Riverside Center for Rehabilitation and Nursing
March 15, 2018 Complaint Survey

Standard Health Citations

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 15, 2018
Corrected date: May 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during an abbreviated survey (Case # NY 255), the facility did not ensure that it prevented further potential abuse, neglect, mistreatment while an investigation was in progress for one resident (Resident #2) of three residents reviewed. Specifically, Resident #2 made an allegation of physical abuse. The alleged perpetrator continued to have access to the resident and to other vulnerable residents. This is evidenced by: Refer to F609 Review of the facility Abuse Prohibition Protocol (undated) documented prevention: The supervision of staff to identify inappropriate behaviors such as rough handling and the assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors. Identification: The recognition of events that may constitute abuse or neglect such as suspicious bruising of residents. Investigation: The investigation of alleged violations and reporting of results to the proper authorities. Protection: Protect residents from harm during an investigation. Reporting: Report all alleged violations and all substantiated incidents to the state agency (NYSDOH) and to all other agencies as required (police) and take all necessary corrective actions depending on the results of the investigation. Resident #2: The resident was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The BIMS (Brief Interview for Mental Status) was assessed as 4/15; severe cognitive impairment on the MDS (Minimum Data Set) dated 11/15/17. Review of the Comprehensive Care Plan (CCP) for Potential Victim of Abuse last reviewed 10/23/17, documented the resident is vulnerable due to cognitive disabilities. Goals: Resident will be protected from being a victim of abuse. Approaches: Assess for behavior used as communication for symptoms of pain. Review of the Accident & Incident Form (A&I) dated 10/28/17 at 7:30 am, written by the RN Nurse Manager (RNNM #1) documented the resident became combative with the CNA during morning care. The resident grabbed the CNA's necklace and sustained a skin tear to left 3rd finger and a bruise to right 5th finger. The resident's statement on 10/28/17 documented yes in response to someone hurting her, and the explanation documented That girl this morning did. She hurt my finger. It's hard to move it. The resident's version of the event documented, She was rolling me back and forth in my bed and I hit the wall a couple of times. Review of the Statement of Events for 10/28/17; 7-3 (day shift) written by RNNM #1 documented an assessment of the resident's injuries: 3rd finger on left hand had a 1cm circular skin tear that required 2 steri strips. There was a small 1 cm ecchymotic (purple discoloration) on the inside of the right 5th finger. RNNM #1 asked the resident what happened to her finger. The resident replied, She did it. She hit me. RNNM #1 asked the resident who hit her. The resident replied, Oh, I don't know her name. It was documented the right 5th finger was re-assessed and it appeared to have more swelling to the entire finger and ecchymotic area had extended down to the knuckle joint and to the palm of the hand. The MD was notified and a stat x-ray was ordered. The allegation of abuse was not reported to the NYSDOH. Review of the Nurse's Note dated 10/28/17 at 12:12 pm, written by RNNM #1, documented the resident was combative/restless with morning care. The resident grabbed the CNA's necklace and upon breaking necklace and letting go, staff found the resident had a small skin tear near middle knuckle of left 3rd finger and bruising to the base of her right 5th finger. The resident was noted to have more swelling, and bruising extending to the palm of her hand just below the 5th finger. MD notified; Ordered x-ray of right 5th finger. The portable x-ray result of the right 5th finger dated 10/28/17, documented acute (abrupt onset) [MEDICATION NAME] fracture (fracture line is perpendicular to the long part of the bone) at the base of the proximal phalanx (bone found at the bottom of the finger) of 5th finger of the right hand. The Hospital Emergency Department (ED) records dated 10/28/17, documented phalanx fracture, finger. The fracture was reduced (restored to the correct alignment) and splinted. The Nurse's Note dated 10/28/17 at 8:41 pm, documented the resident returned from the ED with fractured right 5th finger in a splint covered with an ace bandage. Review of the facility's Investigative Summary dated 10/28/17, documented, the resident initially indicated that an unknown female hit me, and then further into the interview, the resident stated she (herself) had hit her hand on the wall. The facility concluded that there was no finding of abuse, and the resident appears to have a self-inflicted fracture during care. The results of the investigation were not reported to the NYSDOH. During an interview on 2/8/18 at 12:21 pm, with the Administrator regarding protecting the residents from harm following an allegation of abuse, he stated I would have to agree that she (CNA #4) should have been sent home. This incident was not reported to me. Regarding the reporting of the allegation to the NYSDOH, he stated, It wasn't reported to me directly. I found out afterwards. According to the guidelines we had no findings of abuse, therefore it did not get reported. During an interview on 2/8/18 at 12:21 pm, with the Administrator regarding protecting the residents from harm following an allegation of abuse, he stated I would have to agree that she (CNA #4) should have been sent home. This incident was not reported to me. Regarding the reporting of the allegation to the NYSDOH, he stated, It wasn't reported to me directly. I found out afterwards. According to the guidelines we had no findings of abuse, therefore it did not get reported. During an interview on 2/8/18 at 12:40 pm, with RNNM #1, she stated if a resident is combative, the CNA is instructed to make sure the resident is safe, leave the room and re-approach. On the day of the incident 10/28/17, the resident was re-assigned to another aide and CNA #4 (the resident's CNA at the time of the incident) was given a new assignment. During an interview on 2/20/18 at 6:49 am, with CNA #4, she stated she was familiar with the resident and stated the resident gets agitated during the provision of care. Regarding what she does when the resident gets agitated, she stated, You do the best you can. You can't not provide care. She stated, I went to remove her brief and she grabbed my necklace. She yanked the necklace right off me and the necklace broke. She tore her finger open when she grabbed my necklace with the one hand. The other hand never touched my necklace. Regarding the broken finger on the other hand, she stated, She might have hit her hand on the wall when I rolled her. She was burned out when she resigned from a previous facility in (MONTH) (YEAR). She stated, I love the people, but I can't stand getting beat on. The surveyor explained that residents with dementia have problems with controlling their behaviors. She replied, Only about 10% of older people have dementia. Most know what they are doing and they do it on purpose. She stated, I'm tired of chasing them. Tired of getting beat on. She stated she changed her shift a few months ago to the night shift. She stated, I've got a temper problem. She was not suspended following the incident on 10/28/17, she was assigned to the dining room. She stated, After the incident I had to feed residents. The resident (#2) was making comments about her finger bleeding because of my necklace. I told her it was karma because her finger bled. I got written up for it. She is shorter tempered since she left the previous facility in (YEAR). She stated, It doesn't take much. She was pretty sure who called the State to report the incident and stated, I have an attitude when I get stressed out. Regarding what she does when a resident is combative, she stated, You do the best you can. You have to provide care. Regarding leaving the resident and re-approaching when the resident is agitated, she had no response. During an interview on 2/22/18 at 9:12 am, with LPN #2 regarding the incident on 10/28/17, she stated she went to the resident's room after she was told by a CNA that the resident's finger was bleeding. She stated, The resident was very upset. At times she does get upset. I leave the room and send someone else. She'll be ok after that. The facility expects staff to re-approach the resident when the resident is agitated. The resident showed the LPN her finger. There was blood on her finger and on the top part of CNA #4's shirt. The resident stated, She hurt me. Get her out of here. LPN #2 told CNA #4 to leave the room. CNA #4 stated, No. This is how the resident normally acts, and this is how we are going to deal with the resident. LPN #2 stated she told CNA #4 no and told her to get another aide. CNA #4 left the room after that. CNA #4 was not sent home. Regarding what is supposed to happen, she stated, Supposed to send the CNA home pending an investigation. CNA #4 told the person who was taking her statement that she pulled the necklace out of the resident's hand. LPN #2 stated, They do tell us not to wear jewelry and long nails. We get in-serviced when we first start. It was reported to her that CNA #4 walked over to the resident while she was in the dining room and said, My necklace means more to me than you will ever mean. It was LPN #2's understanding that more than one CNA wrote statements about the incident in the dining room. 10 NYCRR 415.4(b)(1)(ii)

Plan of Correction: ApprovedApril 11, 2018

F610 ? D Tag
The following was completed as corrective action for those residents found to have been affected by the alleged practice. For resident #2 the Administrator and Acting DON were educated by the Regional QA Consultant on removing the alleged perpetrator from the building pending the investigation. The education included education on reporting guidelines per the NYS Incident Reporting Manual. The SOD specifically mentions the DON at the time of the incident. The DON on duty at the time of the incident resigned effective immediately on 1/9/18. C.N.A #4 was terminated.
In order to identify other residents having the potential to be affected by the same alleged deficient practice, the following will be completed. The systemic changes will be the corrective action.
In-servicing on the abuse protocols and policy was completed while the surveyor was on site for all personnel in the facility.
The facility will initiate an I/A checklist which includes a description to notify the administrator in the event of any abuse; neglect; exploitation; mistreatment and injury of unknown origin. All RN will be educated on this I/A checklist. The abuse, neglect, mistreatment policy and procedure was reviewed and revised to reflect that while the investigation is ongoing the accused employee will be removed from duty pending the outcome of the investigation.
The facility will do weekly audits of the investigations to ensure that any allegations of abuse, neglect, and mistreatment have been identified and reported to the Administrator and will include removing the accused employee from duty pending the results of the investigation.
The Administrator or designee will be responsible for the oversight of the corrective action. Any negative findings will be brought to the attention of the QAPI committee.

FF11 483.10(g)(14)(i)-(iv)(15):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC.)

REGULATION: §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 15, 2018
Corrected date: May 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during an abbreviated survey (Case # NY 722, NY 112 and NY 200) the facility did not immediately consult the resident's physician when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention, and when there was a significant change in the resident's physical status for two residents (Resident #3, and #11) of three residents reviewed. Specifically, for Resident #3, there was a one-day delay in reporting significant injuries related to a fall to the physician. The resident had additional injuries from the fall that were not documented and not reported to the physician until six days later. Additionally, the resident had a change in physical condition that was not reported to the physician. For Resident #11, there was a two-day delay in reporting an injury of unknown origin to the physician. This is evidenced by: Resident #3: The resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. The BIMS (Brief Interview for Mental Status) was assessed as 14/15; cognitively intact on the MDS (Minimum Data Set) dated 7/28/17. The facility could not provide a policy and procedure regarding physician notification for change in condition. The Interact training tool dated 2014, entitled Change in Condition: When to report to the MD/NP/PA documented immediate notification for any symptom, sign or apparent discomfort that is acute or sudden in onset, and is a marked change (i.e. more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. Review of physician orders [REDACTED]. Review of the Comprehensive Care Plan (CCP) dated 7/26/17, documented the resident was at risk for bleeding and bruising related to anticoagulant (blood thinner). The CCP documented the physician was to be notified of changes. Review of the Accident & Incident (A&I) form dated 8/16/17 at 5:15 am, completed by RN #1 (registered nurse) documented the resident was agitated and deliberately threw herself out of the wheelchair, landing face down. The injuries were a 1/4 inch abrasion across the nose, and swelling to the mid-forehead. A drawing of the face was noted with documentation: Soft tissue swelling 7 am - golf ball size. The RN documented that no emergency care was needed; Dressing applied to nose. It documented the resident was on anticoagulant therapy. The Nurse's Note dated 8/16/17 at 5:56 am, written by RN #1, documented the resident was yelling and was taken to a quiet room to calm down. The resident pitched herself forward and threw herself onto the floor, landing face down. There was some bleeding noted from the nose, and some swelling to mid forehead. A complete assessment of the resident was not documented, and there was no documentation that the physician was notified. The Nurse's Note dated 8/16/17 at 6:14 am, written by RN #1, documented the resident was still agitated and was being kept at the desk under supervision. A dressing was applied to a cut on the bridge of the nose. The Nurse's Note dated 8/16/17 at 7:02 am, written by RN #1, documented a nose abrasion 1/4 inch across the bridge of nose, and forehead swelling has extended to golf ball size. There was no documentation the physician was notified. The A&I dated 8/16/17, documented the physician was notified at 9:15 am and orders were given for [MEDICATION NAME] (used to treat anxiety) 0.25 mg three times a day as needed and a geri-chair for mobility. There were no documented treatment orders for the resident's injuries. The Nurse's Note dated 8/17/17 at 8:06 pm, documented the resident was noted to have bruising over nose, eyes, and forehead following the fall. The daughter asked for an x-ray to be done of the facial area. Review of the facial x-ray results dated 8/17/17, documented nasal bone fracture; otherwise intact facial bones; Minimal fracture 3 mm of tip of nasal bone; Minimally depressed; Appears acute. The Nurse's Note dated 8/18/17 at 12:24 am, documented the facial x-ray was completed at the request of the daughter and the attending physician. The results of the x-ray were documented in the note. The Nurse's Note dated 8/22/17 at 10:00 am, written by the Director of Nursing (DON), documented she spoke with the resident's daughter who voiced concerns over bruising on the resident's limbs; The bruises on the left knee and both shoulders were consistent in appearance with the facial bruising from a previous fall; The resident was seen by the physician and x-rays were ordered. There was no documentation about the bruises, and no documentation that the physician was notified about the bruises prior to 8/22/17. Review of the Medical Services Progress Note written by MD #1 on 8/22/17 at 1:28 pm, documented the resident seemed to be in pain, but was unable to describe the pain because of her dementia; Complaining of pain in the head and questionable pain in left shoulder; Daughter is very concerned with bruising of knees and lower legs; Some ecchymosis of both knees and also both lower legs, with ecchymosis of each measuring about 1-5 cm; Because of the fall, will x-ray head, left shoulder, both knees and both legs for any fracture. Review of the skull, left shoulder, knees, and lower leg x-ray results dated 8/22/17, documented the study was done because of pain from a fall; No fractures/dislocation. The Nurse's Note dated 9/17/17 at 10:00 pm, written by the RN, documented small amount of frank blood observed in the toilet. There was no documentation that the physician was notified. During an interview on 2/12/18 at 1:25 pm, with LPN #1, she stated the resident bruised easily; She was on a blood thinner. She stated, If the resident is on an anticoagulant and there's blood in the toilet, she would call the physician immediately. During an interview on 2/12/18 at 2:54 pm, with the RN nurse manager (RNNM #1), she stated that she would have thought the physician would have gotten an x-ray after the resident fell on [DATE]. Regarding the resident being seen by the physician after the fall, she stated, He did not see her until 8/22/17. That's when he ordered the x-rays. She stated the family was concerned about the bruising on her limbs on 8/22/17. She stated, If new bruises arise the staff are supposed to notify the RN; Even if she fell 3 days ago. They should be documenting that the bruises could be related to the fall. Especially, if the resident is on Eliquis. Staff has to fill out a whole packet for bruising; Similar to the one that is completed for falls. She stated, We still have to rule out abuse. She would have expected ice used as an immediate treatment at the time of the fall. She stated, They should be documenting a head-to-toe assessment following a fall. Regarding the frank blood in the toilet, she stated, If I observed hemorrhoids, I would have documented that. If I didn't observe them, I would have notified the doctor. Especially since she's on Eliquis. That would concern me if I observed that. During an interview on 2/13/18 at 4:33 pm, with the Medical Director, he stated he would expect the initial call to the physician immediately following the fall. Golf ball size swelling was a change in condition and he would expect the physician to be called. Regarding the rectal bleeding, he stated, If there's bleeding, we would expect it to be reported. It's a change in condition. During a phone interview on 2/27/18 at 3:22 pm, with RN #1, she stated the resident threw herself on the floor. The resident was out in the hall in the middle of the night and was having a tantrum like a child. She brought the resident to the dayroom and the resident pitched herself down to the floor. The resident was bleeding from her nose initially. Regarding emergency care, she stated, Initially, the resident did not need it. Sometimes things get worse over time. She stated the bleeding had stopped and believed that the LPN put an ice cap on it, but she did not call the physician. She stated, Initially it didn't look that bad. Regarding no documentation about the physician being called when the swelling on the resident's forehead increased to golf ball size, she stated, It has to be written somewhere on the A&I. In regards to documentation on the A&I dated 8/16/17, the physician was notified at 9:15 am, however, no treatment orders were documented for the injuries; She stated she would not have been there at that time. She gives report at 7:00 am. She stated, If I don't think it's critical, I don't call the doctor. I leave a post-it note on the A&I that notifications need to be done. Regarding the resident being care planned for anticoagulation, she stated, At the time, I wasn't really concerned about it. Regarding the daughter's concern about bruising on the resident's limbs on 8/22/17, she stated the aides usually report the bruises. She stated, I can't believe no one saw anything and didn't mention it in 6 days, 18 shifts. It doesn't surprise me. Regarding a complete assessment at the time of the fall, she stated, I did not strip her down. I was concerned about her face. She was agitated. Resident #11: The resident was originally admitted on [DATE] and readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Additionally, the resident has a history of diabetes. On the MDS dated [DATE], the resident was assessed as rarely makes self understood, rarely understands, and the resident's cognitive skills for daily decision making were severely impaired. Review of the Medical Progress Note dated 1/22/18 at 4:53 pm, documented she was asked to see the resident who was noted to be holding her right leg in strange position; An area around the hip appeared swollen and with a bruise that had been there for several days due to the coloring of it; Right leg appears shortened and is internally rotated, leaving suspicion of possible [MEDICAL CONDITION]. Any movement of right leg clearly causes pain. X-ray was ordered. Review of the Nurse's Notes and 24 Hour Report (nurse communication report) 1/15/18 - 1/22/18, documented no bruising/swelling on the resident's right leg. Review of the facility's investigative (undated) written by the acting Director of Nursing (DON) documented she was asked to assess the resident's right leg; Internal rotation and bruising to right inner thigh measuring approximately 15 cm x 10 cm with varying shades of purple/green to mainly a yellow hue; Bruising based on color is several days old. Below right knee noted also with bruising of yellow coloration and right outer ankle with dark blue bruising; 2nd and 3rd toes of right foot with pale bruising noted; right knee with swelling; right hip with pain and swelling. It documented that the investigation into the root cause was started on 1/22/18. Review of staff statements related to bruising documented: On 1/22/18, CNA #1 wrote she was her aide on 1/20/18, noticed bruising to the resident's right leg, and reported it to LPN #2. On 1/24/18, LPN #2 wrote that she noticed old yellowish bruising; She did not report the bruising. On 1/21/18, CNA #5 wrote that she worked the dayshift on 1/21/18, noticed bruising on right leg that was old and assumed the nurse knew about it. The Nurse's Note dated 1/23/18 at 12:51 am, documented the right hip x-ray was negative. The Medical Progress Note dated 1/23/18 at 11:35 am, by MD #1 documented the resident was sent to the hospital for further evaluation of elevated temperatures, low oxygen saturation, abnormal lung sounds, and [MEDICAL CONDITION]. There was no documentation about the bruising. The Hospital x-ray of the right femur on 1/23/18 documented distal femoral fracture. Review of the Hospital Social Worker Progress Note dated 1/23/18, documented the patient was found to have significant bruising to her right leg; X-ray revealed right femur fracture; The facility did not express that patient had fallen and no explanation of bruise to right leg. The Nurse's Note dated 1/24/18 at 1:06 pm, documented report was received from the hospital stating the resident was admitted with right femur fracture at the distal end (the end down by the knee) and [MEDICAL CONDITION] to right lower leg. During an interview on 2/6/18 at 4:00 pm, with the Administrator, he stated the facility started an investigation as soon as they knew about the fracture. The fracture was reported to the facility by the hospital. He stated, The bruise was not reported to me. During an interview on 2/8/18 at 1:10 pm, with the ADON/Acting DON, she stated, I was never told about the bruising until Monday (1/22/18). The resident had bruising to her upper and inner thigh. If a CNA finds a bruise, they report it to the LPN, and the LPN should chart the observations. The LPN tells the RN and the RN should do an assessment. An investigation needs to be started. She stated, It should get reported to the Administrator immediately. During an interview on 2/8/18 at 1:44 pm, with CNA #2, she stated she did not see any bruising on 1/19/18, however, she did not get the resident out of bed because the resident was sick. She was assigned to the resident on 1/22/18 and noticed the bruising when she pulled back the sheet to start changing her. There was bruising on her inner thigh. She reported it to the Nurse Manager and the PA. During an interview on 2/8/18 at 1:54 pm, with CNA #3, she stated she provided care to the resident on 1/21/18, but did not notice any bruising because she was focused on the resident vomiting. She reports bruises to the LPN and always to the Nurse Manager. During an interview on 2/8/18 at 2:58 pm with LPN #2, she stated while she was helping the aide to reposition the resident on 1/20/18, she noticed a circular bruise on the right middle thigh that was yellow in color. She stated, I touched it. The resident did not express pain. The resident will express pain by making a noise; ouch, ouch. She did not report the bruising to the RN because the resident had been vomiting. She stated, I was busy with the resident because she was vomiting; Making sure she was sitting up. The resident has a history of aspiration. I forgot to mention it to the RN. She usually reports bruises to the RN, because it's a change in condition and to do an investigation to rule out abuse. During an interview on 2/13/18 at 10:10 am, with CNA #1, she stated on 1/20/18 the resident had a shower and when they were transferring her, she noticed an old, small, yellowish bruise on the resident's inner thigh. LPN #2 was in the room with her. During an interview on 2/13/18 at 3:30 pm, with MD #2, he stated, If it (bruising) was noted on 1/20/18; Would expect the investigation to be started immediately. When the PA (physician's assistant) saw the resident on 1/22/18, the resident was having hip pain. The PA ordered an x-ray of the hip and the x-ray was negative. She didn't realize the resident was having referred pain into the hip. The hospital x-rayed the entire femur and found the fracture. When he saw the resident on 1/23/18, if he was told about the leg, he would have evaluated it further. During an interview on 2/14/18 at 8:47 am, with RNNM #1, she stated the resident had no recent reported falls. The leg injury presented as a hip injury. She stated, I was totally surprised by all of it. During an interview on 2/20/18 at 7:33 am with CNA #4, she stated she was basically, the resident's sole caregiver at night. No one in the facility asked her about the bruising. She noticed bruising on the back part of the upper thigh, but not until after the resident returned to the facility from the hospital. She stated she reports all bruises. During a phone interview on 3/6/18 at 9:30 am, with LPN #3, he stated he works the nightshift and was one of the resident's regular caregivers. He did not notice any bruising on the resident. The resident didn't seem to be in any pain. She is non-verbal; facial expression will show signs and symptoms of pain. 10 NYCRR 415.3(e)(2)(ii)(a) 10 NY CRR 415.3(e)(2)(ii)(b)

Plan of Correction: ApprovedApril 9, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Riverside Center for Rehabilitation and Nursing provides this plan of correction without admitting or denying the validity or existence of the alleged deficiencies. The plan of correction is prepared and executed solely because it is required by federal and state law.
F580 ? E Tag
The following was completed as corrective action for those residents found to have been affected by the alleged practice. Resident #3 expired on [DATE] and is no longer at the facility. Upon discovery of the bruise the doctor was notified and investigation initiated for resident #11. LPN #2 was educated and C.N.A #4 was terminated.
In order to identify other residents having the potential to be affected by the same alleged deficient practice, the following will be completed. All progress notes; incident and accidents, and 24 hour report will be monitored by the Administrator/DON/and ADON for thirty days to identify any accidents, incidents, injury, or change in condition that was not reported to the doctor. Any identified areas will have an RN assessment and a notification to the medical provider at that time. The same will occur during a significant change.
In-services will be held to educate LPN, RN, and Unit Managers on the following: reporting of any symptom, sign or apparent discomfort that is acute or sudden onset; Proper MD notification and notification to administration; education on the S-Bar and E-INTERACT tools; institution of the QA audit for signs of medical event which includes significant medical event documented on the 24 hour report; immediate actions taken; RN assessment; MD notification; family/responsible party notified; early warning; SBAR; and other comments.
The significant medical event form/audit will be completed by the ADON daily Monday-Friday based on progress notes from the previous day. The audit will look at significant medical event documented on the 24 hour report; immediate actions taken; RN assessment; MD notification; family/responsible party notified; early warning; SBAR; and other comments. The results of this audit will be reported to QAPI monthly by the ADON. The QAPI committee will evaluate the data and act on the information as indicated on an ongoing basis.
The ADON or designee will be responsible for the oversight of the corrective action. Any negative findings will be brought to the attention of the Administrator/DON immediately.

FF11 483.25(g)(1)-(3):NUTRITION/HYDRATION STATUS MAINTENANCE

REGULATION: §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Isolated
Severity: Actual harm has occurred
Citation date: March 15, 2018
Corrected date: May 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during an abbreviated survey (Case# NY 112) the facility did not ensure that it maintained acceptable parameters of nutritional status and electrolyte balance, and offered sufficient fluid intake to maintain proper hydration and health for one resident (Resident #11) of three reviewed. Specifically, for Resident #11, the facility did not recognize, evaluate, and address the hydration needs of the resident who was already experiencing impaired hydration due to repeated vomiting and elevated temperatures from 1/16/18 to 1/22/18. Subsequently, on 1/23/18 the resident was admitted to the hospital and diagnosed with [REDACTED]. The Facility's policy and procedure (P&P) for nutrition/hydration (undated) documented it was the policy of the facility to provide the tools, people, and systems to provide appropriate interventions to help promote adequate hydration and health. Residents are considered at risk for dehydration with the following risk factors: acute illness, pain, or infection including temperature elevations; any [DIAGNOSES REDACTED].e. vomiting); functional impairments that cause inability to self- hydrate, impairs communication, or cause swallowing difficulties (i.e. [MEDICAL CONDITION], dysphasia). Clinical signs of possible insufficient fluid intake are assessed through nursing assessment: concentrated urine, laboratory values (elevated sodium and BUN), and elevated temperatures. Treatment and Prevention of fluid deficit was documented as: an appropriate assessment is made by the physician to determine if water depletion alone (dehydration) or the more common sodium/water (volume) depletion is present. Treatment is accomplished by increasing oral intake of fluid and electrolytes as needed. Patients with more severe cases and those who are unable to take fluids by mouth are treated by appropriate intravenous (IV) fluid replacement. Dehydration is caused from losing too much fluid from fever or vomiting. Older adults and people with certain diseases, such as diabetes, are also at higher risk for dehydration. (https://medlineplus.gov/ency/article/ 2.htm) The P&P for Enteral Feeding (delivery of nutrients through a feeding tube directly into the stomach) via Pump revised 4/12 documented residents whose nutritional needs must be met by artificial means and who are intolerant of bolus feedings will be placed on a mechanical feeding device to ensure slow administration of the formula. The actual schedule will be determined by the physician. Resident #11: The resident was originally admitted on [DATE] and readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Additionally, the resident has a history of diabetes. The Minimum Data Set ((MDS) dated [DATE], the resident was assessed as rarely makes self understood, rarely understands, and the resident's cognitive skills for daily decision making were severely impaired. Review of the Comprehensive Care Plan (CCP) for Communication last updated 2/1/18, documented the resident cannot make needs known to staff. Speech: [MEDICAL CONDITION] (knows what he/she wants to say, yet has difficulty communicating it to others). Review of the CCP for Swallowing last updated 2/1/18, documented presence of GT (gastrostomy tube; feeding tube); cognitive impairment; [MEDICAL CONDITION] related to [DIAGNOSES REDACTED]. Goals: receive adequate nutrition/hydration and tolerate GT feeding. Interventions: NPO (nothing by mouth) and monitor intake. Review of the CCP for Alteration in GI (gastrointestinal) Status last updated 2/1/18, documented the resident had a problem [MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease) with a goal: will have no untreated signs and symptoms of GI distress, and interventions: monitor for signs and symptoms of distress; vomiting. Review of the CCP for Dehydration/Fluid Volume Deficit/Elevated BUN (blood urea nitrogen; urea nitrogen, a waste product removed by the kidneys; elevated levels may indicate that kidneys are not working efficiently) last updated 2/1/18, documented bolus tube feeds (the administration of a limited volume of enteral formula over brief periods of time) administered by staff; unaware of need to drink. Feeding tube problem/goals: maintain hydration and electrolyte balance, stabilize medical problem through Dietary intervention: monitor intake and output, increase fluid as per physician, monitor for changes and notify physician, and monitor for signs/symptoms of dehydration. Review of the diet orders documented an order dated 12/25/17 for Glucerna 1.5 Cal Oral Liquid; total volume to deliver/24 hours: 1420 ml via GT; bolus via gravity: 355 ml; every 6 hours. The Nurse's Note dated 1/5/18 at 6:36 pm written by RN Nurse Manager (RNNM #1) documented, the MD was in, pharmacy reviews completed; discontinue [MEDICATION NAME] ([MEDICATION NAME]; prevents nausea/vomiting) related to non-use. The Physician order [REDACTED]. The Nurse's Note dated 1/16/18 at 2:20 am, the RN documented the resident vomited a large amount of tan/yellow fluid after the bolus feed. MD expected on rounds. The Physician order [REDACTED]. as needed for fever. The Nurse's Note dated 1/16/18 at 2:10 pm, LPN #2 documented the resident vomited a large amount of brownish fluid after the bolus feed. T (temperature) 101.3. [MEDICATION NAME] given, RN/MD made aware. The Nurse's Note dated 1/17/18 at 12:32 am, LPN #3 documented T 100.2. Tylenol suppository administered and at 5:49 am the RN documented the repeat temperature was 99.5. Tylenol given. The Physician order [REDACTED]. The Nurse's Note dated 1/17/18 at 1:23 pm, the acting Director of Nursing (DON) documented the resident received bolus feeding and then vomited. Physician visit: no was documented in the note. The Nurse's Note dated 1/17/18 at 2:34 pm, the LPN documented the resident vomited 2 times this shift. [MEDICATION NAME] given at 9:48 am. The 12:00 pm bolus given, vomited after. The MAR indicated [REDACTED]. There was no documented explanation for the administration. The Nurse's Note dated 1/18/18 at 12:56 am, LPN #3 documented T 100.8; Tylenol administered. [MEDICATION NAME] was given. The Nurse's Note dated 1/18/18 at 4:55 am, LPN #3 documented [MEDICATION NAME] was given at 12:30 am after the resident vomited; entered late in the MAR. The Nurse's Note dated 1/18/18 at 12:57 pm, the acting DON documented no vomiting reported. T 99.5. Physician visit: no was documented in the note. The Nurse's Note dated 1/18/18 at 4:27 pm, LPN #2 documented Tylenol suppository was given related to increased T, no vomiting noted. The temperature was not documented. The Nurse's Note dated 1/18/18 at 10:28 pm, the RN documented T 101.6; call placed to NP (nurse practitioner); order received. Physician visit: no was documented in the note. The Physician order [REDACTED]. as needed for fever. The Nurse's Note dated 1/19/18 at 3:18 am, LPN #3 documented T 100.8, [MEDICATION NAME] given prior to midnight tube feed; about a ½ hour after tube feed, vomited large amount of undigested tube Glucerna. Temperature came down to 98.2 (had received Tylenol on 3-11 shift). The Physician order [REDACTED]. The Nurse's Note dated 1/19/18 at 3:08 pm, RNNM #1 documented T 98.1, resident vomited 2 times this shift. [MEDICATION NAME] given at 2:39 pm. The portable x-ray KUB 1 view (abdomen) result dated 1/19/18 documented nonspecific abdomen. The Nurse's Note dated 1/19/18 at 10:02 pm, the LPN documented the resident had large vomit right after the tube feeding around 7 pm. T 99.1; Tylenol given. The Nurse's Note dated 1/20/18 at 12:00 am, RN #1 documented the resident's blood sugar was 455 and she called MD #1. It was documented the tube feed was turned off. During a phone interview with RN #1 on 3/8/18 at 1:07 pm, she was asked to explain her note about the tube feeding. She was not able to recall the conversation with MD #1. The Nurse's Note dated 1/20/18 at 7:04 am, the LPN documented T 98.2 The resident vomited 1 time this shift. Tube feed stopped. The Nurse's Note dated 1/20/18 at 9:25 am, the RN documented T 99.8, no vomiting this shift. The Nurse's Note dated 1/20/18 at 5:47 pm, the RN documented T 100.5. Resident spit up yellow emesis about 20 minutes after tube feed started. Tube feed shut off for 1/2 hour. Tylenol given by charge nurse. Results of x-rays obtained yesterday, not yet read by MD. The Nurse's Note dated 1/21/18 at 3:03 am, LPN #3 documented T 101.2. The resident continues with vomiting after tube feeds. [MEDICATION NAME] given ½ hour prior to tube feed. The Nurse's Note dated 1/21/18 at 10:57 am, the acting DON documented the abdominal x-ray was still waiting for a final MD reading; they will call and fax the result shortly. Resident vomited a moderate amount of yellow emesis this morning. T 100.6. MD #1 in, and did see resident. At 12:14 pm MD #1 was made aware of the results of the x-ray. The Nurse's Note dated 1/21/18 at 2:16 pm, LPN #2 documented [MEDICATION NAME] given related to emesis and Tylenol related to temperature. The temperature was not documented. Review of the Medical Progress Note written on 1/21/18 at 2:29 pm by MD #1, documented the resident was seen per request of Nursing with a chief complaint of temperature, vomiting, and possible aspiration; resident is on a bolus feeding; non-verbal; unable to describe the character of her vomiting and the severity of her possible abdominal pain; abdominal x-ray is non-specific; bolus feed had to be lessened; possibly cause of vomiting. Will monitor. There was no documentation that the resident's nutritional and hydration status was evaluated and managed. The Nurse's Note dated 1/21/18 at 9:37 pm, the RN documented staff nurse reports T 101 that was responsive to Tylenol. One episode of projective vomiting. Was given [MEDICATION NAME] at 8:50 pm. Staff report resident is not herself. Current T 99.4. The Nurse's Note dated 1/22/18 at 6:56 am, LPN #3 documented T 100.2, [MEDICATION NAME] and Tylenol given. Vomited small amount after bolus feed at 12:30 am and kept 6:00 am tube feed down (so far). Continues with low grade temperature. The Nutrition Progress Note dated 1/22/18 at 4:04 pm by the Registered Dietician (RD), documented the resident with vomiting/fever since late last week. Some tube feeds held while work up ongoing. Abdominal x-ray was non-specific. Question GI illness vs. true intolerance or other cause. If vomiting continues, consider holding tube feed and offering electrolyte replacement via tube until stable. RD to follow and provide recommendations as needed. The Nurse's Note dated 1/22/18 at 4:37 pm, RNNM#1 documented one episode of vomiting today; yellowish fluid; small amount. Review of the Medical Progress Note dated 1/22/18 at 4:53 pm by the PA (physician assistant) who was asked to see the resident for bruising/swelling in the right leg, documented the resident has been running temperatures, vomiting, and possibly aspirating vomitus. Temperature/vomiting; not clear where this is coming from. Concern is of aspiration. No bolus feedings for now. There was no documentation that the resident's nutrtitional and hydration status was evaluated and managed. The MAR indicated [REDACTED]. There was no documented explanation for the administration. Review of the Medical Progress Note dated 1/23/18 at 11:35 am written by MD #1, documented the resident was being followed for chief complaint of T 101, BP 96/68, PR 104, O2 saturation 69% on 4L oxygen. The Medical Director examined the resident; heard abnormal lung sounds; thought the resident was septic (life-threatening organ dysfunction due to infection); and sent the resident to the hospital. The Hospital laboratory blood test results dated 1/23/18 documented sodium level 164 HH (normal is 135 - 145), BUN 94 H (normal is 7- 20), and creatinine (waste product removed by kidneys) 1.8 H (normal is 0.5 - 1.1). The Hospital Transfer Discharge Summary dated 2/1/18 documented a discharge [DIAGNOSES REDACTED]. On 3/14/18 at 1:18 pm, the DON was contacted and asked to provide documented Laboratory results for (MONTH) (YEAR), documented monitoring of the resident's intake and output for (MONTH) (YEAR), and documented vital signs for (MONTH) (YEAR). There were no documented Laboratory results prior to 1/23/18. There was documentation related to intake via the GT; computer generated Administration Records. There was no documentation regarding output; voiding/vomiting. Nurse's Notes were provided for documented vital signs. During an interview on 2/8/18 at 2:58 pm with LPN #2, she stated on 1/20/18 the resident was vomiting and had been for several days prior to that. She stated, I was busy with the resident because she was vomiting; making sure she was sitting up; she has a history of aspiration. She did not report the vomiting to the RN because the resident had been vomiting prior to that day. During an interview on 2/13/18 at 10:10 am with CNA #1, she stated the resident was vomiting all day on her shower day (1/20/18). She stated, For three days there was constant vomiting. LPN #2 stopped the tube feed and was going to mention it to the supervisor. During an interview on 2/13/18 at 1:54 pm with CNA #3, she stated on 1/21/18 the resident was really vomiting. She reported the vomiting to the LPN #2. During an interview on 2/13/18 at 3:30 pm with the Medical Director (MD#2), he stated he is usually in the facility on Tuesdays and heard the resident was sick. If a resident needs to go to the hospital, they call him for approval. He saw the resident, glanced at her and knew she was septic. The resident had been vomiting for 5-6 days and had fevers. The concern was for aspiration. He stated that MD#1 put the resident on [MEDICATION NAME] for possible aspiration pneumonia. He stated that for someone who had been receiving [MEDICATION NAME] for 4 days, she didn't look good. He would expect a call to the MD when the resident was getting [MEDICATION NAME] and still vomiting, and would expect Nursing to monitor the resident's intake and output. MD #2 stated, We do IVs and Clysis (a rehydration technique) here. During an interview on 2/13/18 at 3:45 pm with MD #1, he stated they can call him 24 hrs/day; he is always available. He stated, If they are really concerned, they call me. Even at night. If the patient is really sick we send them to the hospital. Every time she vomited, she probably aspirated a little at a time and ended up febrile (feverish). During an interview on 2/14/18 at 8:47 am with RNNM #1, regarding the administration of Clysis or IV fluids for the repeated vomiting; resident was admitted for severe dehydration, she stated, It (vomiting) was never consistent. It was random. She stated, It might be before or after the tube feed. There was no rhyme or reason. Sometimes she was keeping her tube feed down. She believed the resident was started on [MEDICATION NAME] (antibiotic) on a Sunday, the PA saw her on a Monday, and the Medical Director sent her out to the hospital the next day. She stated, I felt so bad because she can't tell you how she is feeling or what's wrong. The resident's intake was not measured because it (the vomiting) was random. She stated, The emesis was not measured. During an interview on 2/20/18 at 7:33 am with CNA #4, she stated the resident was vomiting for 3 nights straight. She stated, No matter how fast or slow the tube feed was given, she would vomit. I could hear it from outside the room. During a phone interview on 3/5/18 at 9:32 am with the resident's HCP (health care proxy), he stated the resident was vomiting one day when he visited, but he was not aware that she was vomiting for several days. He stated he did not know the resident was admitted with severe dehydration. During a phone interview on 3/5/18 at 12:27 pm with the RD, she stated she was not contacted by Nursing about the vomiting. She stated she went to the nursing unit because, she saw random notes in the computer about the vomiting. She spoke with LPN #2 about the vomiting and was told the resident was vomiting, but not every feeding. She was not able to talk to the Nurse Manager (RNNM #1), because she was not available that day. The issue with the vomiting should have been reported to the physician so they can evaluate it. Nursing is responsible for monitoring the resident's food/fluid intake. IVs are done in the facility, but usually the physician will order Clysis. Residents with tube feeds are seen monthly. Nursing does not monitor strict I & O (intake and output); they might track the amount of tube feed, or voids. She makes recommendations for nutrition/hydration needs, but ultimately the physician needs to determine if it's best for the resident. She stated, In my opinion, the vomiting wasn't random. When vomiting more than once, the physician should have been called. During a phone interview on 3/6/18 at 9:30 am with LPN #3, he stated the resident was vomiting. He stated, She's a tough resident. It's hard to say what's going on with her because she's non-verbal. He talked to his supervisor about the vomiting, and gave her medication for nausea. When a resident is ill, the LPN notifies the RN, and then the RN notifies the MD. He stated, She has a history of vomiting. We usually turn off her tube feed. Regarding fluid replacement in light of the vomiting, he stated, She probably could have used Clysis. During a phone interview on 3/15/18 at 8:55 am with the ADON (acting DON (MONTH) (YEAR)) regarding the implementation of documented care plan interventions on the CCP for Dehydration for the prevention of dehydration when the resident was vomiting repeatedly from 1/16/18 to 1/22/18, she stated she had to review the notes in the computer system and stated, the resident was seen by MD #1 on 1/21/18. He indicated in his note that the resident was on a bolus feed; he did not order any labs. Prior to 1/21/18, MD #1 saw the resident on 1/5/18 for a routine visit for diabetes. Regarding the care plan intervention to maintain fluid and electrolyte balance, she stated they would administer IV fluids if necessary or Clysis if the MD chose to do that. If the nurses call the doctor, he could make the recommendation for the Clysis. She stated, I talked to him (MD #1) that day (1/21/18) when he came in, I told him about the vomiting and the temperatures. Regarding the care plan intervention for dietary interventions to stabilize the medical problem, she stated, If she's vomiting, try IVs or cut back her tube feeding. She reviewed the RD's note dated 1/22/18 and stated the RD wrote to consider holding her tube feed and offering an electrolyte replacement via the GT if the vomiting continues. There were no notes from the RD from 1/16/18 - 1/21/18. Regarding nurse's notes documenting the tube feed was stopped/turned off on 1/20/18, she stated she believed the resident was getting a bolus feed. The nurse checks for residual tube feed prior to the feeding. If there is residual, they hold the feeding for 1 hour and then recheck. Regarding the care plan intervention to monitor I & O, she stated they do not use hand-written documents to record/monitor intake/output; they use the Administration Records that are generated in the computer to monitor intake. The monitoring of output is done by the CNAs. She stated, If (Resident #11) didn't void, they would tell us. I don't believe that ever came up. She stated, The aides would tell us if something was unusual (dark, strong odor) with the urine. They are pretty good about that. They did not measure the vomit. She stated, MD#1 was aware of the vomiting. He was treating her for a respiratory illness. He was focused on that. Regarding notification to the MD for continued vomiting when the resident was receiving [MEDICATION NAME], she stated the expectation is the nurses would notify the MD if the vomiting continued after the [MEDICATION NAME] was given. Regarding the care plan intervention to monitor for signs and symptoms of dehydration, she stated nurses check for skin turgor (elasticity of the skin), moistness, and fever. Regarding the consideration of administering enteral feeding via pump because the resident was vomiting after the bolus tube feeding, she referenced the RD's note on 1/22/18, and stated there was no recommendation for a pump. She stated the nurses should collaborate with dietary whenever there are concerns about hydration. 10 NYCRR 415.12(j)

Plan of Correction: ApprovedApril 6, 2018

A QAPI meeting was conducted on 4/2/18 to identify causative factors contributing to the deficiency, to identify interventions to eliminate and correct the identified causative factors, to identify the systemic changes that will be implemented and to identify how the facility will measure whether efforts are successful or unsuccessful in maintaining compliance.
The facility hired an outside consultant to develop and implement an acceptable plan of correction.
The following corrective actions have been implemented for the resident found to have been affected by the alleged deficient practice:
Resident #11
The resident?s tube feeding was changed from bolus to continuous feeding for improved tolerance.
The Dietician completed a Nutrition Assessment and a Nutrition Analysis of Tube Feeding for the resident.

Comprehensive review and revision of the residents comprehensive care plan completed by the IDCP team.
The resident was evaluated by the PA on 2/1/18 upon readmission to the facility. She was also evaluated by the attending physician on 2/4/18.
The facility recognizes that all residents have the potential to be affected by this alleged deficient practice. The corrective action will be:
The Dietician will evaluate all residents receiving enteral nutrition for adequate hydration needs. Any identified areas of concern will be addressed through notification to the medical provider and revision to the comprehensive care plan as appropriate.
All residents will be assessed by the RN using the Decreased Fluid Intake/Dehydration Risk Assessment tool. Any identified areas of concern will be communicated to the medical provider and the plan of care revised accordingly.
The following systemic changes will be implemented to ensure that the alleged deficient practice does not recur:
Review of Hydration Management P&P with revisions as deemed necessary.
Review of P&P for Enteral Feeding with revisions as deemed necessary.
The RD at the time of the alleged deficient practice is no longer employed through the facility. The current RD will receive the daily morning meeting minutes via email for her review.
The facility will implement an RN Shift to Shift Report sheet to facilitate effective and comprehensive communication.
A Hydration meeting will be held twice a week with the interdisciplinary team to review the fluid intake, hydration needs and interventions for all residents.
The Consultant that the facility has contracted with will complete the directed education as follows:
All LPN?s and RN?s will be re- educated on the following:
? Proper and timely notification to medical provider.
? Use of the SBAR tool to facilitate prompt, effective and appropriate communication to the medical provider.
? Identification in resident change in condition. This will include use of the Care Paths for GI Symptoms and Potential for Dehydration
All LPN?s, RN?s, the Diet tech and the RD will be re-educated regarding the Hydration Management P&P and Enteral Feeding P&P.
The Diet Tech. will be re-educated regarding timely notification to the RD when residents are experiencing acute changes that are impacting their nutrition and hydration status.
All RN?s will be educated in regards to RN shift to shift report and the new RN Shift to Shift Report Sheet.
These corrective actions will be monitored through:
The ADON or designee will complete an audit Monday-Friday of all completed progress notes. The progress note audit will identify residents with a potential change in condition, the completion of an RN assessment and appropriate notification to the medical provider. Any areas of concern identified during the audit will be addressed by the ADON at that time. In addition, any resident with documented vomiting will have a decreased fluid Intake/Dehydration Risk Assessment completed at that time and findings communicated to the medical provider.
Each Nurse Manager or designee will complete a Hydration Audit 2x/week for 10 residents. The audit will identify residents with potential hydration concerns and that appropriate evaluation and action was taken as indicated.
The efficacy of the corrective measures will be monitored and reviewed monthly by the Quality Assurance Performance Improvement Committee.
For continuous quality improvement the nature and frequency of the audits will be reviewed and revised as determined by the QAPI Committee.
Title of Person Responsible:
The Assistant Director of Nursing will be responsible for oversight and compliance of corrective action. If a problem is identified the Director of Nursing will be notified to take immediate corrective action.

FF11 483.12(c)(1)(4):REPORTING OF ALLEGED VIOLATIONS

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 15, 2018
Corrected date: May 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during an abbreviated survey (Case # NY 255, NY 112, and NY 200) it was determined that for three (Resident #'s 2, 10 and #11) of three residents reviewed for abuse, neglect, mistreatment, and injuries of unknown origin, the facility did not ensure that an allegation of abuse was immediately reported to the Administrator and State Agency, and the results of the investigation were reported within 5 days of the incident for one resident (Resident #2). During the investigation pertaining to Resident #2, it was determined that the facility did not report an injury related to a care plan violation to the State Agency for one resident (Resident #10). For one resident (Resident #11), the Administrator was not notified of an injury of unknown origin, resulting in a delay in the investigation. This is evidenced by: Review of the facility Abuse Prohibition Protocol (undated) documented prevention: The supervision of staff to identify inappropriate behaviors such as rough handling and the assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors. Identification: the recognition of events that may constitute abuse or neglect such as suspicious bruising of residents. Investigation: The investigation of alleged violations and reporting of results to the proper authorities. Protection: protect residents from harm during an investigation. Reporting: report all alleged violations and all substantiated incidents to the state agency (NYSDOH) and to all other agencies as required (police) and take all necessary corrective actions depending on the results of the investigation. Resident #2: The resident was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The BIMS (Brief Interview for Mental Status) was assessed as 4/15; severe cognitive impairment on the Minimum Data Set ((MDS) dated [DATE]. Review of the Comprehensive Care Plan (CCP)for Potential Victim of Abuse last reviewed 10/23/17, documented the resident is vulnerable due to cognitive disabilities. Goals: Resident will be protected from being a victim of abuse. Approaches: Assess for behavior used as communication for symptoms of pain. Review of the Accident & Incident Form dated 10/28/17 at 7:30 am, written by the Registered Nurse (RN) Nurse Manager (RNNM #1) documented the resident became combative with the Certified Nursing Assistant (CNA) during morning care. The resident grabbed the CNA's necklace and sustained a skin tear to left 3rd finger and a bruise to right 5th finger. The resident's statement on 10/28/17 documented yes in response to someone hurting her, and the explanation documented That girl this morning did. She hurt my finger. It's hard to move it. The resident's version of the event documented She was rolling me back and forth in my bed and I hit the wall a couple of times. Review of the Statement of Events for 10/28/17; 7-3 (day shift) written by RNNM #1, documented an assessment of the resident's injuries: 3rd finger on left hand had a 1cm circular skin tear that required 2 steri strips. There was a small 1 cm ecchymotic (purple discoloration) on the inside of the right 5th finger. RNNM #1 asked the resident what happened to her finger. The resident replied, She did it. She hit me. RNNM #1 asked the resident who hit her. The resident replied, Oh, I don't know her name. It was documented the right 5th finger was re-assessed and it appeared to have more swelling to the entire finger and ecchymotic area had extended down to the knuckle joint and to the palm of the hand. The MD was notified and a stat x-ray was ordered. The allegation of abuse was not reported to the NYSDOH. Review of the Nurse's Note dated 10/28/17 at 12:12 pm, written by RNNM #1, documented the resident was combative/restless with morning care. The resident grabbed the CNA's necklace and upon breaking necklace and letting go, staff found the resident had a small skin tear near middle knuckle of left 3rd finger and bruising to the base of her right 5th finger. The resident was noted to have more swelling, and bruising extending to the palm of her hand just below the 5th finger. MD notified; Ordered x-ray of right 5th finger. The portable x-ray result of the right 5th finger dated 10/28/17, documented acute (abrupt onset) [MEDICATION NAME] fracture (fracture line is perpendicular to the long part of the bone) at the base of the proximal phalanx (bone found at the bottom of the finger) of 5th finger of the right hand. The Hospital Emergency Department (ED) records dated 10/28/17, documented phalanx fracture, finger. The fracture was reduced (restored to the correct alignment) and splinted. The Nurse's Note dated 10/28/17 at 8:41 pm, documented the resident returned from the ED with fractured right 5th finger in a splint covered with an ace bandage. Review of the facility's investigative summary dated 10/28/17, documented, the resident initially indicated that an unknown female hit me, and then further into the interview, the resident stated she (herself) had hit her hand on the wall. The facility concluded that there was no finding of abuse, and the resident appears to have a self-inflicted fracture during care. The results of the investigation were not reported to the NYSDOH. During an interview on 2/8/18 at 12:21 pm with the Administrator regarding protecting the residents from harm following an allegation of abuse, he stated I would have to agree that she (CNA #4) should have been sent home. This incident was not reported to me. Regarding the reporting of the allegation to the NYSDOH, he stated, It wasn't reported to me directly. I found out afterwards. According to the guidelines we had no findings of abuse, therefore it did not get reported. During an interview on 2/8/18 at 12:40 pm, with RNNM #1, she stated if a resident is combative, the CNA is instructed to make sure the resident is safe, leave the room and re-approach. On the day of the incident 10/28/17, the resident was re-assigned to another aide and CNA #4 (the resident's CNA at the time of the incident) was given a new assignment. During an interview on 2/20/18 at 6:49 am with CNA #4, she stated she was familiar with the resident and stated the resident gets agitated during the provision of care. Regarding what she does when the resident gets agitated, she stated, You do the best you can. You can't not provide care. She stated, I went to remove her brief and she grabbed my necklace. She yanked the necklace right off me and the necklace broke. She tore her finger open when she grabbed my necklace with the one hand. The other hand never touched my necklace. Regarding the broken finger on the other hand, she stated, She might have hit her hand on the wall when I rolled her. She was burned out when she resigned from a previous facility in (MONTH) (YEAR). She stated, I love the people, but I can't stand getting beat on. The surveyor explained that residents with dementia have problems with controlling their behaviors. She replied, Only about 10% of older people have dementia. Most know what they are doing and they do it on purpose. She stated, I'm tired of chasing them. Tired of getting beat on. She stated she changed her shift a few months ago to the night shift. She stated, I've got a temper problem. She was not suspended following the incident on 10/28/17, she was assigned to the dining room. She stated, After the incident I had to feed residents. The resident (#2) was making comments about her finger bleeding because of my necklace. I told her it was karma because her finger bled. I got written up for it. She is shorter tempered since she left the previous facility in (YEAR). She stated, It doesn't take much. She was pretty sure who called the State to report the incident and stated, I have an attitude when I get stressed out. Regarding what she does when a resident is combative, she stated, You do the best you can. You have to provide care. Regarding leaving the resident and re-approaching when the resident is agitated, she had no response. During an interview on 2/22/18 at 9:12 am with LPN #2 regarding the incident on 10/28/17, she stated she went to the resident's room after she was told by a CNA that the resident's finger was bleeding. She stated, The resident was very upset. At times she does get upset. I leave the room and send someone else. She'll be ok after that. The facility expects staff to re-approach the resident when the resident is agitated. The resident showed the LPN her finger. There was blood on her finger and on the top part of CNA #4's shirt. The resident stated, She hurt me. Get her out of here. LPN #2 told CNA #4 to leave the room. CNA #4 stated, No. This is how the resident normally acts, and this is how we are going to deal with the resident. LPN #2 stated she told CNA #4 no and told her to get another aide. CNA #4 left the room after that. CNA #4 was not sent home. Regarding what is supposed to happen, she stated, Supposed to send the CNA home pending an investigation. CNA #4 told the person who was taking her statement that she pulled the necklace out of the resident's hand. LPN #2 stated, They do tell us not to wear jewelry and long nails. We get in-serviced when we first start. It was reported to her that CNA #4 walked over to the resident while she was in the dining room and said, My necklace means more to me than you will ever mean. It was LPN #2's understanding that more than one CNA wrote statements about the incident in the dining room. Resident #10: The resident was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The BIMS was assessed as 10/15; moderate cognitive impairment on the MDS dated [DATE]. The CCP for At Risk for Falls initiated 4/13/17, documented floor mats were in use next to the bed. The Resident Information (CNA care card) dated 8/2/17 documented a floor mat for fall prevention. Review of the A&I dated 8/7/17 at 5:45 pm, documented the resident was found lying on the floor next to the bed. The resident was not able to report what had happened. There was a skin tear 1.25 cm x 1 cm on the left elbow. It documented the floor mat was not in use at the time of the fall. Review of the facility investigative summary of a fall with resulting skin tear, 1.25 x 1cm to left elbow on 8/7/17, documented the resident had an unwitnessed fall from the bed. The resident's mat was not in place at the time of the fall. CNA #4 was provided written discipline on 8/7/17 for failure to follow the care plan regarding the floor mat. Education was initiated for the CNA and the entire nursing department on fall mat use. The incident was not reported to the NYSDOH. During an interview on 2/8/18 at 12:21 pm, with the Administrator he stated, We didn't report it because we came to the conclusion that we needed to provide education. We felt it was an education issue. During an interview on 2/8/18 at 1:10 pm, with the ADON/acting DON, she stated when there is a violation of the care plan with injury it should be called to the NYSDOH. Resident #11: The resident was originally admitted on [DATE], and readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Additionally, the resident has a history of diabetes. The MDS dated [DATE], assessed the resident as rarely makes self understood, rarely understands, and cognitive skills for daily decision making were severely impaired. Review of the Medical Progress Note dated 1/22/18 at 4:53 pm, documented she was asked to see the resident who was noted to be holding her right leg in strange position; an area around the hip appeared swollen and with a bruise that had been there for several days due to the coloring of it; right leg appears shortened and is internally rotated, leaving suspicion of possible [MEDICAL CONDITION]. Any movement of right leg clearly causes pain. X-ray was ordered. Review of the Nurse's Notes and 24 Hour Report (nurse communication report) 1/15/18 - 1/22/18 documented no bruising/swelling on the resident's right leg. Review of the facility's Investigative Summary (undated) written by the acting Director of Nursing (DON) documented she was asked to assess the resident's right leg; internal rotation and bruising to right inner thigh measuring approximately 15 cm x 10 cm with varying shades of purple/green to mainly a yellow hue; bruising based on color is several days old. Below right knee noted also with bruising of yellow coloration and right outer ankle with dark blue bruising; 2nd and 3rd toes of right foot with pale bruising noted; right knee with swelling; right hip with pain and swelling. It documented that the investigation into the root cause was started on 1/22/18. Review of staff statements related to bruising documented: on 1/22/18, CNA #1 wrote she was her aide on 1/20/18, noticed bruising to the resident's right leg, and reported it to LPN #2. On 1/24/18, LPN #2 wrote that she noticed old yellowish bruising; she did not report the bruising. On 1/21/18, CNA #5 wrote that she worked the dayshift on 1/21/18, noticed bruising on right leg that was old and assumed the nurse knew about it. The Nurse's Note dated 1/23/18 at 12:51 am documented the right hip x-ray was negative. The Medical Progress Note dated 1/23/18 at 11:35 am by MD #1 documented the resident was sent to the hospital for further evaluation of elevated temperatures, low oxygen saturation, abnormal lung sounds, and [MEDICAL CONDITION]. The Hospital x-ray of the right femur on 1/23/18 documented distal femoral fracture. Review of the Hospital Social Worker Progress Note dated 1/23/18, documented the patient was found to have significant bruising to her right leg; x-ray revealed right femur fracture; the facility did not express that patient had fallen and no explanation of bruise to right leg. The Nurse's Note dated 1/24/18 at 1:06 pm, documented report was received from the hospital stating the resident was admitted with right femur fracture at the distal end (the end down by the knee) and [MEDICAL CONDITION] to right lower leg. Review of the facility's submission on 1/24/18 at 4:24 pm to the State Department of Health for an incident that occurred on 1/22/18 at 12:00 pm, (Case #NY 200) documented details from the facility investigation on 1/22/18, unknown date and time of any incident occurring to the resident; Resident is dependent for all care; Unable to determine how the fracture occurred. During an interview on 2/6/18 at 4:00 pm, with the Administrator, he stated the facility started an investigation as soon as they knew about the fracture. The fracture was reported to the facility by the hospital. He stated, The bruise was not reported to me. During an interview on 2/8/18 at 1:10 pm, with the ADON/acting DON, she stated, I was never told about the bruising until Monday (1/22/18). The resident had bruising to her upper and inner thigh. If a CNA finds a bruise, they report it to the LPN, and the LPN should chart the observations. The LPN tells the RN and the RN should do an assessment. An investigation needs to be started. She stated, It should get reported to the administrator immediately. During an interview on 2/8/18 at 1:44 pm, with CNA #2, she stated she did not see any bruising on 1/19/18, however, she did not get the resident out of bed because the resident was sick. She was assigned to the resident on 1/22/18 and noticed the bruising when she pulled back the sheet to start changing her. There was bruising on her inner thigh. She reported it to the Nurse Manager and the PA. During an interview on 2/8/18 at 1:54 pm, with CNA #3, she stated she provided care to the resident on 1/21/18, but did not notice any bruising because she was focused on the resident vomiting. She reports bruises to the LPN and always to the Nurse Manager. During an interview on 2/8/18 at 2:58 pm with LPN #2, she stated while she was helping the aide to reposition the resident on 1/20/18, she noticed a circular bruise on the right middle thigh that was yellow in color. She stated, I touched it. The resident did not express pain. The resident will express pain by making a noise; ouch, ouch. She did not report the bruising to the RN because the resident had been vomiting. She stated, I was busy with the resident because she was vomiting; making sure she was sitting up. The resident has a history of aspiration. I forgot to mention it to the RN. She usually reports bruises to the RN because it's a change in condition and to do an investigation to rule out abuse. During an interview on 2/13/18 at 10:10 am with CNA #1, she stated on 1/20/18 the resident had a shower and when they were transferring her, she noticed an old, small, yellowish bruise on the resident's inner thigh. LPN #2 was in the room with her. During an interview on 2/13/18 at 3:30 pm with MD #2 and MD #1, MD #2 stated, If it (bruising) was noted on 1/20/18; would expect the investigation to be started immediately. MD #1 stated a bruise turns bluish first, then yellowish later. During an interview on 2/14/18 at 8:47 am, with RNNM #1, she stated the resident had no recent reported falls. The leg injury presented as a hip injury. She stated, I was totally surprised by all of it. During an interview on 2/20/18 at 7:33 am, with CNA #4, she stated she was basically, the resident's sole caregiver at night. No one in the facility asked her about the bruising. She noticed bruising on the back part of the upper thigh, but not until after the resident returned to the facility from the hospital. She stated she reports all bruises. During a phone interview on 3/6/18 at 9:30 am with LPN #3, he stated he works the nightshift and was one of the resident's regular caregivers. He did not notice any bruising on the resident. The resident didn't seem to be in any pain. She is non-verbal; facial expression will show signs and symptoms of pain. 10 NYCRR 415.4(b)(2)

Plan of Correction: ApprovedApril 9, 2018

F609 ? E Tag
The following was completed as corrective action for those residents found to have been affected by the alleged practice. For residents #2, #10, and #11 the facility immediately educated all personnel within the facility on abuse, neglect, mistreatment, and injuries of unknown origin; including but not limited to care plan violations and injury of unknown origin. Additionally, the facility immediately educated all staff on the importance of timely reporting to supervisors and administration, have a complete investigation completed, and timely reporting to the State. All staff will report such incidents to the manager on duty or RN Shift Supervisor. All incidents will immediately be reported to the Administrator or his designee in person or by phone (text message or call) for timely investigation and reporting to the State. C.N.A #4 was terminated; the RN Unit Manger and DON are no longer employed by the facility.
In order to identify other residents having the potential to be affected by the same alleged deficient practice, the following will be completed. The systemic changes will be the corrective action.
In-servicing and education was completed while surveyor was on site.
The facility will initiate an I/A checklist which includes a description to notify the administrator in the event of any abuse; neglect; exploitation; mistreatment and injury of unknown origin. All RN will be educated on this I/A checklist. The policy and procedure was reviewed and revised to reflect that while the investigation is ongoing the accused employee will be removed from duty pending the outcome of the investigation.
The facility will do weekly audits of the investigations to ensure that any allegations of abuse, neglect, and mistreatment, as well as bruising of unknown origin and injury of unknown origin have been identified and reported to the Administrator.
The Administrator or designee will be responsible for the oversight of the corrective action. Any negative findings will be brought to the attention of the QAPI Committee.

FF11 483.20(f)(5); 483.70(i)(1)-(5):RESIDENT RECORDS - IDENTIFIABLE INFORMATION

REGULATION: §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 15, 2018
Corrected date: May 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during an abbreviated survey (Case # NY 722) the facility did not ensure in accordance with accepted professional standards and practices, that it maintained medical records on each resident that are complete and accurately documented for one resident (Resident #3) of three residents reviewed. Specifically, for Resident #3, the facility did not have a record of a complete assessment following a fall, did not have a complete and accurate record of the resident's injuries related to the fall, and did not have a record that the physician was notified of significant changes in the resident's medical condition. This is evidenced by: Refer to F580 The resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with a [DIAGNOSES REDACTED]. The BIMS (Brief Interview for Mental Status) was assessed as 14/15; cognitively intact on the MDS (Minimum Data Set) dated 7/28/17. The Nurse's Note dated 8/16/17 at 5:56 am, written by RN#1, documented the resident was yelling and was taken to a quiet room to calm down. The resident pitched herself forward and threw herself onto the floor, landing face down. There was some bleeding noted from the nose, and some swelling to mid forehead. A complete assessment of the resident was not documented, and there was no documentation that the physician was notified. The Nurse's Note dated 8/16/17 at 7:02 am, written by RN #1, documented a nose abrasion 1/4 inch across the bridge of nose, and forehead swelling has extended to golf ball size. There was no documentation the physician was notified. Review of the Medical Services Progress Note written by MD #1 on 8/22/17 at 1:28 pm, documented the resident seemed to be in pain but was unable to describe the pain because of her dementia; complaining of pain in the head and questionable pain in left shoulder; daughter is very concerned with bruising of knees and lower legs; some ecchymosis of both knees and also both lower legs, with ecchymosis of each measuring about 1-5 cm; because of the fall, will x-ray head, left shoulder, both knees and both legs for any fracture. There was no documentation about the bruises, and no documentation that the physician was notified about the bruises prior to 8/22/17. The Nurse's Note dated 9/17/17 at 10:00 pm, written by the RN, documented small amount of frank blood observed in the toilet. There was no documentation that the physician was notified. During an interview on 2/12/18 at 2:54 pm with the RN nurse manager (RNNM#1), she stated They should be documenting that the bruises could be related to the fall. Especially, if the resident is on Eliquis. She stated, They should be documenting a head-to-toe assessment following a fall. Regarding the frank blood in the toilet, she stated, If I observed hemorrhoids, I would have documented that. If I didn't observe them, I would have notified the doctor. Especially since she's on Eliquis. That would concern me if I observed that. During a phone interview on 2/27/18 at 3:22 pm with RN #1, she stated the resident threw herself on the floor. The resident was out in the hall in the middle of the night and was having a tantrum like a child. She brought the resident to the dayroom and the resident pitched herself down to the floor. The resident was bleeding from her nose initially. Regarding emergency care, she stated, Initially, the resident did not need it. Sometimes things get worse over time. She stated the bleeding had stopped and believed that the LPN put an ice cap on it, but she did not call the physician. She stated, Initially it didn't look that bad. Regarding no documentation about the physician being called when the swelling on the resident's forehead increased to golf ball size, she stated, It has to be written somewhere on the A&I. In regards to documentation on the A&I dated 8/16/17, the physician was notified at 9:15 am, however, no treatment orders were documented for the injuries; she stated she would not have been there at that time. She gives report at 7:00 am. She stated, If I don't think it's critical, I don't call the doctor. I leave a post-it note on the A&I that notifications need to be done. Regarding the resident being care planned for anticoagulation, she stated, At the time, I wasn't really concerned about it. Regarding the daughter's concern about bruising on the resident's limbs on 8/22/17, she stated the aides usually report the bruises. She stated, I can't believe no one saw anything and didn't mention it in 6 days, 18 shifts. It doesn't surprise me. Regarding a complete assessment at the time of the fall, she stated, I did not strip her down. I was concerned about her face. She was agitated. 10 NYCRR 415.22(a)(1-4)

Plan of Correction: ApprovedApril 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F842 ? D Tag
The following was completed as corrective action for those residents found to have been affected by the alleged practice. Resident #3 expired on [DATE] and is no longer at the facility.

In order to identify other residents having the potential to be affected by the same alleged deficient practice, the following will be completed. A Review of all fall I&A's for the last 60 days will be completed to ensure a complete assessment was done, any injuries documented and physician notification made. Any identified areas will be addressed through the completion of an RN assessment at that time and notification to the medical provider.
In-services will be held to educate RN/LPN on the following: proper MD notification and notification to administration; education on the S-Bar and E-INTERACT tools. All RN's will be educated in regards to a complete a thorough head to toe assessment following a fall. All RN will be educated on documentation of a complete assessment following a fall, a complete and accurate record of the resident's injuries related to the fall, and a record that the physician was notified of significant changes of the resident's medical condition.
The significant medical event form/audit will be completed by the ADON daily Monday-Friday. The audit will look at significant medical event documented on the 24 hour report; immediate actions taken; RN assessment; MD notification; family/responsible party notified; early warning; SBAR; and other comments. Additionally, we will run a weekly audit of the I/A's to ensure proper notification of MD, RN assessment which would include indication if an injury occurred. The results of this audit will be reported to QAPI monthly by the ADON. The QAPI committee will evaluate the data and act on the information as indicated.
In addition, we will audit documentation of a complete assessment following a fall, a complete and accurate record of the resident's injuries related to the fall, and a record that the physician was notified of significant changes of the resident's medical condition.

The ADON or designee will be responsible for the oversight of the corrective action. Any negative findings will be brought to the attention of the Administrator/DON immediately.

FF11 483.21(b)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 15, 2018
Corrected date: May 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during an abbreviated survey (Case # NY 112) the facility did not ensure that services provided by the facility, as outlined by the comprehensive care plan meet professional standards of quality for one resident (Resident #11) of three residents reviewed. Specifically, Resident #11 was care planned for dehydration. The resident was experiencing impaired hydration due to repeated vomiting and elevated temperatures from 1/16/18 to 1/22/18. The facility did not implement related care plan interventions, and ensure coordination of care among the interdisciplinary team. As a result, on 1/23/18 the resident was admitted to the hospital and diagnosed with [REDACTED]. Refer to F692 The Facility's policy and procedure (P&P) for nutrition/hydration (undated) documented it was the policy of the facility to provide the tools, people, and systems to provide appropriate interventions to help promote adequate hydration and health. Residents are considered at risk for dehydration with the following risk factors: Acute illness, pain, or infection including temperature elevations; any [DIAGNOSES REDACTED].e. vomiting); functional impairments that cause inability to self- hydrate, impairs communication, or cause swallowing difficulties (i.e. [MEDICAL CONDITION], dysphasia). Clinical signs of possible insufficient fluid intake are assessed through nursing assessment: Concentrated urine, laboratory values (elevated sodium and BUN), and elevated temperatures. Treatment and Prevention of fluid deficit was documented as: An appropriate assessment is made by the physician to determine if water depletion alone (dehydration) or the more common sodium/water (volume) depletion is present. Treatment is accomplished by increasing oral intake of fluid and electrolytes as needed. Patients with more severe cases and those who are unable to take fluids by mouth are treated by appropriate intravenous (IV) fluid replacement. Resident #11: The resident was originally admitted on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Additionally, the resident has a history of diabetes. On the Minimum Dat Set ((MDS) dated [DATE], the resident was assessed as rarely makes self understood, rarely understands, and the resident's cognitive skills for daily decision making were severely impaired. Review of the CCP for Dehydration/Fluid Volume Deficit/Elevated BUN (blood urea nitrogen; urea nitrogen, a waste product removed by the kidneys; elevated levels may indicate that kidneys are not working efficiently) last updated 2/1/18, documented bolus tube feeds (the administration of a limited volume of enteral formula over brief periods of time) administered by staff; Unaware of need to drink. Feeding tube problem/goals: Maintain hydration and electrolyte balance, stabilize medical problem through dietary intervention: Monitor intake and output, increase fluid as per physician, monitor for changes and notify physician, and monitor for signs/symptoms of dehydration. Review of the diet orders documented an order dated 12/25/17, for Glucerna 1.5 Cal Oral Liquid; Total volume to deliver/24 hours: 1420 ml via GT; bolus via gravity: 355 ml; every 6 hours. Review of the Medical Progress Note written on 1/21/18 at 2:29 pm by MD #1, documented the resident was seen per request of Nursing with a chief complaint of temperature, vomiting, and possible aspiration; Resident is on a bolus feeding; Non-verbal; Unable to describe the character of her vomiting and the severity of her possible abdominal pain; Abdominal x-ray is non-specific; Bolus feed had to be lessened; Possibly cause of vomiting. Will monitor. There was no documentation that the resident's nutritional and hydration status was evaluated and managed. The Nutrition Progress Note dated 1/22/18 at 4:04 pm, by the Registered Dietician (RD), documented the resident with vomiting/fever since late last week. Some tube feeds held while work up ongoing. Abdominal x-ray was non-specific. Question GI illness vs. true intolerance or other cause. If vomiting continues, consider holding tube feed and offering electrolyte replacement via tube until stable. RD to follow and provide recommendations as needed. Review of the Medical Progress Note dated 1/22/18 at 4:53 pm by the PA (physician assistant) who was asked to see the resident for bruising/swelling in the right leg, documented the resident has been running temperatures, vomiting, and possibly aspirating vomitus. Temperature/vomiting; Not clear where this is coming from. Concern is of aspiration. No bolus feedings for now. There was no documentation that the resident's nutrtitional and hydration status was evaluated and managed. Review of the Medical Progress Note dated 1/23/18 at 11:35 am, written by MD #1, documented the resident was being followed for chief complaint of T 101, BP 96/68, PR 104, O2 saturation 69% on 4L oxygen. The Medical Director examined the resident; Heard abnormal lung sounds; Thought the resident was septic (life-threatening organ dysfunction due to infection); and sent the resident to the hospital. The Hospital laboratory blood test results dated 1/23/18 documented sodium level 164 HH (normal is 135 - 145), BUN 94 H (normal is 7- 20), and creatinine (waste product removed by kidneys) 1.8 H (normal is 0.5 - 1.1). On 3/14/18 at 1:18 pm, the DON was contacted and asked to provide documented laboratory results for (MONTH) (YEAR) and documented monitoring of the resident's intake and output for (MONTH) (YEAR). There were no documented laboratory results prior to 1/23/18. There was documentation related to intake via the GT; Computer generated Administration Records. There was no documentation regarding output; Voiding/vomiting. During an interview on 2/8/18 at 2:58 pm, with LPN #2, she stated on 1/20/18 the resident was vomiting and had been for several days prior to that. She stated, I was busy with the resident because she was vomiting; Making sure she was sitting up; She has a history of aspiration. She did not report the vomiting to the RN, because the resident had been vomiting prior to that day. During an interview on 2/13/18 at 3:30 pm, with the Medical Director (MD #2), he stated the resident had been vomiting for 5-6 days and had fevers. The concern was for aspiration. He stated that MD #1 put the resident on [MEDICATION NAME] for possible aspiration pneumonia. He stated that for someone who had been receiving [MEDICATION NAME] for 4 days, she didn't look good. He would expect a call to the MD when the resident was getting [MEDICATION NAME] and still vomiting, and would expect Nursing to monitor the resident's intake and output. MD #2 stated, We do IVs and Clysis (a rehydration technique) here. During an interview on 2/13/18 at 3:45 pm, with MD #1, he stated they can call him 24 hrs/day; He is always available. He stated, If they are really concerned, they call me. Even at night. If the patient is really sick we send them to the hospital. Every time she vomited, she probably aspirated a little at a time and ended up febrile (feverish). During an interview on 2/14/18 at 8:47 am, with RNNM #1, regarding the administration of Clysis or IV fluids for the repeated vomiting; Resident was admitted for severe dehydration, she stated, It (vomiting) was never consistent. It was random. She stated, It might be before or after the tube feed. There was no rhyme or reason. Sometimes she was keeping her tube feed down. The resident's intake was not measured because it (the vomiting) was random. She stated, The emesis was not measured. During a phone interview on 3/5/18 at 12:27 pm, with the RD, she stated she was not contacted by Nursing about the vomiting. She stated she went to the nursing unit because, she saw random notes in the computer about the vomiting. She spoke with LPN #2 about the vomiting and was told the resident was vomiting, but not every feeding. She was not able to talk to the Nurse Manager (RNNM #1), because she was not available that day. The issue with the vomiting should have been reported to the physician so they can evaluate it. Nursing is responsible for monitoring the resident's food/fluid intake. IVs are done in the facility, but usually the physician will order Clysis. Residents with tube feeds are seen monthly. Nursing does not monitor strict I & O (intake and output); They might track the amount of tube feed, or voids. She makes recommendations for nutrition/hydration needs, but ultimately the physician needs to determine if it's best for the resident. She stated, In my opinion, the vomiting wasn't random. When vomiting more than once, the physician should have been called. During a phone interview on 3/15/18 at 8:55 am, with the ADON (acting DON (MONTH) (YEAR)) regarding the implementation of documented care plan interventions on the CCP for Dehydration for the prevention of dehydration when the resident was vomiting repeatedly from 1/16/18 to 1/22/18, she stated she had to review the notes in the computer system and stated, the resident was seen by MD #1 on 1/21/18. He indicated in his note that the resident was on a bolus feed; He did not order any labs. Prior to 1/21/18, MD #1 saw the resident on 1/5/18 for a routine visit for diabetes. Regarding the care plan intervention to maintain fluid and electrolyte balance, she stated they would administer IV fluids if necessary or Clysis if the MD chose to do that. If the nurses call the doctor, he could make the recommendation for the Clysis. She stated, I talked to him (MD #1) that day (1/21/18) when he came in, I told him about the vomiting and the temperatures. Regarding the care plan intervention for dietary interventions to stabilize the medical problem, she stated, If she's vomiting, try IVs or cut back her tube feeding. She reviewed the RD's note dated 1/22/18 and stated the RD wrote to consider holding her tube feed and offering an electrolyte replacement via the GT if the vomiting continues. There were no notes from the RD from 1/16/18 - 1/21/18. Regarding nurse's notes documenting the tube feed was stopped/turned off on 1/20/18, she stated she believed the resident was getting a bolus feed. The nurse checks for residual tube feed prior to the feeding. If there is residual, they hold the feeding for 1 hour and then recheck. Regarding the care plan intervention to monitor I & O, she stated they do not use hand-written documents to record/monitor intake/output; They use the Administration Records that are generated in the computer to monitor intake. The monitoring of output is done by the CNA's. She stated, If (Resident #11) didn't void, they would tell us. I don't believe that ever came up. She stated, The aides would tell us if something was unusual (dark, strong odor) with the urine. They are pretty good about that. They did not measure the vomit. She stated, MD #1 was aware of the vomiting. He was treating her for a respiratory illness. He was focused on that. Regarding notification to the MD for continued vomiting when the resident was receiving [MEDICATION NAME], she stated the expectation is the nurses would notify the MD if the vomiting continued after the [MEDICATION NAME] was given. Regarding the care plan intervention to monitor for signs and symptoms of dehydration, she stated nurses check for skin turgor (elasticity of the skin), moistness, and fever. Regarding the consideration of administering enteral feeding via pump because the resident was vomiting after the bolus tube feeding, she referenced the RD's note on 1/22/18, and stated there was no recommendation for a pump. She stated the nurses should collaborate with dietary whenever there are concerns about hydration. 10 NYCRR 415.11(c)(3)(i)

Plan of Correction: ApprovedApril 9, 2018

F658 ? D Tag
The following was completed as corrective action for those residents found to have been affected by the alleged practice. Resident #11 will have a care conference held to review and update care plans. The Unit Manager is no longer employed by the facility.
In order to identify other residents having the potential to be affected by the same alleged deficient practice, the following will be completed. The IDT team will review all residents that have the potential to be at risk for dehydration. Each resident nutrition and dehydration care plan will be reviewed and updated based on the review.
In-servicing for the RN staff will include the hydration assessment and the ability to identify if the resident needs IV therapy or clysis initiated and updates Doctor of same.

The diet tech will be educated when it is appropriate to notify the registered dietician. The registered dietician will receive the morning report notes Monday-Friday (Monday will include the weekend report).
The significant medical event form/audit will be completed by the ADON daily Monday-Friday. The audit will look at significant medical event documented on the 24 hour report; immediate actions taken; RN assessment; MD notification; family/responsible party notified; early warning; SBAR; and other comments. With any reports of vomiting the IDT team will review the residents care plan to ensure compliance. The results of this audit will be reported to QAPI monthly by the ADON. The QAPI committee will evaluate the data and act on the information as indicated.
The ADON or designee will be responsible for the oversight of the corrective action. Any negative findings will be brought to the attention of the Administrator/DON immediately.