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Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2023
Corrected date: April 6, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that Quarterly Minimum Data Set (MDS) assessments specified by the state and approved by the Center for Medicare and Medicaid Services (CMS) were completed not less frequently than once every 3 months for 19 (Resident #4, #9, #22, #25, #26, #48, #55, #59, #61, #71 #73, #79, #86, #90, #94, #95, #98, #106, and #107) of 19 residents reviewed for Resident Assessment. Specifically, the facility did not complete Quarterly Minimum Data Set Assessments at least every 92 days following the previous assessment for all 19 Residents sampled for Resident Assessment. Additionally, the facility provided a report titled Overdue MDS, which revealed that 28 Quarterly MDS Assessments were not completed as of [DATE] which included 6 (Res #55, #59, #61, #71, #95 and #98) of 19 Residents reviewed for Resident Assessments. The finding is but not limited to: The Facility MDS 3. 0 Completion policy dated ,[DATE] documented that the facility will utilize the Center for Medicare and Medicaid (CMS) Minimum Data Set (MDS) 3. 0 for resident assessment. The MDS required data elements are transmitted to New York State according to CMS requirements. The MDS assessment, which will be used to develop the resident's Comprehensive Care Plan (CCP), will be completed at the time of admission, whenever there is a significant change, and at least quarterly. Quarterly Assessment reference date of the previous assessment of any type + (plus) 92 calendar days at maximum. The facility report entitled Overdue MDS dated [DATE] documented 103 MDS assessments were overdue facility wide. The report indicated Resident #55, #59, #61, #71, #95 and #98 had an overdue Quarterly MDS. Examples include but are not limited to: -Resident #55's Quarterly MDS dated [DATE] was not completed as of ,[DATE]/ 2023. -Resident #61's Quarterly MDS dated [DATE] was not completed as of ,[DATE]/ 2023. -Resident #90's Quarterly MDS with the assessment reference date of [DATE] was not completed until ,[DATE]/ 2023. Resident #90 expired on [DATE] and Resident #90's Death in Facility Tracking Record dated [DATE] was not completed until ,[DATE]/ 2023. The MDS Coordinator was interviewed on [DATE] at 1:22 PM. The MDS Coordinator stated that they (MDS Coordinator) have been the MDS Coordinator since (MONTH) of 2021. The MDS Coordinator stated that they were the only person doing MDS's for the whole facility. In early (MONTH) 2022, the MDS Coordinator informed the Director of Nursing Services (DNS) that they were falling behind on their work and MDS' were not completed on time. The DNS hired a part-time MDS Coordinator mid-[DATE] to assist with catching up on the MDS assessments. The part-time MDS Coordinator works 3 days a week. The MDS Coordinator stated that even with the part-time MDS Coordinator they are still behind and are catching up. The MDS Coordinator stated that they reviewed the medical records for Resident #4, #9, #22, #25, #26, #48, #55, #59, #61, #71 #73, #79, #86, #90, #94, #95, #98, #106, and #107 on [DATE] and their MDS assessments were not completed yet. The MDS Coordinator stated that they began to work on the list of 19 residents brought to their attention and are in the process of completing their MDS assessments. The DNS was interviewed on [DATE] at 1:41 PM. The DNS stated that they (DNS) were made aware that the MDS Coordinator was behind on MDS's in (MONTH) 2022. The DNS stated that they could not recall the exact date and it was within two weeks of hiring the part-time MDS Coordinator to assist. The DNS stated that when the MDS Coordinator showed them a report of overdue MDS's in (MONTH) 2022, there were about 300 outstanding MDS assessments. The DNS hired a part-time MDS Coordinator 3 days a week to assist in response to the MDS Coordinator's report. The DNS stated that they have a case manager who started to organize the care plan meetings and morning report meeting to free up the MDS Coordinator to work on the over-due MDS assessments. The DNS was re-interviewed on [DATE] at 2:24 PM. The DNS stated that the part-time MDS Coordinator was hired on ,[DATE]/ 2022. The DNS provided a report entitled Overdue MDS dated ,[DATE]/ 2023. The DNS stated that they reviewed the overdue and incomplete MDS report, and the facility was currently behind on 103 MDS assessments as of ,[DATE]/ 2023. In a subsequent interview with the DNS on [DATE] at 9:42 AM the DNS stated that the completion of the Annual and Admission MDS assessments are due 14 days from the assessment reference date (ARD) and the care plan completion is 7 days from the MDS completion date. The transmission of the MDS assessments to CMS is no later than 14 days of the care plan completion date or 35 days from the assessment reference date. The DNS stated that the Unit Managers complete the care plan assessments and organize the care plan meetings within the 21 days of the assessment date. The Unit Managers complete the care plans by reviewing the medical records and their assessments on the units. The MDS Coordinator then reviews the data and completes the MDS after the Unit Managers complete their assessments. The DNS stated that they are looking to hire full time MDS Coordinators and have placed job openings online to recruit. The DNS stated that they (DNS) are having a hard time finding an MDS Coordinator. The Administrator was interviewed on [DATE] at 10:50 AM. The Administrator stated that the DNS informed them (Administrator) that the MDS Coordinator was behind in (MONTH) 2022. The Administrator stated that they responded to the problem by hiring a part-time MDS Coordinator. The Administrator stated that they (Administrator) did an MDS submission in (MONTH) 2022 and received a validation report with a message which indicated that the facility was overdue by way too many MDS's; however, could not recall an exact number. The Administrator stated that the facility ensured that care plans were completed by the Unit Managers so care plan completion was not affected by the overdue MDS assessments. The Administrator stated that they reviewed the report of 103 overdue MDS assessments and expected to have the assessment completed with the help of the part-time MDS Coordinator. The part-time MDS Coordinator needed some time to learn the electronic medical record system in (MONTH) 2022, so they were not able to quickly assist with catching up on MDS assessments. The Administrator decided that the facility had to place an advertisement to hire two more full-time MDS coordinators. The Administrator further stated that they believe it would be best to have MDS Coordinators assigned to the units and solely focus on the care plans and the MDS completion. 10 NYCRR 415. 11(a)(4) | Plan of Correction: ApprovedMarch 10, 2023 F- 636 ?ö?ç?ú Comprehensive Assessments and Timing I. The following actions were accomplished for those residents found to have been affected by the deficient practice: On 2/2/23, the facility reviewed the overdue MDS assessments and ran a report to determine that there were 103 MDS assessments that were overdue or incomplete. Between 2/3/23 and 2/10/23, an audit was conducted by the MDS Coordinator and the Director of Nursing Services to determine that out of the 103 MDS assessments overdue or incomplete, all of the residents involved had up-to-date comprehensive care plans, had their required care plan meetings timely, had their assessments (admission, quarterly, annual, etc.) completed timely, and MDS interviews were also conducted timely. On 2/10/23, the MDS Coordinator was provided with counselling and re-education by the Director of Nursing Services and the Administrator on timely MDS assessment submissions. Re-education included review of the MDS coordinator job description and MDS policy and procedures with a focus on timely completion and submission of Quarterly MDS Assessments (at least every 3 months) and comprehensive admission assessment timeframes and annual assessments timeframes of at least once every 12 months. Between 2/6/23 and 4/6/23, the Director of Nursing Services and Administrator updated and revised employment advertisements on various websites including Indeed and Zip Recruiter, and will continue to search for MDS Coordinators. Our MDS Consultant was also contacted to assist with recruitment of MDS Coordinators. As of 3/3/23, the facility has newly hired one Part Time RN MDS Coordinator and has another Part Time RN MDS Coordinator interested in the position coming for an interview on 3/7/ 23. The facility will continue to recruit for the MDS Department until staffing is adequate to maintain timely MDS submissions. The overdue Admission/Annual MDS for residents 4,9,22,26,59,71,73,86,94,95,98,106,107 have all been completed and submitted as of 2/22/ 2023. II. The following corrective actions will be implemented to identify other residents having the potential to be affected by the same deficient practice: All residents have been identified as potentially being affected by the same practice. Between 2/3/23 and 2/10/23, an audit was conducted by the MDS Coordinator and the Director of Nursing Services to determine that out of the 103 MDS assessments overdue or incomplete, all of the residents involved had up-to-date comprehensive care plans, had their required care plan meetings timely, had their assessments (admission, quarterly, annual, etc.) completed timely, and MDS interviews were also conducted timely. The facility conducted an Ad Hoc meeting with the Administrator, Director of Nursing Services, Associate Director of Nursing Services, Inservice Director, Director of Social Services, MDS Coordinator, Rehabilitation Director, and Dietitian to discuss the concerns and issues identified regarding the F-636 citation and conducted a Root Cause Analysis. Based on the Root Cause Analysis that was part of the Ad Hoc meeting on 3/1/23, the following issues were identified that required corrective actions: ??? The facility's MDS policy and procedures for MDS completion and ensuring adherence to all of the regulations set forth by CMS (Centers for Medicare and Medicaid Services) would benefit from review and updating. ??? All relevant facility staff (MDS nurses, Case Management, Social Services, Dietitian, Rehabilitation, and Recreation staff) would benefit from additional education and evaluation of their knowledge and understanding of MDS Assessments and about the importance of timely MDS Assessment completion and submission. All relevant staff re-educated on the importance of completing and submitting Quarterly MDS Assessments timely (at least every 3 months) and comprehensive admission assessment timeframes and annual assessments timeframes of at least once every 12 months. ??? The facility would benefit from the addition of several competent staff members to join the MDS department to assist with maintaining all MDS Assessment completion and submission accurate, timely and up-to-date. Please refer to corrective actions outlined in Sections II, III and IV of this P(NAME). III. The following system changes will be implemented to ensure that the deficient practice does not recur: On 3/1/23, the Administrator, Director of Nursing Services, and the MDS Coordinator reviewed the MDS policy and procedures to ensure compliance with all of the regulations set forth by CMS (Centers for Medicare and Medicaid Services). Upon review the facility noted the MDS policy and procedures were current and up-to-date with the latest regulations set forth by CMS. Only minor revisions were necessary. Between 2/6/23 and 4/6/23, the Director of Nursing Services and Administrator updated and revised employment advertisements on various websites including Indeed and Zip Recruiter, and will continue to search for MDS Coordinators. Our MDS Consultant was also contacted to assist with recruitment of MDS Coordinators. As of 3/3/23, the facility has newly hired one Part Time RN MDS Coordinator and has another Part Time RN MDS Coordinator interested in the position coming for an interview on 3/7/ 23. The facility will continue to recruit for the MDS Department until staffing is adequate to maintain timely MDS submissions. Effective 3/1/23, the Administrator, Director of Nursing Services, and Inservice Director, along with the facility's MDS Consultant, will conduct retraining and competency skill evaluations of all relevant staff (MDS nurses, Case Management, Social Services, Dietitian, Rehabilitation, and Recreation staff) regarding MDS Assessment completion and will stress accuracy, timely completion and the completion of a Quarterly MDS Assessment at least every 3 months and comprehensive admission assessment timeframes and annual assessments timeframes of at least once every 12 months. Additional competencies will be conducted for those staff who are identified as needing additional education/skills check. This training and competency skill evaluation will continue until all identified staff have participated and completed the required retraining and competency skill check. This training and competency skill evaluation will be provided during orientation, annually, and on an as needed basis with follow-up monitoring to ensure staff understand these protocols. The Administrator, Director of Nursing Services, MDS Coordinator, and MDS consultant will monitor for compliance regarding timely MDS Assessment completion and submission. Immediate corrective actions, such as counselling or reeducating staff, will be implemented as needed. IV. The facility's compliance will be monitored utilizing the following quality assurance system: As per the Plan of Correction, an Ad Hoc meeting with the Administrator, Director of Nursing Services, Associate Director of Nursing Services, Inservice Director, Director of Social Services, MDS Coordinator, Rehabilitation Director, and Dietitian, was conducted to discuss the concerns and issues identified regarding the F-636 citation and a Root Cause Analysis was done. The facility will develop an audit tool to monitor timely completion and submission of all MDS Assessments, including adhering to comprehensive admission assessment timeframes, ensuring every resident has a Quarterly MDS Assessment completed at least every 3 months and annual assessments are completed at least once every 12 months. The MDS Coordinator will conduct the audit (with the above audit tool) for timely completion and submission of all MDS Assessments weekly for 4 weeks, then monthly for 6 months. Corrective actions such as reeducation will be implemented for any negative findings, when indicated. All findings will be reported to the Administrator and Director of Nursing Services for follow-up actions such as reeducation and/or competency skill check. MDS Coordinator will report audit findings to the QAPI Committee monthly for 6 months. At the end of this period, the Committee will determine the need for ongoing monitoring and at what frequency. Completion Date: 4/6/2023 Responsibility: Director of Nursing Services |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2023
Corrected date: April 6, 2023
Citation Details 2012 NFPA 101: 7. 8. 1. 1 Illumination of means of egress shall be provided in accordance with Section 7. 8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways and exit passageways leading to the public way. 7. 8. 1. 2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided in 7. 8. 1. 2. 2 7. 8. 1. 4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0. 2 ft-candle ( 2. 2 lux) in an designated areas. 2010 NFPA 101: 19. 2. 8 Illumination of Means of Egress. Means of egress shall be illuminated in accordance with Section 7. 8. 2010: 7. 8. 1. 2. 3* Energy-saving sensors, switches, timers, or controllers shall be approved and shall not compromise the continuity of illumination of the means of egress required by 7. 8. 1. 2. 2012 NFPA 101: 19. 2. 9. 1 Emergency lighting shall be provided in accordance with Section 7. 9. 2012 NFPA 101: 7. 9. 2. 3* The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting due to any of the following: (1) Failure of a public utility or other outside electrical power supply (2) Opening of a circuit breaker or fuse (3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities 7. 9. 3. 1. 1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7. 9. 3. 1. 1(2). (2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7. 9. 3. 1. 1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. Based on observation, document review and staff interview, the facility did not ensure that (1) the illumination of means of egress shall be either continuously in operation or capable of automatic operation without manual intervention in that exit discharge lighting was operable by a timer device and (2) the emergency battery lighting was tested annually. This occurred for the emergency and egress lighting that serves the facility. The findings are: On 1/31/2023 to 2/1/2023 between 8:45 AM and 4:45 PM during the life safety recertification survey: (1) Egress lighting was observed above the exit door on the exterior of the building, adjacent to the employee break room.was noted to be operable by a timer device. As a result of this configuration, egress lighting would only turn on when the timer was set. There would be no illumination automatically occurring at all times because the timer is set for only a specific time. (2) During document review, the monthly and annual testing for the emergency lighting was requested. Document review revealed no annual testing was conducted for the battery operated lighting within the facility. In an interview on 1/31/2023 at approximately 11:00 PM, the Director of Maintenance stated the exterior lighting is operated by a timer and turns on around 4 or 4:30 PM. In an interview on 2/1/2023 at 11:17 AM, the Administrator stated they should have all the requested documents. In an interview on 2/1/2023 at approximately 1:00 PM, The of Maintenance stated he is new to the position and will look to find the missing records. 2012 NFPA 101 10NYCRR 711. 2(a)(1) | Plan of Correction: ApprovedMarch 10, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F- 0880 ?ö?ç?ú Infection Prevention and Control I. The following actions were accomplished for those residents found to have been affected by the deficient practice: On 2/9/23, resident #272 was seen and assessed by the Physician's Assistant and Infection Preventionist for infectious status evaluation/risk for transmitting infection and plan for discontinuation of transmission-based precautions. As of 2/9/23, resident was discontinued from contact and droplet precaution for RSV infection. On 2/9/23, the IDCPT reviewed the care plan of the resident to address infectious status and updated the plan of care to include that transmission-based precautions have been discontinued. Resident was also provided education on respiratory etiquette to prevent the spread of infection. On 2/2/23, LPN#1 was provided with counselling and re-education by DNS and Infection Preventionist (IP) on the selection and use of PPE for Standard Precaution and Transmission-based precautions and Breaking the Chain of Infection. Education also included the nurse's responsibility related to infection prevention and control protocols. PPE use re-training and competency skill evaluation was conducted on 2/2/ 23. All facility staff, all departments, were provided training and a competency skill evaluation to ensure their understanding of the correct selection and use of personal protective equipment (PPE) for transmission-based precautions and general core principles of Infection Prevention and Control (IPC) to prevent the spread of infection and break the chain of infection, completed between 2/28/23 and 3/10/ 23. II. The following corrective actions will be implemented to identify other residents having the potential to be affected by the same deficient practice: All residents have been identified as potentially being affected by the same practice. Between 2/1/23 and 2/15/23, all residents residing on the nursing unit where LPN#1 was assigned and provided care to on 2/1/23 were monitored daily for signs and symptoms of RSV infection and remained asymptomatic. There was no new [DIAGNOSES REDACTED].#1 was assigned. On 2/2/23 a full house audit was conducted of all residents with current transmission-based precaution orders to ensure proper implementation of PPE use per facility protocol. The audit included an assessment of posting of signage on the door or wall outside the resident room indicating the type of precautions and required PPE use, readily available PPE supplies outside the room, access to hand hygiene supplies, and availability of trash container inside the room and near the exit for discarding PPE after removal. The facility's QAPI Committee and outside Consultant participated in a DP(NAME) QAPI meeting on (MONTH) 27, 2023, to discuss the Infection Control issues identified at F-880 and conducted a Root Cause Analysis. During this meeting, the outside Consultant provided education to the Committee members on Infection Prevention and Control principles and how non-adherence to proper infection control practices resulted in the cited deficient practices. Education also addressed use of a Root Cause Analysis when compliance issues are identified. Based on the Root Cause Analysis that was part of the DP(NAME) QAPI meeting on 2/27/23, the following issues were identified that required corrective actions: ??? The facility's Infection Control policy and procedures for preventing the development and transmission of communicable diseases and infections, including the protocol related to the selection and use of PPE by health care personnel (HCPs) for transmission-based precautions, would benefit review and update to address current State and Federal guidelines, as well as directives from CDC. ??? All facility staff would benefit from additional education and evaluation of their knowledge and understanding about infection prevention and control practices and protocols related the selection and use of personal protective equipment (PPE) for transmission-based precautions (contact, droplet, and airborne precautions /isolation) and the general core principles of Infection Prevention and Control (IPC) to prevent the spread of infection and break the chain of infection. ??? All facility staff providing close-contact resident care activities, including performing resident care and/or contact of potentially contaminated areas in the resident's environment who requires transmission-based precaution would benefit from additional training and a competency skill evaluation to ensure their understanding of the correct selection and use of personal protective equipment (PPE) for transmission-based precautions. ??? The facility would benefit from reviewing and revising, as needed, the surveillance process (random and routine monitoring) related to staff compliance with the correct selection and use of PPE for standard and transmission-based precautions. Please refer to corrective actions outlined in Sections II, III and IV of this DP(NAME). III. The following system changes will be implemented to ensure that the deficient practice does not recur: On 2/27/23, administrative staff and the outside consultant reviewed the Infection Prevention and Control Manual policy and procedure for Transmission-based precaution use to ensure compliance with the CDC guidelines for implementation of PPE to prevent spread of infection. Revisions were made to include the CDC Guidelines for Isolation Precautions for Transmission-based Precaution and policies and procedures related to the three categories of Transmission-Based Precautions: Contact Precautions, Droplet Precautions, and Airborne Precautions. These revisions included general procedure for transmission-based precaution and specific procedures for PPE use, resident placement, transport, and education for each transmission-based category. Effective 2/28/23, IP/designee will conduct retraining and competency skill evaluations of all staff, all departments related to appropriate PPE selection and use (donning and doffing) prior to entering and exiting the resident's environment, providing close-contact resident care activities, and/or contact of potentially contaminated areas in the resident's environment. Additional competencies will be conducted for those staff who are identified as needing additional education/skills check. This training and competency skill evaluation will continue until all identified staff have participated and completed the required retraining and competency skill check. This training and competency skill evaluation will be provided during orientation, annually, and on an as needed basis with follow-up monitoring to ensure staff understand these protocols. Beginning 2/28/23, IP/designee will provide additional education on general infection prevention and control (IPC) practices with a focus on breaking the chain of infection and the selection and use of personal protective equipment (PPE) for standard and transmission-based precaution. This education will be provided during orientation and on an as needed basis with follow-up monitoring to ensure staff understand these protocols. The DNS, IP, Unit RN Managers and Nursing Supervisors will monitor for compliance with infection control practices related to PPE use for standard precautions and transmission-based precautions during routine and random rounds on the resident units. Findings will be documented on the Infection Control Rounding audit tool. Immediate corrective actions, such as counselling or reeducating staff observed not wearing appropriate PPE and or any breach in the practice, will be implemented as needed. Effective 2/28/23, IP/designee will request to address the Resident Council to provide education and discuss infection control practices. The education and discussion would include information about how infections are spread, how they can be prevented (hand hygiene, respiratory etiquette, source control measures), and what signs or symptoms should prompt reevaluation and notification of the patient's healthcare provider. Additional education sessions would be provided to Council members upon request that the IP/designee attend a scheduled meeting/ IV. The facility's compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a QAPI Committee meeting co-chaired by Outside Consultant was convened on 2/27/23, to conduct a Root Cause Analysis and examine the deficiency cited at F- 880. The facility will develop an audit tool to monitor staff knowledge and compliance with the facility's protocols related to the selection and correct use of PPE for standard precaution and transmission-based precautions. The IP/designee will audit 10% of all members for staff knowledge and understanding of the protocol related to the selection and use of PPE monthly for the next three months and then on a quarterly basis for the next two quarters. Corrective actions such as reeducation will be implemented for any negative findings, when indicated. All staff knowledge audit findings will be reported to the Administrator and Director of Nursing. Infection Preventionist/designee will conduct a direct observation audit of five HCPs assigned to each nursing unit to assess compliance with infection prevention and control practices related to selection and use of PPE for standard precautions and transmission-based precautions. Audits will be conducted weekly for 4 weeks then monthly for 3 months. The audit sample will include staff from all shifts. Corrective actions such as reeducation will be implemented for any negative findings, when indicated. All findings will be reported to the Administrator, DNS and IP for follow-up actions such as reeducation and/or competency skill check related to correct PPE use. IP/designee will report staff infection control knowledge and observations, including PPE use audit findings to the QAPI Committee monthly for three months and quarterly for an additional two quarters. At the end of this period, the Committee will determine the need for ongoing monitoring and at what frequency. The IP will continue to conduct routine and random Infection Control Rounds and will report findings to the QA Committee monthly for evaluation and follow-up corrective actions such as staff and/or resident re-education. Completion Date: 4/6/2023 Responsibility: Infection Preventionist |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2023
Corrected date: April 6, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews conducted during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that each resident was free from significant medication errors. This was identified for one (Resident #271) of five residents reviewed for Unnecessary Medication. Specifically, Resident #271 had a physician's orders [REDACTED]. The facility staff administered [MEDICATION NAME] on one occasion to Resident #271 when the medication was supposed to be held and held the medication twice when the medication was supposed to be administered. The finding is: The Policy and Procedure for Medication Administration: General Policies and Practices, dated (MONTH) (YEAR) documented a resident's drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in: Excessive dose including a duplicate drug. The Staff nurse reviews the Electronic Medication Administration Record [REDACTED]. Resident # 271 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) was not available due to the resident being a newly admitted resident at the facility. The physician's orders [REDACTED]. 5 milligrams (mg) tablet, give 1 tablet ( 2. 5 mg) by oral route every 8 hours, every day at 10:00 PM; 2:00 PM; 6:00 AM, and monitor blood pressure (BP) and hold the medication if the Systolic BP (SBP) is greater than (>) 100 millimeters of Mercury (mmHg). The Physician order [REDACTED]. 5 mg tablet, give 1 tablet ( 2. 5 mg) by oral route every 8 hours every day at 10:00 PM; 2:00 PM; 6:00 AM. HOLD FOR SBP > (greater than) 110 mmHg Protocol: HOLD SBP < (less than) 110 mmHg for Orthostatic [MEDICAL CONDITION]. This order was entered by Licensed Practical Nurse (LPN) # 6 on 1/30/2023 at 9:51 AM. The Physician order [REDACTED]. 5 mg tablet, give 1 tablet ( 2. 5 mg) by oral route every 8 hours. HOLD FOR SBP > (greater than)110 mmHg every day at 10:00 PM; 2:00 PM; 6:00 AM. The (MONTH) 2023 Medication Administration Record [REDACTED]. 5 mg, give 1 tablet ( 2. 5 mg) by oral route every 8 hours HOLD FOR SBP > (greater than) 110 mmHg. Protocol: HOLD SBP < (less than) 110 mmHg for Orthostatic [MEDICAL CONDITION] and Monitor blood pressure, Start Date: 1/30/ 2023. On 1/31/2023, [MEDICATION NAME] was held at 6 AM with a Blood Pressure (BP) reading of 96/60 mmHg and on 1/31/2023, [MEDICATION NAME] was administered at 10 PM with a BP reading of 117/81 mmHg. Review (MONTH) 2023 MAR indicated [REDACTED]. 5 mg) by oral route every 8 hours HOLD FOR SBP > (greater than)110 mmHg. Protocol: hold for SBP > (greater than)110 mmHg. On 2/2/2023 at 6 AM, the medication was held with a BP reading of 94/58 mmHg. The package insert for [MEDICATION NAME] medication documented a warning: Supine Hypertension: The most potentially serious adverse reaction associated with [MEDICATION NAME] therapy is marked elevation of supine arterial blood pressure (supine hypertension). It is essential to monitor supine and sitting blood pressures in patients maintained on [MEDICATION NAME]. Uncontrolled hypertension increases the risk of cardiovascular events, particularly stroke. The package insert also documented that the supine and standing blood pressure should be monitored regularly, and the administration of [MEDICATION NAME] Tablets, USP should be stopped if supine blood pressure increases excessively. LPN# 6 was interviewed on 2/2/2023 at 2:10 PM and stated the directions entered into the computer were an input error and should have read to hold if the SBP was over 110 mmHg as per the physician's orders [REDACTED]. The DNS stated that it is also the responsibility of the Medication Nurses to know the medications. If the directions were not clear, the medication nurse should have questioned the directions. Medication nurses should check the MEDICATION ORDERS FOR [REDACTED]. The Electronic Medical Record (EMR) has standardized parameter protocols for BP medications and the nurses should check the parameters and that the directions are correct when they (nurses) are entering the BP medication orders in the EMR. After this medication error was identified, the facility is making sure the nurses write out greater and less than instead of using the symbols. 10NYCRR 415. 12(m)(2) | Plan of Correction: ApprovedMarch 10, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F- 697 ?ö?ç?ú Pain Management I. The following actions were accomplished for those residents found to have been affected by the deficient practice: Resident #64 is known to the facility and the assigned Physician and Physician group due to several admissions over the past few years. Resident # 64 was re-admitted to the facility on [DATE] on [MEDICATION NAME] 5mg- one tablet orally every 6 hours PRN for pain, [MEDICATION NAME] 500mg- one tablet every 12 hours PRN for pain, [MEDICATION NAME] 800mg- one tablet every 8 hours for Idiopathic Peripheral Autonomic [MEDICAL CONDITION], [MEDICATION NAME] 325mg- give two tablets (650mg) every 6 hours PRN for pain, and Pregabalin 100mg capsule- one capsule three times a day for Idiopathic Peripheral Autonomic [MEDICAL CONDITION]. Resident #64 was being given his medications by LPN #2, with Surveyor present, on 2/1/23 at 9:39am when he stated his current pain regimen was ineffective at controlling his pain. On 2/2/23 resident #64 was interviewed by Surveyor at 8:50am where he stated there have been no further pain control medication offered since the previous day and that no one went to see him about his pain since he spoke to LPN # 2. On 2/2/23, at 12:54pm resident #64's pain control medication orders were updated. The [MEDICATION NAME] was increased to 10mg every 6 hours PRN for pain. The next day on 2/3/23 at 2:25pm resident #64's [MEDICATION NAME] was changed to 10mg every 6 hours (standing) for pain. Between 2/4/23 and 2/8/23 resident #64 refused his 6am dose of [MEDICATION NAME] stating it was too much with the increased [MEDICATION NAME], but was adamant about not changing anything and stated he will just be refusing the 6am [MEDICATION NAME] dose. The Physician Assistant was made aware. On 2/8/23 resident had a Care Plan meeting and requested that his [MEDICATION NAME] be changed back to the original dosage because he does not want to continue to refuse the [MEDICATION NAME]. The Physician Assistant and Physician Assistant with PMR made aware and resident became angry when questioned by PA's but their conversation lead to the orders being changed to [MEDICATION NAME] 5mg once daily at 6am (same time as [MEDICATION NAME]) and then [MEDICATION NAME] 10mg 3 times daily (12am, 12pm, and 6pm). Then on 2/10/23 resident #64 requested to Physician Assistant to put him back on [MEDICATION NAME] 5mg every 6 hours PRN for pain because the increased dose made him too sleepy and he did not want to change any of his other pain control medications. Resident was then subsequently discharged to home on 2/17/23 as planned on the same pain control medication regimen that he was readmitted to the facility with on 1/20/ 23. On 2/2/23, the IDCPT reviewed the care plan for the resident to address pain management and updated it to reflect the changes to the resident's medication regimen and the consult with PMR. On 2/10/23, LPN #2 was counselled and re-educated by DNS and Inservice Director regarding addressing a resident's complaint of pain appropriately. Education included always documenting the pain scale prior to giving any pain control medications and then documenting the effectiveness of the pain control medication administered. Education also included reporting any changes in pain, or lack of effectiveness of pain control medications to a RN Supervisor or MD/PA/NP. II. The following corrective actions will be implemented to identify other residents having the potential to be affected by the same deficient practice: All residents who are prescribed pain control medications have been identified as potentially being affected by the same practice. On 2/2/23 all residents on the nursing unit where LPN #2 was assigned were audited for adequate pain control measures. All residents receiving any pain control medications were assessed by the ADNS and Inservice Director for effectiveness and all pain control medications/ measures on the unit were deemed to be effective. All residents on any pain control medications were being followed by PMR routinely. On 2/3/23 a facility-wide audit was conducted on the other 3 units in the facility by the DNS, ADNS, Inservice Director, RN Unit Managers, and RN Supervisors to review any residents receiving medications for pain control. All residents receiving any pain control medications were assessed for effectiveness and all pain control medications/ measures on the unit were deemed to be effective. All residents on any pain control medications were being followed by PMR routinely. The facility's QAPI Committee participated in a P(NAME) QAPI meeting on (MONTH) 27, 2023, to discuss the Pain Management issues identified with F-697 and conducted a Root Cause Analysis. During this meeting, the DNS, ADNS, and Inservice Director provided education to the Committee members on effective pain management, how to evaluate the effectiveness of pain medications, and how to follow up if pain management plan is not effective. They were made aware how a failure to do the above resulted in the cited deficient practices. Education also addressed use of a Root Cause Analysis when compliance issues are identified. Based on the Root Cause Analysis that was part of the P(NAME) QAPI meeting on 2/27/23, the following issues were identified that required corrective actions: ??? The facility's Pain Assessment and Management policy and procedures would benefit from review and update to address current State and Federal guidelines and ensure compliance with all regulations. ??? All relevant facility staff (RNs and LPNs) would benefit from additional education and evaluation of their knowledge and understanding about appropriately addressing a resident's complaint of pain. Necessary education includes always documenting the pain scale prior to giving any pain control medications and then documenting the effectiveness of the pain control medication administered. Necessary education also includes reporting any changes in pain, or lack of effectiveness of pain control medications to a RN Supervisor or MD/PA/NP. ??? All relevant facility staff, specifically licensed nursing staff (RNs and LPNs), would benefit from additional training and a competency skill evaluation to ensure their understanding of how to appropriately address a resident's complaint of pain, ensuring the documentation of the pain scale prior to administering pain control medication, and ensuring the effectiveness of the pain control medication is documented. Also reporting any changes in pain and lack of effectiveness of pain control medications appropriately to a RN Manager/ Supervisor or MD/PA/NP. Please refer to corrective actions outlined in Sections II, III and IV of this DP(NAME). III. The following system changes will be implemented to ensure that the deficient practice does not recur: On 2/27/23, nursing administration staff reviewed the Pain Assessment and Management policy and procedure for compliance with all State and Federal regulations and determined that the policy and procedure is appropriate and up-to-date. Effective 2/28/23, DNS, ADNS, Inservice Director, RN Unit Managers, and RN Supervisors will conduct retraining and competency skill evaluations of all staff (RNs and LPNs) related to appropriate and effective pain assessment and management. Relevant staff (RNs and LPNs) will be re-trained to recognize signs and symptoms of pain and what to do when a resident complains of pain (specifically when current pain control medications/ measures are ineffective) and who to report it to (RN and/or MD/PA/NP). Relevant staff (RNs and LPNs) will also be retrained on documenting pain prior to administering pain control medication and then documenting the effectiveness of the pain control medication post administration in the electronic medical record. Additional competencies will be conducted for those staff who are identified as needing additional education/skills check. This training and competency skill evaluation will continue until all identified staff have participated and completed the required retraining and competency skill check. This training and competency skill evaluation will be provided during orientation, annually, and on an as needed basis with follow-up monitoring to ensure staff understand these protocols. The DNS, ADNS, Inservice Director, RN Unit Managers and Nursing Supervisors will monitor for compliance with documenting pain scale prior to administering pain control medications and documenting effectiveness of pain control medication post administration. They will do so with a Pain Assessment and Management Audit tool. Immediate corrective actions, such as counselling or reeducating staff observed not documenting pain scale prior and effectiveness post administration of pain control medications, will be implemented as needed. IV. The facility's compliance will be monitored utilizing the following quality assurance system: As per the Plan of Correction, a QAPI Committee meeting was convened on 2/27/23, to conduct a Root Cause Analysis and examine the deficiency cited at F- 697. The facility will develop an audit tool to monitor for compliance with documenting pain scale prior to administering pain control medications and documenting effectiveness of pain control medication post administration. A second audit tool will also be developed as a random audit of 5 residents on each unit who are on pain control medications and to evaluate the overall effectiveness of their pain control measures. The RN Unit Managers/designee will be responsible to conduct the two audits listed above. Audits will be conducted weekly for 4 weeks then monthly for 3 months. Corrective actions such as reeducation will be implemented for any negative findings, when indicated. All findings will be reported to the Administrator, DNS, ADNS, and Inservice Director for follow-up actions such as reeducation and/or competency skill check. RN Unit Managers/designee will report all audit findings to the QAPI Committee monthly for three months. At the end of this period, the Committee will determine the need for ongoing monitoring and at what frequency. Completion Date: 4/6/2023 Responsibility: Director of Nursing Services |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2023
Corrected date: April 6, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that resident who need respiratory care, is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #224) of two residents reviewed for oxygen. Specifically, Resident #224 had a physician's orders [REDACTED]. On two separate occasions, the resident was observed not receiving oxygen therapy as prescribed by the resident's Physician. The finding is: The facility's Policy and Procedure for physician's orders [REDACTED]./PA/NP. Resident #224 was admitted with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 14 which indicated the resident had intact cognition. The resident had no behavioral symptoms and did not reject care. The resident was non-ambulatory and required extensive assistance of two staff members for transfers. A Comprehensive Care Plan (CCP) for Oxygen Use dated 10/26/2022 documented the resident required supplemental oxygen due to episodes of shortness of breath related to a history of COVID-19 infection. Interventions included to check for the proper placement of oxygen tubing and to provide oxygen as ordered by the MD. A physician's orders [REDACTED]. The Treatment Administration Record (TAR) dated 1/2023 documented oxygen therapy was administered continuously as per the physician's orders [REDACTED]. Resident #224 was observed on 1/31/2023 at 11:52 AM lying in bed awake and responsive to their name and greetings. The nasal cannula was observed laying on the bed away from the resident still attached to the concentrator while the concentrator was on. The resident was unable to explain why the tubing was laying on the bed. Licensed Practical Nurse (LPN) #8, who cared for the resident on the 7:00 AM-3:00 PM shift on 1/31/2023, was made aware of the observation on 1/31/2023 at 11:53 AM. LPN #8 stated that Resident #224 is on continuous oxygen and sometimes removes their oxygen tubing; however, staff should monitor the resident to ensure that the oxygen tubing is in place. LPN #8 replaced the nasal cannula on the resident. Resident #224 was observed on a second occasion on 2/1/2023 at 10:26 AM. Resident #224 was asleep in bed without the oxygen nasal cannula in place. The oxygen tubing was observed coiled and tucked under the oxygen concentrator handle and the oxygen concentrator was on. LPN #7, who cared for the resident on 2/1/2023 during the 7:00 AM-3:00 PM shift, was interviewed on 2/1/2023 at 10:26 AM. LPN #7 stated that the resident sometimes removed their oxygen tubing; however, the resident could not have coiled the oxygen tubing and tucked the tubing under the oxygen concentrator handle. LPN #7 stated that they could not say who removed the resident's oxygen tubing. LPN #7 stated that the resident is on continuous oxygen as per the physician's orders [REDACTED]. Certified Nursing Assistant (CNA) #3 was interviewed on 2/7/2023 at 12:26 PM and stated that they were assigned to care for the resident on 1/31/2023 and 2/1/2023 and were responsible to ensure that the resident was wearing the nasal cannula to receive their oxygen. CNA #3 stated at times the resident removes their nasal cannula; however, the resident was not able to ambulate and therefore could not have coiled the oxygen tubing and tucked the tubing under the oxygen concentrator handle. The Director of Nursing Service (DNS) was interviewed on 2/7/2023 at 12:40 PM and stated Resident #224 can be non-compliant with their oxygen therapy at times; however, the staff should be checking to ensure the resident was receiving continuous oxygen as per their physician's orders [REDACTED].#2 was interviewed on 2/7/2023 at 3:21 PM and stated that they expected that staff should carry out the physician's orders [REDACTED].#2 further stated that if the resident was identified to be removing the nasal cannula the staff should have monitored the resident to ensure the resident was receiving oxygen as ordered. 10NYCRR 415. 12(k)(6) | Plan of Correction: ApprovedMarch 10, 2023 F- 638 ?ö?ç?ú Quarterly Assessment at Least Every 3 Months I. The following actions were accomplished for those residents found to have been affected by the deficient practice: On 2/2/23, the facility reviewed the overdue MDS assessments and ran a report to determine that there were 103 MDS assessments that were overdue or incomplete. Between 2/3/23 and 2/10/23, an audit was conducted by the MDS Coordinator and the Director of Nursing Services to determine that out of the 103 MDS assessments overdue or incomplete, all of the residents involved had up-to-date comprehensive care plans, had their required care plan meetings timely, had their assessments (admission, quarterly, annual, etc.) completed timely, and MDS interviews were also conducted timely. On 2/10/23, the MDS Coordinator was provided with counselling and re-education by the Director of Nursing Services and the Administrator on timely MDS assessment submissions. Re-education included review of the MDS coordinator job description and MDS policy and procedures with a focus on timely completion and submission of Quarterly MDS Assessments (at least every 3 months). Between 2/6/23 and 4/6/23, the Director of Nursing Services and Administrator updated and revised employment advertisements on various websites including Indeed and Zip Recruiter, and will continue to search for MDS Coordinators. Our MDS Consultant was also contacted to assist with recruitment of MDS Coordinators. As of 3/3/23, the facility has newly hired one Part Time RN MDS Coordinator and has another Part Time RN MDS Coordinator interested in the position coming for an interview on 3/7/ 23. The facility will continue to recruit for the MDS Department until staffing is adequate to maintain timely MDS submissions. The overdue Quarterly MDS assessments for residents 4,9,22,25, 26, 48,55, 59,61, 71,73,79, 86,90, 94,95,98,106,107 have been completed and submitted as of 2/22/ 2023. II. The following corrective actions will be implemented to identify other residents having the potential to be affected by the same deficient practice: All residents have been identified as potentially being affected by the same practice. Between 2/3/23 and 2/10/23, an audit was conducted by the MDS Coordinator and the Director of Nursing Services to determine that out of the 103 MDS assessments overdue or incomplete, all of the residents involved had up-to-date comprehensive care plans, had their required care plan meetings timely, had their assessments (admission, quarterly, annual, etc.) completed timely, and MDS interviews were also conducted timely. The facility conducted an Ad Hoc meeting with the Administrator, Director of Nursing Services, Associate Director of Nursing Services, Inservice Director, Director of Social Services, MDS Coordinator, Rehabilitation Director, and Dietitian to discuss the concerns and issues identified regarding the F-638 citation and conducted a Root Cause Analysis. Based on the Root Cause Analysis that was part of the Ad Hoc meeting on 3/1/23, the following issues were identified that required corrective actions: ??? The facility's MDS policy and procedures for MDS completion and ensuring adherence to all of the regulations set forth by CMS (Centers for Medicare and Medicaid Services) would benefit from review and updating. ??? All relevant facility staff (MDS nurses, Case Management, Social Services, Dietitian, Rehabilitation, and Recreation staff) would benefit from additional education and evaluation of their knowledge and understanding of MDS Assessments and about the importance of timely MDS Assessment completion and submission. All relevant staff re-educated on the importance of completing and submitting Quarterly MDS Assessments timely (at least every 3 months). ??? The facility would benefit from the addition of several competent staff members to join the MDS department to assist with maintaining all MDS Assessment completion and submission accurate, timely and up-to-date. Please refer to corrective actions outlined in Sections II, III and IV of this P(NAME). III. The following system changes will be implemented to ensure that the deficient practice does not recur: On 3/1/23, the Administrator, Director of Nursing Services, and the MDS Coordinator reviewed the MDS policy and procedures to ensure compliance with all of the regulations set forth by CMS (Centers for Medicare and Medicaid Services). Upon review the facility noted the MDS policy and procedures were current and up-to-date with the latest regulations set forth by CMS. Only minor revisions were necessary. Between 2/6/23 and 4/6/23, the Director of Nursing Services and Administrator updated and revised employment advertisements on various websites including Indeed and Zip Recruiter, and will continue to search for MDS Coordinators. Our MDS Consultant was also contacted to assist with recruitment of MDS Coordinators. As of 3/3/23, the facility has newly hired one Part Time RN MDS Coordinator and has another Part Time RN MDS Coordinator interested in the position coming for an interview on 3/7/ 23. The facility will continue to recruit for the MDS Department until staffing is adequate to maintain timely MDS submissions. Effective 3/1/23, the Administrator, Director of Nursing Services, and Inservice Director, along with the facility's MDS Consultant, will conduct retraining and competency skill evaluations of all relevant staff (MDS nurses, Case Management, Social Services, Dietitian, Rehabilitation, and Recreation staff) regarding MDS Assessment completion and will stress accuracy, timely completion and the completion of a Quarterly MDS Assessment at least every 3 months. Additional competencies will be conducted for those staff who are identified as needing additional education/skills check. This training and competency skill evaluation will continue until all identified staff have participated and completed the required retraining and competency skill check. This training and competency skill evaluation will be provided during orientation, annually, and on an as needed basis with follow-up monitoring to ensure staff understand these protocols. The Administrator, Director of Nursing Services, MDS Coordinator, and MDS consultant will monitor for compliance regarding timely MDS Assessment completion and submission. Immediate corrective actions, such as counselling or reeducating staff, will be implemented as needed. IV. The facility's compliance will be monitored utilizing the following quality assurance system: As per the Plan of Correction, an Ad Hoc meeting with the Administrator, Director of Nursing Services, Associate Director of Nursing Services, Inservice Director, Director of Social Services, MDS Coordinator, Rehabilitation Director, Dietitian, and Recreation was conducted to discuss the concerns and issues identified regarding the F-638 citation and a Root Cause Analysis was done. The facility will develop an audit tool to monitor timely completion and submission of all MDS Assessments, including ensuring every resident has a Quarterly MDS Assessment completed at least every 3 months. The MDS Coordinator will conduct the audit for timely completion and submission of all MDS Assessments weekly for 4 weeks, then monthly for 6 months. Corrective actions such as reeducation will be implemented for any negative findings, when indicated. All findings will be reported to the Administrator and Director of Nursing Services for follow-up actions such as reeducation and/or competency skill check. MDS Coordinator will report audit findings to the QAPI Committee monthly for 6 months. At the end of this period, the Committee will determine the need for ongoing monitoring and at what frequency. Completion Date: 4/6/2023 Responsibility: Director of Nursing Services |
Scope: N/A
Severity: N/A
Citation date: February 7, 2023
Corrected date: April 6, 2023
Citation Details None | Plan of Correction: ApprovedMarch 3, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R-610 ?ö?ç?ú Requirements Before Submitting a Request for a Criminal History Record Check. I. The following actions were accomplished for those residents found to have been affected by the deficient practice: On 2/6/2023, Both Employee #1 (Housekeeper) and Employee #2's (Certified Nursing Assistant) personnel files were corrected by obtaining a signed informed consent form (Form #102). On 2/6/2023, Employee #3's personnel file revealed the signed informed consent form (Form #102) was signed on 11/21/2022, when the CHRC request was done on 10/25/ 2022. In a statement Employee #3 stated she must have made a mistake on some of her new hire paperwork because some were dated 10/21/22 and some were dated 11/21/22 and she only came to the facility on [DATE] to fill out new hire paperwork. The Employee #3 statement was added to her personnel file for clarification. On 2/21/2023, the Administrative Assistant was counselled and re-educated by the Administrator on the timely and accurate completion of CHRC documents, specifically, ensuring a signed informed consent (Form #102) was on file prior to submitting a request for a Criminal History Record Check (CHRC). Education included the Administrative Assistant's job description and responsibility related to CHRC. The CHRC policy and procedure was also reviewed. II. The following corrective actions will be implemented to identify other residents having the potential to be affected by the same deficient practice: All employees have been identified as potentially being affected by the same practice. On 2/6/23 a comprehensive audit was done by the Administrative Assistant and Administrator looking at all employee personnel files since the Administrative Assistant was responsible for CHRC. The CHRC documents were reviewed and are in compliance was found. All CHRC informed consent forms (Form #102) were signed timely (prior to submitting a request for a Criminal History Record Check (CHRC)). And a CHRC audit tool was created to monitor compliance going forward. An Ad Hoc meeting between the Administrator, Director of Nursing Services, and the Administrative Assistant was conducted on (MONTH) 27, 2023, to discuss the R610 citation relating to Requirements Before Submitting a Request for a Criminal History Record Check and a Root Cause Analysis was conducted. During this meeting, the Administrator provided education on CHRC policy and procedures and how non-adherence to these policies and procedures resulted in the cited deficient practices. Education also addressed use of a Root Cause Analysis when compliance issues are identified. Based on the Root Cause Analysis that was part of the Ad Hoc meeting on 2/27/23, the following issues were identified that required corrective actions: ??? The facility's Criminal History Record Check (CHRC) policy and procedure would benefit review and update (if needed) to address current State and Federal guidelines and regulations. ??? All relevant facility staff would benefit from additional education and evaluation of their knowledge of CHRC policy and procedures through education and re-training. Please refer to corrective actions outlined in Sections II, III and IV of this DP(NAME). III. The following system changes will be implemented to ensure that the deficient practice does not recur: On 2/27/23, the Administrator, Director of Nursing Services, and the Administrative Assistant reviewed the policy and procedure on Criminal History Record Check (CHRC) and deemed it up-to-date with all current State and Federal regulations. The Administrator will review every informed consent form (Form #102) for compliance with signatures prior to submitted request for CHRC. Effective 2/28/23, the Administrator has reviewed and re-trained all CHRC personnel. This training and competency skill evaluation will continue until all identified staff have participated and completed the required retraining and competency skill check. This training and competency skill evaluation will be provided during orientation, annually, and on an as needed basis with follow-up monitoring to ensure staff understand these protocols. The Administrative Assistant will monitor for compliance with the CHRC documents within the personnel files using a CHRC audit tool. All informed consent forms (Form #102) will be audit for timely signatures prior to the submission of a request for a Criminal History Record Check (CHRC). Immediate corrective actions, such as counselling or reeducating will be implemented as needed. IV. The facility's compliance will be monitored utilizing the following quality assurance system: As per the Plan of Correction, an Ad Hoc meeting was convened on 2/27/23, to conduct a Root Cause Analysis and examine the deficiency cited at R- 610. The facility will develop an audit tool to monitor staff knowledge and compliance with the facility's protocols related to CHRC. Audits will be conducted with each new hire being added to the audit tool and the results of the audit being presented monthly to the QAPI Committee for the next 6 months. Corrective actions such as reeducation will be implemented for any negative findings, when indicated. All findings will be reported to the Administrator and DNS for follow-up actions such as reeducation and/or competency skill check. At the end of this period, the Committee will determine the need for ongoing monitoring and at what frequency. Completion Date: 4/6/2023 Responsibility: Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2023
Corrected date: April 6, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023 the facility did not ensure that an infection prevention and control program was established to maintain a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #272) of four residents observed for medication administration. Specifically, during the medication pass observation, Licensed Practical Nurse (LPN) #1, the medication nurse, did not wear appropriate Personal Protective Equipment (PPE) while administering medications for Resident #272, who was on contact and droplet precautions for Respiratory [MEDICAL CONDITION] (RSV), and was observed coughing. Additionally, LPN #1 did not appropriately remove their PPE before exiting the resident's room when the medication administration was completed. The finding is: The facility's policy titled Control of Communicable Disease-RSV (Respiratory [MEDICAL CONDITION]) revised 9/2022, documented RSV is spread through contact with droplets from the nose and throat of infected people when they cough and sneeze. Utilize proper personal protective equipment (PPE) for contact and droplet precautions. Upon entry to the room all staff must don the following PPE (gown, gloves, mask, and eye protection) and prior to exit all PPE must be doffed (taken off). Resident #272 was admitted with [DIAGNOSES REDACTED]. The 1/17/2023 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A physician's orders [REDACTED]. A nursing progress note dated 1/30/2023 at 11:12 AM documented the resident's cough increasing with an audible wheeze. The physician assistant (PA) was made aware and new orders for a respiratory panel were obtained. A nursing progress note dated 1/30/2023 at 1:28 PM documented that a call was received from the laboratory. Resident #272 was positive for RSV. The isolation protocol was in place. During an observation on 2/1/2023 at 9:13 AM LPN #1 performed medication administration for Resident # 272. The resident's room door had signs indicating the room was on contact and droplet precautions. The droplet precaution sign documented everyone must make sure their eyes, nose, and mouth are fully covered before room entry (illustration included either a face shield or goggles). The sign documented to remove face protection before room exit. After LPN #1 prepared the resident's medications, they (LPN #1) donned a gown and gloves. LPN #1 was wearing an N95 mask (there was no surgical mask covering the N95). LPN #1 did not put on a face shield or goggles. LPN #1 then entered the room and provided the medications to Resident #272, who was sitting in a wheelchair. The resident was not wearing a mask and was observed coughing. After LPN #1 administered the medications, they (LPN #1) removed their gown and gloves and sanitized their hands. The nurse did not remove and change the N95 mask before exiting the resident's room. LPN #1 was interviewed on 2/1/2023 at 9:20 AM after LPN #1 exited Resident #272's room. LPN #1 stated they (LPN #1) do not wear goggles or face shield when working with RSV residents and do not change the N95 face mask after working with RSV residents. LPN #1 stated they would wear a face shield or goggles and change the N95 only if the resident was COVID-19 positive. LPN #1 then proceeded to another resident's room. Registered Nurse (RN) #1, who was the Assistant Director of Nursing Services (ADNS) and the Infection Preventionist (IP), was interviewed on 2/2/2023 at 8:30 AM. RN #1 stated that RSV infection spreads the same way as COVID-19 infection through droplets and direct contact. Residents who are diagnosed with [REDACTED]. RN #1 stated staff must wear goggles or a face shield when caring for RSV-infected residents and that LPN #1 should have changed the N95 mask if it was not covered by a surgical mask because of the potential for contamination from the RSV droplets. RN #2, the Inservice Coordinator, was interviewed on 2/2/2023 at 2:08 PM. RN #2 stated RSV infection spreads like COVID- 19. RN #2 stated LPN #1 should have been wearing goggles and should have changed their N95 mask. The Director of Nursing Services (DNS) was interviewed on 2/3/2023 at 1:30 PM. The DNS stated that droplet precautions do not just apply to COVID-19; RSV infection spread is similar to COVID- 19. The DNS stated LPN #1 should have worn facial protection when administering the medications. The DNS further stated that LPN #1 should have changed the N95 mask after completing the medication pass because the N95 mask was not covered by a surgical mask and was considered potentially contaminated. 10NYCRR 415. 19(a)(1-3) | Plan of Correction: ApprovedMarch 10, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F- 760 ?ö?ç?ú Residents are Free of Significant Med Errors I. The following actions were accomplished for those residents found to have been affected by the deficient practice: On 2/2/23, resident #271 was seen and assessed and noted to be stable and free of harm by the Physician Assistant regarding the medication errors in regards to the medication [MEDICATION NAME]. On 1/31/23 [MEDICATION NAME] was help at 6am with a BP reading of 96/60 mmHg and on 1/31/23 [MEDICATION NAME] was given at 10pm with a BP reading of 117/81 mmHg. Also, on 2/2/23, at 6am [MEDICATION NAME] was held with a BP reading of 94/58 mmHg. On 2/1/23, for resident #271 the parameters for the [MEDICATION NAME] order were clarified to read administer [MEDICATION NAME] 2. 5mg tablet, give 1 tablet ( 2. 5mg) by oral route every 8 hours. Hold for SBP> (greater than) 110mmHg. With the >??ÿ sign being clarified by adding greater than??ÿ to the wording of the order. On 2/2/23, the IDCPT reviewed the care plan of the resident to address the residents cardiac status. The care plan was updated to administer anti-hypotensive medications as ordered and to pay close attention to any ordered parameters. The care plan also states to watch for any symptoms of hypertension/ [MEDICAL CONDITION] throughout the day and especially post administration of cardiac medications. On 2/2/23, LPN #6 was provided with counselling and re-education by DNS, ADNS, and Inservice Director on accurate and appropriate medication order entry, specifically, when entering parameters for cardiac medications. Facility-wide policy and procedure change involving typing out greater than,??ÿ or less than??ÿ when entering parameters was enforced with LPN #6, as long as a facility-wide in-service initiated. On 2/2/23, it was determined that the three medication errors were done by two different LPN's who were temporary employees of the facility, hired through staffing agencies. On 2/2/23 both LPN's and their agencies were notified that their services were no longer needed at the facility due to the recent errors in medication administration. All paperwork provided to the agencies regarding the medication errors. II. The following corrective actions will be implemented to identify other residents having the potential to be affected by the same deficient practice: All residents on cardiac medications with parameters have been identified as potentially being affected by the same practice. On 2/3/23 a facility-wide audit was conducted of all residents on [MEDICATION NAME]. Besides resident #271, there were two other residents on the medication [MEDICATION NAME] and their parameters were reviewed for accuracy and were found to be accurate. The administration record for (MONTH) 2023 and (MONTH) 2023 were reviewed and also were accurate with regards to the administration (and holding if indicated) of [MEDICATION NAME]. In addition, between 2/6/23 and 2/10/23 a facility-wide audit was conducted by the DNS, ADNS, Inservice Director, RN Unit Managers, and RN Supervisors of all residents on cardiac medications that require parameters. All medication orders and administration records were reviewed with 100% accuracy for (MONTH) 2023 and February 2023. The facility's QAPI Committee participated in a P(NAME) QAPI meeting on (MONTH) 27, 2023, to discuss the F-760 citation- Residents are Free of Significant Med Errors and conducted a Root Cause Analysis. During this meeting, the DNS, ADNS, and Inservice Director provided education to the Committee members on accurate and appropriate medication order entry, specifically, when entering parameters for cardiac medications. Also education provided on the facility-wide policy and procedure change involving typing out greater than,??ÿ or less than??ÿ when entering parameters for cardiac medications. They were also made aware how non-adherence to accurate order entry could lead to medication errors as in the cited deficient practices. Based on the Root Cause Analysis that was part of the P(NAME) QAPI meeting on 2/27/23, the following issues were identified that required corrective actions: ??? The facility's Medication Administration: General Policies and Procedure would benefit review and update to address current State and Federal guidelines and maintain compliance with all regulations. The policy and procedure was updated to reflect the facility-wide change involving typing out greater than,??ÿ or less than??ÿ when entering parameters for cardiac medications. ??? All relevant facility staff (RNs and LPNs) would benefit from additional education and evaluation of their knowledge and understanding about accurate and appropriate medication order entry, specifically, when entering parameters for cardiac medications. Also, regarding the administration of all cardiac medications that effect blood pressure. ??? All relevant facility relevant facility staff (RNs and LPNs) would benefit from additional training and a competency skill evaluation to ensure their understanding of accurate and appropriate medication order entry, specifically, when entering parameters for cardiac medications. Also, regarding the administration of all cardiac medications that effect blood pressure. Please refer to corrective actions outlined in Sections II, III and IV of this DP(NAME). III. The following system changes will be implemented to ensure that the deficient practice does not recur: On 2/27/23, nursing administration reviewed the Medication Administration: General Policies and Procedure and updated it to address the facility-wide change involving typing out greater than,??ÿ or less than??ÿ when entering parameters for cardiac medications. The rest of the policy and procedure was deemed appropriate and up-to-date with all current State and Federal regulations. Effective 2/28/23, the DNS, ADNS, Inservice Director, RN Unit Managers, and RN Supervisors will conduct retraining and competency skill evaluations of all staff (RNs and LPNs) related to accurate and appropriate medication order entry, specifically, when entering parameters for cardiac medications. Also, regarding the administration of all cardiac medications that effect blood pressure. Additional competencies will be conducted for those staff who are identified as needing additional education/skills check. This training and competency skill evaluation will continue until all identified staff have participated and completed the required retraining and competency skill check. This training and competency skill evaluation will be provided during orientation, annually, and on an as needed basis with follow-up monitoring to ensure staff understand these protocols. The DNS, ADNS, Inservice Director, Unit RN Managers and Nursing Supervisors will monitor for compliance with accurate order entry for cardiac medications that require parameters by conducting routine and random audits using the Cardiac Medication with Parameter??ÿ audit tool. A random sample of 5 residents on each unit who are on cardiac medications with parameters will be audited for order accuracy and administration accuracy. Immediate corrective actions, such as counselling or reeducating staff, will be implemented as needed. IV. The facility's compliance will be monitored utilizing the following quality assurance system: As per the Plan of Correction, a QAPI Committee meeting was convened on 2/27/23, to conduct a Root Cause Analysis and examine the deficiency cited at F- 697. The facility will develop an audit tool to monitor staff knowledge and compliance with the facility's protocols related to accurate and appropriate medication order entry, specifically, when entering parameters for cardiac medications. Residents on each unit who are on cardiac medications with parameters will be audited for order accuracy and administration accuracy. RN Unit Managers/designee will conduct random sample of 5 residents on each unit who are on cardiac medications with parameters will be audited for order accuracy and administration accuracy. Audits will be conducted weekly for 4 weeks then monthly for 3 months. Corrective actions such as reeducation will be implemented for any negative findings, when indicated. All findings will be reported to the Administrator, DNS, ADNS, and Inservice Director for follow-up actions such as reeducation and/or competency skill check. RN Unit Managers/designee will report audit results to the QAPI Committee monthly for three months. At the end of this period, the Committee will determine the need for ongoing monitoring and at what frequency. Completion Date: 4/6/2023 Responsibility: Director of Nursing Services |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2023
Corrected date: April 6, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was identified for one (Resident #64) of two residents reviewed for Pain Management. Specifically, during the medication administration observation task on 2/1/2023 for Resident #64, the resident complained of inadequate pain control to Licensed Practical Nurse (LPN) #2 medication nurse; however, there was no documented evidence that this was reported by the nurse to the resident's Physician until the next day (2/2/2023). Additionally, the resident's pain was not consistently assessed and monitored before and after administration of the pain medications to identify the effectiveness of the resident's pain management. The finding is: The facility's policy titled Pain Assessment and Management, revised 10/2015, documented the facility recognizes the right of every resident to be free of pain. The physician must be immediately notified if the resident has no relief from the medication and continues to have pain. Additional pain medication may be needed for breakthrough pain. For as-needed (PRN) medications, after every administration, the nurse evaluates the effectiveness of the medication. If the resident is still experiencing pain, the nurse notifies the physician and documents in the medical record. Resident #64 was admitted with [DIAGNOSES REDACTED]. The 1/22/2023 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS documented that the resident frequently had pain, pain affected daily function, and the worst pain over the previous 5 days was 10 on a scale of 0-10, with 10 being the worst pain. A Comprehensive Care Plan (CCP) effective 1/20/2023 titled Pain Management-Acute Pain, documented the resident had pain related to Chronic Pai[DIAGNOSES REDACTED]. Interventions added to the care plan on 2/2/2023 included to administer medications per physician orders; ongoing assessment of the resident's pain with emphasis on the onset, location, description, intensity of pain, and alleviating and aggravating factors; and to monitor side effects and adverse reactions resulting from the interventions rendered. The physician's orders [REDACTED]. Administer [MEDICATION NAME] 500 mg tablet, give 1 tablet every 12 hours as needed (PRN) for pain. Administer [MEDICATION NAME] 800 mg tablet, give 1 tablet every 8 hours for Idiopathic Peripheral Autonomic [MEDICAL CONDITION]. Administer [MEDICATION NAME] 325 mg tablet, give two tablets (650 mg) every 6 hours as needed (PRN) for pain. Administer Pregabalin 100 mg capsule, give 1 capsule three times a day for Idiopathic Peripheral Autonomic [MEDICAL CONDITION]. Review of the (MONTH) 2023 Medication Administration Record [REDACTED]. On 1/20/2023 at 5:54 PM and 11:55 PM; 1/21/2023 at 8:38 AM; 4:31 PM, and 11:27 PM; 1/22/2023 5:55 AM and 6:10 PM; and 1/23/2023 12:31 AM and 10:01 AM; 1/24/2023 at 12:55 AM there was no there was no pain monitoring prior to and after the administration of the medication. The following was documented for other [MEDICATION NAME] administrations: On 1/25/2023 at 8:57 AM the pain was assessed as 6 out of 10; however there was no assessment after the medication administration. On 1/26/2023 at 4:57 PM the pain was assessed at 10 out of 10 with a follow up of 7 out of 10 after the medication administration; On 1/27/2023 at 8:47 AM the pain assessment was documented as 6 out of 10 and there was no assessment post medication administration, at 5:05 PM the pain assessment was documented as 10 out of 10 and a follow-up pain assessment of 9 out of 10 after the medication was administered; and on 1/31/2023 at 1:39 AM the pain assessment documented pain level of 10 out of 10 with a follow up assessment with a pain level of 8 out of 10 after the medication administration, at 4:53 PM the pain level was documented as a 10 out of 10 with a follow up pain level of 9 out of 10 after the pain medication administration. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]#64 was interviewed on 1/31/2023 at 10:42 AM and stated they (Resident #64) have [MEDICAL CONDITION] and [MEDICAL CONDITION] of both lower legs. The best pain relief they (Resident #64) get is 5 out of 10 on their present medication regimen. A Medication Administration Observation was conducted with Licensed Practical Nurse (LPN) #2 on 2/1/2023 at 9:39 AM. Resident #64 reported to LPN #2 that 5 mg of [MEDICATION NAME] was not effective and was providing little pain relief. LPN # 2 stated they (LPN #2) would talk to the doctor right after the medication pass. The resident stated their (Resident # 64) pain level was 10/10 from their shoulders to their feet. The resident stated 5 mg of [MEDICATION NAME] did not help, but the resident took the 5 mg [MEDICATION NAME] that was offered for now. The resident also stated the [MEDICATION NAME] was not effective. Resident #64 was interviewed on 2/2/2023 at 8:50 AM. The resident stated there has been no other new pain control medication offered since reporting the pain control issues to LPN #2 yesterday on 2/1/ 2023. The resident stated no one came to see them after they told LPN #2 yesterday that the current pain medications were not relieving their pain. Review of the medical record revealed no documentation that LPN #2 communicated the pain control concerns to the Nursing Supervisor or the physician. LPN #2 was interviewed on 2/2/2023 at 8:53 AM and stated they (LPN #2) spoke to a Physician Assistant (PA #1) on 2/1/2023 and that PA #1 suggested alternating [MEDICATION NAME] with the [MEDICATION NAME]. LPN #2 stated they (LPN #2) did not enter a progress note after talking to PA#1 on 2/1/2023 and should have. A nursing progress note dated 2/2/2023 at 9:06 AM (entered as late), written by LPN #2, documented Resident #64 had pain level of 10/10 on 2/1/ 2023. The resident states their pain was from their shoulders to their feet. [MEDICATION NAME] 5 mg given with positive effect. Resident stated the medication was not effective all the time. PA made aware with suggestion of alternating [MEDICATION NAME] and Tylenol for pain management. PA #1 was interviewed on 2/2/2023 at 11:18 AM and stated that LPN #2 did not talk to them (PA #1) on 2/1/ 2023. PA #1 stated they (PA #1) were in the facility yesterday (2/1/2023) but did not see Resident #64 because the resident was not due to be seen and LPN #2 did not talk to them (PA #1) about this resident. PA #1 stated the resident should be seen by our pain management service. PA #1 stated the resident is on a significant amount of pain medications, but the pain medications can be adjusted for instance, the dosages and frequency, while we wait for pain management service. A nursing progress dated 2/2/2023 at 1:00 PM, written by LPN #2, documented Resident #64 was complaining of pain from their arms to their feet. [MEDICATION NAME] 5 mg was given with no effect. A new order was received for [MEDICATION NAME] 10 mg every 6 hours as needed for pain. A Physical Medicine and Rehabilitation (PMR) progress note dated 2/2/2023 documented increased pain, generalized in joints, recommend increasing [MEDICATION NAME] to 10 mg every 6 hours. The Director of Nursing Services (DNS) was interviewed on 2/3/2023 at 1:31 PM. The DNS stated if a resident is complaining of pain, the nurse should notify the PA, and if the PA is not around, then notify the Registered Nurse (RN) Supervisor who will do an assessment and notify the doctor. There should have been a progress note written on 2/1/2023 after the resident complained about pain to LPN # 2. RN #2 (Inservice Coordinator) was interviewed on 2/3/2023 at 2:47 PM. RN #2 stated if a resident is complaining of pain, the LPN should have reported the resident's pain to the RN Supervisor so an an assessment could be completed and the findings reported to the physician. RN #2 stated the nurse must document actions and conversations and follow up after a PRN medication is given to determine if the pain medication was effective. 10NYCRR 415. 12 | Plan of Correction: ApprovedMarch 10, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F- 695 ?ö?ç?ú Respiratory/[MEDICAL CONDITION] Care and Suctioning I. The following actions were accomplished for those residents found to have been affected by the deficient practice: On 1/31/23, resident #224 was noted to have oxygen saturations ranging from 96 to 98% on room air and was in no apparent distress for the brief period in time where no oxygen was being administered as evidence by when nasal cannula was lying beside resident #224 with the oxygen concentrator on, he was awake and responsive to his name and greetings. LPN #8 replaced the nasal cannula on the resident per the Physician order [REDACTED]. On 2/1/23, resident #224 was noted to have oxygen saturations ranging from 96 to 98% on room air and the nasal cannula was noted to be coiled and tucked under the oxygen concentrator handle, with the oxygen concentrator on. At this time the resident was sleeping and LPN #7 documented an oxygen saturation of 98% on room air. The Physician Assistant on duty was notified and assessed resident #224, giving the order to the LPN #7 to change the oxygen order to say administer oxygen via nasal cannula at 2-4 liters per minute PRN for Oxygen saturation less than 90% on Room Air. Between 2/1/23 and 2/8/23, resident #224 was noted to have oxygen saturations ranging from 93-98% on room air. On 2/1/23, the IDCPT reviewed the care plan of the resident to address his respiratory status, oxygen use, and oxygen saturations. The care plan was updated to reflect the change to PRN oxygen use from continuous oxygen use. The care plan also was updated to remind staff to monitor resident #224 for any removal of oxygen tubing (when in use) as resident has periods of non-compliance. Resident was also provided education on the importance of oxygen use (as indicated) and signs and symptoms of dyspnea to look out for. On 2/2/23, all nursing staff (RNs and LPNs) was re-educated by Director of Nursing Services, Associate Director of Nursing Services, and Inservice Director on following Physician orders, specifically as it relates to oxygen use and on appropriate use of oxygen. All CNA's were educated and trained on recognizing signs and symptoms of [MEDICAL CONDITION]/ respiratory distress and properly reporting it to a nurse (LPN or RN). LPN #7 and LPN #8 were provided with counselling and re-education by the DNS, ADNS, and Inservice Director on following MD/PA/NP orders, specifically for oxygen use and administration. II. The following corrective actions will be implemented to identify other residents having the potential to be affected by the same deficient practice: All residents with continuous oxygen orders have been identified as potentially being affected by the same practice. On 2/1/23 the DNS and ADNS ran a report to conduct an audit on all residents with orders for continuous oxygen. Between 2/1/23 and 2/8/23 all residents in the facility who had orders for continuous oxygen were monitored for any evidence of non-compliance and their oxygen saturations were monitored routinely on room air. At the end of this audit each residents oxygen saturations were reviewed with appropriate MD/PA/NP to determine if need for continuous oxygen continued or if orders could be made PRN. Three residents in the facility had continuous oxygen orders and they were audited for non-compliance and appropriateness of the continuous oxygen order. All three residents were compliant with their oxygen orders and the oxygen was deemed necessary by the appropriate MD/PA/NP. The facility's QAPI Committee conducted a P(NAME) QAPI meeting on (MONTH) 27, 2023, to discuss the Respiratory/[MEDICAL CONDITION] Care and Suctioning issues identified with F-695 and conducted a Root Cause Analysis. During this meeting, the DNS, ADNS, and Inservice Director provided education to the Committee members on following MD orders, appropriate Respiratory Care and appropriate oxygen use and how non-adherence resulted in the cited deficient practices. Education also addressed use of a Root Cause Analysis when compliance issues are identified. Based on the Root Cause Analysis that was part of the P(NAME) QAPI meeting on 2/27/23, the following issues were identified that required corrective actions: ??? The facility's policy and procedures for physician's orders [REDACTED].??ÿ and Oxygen: Administration and Maintenance of,??ÿ would benefit from review and updating to address current State and Federal guidelines and regulations. ??? All relevant facility staff (LPNs and RNs) would benefit from additional and continued education, and evaluation of their knowledge and understanding about following MD/PA/NP orders, specifically as it relates to oxygen and appropriate use of oxygen. All facility staff would also benefit from additional and continued education to document any non-compliance. ??? All licensed nursing staff (LPNs and RNs) responsible for receiving, transcribing, and carrying out MD/PA/NP orders would benefit from additional training and a competency skill evaluation to ensure their understanding of the importance of accurately following MD/PA/NP orders. ??? All licensed nursing staff (LPNs and RNs) responsible for administering oxygen would benefit from additional training and a competency skill evaluation to ensure their understanding of the importance of administering oxygen appropriately. Please refer to corrective actions outlined in Sections II, III and IV of this DP(NAME). III. The following system changes will be implemented to ensure that the deficient practice does not recur: On 2/27/23, nursing administration reviewed policies and procedures regarding oxygen use and following MD/PA/NP orders to ensure compliance with all State and Federal guidelines. All policies and procedures were reviewed and deemed appropriate and up-to-date. Effective 2/28/23, the DNS, ADNS, Inservice Director, RN Unit Managers, and Nursing Supervisors will conduct retraining and competency skill evaluations of all relevant nursing staff (RNs and LPNs) related to appropriate oxygen use and following MD/PA/NP orders and all CNA's were educated and trained on recognizing signs and symptoms of [MEDICAL CONDITION]/ respiratory distress and properly reporting it to a nurse (LPN or RN). Additional competencies will be conducted for those staff who are identified as needing additional education/skills check. This training and competency skill evaluation will continue until all identified staff have participated and completed the required retraining and competency skill check. This training and competency skill evaluation will be provided during orientation, annually, and on an as needed basis with follow-up monitoring to ensure staff understand these protocols. The DNS, ADNS, Inservice Director, RN Unit Managers and Nursing Supervisors will monitor for compliance with following MD/PA/NP orders related to oxygen use and ensuring appropriate use of oxygen using an Oxygen Use??ÿ audit tool. This tool will also check to ensure any non-compliance with oxygen use is documented appropriately. Immediate corrective actions, such as counselling or reeducating staff who are not carrying out oxygen orders appropriately, will be implemented as needed. IV. The facility's compliance will be monitored utilizing the following quality assurance system: As per the Plan of Correction, a P(NAME) QAPI Committee meeting was held on 2/27/23, to conduct a Root Cause Analysis and examine the deficiency cited at F- 695. The facility will develop an Oxygen Use??ÿ audit tool to monitor staff knowledge and compliance with the facility's protocols related to following MD/PA/NP orders, specifically related to oxygen use, ensuring oxygen use is appropriate, and ensuring any non-compliance is documented. RN Unit Manager/designee for each unit will conduct an audit using the Oxygen Use??ÿ audit tool for all residents with an order for [REDACTED]. The audit sample will include all residents on oxygen (both continuous and PRN). Corrective actions such as reeducation will be implemented for any negative findings, when indicated. All findings will be reported to the DNS, ADNS, and Inservice Director for follow-up actions such as reeducation and/or competency skill check related to appropriate oxygen use and following MD/PA/NP orders related to oxygen use. RN Unit Manager/designee will report Oxygen Use??ÿ audit tool findings to the QAPI Committee monthly for three months. At the end of this period, the Committee will determine the need for ongoing monitoring and at what frequency. Nursing administration will continue to conduct routine and random audits regarding appropriate oxygen use and will report findings to the QA Committee monthly for evaluation and follow-up corrective actions such as staff and/or resident re-education. Completion Date: 4/6/2023 Responsibility: Director of Nursing Services |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2023
Corrected date: April 7, 2023
Citation Details Based on record review and interviews during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that a signed, informed consent for finger printing (Form 102) of the subject individuals specified by the New York State Department of Health (NYSDOH) was obtained prior to submitting a request for a Criminal History Record Check (CHRC). This was identified for three (Employee #1, Employee #2, and Employee #3) of the five employees reviewed for CHRC. Specifically, 1) Employee #1 and Employee #2 employment records did not contain a signed CHRC consent form (Form 102). 2) Employee #3's consent form (Form 102) was signed after a request for CHRC. The finding is: The facility's Criminal History Record Check policy and procedure dated 10/28/2021 documented that prior to initiating the fingerprinting process, the facility will inform the applicant of the CHRC requirement and description of the process. The facility will obtain from the applicant a completed and signed copy of the Acknowledgement and Consent Form for Fingerprinting and Disclosure of Criminal History Information form which includes an authorization for search and exchange of records and disclosure of any finding of resident abuse of a conviction of a crime or violation other than a traffic infraction. Five employees' personnel files were reviewed on 2/6/ 2023. Employee #1 (Housekeeper) and Employee #2 (Certified Nursing Assistant) personnel files did not contain documented evidence of a signed informed consent form (Form #102) as required before a request for CHRC. Employee #3's personnel record revealed a request for CHRC dated 10/25/2022 was completed before obtaining a signed informed consent form (Form 102). The Signed informed consent was obtained on 11/21/2022 more than three weeks after the request for CHRC. The Administrative Assistant, who was the assigned authorized person for CHRC submission, was interviewed on 2/6/2023 at 11:33 AM. The Administrative Assistant stated after the decision is made to hire a new applicant, all appropriate forms including the consent form (Form 102) for fingerprinting are given to the applicant to sign prior to submitting a request for CHRC to the NYSDOH. The Administrative Assistant stated that they (Administrative Assistant) were responsible for obtaining the signed informed consent for all non-licensed applicants and that the consent should be obtained prior to submitting a request for CHRC to the NYSDOH. The Administrative Assistant stated that the informed consent form (Form 102) should have been signed by the applicants prior to submitting a request for CHRC to the NYSDOH. The Administrator was interviewed on 2/7/2023 at 12:54 PM. The Administrator stated that they had trained the Administrative Assistance regarding the fingerprinting process and the Administrative Assistant should have known to obtain written consent prior to submitting a request for CHRC to the NYSDOH. The Administrator stated a signed informed consent must be obtained from all prospective employees prior to submitting a request for CHRC to the NYSDOH. The Administrator stated that the Administrative Assistance was also responsible for reviewing the personnel file to ensure all forms are completed including the accuracy of dates. | Plan of Correction: ApprovedMarch 9, 2023 The Administrator and Director of Maintenance implemented a new Emergency Generator Test Log to comply with NFPA99, that includes date of test, oil pressure, water temperature, AMPS, RMP, transfer time and testing of the transfer switch, and specific gravity for the battery. The form shall indicate weekly, monthly, and length of testing. Testing shall be conducted by the Director of Maintenance. The Director of Maintenance re-labeled the electrical panel that was lacking a panel directory on 3/3/ 2023. The results of the generator testing shall be submitted to QA for review.The Administrator and Director of Maintenance shall review and update the facility's policy and procedure on the emergency generator, as needed, to comply with testing and documentation requirements. The Administrator has inserviced the Director of Maintenance on the NFPA testing and documentation requirements. On an ongoing basis, the Director of Maintenance shall submit monthly generator testing, utilizing the new documentation form, to the QA committee for review. All residents have been identified as potentially being affected by the same practice. Responsibility: Director of Maintenance |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 7, 2023
Corrected date: April 7, 2023
Citation Details 2012 NFPA 101: 9. 7. 1. 1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems 2010 NFPA 13: 8. 3. 3. 2 Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8. 3. 3. 3. 8. 3. 3. 4 When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed. 8. 5. 5. 3* Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8. 5. 5. 3. 2012 NFPA 101: 9. 7. 5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25: 5. 2. 1. 1* Sprinklers shall be inspected from the floor level annually. 5. 2. 1. 1. 1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 5. 2. 1. 1. 2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5) *Loading (6) Painting unless painted by the sprinkler manufacturer 5. 2. 5 Waterflow Alarm and Supervisory Devices. Waterflow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage. 5. 3. 3 Waterflow Alarm Devices. 5. 3. 3. 1 Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 2011 NFPA25: 14. 2 Internal Inspection of Piping. 14. 2. 1 Except as discussed in 14. 2. 1. 1 and 14. 2. 1. 4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. Based on observation, record review and staff interview, the facility did not ensure that the sprinkler system was maintained in accordance with NFPA 101, 2012 edition, NFPA 13, 2010 edition and NFPA 25, 2011 edition. Specifically, different types of sprinklers were installed in a compartment, sprinklers were corroded, sprinklers were installed within 18 inches of an obstruction, an internal pipe inspection was not conducted every 5 years, and the water flow alarm devices were not inspected quarterly. This occurred for the sprinkler system that serves the facility. The findings are: During the life safety code survey on 1/31/2023 to 2/1/2023 between the hours of 8:45 AM and 4:45 PM, the following was noted: 1) The women's bathroom in the basement contained two sprinkler heads. One sprinkler head was quick response type, the other was a standard response type. 2) In the laundry area above the washer trough, a sprinkler showed signs of corrosion and was green in color. 3) In the basement corridor, at the intersection of the laundry corridor, a sprinkler head contained a build-up of dust and the deflector was located within 5 inches of the light fixture. 4) Document review revealed an internal pipe inspection had not been conducted every 5 years. 5) Document review revealed the alarm devices on the sprinkler system was not test quarterly: a) Document review of the quarterly sprinkler testing from an outside vendor titled Fire Sprinkler System Report of Inspection dated 12/12/2022, under Section 6. Alarms: a. water motor and gong tested satisfactorily? contained a checkmark in the yes column, b. Electrical Alarm Test Satisfactory? contained a check mark under the N/A column. Under Section 10. Are electrically operated bells installed within the protected premises? Yes, was circled. If so, were these bells inspected for operation?. No was circled. b) Document review of the quarterly sprinkler testing from an outside vendor titled Fire Sprinkler system report of Inspection dated 9/8/2022 under Section 6. Alarms: a. water motor and gong tested satisfactorily? contained a checkmark in the yes column, b. Electrical Alarm Test Satisfactory? contained a check mark under the N/A column. Under Section 10. Are electrically operated bells installed within the protected premises? Yes, was circled. If so, were these bells inspected for operation?. No was circled. c) Document review of the quarterly sprinkler testing from an outside vendor titled Fire Sprinkler system report of Inspection dated 6/3/2022, under Section 6. Alarms: a. water motor and gong tested satisfactorily? it Contained a checkmark in the yes column, b. Electrical Alarm Test Satisfactory? contained a check mark under the N/A column. Under Section 10. Are electrically operated bells installed within the protected premises? Yes, was circled. If so, were these bells inspected for operation?. No was circled. d) Document review of the quarterly sprinkler testing from an outside vendor titled Fire Sprinkler system report of Inspection dated 3/14/2022 under Section 6. Alarms: a. water motor and gong tested satisfactorily? it Contained a checkmark in the yes column, b. Electrical Alarm Test Satisfactory? contained a check mark under the N/A column. Under Section 10. Are electrically operated bells installed within the protected premises? Yes, was circled. If so, were these bells inspected for operation?. Yes was circled. In an interview on 1/31/2023 at 12:45 PM, the Director of Maintenance stated there is corrosion in the room by the washers due to humidity. In an interview on 2/1/2023 at 2:00 PM, the Administrator state they would contact the sprinkler company about the internal pipe inspection and could not determine who was responsible to test the electronically devices on the sprinkler system. 2011 NFPA 25:5, 14. 10NYCRR 711. 2(a)(1) | Plan of Correction: ApprovedMarch 9, 2023 The Administrator contacted the vendor who is contracted to perform sensitivity testing on the facility smoke detectors and learned that the test was not performed due to an oversight. A sensitivity test has been scheduled to be performed this month. All residents have been identified as potentially being affected by the same practice. The Administrator and the Director of Maintenance reviewed the facility policy on sensitivity testing. No changes were indicated. The Director of Maintenance was in-serviced by the Administrator regarding his responsibility to monitor sensitivity testing completion, as per policy. On an ongoing basis, the Director of Maintenance will maintain a schedule and dates of completion of all required testing conducted by outside vendors on facility systems, such as the fire alarm system, automatic sprinkler system, smoke detectors, generator PM, etc.to ensure completion. The schedule will be presented to the QA Committee for review on a monthly basis. Responsibility: Director of Maintenance |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 7, 2023
Corrected date: April 7, 2023
Citation Details 2010 NFPA101: 8. 3. 3 A written schedule for routine maintenance and operational testing of the EPSS shall be established. 8. 3. 4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available. 8. 3. 4. 1 The permanent record shall include the following: (1) The date of the maintenance report (2) Identification of the servicing personnel (3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced (4) Testing of any repair for the time as recommended by the manufacturer 8. 3. 7* Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications. 8. 3. 7. 1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. 2010NFPA 110: 8. 4 Operational Inspection and Testing. 8. 4. 1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 8. 4. 2. 4 Spark-ignited generator sets shall be exercised at least once a month with the available EPSS load for 30 minutes or until the water temperature and the oil pressure have stabilized. 8. 4. 6 Transfer switches shall be operated monthly 8. 4. 9* Level 1 EPSS shall be tested at least once within every 36 months. 8. 4. 9. 5. 3 For spark-ignited EPSs, loading shall be the available EPSS load. 8. 4. 9. 6 The test required in 8. 4. 9 shall be permitted to be combined with one of the monthly tests required by 8. 4. 2 and one of the annual tests required by 8. 4. 2. 3 as a single test. 8. 4. 9. 7 Where the test required in 8. 4. 9 is combined with the annual load bank test, the first 3 hours shall be at not less than the minimum loading required by 8. 4. 9. 5 and the remaining hour shall be at not less than 75 percent of the nameplate kW rating of the EPS. 2012NFPA99: 6. 4. 4. 1. 1. 4 Inspection and Testing. Criteria, conditions, and personnel requirements shall be in accordance with 6. 4. 4. 1. 1. 4(A) through 6. 4. 4. 1. 1. 4(C). (A)* Test Criteria. Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8. Based on observation, document review and staff interview conducted during the life safety recertification survey on 1/13/2023 to 2/1/2023 between the hours of 8:45 AM and 4:45 PM, the facility failed to ensure that emergency generator was being testing in accordance with NFPA 101, 2012 edition and NFPA 110, 2010 edition. Review of the generator testing logs did not indicate annual, monthly and weekly inspection testing and maintenance, did not record the transfer time, did not record the specific gravity for the battery, and did not record the testing of the transfer switch. Additionally, an electrical panel lacked a panel directory. This occurred for the essential electrical system that serves the building. The findings are: (1) During the life safety recertification survey, the generator inspection testing and maintenance logs were requested. The generator testing log titled generator check sheet stated the date, oil pressure, water temperature, AMPS, RMP. It could not be determined if the required monthly tests and weekly inspections of the generator was conducted for 2022. Additionally, the records did not indicate the transfer time from normal to emergency power, the specific gravity for the battery, and if the transfer switch was tested . In an interview on 2/1/2023 at 3:45 PM, the director of maintenance stated they were recently hired by the facility, they test the generator weekly and monthly. Additionally, they stated they are in the process of creating new logs in January, and that contains more details. (2) On 2/1/2023 at 3:18 PM, the electrical panel in the Electric Room on the B unit was observed lacking a panel directory. In an interview at the time of the finding, the Director of Maintenance stated the system is very old and acknowledged the panel director was missing. 2012 NFPA 101 2010NFPA110 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 9, 2023 The facility Administrator and the Director of Maintenance have reviewed the NFPA99 requirements for a risk assessment for building systems. The Administrator will appoint a committee to complete the risk assessment by 4/7/ 2023. The committee will include, at a minimum, the Administrator, the Director of Maintenance, the Director of Nursing, and the Safety Coordinator. The results of the assessment shall be presented to the QA committee for review. On an annual basis, the Risk Assessment Committee will review the assessment and update, if needed. The results of the review shall be presented to the QA committee for review. All residents have been identified as potentially being affected by the same practice. Responsibility: Administrator Completion Date: 4/7/2023 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2023
Corrected date: April 7, 2023
Citation Details 2012 NFPA 101 9. 7. 2 Supervision. 9. 7. 2. 1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility. 2010 NFPA 72 14. 4. 1 System Testing. 14. 4. 1. 1 Initial Acceptance Testing. 14. 4. 1. 1. 1 Initial acceptance testing shall be performed as required in 14. 4. 1. 1. 1. 1 through 14. 4. 1. 1. 1. 2. 14. 4. 1. 1. 1. 1 All new systems shall be inspected and tested in accordance with the requirements of Chapter 14. 14. 4. 5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14. 4. 5, or more often if required by the authority having jurisdiction. 14. 4. 5. 3* In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14. 4. 5. 3. 1 through 14. 4. 5. 3. 7. 14. 4. 5. 3. 1 Sensitivity shall be checked within 1 year after installation. 14. 4. 5. 3. 2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 2010 NFPA 72: 14. 4. 5. 5. 3 Records shall be kept by the building owner specifying which detectors have been tested . Based on observation, staff interview and document review, the facility did not conduct the sensitivity testing on the automatic smoke detection system that serves the entire facility. The findings are: During the life safety code survey on 1/31/2023 to 2/1/2023, hardwired smoke detectors were observed within the facility. Document review on 2/1/2023 at 1 PM, revealed that there was no record of sensitivity testing having been performed on the automatic smoke detection system. In an interview on 2/1/2023 at 2 PM, the Administrator stated that they have a vendor that comes in to test the sensitivity and will request the report. In an email, the Administrator provided the signed contract indicating the vendor is responsible to conduct the sensitivity testing, had not conducted the testing as required, and stated the vendor is scheduled to perform the test. 2012 NFPA 101 2010 NFPA 72 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 9, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Director of Maintenance completed the following corrections: 1. The doors of the laundry room, the business office storage room, and the medical records room were adjusted to ensure a positive latch. 2. The doors of resident rooms [ROOM NUMBER] were equipped with self-closing devices. All residents have been identified as potentially being affected by the same practice. The facility's policy and procedure on hazardous areas was reviewed by the Administrator and the Director of Maintenance to ensure compliance. An audit was subsequently conducted by the Director of Maintenance on all doors for hazardous areas to ensure the presence of a functioning self-closing device and that the doors positively latched. No issues were found. The audit will be presented to the QA committee for review. On an ongoing basis, the Director of Maintenance or his designee will conduct a monthly audit of the doors of hazardous areas to ensure the self-closing devises are properly functioning and that the doors positively latch. The results of the audit will be submitted to the QA committee for review on a monthly basis. Responsibility: Director of Maintenance All work completed on 2/3/2023 |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 7, 2023
Corrected date: April 7, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012NFPA101: 19. 3. 2 Protection from Hazards 19. 3. 2. 1 Hazardous Areas. Any hazardous areas shall be safe guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8. 7. 1. 19. 3. 2. 1. 3 The doors shall be self-closing or automatic closing. 19. 3. 2. 1. 5. Hazardous areas shall include, but shall not be restricted to, the following: 1. Boiler and fuel-fired heater rooms 2. Central /bulk laundries larger than 100ft2 ( 9. 3 m2) 3. Paint shops 4. Repair shops 5. Rooms with soiled linen in volume exceeding 64 gallon (242L) 6. Rooms with collected trash in volume exceeding (242L) 7. Rooms or spaces larger than 50 ft2 ( 4. 6m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction 8. Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard. Based on observation and staff interview, the facility failed to ensure that hazardous rooms contained self -closing and positively latching doors. This occurred on the C Unit, and in the basement within the facility. The findings are: On 1/31/2023 and 2/1/2023 between the hours of 8:45AM and 4:45PM during the life safety recertification survey, the following was noted: 1) The laundry room door near the dryers did not positively latch into its' frame when tested . The room contained equipment and storage of combustibles 2) The business office room door did not positively latch into its' frame when tested . The room contained storage of combustibles 3) The medical records room door did not positively latch into its' frame when tested . The room contained storage of combustibles. 4) Resident room [ROOM NUMBER] contained storage of paper, paint and equipment used for renovations. The door lacked a self-closing device 5) Resident room [ROOM NUMBER] contained storage of multiple paintings and combustibles. The door lacked a self-closing device. 6) Resident room [ROOM NUMBER] contained storage of Personal Protective Equipment, such as boxes of gloves and gowns. The door lacked a self-closing device. In an interview on 2/1/2023 at 10:40 AM, the Director of Maintenance stated the resident rooms are currently used for storage by the contractors and supplies by the medical staff. They additionally stated the doors are always locked. 2012NFPA101 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 9, 2023 On 2/10/2023, the Director of Maintenance conducted an inspection audit of all egress lighting fixtures. Of the twelve (12) exits in the facility, ten (10) have egress lighting controlled by sensors; however, some were found to have non-functioning sensors. Two exits have lighting on timers. The facility has contacted their contractor electrician who will replace the lighting fixtures on timers with those controlled by sensors, and will repair or replace the non-functioning sensors, as needed. Until all work has been completed, all egress lights will remain on 24/ 7. The facility's policy and procedure for egress lighting has been reviewed and updated by the Administrator and the Director of Maintenance. On an ongoing basis, the Director of Maintenance and/or his designee will inspect and test all egress lighting on a monthly basis. The results of the inspection and testing will be reported to the QA Committee for review. All residents have been identified as potentially being affected by the same practice. The Director of Maintenance conducted an annual testing (90 minutes) of the emergency lighting on 02/10/ 2023. No issues found. The facility's policy and procedure for testing emergency lighting was reviewed by the Administrator and the Director of Maintenance. No changes were indicated. On an ongoing basis, the Director of Maintenance or his designee will test operation of the emergency lights for thirty (30) seconds monthly and for ninety (90) minutes annually. The results will be documented on an audit tool and will be submitted to the QA Committee on a monthly basis for review. All work will begin on 3/17/2023 and will be completed by 4/7/2023 to allow for delivery of new fixtures. Responsibility: Director of Maintenance |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 7, 2023
Corrected date: February 15, 2023
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2023
Corrected date: April 11, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification survey, the facility did not ensure residents were involved in developing their comprehensive care plan (CCP) with the interdisciplinary team (IDT). This was evident for 1 (Resident #66) of 33 sampled residents. Specifically, Resident #66 was not invited to several CCP meetings conducted The findings are: The facility policy titled CCP last revised 1/15/2022 documented the facility must develop and implement a CCPs for each resident consistent with the resident rights. If the facility determines that the inclusion of the resident and/or resident representative is not practicable, documentation of the reasons, including the steps the facility took must be included in the resident's medical record. Resident #66 had [DIAGNOSES REDACTED]. The Minimum Date Set 3. 0 (MDS) assessment dated [DATE] documented Resident #66 was cognitively intact, usually able make self understood, and usually able to understand others. Resident #66 was interviewed on 06/27/22 at 12:51 PM and stated he does not have care plan with anybody in the facility. Nobody talks to him about having a care plan meeting. The activity progress notes dated 2/5/22 documented Resident #66 was able to make their interest known and was able to participate in the interview related to preferences. The nursing progress note dated 5/27/2022 documented Resident #66 was alert and oriented times 4 and able to make all needs known. The CCP Meeting Sign-In sheet dated 2/11/21, 5/13/21, 7/8/21, 2/10/22, 4/14/22, and 5/19/22 documented CCP meetings were held for Resident #66 with signatures of the IDT. There was no documented evidence in the medical record that Resident #66 was invited to or attended scheduled CCP meetings. On 7/5/22 at 3:13 PM, Social Worker #1 was interviewed and stated Resident #66 was not always alert and oriented and had periods of confusion and forgetfulness. On 7/1/2022 at 3:32 PM, the Director of Social Service (DSS) was interviewed and stated the facility received permission from the Resident #66's designated representative to contact to discuss the resident's concerns and to contact the designated representative if there were problems. A follow-up interview was conducted with the DSS on 7/5/2022 at 3:24 PM and the DSS stated there was no documented evidence Resident #66 gave the designated representative permission to represent the resident in CCP meetings. Residents are invited to CCP meetings but Resident #66 was not a candidate to be invited and the Social Worker did not invite Resident #66 to any CCP meetings. 415. 11(c)(2)(i-iii) | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2023
Corrected date: April 7, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012NFPA101: 19. 3. 7 Subdivision of Building Spaces. 19. 3. 7. 1 Smoke barriers shall be provided to divide every story used for sleeping rooms for more than 30 patients into not less than two smoke compartments (see 19. 2. 4. 4), and the following also shall apply: (1) The size of any such smoke compartment shall not exceed 22,500 ft2 (2100 m2), and the travel distance from any point to reach a door in the required smoke barrier shall not exceed 200 ft (61 m). (2) Where neither the length nor width of the smoke compartment exceeds 150 ft (46 m), the travel distance to reach the smoke barrier door shall not be limited. (3) The area of an atrium separated in accordance with 8. 6. 7 shall not be limited in size. 19. 3. 7. 2 For purposes of the requirements of 19. 3. 7, the number of health care occupants shall be determined by actual count of patient bed capacity. 19. 3. 7. 3 Any required smoke barrier shall be constructed in accordance with Section 8. 5 and shall have a minimum 1?2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8. 6. 7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19. 3. 5. 8 has been provided for smoke compartments adjacent to the smoke barrier. 8. 4. 4 Penetrations. The provisions of 8. 4. 4 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke partitions. 8. 4. 4. 1 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a smoke partition shall be protected by a system or material that is capable of limiting the transfer of smoke. Based on observation, document review and interview, the facility failed to ensure the smoke compartmentation was identified and maintained. This occurred for the entire facility. The findings are: On 1/31/2023 and 2/1/2023 between the hours of 8:45AM and 4:45PM during the life safety recertification survey, the following was noted: (1) On 1/31/2023 at 10:30AM, the life safety drawings were requested. The facility provided evacuation route drawings. The drawings did not indicate the location of the smoke barriers. (2) On 1/31/2023 at 2:45 PM, the corridor outside the Dining Room on the A wing was observed to contain cross corridor doors. The Dining Room contained 2 exit doors into the corridor. The cross-corridor doors were located between the 2 exit doors from Dining Room. One exit door contained a magnetic hold open device tied to the fire alarm, the other door did not contain any magnetic device. It could not be determined if the if the cross corridor doors were smoke barriers, and if the smoke barrier extended from exterior wall to exterior wall for smoke compartmentation. (3) On 2/1/2023 at 10:50 AM, cable and pipe penetrations were observed above the ceiling tiles at the cross-corridor doors in the following locations: a) C Unit - The cross-corridor door near the dietary bathroom contained a partially unsealed pipe penetration and 1 cable penetration with firestopping that had separated from the wall. b) C Unit - The cross-corridor door near the shower room contained 1 cable penetration with the firestopping that had separated from the wall c) A Unit - The cross-corridor corridor door adjacent to room [ROOM NUMBER] contained 1 cable penetration with the firestopping material that had separated from the wall. Additionally, it could not be determined if these cross-corridor doors were smoke barriers. In an interview on 1/31/2023 at 2:45 PM, the Director of Maintenance stated they are not sure where the smoke barrier is located. In an interview on 2/1/2023 at 10:55 AM, the Director of Maintenance acknowledge the lack of fire proofing and separation from the wall. In an interview on 2/1/2023 at 4:30PM the Administrator stated the original drawing are from the early 70's and that they would address the concern. 2012NFPA101 10NYCRR 711. 2(a)(1) | Plan of Correction: ApprovedMarch 9, 2023 The facility has arranged with its sprinkler system vendor to replace one of the sprinklers in the women's bathroom in the basement so that they are of the same type, to replace the sprinkler in the laundry room above the water trough, and to conduct an internal pipe inspection of the sprinkler system. The sprinkler head in the laundry corridor has been cleaned by the Maintenance staff. All residents have been identified as potentially being affected by the same practice. The facility will schedule the alarm devices on the sprinkler system to be tested by the facility's fire alarm vendor. The Director of Maintenance will conduct an audit of all facility compartments to ensure that sprinkler heads in each compartment are of the same type. The audit will include a visual inspection for dust and/or corrosion on the sprinkler heads. Corrective action will be taken, as needed. The results of the audit will be submitted to the QA committee for review. The Director of Maintenance will maintain a schedule of required testing on the sprinkler system to include due dates to ensure all testing is performed as required. The Administrator and the Director of Maintenance reviewed and updated the facility policy and procedure for the sprinkler system. On an ongoing basis, the Director of Maintenance or his designee will conduct a monthly audit of the facility sprinkler systems to ensure sprinklers within a compartment are of the same type and that they are free of dust and/or corrosion. The results of the audits will be submitted to the QA committee for review on a monthly basis. Responsibility: Director of Maintenance All work will be completed by 4/7/2023 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2023
Corrected date: April 7, 2023
Citation Details 2012NFPA99: 4. 1* Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code. 4. 1. 1* Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code. 4. 1. 2* Category 2. Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers shall be designed to meet system Category 2 requirements as defined in this code. 4. 1. 3 Category 3. Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort, shall be designed to meet system Category 3 requirements as defined in this code. 4. 1. 4 Category 4. Facility systems in which failure of such equipment would have no impact on patient care shall be designed to meet system Category 4 requirements as defined in this code. 4. 2* Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure. Based on document review and interview conducted during a Life Safety Code Recertification Survey conducted on 1/31/2023 to 2/1/2023, the facility did not ensure that a documented National Fire Protection Association (NFPA) 99 risk assessment was conducted. Specifically, building systems within the facility were not categorized using a defined risk assessment procedure. The findings are: On 2/1//23 the facility emergency preparedness plan binder was provided to the surveyor for review. The binder did not include a NFPA 99 risk assessment for building systems. On 2/1/23 at 11:20 AM, the Administrator stated the facility conducted a risk assessment for emergency preparedness and the generator was included and that they are not sure what a NFPA 99 risk assessment is. 10NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 99: 4. 1, 4. 2 | Plan of Correction: ApprovedMarch 9, 2023 1. The facility life safety drawing depicts evacuation routes, exits, as well as smoke barriers. The smoke barriers are shown as dotted lines, highlighted in yellow. 2. One of the exit doors for the dining room contains a magnetic hold open device as a convenience. It is not connected to the fire alarm system. The facility life safety drawing does not show the cross-corridor doors between the dining room doors as a smoke barrier. The Administrator will make the life safety drawing available to the authority having jurisdiction, when requested. All residents have been identified as potentially being affected by the same practice. The administrator will contract with a life safety specialist to develop new life safety drawings and to conduct a barrier survey throughout the facility by 4/7/ 2023. If it is determined that the cross-corridor doors in question are, in fact, not smoke barriers, they shall be disconnected from the fire alarm and appropriately labeled as non-smoke barriers. The updated life safety plan will be presented to the QA committee for review. 3. The smoke penetrations on C Unit near the dietary bathroom and near the shower room have been sealed with Firestop by the Director of Maintenance. The smoke penetration above the cross-corridor door on A unit has been sealed with Firestop by the Director of Maintenance. The Director of Maintenance and his staff will complete a visual inspection of all smoke barriers to ensure there are no other smoke penetrations present. Any penetrations found will be sealed with Firestop. If any changes or revision to the life safety plan, all staff will be in-serviced on the updates by the In-Service Director. On an annual basis, the life safety drawings, will be reviewed by the Administrator and Director of Maintenance for accuracy. The results of the review will be submitted to the QA Committee. Responsibility: Administrator Completion Date: 4/7/2023 |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 7, 2023
Corrected date: April 7, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that Admission and Annual Minimum Data Set (MDS) assessments were completed within 14 calendar days after admission and not less than once every 12 months for 13 (Resident #4, #9, #22, #26, #59, #71, #73, #86, #94, #95, #98, #106, and #107) of 19 residents reviewed for Resident Assessment. Specifically, three (Resident #86, #106 and #107) of 19 Residents did not have an Admission MDS completed within 14 calendar days of admission and 10 (Resident #4, #22, #26, #59, #71, #73, #94, #95, and #98) of 19 had an Annual MDS assessment completed less than once every 12 months. Additionally, the facility provided a report titled Overdue MDS, which revealed that 18 Admission and 6 Annual MDS Assessments were not completed as of 2/2/23 which included two (Resident #9 and 71) of 19 Residents reviewed for Resident Assessments. The findings include but are not limited to: The Facility MDS 3. 0 Completion policy dated 4/2008 documented that the facility will utilize the Center for Medicare and Medicaid (CMS) Minimum Data Set (MDS) 3. 0 for resident assessment. The MDS required data elements are transmitted to New York State according to CMS requirements. The MDS assessment, which will be used to develop the resident's Comprehensive Care Plan (CCP), will be completed at the time of admission, whenever there is a significant change, and at least quarterly. The admission (Initial) assessment (Comprehensive) MDS must be completed by the 14 th calendar day of the resident's stay, may be combined with the discharge assessment as indicated. The Annual (Comprehensive) MDS must be completed within 366 calendar days of the Assessment Reference Date (ARD) of the last comprehensive assessment. The facility report entitled, Overdue MDS dated 2/2/2023 documented 103 MDS assessments were overdue facility wide. The report indicated that Residents #9 and #71 had an overdue Annual MDS assessment. -Resident #9's Annual MDS assessment dated [DATE] was not completed as of 2/2/ 2023. -Resident #71's Annual MDS assessment dated [DATE] was not completed as of 2/2/ 2023. The Overdue MDS report also documented Resident #106's Admission MDS assessment with an assessment reference date of 9/1/2022 was not completed until 11/7/ 2022. The MDS Coordinator was interviewed on 2/2/2023 at 1:22 PM. The MDS Coordinator stated that they (MDS Coordinator) have been the MDS Coordinator since (MONTH) 2021. The MDS Coordinator stated that they were the only person completing MDS's for the whole facility. In early (MONTH) 2022, the MDS Coordinator informed the Director of Nursing Services (DNS) that they were falling behind on their work and MDS assessments were not completed on time. The DNS hired a part-time MDS Coordinator mid-September 2022 to assist with catching up on the MDS assessments. The Part-time MDS Coordinator works 3 days a week. The MDS Coordinator stated that even with the part- time MDS Coordinator they are still behind and are still catching up. The MDS Coordinator stated that they reviewed the medical records for Resident #4, #9, #22, #25, #26, #48, #55, #59, #61, #71 #73, #79, #86, #90, #94, #95, #98, #106, and #107 on 2/1/2023 and their MDS assessments were not yet completed. The MDS Coordinator stated that there was a mix of Annual, Quarterly, Death entries MDS assessments due for all 19 residents. The MDS Coordinator stated that they began to work on the list of 19 residents brought to their attention and are in the process of completing their MDS assessments. The DNS was interviewed on 2/2/2023 at 1:41 PM. The DNS stated that they (DNS) were made aware that the MDS Coordinator was behind on MDS assessments in (MONTH) 2022. The DNS stated that when the MDS Coordinator showed them a report of overdue MDS's in (MONTH) 2022, there were about 300 outstanding MDS assessments. The DNS hired a part-time MDS Coordinator 3 days a week to assist in response to the MDS Coordinator's report. The DNS stated that they have a case manager who started to organize the care plan meetings and morning report meeting to free up the MDS Coordinator to work on the over-due MDS assessments. The DNS stated that in another week or two, they expect the facility to be caught up. The DNS stated that the facility just did a submission of MDS assessments that were completed in (MONTH) 2022. The DNS was re-interviewed on 2/3/2022 at 2:24 PM. The DNS stated that the part-time MDS Coordinator was hired on 9/20/ 22. The DNS provided a report entitled Overdue MDS dated 2/2/ 2023. The DNS stated that they reviewed the overdue and incomplete MDS assessments, and the facility was currently behind on 103 MDS assessments as of 2/2/ 2023. The DNS was re-interviewed on 2/6/2023 at 9:42 AM and stated that the completion of Annual and Admission MDS assessments are due 14 days from the assessment reference date and the care plan completion is 7 days from the MDS completion date. The transmission to CMS is no later than 14 days the care plan completion date or 35 days from the assessment reference date. The DNS stated that the Unit Managers complete the care plan assessments and organize the care plan meetings within the 21 days of the assessment date. The Unit Managers complete the care plans by reviewing the medical records and their assessments on the units. The MDS Coordinator then reviews the data and completes the MDS assessments after the Unit Managers complete their assessments. The DNS stated that the Unit Managers are not directly involved in the MDS completion. The DNS stated that they are looking to hire full time MDS Coordinators and have placed job openings online to recruit. The DNS stated that they (DNS) are having a hard time finding an MDS Coordinator. The Administrator was interviewed on 2/6/2023 at 10:50 AM. The Administrator stated that the DNS informed them (Administrator) that the MDS Coordinator was behind in (MONTH) 2022. The Administrator stated that they responded to the problem by hiring a part-time MDS Coordinator. The Administrator stated that they (Administrator) did an MDS submission in (MONTH) 2022 and received a validation report with a message which indicated that the facility was overdue by way too many MDS's; however, the Administrator could not recall an exact number. The Administrator was not aware it was that bad in (MONTH) 2022. The Administrator stated that the facility ensured that care plans were completed by the Unit Managers so care plan completion was not affected by the overdue MDS assessments. The Administrator stated that they reviewed the report of 103 overdue MDS assessments and they expect to have the assessments to be completed with the help of the part-time MDS Coordinator. The part-time MDS Coordinator needed some time to learn the electronic medical record system in (MONTH) 2022, so they were not able to quickly assist with catching up on the MDS assessments. The Administrator decided that the facility had to place an advertisement to get two more full time MDS Coordinators. The Administrator further stated that they believe it would be best to have MDS Coordinators assigned to the units and solely focus on the care plans and the MDS completion. 10NYCRR 415. 11(a)(3)(i) | Plan of Correction: ApprovedMarch 9, 2023 The facility's policies on the provision of services have been reviewed by the Administrator and the Director of Maintenance. The policies will be updated to address alternate sources of energy to maintain temperatures. Specifically, during a loss of electric power, the facility's heating system, which is connected to the emergency generator, can maintain comfortable indoor temperatures when outdoor temperatures are cold. During power losses where the outdoor temperatures are warm/hot, the facility will utilize portable air conditioners, connected to generator power, to provide cooling areas for residents and staff. All residents have been identified as potentially being affected by loss of air conditioning due to power loss. Currently, the facility has one (1) portable air conditioner ( BTU's) which will be utilized in the Common Room, which has a capacity for 64 persons. Additionally, the Director of Maintenance has ordered two (2) portable units, which were ordered and have been delivered on 3/7/2023, each having a 16,000 BTU capacity, that can provide both air conditioning and heating functions. The two units will be utilized in the facility's Main Dining Room, which has an occupancy of 153 persons. The facility plans to monitor the performance of the above solutions by when there is power loss and the temperature is greater than 80 degrees inside the facility, the emergency plan will be activated and implemented. In a situation when there is power loss in the building the Administrator and Director of Maintenance must be notified by the Nursing Supervisor on duty (if they are not present). To monitor the effectiveness of the air conditioning units the Director of Maintenance/designee will monitor the temperature in the cooling areas and throughout the facility in resident areas hourly, until power is restored and document the temperature in a log. Under the direction of the Director of Nursing, all nursing staff will monitor all residents for any signs and symptoms of discomfort and facilitate transport to the cooling areas as needed for periods of relief from the heat. In addition to transporting to cooling areas, nursing will manage all other symptoms under the direction of the Attending Physician (including hydration, etc.). The Director of Maintenance will ensure that the portable AC units are securely stored in a basement storage unit when not in service. The Director will be responsible to test the units at least annually, in the Spring, to ensure proper operation. The Director of Maintenance will be responsible for servicing, cleaning, and monitoring the AC units while in use. The revised policies on the provision of services shall be presented to the QA Committee by the Administrator for review. Completion Date: 4/6/2023 Responsibility: Administrator |