New East Side Nursing Home
December 10, 2018 Certification Survey

Standard Health Citations

FF11 483.20(g):ACCURACY OF ASSESSMENTS

REGULATION: §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2018
Corrected date: January 25, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertificaiton survey, the facility did not ensure the accuracy of a resident's assessment. Specifically, a Minimum Data Set (MDS) inaccurately documented that a resident received oxygen and ventilator/respirator therapy while in the facility. This was evident for 1 of 36 residents reviewed. (Resident #9 ) The findings are: The facility's Minimum Data Set(MDS) Policy and Procedure reviewed on 02/2018 documented that using a prescribed set of definitions, information for the MDS completion may come from a variety of sources such as staff, resident, family interviews, and the clinical record. It also documented that each individual who completes a portion of the assessment certifies the accuracy of that portion of the assessment. Resident #9 was admitted to the facility with a [DIAGNOSES REDACTED]. The most recent Quarterly MDS dated [DATE] documented that the resident has moderate cognitive impairments. Under the MDS Section 'O', Special Treatments, Procedures, and Programs, the resident is documented as using oxygen therapy and a ventilator or respirator while a resident. A review of the resident's entire medical record from the MDS assessment reference dates was completed. There was no documented evidence that the resident received any oxygen and/or ventilator/respirator therapy while a resident of the facility. An interview was conducted with the MDS Coordinator on 12/6/18 and 12/10/18. The MDS Coordinator (MDS-C) stated that she is the person responsible for completing the MDS assessments for every resident in the facility. Upon reviewing the resident's 9/14/18, the MDS-C stated that she had made an error when inputting this particular residents information. She stated that the facility does not have ventilator services and that she will review the residents chart again and file a correction on the MDS. The MDS-C is the sole person who compiles information through record review, conducting interviews, and through observations. She also inputs all of the MDS assessments in the facility. Once an MDS assessment has been completed, the MDS-C will review the information that has been inputted to ensure accuracy. There are no follow up audits or reviews done to ensure the accuracy of MDS assessments. Whenever the MDS-C initiates a new MDS assessment to be completed for a resident, she will review the previous MDS to compare the information that has been gathered. Occasionally, she will find discrepancies and file a MDS correction. The MDS-C is part of the Quality Assurance team but states that MDS accuracy is not a topic that they have ever reviewed. 415.11(b)

Plan of Correction: ApprovedJanuary 3, 2019

F 641 SS=D
I. Under a record review and interviews the facility didn?t ensure resident #9 Minimum Data Set (MDS) was documented accurately. The MDS coordinator admitted she had made an error. She stated during her interview the facility does not admit residents with ventilator. The MDS coordinator immediate corrected the error and filed the correction with the State.
II. Residents have the potential to be affected by the deficient practice. An audit of all of the latest submissions will be audited to ensure their MDS?s are documented accurately.
III. To ensure the deficient practice will not happen again the following measures will be put into effect:
? The MDS coordinator and/or designee will do random weekly audits of 20 percent of the MDS that were completed the week prior as part of an Quality Assurance initiative.
? The MDS coordinator will review findings with the DNS on a weekly basis to review its outcome and recommend any corrections if needed.
IV. To ensure the deficient practice will not recur, a monthly QA audit will be conducted of the weekly audits by the DNS and/or designee. The DNS will report the findings to the QA meeting on a quarterly basis for review.
V. The DNS is responsible for the correction of F 641.

FF11 483.10(e)(1); 483.12(a)(2):RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS

REGULATION: §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2018
Corrected date: January 25, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that a restraint was used in accordance with the resident's plan of care and physician's orders [REDACTED].# 42, to be released every 2 hours for 15 minutes and during meals. The MD's order did not document a medical justification for the use of this type of restraint. In addition, on multiple occasions it was observed that nursing staff did not release the seatbelt every 2 hours for 15 minutes and did not have the seatbelt released during meal times. This was evident for 1 of 2 residents reviewed for restraint use. (Resident #42) The findings are: Resident #42 was admitted to the facility with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] documents that the resident has severely impaired cognition, no behavioral issues, and requires the extensive to total assistance of 1 person to complete all activities of daily living (ADL). The MDS also documents that the resident has a trunk restraint that is used daily whenever the resident is out of bed. On 12/6/18, from 8:43AM to 12:08 PM and 12/7/18 from 9:09AM to 12:47 PM, multiple observations were made of the resident while she was seated in her wheelchair with the secure soft seatbelt in place. The resident was observed sitting in the hallway on her unit and then being brought to the Recreation Department on the 4th floor unit on both days. The resident was also observed on both days to be brought back down to her unit from Recreation and then placed in the Floor Day Room (FDR) to await lunch. There were no observed attempts to transfer the resident to her bed for a diaper change or to toilet the resident in any bathrooms. The resident was observed to have her secure soft seatbelt in place during each of these observations. Additionally, the resident was observed being fed by the Licensed Practical Nurse (LPN) #1 during lunch time on 12/7/18 with the secure soft seatbelt still in place. The resident was not observed to be agitated during any of the observations made on 12/6/18 and 12/7/18. At times, the resident would lightly tug on the soft seatbelt strap while seated in the wheelchair but was unable to release the restraint independently. All SA attempts to speak with resident or provide directives for resident to release restraint were unsuccessful due to the resident's severely impaired cognition. The physician's orders [REDACTED]. A Certified Nursing Assistance (CNA) ADL Care Card dated 11/28/18 documents that the resident has a safety device/restraint in place. The secure soft belt is to be used when the resident is in the wheelchair and is to be released every 2 hours for 15 minutes. A Restraints Comprehensive Care Plan (CCP) initiated on 11/14 documents that the resident is at risk for deterioration due to use of restraints related to decreased safety awareness. The goal is for the resident to be free from injury while using the least restrictive device without adverse effects. The document lists the Nursing staff and Medical Doctor (MD) are the disciplines responsible for releasing the restraint every 2 hours for 15 minutes to toilet, provide skin care, range of motion, and ambulate (if feasible). The Nursing staff is the discipline responsible for releasing the restraint for meals. A Restraint Agreement Form dated 10/3/18 documents that the resident is to have a secure soft seat belt in place due to decreased safety awareness and increased risk for falls. An Interim physician's orders [REDACTED]. A subsequent Interim Physicians' Order on 10/1/18 documents that the MD ordered for resident to have the secure soft seat belt when she is in the wheelchair. The restraint is to be released every 2 hours for 15 minutes. The is no documented evidence that the order for secure soft seatbelt was discontinued on any of the Interim Orders reviewed from 10/1/18 to present. There was no medical justification for the soft seatbelt documented on the interim order. A Rehab Restraint Review Form dated 10/1/18 documents that a secure soft belt is recommended. The resident is unable to release the restraint upon command. The reasons for using the secure soft seat belt include promoting an upright sitting position and is due to the resident constantly attempting to stand up unassisted. The recommendation is to discontinue the existing restraint and start the new restraint of a secure soft belt. A Physicians Order Sheet for Adaptive Devices dated 10/1/18 documents that the type of device to order is a secure soft belt when resident is in wheelchair. There was no documentation of a MD review or assessment of the resident's need for restraint noted in the Doctor's Progress Notes from 9/7/18 through 11/1/18. On 12/07/18 at 2:42 PM an interview was conducted with the resident's assigned CNA, CNA #1. According to CNA #1, the resident is at high risk for falls and has several interventions in place to prevent falls. The resident's bed is to be kept in the lowest position, legs are to be kept elevated, a bed alarm is in place, the call bell is to be within reach, and the secure soft seatbelt is to be used when the resident is in the wheelchair. The CNA's responsibility is to make sure that the belt is not too tight and that there is no irritation on the resident's skin from seatbelt usage. The CNA stated that the belt is only to be released during meal times if possible. The seatbelt may not be released if the resident is leaning forward in her chair, putting herself at risk for a fall. The CNA is assigned to the 7am to 3pm shift and meal times are the only time the restraint is released. The resident requires total assistance with her ADLs and the CNA will usually transfer the resident back to bed to be toileted. There are times where the aide will attempt to toilet the resident in the bathroom. The CNA checked the resident's diaper prior to lunch being served today and did not attempt to change or toilet the resident because her diaper was fairly dry. The CNAs use the CNA assignment book as their main source of information when determining how to care for residents on their assignments. On 12/07/18 at 2:53 PM an interview was conducted with LPN #1. Although she has mainly been assigned to work on another unit in the facility, LPN #1 has worked with the resident several times since she was admitted to the facility and is familiar with her care. LPN #1 states that the resident is blind and sometimes will lean forward in her wheelchair in an unsafe manner because she has sensory deficits; however, this is not reflected in the resident's CCP related to Restraint Use. Since the resident is unable to see, she believes that she is included in conversations that may be taking place around her. The resident will then attempt to move her body in the direction of the conversations without having awareness of her safety. LPN #1 states that the resident has an order for [REDACTED]. The resident was observed with the seatbelt in place during lunch time today because there were multiple residents on the floor that required staff assistance with feeding during meal time. There were more residents to assist during meal time than usual because some residents decided to eat on the unit instead of in the main dining room where the normally eat. The resident's seatbelt was not removed because of safety concerns. Resident must be closely monitored if the restraint is removed because she can attempt to stand and then fall. LPN #1 further stated that it is the judgment call of the nurse as to whether a resident's restraint release period is adjusted or changed. When LPN #1 was asked why the resident was not released from her restrain during the timeframe observed by the SA, LPN #1 stated that the resident must have been released and that the CNA documents the release times on a form that is kept separate from the CNA Accountability Record. LPN #1 then stated that she needed to attend to a resident and asked to continue the interview at a later time. A follow up interview was conducted with CNA #1 on 12/10/18 at 9:36 AM. The CNA stated that after her initial interview with the SA, she had been re-inserviced by the nurse on the unit re: the policy and procedure for restraint usage and release times. No documentation was provided by CNA #1 to verify that a formal inservice was provided to her regarding restraint policies and procedures. The CNA stated that the resident's seatbelt is to be checked and released every 2 hours. There is a restraint Monitoring Sheet that the CNA's use to document when the seatbelts are released. CNA #1 presented the Monitoring Sheet to the SA and confirmed that she had filled out the sheet and her signature was present on the dates for 12/6/18 and 12/7/18. The Monitoring Sheet documents that on 12/6/18 the resident was out of bed to the wheelchair at 8am the resident had breakfast good appetite, at 10am the resident was out of bed to wheelchair, and at 12pm, the resident was monitored for safety. The sheet then documents that on 12/7/18, the resident had breakfast- good appetite at 8am, was out of bed to wheelchair at 10am, and was at lunch - 12:45pm released X15 minutes at 12pm. A follow up interview was conducted with LPN #1 on 12/10/18 at 10:38 AM. Staff on the unit who work with the resident determine that a restraint is necessary for residents when it is determined that their safety is at risk despite alternate measures and interventions to deter at risk behavior. A trial period is initiated when a restraint is recommended to see if the resident can remove the restraint and whether it increases safety. Resident #42 would require a one-to-one staff supervision if no restraint were in place. Once the nursing staff makes observations of unsafe behavior, a psychiatric evaluation will be requested, and the nursing supervisor will be made aware. If a resident currently has a restraint in place, the LPN/RN would be responsible for initiating an observation period with the purpose of discontinuing the restraint order. There are times where a significant change in the resident's status will spur an evaluation for possible discontinuance of a restraint. Upon review of the 11/29/18 physician's orders [REDACTED]. When asked for an explanation, LPN #1 stated that orders are sometimes faxed to the pharmacy, but they may not transcribe everything onto the Monthly Order Form accurately. The process is that the night shift is responsible for reviewing and reconciling the orders and making sure any discrepancies are clarified. The evening shift and the night shift verify that the orders are correct. Both nurses sign that they have verified the accuracy of the orders. Then the MD signs to verify that orders are complete and correct. If there continues to be discrepancies in the physician's orders [REDACTED]. LPN #1 stated that since she has had to handwrite in secure soft seatbelt on the physician's orders [REDACTED]. An interview was conducted on 12/10/18 at 11:31 AM with the resident's MD who was responsible for ordering the restraint. The MD stated that he is familiar with the resident, but not specifically with the devices that have been ordered for her. The MD stated that when a restraint is needed, the interdisciplinary team will attempt other interventions. Often, a resident may have an issue that is more so related to positioning as opposed to requiring a restraint. The MD requires a lot of feedback from facility staff and nursing personnel to ensure that a restraint is necessary. Before ordering a restraint, the MD will discuss the concerns with facility staff. If the MD agrees with the recommendation for a restraint use, the interdisciplinary team will get involved to ensure that the resident/family is also made aware and in agreement. Then an MD order is written. The facility has an ongoing process of review for each resident with a restraint. The MD could not say how often the restraints are reviewed. He believes that he reviews the restraint orders when the resident's monthly physician's orders [REDACTED]. [REDACTED]. The MD does a review of all the monthly physician's orders [REDACTED]. If there is a discrepancy, the MD would cross it out and initial it. The MD makes these corrections on the physician's orders [REDACTED]. The MD stated that there would be a notation made in the MD Notes if the resident was assessed with [REDACTED]. medical review and assessment. The MD could not provide a medical justification for the use of the seatbelt as a restraint for this resident. On 12/10/18 at 12:08 PM, an interview was conducted with the Director of Nursing, DON. A restraint evaluation is completed when the nursing staff identifies a safety concern for a resident. Before placing a restraint on a resident, the facility ensures that rehabilitation department assessment is done to evaluate for other possible interventions. The interdisciplinary team meets and makes sure that the family is involved with the decision to initiate a restraint. There is a Monitoring Sheet that documents the release times of any restraint currently ordered for a resident. The MD must agree and write the order for the resident's restraint. A monthly restraint assessment is completed by the nursing supervisor and/or the DON. Restraint reduction may be initiated to determine if there is a continued need for a restraint. The DON stated that the nursing staff assigned to the resident did release the seatbelt on the morning of 12/6 and 12/7 despite the SA observations that resident had the secure soft seatbelt in place for longer than a 2-hour period and throughout meal time. The DON stated that the CNA documented that the restraint was released on 12/6 and 12/7 and that this is accurate information. The DON stated that the surveyor must have missed the release times. The DON stated that the pharmacy transcribes a resident's current physician's orders [REDACTED]. If there is a discrepancy with the orders, the nurses can hand write the orders in and then fax them to the pharmacy to clarify. Sometimes a call will need to be placed to the pharmacy to verbally inform them that there is an issue that they are not resolving. All three nurses from the 3 shifts are required to check the physician's orders [REDACTED]. The DON further stated that the MD should also be checking the accuracy of physician's orders [REDACTED]. [REDACTED]. 483.10(e)(1)

Plan of Correction: ApprovedJanuary 14, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 604 SS=D
1. Plan of correction (P(NAME)) for the affected resident #42:
? The physician order [REDACTED].
? The nursing staff will be in-serviced on the policy and procedure regarding restraints with the emphasis on release time, scheduling, and responsible party.
2. P(NAME) for all other residents potentially affected:
? The physician orders [REDACTED].
restraints will be reviewed and corrected as needed.
? All nursing staff will be in-serviced on the policy
and procedure regarding restraints with the
emphasis on release time, scheduling, and
responsible party.
? The DNS will perform daily spot check of release
time and during meals to ensure any residents with
restraints will have them released in accordance
with policy.
3. How facility will monitor to prevent on-going reoccurrence:
? Monthly audits will be done on all physician orders [REDACTED]. for restraints to ensure completeness, including
medical justification.
? All nursing staff will be in-serviced on the policy
and procedure regarding restraints with the
emphasis on release time, scheduling, and
responsible party. Training will continue on a
quarterly basis for the first year to ensure
compliance.
? The DNS, supervisor and designee will perform daily
spot check of release time and during meals to
ensure any residents with restraints will have them
released in accordance with policy.
? Monthly audits will be completed of all residents
with a restraint to ensure that they are released
as per the physician order.
4. The DNS will report the results of the monthly audit
at the quarterly QA meeting.
5. The DNS is responsible for ensuring corrective
action is implemented and that the condition does
not arise again for F604.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2018
Corrected date: January 25, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview conducted during the recertification survey, the facility did not ensure that services provided met professional standards. Specifically, the Nursing staff did not clarify the absence of a physician's orders [REDACTED]. This was evident for 1 of 2 residents reviewed for restraint use. (Resident #42) The findings are: Resident #42 was admitted to the facility with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] documents that the resident has severely impaired cognition, no behavioral issues, and requires the extensive to total assistance of 1 person to complete all activities of daily living (ADL). The MDS also documents that the resident has a trunk restraint that is used daily whenever the resident is out of bed. On 12/6/18, from 8:43AM to 12:08PM and 12/7/18 from 9:09AM to 12:47PM, multiple observations were made of the resident while she was seated in her wheelchair with the secure soft seatbelt in place. The resident was observed sitting in the hallway on her unit and then being brought to the Recreation Department on the 4th floor unit on both days. The resident was also observed on both days to be brought back down to her unit from Recreation and then placed in the Floor Day Room (FDR) to await lunch. There were no observed attempts to transfer the resident to her bed for a diaper change or to toilet the resident in any bathrooms. The resident was observed to have her secure soft seatbelt in place during each of these observations. Additionally, the resident was observed being fed by the Licensed Practical Nurse (LPN) #1 during lunch time on 12/7/18 with the secure soft seatbelt still in place. The resident was not observed to be agitated during any of the observations made on 12/6/18 and 12/7/18. At times, the resident would lightly tug on the soft seatbelt strap while seated in the wheelchair but was unable to release the restraint independently. All State Agency (SA) attempts to speak with resident or provide directives for resident to release restraint were unsuccessful due to the resident's severely impaired cognition. The physician's orders [REDACTED]. A Certified Nursing Assistance (CNA) ADL Care Card dated 11/28/18 documents that the resident has a safety device/restraint in place. The secure soft belt is to be used when the resident is in the wheelchair and is to be released every 2 hours for 15 minutes. A Restraints Comprehensive Care Plan (CCP) initiated on 11/14 documents that the resident is at risk for deterioration due to use of restraints related to decreased safety awareness. The goal is for the resident to be free from injury while using the least restrictive device without adverse effects. The document lists the Nursing staff and Medical Doctor (MD) are the disciplines responsible for releasing the restraint every 2 hours for 15 minutes to toilet, provide skin care, range of motion, and ambulate (if feasible). The Nursing staff is the discipline responsible for releasing the restraint for meals. A Restraint Agreement Form dated 10/3/18 documents that the resident is to have a secure soft seat belt in place due to decreased safety awareness and increased risk for falls. An Interim physician's orders [REDACTED]. A subsequent Interim Physicians' Order on 10/1/18 documents that the MD ordered for resident to have the secure soft seat belt when she is in the wheelchair. The restraint is to be released every 2 hours for 15 minutes. The is no documented evidence that the order for secure soft seatbelt was discontinued on any of the Interim Orders reviewed from 10/1/18 to present. There was no medical justification for the soft seatbelt documented on the interim order. A Rehab Restraint Review Form dated 10/1/18 documents that a secure soft belt is recommended. The resident is unable to release the restraint upon command. The reasons for using the secure soft seat belt include promoting an upright sitting position and is due to the resident constantly attempting to stand up unassisted. The recommendation is to discontinue the existing restraint and start the new restraint of a secure soft belt. A Physicians Order Sheet for Adaptive Devices dated 10/1/18 documents that the type of device to order is a secure soft belt when resident is in wheelchair. There was no documentation of a MD review or assessment of the resident's need for restraint noted in the Doctor's Progress Notes from 9/7/18 through 11/1/18. On 12/07/18 at 2:42 PM an interview was conducted with the resident's assigned CNA, CNA #1. According to CNA #1, the resident is at high risk for falls and has several interventions in place to prevent falls. The resident's bed is to be kept in the lowest position, legs are to be kept elevated, a bed alarm is in place, the call bell is to be within reach, and the secure soft seatbelt is to be used when the resident is in the wheelchair. The CNA's responsibility is to make sure that the belt is not too tight and that there is no irritation on the resident's skin from seatbelt usage. The CNA stated that the belt is only to be released during meal times if possible. The seatbelt may not be released if the resident is leaning forward in her chair, putting herself at risk for a fall. The CNA is assigned to the 7am to 3pm shift and meal times are the only time the restraint is released. The resident requires total assistance with her ADLs and the CNA will usually transfer the resident back to bed to be toileted. There are times where the aide will attempt to toilet the resident in the bathroom. The CNA checked the resident's diaper prior to lunch being served today and did not attempt to change or toilet the resident because her diaper was fairly dry. The CNAs use the CNA assignment book as their main source of information when determining how to care for residents on their assignments. On 12/07/18 at 2:53 PM an interview was conducted with LPN #1. Although she has mainly been assigned to work on another unit in the facility, LPN #1 has worked with the resident several times since she was admitted to the facility and is familiar with her care. LPN #1 states that the resident is blind and sometimes will lean forward in her wheelchair in an unsafe manner because she has sensory deficits; however, this is not reflected in the resident's CCP related to Restraint Use. Since the resident is unable to see, she believes that she is included in conversations that may be taking place around her. The resident will then attempt to move her body in the direction of the conversations without having awareness of her safety. LPN #1 states that the resident has an order for [REDACTED]. The resident was observed with the seatbelt in place during lunch time today because there were multiple residents on the floor that required staff assistance with feeding during meal time. There were more residents to assist during meal time than usual because some residents decided to eat on the unit instead of in the main dining room where the normally eat. The resident's seatbelt was not removed because of safety concerns. Resident must be closely monitored if the restraint is removed because she can attempt to stand and then fall. LPN #1 further stated that it is the judgment call of the nurse as to whether a resident's restraint release period is adjusted or changed. When LPN #1 was asked why the resident was not released from her restrain during the timeframe observed by the SA, LPN #1 stated that the resident must have been released and that the CNA documents the release times on a form that is kept separate from the CNA Accountability Record. LPN #1 then stated that she needed to attend to a resident and asked to continue the interview at a later time. A follow up interview was conducted with CNA #1 on 12/10/18 at 9:36 AM. The CNA stated that after her initial interview with the SA, she had been re-inserviced by the nurse on the unit re: the policy and procedure for restraint usage and release times. No documentation was provided by CNA #1 to verify that a formal inservice was provided to her regarding restraint policies and procedures. The CNA stated that the resident's seatbelt is to be checked and released every 2 hours. There is a restraint Monitoring Sheet that the CNAs use to document when the seatbelts are released. CNA #1 presented the Monitoring Sheet to the SA and confirmed that she had filled out the sheet and her signature was present on the dates for 12/6/18 and 12/7/18. The Monitoring Sheet documents that on 12/6/18 the resident was out of bed to the wheelchair at 8am the resident had breakfast good appetite, at 10am the resident was out of bed to wheelchair, and at 12pm, the resident was monitored for safety. The sheet then documents that on 12/7/18, the resident had breakfast- good appetite at 8am, was out of bed to wheelchair at 10am, and was at lunch - 12:45pm released X15 minutes at 12pm. A follow up interview was conducted with LPN #1 on 12/10/18 at 10:38 AM. Staff on the unit who work with the resident determine that a restraint is necessary for residents when it is determined that their safety is at risk despite alternate measures and interventions to deter at risk behavior. A trial period is initiated when a restraint is recommended to see if the resident can remove the restraint and whether it increases safety. Resident #42 would require a one-to-one staff supervision if no restraint were in place. Once the nursing staff makes observations of unsafe behavior, a psychiatric evaluation will be requested, and the nursing supervisor will be made aware. If a resident currently has a restraint in place, the LPN/RN would be responsible for initiating an observation period with the purpose of discontinuing the restraint order. There are times where a significant change in the resident's status will spur an evaluation for possible discontinuance of a restraint. Upon review of the 11/29/18 physician's orders [REDACTED]. When asked for an explanation, LPN #1 stated that orders are sometimes faxed to the pharmacy, but they may not transcribe everything onto the Monthly Order Form accurately. The process is that the night shift is responsible for reviewing and reconciling the orders and making sure any discrepancies are clarified. The evening shift and the night shift verify that the orders are correct. Both nurses sign that they have verified the accuracy of the orders. Then the MD signs to verify that orders are complete and correct. If there continues to be discrepancies in the physician's orders [REDACTED]. LPN #1 stated that since she has had to handwrite in secure soft seatbelt on the physician's orders [REDACTED]. An interview was conducted on 12/10/18 at 11:31 AM with the resident's MD who was responsible for ordering the restraint. The MD stated that he is familiar with the resident, but not specifically with the devices that have been ordered for her. The MD stated that when a restraint is needed, the interdisciplinary team will attempt other interventions. Often, a resident may have an issue that is more so related to positioning as opposed to requiring a restraint. The MD requires a lot of feedback from facility staff and nursing personnel to ensure that a restraint is necessary. Before ordering a restraint, the MD will discuss the concerns with facility staff. If the MD agrees with the recommendation for a restraint use, the interdisciplinary team will get involved to ensure that the resident/family is also made aware and in agreement. Then an MD order is written. The facility has an ongoing process of review for each resident with a restraint. The MD could not say how often the restraints are reviewed. He believes that he reviews the restraint orders when the resident's monthly physician's orders [REDACTED]. [REDACTED]. The MD does a review of all the monthly physician's orders [REDACTED]. If there is a discrepancy, the MD would cross it out and initial it. The MD makes these corrections on the physician's orders [REDACTED]. The MD stated that there would be a notation made in the MD Notes if the resident was assessed with [REDACTED]. medical review and assessment. On 12/10/18 at 12:08 PM, an interview was conducted with the Director of Nursing, (DON). A restraint evaluation is completed when the nursing staff identifies a safety concern for a resident. Before placing a restraint on a resident, the facility ensures that rehabilitation department assessment is done to evaluate for other possible interventions. The interdisciplinary team meets and makes sure that the family is involved with the decision to initiate a restraint. There is a Monitoring Sheet that documents the release times of any restraint currently ordered for a resident. The MD must agree and write the order for the resident's restraint. A monthly restraint assessment is completed by the nursing supervisor and/or the DON. Restraint reduction may be initiated to determine if there is a continued need for a restraint. The DON stated that the nursing staff assigned to the resident did release the seatbelt on the morning of 12/6 and 12/7 despite the SA observations that resident had the secure soft seatbelt in place for longer than a 2-hour period and throughout meal time. The DON stated that the CNA documented that the restraint was released on 12/6 and 12/7 and that this is accurate information. The DON stated that the surveyor must have missed the release times. The DON stated that the pharmacy transcribes a resident's current physician's orders [REDACTED]. If there is a discrepancy with the orders, the nurses can hand write the orders in and then fax them to the pharmacy to clarify. Sometimes a call will need to be placed to the pharmacy to verbally inform them that there is an issue that they are not resolving. All three nurses from the 3 shifts are required to check the physician's orders [REDACTED]. The DON further stated that the MD should also be checking the accuracy of physician's orders [REDACTED]. [REDACTED]. 415.11(c)(3)(i)

Plan of Correction: ApprovedJanuary 3, 2019

F 658 SS=D
I. Plan of care for affected resident #42:
? The restraint Comprehensive Care Plan (CCP) for
resident #42 has been reviewed and revised as
indicated. All nursing staff will be in serviced
on protocols for reviewing restraint care plans
prior to care and restraint policy and procedure.
II. Plan of care for other residents potentially
affected:
? The restraint Comprehensive Care Plan (CCP) all
residents with restraints will be reviewed and
revised as indicated.
III. Plan of care for monitoring and prevention are:
? The facility will complete monthly audits of all
restraint Comprehensive Care Plans.
IV. The DNS will report results of ongoing monthly
audits on an quarterly basis to the QA committee.
V. The DNS is responsible for ensuring corrective action
is implemented and that the condition does not arise
again.

Standard Life Safety Code Citations

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2018
Corrected date: January 11, 2019

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that all areas in the building were protected by an automatic sprinkler system in accordance with section 9.7 and NFPA 13. Reference is made to the obstructed sprinkler within the storage closet off the general record room, on the first floor, and to the sprinkler within the storage closet off the general record room,, that was obstructed with the central partition constructed within the storage closet. The findings include: On (MONTH) 4, (YEAR) at 9:30 AM to 3:00 PM, it was observed that although a sprinkler was installed in the storage closet off the general record room on the first floor, the sprinkler was obstructed by a partition constructed within the storage closet and did not provide coverage for the entire closet space. On (MONTH) 4, (YEAR), at approximately 12:30 PM, the facility's director of maintenance stated that partition constructed within the storage closet off the general record room will be removed so as to provide sprinkler coverage for the entire space within the closet. 711. 2 (a)(1) 2012 NFPA 101 2012 NFPA 13

Plan of Correction: ApprovedDecember 20, 2018

K 351 = D
The facility did not ensure that all areas in the building were protected by an automatic sprinkler system in accordance with section 9.7 and NFPA 13. A sprinkler was installed in the storage closet off the general record room on the first floor but was obstructed by a partition constructed within the storage closet. The doors to the closet were removed on (MONTH) 5, (YEAR) allowing the sprinkler access to all areas of the storage closet.
All residents have the potential to be affected by the deficient practice. An audit of the entire building will be conducted to ensure that all areas are protected by an automatic sprinkler system in accordance with section 9.7 and NFPA 13.
To ensure the deficient practice will not happen again the following measures will be put into effect:
a. The Maintenance Director/designee will inspect weekly designate areas to ensure the automatic sprinkler system is not obstructed.
b. The Maintenance Director/designee will review weekly reports for the past month with Administrator to develop any contingency if problems exist.
c. All staff will be educated about the deficient practice to ensure the automatic sprinkler system is free from obstructions.
To ensure the deficient practice will not happen again a monthly QA audit will be developed and conducted by the Maintenance Director/designee of the findings and corrective actions. The reports will be brought to the QA meeting on a quarterly basis for review.
The Administrator is responsible for the correction of K351.

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

REGULATION: Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2018
Corrected date: January 11, 2019

Citation Details

I. Based on observation and staff interview, it was determined that the facility did not ensure that the maximum height of risers in exit stairways was 8 inches as per 7.2.2.2.1.1 (b). Reference is made to the height of the top risers within exit stair leading to the backyard from the main dining room, in the basement, that measured approximately 10 inches instead of the minimum of 8 inches. The findings include: On (MONTH) 4, (YEAR), between 9:30 AM to 3:00 PM, during the recertification survey of the facility, it was observed that the facility had constructed an exit stairway leading to the backyard from the main dining room, in the basement. The top. risers of the exit stairways, immediately before the top landing, measured approximately 10 inches instead of the maximum risers' height of 8 inches in accordance with 7.2.2 1.1 (b). On (MONTH) 4, (YEAR), at approximately 11:30 AM, the facility's director of maintenance stated that the risers' height within exit stairway will be reconstructed so as not to exceed the maximum permitted height of 8 inches. 711.2 (a)(1) 2012 NFPA 101 II. Based on observation and staff interview, it was determined that the facility did not ensure that the open space within exit enclosures was not used for storage that would interfere with the safe usage of the stairway, as per 7.2.2.5.3.1. Reference is made to the stored roofing cement containers and applicators at the top landing within exit stair W. The findings include: On (MONTH) 4, (YEAR), at 9:30 AM to 3:00 PM, it was observed that the facility had stored multiple containers of approximately 5 gallons capacity of the roofing cement (coating) and applicators, at the top landing within exit stair W. Such storage within exit stairway would interfere with the safe and unobstructed egress for the building occupants during fire or other emergency. On (MONTH) 4, (YEAR), at approximately 11:00 AM, the facility's director of maintenance stated that the stored items within exit stair W were being removed and the staff being advised to maintain all stairways free of any storage. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedDecember 20, 2018

K 225 SS=D
It was observed that the facility didn?t ensure that the maximum height of riser (step) in exit stairway was 8 inches per 7.2.2.2.1.1(b) and didn?t ensure that open spaces within exit enclosures are not used for storage that could interfere with the safe usage of the stairway. The facility will cut and repair the step and reduce its height of less than 10 inches and no more than 8 inches per 7.2.2.2.1.1(b). The multiple 5 gallon containers and applicators were removed immediate.
Residents do not have the potential to be affected by the deficient practice as this is a non-resident area. All risers (steps) will be audited to ensure that the maximum heights of riser (step) are no more than 8 inches per 7.2.2.2.1.1(b) and all open spaces within exit enclosures will remain free and not used as storage that could interfere with the safe usage of the exit/stairway.
To ensure the deficient practice will not happen again the following measures will be put in effect:
a. The Maintenance Director/designee will inspect monthly of risers to ensure no changes occur of any of the height of risers due to weather, settling or, new construction.
b. The Maintenance Director/designee will inspect weekly of all exit enclosures open spaces to ensure that it is not used for storage.
c. The Administrator will educate the Maintenance Director, maintenance and Housekeeping staff concerning the importance of not using exit enclosures open spaces for storage.
To ensure the deficient practice will not recur, a monthly QA audit will be conducted by the Maintenance Director/designee for a period of 1 year or upon the following annual health inspection of all risers to ensure the maximum height of riser does not exceed 8 inches per 7.2.2.2.1.1(b). Also, weekly QA audits will be conducted by the Maintenance Director/designee of all exit enclosures open spaces. The reports will brought to the QA meeting on a quarterly basis for review.
The Administrator is responsible for the correction of K225.

ZT1N 713-2:STANDARDS OF CONSTRUCTION FOR NEW NH

REGULATION: N/A

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 10, 2018
Corrected date: January 11, 2019

Citation Details

Physical Plant - State Only Violation NYCRR 713-1.9 (j): Bedpan-flushing devices shall be provided on each resident floor. This requirement is not met as evidenced by : Based on observation and staff interview, it was determined that the facility did not ensure that bedpan-flushing devices were provided on each resident floor. Reference is made to lack of bedpan-flushing devices on all resident floors. The findings include: On (MONTH) 4, (YEAR), at 9:30 AM to 3:00 PM, it was observed that all resident floors lacked bedpan-flushing devices. An interview with the facility's Director of Maintenance revealed that the bedpan-flushing attachments were either removed or the plumbing fixtures for these devices were capped to prevent further use on the 2nd and 3rd floor. The Director further stated that bedpan-flushing devices were not provided on the 4th floor. On (MONTH) 4, (YEAR), at approximately 1:00 PM, the facility's director of maintenance stated that the bedpan-flushing devices will be provided and maintained for use on all resident floors.

Plan of Correction: ApprovedDecember 20, 2018

I570 SS=C
I. The facility does not have a bedpan-flushing device on each resident floor. The facility bedpans and urinals are disposable and are disposed of after once used.
II. All residents are affected by the practice and use the disposable bedpans and urinals. Policy is in place and staff educated on the use and disposal of bedpans and urinals once used.
III. Housekeeping will disinfect the commodes on a daily basis to ensure residents are using sanitized bathroom products.
IV. Housekeeping will monitor and record daily each resident room for cleanliness and for sanitized bathroom products. The daily records will be reviewed by the Housekeeping Director bi-weekly to ensure compliance. An Monthly audit will be brought to the QA Meeting on a quarterly basis for review
V. The Housekeeping Director is responsible for the correction of I570.

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2018
Corrected date: January 11, 2019

Citation Details

Based on observation and staff interview, it was determined that all stairway enclosures were constructed of at least 1-hour fire resistance rating. Reference is made to the annular penetration through the enclosure wall to the exit stairway leading to the backyard from the main dining room, in the basement. The findings include: On (MONTH) 4 and (MONTH) 10, (YEAR) at 9:30 AM to 3:00 PM, it was observed that the facility had constructed an enclosed exit stairway leading to the backyard from the main dining room, in the basement. The fire resistance rating of the exit stairway was compromised by the presence of an approximately 2 inch annular hole around the penetrating cables through the enclosure wall separating the synagogue from the stairway at the 1st floor level. On (MONTH) 4, (YEAR), at approximately 12:30 PM, the facility's director of maintenance stated that the penetration in the stairway enclosure wall will be sealed with a fire resistive sealant. 711.2 (a) (1) 2012 NFPA

Plan of Correction: ApprovedDecember 20, 2018

K 311 SS=D
The facility did not ensure an annular hole around the penetrating cables through the enclosure wall was seal with a fire resistance rating material. The 2 inch annular hole around the penetrating cables was sealed with a fire resistant rating material that same day.
Residents do not have the potential to be affected by the deficient practice as this is a non-resident area. An audit will be conducted of the entire facility to ensure no annular hole or penetration exists and if so, will be sealed with a fire resistant rating material.
To ensure the deficient practice will not happen again the following measures will be put into effect:
a. The Maintenance Director/designee will inspect monthly the facility for any penetrations through an enclose wall. When located the Maintenance Director/designee will seal the hole/penetration with a fire resistant rating material.
b. The Maintenance Director will review with the Administrator on a monthly basis of his/her findings and to ensure the task is being completed.
To ensure the deficient practice will not recur a monthly QA audit will be conducted by the Maintenance Director/designee of the finding and corrective action. The reports will be brought to the QA meeting on a quarterly basis for review.
The Administrator is responsible for the correction of K311.