Nathan Littauer Hospital Nursing Home
January 10, 2017 Certification/complaint Survey

Standard Health Citations

FF09 483.25(l):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during a recertification survey, the facility did not ensure that the medication regimen was free from unnecessary medications for 8 of 17 (Resident # 2, 9, 12, 48, 54, 55, 63, and 85). Specifically, residents # 2, 9, 12, 48, 54, 55, and 63 were given as needed (PRN) pain medications without adequate indications for use and without adequate monitoring for effectiveness. Resident # 9 was given PRN anti-anxiety medication without documentation of symptoms the resident was experiencing, consideration/use of non-pharmacological interventions, and without adequate monitoring for effectiveness. Resident #85 was given PRN antianxiety medication with no documented reason/symptoms for giving the medication. This is evidenced by: A document titled Pain Management last revised on 05/15, was provided by the Director of Nursing, documents the following: Complete a Subjective Assessment 1. Ask the resident do you have pain. If yes initiate care plan for pain management and complete Pain assessment screening tool. 2. Assess residents cognitive ability to communicate pain. 3. Take vital signs (VS) as necessary. 4. Complete subjective assessment as follows: Location, type of pain, severity of pain (using scale appropriate for cognition) Scale (1 to 10) and duration of pain. 5 medicate with Tylenol for moderate pain level 1 to 6 and assessed document effectiveness. 6. Assess and report effectiveness of pain medication, document effectiveness of prn pain medication and any changes in alertness or functional ability and report to the provider. Complete an objective assessment (this must be completed for all Advanced Dementia Residents). 1. Assess facial expressions for grimacing, moaning and body positioning. (grabbing at body parts) 2. Note changes in behavior, changes in VS, increased respirations, 3. Medicate if needed for pain and monitor effectiveness of medication. 4. Use Objective (Wong Baker for residents who cannot answer subjective question related to pain. The Policy & Procedure (P&P) dated 07/2014 and titled [MEDICAL CONDITION] medications documented, [MEDICAL CONDITION] medications shall include: anti-anxiety, sedative/hypnotic, antipsychotic and antidepressant class of drugs. Orders for [MEDICAL CONDITION] medication will be written only for the treatment of [REDACTED]. Will monitor for the presence of target behaviors on a daily basis charting by exception (charting when behaviors are present). Documentation of behaviors will be specific, describing the behavior, not using general terms such as anxious, combative, etc. Documentation will include the non-pharmacological interventions and the effectiveness. Resident # 9 Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident was cognitively intact and was able to understand others and make herself understood. A current physician's orders [REDACTED]. The comprehensive care plan (CCP) dated 11/12/12 and last updated on 12/7/16, titled At risk for alteration in comfort documented a [DIAGNOSES REDACTED]. The CCP dated 11/5/12 and last updated on 11/9/16, titled [MEDICAL CONDITION] Drug Use, documented a [DIAGNOSES REDACTED]. A review of the electronic medication administration record (EMAR) and Progress Notes for (MONTH) (YEAR) revealed [MEDICATION NAME] was administered 43 times without documentation of location, severity, interventions (reposition, comfort measures, diversional activities) attempted, or effectiveness of the medication. An EMAR entry attached to administration of [MEDICATION NAME] documented the resident's pain level 1 hour after medication administration, on a scale of 0-10 as a 2, for 36 administrations and a 0 for 7 administrations. A review of the electronic medication administration record (EMAR) and Progress Notes for (MONTH) (YEAR) revealed [MEDICATION NAME] 0.5 was administered 21 times without documentation of the type and severity of symptoms the resident was experiencing, attempts to use non-pharmacological interventions, and without monitoring for effectiveness. During an interview on 1/9/17 at 10:45 am, Licensed Practical Nurse (LPN) #1 reported the documented pain scale is recorded one hour after administration of pain medications. There is no documentation of the resident's pain level before medications are administered. PRN pain medications are given when the resident requests, so a pain scale is not needed. LPN # 1 further reported that this resident requests [MEDICATION NAME] when she is feeling anxious and interventions at that time would only increase her anxiety therefore there is no need for documentation when [MEDICATION NAME] is given. During an interview on 1/9/17 at 11:15 am, Registered Nurse, Unit Manager #1 reported the nurses should be documenting a before and after medication pain scale on the EMAR or in the progress notes each time a pain medication is given. She further reported that [MEDICATION NAME] is only given when the resident requests, there is no documentation needed. During an interview on 1/10/17 at 11:00 am, the Director of Nursing (DON) stated the nurses should be documenting the reasons for giving a prn antianxiety medication, and the effect of the medication. Resident #85: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact and was usually able to understand others and make herself understood. A Physician order [REDACTED]. The Comprehensive Care Plan (CCP) dated 10/19/16 and titled Mood state, documented the resident had a [DIAGNOSES REDACTED]. Approaches included; approach in a calm pleasant manner, assess for mood changes, allow opportunities to vent feelings, encourage small group activity, and assess for comfort. A review of the Electronic Medication Administration Record (eMAR) dated (MONTH) (YEAR), revealed that the [MEDICATION NAME] was administered without documentation of the reason for administering or the effect on the following occasions: 10/9/16 at 12:13 am, 10/10/16 at 7:51 pm, 10/15/16 at 5:02 am and 9:00 pm, 10/19/16 at 7:09 pm, 10/21/16 at 1:13 am and 8:20 pm, 10/26/16 at 8:06 pm, 10/31/16 at 4:31 am. The Progress notes for (MONTH) (YEAR), had no documented evidence of the reason for administering the [MEDICATION NAME], the effectiveness of the [MEDICATION NAME] or that non- pharmacological interventions were attempted prior to its use. During an interview on 1/10/17 at 10:15 am, the Registered Nurse Manager (RNM) stated that when she started in (MONTH) (YEAR) she did notice that there was no documentation of reasons for administering the antianxiety medication. Additionally, the RNM stated that the Licensed Practical Nurses (LPN) passing medications would give the prn antianxiety when they noticed the resident was anxious, and that they should be documenting the reasons for giving the medication and the effect of the medication. During an interview on 1/10/17 at 11:00 am, the Director of Nursing (DON) stated the nurses should be documenting the reasons for giving a prn antianxiety medication, and the effect of the medication. Resident # 48 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set of 10/18/16, assessed that the resident could understand and was understood. It further documented a Brief Interview of Mental Status of 15/15 (no cognitive impairment) for decision-making, and no behaviors. Physician orders [REDACTED]. The comprehensive care plan (CCP) dated 02/16/16, and last updated on 1/31/16, titled At risk for alteration in comfort, documented a [DIAGNOSES REDACTED]. Approaches included; 1- asses for pain, frequency, location, type and severity level, 2- note any signs and symptoms, 3- medicate as ordered, 4- position for comfort, 5- comfort by talking to, 6- reassurance using touch, 7- attempt to provide diversional activities, 8- monitor for effectiveness of medication and report concerns. A review of the electronic medication administration record (EMAR) and Progress Notes for (MONTH) (YEAR) revealed that from 12/1 - 12/12/16, the Resident received [MEDICATION NAME] 625 mg on 7 occasions. On three of those occasions, there was no documented evidence of the location of pain, on 6 of those occasions, there was no documented evidence of the severity of pain prior to administration and on 4 occasions there was no documented evidence of an assessment of effectiveness after the [MEDICATION NAME] was administered. During an interview on 1/9/17 at 2:45 pm, the LPN #2 reported that a pain scale and location of the pain is required documentation before giving a PRN pain medication. She further stated the place to document the pain scale and location of the pain is on the eMAR and that a note should be placed in the progress note as well. Also, the LPN #2 also stated a follow up pain scale is recorded one hour after administration of pain medications so the physician can determine the effectiveness and need of the medication. During an interview on 1/10/17 at 1:15 pm, Registered Nurse, Unit Manager (RNUM) #2 reported the nurses should be documenting a before and after medication pain scale on the EMAR or in the progress notes each time a pain medication is given, and that it should include the location of the pain, the type of pain, and severity of the pain before and after giving the medication. Additionally, RNUM #2 stated that this information was used by the MD to see if the medication was adequate to relieve the resident ' s pain or was no longer needed. NY 10 CRR 415.12(l)(1)

Plan of Correction: ApprovedFebruary 17, 2017

All Medication Nurses have been instructed to ask resident #2, #9, #12, #54, #55 and #63 to rate her pain level before and after each administration of PRN pain medication and document the results.
All Medication Nurses have been instructed to document the type and severity of symptoms resident #9 is experiencing before administering PRN antianxiety medications. All Medication Nurses have been instructed to attempt non pharmacy interventions and document effect prior to administering PRN antianxiety medications.
Resident #85 has been discharged .
All Medication Nurses have been instructed to ask resident #48 to rate his pain level, location of pain and document results before administering PRN pain medication. All Medication Nurses have been instructed to reassess resident #48 and document the effectiveness of the PRN pain medication.
The Pain Management Policy and Procedure has been revised. Every resident will be asked (observed for those resident who can't verbalize) if they have pain every shift by the assigned Medication Nurse. A pain scale from 0 to 10 is used. Wong Baker faces are used for those cognitively impaired. Nurses will document in the electronic record the residents answer. Residents who say yes when asked if they have pain will be asked/observed for the numeric scale. The Nurse will administer the PRN pain medication, noting the location of pain, the description of pain, the pain scale (1 to 10). One hour after the medication is administered, the Nurse will reassess the resident and document the effectiveness using the pain scale (0 to 10).
All Nurses will be inserviced on the revised Pain Management Policy and Procedure.
Audits of all PRN pain medications administered will be monitored for compliance weekly x 4 then monthly x 4 and the results will be reported to the Performance Improvement Committee. The Committee will determine if further audits are needed.
PRN medications; Administration and Documentation Policy and Procedure has been revised. Medication Nurses will document symptoms requiring the PRN medication at the time of administration. Medication Nurses will document the effectiveness of the PRN medication 1 hour after administration. The policy states that non pharmacological interventions should be attempted and documented before administering PRN antianxiety medications.
All Nurses will be inserviced on the revised PRN Medication Policy and Procedure.
Audits of all PRN antianxiety medications will be monitored for compliance weekly x 4 then monthly x 4 and reported to the Performance Improvement Committee. The Committee will determine if further audits are required.
The Director of Nursing is responsible for compliance.

FF09 483.35(i):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not adhere to generally accepted food sanitation practices. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Chapter 1 Subpart 14 State Sanitary Code, the community standard for food service establishments operating in New York State both state that toxic substances are not to be stored in food preparation areas; cans with compromised seals are not to be used; and food contact surfaces are to be cleaned after use. Specifically, toxic substances were found in food preparation areas, a bulging can of sausage gravy was found stored with the common stock, and food contact equipment was not clean. This is evidenced as follows. The kitchen was inspected on 01/04/2017 at 9:15 am. Cleaners were found stored with cooking equipment and canned foods. A bulging can of sausage gravy was found stored with the common stock, and the slicer blade was soiled. The Director of Food Service (DFS) stated in an interview conducted on 01/04/2017 at 10:15 am that the cleaning chemicals should not be located with the cooking equipment and canned foods, and the new storage clerk needs a little more training. Additionally, the DFS stated that she would have food contact equipment cleaned and review processes with staff. 10 NYCRR 415.14(h); 10 NYCRR Chapter 1, Subpart 14-1.60, 14-1.110; 2013 FDA Food Code

Plan of Correction: ApprovedFebruary 21, 2017

On (MONTH) 04, (YEAR), Dietary Aide was instructed to re-wash / sanitize meat slicer and meat slicer table. The Dietary Aide was then instructed to remove the degreaser spray bottle to the proper chemical storage area.
To ensure staff are trained and are able to appropriately clean and sanitize the meat slicer, the Executive Chef will inservice all Nutrition staff on Proper Sanitation and Cleaning of kitchen equipment and proper Storage of Chemicals in a food service operation (this training includes proper cleaning and sanitizing of kitchen equipment to include a meat slicer. This training also includes proper use and storage location of chemicals).
The meat slicer is on the evening checklist as an item to be checked daily. This will continue at the end of each shift.
On (MONTH) 04, (YEAR), Stores Clerk was instructed to remove all dented cans which are deemed non-conforming to the non-conforming products rack located in the Nutritional Services Store Room. Cans and other items will be called in for credit and either picked up by supplier or discarded.
To ensure staff are trained and can appropriately identify noncompliant products including cans that have dent on side, top or bottom seam, sharp dent with crease, rust or pitting on top or side, leaking or swollen can, springer or flipper on top or bottom or are missing labels, Executive Chef will inservice Stores Clerk and all Nutritional Services staff on Proper Receiving and Storage Procedures. This training includes identifying and removal of dented cans.
To ensure this does not reoccur, compliance audits will be conducted two days per week for a period of one month. Results of audits will be reviewed at the Performance Improvement Committee Meetings and they will determine if further audits are required. If the meat slicer is found to be soiled, if the chemical cleaners are not stored in the proper area or if noncompliant / dented cans are found in use, the issue will be brought to the Manager and the staff. Re-training or other corrective actions will be taken.
Food Service Director will be responsible for compliance.

FF09 483.25(h):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

Based on interview and record review during a recertification survey and an abbreviated survey (NY 687) it was determined the facility did not ensure the environment remained as free of accident hazards as is possible. Specifically, the facility did not have any systems in place a system in place to monitor the integrity/safety of the side rails and beds. This was evidenced by: The New York State, Department of Health (NYS, DOH) Dear Administrator Letter (DAL) dated (MONTH) 19, (YEAR): Subject; DAL NH 15-05, Entrapment Risk with Bed Systems and Components. The letter documented; Many facilities are in the process of purchasing new beds to replace old ones. Please remind your staff to be especially diligent in evaluating the risk of entrapment with bed rails and enabler bars on all beds in your nursing home. It is recommended that initial and ongoing reviews be conducted of your facility's beds to ensure that no mattress, side rail, or enabler bar has gaps that are larger than recommended in the Federal Drug Administration (FDA) document Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued on (MONTH) 10, 2006. The FDA document details seven potential zones for patient entrapment and provides detailed diagrams and instructions on how to measure the open spaces between bed system components. While new bed systems need to be assessed for safety to assure components are compatible and installed correctly, it is equally important to assess bed systems already in use. Wear and tear can compromise the integrity and function of bed components, rendering them potentially unsafe. Over time mattresses become soft and compressed and side rails and enablers can become loose, wobbly, and improperly positioned. The Policy & Procedure (P&P) dated 01/1996 documented, Side rail use will be ordered by the provider, taking into consideration this facilities Restraint Policy. Procedures included: The Interdisciplinary Team (IDT) will assess and determine if the use of side rails is appropriate; resident and/or representative will be informed of risks; The provider will complete side rail order; Provider will review and renew side rail order at each routine visit; IDT will re-evaluate side rail use at least quarterly; side rail use will be added to the care plan and care guide. There was no mention in the P&P of assessing the side rails and beds to ensure safety. During an interview on 1/10/16 at 10:50 am the Administrator (Adm) stated that the maintenance man #1 was responsible for measuring the space between the mattress and side rail but was not sure when or how often this was done. The Adm further stated that years ago, not sure how many, the facility purchased beds and side rails and they were all measured at that time. The side rails in the facility are all the same type, except for one specialty bed that came with it's own side rails. All newly admitted residents are placed in side rail free beds, and the resident and family are educated on not having side rails. During an interview on 1/10/16 at 11:50 am the maintenance man #1 stated that a measurement of the beds and side rails was done years ago, but maintenance had not measured any since then. Maintenance man #1 stated that the side rails and beds had not been periodically checked. 10 NYCRR 415.12(h)(1)

Plan of Correction: ApprovedFebruary 21, 2017

February 03, (YEAR), all bed rails were found to be compliant.
When the interdisciplinary team approves side rail use for a resident, the Nurse Manager will notify Engineering and the Safety Officer for installation. The Safety Officer or designee will measure all FDA's Potential Zones for Entrapment.
All Nurse Managers, Engineering personnel and Safety Officer will be inserviced on the FDA's Potential Zones for Entrapment guidelines.
CNA's will be inserviced on side rail safety to include that side rails are in good repair, no jagged edges and they are not loose.
When installing or maintaining bed rails, the Safety Officer and Engineering staff will follow the FDA's Potential Zones of Entrapment guidelines and the Bed Inspection Policy and Procedure.
The Safety Officer will conduct inspections monthly of all bed frames, mattresses and bed rails as part of a regular maintenance program to identify areas of possible entrapment.
When bed rails and mattresses are used and purchased separately from the bed frame, the facility will select equipment such as bed rails, mattresses and bed frames that are compatible.
The results of the inspections will be submitted to the Safety Committee.
The Safety Officer is responsible for compliance.

FF09 483.10(e), 483.75(l)(4):PERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS

REGULATION: The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. Except as provided in paragraph (e)(3) of this section, the resident may approve or refuse the release of personal and clinical records to any individual outside the facility. The resident's right to refuse release of personal and clinical records does not apply when the resident is transferred to another health care institution; or record release is required by law. The facility must keep confidential all information contained in the resident's records, regardless of the form or storage methods, except when release is required by transfer to another healthcare institution; law; third party payment contract; or the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

Based on observation and interview during a recertification survey, the facility did not ensure privacy was provided for a resident group meeting. Specifically: a resident group meeting with a New York State Department of Health Surveyor, attended by 6 residents, was interrupted by multiple facility staff members and other resident's. This was evidenced by: Finding #1: The group meeting was scheduled for 1/5/17 at 10:00 am in the West dining room by the Activities Director (AD) of the facility. On 1/5/17 at 10:00 am, while waiting for the residents scheduled to attend the group meeting to arrive, the surveyor requested the area be closed off a for privacy. The AD stated that there were no doors and that this was the usual meeting place for the residents group meetings and council meetings. She stated she would post signs and maintain the integrity of the room to ensure privacy. On 1/5/17 at 10:15 am, the last of the 6 residents scheduled for the group meeting arrived. Staff and other residents continued to come in and out of the area where the group was meeting. A group of visitors were in the hallway talking loudly. On 1/5/17 at 10:20 am, a second request was made to the AD to close off the area so the meeting could begin without further interruptions. Facility staff asked residents and family members not scheduled to participate to leave the area. The surveyor asked if there was another room that would afford better privacy for the residents, the AD stated this was the usual room and that the residents had requested to meet here. She stated once again she had signs up and was doing her best to keep people out. On 1/5/17 at 10:23 am, the surveyor began the resident group meeting. There were (6) residents present. The resident's complained about the conversation from the hall and lack of privacy. One resident became concerned that someone would hear what they were saying and expressed concerns of reprisal. The meeting was stopped to deal with the lack of privacy. On 1/5/17 at 10:25 am, other residents, family members and staff not involved in the meeting continued to walk into the meeting area. Also, there was a group of non-residents present in the hallway outside the dining area talking loudly. The Surveyor made a third requests of the AD to remove those persons not scheduled for the meeting. The AD stated again that she had posted a sign and was trying to keep people out. On 1/5/17 at 10:30 am, two surveyors entered the dining room unaware the meeting was in progress. The surveyors stated that there were no signs visible to indicate that a private meeting was in progress. On 1/5/17 at 10:35 am, a resident in a wheelchair came into the room upsetting the residents in attendance at the meeting. The surveyor told the resident she could choose whether to stay at the meeting or leave and the resident chose to leave the meeting. On 1/5/17 at 10:45 am, a kitchen staff member came into the room with a hot cart. The surveyor asked the staff member to wait until the meeting was over, she continued into the room and stated she had to plug the hot cart in and get it ready for lunch. She stated no one had told her she couldn't come in and do her job. She did not exit the room until the cart was place by the kitchen area and plugged in. On 1/5/17 at 10:50 am, one resident expressed concern that she was going to be overheard by staff members who had been coming and going inside and outside the room during the entire meeting. She stated if we can hear them they can hear us. The residents were becoming irritated and were not able to focus on the group interview. On 1/5/17 at 10:55 am, the residents felt uncomfortable with all the interruptions and unanimously agreed to end the meeting. The meeting ended at 10:55 am. During an interview on 1/5/17 at 11:05 am, the Administrator (ADM) stated that the West Dining Room was an area frequently used for resident meetings and that these interruptions had never been an issue before. The Adm apologized for the interruptions and stated a better choice should have been made, as there were other areas that would offer the residents a private area with a door, where they could feel comfortable speaking about their life at the facility. Additionally, the Adm stated she understood the importance of their privacy and that they were exploring a better room in which to hold the meetings in the future. She stated that the food service worker had been reeducated and that she should never have continued into the meeting after she was stopped and the request was made to leave. During an interview on 1/5/17 at 3:45 pm, the AD stated that she understood the importance of the recertification survey group meeting and that the residents needed to be afforded privacy during the meeting. She further stated that the interruptions had been excessive and disruptive and that this had never happened before. 10 NY-CRR 415.3(d)(1)

Plan of Correction: ApprovedFebruary 2, 2017

On Friday, (MONTH) 06, (YEAR) the Resident Council Meeting was held in the East Television Lounge with the doors closed for privacy. A notice was hung on the doors to maintain resident privacy during the meeting.
Residents have agreed to have all future meetings in the East Television Lounge. A notice will be hung on the doors during each meeting to maintain privacy.
On (MONTH) 27, (YEAR), the Director of Recreational Therapy sent a notice to all Department Managers of the Resident Council Meeting location and to educate the staff to follow the notice posted on the door during the meetings to maintain privacy.
The Director of Recreational Therapy will audit the disruptions, if any, during the meetings for three months and report the results of the audits to the Performance Improvement Committee Meeting. The Performance Improvement Committee will determine if further audits are needed.
The Director of Recreational Therapy is responsible for compliance.

FF09 483.25(m)(2):RESIDENTS FREE OF SIGNIFICANT MED ERRORS

REGULATION: The facility must ensure that residents are free of any significant medication errors.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey it was determined the facility did not ensure that residents were free of any significant medication errors. Specifically, for resident #44 who had her insulin held on numerous occasions due to decreased appetite without physician notification. This was evidenced by: Resident #44: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severely impaired cognition and was able to make herself understood and sometimes could understand others. A physician order [REDACTED]. There were no parameters documented to hold the insulin for a decreased appetite. A review of the Electronic Medication Administration Record [REDACTED] On 10/10/16, documented before dinner dose of insulin not given, per conversation with administrator and supervisor insulin held for intake of 25%. On 10/11/16, documented before dinner dose of insulin not given, per Director of Nursing (DON) insulin not given for intake of 25%. On 10/20/16, documented dinner dose of insulin not given, per discussion with the Certified Nursing Assistant (CNA) and supervisor insulin is to be held for intake less than 50%, patient ate 25% this evening. On 10/27/16, there was no documented evidence that the dinner dose of insulin was given. On 10/29/16, documented dinner dose of insulin not given, held for 0% intake of meal. On 11/3/16, documented dinner dose of insulin not given, bites taken for dinner. On 11/4/16, documented dinner dose of insulin not given, poor intake. On 11/7/16, documented dinner dose of insulin not given, per Administrator (Adm) insulin held for intake of bites. On 11/13/16, documented dinner dose of insulin not given, less than 50% of meal taken. On 11/17/16, documented dinner dose of insulin not given, insulin held per CNA for 25% of meal consumed. A review of the nursing progress notes and the 24 hour report revealed there was no evidence of the physician being notified when the insulin was not given. During an interview on 1/5/16 at 9:30 am the Licensed Practical Nurse (LPN) would make the charge nurse aware if a resident did not eat well and was to receive insulin. The charge nurse would call the Physician for the order to hold the insulin. During an interview on 1/9/16 at 10:35 am the Registered Nurse Manager (RNM) stated the LPN along with the Registered Nurse Supervisor (RNS) can hold insulin per nursing judgement if a resident does not eat, but the Physician must be made aware immediately if the insulin is not given. Additionally, the RNM stated she was aware of the insulin being held at times, and she thought the Physician was being notified. During an interview on 1/9/16 at 1:10 pm the Director of Nursing (DON) stated the interdisciplinary team had discussed the Resident's appetite and insulin on numerous occasions. Additionally, the DON stated there were times the nurses held the insulin per nursing judgement, but they should have notified the Physician. 10 NYCRR 415.12(M)(2)

Plan of Correction: ApprovedFebruary 2, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Provider was notified of the past need to hold Resident #44 dinner time insulin due to decreased or no intake at dinner time. Provider wrote order may hold mealtime [MEDICATION NAME] R Insulin if patient does not or will not eat dinner.
All Medication Nurses have been instructed that, if for any reason an ordered medication is not given, the Medication Nurse is to notify the Charge Nurse or Supervisor and document why the medication was held. The Charge Nurse or Supervisor has been instructed to notify the Provider and document the outcome.
The Administration of Medications by Unit Dose Policy and Procedure has been revised to include if for any reason a routine medication ordered by the Provider is held, the Medication Nurse will document the reason in the Nurses Notes and notify the Charge Nurse or Supervisor. The Charge Nurse or Supervisor will notify the Provider and let them know what medication was held, the reason and document in the Nurses Notes the notification and outcome.
All Nurses will be educated on the revised Administration of Medication by Unit Dose Policy and Procedure.
Audit of all routine held medications will be monitored for compliance weekly x 4 then monthly x 4 and results will be reported to the Performance Improvement Committee. The Committee will determine need for further audits.
The Director of Nursing is responsible for compliance.

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and employee interview during the recertification survey, it was determined that the facility did not utilize power strips in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.2.4 requires that all electrical adapters be listed for the purpose. NFPA 70 National Electrical Code 2011 Edition Article 590 section 590.3 (D) requires that temporary wiring, such as extension cords, shall be removed immediately upon completion of construction or purpose for which the wiring was installed. The Centers for Medicare and Medicaid Services notice S&C 14-46-LSC permits the use Relocatable Power Taps (RPT) listed as UL 1363 to power non-patient-care related electrical equipment outside the patient care vicinity. Specifically, non-compliant power strips were used to power patient care and non-patient care electrical devices. This is evidenced as follows. A sample of resident rooms were inspected on 01/10/2017 at 10:45 am. In resident room [ROOM NUMBER], a non-compliant power strip was used to power the ceiling-mounted lift, fish tank, television, fan, and cell phone. In resident room [ROOM NUMBER], a non-compliant power strip was used to power a television. In resident room [ROOM NUMBER], a non-compliant power strip was used to power the hospital bed and personal electrical reclining chair. In resident room [ROOM NUMBER], a non-compliant power strip was used to power two nebulizers and a radio, table light, and clock. In resident room [ROOM NUMBER], a non-compliant power strip was used to power a radio and artificial ornamental tree. And in resident room [ROOM NUMBER], a multi-plug extension cord was used to power a radio and artificial ornamental tree. The Safety Officer stated in an interview conducted on 01/10/2017 at 2:00 pm that he believed the power strips utilized were compliant. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.2.4; 2011 NFPA 70 590.3(D); 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3

Plan of Correction: ApprovedFebruary 6, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On (MONTH) 01, (YEAR), a room survey was completed. room [ROOM NUMBER] - they will have a compliant power strip for non-medical equipment and all medical equipment is plugged into an outlet. room [ROOM NUMBER] - power strip was removed, electrical outlet was used. room [ROOM NUMBER] - no extension cords were discovered. room [ROOM NUMBER] - power strip not found. room [ROOM NUMBER] - will provide appropriate power strip for non patient care related equipment. room [ROOM NUMBER] - informed resident and removed power strip.
Residents, families and staff will be educated on the proper use of power strips.
The Safety Officer and / or their designee will issue proper power strips should one need to be utilized in resident rooms.
The Safety Officer will survey each room weekly for one month and then quarterly to ensure that appropriate power strips are being used, if needed.
The results of the audits will be reported to the Safety Committee.
The Safety Officer is responsible for compliance.

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the automatic sprinkler system was not installed in accordance with adopted regulations. NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition section 8.6.5.1.2 permits particular limitations on obstructions to the sprinkler system discharge pattern. Specifically, the automatic sprinkler system was encumbered with unacceptable obstructions and did not cover all areas. This is evidenced as follows. A sample of resident rooms were assessed for obstructions of the sprinkler system on 01/04/2017 at 2:40 pm and again on 01/10/2017 at 10:45 am. Privacy curtains were bunched-up over the sprinkler heads in resident rooms 18, 19, 20, 28, 41, 42, 45, and 51. The Engineering Supervisor stated in an interview on 01/10/2017 at 11:50 am that the facility has not yet implemented a policy and trained staff on moving the closed privacy curtains away from the sprinkler heads. 42 CFR 483.70 (a) (1); 73, FR ; 2012 NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.6.5.1.2; 10 NYCRR 415.29, 711.2(a) (1)

Plan of Correction: ApprovedFebruary 6, 2017

All rooms will have a line of demarcation to ensure that privacy curtains are not obstructing sprinkler heads in resident rooms.
All staff will be educated that privacy curtains cannot obstruct the sprinkler heads when not in use.
The rooms will be surveyed weekly for 4 weeks then quarterly and reported to the Safety Committee.
The Safety Officer will be responsible for compliance.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.5 requires that smoke barriers shall be continuous from floor to the underside of the roof and through all concealed spaces, such as those found above a ceiling. Specifically, 1 of 1 smoke barriers observed were not continuous through all concealed spaces. This is evidenced as follows. The northwest smoke barrier wall (wall) was inspected on 01/10/2017 at 9:00 am. In the Conference Room a non-fire protected 20-foot by 18-inch metal support beam, and in the corridor two unsealed penetration holes (6-inch by six-inch hole and a 4-inch by 4-inch) were found. The Director of Engineering stated in an interview conducted on 01/10/2017 at 10:40 am that he believed sealing penetrations on one side of the smoke barrier wall was adequate. 42 CFR 483.70 (a) (1); 2012 NFPA 19.3.7.3, 8.5; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedFebruary 6, 2017

Smoke barriers were reviewed by an outside Architect. All four barriers had sealed penetrations on one side. All barriers will be resurveyed and the opposite side will be sealed to achieve a 1-hour fire rating.
All metal support beams located within the smoke barrier wall will be sealed with proper fire proofing.
When completed, all smoke barriers will be inspected by a licensed Architect.
Facility policy for Fire and Smoke Barrier Penetrations will be revised to ensure contractor and staff compliance is maintained any time a permit is issued.
Each time a permit is issued for work to be performed in the ceiling the Director of Engineering or Engineering Supervisor will verify that smoke barriers are intact. An audit will be completed from these observations and reported to the Safety Committee quarterly.
The Director of Engineering is responsible for compliance.

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.6.2 requires that the walls to vertical openings, such as stairwells, have a 1-hour fire resistance rating and be continuous from floor to roof. Specifically, the stairwell walls were not continuous from floor to the underside of the roof and did not maintain a 1-hour fire resistance rating. This is evidenced as follows. The stairwell was inspected on 01/10/2017 at 10:00 am. A 3-foot by 2-foot section of missing wall between the stairwell and corridor, a 15-foot by 1-inch space between the stairwell wall and the underside of the roof, and four 4-inch unsealed penetrations were found. The Director of Engineering stated in an interview conducted on 01/10/2017 at 10:40 am that the missing wall and penetrations found were from the original construction. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.6.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3.2.3.1(2), 8.2.3.2.4.2

Plan of Correction: ApprovedFebruary 21, 2017

A horizontal shaft wall at the ceiling as specified by a licensed Architect will be installed necessary to meet the 1 hour fire resistance rating.
All smoke barrier penetrations will be sealed as required including the stairwell shaft wall.
Each time a permit is issued for work to be performed in the building the Director of Engineering or Engineering Supervisor will verify that smoke barriers are intact. An audit will be completed from these observations.
The results of the audits will be reported to the Safety Committee.
The Director of Engineering is responsible for compliance.