Samaritan Senior Village, Inc.
September 23, 2016 Certification/complaint Survey

Standard Health Citations

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

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

Scope: Isolated
Severity: Actual harm has occurred
Citation date: September 26, 2016
Corrected date: November 28, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification and abbreviated surveys (NY 839), it was determined for 2 of 6 residents (Resident #12 and 14) reviewed for falls, the facility did not provide adequate supervision to prevent accidents for Resident #14 and did not ensure Resident #12's environment was free of accident hazards. Specifically, when Resident #14, identified to be at risk for falls, was left unattended in the bathroom, she fell and fractured her neck; the physician was not notified and the resident expired as a result of the fall. This resulted in actual harm that is not immediate jeopardy to Resident #14. When Resident #12 had several falls associated with his recliner chair, the facility did not ensure the recliner chair was assessed for the resident's safe use to prevent recurrent falls. Findings include: 1) Resident #14 had [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The Minimum Data Set (MDS) assessment signed as complete on [DATE], documented the resident's cognition was severely impaired, she required extensive assistance with most activities of daily living (ADLs) including ambulating and toileting, and had an impairment to one side of her upper extremity. The MDS documented the resident required hearing aids and oxygen therapy, and did not record the resident used any mobility devices. The comprehensive care plan (CCP), dated [DATE], documented the resident was at risk for falls, as she transfers herself on occasion and due to generalized weakness. Interventions included to ambulate the resident to the bathroom every 2 hours and as needed, with rolling walker and gait belt per PT (physical therapy) recommendations; try to anticipate her needs; and keep her call light within reach at all times. The resident care record (care instructions), dated [DATE], documented the resident was alert with confusion. She was a fall risk, utilized a bed and chair alarm, had a ,[DATE] side rail, and a low bed. The care record specified the resident was to be ambulated with the assistance of one person three times a day. The care record did not document that the resident was independent in her ambulation (left blank). It did specify the resident was to be toileted every 2 hours, used a rolling walker and gait belt for transfers, with 1 person assistance. The box indicating the resident could be left alone in the bathroom was blank. RN progress notes, dated [DATE] at 7:36 PM, recorded the resident was yelling out and found on the floor in the bathroom. The RN assessed the resident at that time. The resident denied hitting her head. The RN found no lumps or redness on the resident's head, and noted the resident was able to move her head freely to the left and did not move it well to her right. No redness was noted to her back or buttocks and the resident freely moved her left arm and both legs. LPN notes, dated [DATE] at 8:08 PM, 8:28 PM, and 9:09 PM recorded the resident's neurological checks, with her pupils equal and reactive and motor reactions appropriate. On [DATE] at 9:56 PM, LPN notes recorded the resident was resting at that time with no complaints voiced when she was awakened. A very small abrasion was observed on her upper thigh. At 10:47 PM on [DATE], neurological checks revealed pupils and and motor reaction were appropriate. At 1:20 AM on [DATE], LPN notes specified the resident had a 5 out of 10 pain level. (Tylenol was given at that time.) No neurological checks were documented in these nursing notes at that time. On [DATE] at 4:28 AM, the RN documented staff heard the resident yell out. When they went into her room, they found her lips cyanotic on 2 liters of oxygen via nasal cannula, and she was mouth breathing. The resident's oxygen saturation rate was decreased lying down, oxygen saturation rate was 70%. Staff assisted the resident upright in bed and were instructed to start oxygen at 12 liters via mask. Vital signs included: Temperature was 99.2 degrees F.; blood pressure was ,[DATE]; pulse was 115; respirations were 42; and blood glucose level was 327. The resident was noted to be diaphoretic. The RN called the MD and was told to send the resident to the emergency room . When the ambulance arrived at 4:25 AM, the resident had stopped breathing and was pronounced at 4:33 AM. A Summary of Investigation, dated [DATE], regarding the resident's fall of [DATE] at 7:05 PM, was signed as completed by the Director of Nursing (DON). This Summary included the Incident Details Report, witness statements, and the DON conclusion, including: - An undated witness statement, signed by the unit's charge licensed practical nurse (LPN) #14, specified she found the resident on the bathroom floor, with her wheel chair tipped over on top of her legs at approximately 7:05 PM. She noted she removed the wheel chair from the resident, and called for staff assistance and the nursing supervisor. Certified nurse aides (CNAs) were obtaining the resident's vital signs and a pillow was placed under the resident's head, as the RN supervisor arrived. - The RN supervisor's Incident Report Statement, dated [DATE] at 3:11 AM, and sent via email, described the incident after her arrival to assess the resident on the bathroom floor. The RN supervisor documented the residnet may have been using the wheel chair to ambulate with or pull herself up. The resident was then assisted off the floor via Hoyer lift with the assistance of 3 staff. The RN noted CNA #16 was instructed to support the resident's head. The resident was positioned in bed without difficulty. The RN documented that CNA #16 reported to charge LPN #17 that the resident was in the bathroom alone at the time of her fall, as she had to leave the unit to respond to a fire alarm sounding in the assisted living facility. - When the Director of Maintenance was interviewed on [DATE] at 11:22 AM, he stated there was fire alarm activity in the assisted living building adjacent to the skilled nursing facility on [DATE] at 6:25 PM. From these timelines, it appears the resident was left alone in the bathroom from 6:25 PM until she was found on the floor at approximately 7:05 PM. - The RN supervisor's Incident Report Statement, dated [DATE] at 3:11 AM, also documented the Care card checked - resident alone in bathroom. Care plan was followed. There was no documented rationale how the RN supervisor made the determination that the resident's care plan was followed. The most recent care record dated [DATE] (see above) did not specify that the resident was to be alone in the bathroom. That section was left blank. - The DON's Summary of Investigation specified after the RN assessment, the resident was assisted off the floor per mechanical lift and 2 person assistance. The Summary recorded the resident had a history of [REDACTED]. The DON documented the resident did not require constant supervision while in the bathroom, per her care plan. This DON's summary did not address the RN supervisor's email statement that was 9 days after the resident's fall; did not address the 40 minutes (approximately) the resident was left alone in the bathroom by CNA #16, as she reported to LPN #17; and did not address the lack of interviews of CNA #16 or LPN #17 to determine whether the resident could be left alone in the bathroom for that extended period of time. The undated physician discharge summary documented the resident had been doing well up until the night she fell . The resident's cause of death on [DATE] was determined to be a cervical fracture, secondary to blunt force trauma from a fall that was sustained when the resident tried to get up and go to the bathroom. A death certificate dated [DATE] documented the resident's time of death was 4:33 AM on [DATE] and the immediate cause of death was a cervical vertebra two fracture, as a consequence of blunt force trauma from a fall. During an interview with certified nurse aide (CNA) #15 on [DATE] at 8:15 AM, she stated if a resident was a fall risk and required a bed and chair alarm, she would know that by reviewing the resident's care record. She stated residents who were a fall risk would not be left alone in the bathroom. She stated she was familiar with the resident and on [DATE] when she arrived at work, she was notified the resident fell and there were some questions regarding the CNA actually reporting to the LPN the resident was in the bathroom by herself. She stated the resident was not supposed to be left alone in the bathroom, as she was very unsteady on her feet, and was known to frequently try to transfer herself to the bathroom. During an interview with the RN Manager #8 on [DATE] at 9 AM, she stated residents at risk to fall were identified on the resident care record. She stated she could not recall if the resident was a risk to fall, or if she was safe to be left alone in the bathroom; it would be documented on her care record. RN Manager #8 stated if a resident fell , and there was no injury, the physician did not need to be notified. During an interview with RN #10 Supervisor on [DATE] at 10:15 AM, she stated she completed an assessment on the resident after the fall. There were no obvious injuries and the resident did not complain of any pain. She stated the resident had been care planned to be left alone in the bathroom. She stated she reviewed the resident care record and determined the resident was allowed to be in the bathroom by herself. She stated she could not recall if the resident was a fall risk, or if she utilized a bed or chair alarm. During an interview with LPN #14 on [DATE] at 11:45 AM she stated while she was passing medications on the evening [DATE], she heard a very loud bang and she found the resident on the floor of her bathroom with the wheel chair on top of her. She stated she could not recall if the resident was at risk to fall and when the resident was toileted staff usually waited outside the bathroom door for her as she had a history of [REDACTED]. 2) Resident #12 had [DIAGNOSES REDACTED]. The [DATE] fall risk assessment documented the resident was a high risk for falling. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was moderately impaired, he had no falls and he required one-person physical assistance with transfers and mobility. The [DATE] resident care record (direct care instructions) documented the resident was independent with transfers and ambulation; was a fall risk; and had a low bed for safety. The comprehensive care plan (CCP), updated on [DATE], documented the resident was at risk for falls related to losing his balance often. Interventions included non-skid footwear, call light within reach, following the care record as recommended, and instructing resident to call for assistance before attempting to transfer. The [DATE] at 3:30 PM Incident Report documented the resident was found on the floor in his room, with his back leaning against his recliner. The resident had no injuries; he was independent with ambulation and transfers; and the care plan was followed. The resident stated he slid out of the recliner. The [DATE] at 3:35 PM physical therapy (PT) note documented a quarterly screen was completed for the resident. The note documented that per nursing, the resident no longer ambulated, he only transferred from his recliner to the wheel chair, and a PT evaluation would be requested to upgrade his transfer status and for positioning in the recliner. The [DATE] at 5:09 AM Incident Report documented the resident was found seated on the floor in front of his recliner. The resident had no injuries; was assisted back into his recliner; and when he leaned forward to adjust his blanket, the recliner began to tilt. There was no documented evidence of immediate interventions to prevent recurrence. The [DATE] at 2:28 PM PT note documented the resident was seen for a transfer evaluation. His plan changed to: non-ambulatory, stand pivot transfer from wheel chair to recliner; and one assist from bed to wheel chair. There was no documented evidence the resident's recliner was assessed to determine if it was safe for his continued use. The [DATE] at 10:50 PM Incident Report documented the resident was found on the floor in front of his recliner and there were no injuries. Interventions included a PAC alarm (alarming device clipped to clothing) and the resident would be monitored every 15 minutes through the night. The [DATE] at 6:07 AM nursing progress note documented the resident slept in his recliner; it tipped forward with every small movement; and he had to be pulled up from the bottom few inches of the chair multiple times. The note documented the situation was reported to the supervisor as unsafe, and the nurse manager and assistant nurse manager were emailed regarding the issue. The updated [DATE] resident care record documented the resident had a PAC alarm; was non ambulatory; and required one assist to stand pivot to the wheel chair or side chair. On [DATE] at 4:40 PM, the resident was observed in his room seated in the recliner. The recliner was fully reclined and he was adjusting the blankets on his legs. On [DATE] at 10:10 AM, registered nurse (RN) #10 Supervisor stated in an interview that when she assessed the resident on [DATE] she: - found the recliner tipped forward; the foot rest was extended and touching the floor; the resident slid out; and was seated on the footrest; - checked the function of the recliner and the foot rest retracted without issue; - when the resident scootched down in the chair, and the foot rest was extended, the chair was like a slide; and - she discussed the issue with the Unit Manager. She did not know if the resident's use of the chair had been assessed for safety. On [DATE] at 10:25 AM, RN #3 Manager stated in an interview she did not recall RN #10 speaking with her on [DATE]. She stated PT evaluated the resident on [DATE] and recommended elevating his legs in the recliner. She stated the resident refused to sleep in the bed and when the resident fell from his recliner on [DATE], a PAC alarm was initiated. She stated she did not feel any other changes needed to be made to the plan of care, as multiple interventions were implemented prior. She stated the resident's recliner was never switched out for a different model. On [DATE] at 11 AM, PT #9 Supervisor stated in an interview that on [DATE], she assessed the resident's transfer status and the wounds on his feet, and recommended his feet be elevated in his recliner. She stated she was only aware the resident fell from the recliner on [DATE], and if she had she been aware of the other falls, she would had assessed the chair for safety. 10NYCRR 415.12(h)(1)

Plan of Correction: ApprovedNovember 21, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #12 had been assessed by Nursing to evaluate his fall risk and potential interventions. The recliner chair was removed from his room and replaced with a different chair and a clip alarm was initiated to help alert the staff he may be leaning forward. The resident?s care plan and resident care record have been updated to reflect the interventions initiated to prevent re-occurrence. Resident #12 is no longer a resident in our facility.

After changes in Resident #14?s medical condition the resident was planned to be transferred to the Emergency Department for care and treatment of [REDACTED].
How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
A review of all residents with falls in (MONTH) (YEAR) was conducted to ensure interventions were initiated to prevent re-occurrence. No other residents were identified as affected by the deficient practice.

What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The Resident Care Card (RCR) was updated to document when it is not appropriate for the resident to be left alone in the bathroom, when out of bed, or if they require frequent checks. If the resident is assessed to be a risk for falls the safety portion of the RCR will reflect their individual needs and plan of care. The previous statement on the RCR designated ?may be left alone in the bathroom? was replaced with more specific language to reflect the plan of care.
The Fall Protocol was clarified to include language to notify the QMP if a major injury is suspected or if there are changes in the resident?s level of consciousness/changes in neurological status as per the Head Injury Monitoring Policy. Major injury is defined by CMS/RAI Manual to include bone fractures, joint dislocations, and closed head injuries with altered consciousness, and laceration requiring sutures. If there is no obvious major injury assessed at the time of a fall by the RN , the qualified medical provider (QMP) will be notified of the fall the next business day.
Mandatory nursing education regarding the initiation of strategies to prevent recurrent falls for those residents at risk for and those who have sustained a fall will be conducted.
The facility?s Head Injury Evaluation Guidelines have been reviewed with no revisions required. The facility?s policy documented the Nursing Supervisor will notify the physician immediately if the resident has any of the following symptoms: Bleeding from the nose or ear(s), nausea/vomiting, seizures, headache that progresses, confusion, disorientation, vomiting, slurred speech, unusual sleepiness or difficult to arouse, a droopy eye, clumsiness, any changes in vital signs.
If a fire drill alarm sounds in the assisted living level of care, skilled staff will not be assigned to respond to the drill.

How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing or designee will conduct an audit of all residents who have sustained a fall to ensure intervention(s) were put in place to prevent recurrence each month until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible for this deficiency

Completion date: (MONTH) 22, (YEAR)

FF09 483.13(c)(1)(ii)-(iii), (c)(2) - (4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2016
Corrected date: November 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification and abbreviated surveys (NY 839), it was determined for 1 of 15 residents (Residents #14) reviewed for abuse/neglect, the facility did not ensure all alleged violations involving neglect were thoroughly investigated. Specifically, when Resident #14 sustained an unwitnessed fall, the investigation was not thorough, complete, and staff statements were not obtained to ensure neglect did not occurred. Findings include: Resident #14 had [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The Minimum Data Set (MDS) assessment signed as complete on [DATE], documented the resident's cognition was severely impaired, she required extensive assistance with most activities of daily living (ADLs) including ambulating and toileting, and had an impairment to one side of her upper extremity. The MDS documented the resident required hearing aids and oxygen therapy, and did not record the resident used any mobility devices. The comprehensive care plan (CCP), dated [DATE], documented the resident was at risk for falls, as she transfers herself on occasion and due to generalized weakness. Interventions included to ambulate the resident to the bathroom every 2 hours and as needed, with rolling walker and gait belt per PT (physical therapy) recommendations; try to anticipate her needs; and keep her call light within reach at all times. The resident care record (care instructions) dated [DATE] documented the resident was alert with confusion, was a fall risk, utilized a bed and chair alarm, ambulated with the assistance of one person, and was to be toileted every 2 hours. The box indicating the resident could be left alone in the bathroom was blank. Review of the resident's [DATE] incident report, including 2 staff statements, the care plan and resident care record documented: - the resident was found on her back under the bathroom sink with her head against the wall and her wheelchair on top of her; - a soiled brief was found on the floor near the resident, her oxygen nasal cannula was not on and her oxygen saturation was 88%; - the resident stated she did not hit her head, but could not state how the fall occurred; - the resident had limited neck rotation to the right side; per staff this was her baseline, and there were no obvious injuries. Neuro checks were implemented; - the licensed practical nurse (LPN) found the resident in the bathroom with the wheelchair and oxygen tank on top of her, the registered nurse (RN) Supervisor was immediately notified, a pillow was placed under the resident's head and her oxygen saturation was 88%; - the RN Supervisor was told by a certified nurse aide (CNA) that she left the resident alone in the bathroom, as she had to respond to a fire alarm in an adjacent building. The CNA told the Supervisor that she reported this to the LPN at the time of fire alarm. Recommendations were for anti-tipping bars on the resident's wheelchair and the care card checked resident alone in the bathroom and care plan was followed. The investigative report: - did not include statements from the CNA that left the resident alone in the bathroom, or from the LPN who the CNA reported this to; - did not identify how long the resident was left alone in the bathroom; -did not identify the last time incontinence care was provided prior to the resident's fall, or why a soiled brief was found on the bathroom floor; - did not identify why the resident was without her oxygen; - did not document how it concluded the care plan was followed, when there was no check mark on the care card that indicated the resident could be left alone in the bathroom; and - did not document how neglect was ruled out. Per Death Certificate, dated [DATE], the resident expired on [DATE] at 4:33 AM from a cervical (neck) fracture. The [DATE] investigative summary, completed by the DON documented: - statements were obtained from the RN Supervisor and the LPN that found the resident on floor on [DATE], and from the CNA that was with the resident when she expired on [DATE] at 4:33 AM; and -the resident had a history of [REDACTED]. During an interview with RN Manager #8 on [DATE] at 9:00 AM, she stated the nurse initiating the incident report was responsible for obtaining statements from staff and all staff that participated in the resident's care should be interviewed and statements obtained. She stated that after statements were obtained the incident report was given to the DON and she would make the determination if the incident was reportable or not. She stated she was not in the facility at the time the resident fell and could not recall if she reviewed the incident report and who was interviewed. She stated she would assume the nursing Supervisor obtained statements from the CNA and LPN doing direct care that evening. During an interview with RN #10 nursing Supervisor on [DATE] at 10:15 AM, she stated she thought she had obtained a statement from the CNA. She could not remember if she asked the CNA how long the resident was on the toilet for and could not remember if the resident had her oxygen on at the time of the fall or why the resident had a soiled brief in the bathroom. She stated the CNA told her she left the resident in the bathroom to respond to a fire alarm in the assisted living building. She stated she reviewed the resident Resident care record and determined the resident was allowed to be in the bathroom by herself. She stated she could not recall if the resident was a fall risk or if she utilized a bed or chair alarm. During an interview with the Director of Nursing (DON) on [DATE] at 11:20 AM, she stated the Unit Manager or the Nursing Supervisor were responsible to initiate the incident report and obtain statements from staff involved and working on the unit at the time of the incident. She stated she would want to determine when the resident was last seen and when care was provided last. All that information would be included in the incident report. She stated she spoke to both the nursing Supervisor and the CNA regarding the incident, and it was determined the resident could be left alone in the bathroom. She stated the CNA told her it was normal for the resident to be left alone in the bathroom. She stated she did not obtained a written statement and had no documentation they were interviewed. She stated she could not remember if she determined how long the resident had been in the bathroom alone, or if the resident had her oxygen on at the time of the fall. The DON stated if she questioned this, the information would be included in the incident report and investigation summary. During an interview with the Director of maintenance on [DATE] at 11:22 AM, he stated he had reviewed the Fire Drill Event Form and there as fire alarm activity in the assisted living building adjacent to the long term care building on [DATE] at 6:25 PM. It appears the resident was left alone in the bathroom from 6:25 PM until she was found on the floor at approximately 7:05 PM. The facility's investigation did not include an interview with CNA #16 or LPN #17. CNA #16 who left the resident alone in the bathroom moved away and was not available for interview. LPN #17 who received the report the resident was alone in the bathroom was also not available for interview, and no longer worked at the facility. 10NYCRR 415.4(b)

Plan of Correction: ApprovedNovember 21, 2016

What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Investigation cited for resident #14 occurred in the past, resident no longer resides in the facility.
How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
Incidents from (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) were reviewed and no other residents were identified as affected by the deficient practice.

What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The facility?s Accident and Incident Investigation and Reporting Policy has been reviewed with no changes required. Mandatory education will be provided for all RNs who conduct incident reporting/investigation and will emphasize the investigation process to include; conduct interviews, statements obtained from staff, development of a timeline, determine last time care was provided, and determination if care plan was followed.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing and/or designee will audit each closed incident report to ensure a complete and thorough investigation occurred in accordance with the NYSDOH Incident Reporting Manual monthly until 100% compliance has been achieved for 3 consecutive months. This audit will be conducted by the multi-disciplinary team. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible for this deficiency
Completion date: (MONTH) 22, (YEAR)

FF09 483.25(i):MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

REGULATION: Based on a resident's comprehensive assessment, the facility must ensure that a resident - (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2016
Corrected date: November 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure 1 of 5 residents reviewed for weight loss (Resident #9) maintained acceptable parameters of nutritional status. Specifically, when Resident #9 had a decline in intake with a significant weight loss, the resident did not receive all the items on her meal ticket, often slept through breakfast, and was not provided a breakfast meal at a later time. Findings include: Resident #9 had [DIAGNOSES REDACTED]. The 5/7/2016 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, she required limited assistance for eating, had an unstageable pressure ulcer, weighed 137 pounds, and had not experienced any weight loss. The 6/2016 resident care record (care instructions) documented the resident required total assistance for feeding. The 7/10/2016 dietary progress note documented the resident's nutrition had inadequate oral food/beverage intake related to poor intake, and less than what was needed to prevent weight loss and promote healing. Interventions included 240 milliliters (ml) high protein strawberry milk at each meal, 120 ml high protein milk at breakfast, strawberry ice cream at lunch and supper, 1 scoop of [MEDICATION NAME] (supplement) at lunch and supper, 240 ml Ensure [MEDICATION NAME] (liquid nutritional supplement) at 9:00 AM and 2:00 PM, and 120 ml Ensure [MEDICATION NAME] at 7:00 PM. The 8/2016 meal intake record documented the resident was asleep during breakfast 17 days and refused breakfast 5 days. The resident refused, or was asleep, for the morning snack on 11 of the days she did not have breakfast. The 9/1/2016 to 9/23/2016 meal intake record documented the resident was asleep during breakfast 9 days and refused breakfast 3 days (2 days were blank). Of the days breakfast was missed or refused, the resident was asleep for morning snack 1 day, had only 25% of the morning snack 9 days, and 0% on 1 day. The 9/9/2016 physician orders [REDACTED]. The 9/9/2016 pressure ulcer risk assessment documented the resident was at moderate risk and she had inadequate nutrition. The 9/16/2016 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required extensive assistance for eating, had a Stage 1 or greater pressure ulcer, weighed 116 pounds, and had a weight loss of 5% or more in the last month, or 10% or more in the last 6 months. The 9/19/2016 physician orders [REDACTED]. The updated 9/19/2016 comprehensive care plan (CCP) documented the resident was at risk for involuntary weight loss and dehydration due to suboptimal intake and had increased protein energy needs to promote healing. Interventions included the resident was to be offered extra fluids, provided two tablespoons of [MEDICATION NAME] at breakfast, prune juice for all meals, 240 ml strawberry mighty shake at each meal, one scoop of [MEDICATION NAME] to all meals, 120 ml high protein milk at breakfast, 240 ml Ensure [MEDICATION NAME] at 9:00 AM and 2:00 PM, and 120 ml at 7:00 PM, ice cream at lunch and supper, total feeding assistance for all meals, and fluid choices included strawberry drinks, ice cream, ginger ale, and water. On 9/21/2016 from 3:09 PM to 4:30 PM, the resident was observed in her chair in her room with a full 8 ounce cup of strawberry drink on her tray table that was out of her reach. On 9/21/2016 at 5:00 PM, the resident was observed in the dining room with ground chicken salad, a slice of bread, soup, a piece of banana cream pie, 8 ounce strawberry shake, and 8 ounces prune juice. In addition to the items observed, the resident's meal ticket documented the resident was to receive vanilla ice cream, and 4 ounces each of apple juice, water, and ginger ale. The resident did not receive those items during the meal. On 9/22/2016 at 8:56 AM, the resident was observed to be asleep in bed with no food or drinks observed in her room. The resident's meal tray was not observed in the dining room. On 9/22/2016 at 5:25 PM, the resident was observed in the dining room with a tray which included egg salad, soup, one slice of bread, pureed strawberry shortcake, and 8 ounces of ginger ale. The resident's meal ticket documented the resident was to have egg salad, soup, a biscuit with strawberry puree, whole wheat bread, vanilla ice cream, 8 ounces of strawberry nutritional shake, and 4 ounces each of apple juice, ginger ale, prune juice, and water. The resident did not receive the ice cream, the shake, prune juice, apple juice, or water, and she received a pureed desert and was to have a biscuit with pureed strawberries. The resident's weight record documented the resident weighed: - 137.2 pounds on 5/4/2016; - 132.2 pounds on 6/8/2016; - 130.4 pounds on 7/27/2016; - 122.8 pounds on 8/17/2016; - 121.0 pounds on 9/10/2016; - 115.6 pounds on 9/14/2016; and - 109.2 pounds on 9/21/2016. During an interview on 9/22/2016 at 5:42 PM, certified nurse aide (CNA) #5 stated that CNAs assembled the food trays according to the meal tickets; residents were to receive everything that was on the meal ticket; this resident did not request alternate items or changes to her meal; the resident required total assistance with feeding; preferred desserts and nutritional shakes; and stated snacks/nourishments offered in-between meals would be left on her tray table in her room. On 9/23/2016 at 8:45 AM, the resident was observed sleeping in bed and had an 8 ounce strawberry nutritional drink in a mug on her tray table, which was against the wall opposite her bed. The drink was full and the outside of the mug did not feel cool. There was no breakfast tray in the resident's room. On 9/23/2016 at 8:47 AM, the resident's meal ticket documented an 8 ounce strawberry shake, cream of wheat, whole wheat toast, and 4 ounces each of orange juice, high protein milk, water, and prune juice. The ticket was marked sleeping, and an unidentified dietary aide stated the resident did not have a tray that morning, because she was asleep. On 9/23/2016 at 11:23 AM, two 8 ounce strawberry nutritional drinks were observed in the resident's room and one of those drinks appeared to have approximately 2 ounces consumed. The resident was in the dining room at the time. At 11:55 AM, the resident was fed lunch, and did not receive the ice cream as noted on her meal ticket and nutritional plan. During an interview on 9/23/2016 at 12:50 PM, CNA #6 stated that the resident did not like to get up early and could not eat in her room because of aspiration risk. She stated if the resident refused to get up, she did not get a breakfast tray. CNA #6 stated the resident would be offered a snack of strawberry shake or ice cream when she did get up. The CNA stated the resident was not offered breakfast that day; did not always receive what was on the meal ticket; and said she had no ice cream on her lunch tray. During an interview on 9/23/2016 at 1:05 PM, register dietitian (RD) #7 stated that the resident should be provided all items on her meal ticket. She stated if the resident slept through breakfast most days, her breakfast time should be adjusted and she should be offered a full breakfast. During an interview on 9/23/2016 at 1:15 PM, registered nurse (RN) Manager #8 stated that all items on the meal ticket should be provided on the resident's tray; breakfast should be reordered for the resident if she slept through the meal; and said the resident preferred to get up later. 10NYCRR 415.12(i)(1)

Plan of Correction: ApprovedNovember 21, 2016

What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #9 has been assessed and is currently NPO.

How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
The Mealtime observation was completed on all nursing units to monitor for accuracy of the ticket compared to the tray, to ensure residents are awake during meals and if not are offered a meal when the resident awakens. No other residents were identified as affected by the deficient practice.

What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
Mandatory education will be provided for all staff that feed, assist, and supervise Residents during meal time. This education will emphasize the importance of ensuring accuracy of items on the resident?s tray compared to the ticket, the resident is awake during meal time, and if the resident is not awake during meal time the staff will offer a meal when the resident awakens.

The Dietician will monitor and assess all residents who have experienced a weight loss of 3 pounds in one week, 5 pounds in a 30 day period, or demonstrate a weight loss trend, document recommendations, and update the care plan accordingly. The Dietician will meet weekly with nursing to review each Resident who has experienced a weight loss of 3 pounds in one week, or 5 pounds in a 30 day period and discuss strategies to prevent further weight loss.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Chief Clinical Dietician and/or designee will coordinate an interdisciplinary team audit of each nursing unit monthly, at varying meal times to ensure accuracy of food items on the tray compared to the ticket, residents are awake and eating during meal times or offered a meal when they awaken. The Chief Clinical Dietician will audit all Resident with weight loss on a weekly basis to ensure appropriate measures are in place. Each individual audit will be conducted monthly until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Chief Clinical Dietician and will be reported to the Quality Improvement Council.
The date for correction and the title of the person responsible for each deficiency.
The Chief Dietician will be responsible for this deficiency
Completion date: (MONTH) 22, (YEAR)

FF09 483.25:PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2016
Corrected date: November 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview conducted during the recertification survey, it was determined the facility did not provide the necessary care and services to attain or maintain the highest practicable well-being for 5 of 25 residents (Residents #1, 3, 5, 12 and 13) reviewed for quality of care. Specifically, the facility did not ensure bowel medications were administered when Resident #5 did not have a bowel movement for more than 3 days; did not ensure Resident #3 was consistently provided with the physician-ordered ACE wrap to her leg; did not ensure Resident #12 was provided with heel protectors as planned; and did not ensure Residents #1 and 13 were provided care in a timely manner, when they had to wait for prolonged periods to have their call bells answered. Findings include: 1) Resident #5 had [DIAGNOSES REDACTED]. The facility's bowel care policy dated 1/2013, documented to give a suppository or enema that was ordered by the physician on the third morning after the resident had no bowel movement. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was moderately impaired; she was independent with ambulation, required extensive assistance with toileting, and was continent of bowel. The physician's orders [REDACTED]. - [MEDICATION NAME] suppository 10 milligrams (mg) per rectum as needed (prn) one time a day for constipation; and - enema as directed, prn 1 time a day for constipation. Review of the resident's bowel and bladder summary, nursing progress notes, and Medication Administration Record [REDACTED]. The [MEDICATION NAME] suppository or enema were not administered on these dates. There were no nursing progress notes that documented a rationale for not following the resident's bowel protocol. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was moderately impaired; she was independent with ambulation, required extensive assistance with toileting, and was frequently incontinent of bowel. The resident's comprehensive care plan (CCP) dated 12/27/2015, and reviewed 9/12/2016, documented the resident was frequently incontinent of bowel and at risk for constipation. The goal was the resident would be kept free from constipation. Interventions included: - toileting the resident every 2 hours and as needed: - observing the resident's bowel pattern every shift and charting the amount and consistency; and - providing medications as ordered by the physician, observing the effectiveness, and notifying the physician if ineffective. Review of the resident's bowel and bladder summary, nursing progress notes, and MAR indicated [REDACTED]. The [MEDICATION NAME] suppository or enema were not administered and there were no nursing progress notes documenting a rationale why the resident's bowel protocol was not followed. The resident was observed on 9/21/2016 from 4:22 PM to 5:05 PM in the dining room. She entered the dining room with a nurse and was seated at the table with another resident. She did not talk and when the surveyor attempted to talk to her, her sounds were incomprehensible. She was given beverages to drink and attempted to leave the dining room prior to her meal being served. She was served her meal, tried to leave the dining room again and was redirected by staff and encouraged to eat. When interviewed on 9/23/2016 at 8:30 AM, the day shift licensed practical nurse (LPN) #11 stated usually the evening LPN would print a report of residents that have not had a BM for 2 days. At bedtime, the evening shift LPN was to then administer Milk of Magnesia to the residents on the list who still have not had a BM. The next morning, the 11 PM to 7 AM LPN was to administer a suppository around 6 AM. If the resident did not have results, the day LPN was to give the resident an enema. LPN #11 stated Resident #5 recently had some issues with her bowels and her bowel medications were readjusted. She stated the bowel protocol should be followed and if it did not work, the physician should be notified. When interviewed on 9/23/2016 at 10:45 AM, the registered nurse (RN) Manager stated the resident should get a [MEDICATION NAME] suppository on the morning of the 3rd day without a BM. If the resident did not have a BM after the suppository, a fleet enema was to be given that afternoon. She reviewed the resident's bowel record for 8/24-8/29/2016 and stated the resident should have been administered a [MEDICATION NAME] suppository on 8/26/2016. She stated if it was not given, she would expect an explanation in the nursing notes documenting the rationale as well as a bowel assessment that checked for bowel sounds, distention and pain. She reviewed the resident's bowel record for 9/13 - 9/16/2016 and stated she would have expected documentation as to why the bowel protocol was not administered to the resident. 2) Resident #3 had [DIAGNOSES REDACTED]. The 7/1/2016 nurse practitioner (NP) ordered an ACE wrap to the resident's left foot and lower leg, on in AM and off in PM, for [MEDICAL CONDITION] (swelling). The 7/1/2016 at 2:33 PM licensed practical nurse (LPN) progress note documented the resident was seen by the NP. She had increased [MEDICAL CONDITION] to left lower leg and foot, and the NP ordered an ACE wrap to the left lower leg and foot to be applied in AM and off in PM. The 7/6/2016 NP progress note documented the ACE wrap was applied to the resident's left lower leg for increased [MEDICAL CONDITION] with good results. The 9/2016 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The updated 9/17/2016 comprehensive care plan (CCP) documented the resident required assistance with activities of daily living (ADLs) due to [MEDICAL CONDITION]. Interventions included elevating her heels in bed, keeping legs elevated as much as possible to prevent swelling, and turning and positioning every 2 hours and as needed. The 9/20/2016 physician's orders [REDACTED]. The resident was observed on 9/21/2016: - at 9:30 AM, in bed asking when someone was going to get her up. She was in night clothing with heel protectors on her bare feet; - at 12:02 PM, in her room eating lunch. She had a gauze dressing on her right lower leg and stated the nurse changed it in the morning. The left leg was bare and the skin appeared fragile; she wore fuzzy slipper socks on her feet; and - at 2:45 PM, in the recliner chair in her room and socializing with her visitor. Her feet were elevated and she wore slipper socks. There was not an ACE wrap on the left leg or left foot. The resident was observed on 9/22/2016 at 8:45 AM. She had a gauze dressing on the right leg and an ACE wrap on her left lower leg. The wrap went from below the knee to above the ankle, with a few inches of skin showing between the wrap and the slipper sock. When interviewed at that time, the resident stated the ACE wrap was not on the previous day and said some days, they put it on and, other times they did not. The resident stated she had a sore on the right leg and the nurse changed that dressing every day. When interviewed on 9/23/2016 at 8:30 AM, LPN #11 stated the resident's ACE wrap was applied to the resident's left leg for [MEDICAL CONDITION], and the resident had a gauze dressing with [MEDICATION NAME] to the right leg for [MEDICAL CONDITION]. She stated the 11 PM to 7 AM nurse applied the ACE wrap at 6 AM and the evening nurse took it off at 7 PM. She stated she applied the gauze dressing to the right leg on her shift. She stated the ACE wrap was applied from ankle to knee and she thought the resident had it every day. When interviewed on 9/23/2016 at 10:45 AM, the registered nurse (RN) Manager stated the resident had an ACE wrap applied to her lower left leg for [MEDICAL CONDITION] and it was put on at 6 AM by the night nurse. She stated the dressing should go from ankle to knee. When interviewed on 9/23/2016 at 12:05 PM, LPN #12 stated he normally worked the 3 PM to 11 PM shift and on 9/20/2016, he was mandated to stay and work from 11 AM to 7 AM. He stated the resident had a [MEDICATION NAME] dressing with gauze on her right leg and it was changed once a day by the day shift. He stated there was nothing on the left leg. He stated the resident used to get an ACE wrap to the right leg and it was changed to the [MEDICATION NAME] gauze treatment when she got [MEDICAL CONDITION]. He stated he had not removed an ACE wrap from her leg during the evening shift for a while, and did not apply an ACE wrap on the morning of 9/21/2016. 3) Resident #1 had [DIAGNOSES REDACTED]. The 8/15/2016 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, she required extensive assistance with toileting and was frequently incontinent of bowel and bladder. The updated 8/17/2016 comprehensive care plan (CCP) documented the resident needed assist with ADLs, was frequently incontinent of bowel and bladder, was non-ambulatory with transfers, and was at risk for pressure ulcers. Interventions included to offer the bed pan every 2 hours and as needed, and to have the call light in reach. The 9/3/2016 resident care card (care instructions) documented the resident was alert and oriented, was non-ambulatory, wore an incontinence brief (incontinence product), and was to be toileted every 2 hours and as needed. The 9/14/2016 physician's progress note documented the resident was on [MEDICATION NAME] (diuretic, removes excessive body fluid through urine). On 9/22/2016, the facility's call bell alarm monitor was observed at the nursing station. The alarm monitor showed the resident's call bell: - at 8:28 AM, had been alarming for 21 minutes and 17 seconds; - at 8:35 AM, had been alarming for 28 minutes and 56 seconds; and - at 8:37 AM, stopped alarming at 30 minutes and 6 seconds. On 9/22/2016 at 8:35 AM, the resident was observed in bed and yelling out for a bed pan. Licensed practical nurse (LPN) #2 then entered the room and closed the door. During a resident group interview on 9/22/2016 at 10:00 AM, 6 residents stated slow response to call bells was an on ongoing concern for them. The resident council meeting minutes were reviewed during survey. The 4/21/2016 Minutes documented the residents had ongoing complaints of lengthy wait times for call bell response. On 9/23/2016 at 9:25 AM, LPN #2 stated in an interview that when a resident pushed the call bell for assistance, the light over the resident's door turned on and a certified nurse aide (CNA) was notified by Vocera (wearable communication device). If the call bell was not answered in a certain period of time, it alarmed on the LPN's Vocera. She stated that on 9/22/2016, she entered the resident's room after she saw the light on above her door and said her Vocera never alarmed. On 9/23/2016 at 11:05 AM, registered nurse (RN) #3 Manager stated in an interview that she expected resident call bells to be answered within 5 minutes and no longer than 10-15 minutes. 10NYCRR 415.12


Plan of Correction: ApprovedNovember 21, 2016

What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #12 is no longer a resident in the facility.
Resident # 1 and # 13 call light response time was reviewed with no further incidents greater than 20 minutes noted. Unit staff were educated on the importance of timely call light response.
Resident # 3 was assessed and it was determined ace wraps continue to be an appropriate treatment. Unit staff were educated on the importance of completing treatments as ordered.
The bowel movement history of Resident # 5 was reviewed and there were no further incidence of bowel protocol not followed. Unit staff were educated on the importance of following the bowel protocol policy.

How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
An audit was conducted to ensure heel boots applied on residents as ordered. No other residents were identified with the same deficient practice.
A call light response audit was conducted for responses greater than 20 minutes. Any deficiencies identified were promptly followed-up on, with education provided to any staff as appropriate.
An audit was conducted to ensure ace wraps were applied on residents as ordered. No other residents were identified with the same deficient practice.
An audit was conducted for all residents who had no bowel movement for three (3) or more days to ensure the bowel protocol was implemented and/or the residents were assessed. Any discrepancies identified were promptly followed-up on as required, with education provided to any staff as appropriate.
What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The Bowel Care Policy was reviewed with no changes required. Mandatory nursing education regarding the application of treatments as ordered, documentation of refusal, Bowel Care Policy, and importance of timely call lights will be conducted.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing or designee will conduct the following audits:
An audit for 100% or 30 Residents (whichever is greater) each month who have heel boots ordered to ensure the heel boots are applied as ordered;
An audit for 100% or 30 Residents (whichever is greater) each month who have ace wraps ordered to ensure the ace wraps are applied as ordered;
A random audit of call light response for 30 residents each month to ensure call light response is less than 20 minutes;
A random audit of 30 residents each month to ensure the bowel protocol was implemented for any resident who had not had a bowel movement for 3 or more days.
Each individual audit will be completed monthly until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible for this deficiency
Completion date: (MONTH) 22, (YEAR)

FF09 483.15(b):SELF-DETERMINATION - RIGHT TO MAKE CHOICES

REGULATION: The resident has the right to choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care; interact with members of the community both inside and outside the facility; and make choices about aspects of his or her life in the facility that are significant to the resident.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2016
Corrected date: November 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification survey, it was determined the facility did not ensure 2 of 22 sampled residents (Residents #15 and 16), and 5 of 14 anonymous residents who attended the group meeting had the right to interact with members of the community and make choices about aspects of his or her life in the facility that are significant to them. Specifically, Residents #15 and 16 and five anonymous residents from the resident group meeting were not receiving their mail timely. Findings include: Resident council meeting minutes, dated 4/21/2016, reported the topic of resident mailboxes was addressed and residents were informed mailboxes were not available to residents in the skilled nursing facility. During the resident group interview on 9/22/2016 at 10:00 AM, five of 14 anonymous residents who attended the meeting stated they did not get their mail timely. They stated they had to wait until one of the staff members brought it to them, and there was no central location in which to send/receive mail. One resident stated she received an invitation for a family celebration after the event had taken place. Another resident stated he received mail once or twice per week, and certified nurse's aides (CNAs) delivered it when they had time. Two residents stated they asked the facility about getting mailboxes, were told they could not have them, and mailboxes were only for assisted living residents. 1) Resident #15 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] reported the resident had intact cognitive function, was non-ambulatory, and it was very important to her to remain involved in activities such as news, groups, reading, family, and social interactions. During an interview with Resident #15 on 9/22/2016 at 2:30 PM, she stated her mail was usually slow and CNAs delivered it when they had time. She stated it often took a few days to get her mail and on days that she was feeling well she went to the reception desk and retrieved it herself. During an interview with CNA #5 on 9/23/2016 at 5:42 PM, she stated CNAs or hospitality aides delivered mail for their assigned group of residents. She stated there was no specific procedure or responsible individual to deliver the mail. 2) Resident #16 had [DIAGNOSES REDACTED]. The 8/8/2016 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance with most activities of daily living (ADLs), and wore glasses. The updated 8/17/2016 comprehensive care plan (CCP) documented the resident had an alteration in psychosocial well-being, was at risk for hypertension, and was a fall risk. Interventions included allowing the resident to express feelings, providing support, talking about interests, encouraging choice, and instructing the resident to call for assistance before transferring or ambulation. When interviewed on 9/22/2016 at 3:30 PM, Resident #16 stated he got his mail every 5-6 days, the mail was postmarked a week before he got it, and various people from the facility delivered the mail. When interviewed on 9/23/2016 at 11:04 AM, supply clerk #13 stated she delivered mail on weekdays to the resident's unit and unit staff delivered the mail to the appropriate resident. She stated she delivered packaged mail directly to the resident. She stated weekend mail was delivered to the switchboard operator and she was not sure who was assigned to deliver that mail. When interviewed on 9/23/2016 at 1:00 PM, 3 unidentified certified nurse aides (CNAs) stated the hospitality aides delivered the mail on the units. During the same interview, a hospitality aide stated she normally delivered the mail and the CNAs or nurses delivered the mail when she could not. 10NYCRR 415.5(b)(2)(3)

Plan of Correction: ApprovedNovember 21, 2016

What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
All mail has been delivered to Residents #15 and 16.
How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
All residents who receive mail could be affected by this deficient practice. Mail has been delivered to the residents.
What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The practice of mail delivery was revised to have the Materials Distribution Clerk deliver personal mail and packages to each resident directly. Bulk mailing will be brought to the unit and delivered to the individual residents by unit staff.

How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Activities Director or designee will audit mail delivery of 30 residents to ensure mail is delivered timely. Monitoring will continue monthly until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Activities Director and will be reported to the Quality Council Improvement Council.
The date for correction and the title of the person responsible for each deficiency.
The Activities Director will be responsible for this deficiency
Completion date: (MONTH) 22, (YEAR)

FF09 483.25(j):SUFFICIENT FLUID TO MAINTAIN HYDRATION

REGULATION: The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2016
Corrected date: November 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, it was determined the facility did not ensure 2 of 22 residents (Residents #1 and 17) reviewed for hydration were provided with sufficient fluid intake to maintain proper hydration and health. Specifically, when Residents #1 and 17 had orders for fluid restrictions, there was no system in place to ensure the residents maintained these fluid restrictions. Findings include: 1) Resident #1 had [DIAGNOSES REDACTED]. The original 6/11/2013 physician order [REDACTED]. The physician progress notes [REDACTED]. There was no documentation pertaining to the fluid restriction. The comprehensive care plan (CCP) updated 8/17/2016 documented the resident had [MEDICAL CONDITION] and the goal was to maintain 2000 cc fluid restriction on a daily basis. Interventions included labs as ordered, medications as ordered, monitor intake each shift, provide diet as ordered, weights every 14 days due to fluid retention and [MEDICATION NAME] treatment. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact. She required extensive assistance to total dependence in all activities of daily living (ADLs) with the exception of eating, which required set up only. The registered dietitian (RD) progress note dated 8/19/2016 at 8:00 AM documented the resident was on a 2000 cc fluid restriction, her fluid intake averaged 2311 cc per day, and had a nutritional [DIAGNOSES REDACTED]. The note documented a fluid distribution of 360 cc's with breakfast, 360 ccs with lunch, 240 ccs with dinner, 180 ccs AM, 240 ccs PM, 180 ccs evening, 240 ccs 7-3 shift med pass, and 200 ccs 3-11 shift med pass. The RD progress note dated 9/2/2016 at 11:30 AM documented the resident was on a 2000 cc fluid restriction, her fluid intake averaged 2275 cc per day, and had a nutritional [DIAGNOSES REDACTED]. the note documented the goal was to consume the appropriate amount of fluids to promote a sodium level trend to normal limits with an intervention to monitor fluid consumption and provide fluids as outlined. The resident's care record (care instructions) dated 9/3/2016 documented the resident had a 2000 cc fluid restriction. The physician progress notes [REDACTED]. There was no documentation pertaining to the fluid restriction. The resident's intake records from 6/1/2016 to 9/20/2016 documented her fluid intake ranged from 480 cc/day to 3360 cc/day, and her documented daily intake exceeded 2000 cc at least 46 days during the time period. The resident was observed on 9/21/2016 at 11:48 PM at the dining room table with 240 cc of milk, 240 cc of cranberry juice and 240 cc of water in front of her. At 12:12 PM, the resident had consumed 100% of the milk and cranberry juice, as well as 50% of the water. On 9/22/2016 at 3:42 PM in the dining room, the resident had a 240 cc cup of coffee in front of her, with more than half the coffee consumed. When interviewed on 9/23/2016 at 9:15 AM, certified nurse aide (CNA) #1 stated he would know a resident was on fluid restrictions by looking at the resident care record and the meal ticket. He stated there was no breakdown to refer to between meals if the resident requested additional fluids. He stated the resident was alert and oriented and he would ask her how much she already had to drink that day, to determine whether or not she was able to have it. When interviewed on 9/23/2016 at 9:25 AM, the licensed practical nurse (LPN) #2 stated she would know how much fluid residents on fluid restrictions were able to have, as the Medication Administration Record [REDACTED]. She stated the hospitality aide would know how much fluids a resident could have in between meals and medications. She stated there must be a breakdown from dietary the hospitality aides refers to, and she did not know where that was. When interviewed on 9/23/2016 at 9:45 AM, hospitality aide #4 stated if a resident was on a fluid restriction, it would be documented on their meal ticket and resident care record. She stated if a resident was on a fluid restriction and requested additional fluids she would ask the resident's CNA if they could have it. When interviewed on 9/23/2016 at 10:00 AM the registered dietitian (RD) stated she monitors a resident's fluid restriction weekly. She stated she calculated a weekly average of their fluid intake. She stated if a resident went over the fluid restriction, she created a breakdown of fluids to be given at meals and medication pass. She then would email the breakdown with the Nurse Manager. She was not sure what the Nurse Manager did with that information after that. She stated if the resident was consistently going over their restrictions, she would talk with the resident and provide education on the importance of compliance. She stated she may or may not discuss it during morning meeting. She said she would bring it up if the resident's laboratory values were not within normal limits. She stated the resident was on the fluid restriction for [MEDICAL CONDITION] and low sodium levels. She stated the resident's laboratory values were last completed in (MONTH) (YEAR) and due again in (MONTH) (YEAR). When interviewed on 9/23/2016 at 10:10 AM, the registered nurse (RN) Manager #3 stated when a resident was on fluid restriction, and requesting additional fluids, it was the responsibility of the CNA or hospitality aide to go to the LPN who would run an ADL report to determine how much fluid the resident already had that day and if they were able to have any additional fluids. She stated the resident was non compliant with her fluid restrictions and would expect that to be addressed by dietary. 2) Resident #17 had [DIAGNOSES REDACTED]. The original 3/7/2016 physician order [REDACTED]. The physician progress notes [REDACTED]. There was no documentation pertaining to the fluid restriction. The registered dietitian (RD) progress note dated 5/13/2016 documented the resident was on a 1500 cc daily fluid restriction due to end stage [MEDICAL CONDITION] and her average intake was 1690 cc's/day. The note documented a 1500 cc fluid restriction was based on [MEDICAL TREATMENT]. The nursing progress note dated 6/28/2016 at 10:54 AM documented the resident had [MEDICAL CONDITION] (swelling from excess fluids) in both legs and feet. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact,independent with most activities of daily living (ADLs), was occasionally incontinent of urine, and was not on a diuretic. The comprehensive care plan (CCP) updated 7/6/2016 documented the resident was at risk for shortness of breath/chest pain/[MEDICAL CONDITION] related to [MEDICAL CONDITION] and hypertension, and had abnormal renal labs related to end stage [MEDICAL CONDITION] with [MEDICAL TREATMENT]. Interventions included adhere to diet restrictions, monitor and document diet intake, medications as ordered, a 1500 cc fluid restriction, review labs from [MEDICAL TREATMENT] and confer with [MEDICAL TREATMENT] Registered Dietician (RD). The interventions included a fluid distribution of 240 cc with all meals, 300 cc with medications each day, 360 cc for snacks, and 120 cc as desired. The physician progress notes [REDACTED]. The note documented the resident was on [MEDICAL TREATMENT] for end stage [MEDICAL CONDITION]. There was no documentation pertaining to the fluid restriction. The RD progress note dated 7/11/2016 documented the resident was on a 1500 cc daily fluid restriction due to end stage [MEDICAL CONDITION] and her average intake was 1482 cc's/day. The nursing progress note dated 7/14/2016 at 5:36 PM documented the resident had [MEDICAL CONDITION] in both legs with raised areas and drainage on her pant legs. The nursing progress note dated 7/22/2016 at 3:32 PM documented the resident was to have her [MEDICAL TREATMENT] catheter out on 7/26/2016. The resident's care card (care instructions) dated 9/3/2016 documented the resident had a 1500 cc fluid restriction. The RD progress note dated 9/14/2016 documented the resident was on a 1500 cc daily fluid restriction due to end stage [MEDICAL CONDITION] and her average intake was 1487 cc's/day. The note documented a 1500 cc fluid restriction was based on [MEDICAL TREATMENT]. The resident's intake records from 6/1/2016 to 9/22/2016 documented her fluid intake ranged from 360 cc/day to 2700 cc/day, and her documented daily intake exceeded 1500 cc for 63 days during the time period. The resident was observed on 9/22/2016 at 3:10 PM in her room. On the resident's bedside table was a 240 cc cup of water and a 240 cc cup of gingerale. Both cups contained approximately 50% of fluid in them. When interviewed on 9/23/2016 at 9:15 AM certified nurse aide (CNA) #1 stated he would know a resident was on fluid restrictions by looking at the resident care record and the meal ticket. He stated there was no breakdown to refer to between meals if the resident requested additional fluids. He stated the resident was alert and oriented and he would ask her how much she already had to drink that day to determine whether or not she was able to have it. When interviewed on 9/23/2016 at 9:25 AM the licensed practical nurse (LPN) #2 stated she would know how much fluid residents on fluid restrictions were able to have as the Medication Administration Record [REDACTED]. She stated the hospitality aide would know how much fluids a resident could have in between meals and medications. She stated their must be a breakdown from dietary the hospitality aides refers to and she did not know where that was. When interviewed on 9/23/2016 at 9:45 AM hospitality aide #4 stated if a resident was on a fluid restriction it would be documented on their meal ticket and resident care record. She stated if a resident was on a fluid restriction and requested additional fluids she would ask the resident's CNA if they could have it. When interviewed on 9/23/2016 at 10:00 AM the registered dietitian (RD) stated she monitor's a resident's fluid restriction weekly. She stated she calculates a weekly average of their fluid intake. She stated if a resident goes over the fluid restriction she creates a breakdown of fluids to be given at meals and medication pass. She then emails the breakdown with the Nurse Manager and she was not sure what the Nurse Manager did with it after that. She stated if the resident was consistently going over their restrictions she would talk with the resident and provide education on the importance of compliance. She stated she may or may not discuss it during morning meeting. She stated the resident was on the fluid restriction related to her [MEDICAL TREATMENT]. When interviewed on 9/23/2016 at 10:10 AM the registered nurse (RN) Manager #3 stated when a resident was on fluid restriction and requesting additional fluids it was the responsibility for the CNA or hospitality aide to go to the LPN who would run a ADL report to determine how much fluid the resident already had that day and if they were able to have any additional fluids. She stated the resident was non compliant with her fluid restrictions and would expect that to be addressed by dietary. 10NYCRR415.12(j)

Plan of Correction: ApprovedNovember 21, 2016

What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice?
Resident #1 and 17 fluid restrictions have been assessed and the individual fluid restriction remains appropriate for each resident. The Dietician has reviewed the distribution of fluids for each resident per the plan of care, provided a breakdown of fluid distribution to the unit staff, and provided education to each resident regarding their individual fluid restriction. Unit staff received education regarding the individual resident?s fluid distribution breakdown.
How you will identify other Residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
All other residents ordered to be on a fluid restriction could be affected by this deficient practice. An audit was conducted for residents on a fluid restriction. No other residents were affected by this deficient practice.
What measures will be put in place or what systemic changes you will make to ensure that the same deficient practice does not recur.
The Fluid Restriction Policy was revised to include the Dietician or Nutritional Counselor to develop an individualized fluid distribution for each resident on a fluid restriction and provide a Fluid Distribution Communication sheet for nursing to be placed in the resident?s room. The Director of Nursing in collaboration with the facility?s Medical Director further delineated the term fluid restriction as Strict Fluid Restriction which is calculated daily and Fluid Restriction which the daily fluid intake goal is averaged over the course of a week. Mandatory education will be provided for the Dieticians and all staff that assist residents during meals, provide between meal nourishments, and/or pass medications regarding fluid restriction. The education will emphasize the importance of maintaining the resident?s fluid restriction and providing fluids to the resident as planned and communicated in the breakdown of fluid distribution. The Clinical Dietician will meet weekly with nursing to review each Resident who is on a fluid restriction. During this meeting the weekly or daily average will be reviewed and as appropriate strategies to promote compliance with the resident?s individual goal will be discussed.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing and/or designee will audit 30 residents on a fluid restriction to ensure the individual fluid distribution is communicated to nursing and the resident?s fluid restriction is maintained each month until 100% compliance has been achieved for 3 consecutive months. This audit will be conducted by the multi-disciplinary team. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
The date for correction and the title of the person responsible for each deficiency.
The Director of Nursing will be responsible for this deficiency
Completion date: (MONTH) 22, (YEAR)