NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 3/7/25, the facility did not ensure that as needed (PRN) orders for [MEDICAL CONDITION] drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the order to be extended beyond 14 days; they should document their rationale in the resident's medical record and indicate the duration for the as needed order. Specifically, for one (1) (Resident #24) of five (5) residents reviewed for unnecessary medications an as needed [MEDICAL CONDITION] antianxiety medication was ordered longer than 14 days. Additionally, there was no documented physician rationale to extend the duration of the order. The finding is: The policy and procedure titled [MEDICAL CONDITION] Medication Use dated 11/2021, documented antianxiety medications are considered [MEDICAL CONDITION] medications and are subject to prescribing, monitoring and review requirements specific to [MEDICAL CONDITION] medications. [MEDICAL CONDITION] medications are not prescribed or given on an as needed basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. As needed orders for [MEDICAL CONDITION] meditations are limited to 14 days. If the prescriber or attending physical believes it was appropriate to extend the as needed order beyond 14 days, they would document the rationale for extending the use and include the duration for the as needed order. A medication may be considered as unnecessary if it meets the following criteria: an extended duration. Resident #24 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 12/26/24 documented Resident #24 was cognitively intact, understood and understands. The assessment tool documented that Resident #24 had no behavioral symptoms and received antianxiety medications in the 7-day look back period. The Comprehensive Care Plan revised 1/8/25, documented Resident #24 had a history of [REDACTED]. The care plan documented that Resident #24 received antianxiety medication due to anxiety and delusional/paranoid ideations. Interventions included to administer medication as ordered and observe for possible side effects. Review of the physician's orders [REDACTED].#24 had the following as needed by [MEDICATION NAME] orders: - 0. 5 milligrams every 6 hours as needed for anxiety from 8/8/23-8/29/23; 10/29/23-11/26/23; 11/26/23-12/26/23; 1/2/24-1/22/24; 1/22/24-2/13/24; 2/13/24-3/14/24; 3/15/24-4/15/24; 4/26/24-5/25/24; 5/25/24-6/24/24; 6/26/24-7/5/24; 7/5/24-8/4/ 24. - 0. 5 milligrams every 6 hours as needed for extreme behaviors from 9/2/24-9/23/ 24. -1 milligrams every 4 hours as needed for anxiety from 9/23/24-10/21/24; 11/17/24-12/16/24; 12/16/24-1/12/25; 1/12/25-1/15/25; 1/15/25-2/9/25 and 2/10/25-3/10/ 25. Review of the paper Medication Records from 3/1/24-3/31/25, Resident #24 received: -[MEDICATION NAME] 0. 5 milligrams as needed on 6/9/24, 9/19/24, 9/20/24 and 9/21/24, -[MEDICATION NAME] 1 milligram as needed on 9/23/24, 9/24/24, 9/25/24,10/20/24, 11/23/24, 11/28/24 and 2/7/ 24. Review of the medical providers progress notes from 3/11/24 - 2/25/25 revealed there was no documented evidence that Resident #24's [MEDICATION NAME] ordered was reevaluated every 14 days with a rationale to extend the order or documented duration of the order. Review of the mental health providers notes from 3/18/24 - 3/3/25 revealed there was no documented evidence that Resident #24's as needed [MEDICATION NAME] order was reevaluated every 14 days with a rationale to extend the order or documented duration of the order. During intermittent observations from 3/3/25 - 3/6/25 between the hours of 9:14 AM and 3:02 PM, Resident #24 was observed self-propelling in their wheelchair, walking in the hallway with therapy, in their room or in the dining. Resident #24 was well kempt, pleasant, cooperative with staff and no behaviors were displayed. During an interview on 3/6/25 at 3:02 PM, Resident #24 stated that their anxiety was stable, and they only have anxiety about going home. During a telephone interview on 3/6/25 at 3:15 PM, Certified Nurse Aide #1 stated that Resident #24 has had no behaviors or increased anxiety in the past month or so. They stated Resident #24 used to refuse assist with care, but that was no longer an issue. During a telephone interview on 3/6/25 at 3:44 PM, Nurse Practitioner #1 stated they were familiar with Resident #24, and they started to provide mental health services for the resident the past couple months. Nurse Practitioner #1 stated their understanding was Resident #24 was ordered as needed [MEDICATION NAME] was for [MEDICAL CONDITION]. Nurse Practitioner #1 stated they were not the prescribing clinician for the as needed [MEDICATION NAME] and did not have remote access to Resident #24's electronic medical record so they could not verify the indication of the [MEDICATION NAME]. Nurse Practitioner #1 stated from their understanding, Resident #24 anxiety level had improved significantly, and they were the most cognitively clear they have been. During a telephone interview on 3/6/25 at 4:14 PM, the Consultant Pharmacist stated Resident #24's [MEDICAL CONDITION] medications have been adjusted and that Resident #24, by choice, wanted a standing order for [MEDICATION NAME] along with an as needed dose. The Consultant Pharmacist stated they thought that Resident #24's as needed [MEDICATION NAME] was only ordered for 14 days at a time and the pharmacy should have only allowed for a 14-day order. The Consultant Pharmacist stated as needed [MEDICATION NAME] should only be ordered for 14 days and then reviewed by a medical provider. The medical provider should document the rational for continuation in their progress notes. During a follow up interview on 3/7/25 at 9:50 AM, the Consultant Pharmacist stated they could not locate any documentation of rationales for the continued use of the as needed [MEDICATION NAME] from the providers. During a telephone interview on 3/7/25 at 9:04 AM, the Medical Director stated they were familiar with Resident #24 and their [MEDICATION NAME] use. They stated that Resident #24 was previously on multiple [MEDICAL CONDITION] medications, different [MEDICAL CONDITION] medications, had delusional thoughts and anxiety. The Medical Directors stated that within the past six months Resident #24 went on hospice care and hospice care weaned the resident off their [MEDICAL CONDITION] medications. Resident #24 bounced back after their [MEDICAL CONDITION] medications were discontinued with improvement in their behaviors. The Medical Director stated the indication for the as needed [MEDICATION NAME] was anxiety and any extreme behaviors. They stated Resident #24 was the best point they have ever seen them and recently been discontinued from hospice care. The Medical Director stated that they were aware that an as needed [MEDICATION NAME] should be only order for a 14-day time frame with documented rational for continued use and was unsure how Resident #24's as needed order got overlooked. During an interview on 3/7/25 at 9:23 AM, Register Nurse Supervisor #1 stated Resident #24's behaviors had gotten much better since the [MEDICAL CONDITION] medication had been discontinued. They stated Resident #24 had been more cooperative, much more pleasant and their anxiety was much better in the past three months. During an interview on 3/7/25 at 9:36 AM, Registered Nurse Supervisor #2 stated that Resident #24's behavior had been good in the past few months. They stated the resident had been on hospice care did a complete positive change and hospice care had been discontinued. Registered Nurse Supervisor #2 stated any nurse receiving a new order from a medical provider entered the new order into the electronic medical record. The pharmacy was integrated with the electronic medical record and therefore received the new order as well. Registered Nurse Supervisor #2 stated the pharmacy should know an as needed [MEDICAL CONDITION] medication was only ordered for 14 days and a standing order was for 30 days. Registered Nurse Supervisor #2 state | Plan of Correction: ApprovedApril 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 758 483. 45(e)(4) [MEDICAL CONDITION] Drugs 1. The facility currently has [MEDICAL CONDITION] Medication Use policy that ensures residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is deemed necessary to treat a diagnosed specific condition that is documented in the clinical record. Resident #24s chart was reviewed by the Medical provider and PRN [MEDICAL CONDITION] order was discontinued, and a corrected PRN [MEDICAL CONDITION] order was written immediately with stop date of 14 days. Two (2) separate audits by the Director of Nursing and Pharmacy Consultant on 3/19/25 were completed to ensure [MEDICAL CONDITION] medication use accuracy in all medical records. Audits will continue twice per month for the next 6 months. 2. Nursing Staff were educated immediately by the Director of Nursing with an in-service reviewing Policy and Procedure, Continuing education regarding [MEDICAL CONDITION] Medications and PRN Medication Administration. RN and LPN staff completed this in-service by 3/25/ 2025. The Director of Nursing, Pharmacist Consultant and Social Worker meet once monthly to review resident [MEDICAL CONDITION] use. All residents are reviewed monthly/quarterly and as needed. Residents that need GDRs are determined and reviewed by the Director of Nursing/designee and Medical Director. 3. The Director of Nursing reviewed all Resident Care plans for [MEDICAL CONDITION] drug use. As stated in our [MEDICAL CONDITION] Medication Use policy, residents will not receive [MEDICAL CONDITION] drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. 4. PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days except if the attending physician/designee believes that it is appropriate for the PRN order to be extended beyond 14 days. The Physician/designee will document any clinically contraindicated or specific conditions in clinical record along with their rationale and indicate the duration for the PRN order. 5. All (52) current residents medical records were audited to ensure all active PRN [MEDICAL CONDITION] medications have a 14-day stop date. If the order does not include the 14-day stop date, prescriber will be contacted and a corrected order will be issued. If the prescriber deems it appropriate to extend past 14 days, the prescriber will document rationale in the residents permanent medical record. An audit of the clinical record for PRN [MEDICAL CONDITION] Medications will continue twice monthly x 6 months by the DON/designee and/or Pharmacy Consultant. All audits will be reviewed quarterly for the next 6 months at QA/QAPI meetings. The Director of Nursing/designee will be responsible for the overall implementation of the plan of correction. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details Based on interview and record review during the Life Safety Code survey completed on 3/7/25, fire drills were not completed at least once per shift per quarter. This affected one (Second Floor) of one resident unit. The findings are: The policy and procedure titled Conducting Fire Drills, dated (MONTH) 2010, documented fire drills will be conducted according to the established schedule. In the Skilled Nursing Unit, drills will be conducted once per shift, per quarter at varying times. Review of fire drill reports from 2024 revealed no fire drills were conducted during the fourth quarter (October, November, December). During an interview on 3/4/25 at 8:50 AM, the Facilities Supervisor stated they maintained a schedule of fire drills. They stated there were fire drills scheduled for the fourth quarter of 2024, but those fire drills did not get done, it was an oversight. During an interview on 3/4/25 at 8:55 AM, the Director of Facilities stated the responsibility to plan and conduct fire drills belonged both to themselves and the Facilities Supervisor, and the fourth quarter fire drills were missed. During an interview on 3/5/25 at 1:25 PM, the Administrator stated planning and conducting fire drills was the responsibility of the Director of Facilities and the Facilities Supervisor. They stated they were unaware of the missed fire drills until earlier this week, when fire drill records were requested for the Life Safety Code survey. The Administrator also stated they did not normally review the schedule of upcoming fire drills with the Director of Facilities or the Facilities Supervisor. 10NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 7, 19. 7. 1, 19. 7. 1. 6 | Plan of Correction: ApprovedMarch 31, 2025 K712 Fire Drills 1. The Facility will ensure fire drills are conducted in accordance with NFPA 101 2. The Director of Facilities and Facilities Supervisor reviewed and revised the policy entitled Conducting Fire Drills. Inservice with Maintenance staff conducted reviewing policy and future schedule. The 2025 fire drill schedule was reviewed to ensure drills are planned for once on each shift per quarter. 3. The Director of Facilities will audit fire drills to ensure they are conducted once on each shift per quarter. 4. Fire drill audit will continue for 12 months and be brought to QA/QAPI meetings on a quarterly basis for review and need for continuance. 5. Overall responsibility to ensure action is implemented and maintained is with the Director of Facilities. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code survey completed on 3/7/25, smoke barrier walls were not properly maintained. Specifically, smoke barrier walls were not complete from floor to ceiling/ roof deck, were not designed to have at least a 30-minute fire resistance rating and were not designed to resist the passage of smoke due to open and unsealed penetrations. This affected one (Second Floor) of one resident unit. The findings are: 1a. Observation above the ceiling tiles on the second floor on 3/4/25 at 2:00 PM revealed an open and unsealed penetration through the smoke barrier wall outside of Resident Room 422, due to a piece of damaged drywall. The piece of drywall was one inch wide by three-quarters of an inch high and hung loosely on the wall by its paper backing. At the time of the observation, the Director of Facilities stated the drywall piece needed to be secured and the area re-caulked with fire-rated caulk. 1b. Observation above the ceiling tiles on the second floor on 3/4/25 at 2:10 PM revealed an open and unsealed one inch by one inch square penetration through the smoke barrier wall outside of the Director of Nursing's Office. The penetration had one blue wire through it and was observed on both sides of the wall. At the time of the observation, the Director of Facilities stated they were not sure what the blue wire was from or when it was installed. During an interview on 3/5/25 at 1:50 PM, the Director of Facilities stated the facility did not currently perform regular smoke barrier audits, but they had performed smoke barrier audits in the past related to the construction project several years ago. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 7. 3, 8. 5, 8. 5. 1, 8. 5. 2, 8. 5. 2. 1, 8. 5. 2. 2, 8. 5. 2. 3 | Plan of Correction: ApprovedMarch 28, 2025 K372 Subdivision of Building Spaces ÔÇ£ Smoke Barrier Construction 1. Corrective Action a. The Maintenance Department immediately secured the drywall piece and sealed the penetration using fire caulk in the smoke barrier outside of room 422 and sealed the penetration through the smoke barrier outside of the Director of Nursings office using fire caulk. b. Maintenance Staff were inserviced on inspection and maintenance of smoke barriers. 2. Identification of other smoke barriers having the potential to be affected The Director of Facilities and Maintenance Staff conducted a 100% audit of smoke barriers to ensure there were not any unsealed penetrations. 3. Systematic Changes The Director of Facilities and/or Maintenance Staff will conduct monthly audits of smoke barriers to ensure compliance. 4. Monitor Performance The Director of Facilities/designee will monitor monthly smoke barrier audits for 12 months. All audits will be reviewed quarterly at QA/QAPI meeting, and need for continuance after 12 months. 5. The Director of Facilities will be responsible for overall completion of the plan with respect to K 372. |