feel the spouse was verbally abusive. The Administrator stated that he had never had any conversations with the spouse or other family members related to the issue. (10 NYCRR 415.5(g)(1)(i-xv))

Plan of Correction: ApprovedNovember 30, 2018

1.Residents and Areas Affected by Deficiency: Resident #48 expired prior to citation.
2. Identifying Other Residents/Areas: All residents on comfort care measures/hospice will be reviewed to ensure that privacy has been offered, the opportunity for family input has been provided, and that there is documented social work involvement.
3. Measures and Systemic Changes:
A) Policy for comfort care will be reviewed and revised to ensure that privacy is offered to resident and family while on comfort care. The policy will require an interdisciplinary approach when comfort care or hospice has been initiated, including Social Services. The policy will also require that the family/responsible party shall be involved to the fullest extent possible during end of life care for resident.
B) In-service training will be provided to the Social Work Department and Nurse Managers to review comfort care policy.
Quality Assurance Program:
An audit will be created and completed by the Director of Social Work or designee to assess if family/responsible party are involved with end of life care, documentation that privacy to the fullest extent possible has been offered, and adequate social service involvement has been documented in accordance with the policy. The findings will be prepared and submitted quarterly to the QAPI Committee for at least three consecutive quarters. The QAPI Committee may discontinue the quarterly reports after the third quarter report.
Person Responsible for Completion: Director of Social Services

FF11 483.25(i):RESPIRATORY/TRACHEOSTOMY CARE AND SUCTIONING

REGULATION: § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 3, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review conducted during the Recertification Survey, it was determined that for two (Residents #51 and #159) of four residents reviewed for respiratory care, the facility did not provide proper respiratory treatments and care consistent with professional standards of practice. Specifically, oxygen therapy was not provided per the physician order and/or the resident's respiratory status was not consistently monitored. This is evidenced by the following: Review of the facility policy, Oxygen Therapy, dated (MONTH) 2014, revealed oxygen was a drug and must be administered as prescribed. The policy included to monitor and document the effectiveness of oxygen therapy, check oxygen saturations levels every shift, and document on the vital signs sheet. The policy instructed to change the tubing every other Wednesday on the 3-11 shift. 1. Resident #51 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/7/18, revealed the resident was rarely/never understood, received oxygen therapy and required total assistance of staff for activities of daily living. The current physician orders included oxygen at 2 liters per minute via nasal cannula continuously (start date 8/23/18). Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed an entry to clean the oxygen contractor and filter every Saturday night and oxygen at 2 liters per minute continuously via nasal cannula. Review of the Oxygen Saturation Level Summary sheet revealed oxygen saturations were checked once daily on 8/29/18, 9/19/18, 10/2/18, 10/12/18 and 10/29/18. Review of nursing progress notes, from 10/21/18 through 10/29/18, revealed that on 10/29/18 at 4:00 p.m., vital signs were documented that included an oxygen saturation level that was 96 percent on 2 liters of oxygen, color was good, and skin was warm and dry. During an observation on 10/29/18 at 12:24 p.m., the resident was sitting in a Broda chair (specialized wheelchair) in the dining room. Staff was observed feeding the resident. The resident was wearing a nasal cannula, and the oxygen tank was on the back of the chair. The oxygen tubing was not connected to the oxygen tank. When interviewed at that time, Licensed Practical Nurse (LPN) #1 stated she did not know the oxygen tubing was not connected to the oxygen tank. She said she would need to check on the resident's order for oxygen. Another staff member stated the resident was on 2 liters, and the nurse then connected the tubing to the tank and administered oxygen at 2 liters. During an observation on 10/31/18 at 10:15 a.m., the resident was in bed receiving oxygen at 2 liters per minute via nasal cannula. The oxygen tubing was dated 10/17/18. When interviewed on 10/31/18 at 10:06 a.m., LPN #2 stated that the oxygen tubing was changed by the night nurse every week or two. During an interview on 11/1/18 at 11:15 a.m., the Registered Nurse Manager (RNM) stated she developed the resident's Comprehensive Care Plan (CCP). After review of the resident's CCP, the RNM stated oxygen therapy was not addressed on the CCP and it should have been. 2. Resident #159 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 9/28/18, revealed the resident had moderately impaired cognition and required oxygen therapy. The current physician orders and the (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Records included oxygen at 2 liters per minute continuously for [MEDICAL CONDITION]. During observations on 11/1/18 at 9:06 a.m. and 10:30 a.m., the resident was receiving oxygen at 3 liters per minute via nasal cannula and oxygen concentrator. In an observation with RNM #2, on 11/2/18 at 10:01 a.m., the resident was in bed and was receiving oxygen at 3 liters per minute via nasal cannula. When interviewed at that time, RNM #2 stated that the resident's oxygen was supposed to be set at 2 liters per minute. She said that the nurses are the only staff who adjust the resident's oxygen liter flow. (10 NYCRR 415.12(k)(6))

Plan of Correction: ApprovedNovember 30, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Residents and Areas Affected by Deficiency: Resident #51?s oxygen was immediately connected at two liters per minute upon notification of the issue during survey. Resident?s care plan was updated to reflect oxygen use during survey. Resident #159?s oxygen was immediately changed two 2 liters per minute upon notification of the issue during survey.
2. Identifying Other Residents/Areas: All residents with an order for [REDACTED].
3. Measures and Systemic Changes:
A) Policy entitled Oxygen Therapy has been revised to ensure that all orders for oxygen therapy must be included in the Comprehensive Care Plan. The policy has also been revised to now require a CNA to stay with resident until a licensed nurse properly sets the oxygen level to comply with the physicians order.
B) All residents that require oxygen have been reviewed to ensure orders for oxygen saturation each shift is ordered and documented.
C) In-service education will be provided to all CNA?s, LPN?s, and RN?s to ensure understanding of the updated Oxygen Therapy policy.
D) In-service education will be provided to each Nurse Manager regarding updating Comprehensive Care Plan?s to reflect Oxygen Therapy.
4. Quality Assurance Program:
A) An audit will be created to ensure an appropriate care plan for oxygen therapy is in place for any resident with an order for [REDACTED]. If 100% compliance in accuracy of audits is achieved, the frequency of audits will be reduced to quarterly for two consecutive quarters. If 100% compliance in accuracy is attained in consecutive quarters, the QAPI Committee may discontinue the quarterly reports.
B) An audit will be created to monitor accuracy for oxygen administration. This audit will be completed by the Central Supply Clerk or designee once per month. A report of the audits shall be prepared by the Central Supply Clerk for presentation to the QAPI Committee for a period of three months. If 100% compliance accuracy of audits is achieved, the frequency of the audits will be reduced to quarterly for two consecutive quarters. If 100% compliance in accuracy is attained in consecutive quarters, the QAPI Committee may discontinue the quarterly reports.
Person Responsible for Completion: Director of Nursing

FF11 483.10(i)(1)-(7):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 3, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the Recertification Survey, it was determined that for five of five residential units that the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and homelike environment. Specifically, rigid plastic door coverings were damaged and jagged. This is evidenced by the following: 1. Observations during the initial tour of the facility on 10/29/18 from approximately 1:00 p.m. to 1:20 p.m. revealed the lower edges of the doors and frames to the third-floor day room and Resident room [ROOM NUMBER] were covered with a pink rigid plastic material that was broken and jagged. 2. Observations on 10/30/18 at 8:30 a.m. revealed the rigid plastic covering the lower edges of doors and doorframes in Resident Rooms #200, #202, #206, #210, #214, and #225 were broken, jagged and damaged. 3. Observations on 10/31/18 from 8:22 a.m. to 8:56 a.m. revealed the rigid plastic covering the lower edges of doors and doorframes in Resident Rooms #613, #609, #522, #508, #405, #402, #401, #324, #305, #301, #225, #214, #210, #206 and the fourth floor day room and dining/activities room were broken, jagged, and damaged. 4. On 11/2/18 at 11:18 a.m. the second-floor Registered Nurse Manager (RNM) was shown the jagged damaged edges of the doors on the second floor. When interviewed at that time, the RNM said, yes she could see that the door edges are jagged, and could be a potential accident for residents especially those who self-propel. She said there are some residents in the rooms identified that can self-propel. (10 NYCRR 415.29(j)(1))

Plan of Correction: ApprovedNovember 29, 2018

1. Residents and Areas Affected by Deficiency: The third floor day room, fourth floor day room, fourth floor dining room, resident rooms 200, 202, 206, 210, 214, 225, 301, 305, 324, 401, 402, 405, 508, 522, 609, and 613 all received repairs and/or new plastic coverings replacing the broke, damaged, and jagged pieces.
2. Identifying Other Residents/Areas: All resident rooms, day rooms, and dining rooms were reviewed and any coverings that were broke or damaged were repaired or replaced.
3. Measures and Systemic Changes:
A) The Maintenance Director shall perform environmental rounds on each unit, including every resident room, dining room, and day room, as part of the Preventative Maintenance Program on a quarterly basis. An inspection of each room?s door coverings will be recorded in the Preventative Maintenance Logs.
B) In-service education will be provided to nursing and housekeeping staff to notify and complete a work order if door coverings are noted to be broken or damaged.
4.Quality Assurance Program:
A report of the door covering inspections shall be prepared and submitted by the Director of Maintenance, quarterly to the QAPI Committee for at least two quarters. If 100% compliance in maintaining door coverings are free of damage, the QAPI committee may discontinue the quarterly reports.
Person Responsible for Completion: Director of Maintenance

Standard Life Safety Code Citations

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 3, 2019

Citation Details

Based on observations conducted during the Life Safety Code Survey, it was determined that for one of two exits from the enclosed courtyard and one of two exit stairwells, the facility did not properly maintain exit pathways. Specifically, exit discharge pathways and a door were obstructed by vegetation and a hose. The findings are: 1. Observations on 10/29/18 at approximately 2:00 p.m. revealed the door marked as an EXIT from the enclosed courtyard (nearest the South end of the building) could not be opened and appeared to be locked. There was an accumulation of vegetation in the path of the door swing inside the courtyard. Further observations on the opposite side of this exit door revealed additional vegetation and dirt on the sidewalk preventing the door from being opened. 2. Observations in the presence of the Maintenance Supervisor on 10/30/18 at 2:56 p.m. revealed a green hose draped across the sidewalk that serves as the exit discharge pathway just outside the exit discharge door from the South stairwell. Additionally, the nearby exit door from the enclosed courtyard was obstructed by vegetation and dirt in the path of the door swing. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.1, 7.1.10.1)

Plan of Correction: ApprovedNovember 29, 2018

1. Residents and Areas Affected by Deficiency: The exit from the enclosed courtyard (near South end of the building) was unlocked and all surrounding vegetation was cleared from both sides of the door prior to conclusion of the survey.
2. Identifying Other Residents/Areas: All other exits were reviewed to determine they were unlocked and free of any vegetation or other obstruction.
3. Measures and Systemic Changes:
A) In-service training will be provided by the Maintenance Director to all maintenance employees and laborers about keeping all exits clear of vegetation and unlocked.
B) The Preventative Maintenance Program will be revised to include a quarterly inspection of all facility exit ways to ensure they are clear of obstruction.
4. Quality Assurance Program:
The Maintenance Director shall perform an environmental audit of each facility exit and a report of the findings shall be prepared and submitted quarterly to the QAPI Committee for two quarters. If 100% compliance in inspection reports has been attained for two consecutive quarters, the QAPI Committee may discontinue the quarterly reports.
Person Responsible for Completion: Director of Maintenance

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: November 5, 2018
Corrected date: January 3, 2019

Citation Details

Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for three (second, fourth, and fifth) of six resident use floors, the facility did not properly maintain smoke barrier walls. Specifically, there were unsealed openings through smoke barrier walls. The findings are: Observations above the suspended ceiling on 10/30/18 from 9:15 a.m. to 10:00 a.m. revealed 1-inch unsealed circular openings through smoke barrier walls with a single small yellow wire running through the openings at the following locations: Above the cross-corridor smoke barrier doors outside Resident Rooms #520, #420, and #220. An interview with the Maintenance Supervisor revealed some spaces were recently converted to offices. He said the wires were probably for the offices, and that it was probably like that on all the floors. (10NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.3.7.3, 8.5.2.2)

Plan of Correction: ApprovedDecember 5, 2018

1. Residents and Areas Affected by Deficiency: The three areas identified in the deficiency were corrected prior to survey conclusion.
2. Identifying Other Residents/Areas: All other smoke barriers in the Nursing Facility will be checked for penetrations. Any penetrations found will be sealed.
3. Measures and Systemic Changes:
A) The facility will now require all sub-contractors to do a walk through with the Maintenance Director after completing any work inside the facility. This walk through will allow the maintenance director inspect any smoke barriers that may have been compromised during work and ensure that any penetrations have been sealed.
B) In-service education will be provided to the maintenance department on importance of sealing any penetrations in smoke barriers will be provided.
4. Quality Assurance Program:
An audit of smoke barrier integrity will be performed by the Maintenance Director on a quarterly basis. A report of the findings will be presented to the QAPI committee for two consecutive quarters. If 100% compliance is obtained, the QAPI committee may choose to discontinue the audit.
Person Responsible for Completion: Director of Maintenance