Morningstar Residential Care Center
September 22, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 22, 2017
Corrected date: October 23, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews conducted during the recertification survey, it was determined the facility did not consistently provide a safe environment and adequate supervision for 1 of 11 residents (Resident #2) reviewed for accidents. Specifically, Resident #3 was care planned to be out of bed for meals and was observed in bed with limited supervision for 2 meals. Findings include: Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required the extensive assistance of 2 staff for bed mobility, supervision and assistance of one person for eating, and was on a mechanically altered diet. The speech therapy evaluation and plan of treatment dated 10/5/2016 documented the resident was referred by nursing due to exacerbation of decreased oral/pharyngeal function, decreased safety during oral intake, coughing/choking during oral intake, and risk for aspiration. The speech therapy discharge summary dated 11/3/2016 documented recommendations for safe intake were: - alternating liquids and solids: - no straws and effortful swallow; - upright posture during meals and upright posture for 30 minutes after meals; - and close supervision for oral intake. The physician order [REDACTED]. The resident could have thin liquids in a Provale cup (cup with lid which limits flow of liquid) with staff supervision and allowance for ice cream. The undated resident care instructions (Kardex) documented the resident needed encouragement with fluid intake in order to meet daily requirements. She had mechanical soft solids and nectar thick liquids with an allowance for thick liquids in a Provale cup and allowance for ice cream. The resident was to be up and out of bed for meals and was to eat in the hall or dining room. The comprehensive care plan (CCP) updated 8/9/2017, documented the resident had a nutritional problem related to weight loss and advanced age. The resident was to have a calm setting, adequate time for eating and encouragement for socialization and interaction with table mates during meals. The CCP documented the resident appeared concerned at meals and was to be monitored for signs/symptoms of dysphagia such as pocketing, choking, coughing, multiple attempts to swallow, or refusing to eat. The point of care report for 8/31/2017-9/20/2017 documented the resident received extensive to total assistance for bed mobility, and set up to extensive assistance for eating. On 9/20/2017 the following observations were made: - at 5:56 PM, the resident was in bed, the head of the bed elevated to nearly 90 degrees, the resident was slouched and laying to the left side of the bed, - at 6:16 PM, her dinner tray was brought in and placed on the over-bed table to the left of the resident, - at 6:30 PM, the resident remained in bed, a small portion of her meal and drinks had been consumed, she remained slouched down in the bed, partially on her left side. - by 6:45 PM, no staff had been in the room to supervise or assist the resident with her meal. On 9/21/2017, the following was observed: - at 11:30 AM, the resident was in bed, the head of bed was elevated to 45 degrees, the resident had two plastic cups with straws on the overbed table, each cup contained a nutritional supplement which was partially consumed. - at 12:03 PM, the resident had her lunch on the overbed table in front of her in bed, and - at 12:18 PM, the resident had consumed a small portion of her meal and drinks, no staff had entered her room. On 9/22/2017, the following was observed: - at 8:30 AM, the resident was in bed, the head of bed elevated to 45 degrees; - at 11:12 AM, the resident remained in bed, had an 8 ounce container of Ensure Plus (nutritional supplement) with a straw on her overbed table, partially consumed; and - at 12:15 PM, had her lunch tray on the overbed table, She remained in bed positioned with the head positioned at a 45 degree angle, no staff were present in her room. Certified nurse aide (CNA) #3 stated during an interview on 9/22/2017 at 11:42 AM, the resident refused to get out of bed, ate by herself in her room, and she was not sure if the resident was on thickened liquids. She stated residents on thickened liquids needed supervision. When interviewed on 9/22/2017 at 12:04 PM, CNA #2 stated the resident had been refusing to get out of bed for a while and often stayed in bed for meals. The resident did not need assistance with meals, was supervised intermittently and residents on thickened liquids needed to be up for meals due to positioning and supervision. During an interview on 9/22/2017 at 12:30 PM, CNA #1, stated she did not remain in the room to assist the resident, the resident formerly had to get up for meals, she was unsure of the reason, and the resident often refused to get up, as she did that day. Registered nurse (RN) Unit Manager #4 stated during an interview on 9/22/2017 at 12:30 PM, the resident's typical behavior was to refuse to get up or immediately go back to bed as she has done this for quite a while. She stated the resident's care plan should have been updated to reflect her preference for remaining in bed for meals, as her current care plan stated she was to be out of bed for meals. She stated nursing should be following the precautions as noted on the speech therapy discharge and close supervision meant someone should be with the resident during meal intake. The RN Manager stated she would expect the resident to be re-evaluated by speech therapy based on the change in resident's preferred location for eating to ensure a safe eating plan. Speech language pathologist (SLP) #6 stated on 9/22/2017 at 2:00 PM, she expected residents at risk for aspiration to be closely supervised during meals, and general precautions included getting out of bed for meals and upright positioning. She had not reevaluated the resident since the 11/1/2016 ST discharge, and if there was a change in the resident's status for eating, she would want to reevaluate her in the environment in which she usually ate. 10NYCRR 415.12 (h)(1)(2)

Plan of Correction: ApprovedOctober 9, 2017

F 323
Corrective action(s) accomplished for those residents (rooms) found to have been affected by the deficient practice;
? Resident #2?s careplan was reviewed and revised 09/22/2017
? Resident #2 was evaluated by speech language pathologist 09/25/2017 and resumed therapy (currently ongoing).
To identify other residents having the potential to be affected by the same deficient practice and corrective action (s) taken;
? All residents have been identified as potentially being affected.
? Registered Nurses under the direction and supervision of the DON reviewed all careplans and kardexes to ensure recommended interventions for meals were accurate and appropriate.
? 24 resident?s were identified to have need for supervision documented in their careplans.
? IDCP team review of these 24 residents resulted in 15 careplan revisions upon MD/ RN and SLP recommendations. Careplans were revised 10/04/2017
? DON reviewed careplans and kardexes 10/07/2017 for positioning recommendations. No careplan revisions were required.
Measures put in place and systemic changes made to ensure that the deficient practice does not recur;
? The facility daily assignment record for certified nurse aides was revised to include notation next to those residents requiring direct supervision at meals.
? The new daily assignment record will be updated as needed by LPN charge nurses under the direction and supervision of the RN/ RCC and SLP
? A lesson plan was created for all nursing staff on the new facility process/ daily assignment sheets.
? Facility aspiration precaustion policy was reviewed
? Lesson plan created and education initiated 10/09/2017 for nursing staff on aspiration precautions which includes positioning requirements at meals
? Staff education was initiated on 10/05/2017 regarding the process and daily assignment records.
? SLP was educated on new process 10/05/2017
Corrective action(s) will be monitored to ensure the deficient practice will not recur and quality assurance program put into practice.
? In order to insure compliance, weekly audits will be completed on appropriate residents for 4 (four) weeks, monthly for 3 (three) months , then as frequency determined by the Quality Improvement Committee. Acceptance threshold 85%
The date for correction and the title of the person responsible.
? Responsible Party: Director of Nursing
? Completion Date: 10/23/2016

FF10 483.45(f)(2):RESIDENTS FREE OF SIGNIFICANT MED ERRORS

REGULATION: 483.45(f) Medication Errors. The facility must ensure that its- (f)(2) Residents are free of any significant medication errors.

Scope: Isolated
Severity: Actual harm has occurred
Citation date: September 22, 2017
Corrected date: October 23, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, it was determined the facility did not ensure 1 of 13 residents (Resident #10) were free of significant medication errors. Specifically, Resident #10's anti-[MEDICAL CONDITION] medication was discontinued without a physician's order and the resident had a [MEDICAL CONDITION] requiring hospitalization . Findings include: The Policy Telephone and written orders for medication revised 5/2014 documented the procedure for verbal and telephone orders for medications to include, a nurse checks the order from the chart, verifies that the order is in the computer correctly, if the order is correct the nurse approves the order, if the order is not correct the order is either corrected or rejected. If the order is rejected, pharmacy is notified of the error and then pharmacy corrects the error and sent back to facility for approval. Resident #10 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was moderately impaired and he required extensive assistance with activities of daily living. The resident had a [MEDICAL CONDITION] disorder and a feeding tube. The comprehensive care plan (CCP) updated 8/26/2017, did not document the resident's [MEDICAL CONDITION] disorder. The physician's orders dated 6/12/2017, documented to administer [MEDICATION NAME] [MEDICATION]) 600 milligrams twice a day for the resident's [MEDICAL CONDITION] disorder. The Medication Administration Record [REDACTED]. The record documented the medication was given at 8:00 AM from 7/1 to 7/11/2017, and at 8:00 PM from 7/1 to 7/10/2017. The MAR indicated [REDACTED]. There was no physician order to discontinue the medication. A nursing progress note dated 7/26/2017 at 12:34 PM, documented the resident was convulsing, frothing at the mouth, and unresponsive with very heavy labored breathing. The resident's blood pressure was 240/100, his heart rate was 96 and irregular, a non-rebreather oxygen mask was applied and the resident was sent to the hospital. The nurse practitioner's (NP) note dated 7/26/2017, documented the resident had a grand mal [MEDICAL CONDITION], became unresponsive and was transferred to the hospital. She documented he had been controlled with [MEDICATION NAME] and followed by neurology. The hospital discharge summary dated 8/2/2017, documented the resident was admitted to the hospital after a [MEDICAL CONDITION] and not getting his [MEDICAL CONDITION] medication. When interviewed on 9/22/2017 at 11:30 AM, the registered nurse (RN) Manager #7 stated the resident was on [MEDICATION NAME] and it was discontinued in the computer system by a nurse that no longer worked at the facility. She stated the medication should not have been discontinued and no one saw the mistake until after the resident returned from the hospital. When interviewed on 9/22/2017 at 11:50 AM, the Director of Nursing (DON) stated the [MEDICATION NAME] was discontinued by a nurse without an order. The error was found by RN Manager #7 after the resident's hospitalization . When interviewed on 9/22/2017 at 2:50 PM, the resident's physician stated he was unaware the resident was taken off his [MEDICAL CONDITION] medication until the resident returned from the hospital. When the resident went to the hospital he thought the order for [MEDICATION NAME] was active. The resident's [MEDICAL CONDITIONS] (low blood sodium), and an infected [MEDICATION NAME] (antispasmotic) pump (delivers medication directly into spinal fluid, removed 3/2017) put the resident at risk for [MEDICAL CONDITION], and the risk for [MEDICAL CONDITION] increased without anti-[MEDICAL CONDITION] medication. 10NYCRR 415.12(m)(2)

Plan of Correction: ApprovedOctober 9, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective action(s) accomplished for the resident found to have been affected by the deficient practice;
? Resident #10 was admitted to hospital 7/26/2017 and returned to facility 8/02/2017.
? Resident was assessed by RN 08/02/2017.
? Admission history and physical was completed by physician 08/03/2017.
? Resident #10?s physician orders [REDACTED].
? Resident #10?s care plan was reviewed and revised 10/04/2017
? Resident has planned discharge to community 10/10/2017
To identify other residents having the potential to be affected by the same deficient practice and corrective action (s) taken;
? All residents have been identified as potentially being affected.
? Registered Nurses under the direction and supervision of the DON completed a review of all residents physician?s orders to ensure medications were correctly listed on resident MAR. (Completion date: 10/05/2017). No issues were identified.
Measures put in place and systemic changes made to ensure that the deficient practice does not recur;
? The facility policy and procedure on receiving orders was reviewed and revised 10/04/2017 to specifically include instructions regarding pharmacy entered changes in the electronic medication administration record.
? A lesson plan was created to educate nurses on accepting and rejecting physician?s orders into the MAR indicated [REDACTED].
? LPN/ RN education initiated on 10/05/2016 for all nurses regarding the revised policy. Education to be completed by 10/23/2017.
**NEW** The pharmacy is generating a daily report that includes all imported discontinued orders. The DON or RN designee will access the report daily to ensure discontinued medications have a corresponding physician order.
Corrective action(s) will be monitored to ensure the deficient practice will not recur and quality assurance program put into practice.
? In order to insure compliance with policy and procedure, weekly audits will be completed on all residents for 8 (eight) weeks, monthly for 3 (three) months, then as frequency determined by the Quality Improvement Committee. Acceptance threshold 95%.
**NEW**DON will provide summary report at monthly QAPI regarding any findings on pharmacy daily report and corrective actions (If indicated). Acceptance threshold 95%
The date for correction and the title of the person responsible.
? Responsible Party: Director of Nursing
? Completion Date: 10/23/2017