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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Extended Recertification survey from 7/21/2022 through 8/03/2022, the facility did not ensure that the assessment accurately reflected the resident's status for 2 (Resident #28 & Resident #196) of 47 sampled residents. Specifically, the [DIAGNOSES REDACTED]. The findings are: The facility policy and procedure titled Resident Assessment-RAI reviewed 12/9/21, documented: The current version of the RAI (MDS 3.0) will be utilized when conducting a comprehensive assessment of each resident in accordance with the instructions found in the RAI Manual. and The assessment process will include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. 1) Resident #196 was admitted to the facility with [DIAGNOSES REDACTED]. Physician order [REDACTED]. The Comprehensive Care Plan (CCP) titled Behavioral Symptoms created on 6/16/21 and updated 7/1/22, documented that resident has behaviors of verbal abuse to staff and residents, physical abuse to staff, resists care, persistent anger, hallucinations, delusions, paranoid accusatory behavior, agitation, and restlessness. The interventions included allow resident to vent feelings, counsel by social worker, protect from over stimulation, and Psychiatry consult. The Care Plan Activity Report note dated 7/1/22 documented Resident being verbally threatening and aggressive behaviors, observed very agitated, screaming, yelling, refusing care and non-compliant with smoking policy, noted smoking in his room. The Certified Nurse Aide (CNA) documentation history dated 6/24/22-6/30/22, during the 7 day look back period for the Annual MDS dated [DATE], documented resident resists care. The Annual MDS dated [DATE] documented in Section E0200 Behavior Symptom-Presence and Frequency and Section E0800 Rejection of Care-Presence and Frequency that the resident exhibited no behavioral symptoms. The MDS did not accurately capture the resident's behavioral symptoms. On 07/29/22 at 11:52 AM, Resident was observed yelling and threatening Temporary Nursing Aide (TNA). Resident threatened to knock TNA out if TNA continued to follow resident. On 8/01/2022 at 4:34 PM, the MDS Coordinator (MDSC) was interviewed. MDSC stated that Section E of MDS which captures behavioral symptoms automatically populates from CNA Documentation. MDSC also stated they did not capture behavioral symptoms during the 7 day look back period for the Annual MDS dated [DATE] and did not notice the behavioral documentation of resists care in the CNA documentation history dated 6/24/22-6/30/22. MDSC stated this behavior should have been documented in section E0800 of the MDS. MDSC further stated that in order to complete MDS they review medical records, assess resident, and conduct staff interviews. On 8/03/22 12:29 PM, the Director of Nursing (DON) was interviewed. The DON stated behaviors should have been coded in behavior E0800 section of MDS because CNA Accountability documented resident had behaviors during the 7 day look back period. 2) Resident #28 was admitted to the facility on [DATE] with Dementia Alzheimer, Behavioral disorder, Type II Diabetes, and Cerebral infarction. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented that the resident is severely cognitively impaired. No behaviors were triggered on the MDS. The active [DIAGNOSES REDACTED]. The medications included that the resident received antipsychotic. The MDS included that the resident has a wander/elopement alarm. The Quarterly Minimum Data Set ((MDS) dated [DATE] is missing the following diagnoses; Behavior Disorder, [MEDICAL CONDITIONS]. The Quarterly MDS dated [DATE] documented that the resident is severely cognitively impaired. The MDS also documented that, behaviors other behavioral symptoms not directed towards others occurred 4 to 6 days. Wandering behavior occurred 4 to 6 days, but less than daily. The active [DIAGNOSES REDACTED]. The medications included that the resident received antipsychotic. The MDS included that the resident had a wander/elopement alarm. The Quarterly MDS dated [DATE] is missing the following diagnoses; Behavior Disorder, [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITION]. physician progress notes [REDACTED]. On 08/03/22 at 04:38 PM a phone interview was held with the MDS Coordinator (MDSC) who stated that they are the only one who does MDS assessments at the facility. The MDSC stated they assess and interview the resident and review the medical record to complete the assessments. The MDSC stated the [DIAGNOSES REDACTED]. The MDSC could not explain why the [DIAGNOSES REDACTED]. On 08/03/22 at 04:48 PM an interview was held with the Director of Nursing (DON) who stated the MDS Coordinator does the MDS. The DON stated that the MDS Coordinator may be overwhelmed with work due to short staffing. 415.11(b) | Plan of Correction: ApprovedSeptember 12, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F- 641 I. The following actions were accomplished for the residents identified in the sample: Resident #196 On 8/29/22, the RN/MDS Coordinator submitted a correction MDS related to Section E0200 and Section E0800 of the MDS dated [DATE] The NM reviewed and updated the CCP and CNAAR related to the residentÆs behavior symptoms and review the plan of care with the unit staff. Resident #28 On 8/29/22, the RN/MDS Coordinator submitted a correction MDS related to the quarterly assessment dated [DATE] to include the following [DIAGNOSES REDACTED]. On the same date the RN/MDS Coordinator submitted a correction MDS related to the quarterly assessment dated [DATE] to include the following [DIAGNOSES REDACTED]. The DNS reeducated the RN/MDS Coordinator regarding her responsibilities to ensure the accuracy of MDS data prior to submission. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practice. The MDS Coordinator will review the last submitted MDS assessment for all residents to ensure that the data submitted is accurate, including all pertinent diagnoses. A correction MDS will be submitted as indicated. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, DNS and RN/MDS Coordinator will review and revise, if indicated, the policy and procedure for MDS completion to ensure that it includes disciplines/staff, with skills and qualification to conduct the assessment, responsible to complete each section and the protocol to be followed related to accuracy of data prior to submission. The DNS /designee will provide education to the RN/MDS Coordinator and any newly hired MDS RN staff regarding the above protocol emphasizing the importance of the MDS including accurate data prior to submission so that the developed CCP addresses each residentÆs care needs, strengths as well as diagnoses. Effective 8/29/22, the RN/MDS Coordinator will recheck all MDS data, including [DIAGNOSES REDACTED]. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with the accuracy of MDS data. The audit tool will address accuracy of information for each section of the MDS. The RN/MDS Coordinator will audit 15% of completed MDS assessments for accuracy of data on a quarterly basis. All MDS accuracy audit findings will be reported to the Administrator and DNS on a quarterly basis. Corrective actions, such as submitting a correction MDS or staff re-education, will be implemented as indicated. The RN/MDS Coordinator will report MDS accuracy audit findings to the QAPI Committee on a quarterly basis for evaluation, discussion and follow-up corrective action. Completion Date: (MONTH) 28, 2022 Responsibility: Director of Nursing |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details Based on observations, interviews and record reviews conducted during the extended Recertification survey from 7/21/22 to 8/3 22, the facility did not ensure effective and efficient administration of its resources to attain or maintain the highest practicable well-being of each resident. Specifically, the facility administration 1) changed the facility policy to became smoke-free without notification of their smoking residents and without a plan to address ongoing non-compliance with smoking rules; 2) lacked safeguards and a system in place to control, account for, and accurately reconcile controlled medications; 3) did not sufficiently staff the facility; Facility was sufficiently staffed 4) develop and implement a Water Management Program to minimize the risk of Legionella and other opportunistic pathogens in building water systems; 5) did not employ a qualified and certified Infection Preventionist; and 6) did not employ a qualified dietitian or clinically qualified nutrition professional. The findings are: 1) The facility initiated Smoke Free Policy in (MONTH) 2020, did notify residents of the change in policy and did not ensure that known/prospective smokers were provided with alternatives and adequate supervision to prevent and address unsafe smoking incidents. There were multiple incidents of noncompliant residents smoking in their rooms and the hallways without assessments, investigation, or interdisciplinary care planning. Refer to citation text at F689 for further information. (2) The facility did not implement Controlled Substance Handling policy to safeguard, and account for and reconcile controlled medications. Refer to citation text at F755 for further information. (3) The facility daily nursing staffing assignments from 6/24/22 to 7/25/22 revealed that the facility did not meet the facility-determined staffing level for Licensed Nurses on 26 days out of 32 days, and for Nurse Aides on all 32 days out of 32 days. Refer to citation text at F725 for further information. (4) The facility's Water Management Plan did not include facility's water distribution system, facility risk and environmental assessment and Legionella sampling plan. Refer to citation text at F880 for further information. (5) The facility did not employ an Infection Preventionist who was qualified by education, training, experience, or certification. Refer to citation text at F882 for further information. (6) The facility did not employ a qualified dietitian or clinically qualified nutrition professional. Refer to citation text at F835 for further information. 415.26 | Plan of Correction: ApprovedAugust 26, 2022 F- 835 û Administration I. The following actions were accomplished for the residents identified in the sample: Please refer to corrective actions at F-689, F755, and F880 for individual residents. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practice. Please refer to corrective actions at F-689, F755, F882, F835 and F880. On 9/7/22, Facility Administration will meet with the Outside Consultant to discuss responsibility for the overall management of the facility and need for effective management to maintain compliance with all regulations including the need to have effective systems in place specifically for the issues identified in the Statement of Deficiencies related to 1) safe smoking program; 2) safeguards and a system in place to control, account for, and accurately reconcile controlled medications; 3) sufficient nursing staffing 4) develop and implement a Water Management Program to minimize the risk of Legionella and other opportunistic pathogens in building water systems; 5) did not employ a qualified and certified Infection Preventionist; and 6) did not employ a qualified dietitian or clinically qualified nutrition professional. Administration is facilitating and participating in corrective actions being implemented and is enforcing and monitoring the overall implementation of the Plan of Correction related to the cited F-tag deficiencies. Effective 8/29/22, Administration is participating in daily discussions on a Monday through Friday basis to review and assess the progress of the facility in implementation of the P(NAME) related to the deficiency citation and to discuss identified issues. These discussions will be incorporated into Morning Report for timely follow-up. III. The following system changes will be implemented to assure continuing compliance with regulations: Please refer to corrective actions at F-689, F755, F882, F835 and F880. On 9/9/22 administration will conduct assessment of the current resident population and reviewed the current facility assessment-staffing plan of direct care staff to meet the needs of its patients/ residents and achieve high quality outcomes of care. The assessment includes an evaluation of diseases, conditions, physical, functional or cognitive limitations of the resident populationÆs, acuity (the level of severity of residentsÆ illnesses, physical, mental and cognitive limitations and conditions) and any other pertinent information about the residents that may affect the services the facility must provide. On 8/3/22, Administration had posted Job opening to local newspapers, Indeed, and communicated with staffing agency vendors and facility union to provide assistance with additional direct care staff to the facility. Administration also communicated to with Nursing Home Associations and State Agency (NYSDOH Surge and Flex Operations Center at [PHONE NUMBER]) to address staffing needs of the facility. The Administrator will hold AD Hoc QA meetings as needed. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: Please refer to corrective actions at F-689, F755, F882, F835 and F880. Administration and Director of Nursing with monitor daily nursing staffing to ensure there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residentsÆ needs safely and in a manner that promotes each residentÆs rights, physical, mental and psychosocial well-being. The Administrator will monitor that any identified deficient practices related to compliance with F-689, F755, F882, F835 and F880 are promptly addressed by the QA Committee. If needed, an ad hoc QA Committee meeting will be convened to reassess any reported non-compliance with the Plan of Corrections or additional concerns related to the cited F-tag deficiencies. Administration will assess audit findings reported at the QA Committee meetings and implement additional system revisions when indicated. Consistent follow-up by the Quality Assurance Committee of identified problematic areas. Corrective actions, such as policy revision, additional auditing, or additional education, will be implemented, as indicated Completion Date: (MONTH) 28, 2022 Responsibility: Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the recertification and extended survey from 7/21/2022 through 8/3/2022, the facility did not ensure correct installation and use of bed rails that included assessing residents for risk of entrapment prior to installation, reviewing the risks and benefits of bed rails with the resident or representative, and ensuring the bed's dimensions were appropriate for the resident's size and weight for 2 (Resident #s 80 and 41) of 2 residents reviewed for Physical Restraint. Specifically, Resident #80 had bilateral (B/L) half side rails (SR) in place without an assessment for risk of entrapment from bed rails prior to installation, a review of the risks and benefits with the designated representative, and an evaluation to ensure the bed's dimensions were appropriate for the resident's size and weight. The B/L half SR were not ordered by a physician or included in Resident #80's plan of care. Resident #41 had B/L half SR as an enabler without an assessment for risk of entrapment from bed rails prior to installation, a review of the risks and benefits with the resident, and an evaluation to ensure the bed's dimensions were appropriate for the resident's size and weight. The findings are: The facility policy titled Proper Use of Side Rails last revised 5/18/21, documented The purpose of these guidelines is to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: bed mobility, ability to change positions, transfer to and from bed to chair, risk of entrapment from the use of side rails and that the bed's dimensions are appropriate for the resident's size and weight. The use of side rails as an assistive device will be addressed in the resident's care plan. Documentation will indicate if less restrictive approaches are not successful prior to considering the use of side rails. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment. A side rail consent form was attached to the policy and procedure. 1.) Resident #80 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #80 had moderately impaired cognition with a Brief Interview of Mental Status score of 9 out of 15 and no behaviors. The resident required the total assist of 2 persons for bed mobility, transfers, and toilet use; the resident required the total assist of 1 person for locomotion on unit and off unit, dressing, eating, and hygiene. Ambulation did not occur. The MDS documented bed rails and restraints/alarms were not used. Multiple observations were made of Resident #80 in bed with the bilateral 1/2 side rails up. During these observations, there were no staff present in the room. The observations occurred on 7/21/22 at 12:30 pm, on 7/22/22 at 9:40 AM, 7/25/22 at10:10 AM, 7/25/22 at 3:00 PM, 07/27/22 at 8:32 AM, 7/28/22 at 11:59 AM. During an interview on 7/22/22 at 9:40am, Resident #80 stated they were unable to put the side rails down by themselves. A Comprehensive Care Plan (CCP) titled Devices non Restraints/Bed Bolsters Bilateral/Bilateral Floor mats, initiated 10/27/21 and updated 6/7/22, documented a goal for Resident #80 to maintain comfort and positioning using the least restrictive device x 90 days. Interventions included: education on risk / benefits of device use, encourage use of device to enhance participation in bed mobility, and observe for tolerance to device use. A CCP for Fall, initiated 9/6/2017 and revised 6/20/2022, documented Resident #80 was at risk for fall related to intermittent confusion, requiring assistance to transfer, history of falls, and psychiatric disorder. The interventions included: provide required assistance with ADLs as needed, low bed as appropriate, and bed bolsters in bed. Side rail use was not an intervention in the CCP. A Bed Mobility/Use of Side Rail Assessment, dated 5/27/22, documented Resident #80 could not turn self from side to side, was not able to grab and hold device safely and effectively, could not easily and voluntarily apply/release the device, and could not understand that the device was an enabler nor use it as an enabler. The assessment documented the SR restricts freedom of movement or access to the body, and SR would not be used as an enabler. The Fall Risk assessment dated [DATE] documented no side rail or trunk restraints were used for the resident. The current Resident Nursing Instructions as of 8/3/22 documented the resident had safety monitoring/fall precautions of floor mats, low bed, and bilateral bed bolsters applied in bed at all times with removal on one side only during transfers. The instructions also documented the bilateral bed bolsters should be used for turning and positioning to prevent falls with total assist of 2 persons. The staff should ensure bed bolsters are secured in bed at all times and remove the right side bolster during transfers. There was no documented evidence B/L half SR were ordered for the resident. There was no documented evidence the resident was assessed for the risk of entrapment prior to the SR installation, the resident and representative were educated regarding the risks and benefits and consented to the B/L half SR, or an evaluation to determine the bed's dimensions were appropriate to Resident #80's size and weight. During an interview on 7/28/22 at 12:49 PM, the Certified Nursing Assistant (CNA #7), stated the 1/2 side rails were put up to prevent falls because Resident #80 is a fall risk. CNA #7 stated Resident #80 cannot release the side rails on their own and does not hold onto the side rails during care. Resident #80 requires assist of two persons for care. CNA #7 stated the instructions let them know whether or not a resident has side rails. During an interview on 8/1/22 at 11:14 AM, CNA #1 stated Resident #80 requires assist of 2 persons for turning in bed, and the resident does not participate in turning. Resident #80 also requires a hoyer lift with two assist for transfer. CNA #1 stated Resident #80 does not use side rails, only the bolsters are used to prevent Resident #80 from falling. During an interview on 7/28/22 at 12:42 PM, the Registered Nurse Supervisor (RNS #2) stated the 1/2 side rails are used to prevent falls. The side rails protect Resident #80 from falling because they can't do anything for themselves. RNS #2 stated Resident #80 has not fallen on any shifts they worked with the resident, and RNS #2 did not think Resident #80 could release the side rails independently. RNS #2 stated there should be a physician's orders [REDACTED]. RNS #2 said they are a float so they do not enter instructions for the CNA Accountability. During an interview on 8/1/22 at 11:13 AM, RNS #4 stated the CNA who floats may have put Resident #80's side rails up. If a resident needs side rails, there should be a physician's orders [REDACTED]. RNS #4 stated they check to ensure CNAs are applying devices as ordered. On 8/2/22 at 11:30 AM, an interview was conducted with the Director of Rehab (DOR). The DOR stated Resident #80 has the bolsters at all times, and no side rails are used. 2.) Resident #41 was admitted [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #41 had a BIMS score of 12 (moderately impaired cognition), no behaviors, required total assist of 1 for bed mobility, and required total assist of 2 for transfer. No restraints or alarms were used. On 7/21/22 at 10:23 AM, Resident #41 was observed in bed with the head of bed (HOB) elevated and B/L half SR up. No gaps were observed between the SR and mattress. Resident #41 was interviewed and stated they use the SR to turn side to side and reposition themselves independently. Resident #41 positioned themselves utilizing the SR to demonstrate. On 7/22/22 at 9:52 AM and 7/25/22 at 12:28 PM, Resident #41 was observed in bed with the B/L half SR up. The Comprehensive Care Plan (CCP) titles Devices Non-Restraint Effective 5/10/22 documented Resident has use of half side rails as an assistive device or enabler to facilitate bed mobility related to [MEDICAL CONDITION]. Resident requires total assist of 2 staff to transfer. Resident able to fully grasp and hold both rails to facilitate bed mobility for turning and position at prompt and at will. Therefore, device does not restrain or impair function turning and positioning. Goals to maintain comfort and positioning using the least restrictive device. Interventions include but are not limited to quarterly ongoing assessment of device use (bilateral side rails), encourage use of device, A CCP titled Falls effective 5/10/22, indicates resident is a fall risk related to loss of balance while standing, [MEDICAL CONDITION] medications and [MEDICAL CONDITION]. Goal is to remain free from falls. Interventions include but are not limited to provide assistance with ADL's as needed, apply 2 half side rails as an assistive device to facilitate bed mobility and for turning and positioning. Ongoing assessment of device use and observe tolerance to device use. A CCP titled ADL Functional effective 5/20/22, indicates bed mobility ext. assist of 1 with use of bilateral half side rails as an assistive device /enabler to facilitate bed mobility / turning & positioning. A physician's orders [REDACTED]. The SR Assessments dated 10/20/2021, 1/27/22, and 5/10/22 documented the resident was able to turn themselves from side to side, grab and hold the SR safely and effectively, could easily and voluntarily apply/release the SR, and the SR did not restrict freedom of movement or access to the body. Resident #41 could use the SR as an enabler, and the SR would be used as an enabler. The current Resident Nursing instructions as of 8/1/22 for ADL/bed mobility documented Resident #41 was able to use bilateral half side rails as an enabler for bed mobility, turning, and positioning. (document printed 7/31/22). There was no documented evidence the resident was assessed for the risk of entrapment prior to the SR installation, the resident and representative were educated regarding the risks and benefits and consented to the B/L half SR, or an evaluation to determine the bed's dimensions were appropriate to Resident #41's size and weight. An interview was conducted with the Maintenance Worker (MW), on 8/1/22 at 4:51 PM and 8/1/22 at 6:09 PM. The MW stated he/she installs or removes SR as directed by their boss. The MW stated he/she does not take measurements of the gaps around the side rails. The MW did not remove Resident #80's SR. All new beds are delivered with SR, and the Maintenance staff remove the SR, put the SR in storage, and put the beds together according to the manufacturer's instructions. There should be no gaps between the resident's mattress and the side rails, and they have not seen any gaps. The MW stated they were not instructed to measure the gaps or take residents' height and weight into account prior to side rail installation. The MW stated they did not know if the facility evaluated beds and SR for safety assessments. The MW did not know if there was a policy on SR installation. The MW stated they have not installed any SR since working at the facility. An interview was conducted with the Director of Maintenance (DOM) on 7/29/22 at 12:22 PM. The DOM stated they have been working in the facility for 6 months, and the previous director resigned. The DOM stated they are not aware of any residents using side rails in the facility. There is a program for gap spaces, but they have not had to utilize it because there are no residents with side rails. The DOM stated he/she heard the doctors have to approve SR. If SR are used, the process would be to make sure there is a proper gap between the mattress and SR. The DOM could not recall asking any maintenance staff to install any SR. The SR are kept in storage. On 8/2/22 at 12:38 PM, an interview was conducted with the Director of Nursing (DON) who stated that SR orders should have a medical rationale. The DON stated the facility had a log that contained bed and side rail assessments that included measuring the SR, the space between the mattress and the SR, and the space between the mattress and headboard. The facility was unable to locate the bed assessment log. 415.12(h)(1) | Plan of Correction: ApprovedSeptember 12, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F- 700 I. The following actions were accomplished for the residents identified in the sample: Resident #80 On 8/29/22, the Bed Mobility/Use of side rail assessment to assess risk of entrapment possible benefits of bed rails was completed and reviewed by the IDCPT and determined resident does not need side rails. Side rails were discontinued and removed. IDCPT reviewed and update the ADL care plan and CNA nursing instruction. The Nurse Manager reviewed the plan of care with the unit staff Resident #41 On 8/15/22, the Bed Mobility/Use of side rail assessment to assess risk of entrapment possible benefits of bed rails was completed and reviewed by the IDCPT and determined resident needs side rails as enabler. IDCPT discussed the risk and benefits of side rail use with the resident and family and informed consent was obtained. MD order was obtained, and maintenance staff conducted the dimensional assessment of the residentÆs bed according to the FDA guidelines. The Nurse Manager reviewed the plan of care with the unit staff. The DNS/Designee reeducated identified staff members CNA #7, CNA #1, RNS #2, RNS #4 regarding their responsibility to adhere to the plan of care for side rail use as well as adherence to the facilityÆs side rail policy. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residentÆs beds with side rails have been identified as potentially being affected by the same practice. On 8/29/22, the DNS and Director of Maintenance conducted rounds on all units to identify all residentÆs beds with side rails, functionality, and compliance with the FDA guidelines. On 8/30/22, Bed Mobility/Use of side rail assessment were initiated and completed to all residents identified with side rails. IDCPT ad hoc meeting was conducted on 8/31/22 to review the assessment and rehab bed mobility screen and determine the appropriateness of side rail use. MD orders and informed consents were obtained, and care plan and CNA nursing instructions updated to all resident determined to benefit side rail use. The maintenance department were informed and commenced the removal of side rails identified as not required by a resident. All resident admitted or readmitted to the facility from (MONTH) 2022 were assessed for side rail use using the Bed Mobility/Use of Side Rail assessment tool. Bed Mobility/Use of Side Rail Assessment will be completed for all residents upon admission, re-admission, with significant change of status and during MDS quarterly scheduled assessments. On 8/31/22, a comprehensive list of all residents who used any type of side rail was developed for monitoring purposes by the clinical staff. This list will be updated periodically by DNS/designee and distributed to all nursing units weekly. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Medical Director, and DNS reviewed the facilityÆs policy and procedure related Side Rail Use and determined that no revisions were needed. DNS/designee provided education to all IDCPT members, including CNAs regarding the use of Side Rails, included in this education was a review of the facilityÆs procedure related to side rail use, clinical assessment prior to side rail use, education to resident and/or representative, obtaining an informed consent and MD order, and development of the care plan and communication to the CNA nursing instruction. This education will be incorporated into the orientation of new staff and will be provided at least annually and as needed. DNS/designee provided education to maintenance staff on their responsibility of periodic monitoring and conducting the dimensional assessment of the residentÆs bed according to the FDA guidelines and installing bed rails according to the manufacturer's instructions to ensure a proper fit and reduce the risk of injury resulting from entrapment or falls The RN Supervisors and Nurse Managers will monitor compliance through routine observational rounds, review of physician orders, care plans and CNAAR documentation to ensure policies and procedures are being followed, such as completion of assessments, CNAARs and care plans are current, and a physician order [REDACTED]. Immediate corrective actions, including staff re-education, assessment of the restraint or implementation of a care plan for side rails, will be implemented, as indicated. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with bed rail installation protocols. The audit tool will include appropriate alternatives attempted, assessing residents for risk of entrapment prior to installation, reviewing the risks and benefits of bed rails with the resident or representative, and ensuring the bed's dimensions were appropriate for the resident's size and weight and according to the manufacturerÆs recommendations. The Director of Nursing/designee will audit all residents with side rails on a monthly basis for the next three months and then quarterly for an additional three quarters. Corrective action, including staff re-education, will be implemented as indicated. At the end of the 4th quarter a decision will be made by the QA Committee regarding the need for ongoing monitoring specific to side rail use. The Director of Maintenance will audit all residentÆs beds for presence of side rails and compliance with FDA recommended guidelines (seven zones) and functionality on a monthly basis for the next 3 months then quarterly for an additional three quarters. All bed inspection side rail audit findings will be reported to the Administrator and Director of Nursing as the audits are completed. Additional corrective action, including staff re-education or provision of alternate side rails, will be implemented as indicated. Completion Date: 9/28/22 Responsibility: Director of Nursing and Maintenance Director |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and Extended survey from 7/21/2022 through 8/03/2022, the facility did not ensure that each resident's person-centered, comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs. This was evident for 1 of 4 residents reviewed for Smoking out of a sample of 47 residents (Resident # 48). Specifically, the resident's care plan was not revised and implemented to reflect that the facility was smoke-free and included interventions regarding safe smoking for a resident who had incidents of unsafe smoking in the facility. The finding is: The facility policy and procedure titled Grand Manor Nursing Home Comprehensive Care Plans dated 1/1/2021 documented it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The facility policy titled Resdent Smoking Free Facility dated 04/2020, documented that the facility initiated a smoke free policy on (MONTH) 2020 due to COVID-19 Public Health Emergency and will promote smoking cessation while ensuring resident safety. Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum (MDS) data set [DATE] documented that the resident was cognitively intact and there was no tobacco use. The Quarterly Minimum (MDS) data set [DATE] documented that the resident is cognitively intact and exhibited rejection of care over 1-3 days. The resident required supervision setup help only with all Activities of Daily Living except eating. The Comprehensive Care Plan titled Smoking Care Plan dated 2/24/2017 reviewed 6/7/2022 documented Care Area as - resident is a safe smoker and is able to smoke and extinguish cigarette safely and follow smoking rules and regulations. Goals included resident will continue to have no injuries while smoking and will continue to follow smoking rules daily. Interventions included sign smoking agreement, light will be provided in smoke room, resident will be assessed for his/her ability to smoke safety, resident will receive counseling as a result of non-compliance with rules of Safe Smoking Program as appropriate, Resident's room bags will be checked for cigarettes and or lighting materials as appropriate, smoking cessation will be offered, unannounced room checks will be conducted as appropriate, resident will be observed to insure they use ashtray appropriately, resident will be reminded informed of smoking rules/designated areas/hours as appropriate, and will be supervised while smoking at all times. Social Services Note dated 05/03/2022 documented that the Social Worker met with resident on multiple occasions due to smoking in the facility despite being counseled on facility regulations and guidelines. Resident continues with noncompliant behavior with safety regulations. Nicotine patch offered. MD made aware. Social Services note dated 5/2/2022 documented that the Director of Social Work and Maintenance staff conducted a room search and pills, sharp objects, scissors, cigarettes, and cigarette ashes were found in the room of Resident #48 and were confiscated. SW and staff advised resident this was not allowed in facility and Resident becomes verbally abusive when advised and behaviors were discouraged. The note also documented that the SW would continue to monitor for any changes, provide emotional support and counsel. Psych and Psychological services recommended. There was no documented evidence that the resident's care plan was revised with interventions to address resident's unsafe smoking in the facility since the facility became smoke-free in (MONTH) 2020. On 7/26/22 at 12:20 PM, Registered Nurse (RN) #1 was interviewed. RN #1 stated that sometimes they do care plans and the Admission RN would initiate the care plan for a newly admitted resident. RN #1 also stated that RNs revise and update care plans every 3 months and the supervisor would be responsible to initiate a care plan if a Licensed Practical Nurse (LPN) is covering floor since an LPN cannot do care plans. RN #1 further stated that residents who smoke or have tendencies to smoke will either have a behavior note, behavior care plan, or smoking care plan. On 7/29/22 at 6:16 PM, the Director of Nursing (DON) was interviewed. The DON stated that care plans are to be initiated upon admission by RN supervisor on the floor. The DON also stated that care plans should be updated quarterly, as needed, and upon significant change by supervisor and MDS Coordinator. The DON stated that they also assist with the updating of care plans and that the smoking care plan not being revised and updated must have been an oversight. 415.11(c)(2)(i-iii) | Plan of Correction: ApprovedSeptember 12, 2022 F- 657 I. The following actions were accomplished for the residents identified in the sample: Resident #48 On 7/28/22, the IDCP Team reviewed the residents care plan related to the residentÆs smoking and incidents of unsafe smoking. The care was revised to include the provision of education and counseling on safe smoking policy and consequences of non-compliance. One to one observation for 48 hours and room search will be initiated when non-compliance with smoking policy is observed. The NM reviewed and updated the CNAAR at the same time and reviewed the plan of care with the unit staff. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially affected by the same practices including those residents who indicate a preference to smoke and exhibit unsafe smoking practices. The facility will develop a CCP review schedule to ensure that each residentÆs CCP has been reviewed by (MONTH) 2, 2022. The plan will include a scheduled review per unit by the IDCP Team; scheduling will accommodate members of the IDCP Team who may be part of the IDCP Team on more than one unit. Residents who indicate a preference to smoke and exhibit unsafe smoking practices will be prioritized for review by the IDCPT. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, DNS and RN/MDS Coordinator reviewed the policy and procedure for Comprehensive Care Plans, including protocols related to review and revision of the care plan by the IDCP Team to reflect the current status of the resident on an ongoing basis, but, minimally, quarterly and determined that no revisions were needed. The Staff Educator/designee will provide additional education to the IDCP Team regarding care planning protocols related to the review and revision of the care plan. Education included the importance of individualization of the plan of care with review and revisions being implemented for specific concerns, such as a for a resident who indicates a preference to smoke and exhibits unsafe practices so that the care plan is current related to a residentÆs specific needs. This education will be incorporated into the orientation of new IDCP Team members and will be reviewed on an as needed basis. The RN/MDS Coordinators will monitor for compliance with review and revision of the comprehensive care plan policy during review of the comprehensive care plan during care plan meetings and audits of the CCPs as well as follow-up on an individual basis when a concern, such as non-compliance with safe smoking practices, are identified. Immediate corrective actions, such as revision/updating of an individual residentÆs care plan when it is not reflective of current needs or staff re-education regarding responsibility to update the care plan when needed, will be implemented, as needed. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility developed an audit tool to monitor compliance with the facilityÆs protocols related to comprehensive care plan review and revision including smoking preference and observation of unsafe smoking practices, and corrective measures implemented to reflect current residentÆs specific needs. The MDS Coordinators/designee will audit 20% of resident CCPs on a monthly basis for the next six months and then quarterly for an additional two quarters. The audit sample will include residents who smoke and exhibit unsafe smoking practices. All care plan review and revision audit findings will be reported to the Administrator and DNS. Corrective action, including staff re-education or revision/updating of a residentÆs CCP, will be implemented as indicated. The RN/MDS Coordinator will report all comprehensive care plan review and revision audit findings to the QAPI Committee monthly for three months and then quarterly for an additional three quarters for evaluation and discussion. At the end of the 4th quarter a decision will be made by the QAPI Committee regarding the need for ongoing monitoring and at what frequency. Completion Date: (MONTH) 28, 2022 Responsibility: Director of Nursing |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification and Extended Survey, the facility did not ensure that comprehensive person-centered care plans were developed and implemented for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment for 6 (Resident #s 6, 33, 48, 82, 85 and 196) of 46 sampled residents. Specifically, Resident #82 had no comprehensive care plan (CCP) developed to address [MEDICAL TREATMENT], and unsafe smoking. Resident #48, #33 and 196 had no CCP to address smoking and unsafe smoking. Resident #6 had no CCP developed to address [MEDICAL TREATMENT]. Resident #85 had no CCP developed to address [MEDICAL CONDITION] medication. The findings included but are not limited to: Review of a facility policy, Comprehensive Care Plans dated 01/01/21 documented that Comprehensive Care Plan (CCP) will be developed for each resident that will include measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessments. The policy also stated that the CCP will be completed within 7 days after the completion of comprehensive assessments. It will be prepared by the interdisciplinary team and be periodically reviewed and revised by the team. 1) Resident #82 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment, dated 05/29/22, documented Resident #82 had intact cognition. The MDS further documented the resident received [MEDICAL TREATMENT] while a resident. The resident required limited assistance for transfer, toileting, and ambulation, and extensive assistance for personal hygiene. The physician's orders [REDACTED]. A Nursing Note dated 07/09/22 documented that the resident refused [MEDICAL TREATMENT] today. A Nursing Note dated 07/01/22 documented Resident #82 returned from AV fistula appointment for Left upper Arm AV Graft. A-V access is ready for [MEDICAL TREATMENT]. Resident is to return to the clinic on 7/26/22 by 7.00am for catheter removal. There was no documented evidence a CCP for [MEDICAL TREATMENT] was developed. Initial Social Service Assessment and Psychosocial History dated 05/28/21 documented that the resident admitted to smoking cigarettes and alcohol use. Social Service Assessment and Psychosocial notes dated 01/19/22 and 05/26/22 documented Resident #82 admitted to smoking cigarettes. Social Worker behavioral note dated 07/18/22, documented that nursing staff observed resident with noncompliance behavior. Resident noted smoking in the facility despite being counseled on the facility's current smoking rules. There was no documented evidence a CCP was developed to address the resident's smoking status and unsafe smoking. On 07/29/22 at 11:29 AM, the Registered Nurse (RN#1) stated he/she is responsible for developing the CCP, and there should be a [MEDICAL TREATMENT] CCP. RN #1 stated the facility had been going through some staffing issues lately, and they have to pass medications, follow up on appointments, and f/u on all other resident care. On 07/29/22 at 11:07 AM, an interview conducted with the MDS Coordinator (MDSC). The MDSC stated they make the weekly schedule list of the residents due for care plans. The list is sent to all departments so each discipline will be able to review and revise the resident's care areas prior to the CCP meeting. The MDSC stated he/she ensures the care plans are done and revised timely. The RN Supervisor is responsible to update care plans related to new admissions and revision of care plans. The facility has 3 RN supervisors and 1 LPN on each unit during the day, making it difficult for the nurses to complete the required work, like care planning. The MDSC stated there is a shortage of nurses, and the agencies used are unreliable as their staff do not stay long. 2) Resident # 196 was admitted with [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set 3.0 (MDS) assessment 06/30/22 documented that the resident cognitive status was moderately impaired (BIM 12). The MDS also documented that the resident required a limited assistance with mobility, transfer and toilet use, and an extensive assistance with personal hygiene. On 7/26/22 at 12:25 PM, Resident #196 was observed coming out of the South stairwell and the alarm sounded and was silenced by the resident. Staff did not respond to the alarm. A Social Worker note (SW) Note dated 07/26/22, documented Resident #196 was observed smoking Marijuana in their room. Resident #196 was educated about the smoking policy, informed the facility is non-smoking, and offered a nicotine patch and gum. The SW also documented that the ethics committee will meet, and a 30-day discharge notice will be provided when a placement is found. The SW admission note dated 06/16/21 documented that resident #196 reported that they smoke, and the SW informed resident about the smoking policy and would be assessed for smoking. A review of a Social Work (SW) note dated 05/13/22 documented the fire alarm sounded in the resident #196's room. The room smelled of cigarette smoke, a room search was done, and a cigarette box and ashes were found. Resident #196 was reminded the facility is smoke-free, and Resident #196 The Fire Alarm Record documented the fire alarm was triggered in Resident #196's room due to cigarette smoking on 03/18/22, 05/1/22, and 06/1/22. There was no documented evidence in the medical record that a smoking care plan was developed to address the resident's smoking status and episodes of unsafe smoking. 3) Resident #85 was admitted to the facility with anxiety disorder, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #85 had intact cognition. Resident #85 had active [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The Psychiatry Consult Note dated 6/7/22 documented resident with anxiety, depressive and [MEDICAL CONDITION] disorder, was seen for evaluation. No psychotic symptoms were noted, no reported increase in severity of hypomania. It further documented that Resident #85 is stable and recommended to decrease [MEDICATION NAME] 1 mg q HS to [MEDICATION NAME] 0.5 mg q HS. Resident to be monitor for increased [MEDICAL CONDITION] or poor impulse control. There was no documented evidence a CCP for [MEDICAL CONDITION] medication use was developed for Resident #85. During an interview on 8/1/22 at 09:48 AM, Registered Nurse Supervisor (RNS #4) stated that Resident #85 does not have a CCP developed for [MEDICAL CONDITION] medication use. RNS #4 stated Resident #85 should have a CCP for pscyhotropic medication because he/she receives antipsychotic and antidepressant medication. RNS #4 stated he/she is responsible for reviewing and revising the CCPs, but he/she has not been able to do it because he/she has been coveraing as a unit nurse due to the staffing issues. During a follow-up interview on 8/2/22 at 12:00 PM, the Director of Nursing (DON) stated Registered Nurse Supervisor (RNS) is the staff responsible for the care planning of the resident. However, RNS are currently covering the unit as unit nurse because there is a shortage of nursing stff. DON reviewed Resident #85's care plans and the Medication Administration Record [REDACTED]. DON further stated that there should have been one because the resident was taking [MEDICAL CONDITION] medications. 415.11(c)(1) 415.11(c)(1) | Plan of Correction: ApprovedSeptember 12, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F- 656 I. The following actions were accomplished for the residents identified in the sample: Resident #82 On 7/28/22, the IDCP Team reviewed the residentÆs care plan and updated it to include a plan of care for [MEDICAL TREATMENT] and unsafe smoking. During the care plan review the IDCP Team identified any other care concerns that were not addressed and addressed the same. The Nurse Manager reviewed and updated the CNAAR as needed based on the care plan revision and reviewed the plan of care with the unit staff. Resident was transferred to the hospital on [DATE] for other medical reasons. Residents #48 and #196 On 7/28/22, the IDCP Team reviewed each residentÆs care plan and updated it to include a plan of care for unsafe smoking. During the care plan reviews the IDCP Team identified any other care concerns that were not addressed and addressed the same. The Nurse Manager reviewed and updated the CNAARs as needed based on the care plan revision and reviewed the plan of care with the unit staff. Resident #33 The resident is currently in the hospital; therefore, corrective action could be implemented upon return to the facility. Resident #85 On 8/2/22, the IDCP Team reviewed the residentÆs care plan and updated it to include a plan of care for [MEDICAL CONDITION] medication. During the care plan review the IDCP Team identified any other care concerns that were not addressed and addressed the same. The Nurse Manager reviewed and updated the CNAAR as needed based on the care plan revision and reviewed the plan of care with the unit staff. Resident #6 On 8/5/22, the IDCP Team reviewed the residentÆs care plan to ensure that it included a plan of care for [MEDICAL TREATMENT]. During the care plan review the IDCP Team identified any other care concerns that were not addressed and addressed the same. The Nurse Manager reviewed and updated the CNAAR as needed based on the care plan revision and reviewed the plan of care with the unit staff. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially affected by the same practices including those residents who require [MEDICAL TREATMENT], indicate a preference to smoke as well as those who are prescribed psychoactive drugs. The facility will develop a CCP review schedule to ensure that each residentÆs CCP has been reviewed by (MONTH) 2, 2022. The plan will include a scheduled review per unit by the IDCP Team; scheduling will accommodate members of the IDCP Team who may be part of the IDCP Team on more than one unit. Residents who require [MEDICAL TREATMENT], indicate a preference to smoke as well as those who are prescribed psychoactive drugs will be prioritized for review by the IDCPT. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator DNS and RN/MDS Coordinator reviewed the policy and procedure for Comprehensive Care Plans, including protocols related to care planning for all resident needs and determined that the policy is consistent with Federal regulation as well as reflecting the facilityÆs practices. The Staff Educator/designee will provide additional education to the IDCP Team regarding care planning protocols and the facilityÆs policy. Education included individualization of the plan of care to address special needs, preferences, diagnosis, and use of psychoactive meds. This education will be incorporated into the orientation of new IDCP Team members and will reviewed on an as needed basis. The RN/MDS Coordinator will monitor for compliance with the comprehensive care plan policy for ensuring that the plan of care addresses each residentÆs individual problems, strengths, needs, and [DIAGNOSES REDACTED]. Immediate corrective actions, such as revision/updating of an individual residentÆs care plan or staff re-education on changes to the plan of care, will be implemented, as needed. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility developed an audit tool to monitor compliance with the facilityÆs protocols related to comprehensive care planning. The audit will include residentÆs individual problems, strengths, needs, and [DIAGNOSES REDACTED]. MDS Coordinator/designee will audit 20% of resident CCPs monthly for the next three months and then quarterly for an additional two quarters. Resident sample will include residents who require [MEDICAL TREATMENT], who smoke, and residents receiving psychoactive medication. All care plan audit findings will be reported to the Administrator and DNS. Corrective action, such as staff re-education or revision/updating of a residentÆs CCP, will be implemented as indicated. The RN/MDS Coordinator will report all comprehensive care plan audit findings to the QAPI Committee monthly for three months and then quarterly for an additional two quarters for evaluation and discussion. At the end of the 3rd quarter a decision will be made by the QAPI Committee regarding the need for ongoing monitoring and at what frequency. Completion Date: (MONTH) 28, 2022 Responsibility: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification survey from 7/21/22 to 8/3/22, the facility did not ensure the attending physician (MD) documented review and action, if any, to address pharmacy reported irregularities. This was evident for 1 (Resident #35) of 5 residents reviewed for Unnecessary Medication. Specifically, pharmacy recommendations to perform a Hemoglobin A1c (HbA1c) test for Resident #35 was reviewed and documented by the MD in the resident's medical record. The findings are: The undated facility policy titled Drug Regimen Review - Monthly documented all pharmacy recommendations will be submitted monthly for the prescriber's review and response. The prescriber shall act upon the recommendations within 7-14 days or less and document a clinical rationale if no change is to be made. Resident #35 had [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #35 was cognitively intact. MD Order initiated 8/25/17 and last renewed 7/29/22 documented Resident #35 was prescribed [MEDICATION NAME] 500mg twice daily after meals and 35 units of [MEDICATION NAME] U-100 Insulin subcutaneously in the evening. A laboratory result dated 03/16/21 documented an HbA1c test was performed and Resident #35's values were high (6.7 out of range of 3.5 - 5.6). Pharmacy Recommendations, communicated to the facility via email, dated 1/06/22, 2/04/22, 4/06/22, and 5/05/22 documented Resident #35 received [MEDICATION NAME], an HbA1c result could not be located in the resident's medical record, and an HbA1c test was recommended every 6 months. MD Orders dated 1/26/22, 3/22/22, and 5/15/22 documented HbA1c testing for Resident #35 was ordered and discontinued. There was no documented evidence Resident #35 refused to have lab tests performed. There was no documented evidence the MD reviewed and addressed the pharmacy recommendation for Resident #35 to have HbA1c testing every 6 months. On 08/02/22 at 3:00 PM, a Laboratory Representative was interviewed and stated the lab's computer system reflected Resident #35 had labs drawn on 4/26/22 but was unable to provide documented evidence upon multiple requests. On 08/02/22 at 02:00 PM, the Director of Nursing (DON) was interviewed and stated the night shift reconciles MD orders by printing them out and filing them in the laboratory logbook. The DON was unable to explain the reason MD orders for HbA1c testing for Resident #35 were initiated and then discontinued. MD unit assignments changed approximately 1 year prior, and the facility team met because there were a lot of missing orders. There were some units that temporarily did not have MD coverage. On 07/29/22 at 01:09 PM, MD #1 was interviewed and stated MD #1 is covering for the Medical Director who was assigned to Resident #35 and on vacation. The pharmacy consultant sends recommendations to the DON, Medical Director, and Administrator. MD #1 was unable to provide documented evidence pharmacy recommendations for Resident #35 were reviewed and addressed and could not provide a reason the pharmacy recommendations were not addressed. On 08/02/22 at 11:33 AM, the Administrator was interviewed and stated the pharmacy consultant send their recommendations to the DON and Medical Director. The DON prints out the pharmacy recommendations and gives them to medical staff to address. The DON and Medical Director are responsible for ensuring pharmacy recommendations are addressed and the Administrator was not aware of any issues. 415.18(c)(2) | Plan of Correction: ApprovedAugust 26, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F756 - Drug Regimen Review, Report Irregular, Act On I. The following actions were accomplished for the residents identified in the sample: Resident #35 On 7/29/22, attending physician seen, examined and reviewed residentÆs plan of care as well as medication regimen and addresses irregularities identified by the pharmacy consultant related to residentÆs HbgA1C blood level monitoring. HgBA1C was ordered on [DATE] with result indicating 8.0%. Resident was seen by the attending physician on 8/17/22 to address the HgbA1C result with no new orders. Between 8/29/22 and 9/2/22, Medical Director discussed with attending medical staff the policy and procedure related to Drug Regimen Review to ensure all pharmacy recommendations will be acted upon within 7-14 days or less and document a clinical rationale if no change is to be made. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practice. The DNS and Medical Director conducted a full house review of all completed and submitted Drug Review Regimen from (MONTH) to (MONTH) to ensure all pharmacy recommendations will be acted upon within 7-14 days or less and document a clinical rationale if no change is to be made. Corrective action will be implemented to any identified deficient practice. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Medical Director and Consultant Pharmacist will review and revise, as needed, the facilityÆs policy and procedure for Drug Regimen Review. The policy was updated to address system process of monitoring compliance with action taken to any pharmacy recommendations. All medical providers will be educated by the Medical Director/designee on the above protocol to ensure pharmacy recommendations in completed monthly DRRs are acted upon within 7-14 days or less and document a clinical rationale if no change is to be made. The Consultant Pharmacist will continue to review each residentÆs drug regimen on a monthly basis and will make recommendations that will be provided to the Physician for review and evaluation. Consultant Pharmacist shall also review prior completed and submitted DRRs to ensure recommendation are acknowledged by the attending physician or Medical Director. Medical Director to conduct follow-up reviews of all submitted DRRs to ensure all pharmacy recommendations will be acted upon within 7-14 days or less and document a clinical rationale if no change is to be made. Corrective action will be implemented to any identified deficient practice IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with protocols related to timely response to pharmacy recommendations made in monthly drug regimen reviews. All completed and submitted monthly DRRs from (MONTH) 2022 will be audited by the Medical Director/designee monthly x 6 months and then 20% quarterly thereafter. The Medical Director will report audit findings to the Administrator and QAPI Committee initially on a monthly basis for 6 months and then quarterly. Responsible Team Member: Medical Director Completion Date: (MONTH) 28, 2022 |
Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Extended Recertification and Complaint survey (NY 383, NY 660 and NY 005) from 07/21/2022 through 08/03/2022, the facility did not ensure residents were adequately supervised to prevent smoking accidents. This was evidenced for 4 of 4 residents reviewed for Smoking. (Resident #s 196, 82, 33, and 48) Specifically, the facility failed to provide adequate supervision and interventions to address residents with unsafe smoking and smoking in their rooms. Additionally, incidents of unsafe smoking were not investigated to determine adequate interventions to prevent recurrence. This was evident for 4 (Resident #s 196, 48, 82, and 33) of 4 residents reviewed for smoking. Resident #196 was identified as a smoker when admitted on [DATE] and had a BIMS score of 12 out of 15, indicating moderately impaired cognition. A smoking safety assessment was not completed, and a smoking care plan was not developed. A Social Work (SW) note dated 5/13/2022 documented the fire alarm sounded in Resident #196's room. The room smelled of smoke, a room search was done, and a cigarette box and ashes were found. Resident #196 was reminded the facility is smoke-free, and Resident #196 denied smoking. The Fire Alarm Report documented the fire alarm was triggered in Resident #196's room due to unsafe smoking on 3/18/2022, 5/1/2022, and 6/1/2022. There was no documented evidence Resident #196 was provided a 30-day discharge notice, had increased monitoring, or care planned interventions to address the unsafe smoking. There was no documentation the incidents of unsafe smoking were investigated. A SW Note dated 07/26/2022 documented Resident #196 was observed smoking marijuana in their room. Resident #196 was educated about the smoking policy, informed the facility is non-smoking, and offered a nicotine patch and gum. The SW documented the ethics committee would meet, and a 30-day discharge notice would be provided when a placement was found. Resident #s 48, 82, and 33 also had incidents of unsafe smoking that were not investigated. There was no evidence of increased monitoring or new interventions implemented after the incidents. During observations of the stairwells conducted on 7/26/22, surveyors smelled smoke and found cigarette butts throughout the stairwells. This resulted in Substandard Quality of Care that was Immediate Jeopardy (IJ) with the likelihood for serious injury, serious harm, serious impairment, or death to all residents smoking unsafely without adequate assessment and supervision. It was identified and declared. The IJ began on 07/26/2022 and was called on 07/27/2022 at 05:12 PM The facility submitted a removal plan on 07/28/2022 at 01:42 AM. IJ was removed 08/01/2022 at 05:36 PM. The findings include but are not limited to: The facility policy titled Smoking Free Facility dated 04/2020, documented the following: -The facility initiated a smoke free policy on (MONTH) 2020 due to COVID-19 Public Health Emergency and will promote smoking cessation while ensuring resident safety. -Smoking is prohibited in all areas of the facility and residents admitted after the facility became smoke-free will be notified of this policy during the admission process, and as needed. -All residents will be asked about tobacco use urges during admission, quarterly, or upon comprehensive Minimum Data Set 3.0 (MDS) assessment. 1.) Resident #196 was admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #196 had mild moderately impaired cognition and required limited to extensive assistance to complete Activities of Daily Living (ADL). On 7/26/2022 at 12:25 PM, the South Stairwell (SS) alarm sounded, and Resident #196 was observed exiting the SS and entering the unit. Staff were not observed responding to the door alarm. Resident #196 was observed silencing the SS door alarm. On 07/26/2022 from 06:30 PM to 6:45 PM, observations of the SS were conducted: there was a strong odor of cigarette smoke; a burnt cigarette butt (CB) on the floor between the 5th and 6th floor; 4 CBs placed behind a fire hydrant pipe on the 5th floor landing; 3 CBs stuffed into cracks in the wall by the sprinkler pipe between the 3rd and 4th floor landings; 1 CB on the 4th floor landing; multiple CBs stuffed behind the fire standpipe risers of the 4th floor; 1 CB on the 2nd floor landing; and, 10 CBs in a space between the staircase and the wall between the 2nd and 1st floor. On 07/26/2022 at 06:48 PM, the North Stairwell (NS) 3rd floor landing was observed with 1 CB behind a fire hydrant pipe. The SW admission note dated 06/16/2021 documented Resident #196 identified themselves as a smoker, was informed of the facility smoking policy, and would be assessed for smoking. Fire Alarm Records dated 03/18/2022, 05/1/2022, and 06/1/2022 documented the fire alarm was triggered in Resident #196's room due to cigarette smoke. SW note dated 05/13/2022 documented the fire alarm sounded in the Resident #196's room. The room smelled of cigarette smoke, a room search was done, and a cigarette box and ashes were found. Resident #196 was reminded the facility is smoke-free. A SW note dated 07/26/2022 documented Resident #196 was observed smoking Marijuana in their room. Resident #196 was educated about the smoking policy, informed the facility is smoke-free, and offered a nicotine patch and gum. The ethics committee will meet, and a 30-day discharge notice will be provided to Resident #196 when a placement is found. There was no documented evidence the facility assessed Resident #196 for smoking, provided adequate supervision to prevent smoking incidents, investigated incidents of unsafe smoking, or addressed the resident's unsafe smoking with revised care plan interventions. On 07/27/2022 at 08:56 AM, the Registered Nurse (RN #2) assigned to Resident #196's unit, was interviewed and stated staff do not monitor resident use of the stairwells. Residents are not allowed to use the stairwell, but there are residents who use the stairwell when the elevator takes too long. Staff check the stairwells when the stairwell door alarms sound. 2.) Resident #82 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented Resident #82 was cognitively intact and required limited to extensive assist with Activities of Daily Living (ADL). On 07/21/2022 at 10:01 AM and 07/25/2022 at 11:51 AM, Resident #82 was observed in bed in their room. The room had a strong odor of stale cigarette smoke. Resident #82 was interviewed and stated they smoke in their room sometimes because the facility does not address their smoking concerns. Resident #82 could not recall being informed of the facility smoking policy. Social Work (SW) Assessments dated 05/28/2021, 01/19/2022, and 05/26/2022 documented Resident #82 reported being a smoker. There was no documented plan to address Resident #82 as a smoker. A SW note dated 6/10/2022 documented the SW met with Resident #82 on multiple occasions due to noncompliance with smoking safety regulations, but Resident #82 continued to smoke in the facility. A Nicotine patch was offered, and the Medical Doctor (MD) was made aware. The was no documented evidence the MD evaluated and assessed Resident #82 for smoking cessation or intervention. A SW note dated 7/18/2022 documented Resident #82 was observed by nursing staff smoking in the facility despite being counseled on current regulations and guidelines. Resident #82 became verbally and physically aggressive by using profanity and throwing objects at staff. There was no documented evidence the facility assessed Resident #82 for smoking, provided adequate supervision to prevent smoking incidents, investigated incidents of unsafe smoking, or addressed the resident's unsafe smoking with revised care plan interventions. On 07/25/2022 at 12:04 PM, Certified Nursing Assistant (CNA) #1 was interviewed and stated they observe Resident #82 smoking in their room all the time. When the fire alarm goes off, the security announces the location of suspected smoke/fire, and the staff conduct a search of the room. CNA #1 never found smoking materials when they searched residents' rooms. The Registered Nurses (RN) Supervisors, SW, and Administrator are aware there are constant smoking issues. On 07/25/2022 at 11:54 AM, an interview was conducted with RN Supervisor #1 who stated the facility is smoke-free, and most of the smokers don't leave the building to smoke. Some of the smoking residents smoke in their rooms, and the alarm goes off very often. RN Supervisor #1 was not aware of a facility plan to address the smoking residents. The staff reinforce with smoking residents that the facility is smoke-free. 3.) Resident #33 was admitted to the facility on [DATE] with [MEDICAL CONDITION] due to spinal cord injury and major [MEDICAL CONDITION]. The MDS dated [DATE] documented Resident #33 was cognitively intact and required the extensive assist of two people for bed mobility and transfers. The Baseline Comprehensive Care Plan (CCP) dated 11/24/2021 documented Resident #33's status as a smoker was a safety concern. On 07/21/2022 at 10:02 AM, Resident #33 was observed in their room and the room had strong cigarette smoke smell. The Social Work (SW) assessment dated [DATE] documented Resident #33 smokes cigarettes. The SW notes dated 04/28/2022, 5/05/2022, 5/06/2022, and 06/10/2022, documented Resident #33 was counseled on facility regulations and guidelines due to smoking in the facility. Resident #33 continued to be noncompliant, and a nicotine patch was offered. There was no documented evidence the facility assessed Resident #33 for smoking, provided adequate supervision to prevent smoking incidents, investigated incidents of unsafe smoking, or addressed the resident's unsafe smoking with revised care plan interventions. On 07/27/2022 at 10:39 AM, Housekeeper was interviewed and stated residents use the stairwell. The Housekeeper found cigarette butts in the stairwell previously and reported it to their supervisor. On 7/26/2022 at 11:12 AM, the Director of SW (DSW) was interviewed and stated the DSW informs potential residents the facility is smoke-free prior to admission by providing brochures and facility information to the hospital discharge planner. Potential residents are aware the facility is smoke-free and the DSW is not involved in approving potential residents for admission. The SWs meet with residents on the first day they are admitted to the facility and reinforces the facility is smoke-free. Residents with a history of smoking are offered nicotine gum and patches or a transfer to a facility that allows smoking. If a resident violates the smoking policy, the DSW searches their room, revokes their visitation and out-on-pass privileges, and gives them a 30-day discharge notice. The issue of unsafe smoking began in 10/2021 and, in the past, the facility issued 30-day discharge notices to 2 residents due to unsafe smoking. On 07/26/22 at 11:17AM, an interview was conducted with the Director of Nursing (DON) who stated prospective residents are informed the facility is smoke-free prior to admission. Noncompliant unsafe smoking residents receive counseling from the SW. Residents are offered smoking cessation. Resident family members were notified the facility became smoke free and not to bring in cigarettes to the residents. The unsafe smokers are having difficulty accepting the facility smoking policy. On 7/26/2022 at 11:29 AM, the Administrator was interviewed and stated residents continue to smoke despite the facility being smoke-free. Noncompliant residents are counseled, informed they may receive a 30-day discharge notice, and the family is made aware. Residents and visitors bring smoking materials into the facility. The Administrator did not identify smoking as a concern. The Administrator stated he/she did not think the unsafe smokers in the facility required assessments and care plan interventions because the facility became smoke-free, and the residents were informed of the policy upon admission. On 07/27/2022 05:12 PM, Immediate Jeopardy (IJ) was identified and declared. The facility Administrator and Director of Nursing were notified. On 07/28/2022 at 01:42 AM, the facility submitted a removal plan that was reviewed and accepted by the NYSDOH. On 08/01/2022 at 05:36 PM, the survey team declared the IJ was removed based on the following corrective actions taken by the facility: 1- For Resident #196 and Resident #82, smoking assessments, Smoking Comprehensive Care Plans (CCP), and smoking contracts were completed. Both residents were observed with one-to-one monitoring, room searches conduct every 4 hours and no further smoking safety concerns identified. All corrections completed by 7/30/2022 2- For Resident #33, a review of nurse's progress note dated 07/24/2022 documented that the resident was transferred to the hospital due to other medical related condition. 3- Resident # 48, smoking assessment was done on 7/29/2022. MD order dated 7/29/2022 at 7:29pm documented allowed to smoke per facility protocol. Smoking care plan effective 7/29/2022. Smoking contract signed 7/30/2022. 4- All residents were reviewed, and the smoking list was updated. All other residents identified as smokers were assessed for safety and smoking care plans were developed and completed as of 08/01/2022. 5- A new smoking policy was developed on 7/2022. The revised policy ensured consistency in assessing residents for smoking, care plans and supervisions. 6- In-service lesson plan and sign-in sheets were reviewed 08/01/2022 and education was provided to 90% of staff (department heads, Administration, Nursing, MDS Department, Dietary, Housekeeping/Maintenance, Recreation, Social Work, Rehabilitation Department) regarding smoking safety protocols, accident/incident reporting, and the revised smoking policy. 7- Interviews were conducted with the following staff regarding smoking safety protocols on from 7/28/2022 through 8/1/2022 the following staff were inserviced and knowledgeable re: the facility's smoking policy: RN = 7, Licensed Practical Nurse = 12, CNA = 25, Therapeutic Nursing Aide = 3 Personal Care Attendant = 1, Medical Doctor = 1, Nurse Practitioner = 1, DSW = 1, Director of Rehabilitation = 1, Certified Occupational Therapy Aide = 2, Physical Therapy Aide = 2, Recreation = 4, Maintenance/Housekeeping = 4, Security = 3, Admissions = 1, SW = 2, and the Administrator = 1. Based on observation, interview and record review conducted on 08/01/2022, the facility fully implemented the IJ Removal Plan, and the IJ was removed as of 08/01/2022 at 5:36 PM. 415.4(a)(2-7) | Plan of Correction: ApprovedAugust 26, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F- 689 I. The following actions were accomplished for the residents identified in the sample: Resident #196 On 7/28/22, IDCP team provided education and counseling to resident on the smoking policy and smoking contract. Smoking assessment, smoking contact and care plan were completed. Resident was placed on one-to-one monitoring, room search conducted every 4 hours and no further smoking safety concerns identified. Resident #82 On 7/28/22, IDCP team provided education and counseling to resident on the smoking policy and smoking contract. Smoking assessment, smoking contact and care plan were completed. Resident was placed on one-to-one monitoring, room search conducted every 4 hours and no further smoking safety concerns identified. Resident was transferred to the hospital on [DATE] for other medical reasons. Resident #33 The resident is currently in the hospital; therefore, corrective action could be implemented upon return to the facility. Resident # 48 On 7/29/22, IDCP team provided education and counseling to resident on the smoking policy and smoking contract. Smoking assessment, smoking contact and care plan were completed. Resident was placed on one-to-one monitoring, room search conducted every 4 hours and no further smoking safety concerns identified On 7/28/22, in-service education was provided to all staff on the new smoking policy that includes staff responsibilities related to: ò 1 to 1 observations and CNA 30 Minute smoking monitoring of identified residents with documentation of record in the CNA Accountability spreadsheet and Spreadsheet called room search findings. ò CNA and Housekeeping staff will monitor stairwells every hour, on each unit. Documentation will be completed in a spreadsheet called Stairwell Checks. Which will then be checked every shift by the RN Supervisor. ò The security guard will search all bags for items prohibited by the facility such as smoking materials, guns, alcohol, and other related contraband items. ò RN will ensure that CNA will be monitored for completing the required 30-minute monitoring and 1 to 1 observation for smokers II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All smoking residents have been identified as potentially being affected by the same practice. On 7/31/22, a full house audit was conducted by the Activity Director/designee to identify residents who smoke. Smoking assessments were completed to determine safe and unsafe/hazardous smoking behaviors. Smoking observation tool and smoking care plans were also developed and completed on all identified smokers on 8/1/22. Smoking care instructions and interventions were also communicated and addressed in the CNA nursing instruction. Each identified resident will have a new Safe Smoking Assessment completed to determine his or her current risk for unsafe/non-compliant smoking. The IDCP Team will review and revise the care plan of each resident who smokes to ensure that the plan of care includes safe smoking interventions, such as room checks for smoking supplies, supervision when smoking, the facility holding the or monitoring of a resident who is considered to be an unsafe, non-compliant smoker. The RN Supervisor/Unit Charge Nurse will review and revise, as needed, the CNA Nursing Instructions to ensure that it includes all interventions that the CNAs are responsible for related to a resident who smokes and will review the plan of care with the unit staff including their documentation responsibilities. The RN Supervisor and the IDCP Team will identify all residents whose plan of care includes daily room search and/or visual checks on a specific schedule. The IDCP Team will reevaluate the plan of care for each identified resident and determine if the room and/or visual checks continue to be required. The IDCP Team will review and revise the care plan of each resident based on their evaluation of the residentÆs ongoing need for room and/.or visual checks. The RN Supervisor/Unit charge nurse will review and revise, as needed, the CNA Nursing Instructions to ensure that it includes all interventions that the CNAs are responsible for related to a resident who requires room and/or visual checks and will review the plan of care with the unit staff including their documentation responsibilities. Effective 7/29/22, all residents identified as smokers will have discussion with the IDCPT on the smoking policy and a new smoking contract was completed. Discussion about the smoking policy and smoking contact must be included during scheduled care plan meetings and annually. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator and Director of Nursing, and Social Work reviewed the facilityÆs current policies and procedures related to accident prevention and provision of adequate supervision and assistance to prevent accidents, including protocols regarding its safe smoking program and visual checks. A new smoking policy was developed on 7/2022. The revised policy ensured consistency in assessing residents for smoking, care plans and supervisions. Outside Consultant reviewed the Safe Smoking Program policy on 8/2/122 and revision were made to include room search and 1:1 monitoring guidelines for resident with unsafe/hazardous smoking behavior. On 7/28/22, all residents were notified of the new smoking policy during the resident council meeting. New smoking policy guidelines are posted in designated areas in the facility. As per the Directed In service, the Outside Consultant provided education from 8/29/22 to 9/28/22 to all staff regarding the facilityÆs protocols related to accident prevention including protocols related to the Safe Smoking Program. This education included a review of the survey findings, policy and procedure revisions, and processes implemented. Emphasis was also given in the staffÆs responsibilities when unsafe/hazardous smoking behaviors are observed. This education will continue to be provided by the Director of Staff Education until all facility staff receives this required education. Additional education will be provided by DNS/designee on the Safe Smoking Program during orientation, minimally on an annual basis, and as needed. Effective 7/28/22, any observed/reported smoking incident/occurrence will be investigated immediately and thoroughly. Any smoking incidents will be investigated as part of the facilities A&I procedure. Smoking assessment will be completed post smoking incident and care plans reviewed and revised to address interventions to prevent recurrence. The Administrator is monitoring implementation of all corrective actions related to the Safe Smoking Program. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a QAPI Committee meeting co-chaired by Outside Consultant was convened on 08/12/22 to examine this deficiency. The facility will develop an audit tool to monitor compliance with the Safe Smoking Program protocols during scheduled smoking activity and attendant monitor. The facility will develop an audit to monitor compliance with Smoking documentation in the clinical record of residents identified as smokers. The facility will develop audit tools to monitor compliance with protocols related to unsafe smoking and completion of room search finding and stairwell checks. The Director of Activities/designee will audit 20% of smoking residents who attends the smoking activity for compliance with the Safe Smoking Program on a monthly basis for the next three months and then quarterly for an additional three quarters. Corrective action, including staff re-education, will be implemented as indicated. At the end of the 4th quarter, the Committee will make a decision regarding the need to continue auditing these areas and the frequency of audit if auditing is to continue as well as the need for additional corrective actions The Director of Activity/designee will report to the QAPI Committee the findings of the above audit on a monthly basis for the first three months and then quarterly for the next three quarters. The Director of Social Services/designee will audit 20% of smoking residents for Smoking documentation compliance on a monthly basis for three months and then quarterly for three quarters for evaluation and follow-up. Corrective action, including staff re-education, will be implemented as indicated. At the end of the 4th quarter, the Committee will make a decision regarding the need to continue auditing these areas and the frequency of audit if auditing is to continue as well as the need for additional corrective actions. The Director of Social Services/designee will report to the QAPI Committee the findings of the above audit on a monthly basis for the first three months and then quarterly for the next three quarters. The DNS/designee will audit all Room Search Finding and Stairwell Check documentation for compliance with the Safe Smoking Program on a monthly basis for the next three months and then quarterly for an additional three quarters. Corrective action, including staff re-education regarding documentation responsibilities, will be implemented as indicated. At the end of the 4th quarter, the Committee will make a decision regarding the need to continue auditing these areas and the frequency of audit if auditing is to continue as well as the need for additional corrective actions. The Director of DNS/designee will report to the QAPI Committee the findings of the above audit on a monthly basis for the first three months and then quarterly for the next three quarters. Completion Date: September 28, 2022 Responsibility: Director of Nursing |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Recertification survey from 7/21/2022 to 8/03/2022, the facility did not ensure infection prevention and control standards were maintained. This was evident for 1 (Resident #134) of 4 residents reviewed for infections and the facility's Legionella Water Management Program reviewed during the Infection Prevention and Control Program (IPCP) review. Specifically, 1) a Certified Nursing Assistant (CNA) was observed without Personal Protective Equipment (PPE) in place while providing care to a resident on transmission-based precautions, Resident #134; and, 2) the facility water management plan lacked a facility risk assessment, environmental assessment, Legionella sampling plan, and a description of the water distribution system. The findings are The facility policy titled Grand Manor Nursing Home Infection Prevention and Control Program dated 02/1/2022 documented the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility policy titled, Grand Manor Legionella Surveillance last revised 02/2022 documented strategies for the prevention and control of Legionella and other opportunistic pathogens (Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) in the facility's water systems. The Maintenance Director maintains documentation that describes the facility's water system, a risk assessment will be conducted by the water management team annually, and control points will be identified based on the risk assessment. 1) Resident #134 was diagnosed with [REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #134 was had moderate cognitive impairments. On 07/29/22 at 03:34 PM, Certified Nursing Assistant (CNA) #9 was observed walking into the room of Resident #134 wearing gloves and N95 face mask. CNA #9 did not don a gown or face shield. A PPE bin filled with supplies was stationed in the hallway outside of Resident #134's room. A sign from the Centers for Disease Control (CDC) posted on Resident #134's door documented Sequence for Putting on PPE - Gown, Mask, Face Shield, and Gloves. And included instructions on how to don and doff PPE. CNA #9 was observed at the bedside of Resident #134, handling the resident's head and body to adjust their position in bed. CNA #9 adjusted the resident's clothing and pillow, discarded their gloves, washed their hands, and then left Resident #134's room. Lab Result documented that Resident #134 tested positive for COVID-19 on 7/26/2022. Nursing note dated 7/26/2022 documented Resident #134 was placed on contact isolation precautions due to positive COVID-19 test. On 07/29/22 at 03:38 PM, CNA #9 was interviewed and stated Resident #134 is Covid-19 positive and CNA #9 is supposed to don a gown and face shield when entering the resident's room. Resident #134's head was not in a good position and CNA #9 had to rush in quickly to adjust the resident. There is a PPE bin outside the resident's door and CNA #9 stated they could have taken PPE from the bin prior to entering the resident's room. On 08/01/22 at 05:47 PM, an interview was held with Licensed Practical Nurse (LPN) #5 who stated they reinforce PPE usage with all staff on the unit. The CDC sign on the Resident #134's door makes staff aware of the resident's isolation status. On 08/01/22 at 05:53 PM, Registered Nurse (RN) #6 was interviewed and stated they are responsible for stocking the PPE bins outside of contact isolation rooms. Staff must don PPE prior to entering room and doff PPE when leaving room. On 08/01/22 at 06:07 PM, the Director of Nursing was interviewed and stated infection control in services are given to the staff as needed. The CDC posting on the provides staff instructions on how to don and doff PPE. 2) The facility Water Management Plan was reviewed and there was no documented evidence the facility performed a risk assessment or environmental assessment. There was no documented evidence of a Legionella sampling plan and a description of the facility's water distribution system. On 07/27/2022 at 06:40 PM, the Administrator was interviewed and stated the facility does not have a risk assessment, environmental assessment, Legionella sampling plan, or a description of the facility's water distribution system. The Administrator stated the facility would be working towards completing and updating the Water Management Plan. 415.19(a) (1-3) | Plan of Correction: ApprovedSeptember 12, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-880 û Infection Prevention and Control I. The following actions were accomplished for those residents found to have been affected by the deficient practice: Resident #134 On 8/4/22, the resident was seen and examined by the attending physician for infectious status evaluation/risk for transmitting infection and plan for discontinuation of transmission-based precautions. As of 8/11/22, resident was discontinued from transmission-based precautions. The resident did not experience a negative outcome from identified staff entering his room without donning the appropriate PPE. Resident is monitored for s/s of infection and remains symptom free for other infectious disease. On 8/1/22, identified staff was provided with a counselling and re-education by DNS on the selection and use of PPE for Standard Precaution and Transmission-based precautions and Breaking the Chain of Infection. Education also included the nurseÆs responsibility related to infection prevention and control protocols. PPE use re-training and competency skill evaluation was conducted on 8/1/22. II. The following corrective actions will be implemented to identify other residents having the potential to be affected by the same deficient practice: All residents have been identified as potentially being affected by the same practice. The facilityÆs QAPI Committee and outside Consultant participated in a DP(NAME) QAPI meeting on (MONTH) 24, 2022, to discuss the Infection Control issues identified at F-880 and conducted a Root Cause Analysis. During this meeting, the outside Consultant provided education to the Committee members on Infection Prevention and Control principles and how non-adherence to proper infection control practices resulted in the cited deficient practices. Education also addressed use of a Root Cause Analysis when compliance issues are identified Please refer to corrective actions outlined at Sections II, III and IV of this DP(NAME). Between 8/8/22 and 8/12/22, all residents of the nursing unit where identified staff was assigned and provided care on 7/29/22 were seen and examined by the attending MD for signs and symptoms of COVID-19 infection. All residents were monitored daily for s/s of COVID-19 infection and remain symptom free. There was no new [DIAGNOSES REDACTED]. On 8/29/22, a full house audit was conducted of all residents with current transmission-based precaution orders to ensure proper implementation of PPE use per facility protocol. The audit included an assessment of posting of signage on the door or wall outside the resident room indicating the type of precautions and required PPE use, readily available PPE supplies outside the room, access to hand hygiene supplies, and availability of trash container inside the room and near the exit for discarding PPE after removal. On 8/29/2022 the facility contacted Barley Water Management to assist in updating the Water Management Plan related to the environmental assessment of the water system and to arrange for Legionella water samples from the potable water system to be obtained and tested . These sample were obtained on 9/16/22 and were submitted to the laboratory for analysis. Corrective actions, such as implementation of short-term control measures and notification of NYSDOH, will be implemented when indicated based on the results of the water samples test results. III. The following system changes will be implemented to ensure that the deficient practice does not recur: On 8/8/22, administrative staff and the outside consultant reviewed the policy and procedure for Standard Precaution and Transmission-based precaution use to ensure compliance with the CDC guidelines for implementation of PPE to prevent spread of infection. Revisions were made to include the selection and use of PPEs for standard and transmission-based precautions and the surveillance process related to the correct use of PPE. On 9/6/22, Staff Educator/designee will provide additional education on the revised Standard and Transmission Based Precaution policy with a focus on breaking the chain of infection and the selection and use of personal protective equipment (PPE) for standard and transmission-based precaution. The education will also include the use of PPE when performing ôshort tasksö. This education will continue until all identified staff have participated in the education. This education will be provided during orientation and on an as needed basis with follow-up monitoring to ensure staff understand these protocols. On 9/6/22, DNS/designee will conduct retraining and competency skill evaluations to all staff related to PPE use upon entering the residentÆs environment, providing close-contact resident care activities, including performing ôshort tasksö and/or contact of potentially contaminated areas in the residentÆs environment. Additional competencies will be conducted for those staff who are identified as needing additional education/skills check. The DON and Nursing Supervisors will monitor for compliance with infection control practices related to PPE use for standard precautions and transmission-based precautions during routine and random rounds on the resident units. Findings will be documented on the Infection Control Rounding audit tool. Immediate corrective actions, such as counselling or reeducating staff observed not wearing appropriate PPE, will be implemented as needed. The facilityÆs vendor will review of the current Water Management Plan will ensure that the sampling and management plan includes at a minimum all requirements contained in Section 4-2.4 for Sampling and Management Plan. o The sampling and management plan will include Legionella culture sampling sites as determined by the environmental assessment. o The sampling and management plan will have provisions for Legionella culture sampling and analysis to be conducted at intervals not to exceed 90 days for the first year following adoption of the sampling and management plan. Thereafter, the plan shall include provisions for annual Legionella culture sampling and analysis. o The sampling and management plan will have provisions requiring actions in response to Legionella culture analysis results, including all responsive actions required by Appendix 4-B, and specific time frames for such actions. o The sampling and management plan will have provisions requiring additional sampling and analysis of the potable water system in a timeframe to be determined by the department upon: a determination by the department that one or more cases of [DIAGNOSES REDACTED] are, or may be, associated with the facility, or any other conditions specified by the department. o The sampling and management plan will require an annual review of the sampling and management plan and under the following conditions: in the event that one or more cases of [DIAGNOSES REDACTED] are, or may be, associated with the facility, or any other conditions specified by the department and upon completion of any construction, modification, or repair activities that may affect the potable water system. o The sampling and management plan and the sampling results will be retained in accordance with section 4-2.6. The vendor along with the Administrator, Infection Preventionist and Director of Maintenance will complete the facility annual facility risk and environmental assessment for Legionella and the development of the description and diagram of the facilityÆs water distribution system. Effective immediately, the Administrator will include a review of Legionella water testing being completed as per requirement as part of the annual review of the infection Prevention and Control Program. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a QAPI Committee meeting co-chaired by Outside Consultant was convened on (MONTH) 24, 2011 to conduct a Root Cause Analysis and examine the deficiency cited at F-880. The facility will develop an audit tool to monitor staff knowledge and compliance with the facilityÆs protocols related to the selection and correct use of PPE for standard precaution and transmission-based precautions. The DNS/designee will audit 10% of all staff members for knowledge and understanding of the protocol related to transmission-based precautions and the selection and use of PPE monthly for the next three months and then on a quarterly basis for the next two quarters. Corrective actions, such as reeducation or additional skills competency evaluations, will be implemented when indicated. All staff knowledge audit findings will be reported to the Administrator, ICP and Director of Nursing. Nursing Management/designee will conduct an audit related to transmission-based precautions, PPE use and hand hygiene, of 5 staff members assigned to each nursing unit per shift, on a weekly basis for one (1) month and then monthly for three (3) months. The audit sample will include all interdisciplinary care team members (clinical and non-clinical) from all units and all shifts. All findings will be reported to the Administrator and DNS for follow-up actions, such as re-education and / or competency evaluation related to PPE use / hand hygiene. The DNS/designee will continue to conduct weekly Infection Control Rounds and report findings to the QAPI Committee monthly for evaluation and follow-up corrective actions such as staff / resident or visitor re-education, completion of additional competency evaluations or revision of policies and procedures to be consistent with State and Federal requirements and CDC guidance. The DNS / Designee will report all Infection Control audit findings related to implementation of transmission-based precautions, proper PPE use and hand hygiene to the QAPI Committee monthly for three (3) months for evaluation and follow up discussion. At the end of this period, the Committee will determine the need for ongoing monitoring specific to transmission-based precautions and the appropriate use of PPE and/or hand hygiene practices and at what frequency. The facility will develop an audit tool to monitor compliance with protocols related to the testing and sampling of the water for Legionella and ensuring the environmental assessment of the water system is kept current and is reviewed annually. The audit tool will include the Legionella culture sampling sites as determined by the environmental assessment, frequency of testing, actions taken in response to Legionella culture analysis results, and annual review of the water management plan. The Director of Maintenance will conduct the audit for the water management plan quarterly for the next three (3) quarters. At the end of this period, the QAPI Committee will determine the need for ongoing monitoring and at what frequency. The Director of Maintenance will report all testing and sampling of water findings to the Administrator as testing and sampling is completed. The Director of Maintenance will report Legionella testing and sampling audit findings to the QAPI Committee on a quarterly basis for evaluation and follow-up discussion. The Administrator, DNS and Director of Maintenance will review the facilityÆs Water Management Plan and update the facility risk assessment for Legionella annually and report the results of the risk assessment to the QAPI Committee. Completion Date:September 28, 2022 Responsibility: Director of Nursing & Administrator |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details Based on observation, interviews, and record review conducted during the Recertification survey from 7/21/2022 to 8/3/2022, the facility did not ensure an Infection Preventionist with specialized training was designated to be responsible for the facility's Infection Prevention and Control Program (IPCP). This was evidenced during review of the facility IPCP. Specifically, the designated IP did not receive specialized education, training, experience, or certification in infection prevention and control. The findings are: The facility policy titled IPCP dated 02/1/2022 documented the facility has established and maintains an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. On 07/26/22 at 12:20 PM, RN #1 was interviewed and stated their job responsibilities include being a Nursing Supervisor at times. RN #1 stated they were not the Assistant Director of Nursing (ADON) or the facility's second IP, and they have not received specialized training in infection prevention and control. RN #1 was surprised the Director of Nursing (DON) reported RN #1 as a designated IP. On 7/21/2022 at 11:33 AM and 07/29/22 at 06:27 PM, the DON was interviewed and stated the DON and Registered Nurse (RN) #1 are the facility IPs. The DON and RN #1 have not received specialized education and did not complete the IP training and certification. The DON plans to register for the IP training course soon and RN #1 will also complete the IP training. The facility does not currently have a trained and certified IP on staff. The former IP left the position, and the facility has been unable to hire a replacement. On 08/01/22 at 06:18 PM, the Administrator was interviewed and stated the DON is the facility's IP. The Administrator was not aware an IP requires specialized education, training, and certification to qualify for the IP designation. The Administrator was not aware the DON did not have the necessary training and certification to be the facility's IP. 415.19 | Plan of Correction: ApprovedSeptember 12, 2022 F-882 û Infection Preventionist I. The following actions were accomplished for the residents identified in the sample: No residents were identified in the Statements of Deficiencies. The facility designated Infection Preventionist will be the Director of Nursing who will receive and complete the specialized education, training, experience, or certification in infection prevention and control by 9/28/22. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected by the same practice. While the facilityÆs designated infection preventionist is in the process of obtaining the required specialized training in infection control and prevention, the facility will have scheduled consultation from a qualified infection preventionist, at minimum on a weekly basis to review current concerns as well as whenever a new infection is identified, to provide guidance to the Director of Nursing/designee. III. The following system changes will be implemented to assure continuing compliance with regulations: With the assistance of the Outside Consultant, the Administrator, Medical Director, Director of Nursing reviewed the facilityÆs policy and procedure for Infection Prevention and Control Program (IPCP) and developed the Infection Preventionist Job Description. Effective immediately, the facility will designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facilityÆs IPCP. The IP must: a) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; b) Be qualified by education, training, experience, or certification; c) Work at least part-time at the facility; and d) Have completed specialized training in infection prevention and control. e) Participation on quality assessment and assurance committee. The facilityÆs designated Infection Preventionist will be the Director of Nursing. The designated Infection Preventionist shall complete the free online training at https://www.cdc.gov/longtermcare/training.html. This training includes 23 modules, a certificate of completion for each section, and a multitude of resources and will be available through (MONTH) 1, 2023. The facility advertised job posting for infection preventionist who must have completed a specialized training in infection prevention and control. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The Administrator will be responsible in monitoring the designation of Infection Preventionist with the appropriate credentials indicating the completion of specialized education, training, experience, or certification in infection prevention and control In the event that a full-time or part-time qualified Infection Preventionist is not employed, the facility will assure scheduled and emergency situation consultation from a qualified infection preventionist will take place to provide guidance to the Director of Nursing/designee until the staffing vacancy is filled. The designated Infection Preventionist will be a member of the QAPI Committee and will be responsible for reporting infection prevention and control program issues and concerns during the scheduled QAPI committee meetings. Completion Date: (MONTH) 26, 2022 Responsibility: Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the extended Recertification and Complaint survey (NY 005), the facility did not ensure that an investigation was completed for a resident with an injury of unknown origin for 1 (Resident #26) of 12 residents reviewed for Accident. Specifically, an investigation was not initiated when Resident #26 was found with a bruised nose of unknown origin to rule out abuse, neglect, or mistreatment. The finding is: The Policy and Procedure (P&P) titled Accident/Incident revised 5/20/17 documented that resident incident/accidents occurring on premises, along with injuries to residents of unknown origin, must be investigated and reported in a timely fashion. Resident #26 was admitted to the facility on [DATE] for emergency placement and [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) 2/7/22 documented Resident #26 had severely impaired cognition. The MDS documented that resident required the extensive assist of one person for bed mobility, transfer, dressing, eating and personal hygiene. The resident required the extensive assist of two persons for toilet use. On 7/25/22 at 9:03 AM, the Complainant was interviewed via phone. The Complainant stated that Resident #26 was observed with bruised nose, and nursing staff was not able to explain the bruise. The Comprehensive Care Plan (CCP) titled Peer Abuse Prevention created 11/1/21, revised 7/18/22. Interventions included to allow resident to vent feelings, anticipate needs, family involvement, hospitalization as needed, medication per MD order, protect from over stimulation, psychiatry consult, redirect/refocus attention by offering alternative activities, and use stop sign at doorway. The CCP titled Accident/Incident/Injury created 4/21/22, revised 6/24/22. Interventions included to maintain adequate lighting, clutter free environment, keep bed in lowest position, keep call bell within reach, wears helmet at all times when out of bed and removes only at bedtime. The CCP titled Victimize/Victimization created 5/11/22, revised 7/25/22. Interventions included to use calm approach, talk in a soothing manner, identify triggers for behavior, keep separate from other residents possibly disturbed by the behaviors exhibited whenever possible, encourage family/friends involvement, observe for peer's wandering behaviors and redirect, provide calming activities, redirect as needed, and utilize stop sign on doorway as needed. The Nursing Note dated 11/12/21 documented Resident #26 was noted with a dark area on nose. Management was made aware, and the concern was documented in MD/NP communication book for follow up. The Physician Note dated 11/15/21 documented Resident #26 was seen and noted with yellow discoloration about 1 cm of diameter on resident's nasal bridge. X rays of nasal bones and head were ordered. The Physician order [REDACTED]. The X Ray Reports dated 11/15/21 documented results showed no evidence of displaced fracture or dislocation of the nasal and facial bones. The Social Service note dated 11/15/21 documented resident's family was made aware of the bruise on the resident's nose. There was no documented evidence in the medical record that the resident had any accidents or falls from 10/29/21 to 11/12/21. There was no documented evidence that facility investigated Resident #26's injury to rule out abuse, neglect or mistreatment. On 08/02/22 at 11:44 AM, the Licensed Practical Nurse (LPN #1) was interviewed. LPN #1 stated that she does not remember the resident having a bruised nose. LPN #1 stated that when a resident is observed with an unknown injury, the RN Supervisor will evaluate the injury and notify the physician for treatment. An Accident/Incident (A/I) Investigation is completed and submitted to DON for review. LPN #1 does not know why A/I was not completed, but it should have been initiated. On 08/02/22 at 12:00 PM, the Director of Nursing (DON) was interviewed. The DON stated that there was no Accident/Incident report completed for this incident. The nurse who documented the dark area observed on Resident's #26's nose, did not notify the RN Supervisor. The DON stated he/she could not recall this event because it was not investigated nor reported to her. The DON stated the injury should have been investigated. 415.4(b)(3) | Plan of Correction: ApprovedSeptember 12, 2022 F- 610 I. The following actions were accomplished for the residents identified in the sample: Resident #26 On 8/29/12, the IDCPT reviewed the residentÆs CCPs related to risk to be abused and risk for an accident/incident and updated the plan of care to include injuries of unknown origin will be reported to the RN Supervisor immediately. The Nurse Manager updated the CNAAR to include the responsibilities of the CNAs related to the accident/incident and abuse preventative plan of care and reviewed the plan of care with the unit staff. On 8/2/22, the DNS completed an Incident Report and Investigation Summary and determined that no abuse had occurred On 8/29/22, the identified licensed nurse was provided with an educational counseling by the DNS regarding her responsibility to initiate an Occurrence Report and associated investigation for any reported change in skin condition of unknown origin that could potentially be abuse as well as the nurseÆs overall responsibility to document a progress note when an assessment is completed, and the medical practitioner is contacted for a treatment order. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practices. The RN Supervisor will review all residents with a change in skin condition or injury since 6/1/2022. The NMs will ensure that an Incident Report and investigation is implemented, if not already completed, for any injury of unknown origin. When indicated the responsible Nurse Manager will document a progress note that addresses his/her assessment findings, contact with the medical practitioner to discuss the assessment findings and directives provided by the practitioner when such a note is indicated. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Medical Director and Director of Nursing reviewed the facilityÆs policy and procedure related to Occurrence Reporting and Investigation of injuries of unknown origin regarding ruling out abuse and determined that no revisions were necessary. The Staff Educator/designee will provide education to all licensed nurses and RNSs regarding reporting of all occurrences, completion of an Occurrence Report and associated Investigation for all injuries, including those of unknown origin that are identified by the nurse and reported to the RNS including the responsibility of the RN Supervisor to document a progress note that addresses his/her assessment findings, contact with the medical practitioner and directives provided by the practitioner. Education will also emphasize the importance of reporting 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. Effective 8/18/22, the Director of Nursing/designee will monitor that information related to injuries of unknown origin identified by staff observation, shared at Morning Meeting or in the 24 Hr. Report are reported per regulatory requirements and that an investigation completed, as indicated, to ensure that no abuse has occurred. Immediate corrective action, such as completing an Occurrence Report and investigation, providing staff reeducation, or reporting to the state agency within the required timeframe, will be implemented as needed. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with appropriate actions taken in response to allegations of abuse, neglect, exploitation, or mistreatment to ensure alleged violations are thoroughly investigated, effective measures/corrective actions implemented to prevent recurrence while the investigation is in process, and results of all investigation are reported to the Administrator/designee and to the State Survey Agency within 5 working days of the incident. The DNS/designee will audit 20% of all Occurrence Reports and associated investigations monthly for the next 3 months. All injuries of unknown origin will be included in the audit sample. All Occurrence Report and investigation audit findings will be reported to the Administrator monthly. Corrective actions, such as staff reeducation, will be implemented as needed. The Director of Nursing will provide a summary of all Occurrence Report and investigation findings to the QAPI Committee monthly for evaluation, discussion and follow-up corrective actions. Completion Date: (MONTH) 28, 2022 Responsibility: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details Based on observations, interviews, and record review conducted during the recertification and survey from 7/21/2022 to 8/3/2022, the facility did not ensure biologicals were stored in accordance with professional principles. This was evident for 2 (Unit 3 and 4) of 6 medication storage areas reviewed. Specifically, 1) controlled drugs were stored in the Unit 3 medication area in a single lock compartment; and, 2) the Unit 4 medication area contained a controlled drugs compartment with a broken lock. The findings are: The facility policy titled Controlled Substance Handling revised 05/13/2018 documented all controlled drugs will be stored in a permanently affixed, double-locked cabinet with 2 separate keys. The access keys to the controlled substance cabinets shall not be the same keys giving access to other drugs. 1) On 07/22/2022 at 01:13 PM, Registered Nurse (RN) #1 was observed in the Unit 3 medication area using one key to open both the first and second door of the cabinet storing controlled drugs. On 7/22/2022 at 01:14 PM, RN# 1 was interviewed and stated the controlled drugs are stored in a cabinet that requires only one key to open it and RN #1 has only used one key to access the controlled drugs since being assigned to Unit 3. On 07/22/2022 01:17 PM, the Director of Nursing (DON) was interviewed and stated they were unaware the controlled drug cabinet required a 2 double-lock system with separate keys. The regulation is that controlled drugs must be kept under safe storage. The Maintenance Department will be notified to change the locks of the Unit 3 controlled drug cabinet. 2) On 07/22/22 at 10:52 AM, Licensed Practical Nurse (LPN) #2 was observed unlocking the outer lock of the controlled drug cabinet in the Unit 4 medication area. The second inner door to the controlled drug during cabinet was unlocked and did not require a key to open it. LPN #2 was immediately interviewed and stated the controlled drug cabinet is supposed to have a double lock, but the second lock has been broken for a while. LPN #2 informed the Registered Nurse (RN) supervisors and the Director of Nursing (DON) the controlled drug cabinet required lock repair. There is no maintenance logbook on Unit 4 and LPN #2 did not have documented evidence of a repair request. On 07/25/22 at 11:06 AM, the controlled drug cabinet on Unit 4 was observed and the outer door to the cabinet was unlocked and opened. RN #1 was present on the unit at the time of the observation and was interviewed. RN #1 stated they were conducting medication pass and intended to lock the controlled drug cabinet when they finished. Other staff and residents would not have access to the controlled drug cabinet because there are always nursing staff sitting by the medication area. 415.18(e)(1-4) | Plan of Correction: ApprovedSeptember 12, 2022 F 761 (Label/Store Drugs and Biologicals) I. The following actions were accomplished for the residents identified in the sample: No residents were identified in the Statements of Deficiencies. RN#1 On 7/22/22, DNS/designee provided education and counseling to identified staff regarding facility policy and procedure related to storage of controlled drugs. Emphasis of the education was on the storage of all drugs and biologicals in locked compartments, including the storage of schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access and responsibility in immediately reporting broken locked compartments to administration and documentation in the unit maintenance logbook to repair request. LPN#1 On 7/22/22, DNS/designee provided education and counseling to identified staff regarding facility policy and procedure related to storage of controlled drugs. Emphasis of the education was on the storage of all drugs and biologicals in locked compartments, including the storage of schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access and responsibility in immediately reporting broken locked compartments to administration and documentation in the unit maintenance logbook to repair request. On 8/4/22, new controlled drug cabinets were installed in Unit 3 and Unit 4 controlled drug cabinet second lock was replaced on 7/22/22 by the maintenance department. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practice. Between 8/29/22 and 9/2/22, the pharmacy consultant and unit manager conducted a full house audit to all locked compartments used as storage for the controlled drugs to ensure functionality and security. On 7/22/22, DNS/designee provided education to all licensed nurses on the policy and procedure for Storage and Labeling of Drugs and Biologicals and their responsibilities in the proper storage and accessibility of controlled drugs. III. The following system changes will be implemented to assure continuing compliance with regulations: On 8/29/22, the Administrator, Medical Director, and Director of Nursing reviewed and revised the policy and procedure for Controlled Substance Handling to ensure the policy is consistent with State and Federal regulation as well as reflecting the facilityÆs protocols. Revision to the policy was made to address licensed nurse responsibility to immediately notify Director of Nursing and Administration when locked compartments for the controlled drugs are compromised. DNS/designee will provide additional education to the licensed nurses regarding revised policy and procedure. The education will include the discussion on their responsibilities in ensuring all controlled drugs are stored in separately locked, permanently affixed compartments, permitting only authorized personnel to have access and responsibility in immediately reporting broken locked compartments to administration and documentation in the unit maintenance logbook to repair request. This education will be incorporated into the orientation of new licensed nurses. The pharmacy consultant will monitor for compliance with the storage of controlled drugs and ensuring all controlled drugs are stored in separately locked, permanently affixed compartments, permitting only authorized personnel to have access, and in accordance with federal and state laws. Effective 8/18/22, all nursing units were provided with maintenance logbooks for IDCPT use including CNAs to document and report building/furnishing/storage issues that are in poor repair. The Director of Maintenance/designee is conducting daily rounding to check the maintenance logbook in nursing units to identify issues that require corrective action, including immediate action for securing controlled drug storage areas. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility developed an audit tool to monitor compliance with the facilityÆs protocols related to storage of controlled drugs to ensure that storage compartments are permanently affixed, with double-locked cabinet with 2 separate keys and different from the key access to other drugs, and both inner and outer doors are locked at all times. DNS/designee will audit all nursing unit medication carts, refrigerators and cabinets for the next three months to ensure that controlled drugs are stored in separately locked, permanently affixed compartments, permitting only authorized personnel to have access. Corrective actions, such as reeducation and counseling, will be implemented when indicated. DNS/designees will report all occurrence audit findings related to storage of controlled drugs to the QAPI Committee monthly for the three months for evaluation and follow-up discussion. At the end of this period, the Committee will determine the need for ongoing monitoring specific to Occurrence Reporting and Investigation and at what frequency. Completion Date: (MONTH) 28, 2022 Responsibility: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the Recertification Survey, the facility did not ensure residents were informed of changes to items and services covered by Medicare as soon as is reasonably possible. This was evident for 1 (Resident #268) of 3 residents reviewed for the Skill Nursing Facility (SNF) Beneficiary Protection Notification. Specifically, the facility did not provide the provide the Notice of Medicare Non-coverage (NOMNC) letter to Resident #68, a Medicare Part A beneficiary, prior to termination of services. The finding is: The facility policy and procedure, titled Changes to Medicare Beneficiary Health Coverage dated 10/2018 documented that the facility will ensure changes to a beneficiary's health coverage comply with regulations regarding enrollment/disenrollment and resident's rights. The policy also documented that, any changes in a beneficiary health coverage must be initiated by the resident or his or her caregiver. Upon request, the facility provided the State Agency a list of residents with Medicare Part A, who were discharged in the past 6 months with benefit days remaining. The Admission Face Sheet/Discharge record documented Resident #268 was admitted to the facility on [DATE] and discharged home on[DATE] with Medicare Part A coverage, and Resident #268 had Medicare days remaining at the time of discharge. A Social Service note dated 6/6/22 documented Resident #268 was a short term resident in this facility from 03/23/2022 to 06/03/2022. The SW documented Resident #268 completed rehab and no longer required skilled nursing services, and the resident was discharged home. There was no doumented evidence the (NOMNC) form CMS- was provided to Resident #268 to inform him/her of their right to an expedited review of a service termination. On 08/03/22 12:35 PM an interview was conducted with the Registered Nurse (RN#) who is also the MDS Coordinator. They stated that the NOMNC letter is given to Medicare part A residents prior to termination of services only if the resident is going to remain in the facility long-term . The RN/MDS Coordinator also stated that residents who are being discharged home do not need NOMNC. As a result, the NOMNC letter was not provided to Resident s#268. During an interview on 08/03/22 at 2:45 PM, the Administrator stated that MDS coordinatoir is responsible for NOMNC, and he/she could not explain why NOMNC was not offered. 415.3(g)(2)(i) | Plan of Correction: ApprovedSeptember 12, 2022 F- 582 I. The following actions were accomplished for the residents identified in the sample: Resident #268 The resident no longer resides in the facility; therefore, no corrective action could be implemented. Director of Nursing reeducated the RN/MDS Coordinator regarding her responsibility to provide the NOMNC as required. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents who are receiving items and services covered by Medicare have been identified as potentially affected by this practice. Effective 8/18/22, the MDS Coordinator will monitor all residents receiving Medicare covered services who are scheduled for discharge on a Monday through Friday basis to ensure that he/she receives a NOMNC as per regulation. The MDS Coordinator reviewed all residents who were discharged since 06/01/22 and had Medicare days remaining and did not identify any other residents who did not receive the NOMNC as required III. The following system changes will be implemented to assure continuing compliance with regulations: Administrator and/or Designee with the DNS will review and revise, as necessary, the facilityÆs policy and procedures regarding Beneficiary Notices, including protocols specific to Notice of Medicare Non-coverage (NOMNC). The policy was revised to include beneficiary notice guidelines and that the MDS Coordinator / designee will review all residents scheduled for discharge on a Monday through Friday basis to ensure that he/she receives a NOMNC as per regulation. The DNS/Designee will provide education to all relevant staff, including, but not limited to, the RN / MDS Coordinator, MDS staff, and Social Workers on the facility Policy and Procedures relating to Medicaid / Medicare Coverage / Liability Notice, specifically, issuing a NOMNC (Notice of Medicare Non-Coverage); the beneficiaryÆs right to an expedited review of a services termination. The re-education will include a review of the specific issues identified during the re-certification survey. The RN/MDS Coordinator/Designee will monitor for compliance regarding issuing, and timeliness of issuing, the NOMNC on a Monday through Friday basis. Immediate corrective action will be conducted, including re-education of the staff member who did not provide the required NONMC/beneficiary notice. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with protocols related to providing Beneficiary Notices, including issuing the NOMNC (form CMS- ) to all relevant beneficiary receiving Medicare Part A services in the facility to convey notice of his / her right to an expedited review of a services termination. The MDS Coordinator will conduct quality monitoring audits monthly for three months for all individuals receiving Medicare Part A Services / Skilled Care services and the covered services are being terminated. Findings will be reported to the Administrator monthly. Corrective actions, such as staff re-education, will be implemented as necessary. Subsequent auditing will be completed quarterly for 3 quarters for 15% of those individuals identified as receiving Medicare covered Skilled Care benefits. The RN/MDS Coordinator will report all Beneficiary Notice audit findings to the QAPI Committee on a monthly basis for 3 months and then quarterly for an additional 3 quarters for evaluation and follow-up action. At the end of the 4th quarter the Committee will make a determination regarding additional auditing and at what frequency. Completion Date: (MONTH) 28, 2022 Responsibility: RN/MDS Coordinator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the extended recertification survey from 7/21/2022 to 8/3/2022, the facility did not ensure an account of all controlled drugs was maintained and periodically reconciled. This was evident for 1 (Unit 5) of 5 units observed for medication storage. Specifically, 1) a Registered Nurse (RN) on Unit 3 documented a narcotics supply count and the signed Control Drug Licensed Staff Signature Record Form (CDLSSR) for Resident #41 without reconciling with a licensed relief nurse, and the Controlled Drug Distribution Form (CDD) did not match the narcotics medication count for Resident #41. The findings are: The facility policy titled Controlled Substance Handling last revised 05/13/2018 documented all controlled drugs will be subject to special receipt, handling, storage, disposition, and record keeping. A physical inventory of all controlled drugs is made at the change of each shift by two licensed nurses and is documented on an audit record. If a nurse is late the supervisor will go to the floor and count with the nurse who is leaving. The drugs are never to leave the cabinet on the floor for purposes of conducting a count. Once the next shift nurse arrives, the supervisor will return to the floor and perform another count. Resident # 41 had [DIAGNOSES REDACTED]. On 07/22/2022 at 12:59PM, the Unit 5 medication room narcotics locker was observed with RN #4. The locker contained 2 blister packs of [MEDICATION NAME] 5mg for Resident #41 with a total count of 51 tablets. A Physician order [REDACTED].# 41 was prescribed [MEDICATION NAME] 5mg every 8 hours as needed. The CDD form dated 7/22/22 documented Resident #41 was given 1 tablet of [MEDICATION NAME] 5mg at 6AM and 52 tablets were remaining. The CDLSSR form for Resident #41 was reviewed on 7/22/22 at 12:59 PM documented the signature of RN #4 in the 7AM-3PM Nurse (Out) section for 7/22/22. The total count of [MEDICATION NAME] 5mg remaining was 51 tablets. On 07/22/2022 at 12:59PM, RN#4 was interviewed and stated Resident #41 was given [MEDICATION NAME] 5mg after 12 noon and RN #4 did not sign then CDD form updating the tablet count because the Bureau of Narcotics Enforcement came to the unit and requested to count narcotics. RN #4 signed the CDLSSR before the end of their shift and without a licensed nurse present, but the 3PM-11PM nurse will check the narcotics count and will also sign the CDLSSR form. On 07/22/2022 at 1:10PM, the Director of Nursing (DON) was interviewed and stated RN # 4 should have updated and signed the CDD form after Resident #41 swallowed their medication. RN #4 should have updated and signed the CDLSSR form after counting the narcotics with the incoming 3PM-11PM nurse. Two licensed staff are required to provide visual verification of narcotics count and sign at the change of each shift. 415.18(b)(1)(2)(3) | Plan of Correction: ApprovedAugust 26, 2022 F755 û Pharmacy Services I. The following actions were accomplished for the residents identified in the sample: No residents were identified in the Statements of Deficiencies. RN#4 On 7/22/22, DNS/designee provided education and counseling to identified staff regarding facility policy and procedure related to Controlled Substance Handling. Emphasis of the education was on the licensed nurse responsibility related to the receipt, handling, storage, disposition, and record keeping of controlled drugs. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practice. Between 8/29/22 and 9/2/22, Consultant Pharmacist conducted a full house audit of all Controlled Drug Distribution (CDD) and the Control Drug Licensed Staff Signature Record (CDLSSR) forms to ensure an account for all controlled drugs was maintained and periodically reconciled according to state and federal guidelines. Corrective action will be implemented to any identified deficient practice. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Medical Director and Consultant Pharmacist will review and revise, as needed, the facilityÆs policy and procedure for Controlled Substance Handling. No revisions were made. DNS/designee provided education to all licensed nurses regarding facility policy and procedure related to Controlled Substance Handling. Emphasis of the education was on the licensed nurse responsibility related to the receipt, handling, storage, disposition, and record keeping of controlled drugs in order to prevent loss, diversion, or accidental exposure. This education will be provided during orientation, annually, and a needed. The Consultant Pharmacist will continue to conduct periodic medication room and cart observation to ensure medication records are maintained and completed that enables periodic accurate reconciliation and accounting for all controlled medications. Deficient findings will be communicated to the Director of Nursing and Administration. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with protocols related to accurate reconciliation and accounting for all controlled medications. The Director of Nursing/designee will conduct direct observation and record review of all controlled substance handling on all Nursing units every shift weekly for 1 month then monthly for 3 months, then quarterly for the next three quarters. The Director of Nursing will report audit findings to the Administrator and QAPI Committee initially on a monthly basis for 3 months and then quarterly. Corrective action, including staff re-education, will be implemented as indicated. At the end of the 4th quarter, the Committee will make a decision regarding the need to continue auditing these areas and the frequency of audit if auditing is to continue as well as the need for additional corrective actions. Responsible Team Member: Director of Nursing Completion Date: (MONTH) 28, 2022 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews conducted during the Recertification and Extended survey from 7/21/2022 through 8/03/2022, the facility did not ensure that the attending physician reviewed the resident's total program of care, including medications and treatments, at each visit. This was evident for 1 of 5 residents reviewed for Unnecessary Medications and 1 of 1 resident reviewed for [MEDICAL TREATMENT] out of 47 sample residents. Specifically, there was no documented evidence that the attending physician evaluated the resident's medication regimen and addressed irregularities as identified by the pharmacy consultant (Resident # 35). In addition, there was no physician order for [REDACTED]. The findings are: 1. Resident #35 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented that the resident had intact cognition and did not reject care. The MDS also documented that the received insulin injections on 7 of 7 days. Physician order dated 01/23/22, last renewed 7/29/22 documented [MEDICATION NAME] U-100 Insulin 100 unit/mL subcutaneous solution. Inject 35 units by subcutaneous route once daily in the evening and [MEDICATION NAME] 500 mg tablet give 1 tablet (500 mg) by oral route 2 times per day after meals. The Drug Regimen Review dated 01/06/2022, 02/04/2022, 04/06/2022 and 05/05/2022 documented currently receiving [MEDICATION NAME], unable to locate recent HbA1C (blood test to obtain the three month average of blood glucose) in chart. Recommended every 6 months. Please consider ordering. Review of the discontinued physician orders documented the following: 1/26/2022-Laboratory Routine Lab Order: CBC, CMP, lipid profile, Hgb A1c every 3 months 03/22/2022-Laboratory Routine Lab Order: CBC, CMP, lipid profile, Hgb A1c every 3 months 5/15/2022-laboratory for complete blood count (CBC), Comprehensive Metabolic Panel (CMP), [MEDICAL CONDITION] Stimulating Hormone (TSH), hemoglobin HBA1C, lipid routine LAB every 3 months Laboratory report dated 03/16/21 documented HbA1c of 6.7% which was outside the normal range (normal range 3.5 - 5.6 %). There was no documented evidence that any other HbA1c had been obtained since 3/16/21. There was no documented evidence in the medical records that the physician followed up on lab work requested for HbA1c. In addition, there was no documented evidence that the resident refused laboratory workup. On 07/29/22 at 12:42 PM, Registered Nurse (RN) #4 was interviewed and stated that the once physician generates an order, it goes straight to the lab company and the lab technician will come early in the morning to collect the blood sample. If the resident refuses, they let us know and we document it in the medical records. RN # 4 also stated that there was no report from the lab technician that the resident had refused to have the labs drawn and they and could not explain why the lab work had not been obtained. On 07/29/22 at 01:09 PM, Medical Doctor (MD) #1 was interviewed and stated they are covering for the Medical Director who is currently on vacation. MD #1 stated they could not explain why the HbA1c had not been addressed for this period of time. MD #1 reviewed the medical record and stated they could not find any documentation indicating that the resident had refused to have lab work completed in the past. On 08/02/22 at 02:00 PM, the Director of Nursing (DON) was interviewed and stated that the night supervisor picks up the order, prints them out and places them in the lab logbook and for regular lab work the lab technician comes to the facility daily to pick up the order and collect samples. The DON also stated that they could not tell the reason why this order was not picked up. The DON further stated the provider resident assignments had been changed a year ago due to reassignments of unit among physicians. The DON also stated that the issue of multiple missing orders was identified and the team met and realized that some units had not had physician coverage temporarily. On 08/02/22 at 11:33 AM, the Administrator was interviewed and stated that they are usually copied on the recommendations sent to the Medical Director and the Director of Nursing. The Administrator also stated that no one had informed them that recommendation were not being followed up on by the physician. 2. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented resident is cognitively intact and requires supervision set up help with bed mobility and eating. The resident requires limited one person assist with transfer, dressing, and toilet use. The resident is on a therapeutic diet and receives [MEDICAL TREATMENT]. The Nursing Assessment titled Admission/Readmission Assessment dated 4/15/2022 documented Diabetes Mellitus Type II; Hypertension; End Stage [MEDICAL CONDITION] on [MEDICAL TREATMENT] Tuesdays, Thursdays, and Saturdays. A Nursing progress note dated 07/23/2022 documented that the resident went for [MEDICAL TREATMENT] this morning at 8 am and returned at 2:40 pm. A Medical progress note dated 7/26/2022 documented Plan and Assessment: End Stage [MEDICAL CONDITION] on [MEDICAL TREATMENT]; [MEDICATION NAME]; Renal diet, fluid restriction to 1L; Continue [MEDICAL TREATMENT] as scheduled (Tue-Thu-Sat). Review of the physician orders from admission to present revealed no order for [MEDICAL TREATMENT] treatment. On 07/29/22 at 06:05 PM, Registered Nurse (RN) #6 was interviewed and stated that the missing Physicians order must have been an oversight. RN #6 also stated that that the resident has been on [MEDICAL TREATMENT] for a while and the Licensed Practical Nurse or RN should have notified the doctor that there was no order for [MEDICAL TREATMENT]. RN #6 further stated that a Medical Doctor or Nurse Practitioner who does assessments for the resident should have entered an order. On 07/29/22 at 06:12 PM, the Director of Nursing was interviewed and stated that the nursing supervisors enter the orders from the hospital discharge summary and call the MD or NP for confirmation. The MD or NP are supposed to verify the orders and ensure whatever was entered by nurse is consistent and accurate with recommendations from the hospital. The DON also stated that the admitting nurse should have entered the [MEDICAL TREATMENT] order but the nurse may have missed it. The DON further stated that the MD/NP should also review the discharge orders from the hospital. On 07/29/22 at 01:09 PM, Medical Doctor (MD) #1 was interviewed and stated that the physician usually would see residents few days after admission and review the hospital discharge records. All orders would be signed off and any additional orders would be added on if necessary. MD #1 also stated that they did not know why there was no order for [MEDICAL TREATMENT] treatment. 415.15(b)(2)(iii) | Plan of Correction: ApprovedAugust 26, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F711 û Physician Visits I. The following actions were accomplished for the residents identified in the sample: Resident #35 On 7/29/22, attending physician seen, examined and reviewed residentÆs plan of care as well as medication regimen and addresses irregularities identified by the pharmacy consultant related to residentÆs HbgA1C blood level monitoring. HgBA1C was ordered on [DATE] with result indicating 8.0%. Resident was seen by the attending physician on 8/17/22 with HgbA1C result addressed. Resident #6 On 8/17/22, attending physician seen and examined the resident for current status and medical regimen. Attending physician ordered for [MEDICAL TREATMENT] treatment on 7/28/22. MD#1 On 8/30/22, Medical Director provided education and counselling to medical staff on the policy and procedure related Physician visits. Education emphasized on the physicianÆs active role in supervising the care of the resident that must include an evaluation and documentation of the residentÆs condition and total program of care, including medications and treatments, and consultant pharmacy recommendations, and a decision about the continued appropriateness of the residentÆs current medical regimen. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practice. Between 8/29/22 and 9/16/22, Medical Director/designee conducted a full house audit of all monthly physician progress notes [REDACTED]. Between 8/29/22 and 9/16/22, Medical Director/designee conducted a full house audit of all admission orders [REDACTED]. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Medical Director and Consultant Pharmacist will review and revise, as needed, the facilityÆs policy and procedure for Physician Visits. No revisions were made. Between 8/29/22 and 9/16/22, Medical Director provided education to all medical staff on the policy and procedure related Physician visits. Education emphasized on the physicianÆs active role in supervising the care of the resident that must include an evaluation and documentation of the residentÆs condition and total program of care, including medications and treatments, and consultant pharmacy recommendations, and a decision about the continued appropriateness of the residentÆs current medical regimen. The same education will be provided upon orientation, annually, and as needed. Medical Director/designee will be responsible in reviewing all admission orders [REDACTED]. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with protocols related to physician visits to ensure all admission and current physician orders [REDACTED]. The Medical Director/designee will audit all admission orders [REDACTED]. The Medical Director will report audit findings to the Administrator and QAPI Committee initially on a monthly basis for 3 months and then quarterly. Corrective action, including staff re-education, will be implemented as indicated. At the end of the 4th quarter, the Committee will make a decision regarding the need to continue auditing these areas and the frequency of audit if auditing is to continue as well as the need for additional corrective actions Responsible Team Member: Medical Director Completion Date: (MONTH) 28, 2022 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification survey conducted from [DATE] to [DATE], the facility did not ensure a qualified dietitian or other clinically qualified nutrition professional was employed. This was evident during review of the Kitchen. Specifically, the facility did not employ a Registered Dietician (RD) part-time, full-time, or as a consultant since [DATE]. The findings are: The undated facility policy titled Food Service Management documented the food and nutrition services department head must meet New York State Department of Health requirements for food service manager, and plans, organizes, supervises, and directs all administrative and operational activities of the Food and Nutrition Services Department. On [DATE] at 12:21 PM, the Dietician was interviewed and stated they have worked at the facility since ,[DATE] and their Food and Nutrition certification expired in (YEAR) and was not renewed. The Dietician lost their credentials and certifications during a change in residence. They were being supervised by an RD until [DATE] when the RD went on sick leave. The facility does not have a full-time, part-time, or consultant RD. The Dietician stated they work with the facility physicians to ensure the physicians sign off on the Dietician's recommendations. On [DATE] at12:43 PM, the Administrator was interviewed and stated the facility must employ a RD, but the facility does not have an RD on staff or as a consultant. The facility hired an RD a few days ago but Human Resources (HR) must review the RD's documentation before the RD can start working. On [DATE] at 10:37 AM, the Director of HR was interviewed and stated the current Dietician was hired [DATE] with Bachelor of Science in Food and Nutrition. There are no other certifications or registrations relative to nutrition and or dietetics in the Dietician's file. . 415.14(a)(1)(2) | Plan of Correction: ApprovedSeptember 12, 2022 F-801 I. The following actions were accomplished for the residents identified in the sample: No residents were identified in the Statement of Deficiency. II. The following actions were accomplished for the observations identified in the statement of deficiencies: All residents have been identified as potentially being affected by the same practice. The facility has employed a full time Director of Food Service who is an RD, who starts on (MONTH) 6, 2022. Starting (MONTH) 6,2022, Director of Food Service/Registered Dietitian will review all menus to assure that they are nutritionally adequate and will review all nutrition related policy and procedures. Director of Food Service/Registered Dietitian will oversee current DietitianÆs clinical work, and audit medical record as needed. III. The following system changes will be implemented to assure continuing compliance with regulations: Effective (MONTH) 6, 2022, the Director of Food Service/Registered Dietitian will review menus to assure that they are nutritionally adequate and meet established national guidelines. Effective (MONTH) 6, 2022, the Director of Food Service/Registered Dietitian will review all nutrition related policy and procedures to assure they reflect current standards of practice. Effective (MONTH) 6, 2022, the Director of Food Service/Registered Dietitian will oversee dietitians clinical work and audit 10% of residents monthly to ensure documentation meets clinical standards. The Director of Food Service/Registered Dietitian will review any findings with the Administrator monthly for three months then quarterly. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility developed an audit tool to monitor compliance with the facilityÆs protocols related to ensuring a qualified dietitian or other clinically qualified nutrition professional with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service is employed at all times. Human Resources/designee will audit all employed dietician and/or other clinically qualified nutrition professional monthly for 3 months then quarterly for then next 3 quarters. All audit findings will be reported to the Administrator as the audits are completed. Additional corrective action, including employment of a Registered Dietician on a consultant basis, will be implemented as indicated. The facility will continue to assure that a Registered Dietitian is employed by facility, and that Registered Dietitian oversees all menu development, nutrition-related policies and procedures, and all aspects of Clinical Nutrition. In the event that a full time Registered Dietitian is no longer employed by facility, facility will assure that as Registered Dietitian is employed on a consultant basis, at minimum, to meet these requirements. Any concerns related to Food and Nutrition, and Clinical Nutrition, will be brought to the QAPI Committee for discussion and evaluation, minimally, quarterly with follow-up action implemented as indicated. Completion Date: (MONTH) 28, 2022 Responsibility: Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the Recertification and Complaint (NY 383) survey from (MONTH) 21, 2022, to (MONTH) 3,2022, the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours, to the New York State Department of Health (NYSDOH) for 3 (Resident #s 42, 121,and 28) of 7 residents reviewed for Abuse out of a total sample of 47 residents. Specifically, the facility did not report an incident of alleged resident-to-resident physical abuse (NY 383), involving Residents #42 and #121, to the NYSDOH within 2 hours. The facility did not report an alleged incident of resident-to-resident abuse involving Resident #28 to NYSDOH. The findings include: A facility policy titled Accident/Incident Resident dated reviewed or revised (MONTH) 20,2017, states the purpose of to provide immediate assessment and emergency medical intervention. To provide data for the investigation of accidents/incidents in order to promote a safe environment. To ensure all accidents/ incidents are reported and correct action has been taken. A facility policy titled Accident/Incident dated (MONTH) 20, (YEAR), states It is the policy of Grand Manor Nursing & Rehabilitation Center that resident incident/accidents occurring on premises, along with injuries to residents of unknown origin, must be investigated and reported in a timely fashion. The procedure includes the completion of the investigation within 3 days. The DNS is then to review and log in a tracking record. The Medical Director and Administrator are to review and sign off all accident and incident reports. 1) Resident #42 had [DIAGNOSES REDACTED]. An admission Minimum Data Set 3.0 ((MDS) dated [DATE] documented Resident #42 had intact cognition and no behaviors. The resident required limited assistance of on person for bed mobility, transfer, and locomotion on unit. Resident #121 had [DIAGNOSES REDACTED]. An admission MDS dated [DATE] documented Resident #121 had intact cognition and no behaviors. Resident #121 required extensive assistance of 2 for bed mobility, transfer, and total assistance of 1 for locomotion on unit. An Accident/Incident report dated 3/5/2022 documented at 6 PM, Resident #42 and Resident #121 had a verbal altercation that led to a sudden physical altercation. Resident #42 was noted with a superficial pinpoint sized cut with scant amount of bleeding. Resident #42 refused hospitalization . Resident #121 did not sustain any injuries. The undated investigation summary documented there was cause to believe alleged abuse, mistreatment or neglect occurred. The NYSDOH ACTS system for intake number NY 383 documented the facility reported the incident on 3/10/2022 at 09:17 AM. This allegation of resident-to-resident abuse was not reported within 2 hours. 2) Resident #76, the Aggressor, had [DIAGNOSES REDACTED]. An admission MDS dated [DATE] documented Resident #76 had severely impaired cognition. Resident #76 exhibited physical and verbal behaviors toward others, other behaviors not directed towards others, rejection of care, and wandering behaviors for 1 to 3 days of the assessment period. Resident #76 required supervision with set-up for bed mobility and transfer. Resident #28, the victim, had [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] documented Resident #28 had severely impaired cognition and no behaviors. Resident #28 required extensive assist of 1 for bed mobility, limited assist of 1 for transfer, and supervision set-up assistance to walk in room/corridor. Resident #28 had a Wander/elopement alarm. An Accident/Incident report dated 3/22/2022 documented Resident #76 was the aggressor and punched/pushed Resident #28 to the floor. A nursing note from Resident #76's medical record written on 3/22/2022 @ 3:02 pm resident #76 attacked resident #28 and pushed them to the floor in the day room. Supervisor made aware. Staff intervened to de-escalate the situation. Resident was assisted to their room. A Nursing note dated 3/22/22 documented Resident #76 was very aggressive and physically trying to abuse other resident and Staff. Resident trying to attack staff and residents for no reason and unprovoked. They were transferred to ER for further evaluation. A Nursing Note written on 3/23/2022 at 1:04 PM documented on 3/22/22 at approximately 3pm the writer was notified that Resident #28 was pushed by another resident. Resident #28 was immediately separated from the aggressor, the supervisor was called, and Resident #28 was assisted back to the chair. No signs of bruising noted. The RN supervisor and physician were made aware. A Nursing Note written on 3/23/22 by the Registered Nurse Supervisor (RNS #3) documented on 3/22/22 at around 3pm writer was notified Resident #28, who was alert and oriented X 1, was approached by another resident and pushed on the floor. Staff immediately intervened and separated both residents. Upon RNS #3's arrival, Resident #28 was on the floor. Resident #28 was assisted back to the chair, and he/she was not in distress and denied pain. The physician was informed, and the aggressor sent to the ED for psych evaluation. Next of kin informed. This incident was not reported to NYSDOH. On 7/29/22 at 6:34 PM and 8/1/22 at 3:51 PM, an interview was conducted with the Director of Nursing Services (DNS). The DNS stated Resident #76 was confused, and their actions were not intentional. The occurrence on 3/22/2022 was done for no reason without any provocation. The DNS stated he/she is responsible for reporting to NYSDOH, and allegations of abuse should be reported within 2 hours. The failure to report the incident was an oversight. 415.4(b)2 | Plan of Correction: ApprovedSeptember 12, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F- 609 I. The following actions were accomplished for the residents identified in the sample: Resident #42 On 8/29/22, the IDCPT reviewed residentÆs plan of care related to the potential to abuse/be abused and determined resident to be a high risk for abuse due to behavioral symptoms exhibited. Resident continues to be monitored by nursing, psychiatrist, and social work for behavioral symptoms. Resident #121 Resident was discharged to the hospital on [DATE] for other medical reason and was readmitted to the facility on [DATE]. IDCPT reviewed residentÆs plan of care related to the potential to abuse/be abused and determined to be at risk for abuse due to opioid dependence and psychiatric illness. Resident continues to be monitored by nursing, psychiatrist and social work for behavioral symptoms Residents #42 and #121 have not been involved in a resident-to-resident altercation since 3/5/22. No reports to the NYSDOH have been needed since this date. Resident #76 On 8/15/22, the IDCPT reviewed residentÆs plan of care related to the potential to abuse/be abused and determined resident to be a high risk for abuse due to behavioral symptoms exhibited. Resident continues to be monitored by nursing, psychiatrist and social work for behavioral symptoms Resident #28 On 8/2/22, the IDCPT reviewed residentÆs plan of care related to the potential to abuse/be abused and determined resident continues to be at risk for abuse due to wandering behavior and behavioral symptoms exhibited. Resident continues to be seen by psychologist for individual psychotherapy and routinely monitored for behavioral symptoms by nursing, social work, and psychiatrist. Residents #76 and #28 have not been involved in any resident-to-resident event that would require a report to the NYSDOH since 3/22/22. The Administrator provided counselling and reeducation to the DNS regarding the importance of reporting all alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and reporting the results of all investigations to the proper authorities within prescribed timeframes. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All occurrences or accident/incident reports related to allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property from 3/1/22 to present will be reviewed by the Administrator and Director of Nursing to determine if the 2-hr. reporting requirement was met. No additional occurrences related to reporting of allegations of abuse were identified that were not reported within the 2-hr. timeframe. III. The following system changes will be implemented to assure continuing compliance with regulations: Administrator, Medical Director, and Director of Nursing reviewed the policies and procedures related to ôAccident/Incident Prevention Investigation and Reportingö to ensure that the policy is consistent with regulatory reporting requirement to Administrator and other officials (State Survey Agency, law enforcement, APS) in accordance with State law. There was no need for additional revisions identified during this review. The DNS/designee will provide education to all nursing staff on Abuse Prevention and Reporting protocols and requirements. The education will include Abuse Prevention elements, the NYSDOH guidance on which incidents are reportable and how they should be reported. Emphasis will be given to what constitutes abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, who is required to report, to whom allegation of violation will be reported and the reporting timeframes to the proper authorities. Abuse Prevention and Reporting education will be provided to all staff during orientation, on an annual and as needed basis with follow-up monitoring to ensure staffs understand these protocols. The Director of Nursing/designee will continue to review all incident/accident reports to determine if there are occurrences that meet reporting requirements. The Director of Nursing will report all reportable events to the Administrator, the State Survey Agency, Local Law Enforcement or APS, to meet the 2-hr. abuse allegation reporting requirement. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility will develop audit tools to monitor compliance with reporting of alleged violations involving abuse, neglect, exploitation, and mistreatment, including injuries of unknown origin and misappropriation of resident property to the Administrator and to the State Survey Agency, Local Law Enforcement, or other agency as per State Law and regulation. The Director of Nursing/designee will audit all occurrences of alleged violations the meet NYSDOH reporting requirement monthly for the next 3 months to ensure reporting requirements are met and reported timely to the NYSDOH and/or Local law Enforcement according to regulation and State law. Corrective actions, such as reeducation or submission of a report to the State Survey Agency or Local Law Enforcement, will be implemented when indicated. The DNS will report the NYSDOH reported occurrence audit findings to the QAPI Committee monthly for the next three months and then quarterly for evaluation and follow-up corrective actions. Completion Date: (MONTH) 29, 2022 Responsibility: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Extended Recertification and complaint survey (NY 022) from 7/21/2022 through 8/03/2022, the facility did not ensure that medical records were maintained on each resident that were complete and accurately documented in accordance with professional standards and practice. Specifically, the Medication Administration Record did not contain documentation of medication administration for 9 of 11 prescribed medication days in (MONTH) 2022 and for 10 of 18 days in (MONTH) 2022 for multiple medications. This was evident for 1 of 5 residents reviewed for Medication Administration out of sample size of 47 residents. (Resident # 366). The findings are: The Medication Administration and Documentation-General Policy #PHNY69 revised (MONTH) (YEAR) documented that the LPN (Licensed Practical Nurse) documents administration of medication on the MAR or eMAR immediately following administration, documents any medication not administered (i.e., refused, etc.,) and documents reason, documents specific reason and result for each dose of as needed medication on the MAR, documents all held or refused medication on MAR or eMAR, and uses prudent professional judgement by informing Physician in a timely manner when medications, held, refused or otherwise unavailable for administration. Resident #366 was admitted to the facility with [DIAGNOSES REDACTED]. Admission MDS dated [DATE] documented the resident had intact cognition, no behaviors, and no rejection of care. The following medications were not documented on the Medication Administration Record dated (MONTH) 2022: Senna 8.6 mg tablet (give 2 tablets (17.2 mg) by oral route once daily for constipation unspecified was not documented at 5PM from 1/24/2022 to 1/28/2022, Pantoprazole 40 mg delayed release tablet at 6:30AM (give 1 tablet daily orally) was not documented from 1/21/2022, 1/22/2022, and 1/24/2022, [MEDICATION NAME] 45mg tablet (give 1 tablet by oral route daily before bedtime) was not documented on 1/21/2022, 1/22/2022, from 1/24/2022 to 1/28/2022, and on 1/30/2022, [MEDICATION NAME] 100mg (give 5 capsules by oral route three times a day) was not documented at 1PM from 1/23/2022 to 1/27/2022, 1/31/2022 and at 5PM pm from 1/24/2022 to 1/28/2022, [MEDICATION NAME] (Vit D3) 10 mcg (400 unit) chewable tablet order start 1/21/2022 at 12:00am was not documented on 1/21/2022, 1/22/2022, and 1/24/2022. The following medications were not documented on the Medication Administration Record dated (MONTH) 2022: [MEDICATION NAME] ER 150 mg capsule extended release 24 hour (give 1 capsule (150 mg) was not documented on 2/1/2022, 2/2/2022, from 2/4/2022 to 2/6/2022, and 2/12/2022, Senna 8.6mg tablet (give 2 tablets by oral route once daily) was not documented on 2/1/22, from 2/4/2022 to 2/6/2022, 2/8/22, 2/13/2022, and 2/14/2022, Pantoprazole 40mg delayed release tablet (give 1 tablet by oral route once daily) was not documented on 2/1/22, 2/6/22, and 2/7/22, [MEDICATION NAME] 45 mg was note documented on 2/1/22, from 2/4/2022 to 2/6/2022, 2/8/22, 2/13/2022, and 2/14/2022, [MEDICATION NAME] was not documented at 9:00AM on 2/1/2022, 2/2/2022, from 2/4/2022 to 2/6/2022, and 2/12/2022; at 1pm on 2/1/2022, 2/2/2022, from 2/4/22 to 2/7/2022 and 2/12/2022, and at 5PM on 2/1/2022, from 2/4/2022 to 2/6/2022, 2/8/2022, 2/13/2022 and 2/14/2022, [MEDICATION NAME] 20 mg tablet was not documented on 2/1/2022, 2/2/2022, from 2/4/2022 to 2/6/2022, and 2/12/2022, and [MEDICATION NAME] 10 mcg tablet was not documented on 2/1/2022, 2/6/2022, and 2/7/2022. On 07/28/2022 at 5:05PM, Registered Nurse (RN) #3 was interviewed. RN #3 stated that some residents want to take meds exactly at the time ordered and some medications interact with each other. RN #3 also stated that the ratio is 1 nurse per 40 residents and medications are always given 1 hour before or after ordered time. RN #3 further stated they always administer resident medications within the time frame. On 08/02/2022 at 12:49PM, the Director of Nursing (DON) was interviewed and stated that they have the supervisor check at the start and end of the shift for completion and omission of documentation on the MAR. The DON also stated that some medications were not signed for and not accounted for on the resident's (MONTH) 2022 MAR and the supervisor should have picked up on it and alerted the nurse. Attempts to contact RN #2 and RN #3 regarding missing documentation on the MAR on 8/3/22 were unsuccessful. On 08/03/22 at 11:28 AM, RN #1 was interviewed and stated that the days that they did not initial the MAR after administering medications was due to their heavy workload. RN #1 also stated that they usually run a report to check for omissions on the MAR and they would sometimes enter their initials on the next day when this happened. On 08/02/22 at 12:17 PM, LPN #2 was interviewed and stated that according to the legend, the dashes on resident's (MONTH) MAR indicates the nurse did not document that medication was administered. LPN #2 also stated they forgot to put their initial in slots on the (MONTH) MAR. At the end of every shift every nurse is responsible to review the dashboard & make sure they have documented in the resident's MAR. Also, the medication would show up in red if the medication was late. LPN #2 further stated they have a time limit in which to give medications and a medication that was not documented does not mean the resident did not receive the medication. LPN #2 stated that Resident #366 would remind the nurse when it is time for their medication and would not let the nurses forget to give them their medication and the resident had not refused any medications when they were on duty. 415.12 | Plan of Correction: ApprovedAugust 26, 2022 F-842 û Resident Records I. The following actions were accomplished for the residents identified in the sample: Resident #366 The resident no longer resides in the facility; therefore, no corrective action could be implemented. RN#1 On 8/2/22, DNS provided education and counselling to identified staff on the policy and procedure related to Medication Administration documentation and responsibilities in monitoring the EMR Dashboard Admin Record notification for not documented medication and treatment orders. LPN#2 On 8/2/22, DNS provided education and counselling to identified staff on the policy and procedure related to Medication Administration documentation and responsibilities in monitoring the EMR Dashboard Admin Record notification for not documented medication and treatment orders. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected by the same practice. Between 8/29/22 and 9/16/22, a full house review was conducted by the RN supervisors of all MAR indicated [REDACTED]. A report from the EMR was generated to identify residents with multiple medication documentation omissions in the MAR. Resident identified with multiple omissions were referred to, seen, and examined by the attending physicians foy any adverse effects. Between 9/12/22 and 9/16/22, DNS will provide education and counselling to all licensed nurses on the policy and procedure related to Medication Administration documentation and responsibilities in monitoring the EMR Dashboard Admin Record notification for not documented medication and treatment orders. III. The following system changes will be implemented to assure continuing compliance with regulations: With the assistance of the Outside Consultant, the Administrator, Medical Director, Director of Nursing reviewed the facilityÆs policy and procedure for Medication Administration and Documentation-General Policy #PHNY69. The policy was updated to address licensed nurse and nursing administration responsibilities in routine monitoring the EMR notification dashboard to medication omissions. DNS/designee provided education to all licensed nurses on the policy and procedure related to Medication Administration documentation and responsibilities in monitoring the EMR Dashboard Admin Record notification for ônot documentedö medication and treatment orders. Education emphasizes on the responsibility of the licensed nurse for recording medication/treatment administration in the resident's electronic Medication Administration Record [REDACTED]. The medication nurse is never to report off duty without first completing the recording of all medications which were administered. RN supervisor will be responsible in monitoring the EMR dashboard at least twice per shift for any overdue notifications in the administration tab. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with medication/treatment administration documentation. The DNS/designee will conduct administration documentation audits with 15% of the resident population monthly for three (3) months then quarterly for the next three quarters. All survey findings will be reported to the Administrator monthly. Corrective action such as revision to the plan of care or staff re-education will be implemented as indicated. The DNS/designee will report administration documentation audit findings to the QA Committee monthly for three (3) months then results quarterly for an addition three (3) quarters for evaluation and follow-up discussion. The QA Committee will determine at the end of the fourth quarter the need for ongoing monitoring and at what frequency. Completion Date: (MONTH) 28, 2022 Responsibility: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Extended Recertification survey from 7/21/2022 through 8/03/2022, the facility did not ensure that a resident was cared for in a manner that maintained or enhanced his or her dignity for 1 (Resident #41) of 2 residents reviewed for dignity out of a sample of 47 residents. Specifically, a resident's Foley catheter bag was uncovered and exposed to public view. The finding is: The facility policy and procedure regarding Resident Rights dated 06/2022 documented the resident has a right to personal privacy and confidentiality of his or her personal and medical records. Also, personal privacy includes accommodations, medical treatment, and personal care. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident's cognitive status was Moderately impaired with a Brie Interview of Mental Status score of 12 out of 15. The resident required total assistance of 1 for bed mobility and toilet use and total assistance of 2 for transfers. On 07/21/22 at 10:23 AM, 07/22/22 at 9:52 AM, and 07/25/22 at 12:28 PM, Resident #41 was observed in bed with a Foley catheter bag containing urine attached to the bed frame. The resident's door was open, and the Foley catheter bag could be seen from the hallway. The physician's orders [REDACTED]. The Indwelling Catheter Comprehensive Care Plan (CCP), effective 5/15/22, documented the following interventions: keep drainage bag below supra pubic level and off the floor, provide privacy, observe urine for sediment, cloudy, odor, blood, and amount, and change catheter as ordered or when blocked. On 07/28/22 at 2:16 PM, an interview was conducted with the Certified Nurse Assistant (CNA# 9) who stated the resident's Foley catheter bag is supposed to be covered since it is seen from the hallway. CNA #9 stated he/she has worked with Resident #41 for some time, and he/she has not seen a privacy bag on the Foley catheter bag before. CNA #9 stated he/she will ask the supply person if the privacy bag is in stock. On 07/29/22 at 11:44 AM, an interview was conducted with Registered Nurse (RN # 4) who stated the CNAs are instructed to hang the Foley catheter bag on the opposite side of the bed, away from public view. RN #4 stated he/she didn't realize the bag was hung facing the hallway. RN #4 stated he/she will ask the supply person to bring up a Privacy bag or order one for Resident #41. On 08/02/22 at 12:38 PM, an interview conducted with the Director of Nursing (DON) who stated the resident's Foley catheter bag should be placed on the other side of the bed, out of public view. There is also a Privacy bag for Foley catheter bags that should be used to cover from public view. 415.5 (a) | Plan of Correction: ApprovedAugust 26, 2022 F- 550 û Resident Rights I. The following actions were accomplished for the residents identified in the sample: Resident #41 On 8/2/22, the staff provided a privacy cover for the residentÆs Foley drainage bag. The DNS/designee provided education to the unitÆs nursing staff regarding their responsibility to maintain the Foley drainage bag with a privacy cover and maintaining the drainage bag out of public view to preserve the residentÆs personal privacy and dignity related to the need to have an indwelling catheter. The Nurse Manager updated the care plan and CNAÆs assignment to reflect this care need. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The Nurse Managers will identify all residents who have an indwelling catheter. All identified residents will be observed to ensure that their indwelling catheter drainage bag has a privacy cover and is maintained out of public view. All residents without a privacy cover will have one placed by the responsible CNA. The Nurse Manager will update, as needed, the care plan for indwelling catheter use to ensure that the plan of care includes use of the privacy cover for the drainage bag and maintaining the drainage bag so that it is not in public view. CNA nursing instructions will be updated as needed and the plan of care reviewed with the unit staff. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Director of Social Work and DNS will review the facilityÆs policy on Resident Rights related to privacy and dignity, including protocols related to the management of indwelling catheter drainage bags with a privacy cover and being maintained out of public view. The Staff Educator/designee will provide education on the above protocols to all Nursing Staff. This education will be reviewed during orientation, annually, and as needed. The RN Supervisors and Nurse Managers will monitor for compliance with maintaining indwelling catheter drainage bags in a dignified and private manner during routine rounds and resident observations. Any issues related to privacy and dignity of a resident requiring a catheter drainage bag will be immediately addressed, and staff re-education provided. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility has developed an audit tool to monitor compliance with residentsÆ rights related to privacy and dignity related to maintaining indwelling catheter drainage bags with a privacy cover and out of public view. DNS/SW/NM/designee will audit each unit weekly x 4 weeks and then monthly for an additional 2 months. All audit findings will be reported to the Administrator. Corrective actions, such as staff reeducation or providing an indwelling catheter drainage bag or placing the covered drainage bag out of public view will be implemented. The DNS will summarize the indwelling catheter drainage bag findings and present the findings to the QAPI committee monthly for 3 months for evaluation and follow-up discussion. At the end of the three months, the committee will determine if further monitoring is indicated and at what frequency. Completion Date: (MONTH) 28, 2022 Responsibility: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification survey from 07/21/2022 to 08/03/2022, the facility did not ensure an employee with negative determination letter was terminated from the Criminal History Record Check (CHRC) system within 30 days. This was evident for 1 (Employee #1) of 7 employee files reviewed. The finding is: The New York State Department of Health (NYSDOH) Dear Administrator Letter dated 2/14/2020, documented a provider must immediately, but no later than 30 calendar days after the event, notify CHRC when a prospective employee is no longer being considered by the provider. The facility policy titled State Mandated CHRC last revised on 02/2022 documented in the event an employee who has been registered with CHRC is terminated, was never hired, or is no longer employed in a position requiring CHRC, the authorized person will submit and complete the CHRC form 105-E Termination Form immediately, but no later than 30 days after this event. A copy of the 105E will be printed and maintained with all related CHRC forms in the employee's personnel file. Employee #1 was hired on 3/28/2022 and the CHRC was submitted on 04/21/2022. Employee #1 was terminated from the facility on 6/03/2022. A NYSDOH Denial Letter for Employee #1 was issued to the facility on [DATE]. There was no documented evidence a CHRC 105-E Termination Form was submitted to remove Employee #1 from the CHRC system. On 07/29/2022 at 3:47PM, the Human Resources Controller was interviewed and stated Employee #1 was removed from the CHRC system today. There were no other staff terminated from the facility within the last month that required CHRC 105-E Termination Form. On 08/01/2022 at 1:20PM, the Administrator was interviewed and stated the Administrator is responsible for monitor the CHRC system, being a relief person, and checking the CHRC system once daily. Once an employee is terminated from the facility, they need to be removed from the CHRC system within 30 days. The Administrator did not know the reason Employee #1 was not terminated from the CHRC system within 30 days of termination from employment. | Plan of Correction: ApprovedAugust 26, 2022 R-1022 I. The following actions were accomplished for the residents identified in the sample: No residents were identified in the Statement of Deficiencies. The termination notice (Form 105) for Employee #1 was submitted to DOH on (MONTH) 29, 2022. The Administrator reeducated the Human Resources Controller regarding their responsibility to ensure that the 105 Termination Form is submitted to the CHRC system as required no later than 30 days after termination II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as having the potential to be affected by the same practice. The Human Resources Controller reviewed the Criminal History Record Check (CHRC) database to ensure that all terminations have been reported to DOH via the CHRC system. No additional form #105s needed to be submitted. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator and Human Resources Controller reviewed the CHRC Policy & Procedure related to the protocol for submitting the 105 Termination Form within 30 days of termination and there was no need for any revisions. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility will develop a CHRC audit tool to identify all employees terminated and ensure a 105 Termination Form was completed and submitted within 30 days of termination. The Human Resources Controller will audit the CHCR Log weekly for 4 weeks and then monthly. All findings will be reported to the Administrator and a 105 Termination Form submitted for any negative findings. The Human Resources Controller will report all CHRC audit findings to the QAPI Committee on a monthly basis for evaluation, discussion and any necessary follow-up actions. Completion Date: (MONTH) 28, 2022 Responsibility: Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the extended recertification survey from 7/21/2022 through 8/3/2022, the facility did not ensure that each resident remained free from physical restraints not required to treat the resident's medical symptoms for 1 (Resident #s 80) of 2 residents reviewed for Physical Restraints out of a sample of 47 residents. Specifically, Resident #80, a resident with [MEDICAL CONDITION] and moderately impaired cognition, was observed with bilateral 1/2 side rails in place without a medical justification and physician's orders [REDACTED]. The findings include: The facility policy titled Proper Use of Side Rails last revised 5/18/21, documented The purpose of these guidelines is to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: bed mobility, ability to change positions, transfer to and from bed to chair, risk of entrapment from the use of side rails and that the bed's dimensions are appropriate for the resident's size and weight. The use of side rails as an assistive device will be addressed in the resident's care plan. Documentation will indicate if less restrictive approaches are not successful prior to considering the use of side rails. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment. A side rail consent form was attached to the policy and procedure. Resident #80 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #80 had moderately impaired cognition with a Brief Interview of Mental Status score of 9 out of 15 and no behaviors. The resident required the total assist of 2 persons for bed mobility, transfers, and toilet use; the resident required the total assist of 1 person for locomotion on unit and off unit, dressing, eating, and hygiene. Ambulation did not occur. The MDS documented bed rails and restraints/alarms were not used. Multiple observations were made of Resident #80 in bed with the bilateral 1/2 side rails up. During these observations, there were no staff present in the room. The observations occurred on 7/21/22 at 12:30 pm, on 7/22/22 at 9:40 AM, 7/25/22 at10:10 AM, 7/25/22 at 3:00 PM, 07/27/22 at 8:32 AM, 7/28/22 at 11:59 AM. 7/29/22 at 11:39 AM, Resident #80's room was observed with the Registered Nurse Supervisor (RNS #4) present. The resident's bed had bilateral bed bolsters in place, and the half side rails were removed. During an interview on 7/22/22 at 9:40am, Resident #80 stated they were unable to put the side rails down by themselves. A Comprehensive Care Plan (CCP) titled Devices not Restraints/Bed Bolsters Bilateral/Bilateral Floor mats, initiated 10/27/21 and updated 6/7/22, documented a goal for Resident #80 to maintain comfort and positioning using the least restrictive device x 90 days. Interventions included: education on risk / benefits of device use, encourage use of device to enhance participation in bed mobility, and observe for tolerance to device use. A CCP for Fall, initiated 9/6/2017 and revised 6/20/2022, documented Resident #80 was at risk for fall related to intermittent confusion, requiring assistance to transfer, history of falls, and psychiatric disorder. The interventions included: provide required assistance with ADLs as needed, low bed as appropriate, and bed bolsters in bed. Side rail use was not an intervention in the CCP. A Bed Mobility/Use of Side Rail Assessment, dated 5/27/22, documented Resident #80 could not turn self from side to side, was not able to grab and hold device safely & effectively, could not easily and voluntarily apply/release the device, and could not understand that the device was an enabler nor use it as an enabler. The assessment documented the the side rails restrict freedom of movement or access to the body. The assessment documented SR would not be used as an enabler. The Fall Risk assessment dated [DATE] documented no side rail or trunk restraints were used for the resident. The current Resident Nursing Instructions as of 8/3/22 documented the resident had safety monitoring/fall precautions of floor mats, low bed, and bilateral bed bolsters applied in bed at all times with removal on one side only during transfers. The instructions also documented the bilateral bed bolsters should be used for turning and positioning to prevent falls with total assist of 2 persons. The staff should ensure bed bolsters are secured in bed at all times and remove the right side bolster during transfers. There was no documented evidence in the medical record that bilateral half side rails were ordered for the resident. During an interview on 7/28/22 at 12:49 PM, the Certified Nursing Assistant (CNA #7), stated the 1/2 side rails were put up to prevent falls because Resident #80 is a fall risk. CNA #7 stated Resident #80 cannot release the side rails on their own and does not hold onto the side rails during care. Resident #80 requires assist of two persons for care. CNA #7 stated the instructions let them know whether or not a resident has side rails. During an interview on 8/1/22 at 11:14 AM, CNA #1 stated Resident #80 requires assist of 2 persons for turning in bed, and the resident does not participate in turning. Resident #80 also requires a hoyer lift with two assist for transfer. CNA #1 stated Resident #80 does not use side rails, only the bolsters are used to prevent Resident #80 from falling. CNA #1 stated he/she believed the reason the bolster are used is because sometimes Resident #80 may try to turn on their own, and Resident #80 may have fallen in the past. During an interview on 7/28/22 at 12:42 PM, the Registered Nurse Supervisor (RNS #2) stated the 1/2 side rails are used to prevent falls. The side rails protect Resident #80 from falling because they can't do anything for themselves. RNS #2 stated Resident #80 has not fallen on any shifts they worked with the resident, and RNS #2 did not think Resident #80 could release the side rails independently. RNS #2 stated there should be a physician's orders [REDACTED]. RNS #2 said they are a float so they do not enter instructions for the CNA Accountability. During an interview on 8/1/22 at 11:13 AM, RNS #4 stated the CNA who floats may have put Resident #80's side rails up. If a resident needs side rails, there should be a physician's orders [REDACTED]. RNS #4 stated they check to ensure CNAs are applying devices as ordered. RNS #4 was re-interviewed on 8/2/22 at 11:15 AM and stated the bed bolsters are used to prevent falls, and Resident #80 had them in place since he/she worked on the unit. RNS #4 stated Resident #80 likes to move to the edge of the bed, and will fall out of bed without them. On 8/2/22 at 11:30 AM, an interview was conducted with the Director of Rehab (DOR). The DOR stated Resident #80 has the bolsters at all times and no side rails are used. Resident #80 has [MEDICAL CONDITION] and very limited movement. The DOR stated restraints are determined on a case-by-case basis. The DOR stated side rails are not considered a restraint if they assist the resident with mobility. 415.4(a)(2-7) | Plan of Correction: ApprovedSeptember 12, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F- 604 I. The following actions were accomplished for the residents identified in the sample: Resident #80 On 7/29/22, the Bed Mobility/Use of side rail assessment to assess risk of entrapment possible benefits of bed rails was completed and reviewed by the IDCPT and determined resident does not need side rails. Side rails were discontinued and removed. IDCPT reviewed and update the ADL care plan and CNA nursing instruction. The Nurse Manager reviewed the plan of care with the unit staff The DNS/Designee reeducated identified staff members CNA #7, CNA #1, RNS #2, RNS #4 regarding their responsibility to adhere to the plan of care for side rail use as well as adherence to the facilityÆs side rail policy. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents who reside in the facility have been identified as potentially being affected by the same practice. The Nurse Managers and IDCPT will review the plan of care for all residents to identify any resident who utilizes a restraint/side rail. All residents who are identified as utilizing a restraint/side rails will be re-assessed by the IDCPT for continued need of the restraint/side rails. The IDCPT will review and update, as needed, the CCP and CNAAR of each identified resident to reflect the residentÆs current status, device/s in use and the outcome of any alternatives attempted. The Nurse Manager will review all revisions to the plan of care with the responsible unit staff. All identified residents utilizing a restraint/side rails will have their medical orders reviewed to ensure that there is an order in place for use of the restraint/side rails as needed including an appropriate rationale for use. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Director of Nursing and Medical Director will review and revise, as indicated, the facilityÆs policies and procedures related to restraints/side rails including protocols regarding assessment for ongoing use of a restraint, physician orders [REDACTED]. The protocol will include monitoring of documentation to validate completion of periodic assessment of the ongoing need for a restraint, a physician order [REDACTED]. The DNS/designee will provide education to the IDCPT, including CNAs, regarding their responsibilities related to the above policies and procedures with an emphasis on what devices can be considered a restraint, including side rail. This education will be incorporated in the orientation of new clinical team members and will be reviewed annually and as needed. The RN Supervisors will monitor compliance through routine observational rounds, review of physician orders, care plans and CNAAR documentation to ensure policies and procedures are being followed, such as completion of assessments, CNAARs and care plans are current, and a physician order [REDACTED]. Immediate corrective actions, including staff re-education, assessment of the restraint or implementation of a care plan for a restraint/side rail, will be implemented, as indicated. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with protocols related to the use of restraints/side rails. The audit will address physician order [REDACTED]. The RN Supervisors/designee will audit 15% of residents who utilize a restraint/side rails monthly for the next 3 months and then 15% quarterly for an additional 3 quarters. The RN Supervisors will report all restraint audit findings to the Administrator and Director of Nursing monthly for 3 months and then at the end of the next 3 quarters. Corrective actions, including education, completion of an assessment or care plan, or obtaining a physician order [REDACTED]. The DNS will report all restraint/side rail audit findings to the QAPI Committee on a monthly basis for 3 months and again at the end of the next 3 quarters. At the end of this period, the Committee will evaluate the need for additional monitoring and at what frequency or other corrective actions to be implemented. Completion Date: (MONTH) 28, 2022 Responsibility: Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the Recertification survey, the facility failed to ensure the resident had the right to and the facility promoted and facilitated self-determination through support of resident choice about aspects of his or her life in the facility that are significant to the resident for all smoking residents in (MONTH) 2020, including 2 of 47 sampled residents (Resident #48 and #35). Specifically, the facility became a smoke-free facility and failed to provide smoking accommodations to smoking residents who resided in the facility prior to becoming smoke-free and did not wish to participate in smoking cessation. The findings are: The facility policy and procedure titled Grand Manor Nursing Home Resident Rights dated 06/2022 documented the facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing. The Resident Smoking Free Facility policy dated 4/2020 documented a facility-wide Smoke Free Facility Policy was initiated on (MONTH) 2020 due to the COVID-19 public health emergency. The policy further documented the change affected all facility residents who were smokers as of that date. The facility policy would promote smoking cessation efforts while ensuring resident safety as related to residents who did smoke. The policy indicated smoking was prohibited in all areas of the facility at all times, including electronic cigarettes and vapes. Residents who were smokers wold be offered counseling, drug cessation programs, and pharmacological interventions and /or behavioral interventions to assist with smoking cessation, and educational materials regarding smoking and smoking cessation. The facility would also develop a safe plan to help residents quite smoking. All residents would be asked about tobacco urges during the admission process, quarterly, and comprehensive assessments. 1) Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #48 had intact cognition. No tobacco use was documented. On 07/25/22 at 05:04 PM, an interview was held with Resident #48. Resident #48 stated that they used to smoke three times per day before the facility shut the smoke room down during the COVID-19 pandemic. Resident #48 stated that when the facility became a non-smoking facility, the facility did not provide anything for him/her to sign regarding an agreement to the facility becoming a non-smoking facility. Resident #48 stated the nurses and recreation verbally informed them the facility was transitioning to a non-smoking one. Resident #48 could not remember how much time the facility gave smoking residents to adjust before fully transitioning to a non-smoking facility. Resident #48 stated that they do not want to stop smoking. Resident #48 stated staff did not ask if they wished to stop smoking, and no smoking cessation program or nicotine patch was offered. Resident #48 stated he/she was not offered a transfer to a smoking facility. Resident #48 stated that they have not smoked since 2020 when the facility became a non-smoking facility. Resident #48 further stated that if they had a cigarette right now, they would smoke it and relax with a coffee in their hand. The Comprehensive Care Plan (CCP) titled Smoking Care Plan, initiated 02/24/2017 and reviewed 06/07/2022, documented Resident #48 was a safe smoker, able to smoke and extinguish cigarettes safely, and followed the smoking rules and regulations. The CCP interventions included: Resident will be advised of the rules of the Safe Smoking Program and informed of smoking rules/designated areas/hours as appropriate. Smoking cessation would also be offered. During an interview on 07/26/22 at 12:20 PM, Registered Nurse (RN) #1 stated he/she did not know how residents were informed the facility would be transitioning to a non-smoking facility. RN #1 was not given a formal notice about the change. RN #1 did not know if residents were given any agreement to sign regarding the facility's transition to non-smoking. During an interview on 7/25/2022 at 1:53 PM, the Director of Recreation (DOR) stated they did not work at the facility at the time of the transition. The DOR stated a folder is kept for residents who were active smokers. The DOR stated the residents signed a document informing them of the transition to non-smoking, but the facility no longer has the records because they were destroyed in a flood. The DOR could not provide documented evidence that residents were offered a transfer to a smoking facility, but the DOR stated it was mentioned to the residents. The DOR stated the residents who resided in the facility prior to becoming non-smoking were not provided an exception to allow them to smoke in a designated area. On 07/25/22 at 12:48 PM, 7/25/2022 at 2:48 PM, and 7/26/22 at 11:29 AM, the Administrator was interviewed and stated the facility went smoke free in 2020. The plan was to put smoking residents on a smoking cessation program, like a nicotine patch. The Administrator stated the recreation activities assist the smoking residents with their smoking urges. The Administrator stated the residents were provided verbal notification, and families and residents were provided documentation for them to sign informing them the facility was transitioning to smoke-free. The residents were given 2 to 3 weeks notice before the transition occurred. The Administrator stated the facility does not have the signed agreements completed for the residents and families. 2) On 7/26/22 at 11:23 AM, Resident #35, the Resident Council President was interviewed. Resident #35 stated the residents were not informed about the change to smoke freee, it was forced on them. He/she further stated residents still smoke in the facilty, but they do it undercover in the hallways, resident rooms, and where the fire alarm won't trigger. Resident #35 stated they were a smoker at the time of the transition to smoke free, but he/she does not smoke anymore because as the Resident Council President he/she neefds to set an example for others and not smoke against the rules. Resident #35 stated facility staff/administration did not discuss the smoke free policy with the Resident Council. Resident #35 stated the residents found out the smoke room was closed when they went down to smoke. The Certified Nursing Assistant (CNA) assigned to monitor the smoke room and recreation staff informed them the room was closed. Resident #35 stated he/she was upste about the way it was done, and other residents were ready to break into a riot. Resident #35 stated he/she heard residents were offered patches when they were caught smoking in the building, and residents cigarettes were confiscated. Resident #35 stated their family was not informed about the policy change. The cigarettes that were being held for the residents are still in storage. Resident #35 stated he/she asked the Administrator about compensating the residents for the cigarettes since they cannot smoke anymore, and the Administrator told him/her no. Resident #35 stated residents complained at the Resident Council meetings, and he/she felt they put a lot of pressure on him/her. The facility was unable to provide any Resident Council meeting minutes from 2020 to 2021 or documentation regarding informing residents and families about the transition to a smoke-free facility, alleging they were destroyed in a flood. 415.5(b)(1-3) | Plan of Correction: ApprovedSeptember 12, 2022 F- 561 I. The following actions were accomplished for the residents identified in the sample: Resident #48 On 7/29/22, the IDCPT met with the resident to discuss their preference related to smoking. The resident indicated preference to continue to smoke and a smoking assessment was completed by the team so that this preference could be accommodated. The IDCPT, with the input from the resident, developed a safe smoking care plan to address the residentÆs preference to smoke, including interventions for education of the resident on the identified location for smoking, that staff will be monitoring the smoking area to provide assistance and oversight of the residentsÆ smoking and times for smoking sessions, management of smoking materials, resident signing a contract, the availability of a smoking cessation program and a review of the smoking policy. The responsible nurse supervisor reviewed and updated the CNA nursing instruction with information related to the residentÆs preference to smoke and reviewed the plan of care for safe smoking with the unit staff, including their responsibility to report and evidence of the resident smoking in an undesignated area so that the residentÆs non-compliance with safe smoking could be addressed. The Social Worker will meet with the resident following any episode of non-compliant smoking to discuss the occurrence so that follow-up can be done with the IDCPT, and the care plan revised. Resident #35 On 7/30/22, the IDCPT met with the resident to discuss their preference related to smoking. The resident indicated preference to continue to smoke and a smoking assessment was completed by the team so that this preference could be accommodated. The IDCPT, with the input from the resident, developed a safe smoking care plan to address the residentÆs preference to smoke, including interventions for education of the resident on the identified location for smoking, that staff will be monitoring the smoking area to provide assistance and oversight of the residentsÆ smoking and times for smoking sessions, management of smoking materials, resident signing a contract, the availability of a smoking cessation program and a review of the smoking policy. The responsible nurse supervisor reviewed and updated the CNA nursing instruction with information related to the residentÆs preference to smoke and reviewed the plan of care for safe smoking with the unit staff, including their responsibility to report and evidence of the resident smoking in an undesignated area so that the residentÆs non-compliance with safe smoking could be addressed. The Social Worker will meet with the resident following any episode of non-compliant smoking to discuss the occurrence so that follow-up can be done with the IDCPT, and the care plan revised. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents who smoked at the time the facility transitioned to a non-smoking environment will be identified by the IDCPT as well as all other resident who are currently active smokers and indicated a preference to continue smoking. An IDCPT member will meet with each identified resident to discuss their choice related to smoking at the present time. Following this discussion, the IDCPT will review and update each identified residentÆs plan of care related to their smoking preference, complete a smoking assessment, and provide education to all residents who indicated a preference to smoke regarding the facility smoking policy, location of the identified smoking area, times of smoking sessions, management of smoking materials, and how staff will be monitoring the designated smoking area. The CNAAR for each of the residents who indicated a preference to smoke will be reviewed and updated, as needed, and the plan of care related to smoking reviewed with the unit staff, including the staffÆs responsibility to report any residentÆs non-compliance with the smoking policy and the residentÆs smoking contract. Over the next 3 months at the next scheduled CCP review, the IDCPT will review and update as needed each residentÆs plan of care to ensure that all choices, such as activity participation, smoking activity, schedules for bathing, sleeping, and waking times are addressed in their individual care plan. The Nurse Manager will review and update as needed the CNAAR and review the plan of care with the unit staff. The Director of Recreation will discuss the resumption of the facilityÆs safe smoking program with residents attending the next monthly Resident Council meeting scheduled for (MONTH) 8, 2022. All residents who smoke will be encouraged to attend this meeting. The Director will advise the Administrator of any resident smoking concerns and will share the plan to address verbalized concerns and AdministrationÆs plan to address related to smoking or other concerns at the following scheduled Resident Council meeting. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Director of Social Work and DNS will review and revise, as needed, the facilityÆs policy on Resident Rights related to resident choice, including protocols related to resident smoking preferences. The policy was updated to address the determination of residentÆs daily routine and activity preferences and interest, including smoking preference, that will be shared and documented in the clinical record û care plan and discussion of the safe smoking program to current residents identified as smokers and newly admitted residents. Effective (MONTH) 8, 2022, the Director of Recreation will address resident choice/preference concerns discussed at Resident Council, including those related to smoking, with the Administrator following each Resident Council meeting to develop a follow-up corrective action plan that will be presented to the council members at the following scheduled council meeting. The DNS/designee will provide education on the above protocols to all members of the IDCPT, including CNAs with emphasis on resident choice related to activities, schedules, health care and other aspects of his/her life that are significant to the resident, including smoking when applicable. This education will be reviewed during orientation., as well as reviewed annually, and on an as needed. The Social Workers, RN Supervisors and Nurse Managers will monitor for compliance with honoring resident choices and preferences during routine resident observations and resident interviews. Any issues related to resident choices being honored will be immediately addressed, and staff re-education provided. IV. The facilityÆs compliance will be monitored utilizing the following quality assurance system: The facility will develop a resident satisfaction audit tool to monitor compliance with residentsÆ rights related to choices and preferences, including a preference to smoke or assistance with a smoking cessation program. DNS/SW/RN Supervisor/designee will complete a satisfaction survey with 10 residents per unit per month for 3 months and then quarterly for another 3 quarters. Residents who smoke will be included in the audit sample. All resident satisfaction survey audit findings will be reported to the Administrator. Corrective actions, such as staff reeducation or updating the plan of care will be implemented as indicated. The Director of Social Work will summarize the resident satisfaction survey findings and present the findings to the QAPI Committee monthly for 3 months and then quarterly for an additional 3 quarters for evaluation and follow-up discussion. At the end of the 4th quarter, the QAPI Committee will determine if further monitoring is needed and at what frequency. Completion Date: (MONTH) 28, 2022 Responsibility: Director of Social Work |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details Based on the observation and staff interview conducted during the Life Safety Code recertification survey, the facility did not ensure to provide the required components for the emergency generator. Specifically, a remote manual stop station was not installed outside the Emergency Generator enclosure. This occurred in 1 of 2 generators. The findings are: During the tour of the facility on 07/26/2022 between 10:00AM - 2:15PM, it was observed that facility's (130kW)generator located outside, did not have a manual stop station outside the generator enclosure at a remote and accessible location. The above finding was confirmed by the Director of Environmental Services and Regional Operations Director at the time of the observation. 2012 NFPA 101: 9.1.3.1 2010 NFPA 110: 5.6.5.6* 10 NYCRR, 711.2 (a) (1) | Plan of Correction: ApprovedSeptember 2, 2022 K918 Plan of Correction for affected areas The facility Emergency Generator vendor permanently installed remote shut off buttons on both emergency generators. Plan of Correction to identify other areas potentially affected The facility acknowledges that residents have the potential to be affected by this practice. The facility permanently installed remote shut off buttons on both emergency generators. Plan of Correction for system measures to prevent reoccurrence The facility provided an Emergency Generator Emergency Shut off button Policy and Procedure. Maintenance staff will receive additional education and all participants will understand the life safety issues identified during the facilityÆs survey and the importance of ensuring compliance with the Emergency Generator Emergency Shut off button Policy and Procedure. The Director of Maintenance or Designee will inspect both emergency generators remote shut off switches monthly. The Director of Maintenance or Designee will complete documentation in an audit tool for a period of six (6) months. The Director of Maintenance has been assigned the responsibility for the education of staff and report the findings to the Safety Committee for the period of 6 months. Plan of Correction for monitoring corrective actions The Director of Maintenance will review the audit tool for any cases of non-compliance. The Director of Maintenance will report the staff education compliance quarterly to the QA Committee for a period of 6 months. The Director of Maintenance will report the findings quarterly to the QA Committee for a period of 6 months, as well as correction plan if warranted. Responsibility: Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, document review and interview, the facility did not maintain the required clearance around electrical panels and space heating electrical devices in accordance with NFPA 99, 2012 Edition, Section 6. This occurred on 1 of 7 floors. The findings are: During the tour of the facility on 07/26/2022 between 10:00AM - 2:15PM, it was observed that storage room # 114C located inside the kitchen on 1st floor contained a door sign stating Danger High Voltage. Inside room [ROOM NUMBER]C, combustibles were being stored within 1 feet of electrical panels. The above findings were confirmed by the Director of Facilities & Physical Plant Life Safety Consultant at the time of the observation. 2012 NFPA 99: 2012 NFPA 101: 19.7.8 10 NYCRR, 711.2 (a)(1) | Plan of Correction: ApprovedAugust 26, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K911 Plan of Correction for affected areas The maintenance staff permanently removed combustible storage that was within 3Æ of the electrical panels in room [ROOM NUMBER]C. Plan of Correction to identify other areas potentially affected The facility acknowledges that residents have the potential to be affected by this practice. The facility checked all areas for the same deficiency. Any obstructions to panels were immediately removed if found. Plan of Correction for system measures to prevent reoccurrence The facility updated the Electrical Safety Policy and Procedures. Kitchen staff will receive additional education and all participants will understand the life safety issues identified during the facilityÆs survey and the importance of ensuring compliance with the Electrical Safety Policy and Procedures. The Director of Maintenance or Designee will inspect all floors monthly for to verify Electrical Panels are not obstructed. The Director of Maintenance or Designee will complete documentation in an audit tool for a period of six (6) months. The Director of Maintenace has been assigned the responsibility for the education of staff and report the findings to the Safety Committee for the period of 6 months. Plan of Correction for monitoring corrective actions The Director of Maintenance will review the audit tool for any cases of non-compliance. The Director of Maintenance will report the staff education compliance quarterly to the QA Committee for a period of 6 months. The Director of Maintenance will report the findings quarterly to the QA Committee for a period of 6 months, as well as correction plan if warranted. Responsibility: Administrator |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details Based on observation and staff interview conducted during the Life Safety Code recertification survey, the facility did not ensure that portable fire extinguishers were properly installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. This occurred on 4 of 7 floors. The findings are: Observations during the tour of the facility on 07/26/2022 between 10:00AM - 2:15PM and on 07/27/2022 between 08:00AM - 11:00AM identified the following: - Four ABC type portable fire extinguishers installed inside the nurse stations on 2, 3, 4th floors and by emergency exit on receiving area on 1st floor revealed inspection tags recorded the last monthly inspection 06/01/2022. - One ABC type portable fire extinguisher installed inside the dining room on the 1st floor revealed that the fire extinguisher was not inspected monthly. The inspection tag was blank and did not indicate that monthly inspection (date and initials) was completed. - Two ABC type portable fire extinguishers installed in the administrator wing by room# 101A and the dining room on 1st floor revealed inspection tags recorded last annual service (MONTH) 2021 and monthly inspections on 04/01/2022 and 01/01/2022 respectively. The above findings were confirmed by the Director of Facilities & Physical Plant Life Safety Consultant at the times of the observations. 2012 NFPA 101: 19.3.5.12 2010 NFPA 10: 6, 7.2.1.2*, Table-7.3.1.1.2 10 NYCRR, 711.2 (a)(1) | Plan of Correction: ApprovedAugust 26, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K355 Plan of Correction for affected areas The maintenance staff completed the monthly inspections of the identified portable fire extinguishers located at the nurseÆs stations on the 2nd, 3rd, and 4th floor. The maintenance staff also completed the monthly inspection of the portable fire extinguisher on the 1st floor by the emergency exit in the receiving area and inside the 1st floor Dining Room. The results were documented on the extinguisher tags and the facilities Records & Logs. The identified portable fire extinguishers Administration wing by room [ROOM NUMBER]A and the 1st floor Dining Room were replaced by maintenance staff with spare extinguishers that were complete with annual and monthly inspection tags. Plan of Correction to identify other areas potentially affected The facility acknowledges that residents have the potential to be affected by this practice. The facility checked all portable fire extinguishers for current monthly and annual inspections. No other deficiencies were found. Plan of Correction for system measures to prevent reoccurrence The Director of Maintenance or his designee will complete an inventory list of all portable fire extinguishers and their locations. Maintenance staff will inspect all fire extinguishers monthly and document the findings on the extinguishers tag and in the facilities Records & Logs Book. The Director of Maintenance or Designee will complete documentation in an audit tool for a period of six (6) months. Plan of Correction for monitoring corrective actions The Director of Maintenance will review the audit tool for any cases of non-compliance. The Director of Maintenance will report the findings quarterly to the QA Committee for a period of 6 months, as well as correction plan if warranted. Responsibility: Administrator |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details Based on observations, staff interview, and document review conducted during the Life Safety Code recertification survey, the facility did not ensure that facility's smoking policy was properly implemented, and smoking was prohibited in the non-smoking facility. This was evidenced by cigarette butts observed in 2 of 3 exit stairwells. The findings are: Observations during the tour of the facility on 07/26/2022 between 10:00AM - 2:15PM and on 07/27/2022 between 08:00AM - 11:00AM identified the following: 1) Cigarette butts were observed inside the stairwells as follows: - In the South stairwell landings by the standpipe and sprinkler riser pipes on the 5th floor and on the 4th floor (2 butts each) - In the South stairwell on the 3rd, 2nd and 1st floor (1 butt each) on all landings between the floors. - In the East stairwell landings by the standpipe and sprinkler riser pipes on 3rd, 2nd, and 1st floor (2 butts) In an interview during the tour of the facility on 07/26/2022 between 10:00AM - 2:15PM, the Director of Facilities & Physical Plant Life Safety Consultant stated the facility was a smoking facility before Covid-19 pandemic. When pandemic started the facility became non-smoking facility. 2) It was observed that facility is in use of a double door entrance from the parking lot as a main employee and resident entrance. The entrance was missing a prominently placed NO SMOKING. Signs were placed inside the facility after the beyond entrance lobby. During the record review on 08/27/2022 at approximately 04:30PM, the facility's policy entitled Grand Manor Nursing Home Resident Smoking Free Facility date implemented: 04/2020 revealed under the heading Policy Explanation and Compliance Guidelines that smoking is prohibited in all areas of the facility at all times and No-Smoking signs will be maintained on the door or gate and where oxygen is used or stored. The above findings were confirmed by the Director of Facilities & Physical Plant Life Safety Consultant at the times of the observations. 2012 LSC, NFPA 101 - 19.7.4 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedSeptember 1, 2022 K741 - NFPA 101 Smoking Regulations Plan of Correction for affected areas Effective 7/28/22, CNA and Housekeeping staff will monitor stairwells every hour, on each unit. Documentation will be completed in a spreadsheet called Stairwell Checks. Which will then be checked every shift by the RN Supervisor. Effective 7/29/22, Smoking will be permitted only in smoking room located in the basement at the following designated times 9:30am, 1:30pm, and 6:30pm. The smoking-room location and times will be posted through the facility. Effective 7/28/22, no resident is to use any staircase leading to the basement. Plan of Correction to identify other areas potentially affected The facility acknowledges that residents have the potential to be affected by this practice. On 7/31/22, a full house audit was conducted by the Activity Director/designee to identify residents who smoke. Smoking assessments were completed to determine safe and unsafe/hazardous smoking behaviors. Smoking observation tool and smoking care plans were also developed and completed on all identified smokers on 8/1/22. Smoking care instructions and interventions were also communicated and addressed in the CNA nursing instruction. The RN Supervisor and the IDCP Team will identify all residents whose plan of care includes daily room search and/or visual checks on a specific schedule. On 7/29/22, all residents identified as smokers will have discussion with the IDCPT on the smoking policy and a new smoking contract was completed. Discussion about the smoking policy and smoking contact must be included during scheduled care plan meetings and annually. Plan of Correction for system measures to prevent reoccurrence The Administrator and Director of Nursing, and Social Work reviewed the facilityÆs current policies and procedures related to accident prevention and provision of adequate supervision and assistance to prevent accidents, including protocols regarding its safe smoking program and visual checks. A new smoking policy was developed on 7/2022. The revised policy ensured consistency in assessing residents for smoking, care plans and supervisions. Outside Consultant reviewed the Safe Smoking Program policy on 8/2/122 and revision were made to include room search and 1:1 monitoring guidelines for resident with unsafe/hazardous smoking behavior. On 7/28/22, all residents were notified of the new smoking policy during the resident council meeting. New smoking policy guidelines are posted in designated areas in the facility. As per the Directed In service, the Outside Consultant provided education from 8/29/22 to 9/28/22 to all staff regarding the facilityÆs protocols related to accident prevention including protocols related to the Safe Smoking Program. This education included a review of the survey findings, policy and procedure revisions, and processes implemented. Emphasis was also given in the staffÆs responsibilities when unsafe/hazardous smoking behaviors are observed. This education will continue to be provided by the Director of Staff Education until all facility staff receives this required education. On 7/29/22, signages indicating, ôSmoking Allowed Only in Designated Areaö is prominently posted throughout the facility. ôNo Smoking Signsö will be posted where oxygen is used or stored. The Administrator has arranged for the smoking area to be provided with ashtrays made of noncombustible material and safe design as per NFPA 19.7.4. The Administrator has also arranged for a metal container with a self-closing cover into which ashtrays can be emptied to be readily available in the designated smoking area. The Housekeeping staff will be responsible for the cleaning and emptying of the ashtrays and metal container. The Director of Housekeeping will be responsible for developing the cleaning and emptying schedule and educating the Housekeeping staff. Plan of Correction for monitoring corrective actions The facility will develop audit tools to monitor compliance with protocols related to unsafe smoking and completion of room search finding and stairwell checks. The DNS/designee will audit all Room Search Finding and Stairwell Check documentation for compliance with the Safe Smoking Program on a monthly basis for the next three months and then quarterly for an additional three quarters. Corrective action, including staff re-education regarding documentation responsibilities, will be implemented as indicated. At the end of the 4th quarter, the Committee will make a decision regarding the need to continue auditing these areas and the frequency of audit if auditing is to continue as well as the need for additional corrective actions. The Director of DNS/designee will report to the QAPI Committee the findings of the above audit on a monthly basis for the first three months and then quarterly for the next three quarters. Responsibility: Administrator |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details Based on observations and staff interview conducted during a Life Safety Code Recertification survey, the facility did not maintain all components of the automatic sprinkler system and the ceilings around the sprinkler per NFPA 13 and NFPA 25. NFPA 13, 2010 edition, Section 3.3.5.4 defines a smooth ceiling as a continuous ceiling free from significant irregularities, lumps, or indentations. The ceiling traps hot air and gases around the sprinkler and cause the sprinkler to operate at a specified temperature. This occurred on 6 of 7 floors. The findings are: Observations during the tour of the facility on 07/26/2022 between 10:00AM - 2:15PM, identified the following: - Sprinklers were observed missing cover plates/escutcheons at locations including but not limited to: porter's closet east wing on 6th floor (1 missing), soiled holding room by room# 613 (1 missing), porter's closet east wing 5th floor (1 missing), porter's closet by nurse station on 4th floor, and in the kitchen by the refrigerator on first floor (1 missing). - Smoke proof ceilings/sheetrock were observed missing tiles at locations including but not limited to: sprinkler shut off valve room by room# 621 on 6th floor (1 missing), porter's closet east wing on 3rd floor (1 missing), IT closet on 1st floor (1 missing), staff dining room by the kitchen on 1st floor, barber and beauty shop room B5 in basement (1 missing), and B23 room in basement (5 missing). The above finding was confirmed by the Director of Environmental Services and Regional Operations Director at the time of the observations. NFPA 101 (2012): 19.3.5, 9.7.5, 9.7.6 NFPA 25 (2010): 5 10NYCRR 415.29 10 NYCRR, 711.2 (a)(1) | Plan of Correction: ApprovedSeptember 2, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K353 Plan of Correction for affected areas The maintenance staff replaced missing ceiling assemblies (ceiling tiles/sheetrock) in the following locations; 1. 6th Floor Sprinkler Shut Off Room by room [ROOM NUMBER]. 2. 3rd Floor PorterÆs Closet East Wing. 3. 1st Floor IT Closet. 4. 1st Floor Staff Dining Room by Kitchen. 5. Basement Room B5 Beauty Shop. 6. Basement Room B23. The facility engaged our Sprinkler Service Company to install the following missing sprinkler escutcheons: 1. 6th Floor East Wing PorterÆs Closet. 2. 6th Floor Soiled Holding Room by room [ROOM NUMBER]. 3. 5th Floor East Wing PorterÆs Closet. 4. 4th Floor PorterÆs Closet by Nurses Station. 5. 1st Floor Kitchen by the refrigerator. Plan of Correction to identify other areas potentially affected The facility acknowledges that residents have the potential to be affected by this practice. The Director of Maintenance checked all sprinklers for similar deficiencies. Any missing escutcheons were immediately installed if found. The Director of Maintenance checked the facility for missing ceiling assemblies (ceiling tiles/sheetrock). Any missing ceiling tiles were immediately replaced if found. Plan of Correction for system measures to prevent reoccurrence All maintenance staff will receive additional education and all participants will understand the life safety issues identified during the facilityÆs survey and the importance of ensuring compliance with the proper installation of sprinklers and assemblies, along with ceiling openings can affect the proper operation of sprinkler activation. Staff were educated that any deficiency identified will be corrected immediately. The facility Sprinkler Service Company and the Director of Maintenance or Designee will inspect the sprinkler system monthly and complete documentation in an audit tool for a period of six (6) months. The Director of Maintenance or Designee will inspect the building for penetrations monthly and complete documentation in an audit tool for a period of six (6) months. Plan of Correction for monitoring corrective actions The Director of Maintenance will review the audit tool for any cases of non-compliance. The Director of Maintenance will report the findings quarterly to the Safety Committee for a period of 6 months, as well as correction plan if warranted. Responsibility: Administrator |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details Based on observations and staff interview conducted during the Life Safety Code recertification survey, the facility did not ensure to properly mark the exit stairs with path markings on the handrails and landing perimeters in accordance with chapter 7 of NFPA 101 Life Safety Code 2012 edition. This occurred on 6 of 7 floors. The findings are: During the tour of the facility on 07/26/2022 between 10:00AM - 2:15PM, it was observed that contrasting colored path markings were not applied on perimeters of each landing inside the North, South, and East exit stairs on floors 1 through 6. The above finding was confirmed by the Director of Environmental Services and Regional Operations Director at the time of the observation. 2012 NFPA 101: 19.2, 7.2.2.5 10 NYCRR, 711.2 (a) (1) | Plan of Correction: ApprovedAugust 26, 2022 K225 Plan of Correction for affected areas The maintenance staff completed the exit stair landing perimeter stripes in contrasting color to readily identify the landings floors 1 through 6 in the North, South and East stairwells. Plan of Correction to identify other areas potentially affected The facility acknowledges that residents have the potential to be affected by this practice. The Director of Maintenance checked all stairs for landing stripes to readily identify the landings. No other areas were identified. Plan of Correction for system measures to prevent reoccurrence The Director of Maintenance or Designee will inspect stairs quarterly for proper markings and complete documentation in an audit tool for a period of six (6) months. Plan of Correction for monitoring corrective actions The Director of Maintenance will review the audit tool for any cases of non-compliance. The Director of Maintenance will report the findings quarterly to the Safety Committee for a period of 6 months, as well as correction plan if warranted. Responsibility: Administrator |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2022
Corrected date: September 28, 2022
Citation Details Based on observation and staff interview conducted during the Life Safety Code recertification survey, the facility did not ensure that doors in smoke barrier walls did not have gaps between the doors and could resist fire for a minimum of twenty-minutes in accordance with NFPA 101, 2012 Edition, Section 19.3.7.6, 19.3.7.8 and 19.3.7.9. This occurred on 4 of 7 floors. The findings are: Observations During the tour of the facility on 0726/2022 between 10:00AM - 2:15PM, identified the following: a) The undercuts on 2 smoke barrier double doors were observed and measured to have ¾ - 1? inch gap between top of floor and bottom of doors at following locations: - Between South wing and nurse station on 3rd floor. - Between North wing and nurse station on 2nd floor. b) One-quarter to one-inch gaps were observed between the meeting edges of the smoke barrier double doors at following locations: - Between South wing and nurse station on the 5th floor. - Between South wing and nurse station on the 6th floor. - Between North wing and nurse station on the 2nd floor. The above findings were confirmed by the Director of Facilities & Physical Plant Life Safety Consultant at the times of the observations. 2012 NFPA 101: 19.3.7.6, 19.3.7.8, 19.3.7.9 2010 NFPA 80: 4.8.4.1, 6.3.1.7 10 NYCRR, 711.2 (a) (1) | Plan of Correction: ApprovedSeptember 2, 2022 K374 Plan of Correction for affected areas The facility permanently installed a UL listed fire rated door gap extender in compliance with NFPA 80 and 252 for 90-minute fire rated doors, that closed the meeting edge center gap in the identified smoke barrier doors on the 5th floor between the South wing and the nurseÆs station. The facility permanently installed a UL listed fire rated door gap extender in compliance with NFPA 80 and 252 for 90-minute fire rated doors, that closed the meeting edge center gap in the identified smoke barrier doors on the 6th floor between the South wing and the nurseÆs station. The facility permanently installed a UL listed fire rated door gap extender in compliance with NFPA 80 and 252 for 90-minute fire rated doors, that closed the meeting edge center gap in the identified smoke barrier doors on the 2nd floor between the North wing and the nurseÆs station. The facility permanently installed a UL listed fire rated door gap extender in compliance with NFPA 80 and 252 for 90-minute fire rated doors, that closed the gap to less than ¾ö between the bottom of the door and the floor in the identified smoke barrier doors between the 3rd floor South wing and the nurseÆs station. The facility permanently installed a UL listed fire rated door gap extender in compliance with NFPA 80 and 252 for 90-minute fire rated doors, that closed the gap to less than ¾ö between the bottom of the door and the floor in the identified smoke barrier doors between the 2nd floor North wing and the nurseÆs station. Plan of Correction to identify other areas potentially affected The facility acknowledges that residents have the potential to be affected by this practice. The facility checked all smoke barrier doors for gaps exceeding NFPA requirements to resist the passage of smoke. Any deficiencies were corrected immediately. Plan of Correction for system measures to prevent reoccurrence The Director of Maintenance or Designee will inspect all smoke barrier doors monthly. The Director of Maintenance or Designee will complete documentation in an audit tool for a period of six (6) months. Plan of Correction for monitoring corrective actions The Director of Maintenance will review the audit tool for any cases of non-compliance. The Director of Maintenance will report the findings quarterly to the QA Committee for a period of 6 months, as well as correction plan if warranted. Responsibility: Administrator |