Fort Hudson Nursing Center, Inc.
September 5, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident?s medical record. (iv)In consultation with the resident and the resident?s representative (s)- (A) The resident?s goals for admission and desired outcomes. (B) The resident?s preference and potential for future discharge. Facilities must document whether the resident?s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2017
Corrected date: October 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during a recertification survey, the facility did not ensure a comprehensive care plan (CCP) was developed for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 3 (three) (Resident #'s 127, 139 and #198) of 30 (thirty) residents reviewed. Specifically, for Resident #'s 127 and 139, the facility did not ensure a CCP was developed for a resident with an increased risk for bleeding related to medication usage. Also, for Resident #198, the facility did not ensure a CCP was developed for a resident with an infected diabetic foot wound. This is evidenced by: Resident #127: The resident was admitted [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident with moderately impaired cognition, understands and is understood. The resident was previously a respite resident at the facility on 12/17/2015, 4/6/2016, 7/8/2016. Review of a Pharmacy Consultation Report dated 12/31/2016 documented that the resident receives an antidepressant, [MEDICATION NAME], and a medication that may increase the risk of bleeding, [MEDICATION NAME] and Consider modifying the care plan to include increased monitoring for bleeding complications such as rusty discolored urine, black or tarry stools, bruising and sudden changes in mental status or vital signs. Review of physician's orders [REDACTED]. Review of comprehensive care plans revealed a care plan was not in place to address the resident's increase risk of bleeding related to anti-coagulation therapy. Resident #139: The resident was admitted [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident as moderately impaired cognitively and that the resident usually understands and is usually understood. Review of a Pharmacy Consultation Reported dated 7/26/2017 documented that the resident receives an antidepressant, [MEDICATION NAME] Oxalate, and a medication that may increase the risk of bleeding, Aspirin. The recommendation documented: recommend modifying the care plan to include increased monitoring for bleeding complications such as rusty discolored urine, black or tarry stools, bruising and sudden changes in mental status or vital signs. The report was signed by the Registered Nurse Manager on 8/17/2017. The electronic Medication Administration Record [REDACTED]. During an interview with the Director of Nursing on 8/31/2017 at 1:25 pm, she stated that the resident's care plans should include a care plan for bleeding risk and should already be in place. Review of comprehensive care plans revealed that a care plan was not in place to address the resident's increase risk of bleeding related to taking aspirin daily. Resident #198: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as being cognitively intact, able to make himself understood and was able to understand others. Physician orders [REDACTED].) Give 1 tablet by mouth every 12 hours [MEDICAL CONDITION] for 13 days. Physician orders [REDACTED]. Cover with [MEDICATION NAME] (dressing that absorbs wound drainage) one time a day. The electronic Medication Administration Record [REDACTED]. Review of the Comprehensive Care Plans (CCPs) revealed that there was no care plan present to address the resident receiving an antibiotic for an infected [MEDICAL CONDITION]. Admission History and Physical dated 7/25/17, documented the resident was hospitalized for [REDACTED]. Medical Discharge Summary dated 8/17/17, documented the resident's foot infection had healed and he was ready to be discharged . During interview on 8/29/17 at 9:25 am, the Registered Nurse Manager (RNM) reviewed the resident's CCP's and stated she couldn't find a careplan for the resident's infected foot wound. The RNM stated the resident was admitted with an infected diabetic ulcer to his foot and there probably should be a careplan to indicate goals and interventions. 10NYCRR415.11(c)(1)

Plan of Correction: ApprovedSeptember 29, 2017

1. The CCP for resident #?s 127 & 139 were updated to include monitoring for risk of bleeding. Resident # 198 had been discharged as of 8/17/17 prior to survey team entry.
2.
a.) All pharmacy Consultation reports for the past 30 days will be reviewed to assure recommendations related to care planning have been addressed as determined appropriate.
b.) All residents with current antibiotic orders will have their CCP reviewed to assure appropriate plan of care is present.
3.
a.) Policy and procedure related to pharmacy recommendations will be reviewed and updated as necessary; will be reviewed with Registered Nurses.
b1.) All registered nurses will be provided a review of Comprehensive Care Plan requirements associated with pharmacist recommendations and infection care planning.
b2.) All new admissions admitted on or any current residents with newly prescribed antibiotics will have their medical record reviewed within 48 hours to ensure compliance with care plan requirements.
4. All new admissions admitted on or current residents with newly prescribed antibiotics will have CCP audited for the next three months, and then at least 50% for 3 months. Results will be submitted to QAPI Committee for review monthly; auditing frequency may be amended by Committee after six months based on compliance.
Responsible Party: DNS

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2017
Corrected date: October 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure each resident's drug regimen was free from unnecessary drugs for 11 (Resident #'s 18, 32, 40, 47, 98, 113, 122, 127, 143, 175, and #198 ) of 30 residents reviewed during the recertification survey. Specifically: For Resident #'s 18, 32, 40, 47, 113, and #198, there was a lack of adequate monitoring of post pain medication administration; For Resident #'s 122 and 175, there was a lack of documentation of non pharmacological interventions tried prior to the administration of antianxiety medications, and/or lack of adequate indications for use of antianxiety medications, and or lack of monitoring of the effectiveness of the use of antianxiety medication; and for Resident #'s 98, 122, 127, and #143 there was a lack of adequate indications for use of medications. This is evidenced by: A Pain Rating Scale shall be completed and documented to identify and monitor the level of pain and/or the effectiveness of treatment modalities until the resident achieves consistent pain relief control AHRQ, National Guideline Clearinghouse. Health Care Association of New Jersey (NCANJ): (MONTH) 18.23. Resident #175: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set of 7/12/17, assessed the resident understands, was understood and had a Brief Interview of Mental Status of 8/15 or moderately impaired cognitive ability. It identified that the resident received antianxiety medication for the six days prior. A physician order [REDACTED]. The Medication Administration Record [REDACTED]E documented for effectiveness. Nursing Progress Notes dated (MONTH) (YEAR), did not include any non-pharmacolocical measures tried prior to administering [MEDICATION NAME]. The MAR indicated [REDACTED]. Nursing progress notes (related to [MEDICATION NAME] administration) for (MONTH) (YEAR) documented: 8/1/17 at 1:42 pm - Anxious and requested and received. At 3:01 pm - administration was effective. 8/2/17 at 8:33 am - Anxious after tub bath (no notation the [MEDICATION NAME] was given). At 10:49 am Effective, calm and pleasant. 8/2/17 at 2:08 pm - prior to as needed medication very anxious and got self half dressed and put self back in chair, repeated when am I going home? Lots of 1:1 with reassurance with no effect. Bath given with lots of encouragement then again anxious and some resistance. Snacks given with no effect. Repeatedly asked for nerve pill given with good effect. At 5:38 pm administration was ineffective, continues with a lot of anxiety. 8/7/17 at 1:31 pm - very anxious, many attempts to redirect and do 1:1 and engage in activity with no effect. At 2:49 pm administration was effective. 8/8/17 at 9:11 am - very restless and anxious, I want to go home. I have to check on my husband. When am I going home? Lots of 1:1 and reassurance, attempts made to redirect to a different subject, engage in activities with no effect. As needed [MEDICATION NAME] given. At 12:24 pm, administration was effective, calm and napping. 8/14/17 at 1:00 pm - Resident was very anxious anger lunch while walking I am going to fall, help me, I need a nerve pill, lots of reassurance with 1:1. Many attempts to redirect with activities with no effect, continued to yell. As needed [MEDICATION NAME] given. At 2:41 pm administration was effective, resting. 8/21/17 at 10:46 am - given for anxiety. At 11:39 am administration was effective. 8/23/17 at 1:06 pm - resident requested. At 2:56 pm administration was effective. 8/25/17 at 12:45 pm - resident was yelling out all of shift. Non compliant with transfers and attempting to self transfer continuously throughout the shift. Toileted resident frequently to redirect her and attempt to calm her. As needed [MEDICATION NAME] was given at resident's request. At 2:48 pm administration was ineffective. 8/29/17 at 12:16 pm very anxious and complaint of shaking. (Time on MAR indicated [REDACTED].) At 1:34 pm - resident very resistive with transfers and yelling out repeatedly help me when trying to assist her. Refused to stand so a mechanical lift with assist of 3 needed for toileting due to non compliant. Get me my wheelchair. Appetite poor for meals despite much encouragement, yelling at lunch help me, hey help me, someone help me please. When meeting her needs lots of 1:1, reassurance with no effect. Requested nerve pill'. As needed [MEDICATION NAME] given as ordered. Continues to be a mechanical lift for transfers due to refusing to stand. There was no documentation of the effectiveness of the [MEDICATION NAME]. During interview on 8/31/17 at 10:00 am, an LPN (Licensed Practical Nurse) stated she was not the regular nurse for the resident but had given medications at times. The LPN was asked what the process was/when would you give the resdient the as needed [MEDICATION NAME]. The LPN stated when the resident was agitated, anxious, unable to calm down, you would give the medication and would watch to see if it was taking effect. When giving the medication, the LPN explained the process in the computer, that a screen comes up for the medication. You need to explain why you are giving the medication, it is not enough to say the resident is anxious. You need to explain the reason, what the resident is doing. She stated they should do non pharmacolocical interventions prior to giving the [MEDICATION NAME]. She was asked where the non pharmacological interventions specific to this resident would be and said she was not sure. The LPN stated that you have to follow up after the medication was given. She said they have to write a note saying why the medication was effective. Just saying the word effective was not enough, way have to explain what the resident is now doing. During interview on 8/31/17 at 2:11 pm, the Registered Nurse Manager (RNM) said staff should be documenting the reason to give the [MEDICATION NAME]. Non pharmacological interventions should be tried first, then the effectiveness of the medication should be documented. Just saying for anxiety and effective is not appropriate. You need to describe what the resident is doing. Resident #47: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with no cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 15, and that the resident was able to be understood by others and able to understand others. Physician orders [REDACTED].) give 1 tablet by mouth every 4 hours as needed for pain scale 1-5. Physician orders [REDACTED].) give 2 tablet by mouth every 4 hours as needed for pain scale 6-10. The Medication Administration Record [REDACTED] 8/12/17 2:08 pm - pre-pain scale = 7 and post-pain scale documented E effective. 8/14/17 1:56 am - pre-pain scale = 6 and post- pain scale documented E effective. 8/15/17 2:16 am - pre-pain scale = 6 and post- pain scale documented E effective. 8/19/17 6:30 pm - pre-pain scale = 8 and post- pain scale documented E effective. 8/20/17 12:47am - pre-pain scale = 8 and the post- pain scale documented E effective. 8/23/17 1:44am - pre-pain scale = 6 and the post- pain scale documented as E effective. Progress notes dated 8/12/17 at 2:08 pm documented E as effective with no post pain scale noted. Progress notes dated 8/14/17 at 1:56 am documented E as effective with no post pain scale noted. Progress notes dated 8/15/17, 2:16 am documented E as effective with no post pain scale noted. Progress notes dated 8/19/17, 6:30 pm documented E as effective with no post pain scale noted. Progress notes dated 8/20/17, 12:47 am documented E as effective with no post pain scale noted. Progress notes dated 8/23/17, 1:44 am documented E as effective with no post pain scale noted. During interview on 9/5/17 at 3:00 pm, the Registered Nurse Unit Manager (RNUM) stated using the term effective for determining how much pain was relieved is not as descriptive as using the post administration pain scale to measure how much pain was relieved. Resident #127: The resident was admitted [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident as moderately impaired cognitively and understands and is understood. The resident was previously a respite resident at the facility on 12/17/2015, 4/6/2016, and 7/8/2016. Review of Electronic Medication Administration Record [REDACTED] Calcitonin (Salmon) Solution 200 unit/ml, 1 spray alternating nostrils one time a day on even days for Supplemental. This medication's indication for use is fo the treatment for [REDACTED]. [MEDICATION NAME] tablet 20 mg ([MEDICATION NAME]). Give one tablet by mouth one time a day for Supplemental. (This medication is used for the treatment of [REDACTED]. [MEDICATION NAME] Packet 4 gm - Give 0.5 packet by mouth before meals for Supplemental Questran 3 x a day with meals. (This medication is used for the treatment of [REDACTED]. [MEDICATION NAME] Bisulfate Tablet 75 mg Give 1 tablet by mouth one time a day for Supplemental. (This medication is used for the prevention of blood clots) [MEDICATION NAME] Capsule (Tamsulosin HCL) Give 0.4 mg by mouth one time a day for Supplemental in evening. (This medication is used to improve urination related to enlarged prostate) Losartan Potassium Tablet 25 mg Give 1 tablet by mouth one time a day for Supplemental. (This medication is used for the treatment of [REDACTED]. [MEDICATION NAME] Tablet 10 mg Give 1 tablet by mouth one time a day every Mon, Wed, Fri for Supplemental. (This medication is used for the treatment of [REDACTED]. physician's orders [REDACTED]. [MEDICATION NAME] tablet 20 mg ([MEDICATION NAME]) Give one tablet by mouth one time a day for Supplemental. [MEDICATION NAME] Packet 4 GM Give 0.5 packet by mouth before meals for Supplemental Questran 3 x a day with meals. [MEDICATION NAME] Bisulfate Tablet 75 MG Give 1 tablet by mouth one tine a day for Supplemental [MEDICATION NAME] Capsule (Tamsulosin HCL) Give 0.4 mg by mouth one time a day for Supplemental in evening. [MEDICATION NAME] Tablet (Alendronate Sodium) Give 70 mg by mouth one time a day every 7 days for supplement give on empty stomach. Losartan Potassium Tablet 25 MG Give 1 tablet by mouth one time a day for Supplemental [MEDICATION NAME] Tablet 10 MG Give 1 tablet by mouth one time a day every Mon, Wed, Fri for Supplemental. During an interview with the Administrator on 8/31/17 at 9:18 am, the Administrator stated that the physician is supposed to write a [DIAGNOSES REDACTED]. During an interview with the Director of Nursing (DON) on 8/31/17 at 9:31 am, the DON stated that it is the physician's responsibility to document the indication for use with medications ordered. The DON stated that physicians seldom write orders out anymore. She stated that the nurse entering orders into the electronic medical record (EMR) must choose an indication for use from a drop-down box before they can move on with entering the order and if the indication for use is not documented the nurses are choosing Supplemental just so they can get the order into the EMR and onto the electronic Medication Administration Record [REDACTED]. The DON stated that the process for what nursing staff should do when a [DIAGNOSES REDACTED]. The DON stated that when the facility began the implementation of EMAR, the indication for use drop down box was not populated with all the indications for use, so nurses were using the choice in the drop down box of Supplemental in order to move (the process of entering orders) entering orders in the eMAR. The DON further stated that nursing staff on the night shift do audits on the medication administration records, however, they are not auditing for indication for use. During an interview with the Medical Director on 8/31/2017 at 9:55 am, he stated that it is the physician's responsibility to document the [DIAGNOSES REDACTED]. 10NYRCC 415.12(l)(1)

Plan of Correction: ApprovedSeptember 29, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. All nurses who had administered medication (pain or [MEDICAL CONDITION]) to residents 18, 32, 40, 47, 98, 113, 122, 127, 143, 175, and 198 were remediated on the documentation specifically required in the administration of PRN pain medications and [MEDICAL CONDITION].
2. All residents who have current prn pain or [MEDICAL CONDITION] medication order will have a review of their medication administration record (MAR) and documentation to determine if correct policy is followed; corrected if/when indicated.
3. All nurses will be re-educated on the policy and procedures specifically related to the documentation required in the administration of prn pain and [MEDICAL CONDITION] medications.
4. All current residents and new admissions that are prescribed or continue on a prescribed PRN pain or [MEDICAL CONDITION] will have their EMAR and EMAR progress notes audited weekly for 1 month, and no less than monthly for the next 5 months. Results will be submitted to QAPI Committee for review monthly; auditing frequency may be amended by Committee after 6 months.
Responsible Party: DNS

FF10 483.45(c)(1)(3)-(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: c) Drug Regimen Review (1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. (3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic. (4) The pharmacist must report any irregularities to the attending physician and the facility?s medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility?s medical director and director of nursing and lists, at a minimum, the resident?s name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident?s medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident?s medical record. (5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2017
Corrected date: October 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview during a recertification survey the facility did not ensure that the Licensed Pharmacist reported drug regimen irregularities to the attending Physician, and the Director of Nursing (DON), and that these reports were acted upon for five (5) Resident #'s 3, 10, 36, 127, and 143) of 12 residents reviewed for medication irregularities and unnecessary medications. Specifically: For Resident #'s 3, 10, and #36, the pharmacist did not observe or report to the physician multiple irregularities with administration times for insulin (medication for diabetes) for residents with diabetes and tha For Resident #'s 3 and 10, insulin was not given in accordance to standards of practice according to the physicians order and the facility did not notify the physician when medications were given more than an hour late. For Resident #127, the pharmacist did not observe the lack of an indication for use of a medication; For Resident #143, the facility did not ensure that a duplicate order for insulin was discovered during the consulting pharmacist's drug regimen review for a period of 5 months. This is evidenced by: The facility's Long Term Care Pharmacy Services Contract for medication management dated 11/28/16, documented the following: the consulting pharmacist will regularly review each residents medication charts for harmful medication, interactions, and duplications; and monthly, computer generated physician order [REDACTED]. condition; When the consultant Pharmacist identifies an urgent medication irregularity during review of the MRR (medication record review) that requires immediate action, the consultant pharmacist will notify the nurse and request the facility contact the attending physician to communicate the issue and obtain direction or new orders. Resident #10: The facility did not ensure that insulin was given in accordance to standards of practice according to the physicians order and did not notify the physician when medications were given more than an hour late. The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was understood and could understand. A Brief Interview for Mental Status (BIMS) score assessed the resident 14/15; cognitively intact. Physician (MD) Orders documented: 5/10/17 - Insulin Glargine (Lantus a long acting injectable medication to treat diabetes) Solution 100 unit/ml - Inject 40 units subcutaneously (sub-cu) one time a day for Supplemental at bedtime. 5/04/17 - NovoLog solution 100 unit/ml (insulin Aspart) (a short acting injectable medication for diabetes). Inject 10 units sub-cutaneously before meals. Hold if blood sugar (BS) is less than 90. During a review of the residents Comprehensive Care Plan (CCP), the CCP for diabetes mellitus interventions documented Diabetes medication as ordered by the doctor. Monitor for side effects and effectiveness. The electronic Medical Administration Record (eMAR) for (MONTH) (YEAR), documented Insulin Glargine Solution 100 unit/ml, Inject 40 unit subcutaneously one time a day for supplemental at bedtime: The eMAR documented that insulin was administered more than one hour later than the scheduled time of administration on 7 occasions. The electronic Medical Administration Record (eMAR) for (MONTH) (YEAR), documented Insulin Glargine Solution 100 unit/ml Inject 40 unit subcutaneously one time a day for supplemental at bedtime: The eMAR documented that insulin was administered more than one hour later than the scheduled time of administration on 8 occasions The electronic Medical Administration Record (eMAR) for (MONTH) 1st, (YEAR) to (MONTH) 5th, (YEAR) documented Insulin Glargine Solution 100 unit/ml Inject 40 unit subcutaneously one time a day for supplemental at bedtime: The eMAR documented that insulin was administered more than one hour later than the scheduled time of administration on 3 occasions. The electronic Medical Administration Record (eMAR) for (MONTH) (YEAR), documented NovoLog solution 100 unit/ml (insulin Aspart) (a short acting injectable medication for diabetes). Inject 10 units sub-cutaneously before meals. Hold if blood sugar (BS) is less than 90: The eMAR documented that insulin was administered more than one hour later than the scheduled time of administration The eMAR documented that insulin was administered more than one hour later than the scheduled times of administration (0730, 11:30, 16:30) on 16 occasions. The electronic Medical Administration Record (eMAR) for (MONTH) (YEAR) documented NovoLog solution 100 unit/ml (insulin Aspart) (a short acting injectable medication for diabetes) Inject 10 units sub-cutaneously before meals. Hold if blood sugar (BS) is less than 90: The eMAR documented that insulin was administered more than one hour later than the scheduled times of administration (0730, 11:30, 16:30) on 12 occasions The electronic Medical Administration Record (eMAR) for (MONTH) 1st, (YEAR) to (MONTH) 5th, (YEAR) documented NovoLog solution 100 unit/ml (insulin Aspart) (a short acting injectable medication for diabetes) Inject 10 units sub-cutaneously before meals. Hold if blood sugar (BS) is less than 90: The eMAR documented that insulin was administered more than one hour later than the scheduled times of administration (7:30 pm , 11:30 pm, 4:30 on 4 occasions. On 9/2/17, the 7:30 am dose of insulin documented 10:02 am for the time of administration and documented that the next dose of insulin scheduled for 11:30 was administered at 11:15 am. During a review of the Pharmacy Consultation Reports for the months of May, (MONTH) and (MONTH) (YEAR), there were no irregularities documented for Residents #'s 3, 10, 36, 127, and 143. During an interview on 9/5/2017 at 1:35 pm, the consultant Pharmacist stated that she reviews the entire health record during her monthly reviews. She states that she looks for a trend with late medication and reviews charts according to standards of care. She stated she tries not to miss things and should pick up on any irregularity and report them to the physician. She stated she reviews any concerns with the RNUM of each unit while in the facility. Other than her reviews she utilizes no other electronic method in the chart to document any irregularity. When asked about the review process, the pharmacist stated that she reviews the physician's orders [REDACTED]. She stated it does not make me happy to know that I missed something. She stated nurses cannot change orders and need to call the physician if the medication times need to be changes. The pharmacist stated she had completed her reviews for (MONTH) (YEAR) on 8/23/17 and had not noticed any irregularities with late insulin at that time. During an interview on 9/5/17 at 4:00 pm, the Registered Nurse Unit Manager (RNUM) stated after a review of the eMAR for the resident, she had not realized the insulin's on the unit had been given so late with such frequency. She stated the pharmacist had not mentioned to her that there was an problem with late administration of insulin insulin. The RNUM stated she does meet with the pharmacist regularly about concerns with residents medication, but this issue was never brought forth. She further stated when she reviewed the pharmacy recommendations for insulin dependent diabetics, there was no recent documentation of irregularities with insulin administration. During an interview on 8/31/17 at 4:45 pm, the Assistant Director of Nursing (ADON), the ADON stated the pharmacist had not made anyone aware of any concerns with late administration of insulin's or any other medication. She stated the pharmacists meets with the unit managers if there are concerns and also documents them on the consultation reports. Resident #143: The facility did not ensure that a duplicate order for insulin was discovered during the consulting pharmacist's drug regimen review for a period of 5 months The resident was admitted [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident as severely impaired cognitively, and usually understands and is usually understood. The Physician's Dictated Progress Note, dated 3/21/2017 at 3:51 pm, documented Her sugars have been doing better. She had been high at 434. She is on Glipizide, and her average sugar has come down to 130. She is getting blood sugars four times a day and we can decrease that to twice a day with an alternating pattern. The Nurse's Progress Note, dated 3/21/2017 at 2:29 pm, documented Resident fingersticks changed from four times a day to two times a day. Before BF and at HS on one day, before lunch and before dinner the next day alternating. physician's orders [REDACTED]. The first order: Novolog Solution (Insulin Aspart) Inject as per sliding scale: if 150 - 250 = 2 units; 251-300 = 3 units; 301-400 = 4 units if BS > then 401 call MD, subcutaneously two times a day for DM. The second order (exactly the same as the first order): Novolog Solution (Insulin Aspart) Inject as per sliding scale: if 150 - 250 = 2 units; 251-300 = 3 units; 301-400 = 4 units if BS > then 401 call MD, subcutaneously two times a day for DM. The third order documented to discontinue Novolog Solution (Insulin Aspart) Inject as per sliding scale: if 150-250 = 2 u; 251-300 = 3u; 301-400 = 4 u If BS is greater than 401 call MD, subcutaneously four times a day for elevated BS. physician's orders [REDACTED]. The first Novolog Insulin sliding scale order was documented for administration on the EMAR at 12:00 pm and 7:30 pm, daily; and the second order at 8:00 am and 9:00 pm, daily; since (MONTH) of (YEAR). During a review of the Pharmacy Consultation Reports for the months of May, (MONTH) and (MONTH) (YEAR), there were no irregularities documented for Residents #'s 3, 10, 36, 127, and 143. During an interview with the physician on 9/5/17 at 9:55 am, he stated that he thought he changed the sliding scale coverage to twice a day, but could not be sure. He would need to check his progress note. During an interview with the Registered Nurse (RN), on 9/5/17 at 10 am, who transcribed the order into the eMAR, stated she couldn't remember the order, however stated she usually puts a note in the progress notes. Upon review of the record, the RN found a note by another RN and remembered that she was helping this RN do orders. After review of the notes and orders the RN verbalized that she recognized her mistake, and stated she would review with physician. During an interview with the Registered Nurse Manager (RNM) on 9/5/17 at 10:35 am, she stated she was not the nurse manager in (MONTH) of (YEAR). Insulin orders were reviewed and she verbalized confusion of why there were two separate orders for the insulin. She reviewed pharmacy recommendations from (MONTH) (YEAR) through (MONTH) of (YEAR), for the resident and found none. She stated that the night shift audits new orders from the previous day and should have communicated an issue concerning the insulin order. During a phone interview with the consultant Pharmacist on 9/5/2017 at 1:35 pm, she stated that she reviews the entire health record during her monthly reviews. She states that ideally, she should pick up on things that are documented, however, she stated she is human and has missed somethings, though she tries not to. When asked about the review process, the pharmacist stated that she reviews the physician's orders [REDACTED]. She also stated there is a large volume at the facility. Resident #127: The facility did not ensure the consulting pharmacist discovered the lack of an indication for use of medications. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident as moderately impaired cognitively and understands and is understood. The resident was previously a respite resident at the facility on 12/17/2015, 4/6/2016, 7/8/2016. Review of eElectronic Medication Administration Record [REDACTED] Calcitonin (Salmon) Solution 200 unit/ml, 1 spray alternating nostrils one time a day on even days for Supplemental. Celexa tablet 20 MG (Citalopram Hydrobromide) Give one tablet by mouth one time a day for Supplemental. Cholestyramine Packet 4 GM Give 0.5 packet by mouth before meals for Supplemental Questran 3 x a day with meals. Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one tine a day for Supplemental Flomax Capsule (Tamsulosin HCL) Give 0.4 mg by mouth one time a day for Supplemental in evening. Losartan Potassium Tablet 25 MG Give 1 tablet by mouth one time a day for Supplemental Simvastatin Tablet 10 MG Give 1 tablet by mouth one time a day every Mon, Wed, Fri for Supplemental. Review of physician's orders [REDACTED]. Celexa tablet 20 MG (Citalopram Hydrobromide) Give one tablet by mouth one time a day for Supplemental. Cholestyramine Packet 4 GM Give 0.5 packet by mouth before meals for Supplemental Questran 3 x a day with meals. Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one tine a day for Supplemental. Flomax Capsule (Tamsulosin HCL) Give 0.4 mg by mouth one time a day for Supplemental in evening. Fosamax Tablet (Alendronate Sodium) Give 70 mg by mouth one time a day every 7 days for supplement give on empty stomach. Losartan Potassium Tablet 25 MG Give 1 tablet by mouth one time a day for Supplemental. Simvastatin Tablet 10 MG Give 1 tablet by mouth one time a day every Mon, Wed, Fri for Supplemental. During a review of the Pharmacy Consultation Reports for the months of May, (MONTH) and (MONTH) (YEAR), there were no irregularities documented for Residents #'s 3, 10, 36, 127, and 143. During an interview with the Director of Nursing (DON) on 8/31/17 at 9:31 am, she stated that it is the physician's responsibility to document the indication for use with medications ordered. The DON stated that physicians seldom write orders out anymore. She stated that the nurse entering orders into the electronic medical record (EMR) must choose an indication for use from a drop-down box, before they can move on with entering the order and if the indication for use is not documented the nurses are choosing Supplemental so they can get the order into the EMR and onto the electronic Medication Administration Record [REDACTED]. She stated that when a resident is discharged from the facility, all their orders are discontinued in the EMR. Asked DON what nursing staff should do when a [DIAGNOSES REDACTED]. The DON further stated that the nursing staff on the night shift do audits on the medication administration records however they are not auditing for indication for use. During a phone interview with the consultant Pharmacist on 9/5/2017 at 1:35 pm, she stated that she reviews the entire health record during her monthly reviews. She states that ideally, she should pick up on things that are documented, however, she stated she is human and has missed somethings, though she tries not to. When asked about the review process, the pharmacist stated that she reviews the physician's orders [REDACTED]. She also stated there is a large volume at the facility. 10 NY - CRR 415.18(c)(1)

Plan of Correction: ApprovedSeptember 29, 2017

1. Residents #3, 10, 36, 127 and 143 were addressed in regards to the identified medication administration irregularities, duplication of order (transcription error), and lack of an indication for use.
2. The consultant pharmacist will generate: 1. A list of all current residents who may have a current order without an appropriate indication for use; 2.Any resident that has insulin injection administration irregularities over the last month.
3. The Order Entry Nightly Audit Policy and Procedure will be reviewed with all 10-6 med nurses and amended to include checkpoints regarding indication for use and transcription orders which might appear as potentially duplicative orders. The Policy and Procedure for Insulin Administration will be reviewed with all nurses.
4. A. Nursing will review no less than 100% of night audits weekly for 1 month; no less than 50% over the next 3 months; and no less than 25% over the next 3 months. Results will be submitted to the QAPI Committee for review; auditing sample and frequency may be amended by the committee after six months.
B. Nursing will audit insulin administration times with relation to scheduled times 100% weekly for 3 months; no less than 50% weekly for the next 3 months. Results will be submitted to QAPI Committee for review monthly; auditing sample and frequency may be amended by Committee based on compliance with administration policies.
Responsible Party: DNS

FF10 483.60(i)(1)-(3):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2017
Corrected date: October 24, 2017

Citation Details

Based on observation, and staff interview during the recertification survey, the facility was not in compliance with adopted food safety regulations, in the main kitchen and on 4 out of 5 units. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Part 14, the community standard for food service establishments operating in New York State both state that soiled food service gloves (gloves) may not be used to prepare food, potentially hazardous foods is to be cooled to 41 degrees Fahrenheit (F) within 6 hours, and food contact surfaces are to be cleaned after use. Specifically, soiled food service gloves were used to prepare food, the internal temperature of tomato soup was greater than 41 F six hours after preparation, and the mixer was not clean. Additionally, a food service worker did not change gloves or wash hands when needed while making sandwiches. Also, on the G Unit, a food service worker did not wash hands or change gloves when needed while preparing toast. This is evidenced as follows. Finding #1: The main kitchen was inspected on 08/29/2017 at 8:45 am. The temperature of tomato soup stored in the walk-in refrigerator was 46 F when measured at 9:20 am, and the mixing machine required cleaning. The Food Service Director stated in an interview conducted on 08/29/2017 at 9:30 am that on 08/28/2017, room temperature canned tomato soup was reconstituted without heating then placed in the walk-in refrigerator for use tomorrow, and the soup should have been cooled to 41 F within six hours after opening and reconstituting the soup. Additionally, the Food Service Director stated that the mixer will be cleaned. Finding #2: G Unit The facility did not ensure that the food service staff maintained hand washing, changed gloves, and used utensils at the appropriate times, when handling food to prevent cross contamination. Specifically, the food service worker did not wash his hands and change his gloves at the appropriate times while making toast. During an observation on 8/30/17 at 8:35 am, a Dietary Worker preparing toast with gloves on, opened the refrigerator to retrieve butter and went back to preparing toast without changing gloves or washing hands. The Dietary Aide then moved the steam table, removed tin foil covering from warmed plates and returned to preparing toast with out changing gloves or washing hands. During an obervation on 8/30/17 at 8:41 am, observed 3 Certified Nursing Assistants (CNA's) during breakfast service: CNA #1 washed her hands for 6 seconds. CNA #2 washed her hands for 5 seconds and turned off the water faucet with wet hands and then dried her hands with a paper towel. CNA #1 picked up a cup that had fallen on the floor, washed her hands for 6 seconds and turned off with faucet with wet hands before drying with a paper towel. CNA #3 washed her hands and turned off the faucet with wet hands before drying with a papertowel. Review of Hand Hygiene Policy and Procedure documents to vigorously rub hands together for 10-15 seconds, rinse hands thoroughly and avoid contaminating the hands by using a paper towel to shut off the faucet. During an interview on 8/30/17 at 8:45 am, CNA #1 verbalized proper handwashing technique and stated she did turn off the faucet with wet hands. She verbalized that she should have dried her hands and then turned off the faucet with a dry paper towel. During an interview on 8/30/16 at 8:47 amm CNA #2 verbalized that she washes her hands for 30 seconds, rinses and uses a papertowel to dry her hands. When asked how she turns off the water she stated with a paper towel, but right now, I didn't. During an interview on 8/31/17 at 2:15 pm, the Food Service Director verbalized that the Dietary Aide should have removed her gloves and washed her hands as soon as she left the service area. He stated the Dietary Aide should have removed her gloves, washed her hands properly, gotten what she needed, rewashed her hands and then donned gloves and return to work station. Finding #3: Large Main Dining Room The facility did not ensure that the food service staff maintained hand washing, changed gloves, and used utensils at the appropriate times, when handling food to prevent cross contamination. Specifically, the food service worker did not wash his hands and change his gloves at the appropriate times when making sandwiches. During observation of lunch in the Main Dining Room (large-Dining Room) on 8/29/17 at 12:35 , the food service worker who was making sandwiches did not wash his hands and change his gloves at the appropriate times. There was a small sandwich cart, with limited working space, set up near the steam table. The food service worker was the only staff member making sandwiches per individual resident's request. The food service worker was observed making a peanut butter and jelly sandwich. He had opened the cabinet door with his gloved hands, then took the large containers of peanut butter and fluff out of the cabinet, removed the lids on the containers, removed the slices of bread from the plastic bag with the same gloves , spread the peanut butter and fluff on the bread, placed the sandwich on a plate with the same gloves on, replaced the lids on the containers and placed the containers in the cabinet, and closed the cabinet doors. The food service worker did not wash his hands and changed his gloves after making the peanut butter and fluff sandwich. He then proceeded to make a sandwich wrap. With the same gloved hands , the food service worker picked up a wrap, picked up some lettuce, tomatoes, and turkey from the designated areas on the opened cart. He opened a lower cabinet door to take a few strips of bacon and made the wrap. The food service worker did not wash his hands or change gloves. The food service worker held down the wrap sandwich with one unchanged gloved hand and cut the wrap in half , picked it up with his gloved hands and placed it on a plate. The food service worker continued to make another sandwich with the same gloves on and did not wash his hands. The Clinical Nutrition Manager (CNM) was observed in the Main Dining Room talking to some residents. This surveyor asked the CNM to observe the process of making individual sandwiches on the sandwich cart. The food service worker continued to make the sandwiches, while opening and closing cabinet doors, taking the slices of bread out of the plastic loaf bag, picking up the sandwich meat , lettuce, and tomatoes with the same gloves hands . During an interview with the CNM on 8/29/17 at approximately 1:00 pm , the CNM stated that the food service worker needed to wash his hands and change his gloves after opening and closing cabinet doors and before touching any food. During an interview with the Food Service Manager (FSM) on 9/5/17 at approximately 2:15 pm, the FSM stated he was aware of the incident regarding the dietary worker not washing hands and not changing gloves when making sandwiches in the Main Dining Room at lunchtime on 8/29/17. He stated that the some of the residents were complaining about stale sandwiches, so the facility started the sandwich cart to accommodate the residents request. He stated that the facility is now making the sandwiches before meal times in the kitchen. Attempted to interview the dietary worker on 9/5/17 at 2:30 pm, but was unable to interview because the dietary worker was off that day . 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.40(b), 14-.110

Plan of Correction: ApprovedOctober 4, 2017

1. The identified soup was discarded; although product had not been pre-cooked. Mixer was cleaned at time identified.
2. (a) Temperature logs for all chilled foods were reviewed to verify cooling rate and temperatures were appropriate ? all found to be within standards.
(b) All other kitchen equipment inspected to assure cleanliness, which was found to be satisfactory
3. (a) Food refrigeration guidelines (as per HAACP guidelines) were reviewed with all appropriate kitchen staff, including limiting the volume of product (size of container) being cooled; and that all foods Time-Temperature Controlled for Safety will be cooled from 140F to 70F within the first 2 hours of cooling; and to 41F within 6 hours of cooling.
(b) Protocol changed to place canned soups and/or related products in the cooler in advance of preparation, when feasible. Existing policy for pre-cooked food was reviewed with cook staff.
(c) Facility employees who prepare food will be provided re-education on proper practices related to use of gloves, handwashing and food preparation.
4. (a) Food service will continue to monitor cooling temps daily, and will conduct monthly audit of temperature logs of foods being cooled, no less than 10 per week for no less than 2 months. The results of the audits will be provided to the QAPI committee. The QAPI may amend the auditing frequency/scope after two months based on results.
(b) Food Service will conduct weekly auditing of food preparation stations, no less than 5 observations per week for 1 month, and no less than 10 observations per month for 3 months. Results will be submitted to QAPI Committee for review; auditing frequency may be amended by Committee after four months.
Responsible Party: Director of Food Service

FF10 483.10(h)(1)(3)(i); 483.70(i)(2):PERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS

REGULATION: 483.10 (h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (h)(3)The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. §483.70 (i) Medical records. (2) The facility must keep confidential all information contained in the resident?s records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2017
Corrected date: October 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility did not ensure it maintained privacy for medical treatments on 4 of five units and did not ensure it maintained confidentiality of information contained in the resident's records on one of five units during the recertification survey. Specifically, the facility did not ensure: On Unit S and Unit A, that residents' blood sugar testing was not performed in the dining rooms; On Unit B, that a resident did not receive an injection in the hallway; On Unit G, that residents' did not receive medications while eating in the dining room; and on Unit D, that resident records were not stored in an unlocked linen room in unlocked file cabinets. This is evidenced by: Finding #1: Unit S On 8/30//17 at 8:33 am, during breakfast, a Licensed Practical Nurse (LPN) #1 was observed performing blood sugar testing on a resident sitting at a table in Dining room [ROOM NUMBER]. There were two other residents sitting at this table. During interview on 8/30/17 at 8:35 am, LPN #1 said she did the blood sugar on the resident in the dining room. She stated she was in training and had to look in the computer to see what to do for insulin for the resident. During interview on 8/30/17 at 8:39 am, LPN #2 said that she was orienting LPN #1. She stated that normally they do not do blood sugars in the dining room, they would take the resident to her room to do the blood sugar. During interview on 8/31/17 at 3:00 pm the Registered Nurse Manager stated it was inappropriate for the LPN to do the blood sugar fingerstick in the dining room. Finding #2: B unit On 8/30/17 at 8:25 am, during observation, in the hallway outside of the resident's room, a Licensed Practical Nurse (LPN) was observed lifting the resident's clothing covering the left lower quadrant of the resident's abdomen and administering an injection. The resident was sitting in her recliner receiving medications while other residents passed by. During interview on 8/31/17 at 9:30 am, the LPN stated that she should have taken the resident to her room to give the injection. The LPN stated from here on out she will bring this resident or any other resident to their room to maintain privacy for the resident. During interview on 8/31/17 at 3:00 pm, the Registered Nurse Unit Manager (RNUM) stated the LPN should not have administered an injection to the resident in the hallway. The resident should have been brought back to her room for the injection to maintain the resident's privacy Finding #3: Unit G During an observation on 8/30/17 at 8:40 am, two LPN's administered by mouth medications in the dining room, during breakfast. During an interview on 8/31/17 at 8:31 am, the Administrator stated that medications should not be administered in the dining rooms. Finding #4: Unit D During a tour of Unit D on 8/29/17 at 9:25 am, the Clean Utility Room had approximately 6 unlocked file cabinets with 5 or 6 drawers in each cabinet. The Clean Utility Room is set back from the main hallway by a very small alcove and the door to the Clean Linen Room did not have any type of lock, therefore it could never be locked. Each indivivdual drawers in the 6 file cabinets (with the ability to lock) were not locked. All of the unlocked file cabinets drawers were full to capacity with residents medical records (discharge charts and overflow parts of current residents charts) including personal information such as diagnoses, social security numbers, family members names and phone numbers. Additionally a large cart of clean linen, 2 vacuum cleaners, and extra toiletry items were observed in the Clean Utility Room. During an interview and observation with the ADON on 8/30/17, at approximately 2:30 pm, the Assistant Director of Nursing (ADON) stated that the Clean Utility Room is also used for Medical Records and that the door to the Clean Utility Room cannot be locked because there is no lock on the door. The ADON stated that the Clean Utility Room is set back a little from the main hallway and residents and visitors probably don't see the door to the Clean Utility Room as they walk down the hall. The ADON stated that keeping the medical records in the unlocked Clean Utility Room is really no different then keeping the residents current medical charts on the open shelves in the open nurses station on the unit. During an interview and observation of the file cabinets in the Clean Utility Room with the Administrator on 8/31/17 at approximately 2:00 pm , there were 2 file cabinets ( with at least 5 drawers) that were found unlocked . The Administrator stated that the facility has a system in place by which all the file cabinets are to be locked and all the drawers are to be locked, however an employee did not follow the facility's policy. On 8/31/17 at 4:00 pm, the Administrator was observed moving all the residents medical files from the drawers of the file cabinets to the Medical Records Department. 10NYCRR 415.3(d)(1)

Plan of Correction: ApprovedSeptember 29, 2017

1. LPN #1, LPN #2, and B Wing LPN all received immediate remediation that they are to only conduct finger sticks and administer injections in private areas.
2. All LPNs provided re-education on policy requirements related to assuring privacy when completing finger sticks and injections.
3. Medication Administration Policy and Procedure will be reviewed and amended (if necessary) to: 1) Specify acceptable locations for injections/finger sticks 2) To Clarify PO medication administration requirement/standards during meal time.
4. Observation audits will be conducted of finger sticks and injections to ensure administration is not in public areas, no less than 5 observations per unit per week for 1 month, and no less than 10 observations per unit per month for 6 months. Results will be submitted to QAPI Committee for review monthly; auditing frequency may be amended by Committee after six months.
1. All PHI in the clean linen room was secured immediately. Re-education provided to involved employee regarding existing policy on medical record storage.
2. All(NAME) clerks educated on facility policy related to protection of PHI.
3. File cabinets for discharged resident charts will be removed from the clean linen room on D wing and stored in a secure location. Overflow records for current residents will be relocated to a secure area and maintained in a locked file cabinet.
4. Each resident wing will be audited for unsecured PHI, no less than 1 observation per week for 3 months, and no less than 10 observations per month for the next 3 months. Results will be submitted to QAPI Committee for review; auditing frequency may be amended by Committee after six months.
Responsible Party: DNS

ZT1N 415.29:PHYSICAL ENVIRONMENT

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2017
Corrected date: October 24, 2017

Citation Details

Based on observation and staff interview during the standard recertification survey, the facility did not provide protection to prevent potential of contamination of the potable water supply. 10 NYCRR 713-2.21(e)(iii) requires that backflow preventers (vacuum breakers) shall be installed on all fixtures to which hoses or tubing can be attached. Specifically, four hose fixtures did not have backflow preventers. This is evidenced as follows. Observations on 08/31/2017 at 11:15 am and again at 12:45 pm revealed 2 hose bibbs in the basement custodial closet and 2 hose bibbs in the B-Unit custodial closet had hoses attached and were not plumbed with backflow preventers. The Director of Plant Operations stated in an interview conducted on 09/05/2017 at 2:30 pm that he will have vacuum breakers installed on the hose bibbs found. 10 NYCRR 415.29(b), 713-2.21(e)(iii)

Plan of Correction: ApprovedSeptember 29, 2017

1. Hose bibs identified in SOD had backflow preventers/vacuum breakers installed on 9/18/17.
2. All hose bibs within the facility to which hoses or tubing can be attached will be visually inspected to assure proper back flow preventers are in place.
3. Any hose bib found to be lacking will have the appropriate back flow preventer installed.
4. Any future installation of hose bibs within the facility will have backflow preventer/vacuum breaker installed at time of work.
Responsible Party: Director of Plant Operations

FF10 483.30(b)(1)-(3):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDERS

REGULATION: (b) Physician Visits The physician must-- (1) Review the resident?s total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; (2) Write, sign, and date progress notes at each visit; and (3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2017
Corrected date: October 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews during a recertification survey, the facility did not ensure physician review of the resident's total program of care, including medications and treatments, for 1 of 6 residents receiving insulin injections. Specifically, for Resident #, 143 the facility did not ensure medication management . This is evidenced by: Resident #143: The resident was admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident as severely impaired cognitively, and usually understands and is usually understood. The Physician's Dictated Progress Note, dated 3/21/2017 at 3:51 pm, documented Her sugars have been doing better. She had been high at 434. She is on [MEDICATION NAME], and her average sugar has come down to 130. She is getting blood sugars four times a day and we can decrease that to twice a day with an alternating pattern. The Nurse's Progress Note, dated 3/21/2017 at 2:29 pm, documented Resident fingersticks changed from four times a day to two times a day. Before BF (breakfast) and at HS (hour of sleep) on one day, before lunch and before dinner the next day alternating. Physician's Orders dated 3/21/17 at 2:12 pm, documented 3 verbal orders. The first order: [MEDICATION NAME] Solution (Insulin [MEDICATION NAME]) Inject as per sliding scale: if 150 - 250 = 2 units; 251-300 = 3 units; 301-400 = 4 units if BS > then 401 call MD, subcutaneously two times a day for DM. The second order (exactly the same as the first order): [MEDICATION NAME] Solution (Insulin [MEDICATION NAME]) Inject as per sliding scale: if 150 - 250 = 2 units; 251-300 = 3 units; 301-400 = 4 units if BS > then 401 call MD, subcutaneously two times a day for DM. The third order documented to discontinue [MEDICATION NAME] Solution (Insulin [MEDICATION NAME]) Inject as per sliding scale: if 150-250 = 2 u; 251-300 = 3u; 301-400 = 4 u If BS is greater than 401 call MD, subcutaneously four times a day for elevated BS. Physician's Orders and Electronic Medication Administration Records (EMAR) documented the physician signed (electronically and personally) both orders for the [MEDICATION NAME] sliding scale since (MONTH) of (YEAR) and the duplicate order was transcribed twice on the EMAR, with different times assigned to the order. The first [MEDICATION NAME] Insulin sliding scale order was designated on the EMAR at 1200 and 1730, daily; and the second order at 0800 and 2100, daily; since (MONTH) of (YEAR). During an interview with the physician on 9/5/17 at 9:55 am, he stated that he thought he changed the sliding scale coverage to twice a day, but could not be sure. He would need to check his progress note. During an interview with the Registered Nurse (RN), on 9/5/17 at 10:00 am, who transcribed the order into the electronic medical record (EMR), stated she couldn't remember the order, however stated she usually puts a note in the progress notes. Upon review of the record, the RN found a note by another RN and remembered that she was helping this RN do orders. After review of the notes and orders the RN verbalized that she recognized her mistake, and stated she would review with the physician. During an interview with the Registered Nurse Manager (RNM) on 9/5/17 at 10:35 am, the RNM stated she was not the nurse manager in (MONTH) of (YEAR). Insulin orders were reviewed and she verbalized confusion of why there were two separate orders for the insulin. She reviewed pharmacy recommendations from (MONTH) (YEAR) through (MONTH) of (YEAR) for the resident and found none. She stated that the night shift audits new orders from the previous day and should have communicated an issue concerning the insulin order. 10 NYCRR 415.159(b)(2)(iii)

Plan of Correction: ApprovedSeptember 29, 2017

1. Resident #143 insulin medication regime was reviewed by the attending provider, a transcription error was identified and a medication error report generated.
2. All residents? insulin regimes were reviewed for similar situations involving transcription errors; none identified.
3. The Order Entry Nightly Audit Policy and Procedure will be reviewed with all RNs and amended to include a checkpoint for potential transcription errors which could appear as order duplication.
4. Nursing will review no less than 100% of night audits weekly for 1 month; no less than 50% over the next 3 months; and no less than 25% over the next 3 months. Results will be submitted to the QAPI Committee for review; auditing sample and frequency may be amended by the committee after six months.
Responsible Party: DNS

FF10 483.10(c)(7):RESIDENT SELF-ADMINISTER DRUGS IF DEEMED SAFE

REGULATION: (c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2017
Corrected date: October 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey, the facility did not ensure that for 1 (Resident #36) of 1 residents reviewed for the self administration of medication that the facility's interdisciplinary team determined that this resident was clinically appropriate to safely self administer medications and that the resident's comprehensive care plan included a determination for who would be responsible for the storage, documentation and location of medications for self administration. This is evidenced by: Resident #26: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident was able to understand others and was able to be understood and had a Brief Interview for Mental Status (BIMS) score of 14/15 or no cognitive impairment. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Levemer Flex Pen Solution Pen-Injector (Insulin Detemir) Inject 6 units subcutaneously one time a day for diabetes; [MEDICATION NAME] Flex Pen Solution Pen-Injector (Insulin [MEDICATION NAME]) Inject 2 unit subcutaneously one time a day for diabetes; and [MEDICATION NAME] Flex Pen Solution Pen-Injector (Insulin [MEDICATION NAME]) Inject 4 units subcutaneously two times a day for diabetes. A self administration assessment (SAM) tool dated 7/25/17, documented the resident had been assessed as being suitable for self administration. The resident was assessed as a Level 3 that documented the patient has possession of the key to the individual bedside medication drawer and is responsible for storage and self administration. It documented patient completes tick chart to record medication administration. Question #19 on the SAM asked whether the resident was given a medicine reminder chart and patient tick chart. The SAM tool documented that the resident was not given a medicine reminder chart and patient tick chart. The area on the tool to indicate the reason the resident did not receive a medicine reminder chart and patient tick chart was blank. The Residents Comprehensive Care Plan (CCP) for diabetes documented the resident could self administer medication: Specifically - Insulin and self performance of Blood Glucose (BG) testing. The CCP did not note who would be responsible for the storage and documentation of, as well as the location of administration of the self administered medications. The Electronic Medication Administration Record [REDACTED] 1. Elemi Flex Pen Solution Pen-Injector (Insulin Detemir) Inject 6 units subcutaneously one time a day for diabetes at 0800, Order date 07/11/2011. 2. Levimer Flex Pen Solution Pen-Injector (Insulin Detemir) Inject 6 units subcutaneously one time a day for diabetes at bedtime (20:00) Order date 07/11/2011. 3. [MEDICATION NAME] Flex Pen Solution Pen-Injector (Insulin [MEDICATION NAME]) Inject 2 units subcutaneously one time a day for diabetes at 12:00 with Blood Glucose (BG). (test to determine blood sugar level). 4. [MEDICATION NAME] Flex Pen Solution Pen-Injector (Insulin [MEDICATION NAME]) Inject 4 units subcutaneously two times a day for diabetes at 08:00 and 17:00 with BG. During record review, the resident's record documented the resident received [MEDICATION NAME] and Elemi using the Flex Pen (device used to deliver insulin) daily as ordered. The eMAR recorded the nurses signatures and location of the medication and time the medication was administered from (MONTH) 11th to (MONTH) 31st, (MONTH) 1st to (MONTH) 31st, and (MONTH) 1, (YEAR) to (MONTH) 5, (YEAR). The eMAR did not include documentation that the resident self administered her insulin. During observation on 9/5/17 between the hours of 9:00 am and 4:30 pm, the resident's glucometer, insulin Flex pens, and needles were located on the resident's overbed table in her room. During an interview on 9/5/17 at 12:45 pm, the resident stated she did her own BG throughout the day prior to administering the scheduled doses of insulin. She stated she keeps the insulin in her room in her overbed table. When she decided to stay at the facility after rehabilitation for a fall she had been moved to this unit and because she had been doing her own BG's and giving her own insulin prior, she was allowed to continue. She stated she had been a Licensed Practical Nurse (LPN) and knew how to perform injections. She stated she tells the nurses throughout the day what her BG is, but not always where she injected. During an interview on 9/5/17 at 2:20 pm, the Registered Nurse Unit Manager (RNUM) stated there was no physicians order for the resident to self administer any of her insulin's. She stated the resident had come from another unit and had been giving her own insulin. She stated she had done an evaluation of the resident on 7/25/17, because she realized the required self administration assessment tool had not been done prior to the resident performing self administration of insulin. She stated at this time the order from the physician should have been obtained, but had been overlooked. She stated the nurses are told by the resident what her BG level is and how much insulin was administered and they record this on the eMAR. She also stated the insulin [MEDICATION NAME] and sharps are returned to the medication nurse and locked up in the medication cart after use. During interview on 9/5/17 at 3:00 pm, a Licensed Practical Nurse (LPN) stated the resident has always self administered her own insulin. The resident tells her what her BG is, how much insulin she took, and injection site and she records it. She stated she was told this is how it's done for this resident by the nurse who trained her. She stated she never noticed if there was an order from the doctor for the resident to self administer her medications. During an interview on 9/5/17 at 4:45 pm, the Director of Nursing (DON) stated a physician's orders [REDACTED]. An assessment of the resident is needed prior to the resident performing self administration of the medication and the eMAR should reflect that the resident is self administering medication. If the nurses are not administering the medication they should be documenting the resident self administered. In the case of insulin, the medication should be kept in a locked drawer in the resident's room and a comprehensive care plan should reflect what is expected for the resident. 10 NYCRR415.3(e)(1)(vi)

Plan of Correction: ApprovedSeptember 29, 2017

1. Resident #36 had been reassessed for competence to safely self-administer insulin during survey but has since had a decline in condition and self-administration has been discontinued.
2. All residents who are currently self-administering a medication will be reviewed to ensure all policy requirements are being adhered to.
3. The Self-Administration of Medication (SAM) Policy and Procedure will be reviewed and revised if appropriate; protocol will be reviewed with all licensed nurses.
4. All Self-Administering resident records and room will be audited upon initiation of self- administration for adherence to all aspects of the policy for 6 months. Audit results will be presented monthly to the QAPI Committee which reserves the right to revise the frequency of the audit based on compliance.
Responsible Party: DNS

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2017
Corrected date: October 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined during recertification survey the facility did not ensure it was free of significant medication errors for 3 (Resident #'s 3, 10, and #70) of 7 residents reviewed for medication errors. Specifically for Resident #'s 3, and 10, physicians orders were not followed when administering insulin according to the specified times ordered and the physician was not notified when the insulin was given late. For Resident #70, an intravenous antibiotic scheduled for administration at 8:00 am, was not administered until one and one-half hours later than the time of the scheduled dose. This is eveidenced by: The Policy and Procedure for Medication Administration and Treatment Documentation dated as revised 3/29/13 documented that it is the facility policy that all resident medications and treatments will be accurately administered and preformed by licensed nurses as prescribed by the physician. The procedure section documented that the 5 rights of Medication Administration will be adhered to including right medication, right time, right dose, right resident, and right route. Resident #70: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with full cognition, Brief Interview for Mental Status (BIMS) score of 15, and full ability to understand and be understood. During observation of the resident on 8/30/17 at 9:30 am, the Registered Nurse (RN) flushed the resident's Peripherally Inserted Central Catheter (PICC) line with a syringe filled with 10 cubic centimeters (cc's) of normal saline to assure the PICC line was patent. The RN was completed the flush and attached the intravenous line connected with a mini-bag of [MEDICATION NAME] 900 milligrams (mg) mixed in a mini-bag of 5% [MEDICATION NAME] and water. The tubing to the intravenous line was then inserted into an IV pump to control the flow rate to 50 cc's over one hour. A physician's orders [REDACTED]. The Medication Administration Record (MAR) dated 8/1/17 to 8/31/17, documented on 8/30/17, the Registered Nurse initialed the MAR for 8:00 am to indicate that [MEDICATION NAME] was administered intravenously. The MAR documented the medication will be administered every eight hours at 12:00 am, 8:00 am, and 4:00 pm. The Medication Error Incident Report dated 8/31/17 at 9:50 am, documented the date of the original error as 8/28/17, 8/29/17, and 8/30/17. The number of administrations involved 3. The type of error documented that the dose of the medication was administered at the wrong time. The Directed Action Plan was documented as follow the 5 rights of medication pass. During interview on 8/31/17 at 9:45 am, the Registered Nurse (RN) stated that she was told the administration time for the [MEDICATION NAME] 900 mg Intravenously was at 9:00 am not 8:00am as documented on the MAR. The RN stated that because the medication was given at 9:30 am and not 8:00 am it is a medication error for not being given at the right time. During interview on 8/31/17 at 10:30 am, the Registered Nurse Manager (RNM) stated that giving an intravenous medication scheduled on the MAR at 8:00 am and given at 9:30 am is a medication error for the wrong time. The RNM stated that the doctor will choose the frequency based on a number of considerations, one of which is to maintain a blood level of the antibiotic to adequately fight infection. Resident #3: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was understood and could understand. A Brief Interview for Mental Status Score (BIMS) documented a score of 6/15, which signified a severe cognitive deficiency for daily decision making. The resident had received an antidepressant medication over the last 7 days. Physician (MD) Orders documented: 7/6/17 - Insulin [MEDICATION NAME] ([MEDICATION NAME] a long acting injectable medication to treat diabetes) Solution 100 unit/ml - Inject 50 units subcutaneously (sub-cu) one time a day for Diabetes Mellitus. 7/6/17 - Insulin [MEDICATION NAME] ([MEDICATION NAME] a long acting injectable medication to treat diabetes) Solution 100 unit/ml - Inject 36 units subcutaneously (sub-cu) one time a day for Diabetes Mellitus. 1/19/15 - HumaLog solution 100 unit/ml (insulin [MEDICATION NAME]) (a short acting injectable medication for diabetes) Inject 12 units sub-cutaneously three times a day for supplemental. Hold if blood sugar (BS) is less than or equal to 100. The electronic Medication Administration Record (eMAR) for (MONTH) (YEAR), documented Insulin [MEDICATION NAME] Solution 100 unit/ml Inject 50 unit subcutaneously one time a day for diabetes mellitus documented time for administration at 7:00 pm, was given more than 1 hour late on 6 occasions. The electronic Medical Administration Record (eMAR) for (MONTH) (YEAR), documented Insulin [MEDICATION NAME] Solution 100 unit/ml, Inject 36 unit subcutaneously one time a day for supplemental at bedtime with the time for administration at 4:30 pm was given more than 1 hour late on 7 occasions. The electronic Medical Administration Record (eMAR) for (MONTH) (YEAR), documented Insulin [MEDICATION NAME] Solution 100 unit/ml Inject 50 unit subcutaneously one time a day for diabetes mellitus with a time for administration of 7:00 am, was given more than 1 hour late on 5 occasions. The electronic Medical Administration Record (eMAR) for (MONTH) (YEAR), documented Insulin [MEDICATION NAME] Solution 100 unit/ml Inject 36 unit subcutaneously one time a day for diabetes mellitus documented time for administration at 4:30 pm was given more than one hour late on 8 occasions. The electronic Medical Administration Record (eMAR) for (MONTH) 1st, (YEAR) to (MONTH) 5th, (YEAR) documented Insulin [MEDICATION NAME] Solution 100 unit/ml Inject 50 unit subcutaneously one time a day for diabetes mellitus with a documented time for administration of 7:00 pm was given more than 1 hour late on 1 occasion. The electronic Medical Administration Record (eMAR) for (MONTH) 1st, (YEAR) to (MONTH) 5th, (YEAR), documented Insulin [MEDICATION NAME] Solution 100 unit/ml Inject 36 unit subcutaneously one time a day for diabetes mellitus with a documented time of 4:30 was given more than 1 hour late on 1 occasions. The electronic Medical Administration Record (eMAR) for (MONTH) (YEAR), documented Humalog solution 100 unit/ml (insulin [MEDICATION NAME]), a short acting injectable medication. Inject 12 units sub-cutaneously three times a day for supplemental. Hold if blood sugar (BS) is less than 100: with a documented times of administrations with BS 7:30 am 1200, and 5:00 pm was given more than an hour late on 12 occasions. The Electronic Medical Administration Record (eMAR) for (MONTH) (YEAR), documented [MEDICATION NAME] solution 100 unit/ml (insulin [MEDICATION NAME]), a short acting injectable medication. Inject 12 units sub-cutaneously three times a day for supplemental. Hold if blood sugar (BS) is less than 100 with a documented time for administrations with BS 7:30 pm, 12:00 pm, and 5:00 pm was given more than an hour late on 11 occasions. During an interview on 8/31/17 3:00 pm, the Licensed Practical Nurse (LPN) on A wing stated she was running behind with medication because she was new, she further stated she wasn't the only nurse that does late administration because there are a lot of residents. She stated she does her best. She stated she did not call the physician on 8/30/17 when the 4:30 pm insulin for this resident was given late. She stated no one had told her she needed to. She stated she had not called the supervisor about lateness of the medication and just kept on going until she was finished. During an interview on 8/31/17 at 3:24 pm, the Registered Nurse Unit Manager (RNUM) stated that the unit was a very heavy unit and sometimes the medications are late. She stated she had not realized the LPN had difficulty prioritizing and would need to reeducate her on the importance of being timely with the insulin's. She stated that she was not aware if anyone reviews the medication to ensure the residents are receiving the medication within the scheduled time. She stated they will come up pink in on the eMAR if they are late so the nurse giving the medication will know, but once signed for it doesn't appear if they were given late. She stated the facility will have to take a closer look at this. She further said all nurses are made aware if they are having a problem they need to call the supervisor for assistance and she had not been made aware that this occurred. During interview on 8/31/17 at 4:30 pm, the Assistant Director of Nursing (ADON) stated she was not able to look at the eMAR and determine what time medications were being given late. She stated she would have to check with Point Click Care (PCC) to see if there was a way to look at this issue. She stated she was not aware if the insulin's had been late, but that when a medication is late the provider needed to be notified. Medications are covered by doctors orders and they need to be followed. The nurses cannot change the time of a physicians orders and if there is a problem they need to notify the supervisor. When the ADON was asked if it was acceptable to administer a 4:30 pm insulin at 9:00 pm, she stated it was not without calling the provider. Resident #10: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was understood and could understand. A BIMS score assessed the resident 14/15: cognitively intact. Physician (MD) Orders documented: 5/10/17 - Insulin [MEDICATION NAME] ([MEDICATION NAME] a long acting injectable medication to treat diabetes) Solution 100 unit/ml - Inject 40 units subcutaneously (sub-cu) one time a day for Supplemental at bedtime. 5/04/17 - [MEDICATION NAME] solution 100 unit/ml (insulin [MEDICATION NAME]) (a short acting injectable medication for diabetes). Inject 10 units sub-cutaneously before meals. Hold if blood sugar (BS) is less than 90. During a review of the residents comprehensive care plan for diabetes mellitus, the intervention states Diabetes medication as ordered by the doctor. Monitor for side effects and effectiveness. The electronic Medication Administration Record (eMAR) for (MONTH) (YEAR), documented Insulin [MEDICATION NAME] Solution 100 unit/ml, Inject 40 unit subcutaneously one time a day for supplemental at bedtime. The insulin was scheduled for administration at 7:00 pm: more than 1 hour late on 7 occasions. The electronic Medical Administration Record for (MONTH) (YEAR) documented Insulin [MEDICATION NAME] Solution 100 unit/ml Inject 40 unit subcutaneously one time a day for supplemental at bedtime: The insulin was scheduled for administration at 7:00 pm: more than 1 hour late on 7 occasions. The electronic Medical Administration Record for (MONTH) 1st, (YEAR) to (MONTH) 5th, (YEAR) documented Insulin [MEDICATION NAME] Solution 100 unit/ml Inject 40 unit subcutaneously one time a day for supplemental at bedtime: documented time 1900 was given more than 1 hour late on 3 occasions. The Electronic Medical Administration Record for (MONTH) (YEAR) documented [MEDICATION NAME] solution 100 unit/ml (insulin [MEDICATION NAME]) (a short acting injectable medication for diabetes) Inject 10 units sub-cutaneously before meals. Hold if blood sugar (BS) is less than 90. The insulin was scheduled for administration at 7:00 pm. The documented times for administrations for 07:30 am, 11:30 pm, 4:30 pm revealed insulin was administered more than an hour late on 16 occasions. The electronic Medical Administration Record (eMAR) for (MONTH) (YEAR), documented [MEDICATION NAME] solution 100 unit/ml (insulin [MEDICATION NAME]) (a short acting injectable medication for diabetes) Inject 10 units sub-cutaneously before meals. Hold if blood sugar (BS) is less than 90: The documented times for 7:30 am, 11:30 am and 4:30 pm revealed insulin was administered an hour late on 12 occasions. The electronic Medical Administration Record (eMAR) for (MONTH) 1st, (YEAR) to (MONTH) 5th, (YEAR) documented [MEDICATION NAME] solution 100 unit/ml (insulin [MEDICATION NAME]) (a short acting injectable medication for diabetes) Inject 10 units sub-cutaneously before meals. Hold if blood sugar (BS) is less than 90: documented times 0730, 11:30, 16:30 was given more than an hour late on 4 occasions. On 9/2/17, the 7:30 am dose of insulin documented administration at 10:02 am with the next dose ordered at 11:30 am, administered at 11:15 am. During an interview on 9/5/17 at 10:00 am, the day LPN on A wing stated that medications are late at times when staffing is a problem. The nurses try to keep up and do the best they can. During an interview on 9/5/17 at 4:00 pm, the RNUM stated after a review of the eMAR for the resident that she had not realized the insulin's on the unit had been given so late with such frequency. She stated it is possible that the medications were being given on time and that the nurses were charting late, but she believed reeducation was needed. When a medication is given it is supposed to be signed for immediately using a three check system adhering to the 5 rights of medication. Right time, right med, right resident, right dose, and right route. The importance of this is to prevent medication error. When an insulin is ordered at meal time it is to cover the residents meal to prevent elevated a blood sugar that could cause the resident with diabetes complications. The medications can be given an hour before to an hour after but nurses need to follow the MD's orders. The RNUM stated she will have to monitor the eMARS especially with the insulin's more closely to address these concerns. 10NYCRR 415.12(m)(2)

Plan of Correction: ApprovedSeptember 29, 2017

1. A medication error report was generated and provider was notified for residents #3, 10, and 70 related to physicians? orders not being followed.
2. All residents on a prescribed insulin injection or IV antibiotic will be identified and administration times reviewed and revised as necessary.
3. All nurses will be re-educated on policy and procedure of medication administration and the additional notification and documentation requirements should an insulin or IV medication not be successfully administered within the allowable time frame.
4. Administration times of insulin and IV medications in comparison to scheduled times will be audited 100% weekly for 3 months; no less than 50% weekly for the next 3 months. Results will be submitted to QAPI Committee for review monthly; auditing sample and frequency may be amended by Committee based on compliance with administration policies.
Responsible Party: DNS

Standard Life Safety Code Citations

K307 NFPA 101:COOKING FACILITIES

REGULATION: Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2017
Corrected date: October 24, 2017

Citation Details

Based on staff interview during the recertification survey, the facility did not protect all cooking facilities in accordance with adopted regulations. NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2011 Edition Section 11.1.4 requires that instructions for manually operating the kitchen fire-extinguishing system shall be reviewed with employees by the management. Specifically, 2 of 3 kitchen staff interviewed did not know how to manually activate the kitchen fire-extinguishing system. This is evidenced as follows. During an interview on 08/29/2017 at 9:45 am, Cook #1 did not know how to manually operate the kitchen fire-extinguishing system. During an interview on 08/28/2017 at 9:47 am, Cook #2 indicated the incorrect pull station when asked how to manually activate the kitchen fire suppression system located over the deep fat fryer. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.2.3; 2011 NFPA 96 11.1.4; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.2.6; 1998 NFPA 96

Plan of Correction: ApprovedSeptember 29, 2017

1. Employees identified in SOD were provided additional education on the location and operation of the kitchen fire extinguishing system (completed 8/29/17).
2. All Food Service employees will be provided with specific information pertaining the location and operation of the kitchen fire extinguishing system.
3. Policy and Procedure for kitchen fire extinguishing systems and their operation will be reviewed and updated as necessary, including routine education for all food service employees.
4. No less than 25% of the food service employees will be interviewed monthly on their knowledge of location and operation of the kitchen fire extinguishing system for at least four months; and then no less than quarterly for one year. Frequency and scope of auditing may be amended based on the results of the audit and recommendation of the QAPI Committee.
Responsible Party: Director of Food Service

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

REGULATION: Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2017
Corrected date: October 24, 2017

Citation Details

Based on record review and staff interview during the recertification survey, the facility did not maintain the fire alarm system in accordance with adopted regulations. NFPA 72 National Fire Alarm Code 2010 edition section 14.2.1.2.2 requires that defects and malfunctions shall be corrected. Specifically, defective fire alarm system initiating devices were not replaced. This is evidenced as follows. The fire alarm testing reports were reviewed on 08/31/2017. The 12/15/2016 Fire Alarm Inspection and testing Form (testing report) documents that two smoke detectors need replacement, one smoke detector is not securely mounted, and one manual pull station requires replacement. No records were provided documenting that these smoke detectors were replaced. The Director of Plant Operations stated in an interview conducted on 09/05/2017 at 9:00 am that these repairs were not caught during the personnel transfer from the person who was previously the Director of Plant Operations. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 9.6.1.3; 2010 NFPA 72: 14.2.1.2.2; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101: 9.6.1.3; 1999 NFPA 72: 7-1.1.2,

Plan of Correction: ApprovedOctober 4, 2017

1. Fire alarm system initiating devices noted in the SOD were replaced on 9/1/17.
2. Review conducted of the past two years of fire alarm testing reports were reviewed to assure no other recommendations had been addressed ? none found.
3. Fire alarm system inspections will continue to be conducted by an independent qualified agency on annual basis. Recommendations of annual inspections will be reviewed by the Director of Plant Operations for actionable items. Defects identified will be corrected.
4. Fire alarm system inspection reports will be provided to the Safety Committee for review and verification of corrections, as applicable.
Responsible Party: Director of Plant Operations

K307 NFPA 101:FUNDAMENTALS - BUILDING SYSTEM CATEGORIES

REGULATION: Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2017
Corrected date: October 24, 2017

Citation Details

Based on staff interview during the recertification survey, the facility did not conduct a building systems risk assessment as required by adopted regulation. NFPA 99 Standard for Health Care Facilities 2012 Edition section 4.2 requires that building systems, such as gas and vacuum systems; electrical systems; heating, air conditioning, and ventilation systems; electrical equipment; and gas equipment are to undergo a formal and documented risk assessment by qualified personnel. Specifically, the required building systems risk assessments were not conducted. This is evidenced as follows. The Chief Operating Officer was interviewed on 08/30/2017 at 11:10 am and revealed that the facility building systems have not undergone a risk assessment and been assigned risk categories. 42 CFR 483.70 (a) (1); 2012 NFPA 99 4.2

Plan of Correction: ApprovedOctober 4, 2017

1. The Building Systems Risk Assessment as per NFPA 99 2012 Edition will be conducted by qualified personnel. Assessment shall conform to a formal process and be documented as per NFPA standard.
2. Building System Risk Assessment Policy and Procedure will be reviewed and amended as necessary to incorporate all required elements of the Standard; review with all members of the maintenance staff and Safety Committee.
3. Risk Assessment will be submitted to the Safety Committee for final review at an interval identified in policy.
Responsible Party: Director of Plant Operations

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2017
Corrected date: October 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not installed in accordance with adopted regulations. NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition section 8.6.5.1.2 permits particular limitations on obstructions to the sprinkler system discharge pattern. Specifically, the automatic sprinkler system (sprinkler system) was encumbered with unacceptable obstructions and did not cover all areas. This is evidenced as follows. Observations on 08/30/2017 at 11:30 am revealed that utility piping obstructed the sprinkler system discharge pattern in the hairdresser storeroom and 2 sprinkler heads were caked with dust in the Compressor Room. The Director of Plant Operations and the Director of Housekeeping stated in an interview on 08/30/2017 at 1:00 pm that the obstructions found were overlooked. Observations on 08/31/2017 at 11:15 am and again at 12:45 pm revealed a ventilation duct and utility piping obstructed the sprinkler system discharge pattern in room [ROOM NUMBER], sprinkler protection was missing under the ventilation duct in the Fan Room, and 3 sprinkler heads in the D-Unit nurse station and 2 sprinkler heads in the main dining room were dusty. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.6.5.1.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101: 19.3.5; 1999 NFPA 13: 5-13.3.2

Plan of Correction: ApprovedSeptember 29, 2017

1. Sprinkler head with noted obstruction was corrected according to existing standards on 9/1/17; sprinkler heads to be added under ventilation duct. Sprinkler heads noted with dust as per SOD were addressed and corrected on 9/1/17.
2. All areas of the building with potential obstructions, including areas of ventilation ducting as identified in the SOD will be inspected to assure sprinkler design meets applicable regulatory standards. All sprinkler heads will be visually inspected to assure they are unencumbered with dust. Corrections will be made as appropriate.
3. Maintenance staff will receive education on the proper condition of sprinkler heads (dust build up) and actions to take in the event heads are found to be below standards.
4. Building inspection will be scheduled on a monthly basis to inspect sprinkler head condition, with no less than 25% of the building space included during any month. Inspection process will continue for at least four months with the frequency reevaluated by the Safety Team, with quarterly reports provided to the QAPI Team. All sprinkler heads will be inspected at least annually.
Responsible Party: Director of Plant Operations

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2017
Corrected date: October 24, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.5.6 requires that penetrations and miscellaneous openings in smoke barrier walls be sealed with materials capable of maintaining the smoke rating of the smoke barrier wall. Specifically, openings in 1 of 1 smoke barriers observed were not sealed. This is evidenced as follows. The D-Wing north smoke barrier wall (wall) was inspected on 08/31/2017 at 10:10 am. In the telephone area, a 4-inch by 4-inch hole for a conduit pipe and a 6-foot by 1/8-inch unsealed length where the wall meets the underside of the roof were found. The Director of Plant Operations stated in an interview conducted on 08/31/2017 at 10:10 am that he is new to his position and was not aware of the hole found. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.5.6; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedSeptember 29, 2017

1. Smoke barrier penetration identified in the SOD will be sealed per current standards.
2. All smoke barrier walls will be inspected to identify any unsealed penetrations.
3. Any unsealed penetration identified will be sealed per regulations. Maintenance staff will be provided information on the proper method of sealing smoke barrier penetrations.
4. Smoke barrier locations will be inspected on a monthly basis to identify new or existing unsealed penetrations, with no less than 20% of the building areas inspected per month; to continue for no less than 6 months; with results of the audit provided to the Safety Committee, and quarterly reports provided to the QAPI Team. The frequency and/or locations of inspection may be amended based on recommendations of the Safety or QAPI Committee after 6 months.
Responsible Party: Director of Plant Operations

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2017
Corrected date: October 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition sections 8.6.1, 8.5.6, and 8.3.5 require that penetrations and miscellaneous openings in vertical openings, such as floor-ceiling assemblies, be sealed with materials capable of limiting the spread of fire for a time period equal to the fire resistance rating of the assembly. Specifically, penetrations in the floor-ceiling assembly between the basement and A-Wing residential unit were not sealed with materials capable of maintaining the fire rating of the assembly. This is evidenced as follows: Sections of the floor-ceiling assembly between the basement and A-Wing residential unit were inspected on 08/31/2017 at 10:50 am. Two unsealed penetrations (penetrations) for piping were found in the laundry room, Three penetrations were found in the lounge, eleven penetrations were found in room [ROOM NUMBER], five penetrations were found in the cafeteria, seven penetrations were found in room [ROOM NUMBER], two penetrations were found in the break room, and one penetration each was found in the Clean Linen room and kitchen dry storage room. The Director of Plant Operations stated in an interview conducted on 08/31/2017 at 11:10 am that he will fire-seal the penetrations found. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.6.1, 8.5.6, 8.3.5; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3.2.3.1(2), 8.2.3.2.4.2

Plan of Correction: ApprovedSeptember 29, 2017

1. Vertical openings between the basement and A wing identified in the SOD sealed with the appropriate materials as per existing regulation ? completed 9/11/17.
2. All building areas which have similar penetrations and miscellaneous openings between the ceiling and floor will be inspected to determine status of existing sealant.
3. Any penetration identified will be sealed with the appropriate materials as per existing regulation.
4. Following initial inspection and corrective action, a final inspection will be conducted by the Director of Plant Operations to verify completion.
Responsible Party: Director of Plant Operations