Park Nursing Home
November 6, 2018 Complaint Survey

Standard Health Citations

ZT1N 415.26:ORGANIZATION AND ADMINISTRATION

REGULATION:

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 6, 2018
Corrected date: December 31, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during an offsite (NY 568) investigation, it was determined that the facility did not report a smoke incident in a timely manner. Specifically, on 10/17/2018 at 2:15 PM, smoke in a resident's room activated the fire alarm and New York City Fire Department (FDNY) responded. In addition, a resident was transferred to the Hospital for evaluation. The facility reported the incident to New York State Department of Health (NYSDOH) on 10/24/2018 at 5:04 PM (7 days) after the incident occurred. Review of the Facility Policy on General Fire Procedure dated 08/13/2018, revealed that there were no instructions on reporting to NYSDOH. On 10/24/2018 at 5:04 PM, the facility submitted a report to NYSDOH noting that on 10/17/2018, a smoke alarm in a resident's room was activated due to smoke coming from a portable Air Conditioner (A/C) in the wall. The resident was removed from the room and the A/C was immediately unplugged and the room was ventilated. FDNY responded to the alarm, cleared and reset the alarm. The resident was assessed and transferred to the emergency room (ER) for evaluation. The resident returned to the facility on [DATE] with no adverse effect from the smoke. The Administrator was interviewed on 10/31/2018 at 3:47 PM and stated that he did not report the incident to NYSDOH right away because, he was not sure that he had to report it. The Director of Nursing was interviewed on 10/31/2018 at 2:43 PM and stated that on 10/17/2018 around 2:15 PM, the fire alarm was triggered due to smoke coming from a resident's A/C and FDNY reponded. The resident assessed wih no injury and the Medical Doctor informed with an order to transfer the resident to the hospital for evaluation. 415.26 (13)

Plan of Correction: ApprovedNovember 21, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I) Immediate Corrective Action for Resident affected:
1) As noted in the SOD, the resident whose A/C started to smoke was transferred to the hospital on [DATE] for evaluation. The resident returned back to the facility on [DATE] with no noted negative findings. The resident was readmitted back to his original room, as the A/C, which was smoking, was replaced with a new A/C unit while he was in the hospital.
2) On 10/17/18 immediately following the evacuation of the resident from the room, the Maintenance Director identified that the smoke was caused by a Freon leak in the A/C unit. Subsequently, the A/C unit was removed and replaced with a new A/C unit.
3) On 10/7/18 the Fire Department reset the fire alarm system/panel and left the building.
4) An educational counseling was issued by Ownership/Designee to the Administrator regarding the reporting guidelines related to smoke and fire in any area in the building. A copy of the lesson plan and sign-in sheet is on file for validation.
II) Identification of Other Resident:
1) On 10/25/18 the Director on Maintenance conducted an audit of all A/C units in the facility to ascertain if any other units were noted to have a Freon leak or were not functioning appropriately. The facility respectfully states that any units needing repair were disconnected, locked and tagged out and are in the process of being replaced.
III) Systemic Changes made so the deficiency will not reoccur:
1) The Administrator reviewed and revised the current facility P&P for Inspecting A/C Units. The Revised P&P will be in-serviced to the Maintenance Staff by the Administrator. The lesson plan will focus on the following;
-All A/C units will be inspected before the summer season, on installation of any new A/C unit and monthly during the months that the A/C units are in use by the Maintenance Director/Designee.
-When conducting inspections of the A/C units, the following areas must be checked for damage and functionality;
a) Power Cord integrity.
b) Plug integrity.
c) Outlet that A/C unit is plugged into.
d) Blower, located inside A/C unit for both integrity and debris.
e) Filter for integrity and debris.
f) Overall A/C unit tubing for cracks and rust.
-All A/C units must be plugged in and turned on, after inspections of components have been completed, to ensure that the unit is functioning correctly.
A copy of the lesson plan and sign-in sheet will be kept on file as validation.
2) Ownership/Designee and the Administrator reviewed and revised the current facility P&P on General Fire/Smoke Procedures. The revised P&P will be in-serviced to the Administrator by the ownership/designee. The lesson will concentrate on the following;
-Reporting to DOH
-Fire/Smoke must be reported to DOH immediately or immediately after the initial threat to the residents/facility has been contained. Report/Call will be made by the Administrator or DNS.
A copy of the lesson plan sign-in sheet is kept on file as validation.

IV) Monitoring of the Corrective Action/Quality Assurance:
1) The Administrator will develop a QA audit tool to track the facility?s compliance with inspecting A/C units. The audit will be completed by the Administrator/Designee on 5 randomly selected A/C units monthly during the summer months, when A/C units are in use. The facility respectfully states that all Resident?s A/C units have been winterized, covered and are not in use at this time. Auditing will be initiated once the A/C units are back in use. Auditing will be done monthly until A/C units are in use. All negative findings will be immediately corrected by the Maintenance Director/Designee. All audit findings will be presented to the QA committee at the completion of the first round of auditing.
2) Ownership/Designee will develop a QA audit tool to track the Leaderships? knowledge of reporting fire/smoke to DOH. Auditing will be completed by ownership/designee monthly x 3 months and quarterly thereafter. All audit findings will be presented to the QA committee monthly x 3 months and quarterly thereafter.
V) Responsibility:
Administrator