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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2023
Corrected date: March 14, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the Recertification Survey and Abbreviated Survey (NY 893) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not conduct COVID-19 testing individuals with known or suspected exposure to COVID-19. This was identified for one (Resident #263) of one resident reviewed for Infection Control. Specifically, Resident #263 was transferred to the hospital for low blood pressure, low heart rate and low oxygen saturation on 12/22/2022. At the hospital the resident was diagnosed with [REDACTED].#263 to identify transmission of COVID-19 infection and did not conduct COVID-19 testing. The finding is: The facility policy entitled Long Term Care Facility Testing/Visitation dated 9/23/2022 documented that facilities are required to test residents and staff based on parameters and frequency set forth by the Health and Human Services (HHS) Secretary. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. Close Contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period. Resident #263 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderately impaired cognition. The physician's orders [REDACTED]. The nursing note dated 12/22/2022 at 2:09 PM documented Resident #263 was hypotensive (low blood pressure), bradycardic (low heart rate) and hypoxic (low oxygen saturation). The resident's oxygen was increased from 2 liters to 4 liters per minute. The Physician was notified and ordered to transfer the resident to the hospital. The nursing progress note written by the Registered Nurse (RN) #2 dated 12/22/2022 at 9:41 PM documented Resident #263 was admitted to the hospital with [REDACTED]. The hospital admission note dated 12/22/2022 documented the reason for the resident's admission to the hospital was [MEDICAL CONDITION] and COVID-19 infection. The Certified Nursing Assistant (CNA) Accountability Record dated (MONTH) 2022 documented CNA #4 and CNA #5 provided care for Resident #263 from 12/20/2022 to 12/22/2022. The progress note dated 12/23/2022 at 10:58 AM documented RN #1 performed a Rapid COVID-19 test for Resident #24, who was Resident #263's roommate. Resident #24 was negative for COVID-19 infection. RN #1 was interviewed on 1/10/2023 at 12:20 PM. RN #1 stated that they were assigned to Resident #263 on 12/22/2022 before the resident was transferred to the hospital. RN #1 stated that the night nurse, RN #2, called the hospital on [DATE] and was notified by the hospital that the resident was admitted with COVID-19 infection. RN #2 notified RN #1 of the resident's COVID-19 [DIAGNOSES REDACTED].#1 stated that after the resident's [DIAGNOSES REDACTED].#1) were not tested and were not aware if other staff members who provided care to Resident #263 were tested for COVID-19. RN #2 was interviewed on 1/11/2023 at 9:46 AM and stated that they (RN #2) informed the Director of Nursing Services (DNS) on 12/22/2022 at 9:38 PM via a text message that Resident #263 tested positive for COVID-19 infection at the hospital. CNA #4 was interviewed on 1/11/23 at 9:54 AM. CNA #4 was Resident #263's regular CNA during the day shift. CNA #4 stated that they (CNA #4) provided care for Resident #263 the week of 12/19/2022 through 12/22/2022. CNA #4 stated that during the week, Resident #263 had a cough and CNA #4 was told by RN #1 it was just Pneumonia. Resident #263 was not wearing a surgical mask and CNA #4 was wearing a surgical mask when CNA #4 provided care. Resident #263 was not on any precautions. As CNA #4 noticed Resident #263's cough worsened, CNA #4 decided to wear an N95 mask but did not wear eye protection. CNA #4 stated that they spent 30 minutes every morning with Resident #263 to assist with toileting, washing, oral swabbing, washing the dentures and combing the resident's hair. In addition to the 30 minutes spent in the morning, CNA #4 also toileted Resident #263 throughout the day which would take a minimum of 5 minutes on each occasion because they had to stay with Resident #263 during toileting activities and the resident requested to be toileted frequently. CNA #4 did not work on 12/23/2022 and returned to the facility on [DATE]. No one from the facility notified CNA #4 that they had close contact with a positive COVID-19 case and they (CNA #4) were not instructed to get tested for COVID-19. CNA #5 was interviewed on 1/11/23 at 3:20 PM. CNA #5 stated that they were the regularly assigned evening shift CNA for Resident #263. CNA #5 stated that they spent 15-25 minutes providing care to Resident #263 before bedtime each night from 12/20/2022 through 12/22/2022. In addition to the 15-25 minutes of care, CNA #5 would spend about 10 minutes with Resident #263 every 2 hours to provide incontinence care. CNA #5 stated that Resident #263 did not wear a mask. CNA #5 stated that they wore an KN95 mask but did not wear eye protection. CNA #5 stated that Resident #263 was not on any precautions. CNA #5 further stated that the facility did not contact CNA #5 about getting tested for COVID-19. The Administrator was interviewed on 1/11/23 at 3:43 PM. The Administrator stated that they were aware that Resident #263 tested positive for COVID-19 infection in the hospital on [DATE]. The Administrator stated that the DNS at that time was the Infection Preventionist. The Administrator stated that staff members who provided care for Resident #263 were not tested because the previous DNS, who was also the Infection Preventionist, did not tell them (Administrator) that the staff had to be tested . 10NYCRR 415.19 | Plan of Correction: ApprovedMarch 3, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) WHAT CORRECTIVE ACTIONS WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE. - Resident # 263 was readmitted to room [ROOM NUMBER]P (private room) upon readmission on 1/3/23 and no longer required isolation. -Contact tracing was conducted on all staff and residents on affected unit, 01/23/23 , all result were negative. 2) HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN -All residents and staff have the potential to be affected by this deficient practice. - All residents and staff on the affected unit were tested for covid 19 a and results were all negative. - All family/representative were notified of result and appropriate state agency was notified. The Epidemiologist was informed of testing results and all recommendations were followed. 3)WHAT MEASURES WILL BE PUT IN PLACE OR WHAT SYSTEMIC CHANGES YOU WILL MAKE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR -The director of nursing, administrator and RN supervisors will be in-serviced by the IP on proper protocols when an outbreak occurs. - Testing will include, staff, residentÆs with identified exposure to COVID-positive residents and procedures on proper contact tracing. -Policy and procedure on Long Term Care Facility Testing/ Visitation were reviewed with IP and no revision was necessary. 4)HOW THE CORRECTIVE ACTIONS WILL BE MONITORED TO ENSURED THE DEFICIENT PRACTICE WILL NOT RECUR, IE, WHAT QUALITY ASSURANCE PROGRAM WILL BE PUT INTO PRACTICE - Daily audit for 3 months will be completed by IP/designee at the Morning Meeting. -The daily audit will include any outbreak with residents or staff to ensure proper protocol has taken place. -All negative findings will be corrected immediately and reported to the quarterly QA committee. 5)THE DATE FOR CORRECTION AND THE TITLE OF THE PERSON RESPONSIBLE FOR CORRECTION OF EACH DEFICIENCY. -The IP/designee will be responsible to correct this deficiency- 03/14/23 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2023
Corrected date: March 14, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 1/05/2023 and completed on 1/13/2023, the facility must develop and implement a Comprehensive Person- Centered Care Plan (CCP) for each resident that includes measurable objective and time frames to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #54) of one resident reviewed for Communication and Sensory: Hearing/Vision. Specifically, Resident #54 utilized bilateral hearing aids. There was no CCP developed for the use of the hearing aids. The finding is: The facility Policy and Procedure for Comprehensive Care Plan dated 6/2017 documented that each resident must have an individualized interdisciplinary plan of care in place. Within 48 hours, there must be a baseline care plan in place. Within 21 days of admission, the Interdisciplinary Team will develop and implement the Comprehensive Care Plan. All care plans are then reviewed and revised quarterly, annually, and as needed. The facility's Resident Care Policy and Procedure for Hearing Aids dated 3/2015, documented residents with hearing aids will be assisted by the staff in application and maintenance of their devices. Resident #54 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS documented the resident had adequate hearing and utilized hearing aids or other hearing appliances. The physician's orders [REDACTED]. The resident may keep the hearing aids at their bed side. Resident #54 was observed on 1/13/2023 at 10:55 AM lying in bed. Resident #54 was not wearing their hearing aids. Resident #54 had difficulty hearing, and voices had to be raised for them to hear. A hearing aid was observed on the resident's nightstand. Resident #54 stated they keep their hearing aids at their bedside. The Resident stated they have two hearing aids, and the second hearing aid is located in their nightstand. Resident #54 stated they charge their hearing aids in their room across from the bed with a Universal Serial Bus (USB) cord. The resident was observed to get out of their bed and placed one of the hearing aids on the USB charger. Resident #54 further stated they charge one hearing aid at a time and while one hearing aid is charging they utilize the other hearing aid. Review of the Comprehensive Care Plan on 1/13/2023 revealed that there was no CCP developed for hearing deficit, use of hearing aids, or communication deficit. The Treatment Administration Record (TAR) for (MONTH) 2023, documented the hearing aids were applied and removed by the nurse from 1/1/2023 to 1/13/2023. Registered Nurse (RN) #1 Supervisor was interviewed on 1/13/2023 at 12:13 PM and stated they did not develop any care plans for Resident #54. The former Director of Nursing Services was responsible for developing CCPs. RN #1 further stated the CCP for hearing loss and use of the hearing aids was not in place for Resident #54. The current DNS was interviewed on 1/13/2023 at 1:07 PM and stated there should be a care plan developed for Resident #54's hearing and hearing aid use. The DNS stated they did not see a care plan for communication, hearing, or hearing aids in Resident #54's electronic medical record and that there should be one. 10NYCRR 415.11(c)(1) | Plan of Correction: ApprovedMarch 3, 2023 1)WHAT CORRECTIVE ACTIONS WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE. -An individualized communication care plan was formulated for resident #54. -The nurse manager responsible for formulating the communication care plan was counselled by the director of nursing to ensure that a person- centered care plan is created and implemented for all residents with hearing aides. 2)HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTILA TO BE AFFECTED BY THE SAME DEFICIENT PARACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN. -All residents with hearing aides have the potential to be affected by the same deficient practice. -An audit was conducted with all residents with hearing aides to ensure that a communication care plan is in place, person centered and up to date. 3)WHAT MEASURES WILL BE PUT IN PLACE OR WHAT SYSTEMIC CHANGES YOU WILL MAKE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR. -All nurses will be in-serviced on development and implementation of a comprehensive person center communication care plan, for all residents with hearing aids. -Within 48 hours, upon admission, nursing will initiate a communication care plan for anyone with hearing aides as well as any other communication deficit. -The comprehensive Care plan policy was reviewed and no changes were necessary. 4 ) HOW THE CORRECTIVE ACTIONS WILL BE MONITORED TO ENSURED THE DEFICIENT PRACTICE WILL NOT RECUR, IE, WHAT QUALITY ASSURANCE PROGRAM WILL BE PUT INTO PRACTICE. -An audit was conducted for all residents with hearing aides to make sure that communication care plans are developed and implemented with individualized preferences that are noted/updated in the care plan. -The care plan will be updated quarterly, annually or as needed during the care plan meeting. -An audit of 50% of all residents with hearing aides will be conducted by the unit mangers/designee weekly times 3 months. -All negative findings will be corrected immediately and reported to the QA committee. 5)THE DATE FOR CORRECTION AND THE TITLE OF THE PERSON RESPONSIBLE FOR CORRECTION OF EACH DEFICIENCY. 5. Director of Nursing/designee û 03/14/23 |
Scope: Isolated
Severity: Actual harm has occurred
Citation date: January 13, 2023
Corrected date: March 14, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 184) initiated on 1/5/2023 and completed on 1/13/2023, the facility staff did not effectively implement interventions to prevent an avoidable accident. This was identified for 1 (Resident #47) of five residents reviewed for Accidents. Specifically, Resident #47 required two-person assistance for bed mobility as per the resident's assessments and care plans. On 6/8/2022, the assigned Certified Nursing Assistant (CNA) #2 provided incontinent care to Resident #47 independently and did not seek assistance from another staff member. Resident #47 rolled out of the bed and fell to the floor and sustained a Hematoma (pool of mostly clotted blood that forms in an organ, tissue, or body space) to the frontal lobe, and Ecchymotic (bruise) areas to the left eye, nose, and face. Subsequently, Resident #47 was transferred to the hospital and was diagnosed with [REDACTED]. This resulted in actual harm to Resident #47 that is not Immediate Jeopardy. The finding is: The facility's policy titled CNA Accountability and Assignment Record, dated 10/2021, documented that a CNA provide activities of daily living (ADL) care to all residents according to the plan of care as reflected in their accountability record. This plan of care is given to each CNA, and the CNA signs for all the care provided to the resident for a particular time/day the care is provided. It is the responsibility of the CNA to read the resident's accountability record at the beginning of each shift prior to giving care. Resident #47 was admitted with [DIAGNOSES REDACTED]. The 5/22/2022 Annual Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score as the resident had severely impaired cognitive skills for daily decision making. The MDS documented that the resident required total assistance of two staff members for bed mobility and for toilet use. The resident was always incontinent of the bladder and frequently incontinent of bowel. A Rehabilitation (Rehab) Department screen dated 5/23/2022 documented Resident #47 required total assistance of two staff members for bed mobility and required a Hoyer (Mechanical) lift for transfers. The Resident Nursing Instructions (CNA care instructions), from the Electronic Medical Record (EMR), documented two-person physical assistance for bed mobility effective 6/23/2017. A Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADL) Function, effective 7/17/2017 and reviewed on 6/7/2022 prior to the accident, documented the resident is dependent in care needs. Requires total assistance to complete ADLs. A nursing progress note dated 6/8/2022 at 7:14 AM, written by Registered Nurse (RN) #5 (who was the 11 PM-7 AM nursing Supervisor), documented that RN #5 was called by the charge nurse at 6:56 AM to assess Resident #47 who had rolled off the bed onto the floor during morning care. RN #5 observed the resident on the floor lying on their back on the right side of the bed with fresh blood oozing from their nose. A full body assessment was conducted. The resident was noted with a Hematoma to the frontal lobe measuring 3-centimeter (cm) x 3 cm; Ecchymotic area to the left eye, nose, and face measuring 4 cm x 4 cm. No change in level of consciousness was noted. Resident #47 was assisted back to bed with a Hoyer lift. The physician was immediately made aware, and an order was received to transfer the resident to the hospital. The Occurrence Report (Accident/Incident (A/I) Report) dated 6/8/2022 at 6:56 AM documented a nurse (LPN #2) was called to the resident's room and Resident #47 was found lying on the floor. The Supervisor (RN #5) was notified. The resident's Primary Care Physician was contacted, and the resident was transferred to the hospital for further evaluation. A nursing progress note written by the 7 AM- 3 PM RN #1 dated 6/8/2022 at 2:18 PM documented the resident was admitted to the hospital with [REDACTED]. A written statement from CNA #2 (assigned CNA to Resident #47) in the A/I report dated 6/8/2022 documented the CNA was providing incontinence care when they (CNA #2) tried to stop Resident #47 from scratching the resident's back. Resident #47 was rolling and slid from the bed. CNA #2 tried to catch the resident, but the resident slid. Then CNA #2 called the nurse for help. The nurse (LPN #2) responded and called the Supervisor (RN #5) to evaluate the resident who was lying on the floor. The A/I Report included written statements from two other CNAs who worked on the 11 PM-7 AM shift on 6/7/2022-6/8/2022. Both CNAs documented that they were never called by CNA #2 to assist with incontinence care for Resident #47. Review of the Administrative A/I Investigative Summary dated 6/9/2022, signed by the former Director of Nursing Services (DNS), concluded that no abuse, neglect, or mistreatment of [REDACTED]. The incident was a result of a care plan violation. The CNA Accountability Record indicated Resident #47 required two-person assistance for bed mobility and incontinence care. CNA (#2) provided care to the resident by themselves and did not ask any other staff member for help. CNA #2 was taken off the schedule and suspended for five days. Review of the hospital discharge instructions dated 6/17/2022 documented that the resident was admitted on [DATE] with an acute left orbital (eye) fracture, acute [MEDICAL CONDITION] superior and inferior pubic rami (pelvis), and the left sacrum (a large triangular bone at the base of the spine). RN #4 (current A/I coordinator) was interviewed on 1/12/2023 at 3:02 PM and stated Resident #47 required two-person assistance for bed mobility, but one aide was doing the care and the resident fell out of bed. RN #4 stated that CNA #2 did not follow the plan of care for Resident #47, which led to Resident #47 falling from their bed. The Rehabilitation Director was interviewed on 1/13/2023 at 9:41 AM and stated the Rehabilitation screen was completed in (MONTH) 2022 and documented that Resident #47 required total care for Activities of Daily Living (ADLs). The Rehabilitation Director stated Resident #47 required two-person assistance for bed mobility, was transferred with a Hoyer lift, and was non ambulatory. CNA #2 was interviewed on 1/13/2023 at 9:50 AM. CNA #2 stated they (CNA #2) were assigned to care for Resident #47 on 6/8/2022. CNA #2 stated they knew Resident #47 needed the assistance of two people for transfers, but they (CNA #2) just had to change the resident's brief and provided the incontinence care alone for Resident #47 on 6/8/2022. CNA #2 stated they did not ask for help from other staff members because they did not see any other staff members outside the room. CNA #2 stated the resident had a wound on their back and the resident was scratching it and the wound was bleeding. CNA #2 stated while they (CNA #2) had the resident on the resident's side to provide incontinence care, the CNA attempted to try to get the resident to stop scratching the resident's back and the resident rolled out of bed. CNA #2 stated that they reviewed the CNA care instructions for each resident on 6/8/2022; however, they (CNA #2) did not know that Resident #47 needed two-person assistance for bed mobility. RN #5, who was the nursing supervisor for the 11 PM-7 AM shift on 6/8/2022, was interviewed on 1/13/2023 at 10:14 AM. RN #5 stated they responded to Resident #47's fall on 6/8/2022. The Licensed Practical Nurse (LPN) #2 was already in the resident's room. RN #5 stated that Resident #47 required two persons to provide incontinent care, not just for Hoyer transfers. RN #5 stated that CNA #2 was providing care by themselves, and the resident rolled out of bed. RN #5 stated CNA #2 did not call for help and other staff were there to help if needed. RN #5 stated CNA #2 was a new CNA and did not follow Resident #47's plan of care. LPN #2, the unit charge nurse on the 11 PM-7 AM shift, was interviewed on 1/13/2023 at 10:30 AM. LPN #2 stated they (LPN #2) responded to CNA #2's call for help after Resident #47 fell out of bed. LPN #2 stated Resident #47 was a two-person assist for bed mobility and CNA #2 did not call anyone for help when providing incontinence care. Review of CNA #2 Inservice Attendance Record dated 4/4/2022 indicated the CNA received education on the following topics: see accountability record for safe patient handling and transfers and read accountability record before starting care. Physician #2 was interviewed on 1/13/2023 at 10:57 AM and stated that the CNA was supposed to follow the plan of care, but unfortunately accidents happen. The Current Director of Nursing Services (DNS) was interviewed on 1/13/2023 at 11:53 AM and stated when the staff are in a rush, some of them do what they want to do, especially in the morning when there is a lot of rushing. The DNS stated it is not that staff are not aware, they (staff) are supposed to follow the care plan. The DNS stated the CNAs know they are supposed to follow the plan of care or ask a co-worker if they are not sure. The DNS further stated the resident sustained [REDACTED].#2 did not follow the plan of care and ask for help when providing care to the resident. 10 NYCRR 415.12(h)(2) | Plan of Correction: ApprovedMarch 3, 2023 1)WHAT CORRECTIVE ACTIONS WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE - Residents # 47 was immediately transferred to the hospital for evaluation after MD was notified on 6/8/22. -The CNA involved with resident #47 was terminated. 2) HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PARACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN -All residents have the potential be affected by this deficient practice. -Facility wide CNA accountability record audit was completed by the DON on bed mobility, to include all residents was done to ensure accuracy. -Rehab director checked to make sure all orders for bed mobility are accurate -The DON/designee reviewed all CNA documentation to ensure proper implementation of the care plan. 3)WHAT MEASURES WILL BE PUT IN PLACE OR WHAT SYSTEMIC CHANGES YOU WILL MAKE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR -Inservice will be done by DON/designee for all CNAÆs to include safe patient handling and effective implementation of plan of care. -All nurses will be in-serviced by DON/designee to ensure that CNAÆs are supervised during provision of care to ensure proper implementation of care plan -The policy and procedure on ADL care was reviewed and no revision was necessary. 4 ) HOW THE CORRECTIVE ACTIONS WILL BE MONITORED TO ENSURED THE DEFICIENT PRACTICE WILL NOT RECUR, IE, WHAT QUALITY ASSURANCE PROGRAM WILL BE PUT INTO PRACTICE. - 10% of CNAÆs will be observed for bed mobility performance and effective implementation of plan of care weekly times 3 months and monthly there after x 6 months. -Any negative findings will be corrected immediately and will be reported to the quarterly QA committee. 5)THE DATE FOR CORRECTION AND THE TITLE OF THE PERSON RESPONSIBLE FOR CORRECTION OF EACH DEFICIENCY. 5. Director of Nursing/designee will be responsible to correct this deficiency. 3/14/23 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2023
Corrected date: March 14, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 1/5/2023 and completed on 1/13/2023 the facility did not ensure for influenza vaccine that each resident's medical record indicated either the resident received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. This was identified for one (Resident #104) of five residents reviewed for influenza vaccine; and for Pneumococcal vaccine the facility did not ensure that each resident's medical record indicated either the resident received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal for two (Resident #104 and #99) of five residents reviewed for pneumococcal vaccine. The findings are: The facility's policy dated 12/2021, titled Influenza Vaccination (seasonal flu), documented all new admissions will be assessed for the need for this vaccine as part of the admission medical work-up; and documentation of the vaccine will be noted in the Medication Administration Record, [REDACTED]. The facility's undated policy titled Immunization Specific to Pneumococcal Vaccines documented that on admission, annually, and with significant change the nursing department will review the resident's pneumococcal vaccination history; and each resident will have an immunization care plan, and this will be updated accordingly, and each resident will have all immunizations listed in the electronic medical record. 1a) Resident #104 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. The MDS assessment documented the influenza vaccine was not administered in the facility and was not offered in the facility. The pneumococcal vaccine was not up to date and the vaccine was not offered in the facility. Review of the nursing admission assessment dated [DATE] revealed documented that the resident/representative were not educated regarding the influenza and pneumococcal vaccines and did not receive an opportunity to consent or decline the vaccines. Licensed Practical Nurse (LPN) #1, unit charge nurse, was interviewed on 1/6/2023 at 1:05 PM. LPN #1 reviewed Resident #104's medical record and stated there was no documentation of whether the resident received the influenza vaccine. LPN #1 stated they (LPN #1) were not sure if the vaccine was offered, and that Resident #104 may have received the influenza vaccine before admission. A nursing progress note, written by Registered Nurse (RN) #1, dated 1/9/2023 at 8:29 AM documented they (RN #1) spoke to the resident's family regarding the 2022 flu shot. The family member stated the vaccine was declined upon admission because the resident was previously vaccinated by their (Resident #104) primary care physician in community. The progress note indicated that the flu shot was administered on 9/24/2022. RN #1, unit supervisor, was interviewed on 1/9/2023 at 9:05 AM. RN #1 stated whoever did the admission failed to put the vaccination status in the admission note and assessment. 1b) Review of a vaccination history document provided by a community physician for Resident #104 revealed that the resident received the pneumococcal vaccine on 10/26/2015. A nursing progress note written by RN #3 dated 1/9/2023 at 11:56 AM documented the writer spoke to the resident's family member and the family member agreed that Resident #104 can get the pneumococcal vaccine in the facility as the last pneumococcal vaccination was given on 10/26/2015. The facility physician was made aware and ordered the pneumococcal vaccine on 1/9/2023. RN #2, who was the evening RN supervisor/ admission nurse, was interviewed on 1/13/2023 at 8:27 AM. RN #2 stated the resident spoke Italian and RN #2 had left a message with the family regarding the vaccines. RN #2 stated admissions usually come in late in the day, so follow up the next day regarding vaccine status is usually needed. RN #2 stated Social Work is supposed to follow up. 2.) Resident #99 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS assessment documented the pneumococcal vaccine was not up to date and the vaccine was not offered in the facility. The nursing admission assessment dated [DATE] revealed no documentation for the pneumococcal vaccine. There was no documentation in the medical record that the resident was offered and or received the pneumococcal vaccine. Registered Nurse (RN) #3 (unit supervisor) was interviewed on 1/9/2023 at 2:31 PM and stated there was nothing in the medical record regarding the status of the pneumococcal vaccine for Resident #99, so we just asked the resident today (1/9/2023) and the resident declined the vaccine. RN #1, the admission nurse, was interviewed on 1/12/2023 at 1:35 PM and stated there was no determination of the resident's pneumococcal vaccination status upon admission. RN #1 further stated sometimes the information is not available at admission and it has to be followed up. The current DNS was interviewed on 1/13/2023 at 2:09 PM and stated they (DNS) thought the former DNS followed up the resident vaccine status after an admission. The DNS stated going forward the RN supervisors will be responsible to follow up on the residents' vaccination status. 10 NYCRR 415.19(a)(3) | Plan of Correction: ApprovedMarch 3, 2023 1) WHAT CORRECTIVE ACTIONS WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE. -Resident #104 received the influenza vaccine prior to admission on 9/24/22. -Resident # 104 was educated reference to benefits and potential side effects of Pneumococcal vaccine, and agreed and was administer on 1/14/23. This were both documented on the resident medical record. - Resident #99 was provided education in reference to benefits and potential side effects of Pneumococcal immunization, however refused on 1/10/23. This was documented on resident record. 2) HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN -All residents have the potential to be affected by this deficient practice. -All new admissions between 11/1/22 to 1/31/23 and all current residents were reviewed to ensure accurate documentation is in place regarding influenza and pneumococcal vaccine, immunizations or refusals. 3)WHAT MEASURES WILL BE PUT IN PLACE OR WHAT SYSTEMIC CHANGES YOU WILL MAKE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR -All nurses will be in serviced by the IP/designee on proper protocols for influenza and pneumococcal immunization to ensure that accurate documentation of acceptance/refusal is recorded in medical chart. -As part of the admission process /intake residents/resident representative will be asked by the admitting Nurse if they received influenza and pneumococcal vaccines. Documentation will be entered in medical chart. -If not received, resident and resident representative will be educated regarding benefits and potential side effects of influenza and pneumococcal immunization. -Resident or resident representative will be offered influenza and pneumococcal immunization following the department of health guidelines on appropriate dates. -All issues with refusals and acceptance will be followed up by the Unit Manager 24-48 hours after admission and documented in the medical chart. -Residents PCP/representative will be contacted to ensure proper documentation of immunization in the medical record. -The IP Registered Nurse will ensure that each unit manager follow up on all vaccination/refusals and check for proper documentation. -Policy and Procedure on Immunization of prevention of Influenza and Pneumococcal vaccines was reviewed by IP and no revision was necessary. 4)HOW THE CORRECTIVE ACTIONS WILL BE MONITORED TO ENSURED THE DEFICIENT PRACTICE WILL NOT RECUR, IE, WHAT QUALITY ASSURANCE PROGRAM WILL BE PUT INTO PRACTICE. -All admissions will be audited monthly for 3 months by IP/designee. -All negative findings will be corrected immediately and will be reported to the quarterly QA committee. 5)THE DATE FOR CORRECTION AND THE TITLE OF THE PERSON RESPONSIBLE FOR CORRECTION OF EACH DEFICIENCY. -The Infection Preventionist will be responsible to correct this deficiency. 3/14/23 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2023
Corrected date: March 14, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY 723) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that all alleged violations were thoroughly investigated for one (Resident #21) of one resident reviewed for Change of Condition. Specifically, Resident #21 was identified with swelling and pain of the right lower extremity beginning on 3/8/2022. An x-ray of the right lower extremity was not ordered until 3/15/2022, upon which a [MEDICAL CONDITION] tibia was identified. The accident and incident (A/I) investigation dated 3/18/2022 concluded that no abuse, neglect, or mistreatment had occurred; however, interviews with staff only went back to 3/14/2022, and not to when the pain and swelling initially started on 3/8/2022. The finding is: Resident #21 was admitted with [DIAGNOSES REDACTED]. The 3/10/2022 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident had severely impaired cognitive decision-making skills. The MDS documented the resident required extensive assistance of two staff members for bed mobility and transfers, was non-ambulatory and had no falls. The MDS indicated the resident utilizes wheelchair for locomotion when out of bed. A nursing progress note written by Registered Nurse (RN) #1 on 3/8/2022 at 8:32 AM documented Resident #21 was alert and responsive and complained of pain in the right foot. Upon examination right foot had [MEDICAL CONDITION], was warm to touch, and very tender. Pedal pulses were present and equal bilaterally. Physician notified and ordered [MEDICATION NAME] 400 milligram (mg) as a onetime dose and stat (immediate) laboratory blood work. A nursing progress note dated 3/9/2022 at 6:18 AM documented the laboratory blood work results were received and reviewed with the Physician with no new orders were obtained. A nursing note written by RN #1 dated 3/10/2022 at 2:06 PM documented the resident was alert and responsive. The resident's right foot remains swollen and tender to touch. Blood work was completed and was within normal limits. The Physician notified and ordered Tylenol 650 mg every 6 hours as needed for pain and to elevate the foot while in bed. A nursing note written by RN #1 dated 3/11/2022 at 2:15 PM documented the resident's right foot remains swollen and tender to touch. Orders were in place for Tylenol 650 mg every 6 hours as needed for pain and to elevate the foot while in bed. A nursing note written by the wound RN on 3/15/2022 at 12:02 PM documented Resident #21 was seen and examined by the wound care physician for evaluation of right lower extremity pain and tenderness. The Right ankle and right distal leg were identified with tenderness and warmth compared to the left leg. A nursing note written by RN #1 on 3/15/2022 at 12:41 PM documented resident alert and responsive. Seen today by Wound Care/Vascular Physician. Suggested ordering a right lower extremity Venous Doppler and Physician (#1) was in agreement. A STAT Portable x-ray was ordered and to be completed today. A nursing note dated 3/15/2022 at 7:56 PM documented the x-ray and venous Doppler results were received and Physician #1 was made aware. X-ray of the right ankle revealed an acute nondisplaced spiral distal tibial fracture. A new order was obtained to transfer the resident to the hospital. This fracture was reported to the New York State Department of Health on 3/16/2022 as an injury of unknown origin (NY 723). Review of the A/I report dated 3/18/2022, and signed by the former Director of Nursing Services (DNS), documented the investigation was completed. The facility concluded that no abuse, neglect, or mistreatment regarding this resident occurred. There was no care plan violation. Review of the A/I report revealed that the interviews with staff went back to 3/14/2022, not to when the swelling and pain were first identified on 3/8/2022. Registered Nurse (RN) #4 was interviewed on 1/10/2923 at 12:49 PM and stated they are the wound care nurse, and they currently perform the accident investigations for the facility. RN #4 stated they (RN #4) were not doing the accident and incident investigations in (MONTH) 2022 when the incident related to Resident #21 occurred. RN #4 stated they (RN #4) did not know why the investigation did not go back to 3/8/2022 when the pain and swelling were first identified. RN #4 further stated it was the former DNS's error for not going back to 3/8/2022. The current DNS was interviewed on 1/10/2023 at 2:20 PM and stated the investigation should have included interviews with staff going back to 48 hours before 3/8/2022 when the pain and swelling were first identified. 10NYCRR 415.4(b) | Plan of Correction: ApprovedMarch 3, 2023 1) WHAT CORRECTIVE ACTIONS WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE. -An incident report was completed for resident #21. -Staff interviews and statements will be collected from 3/6 /2022 through 3/8/2022, which is seventy-two (72) hours prior to residents initial compliant of pain, that occurred on 3/8/22. -The nurse manager responsible for initiating the A/I report was in-serviced by the Director of Nursing on how to conduct a complete and thorough investigation. - Upon resident return to facility on 3/16/22, transfer status was changed to hoyer lift with assist of two. 2)HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN. -All residents have the potential to be affected by the same deficient practice. - All A/I with injuries from (MONTH) 2023 to current were audited by the DON to ensure that investigation was done thoroughly. -All nurses were educated by Director of Nursing on the following: -Proper identification of injuries, example, pain, swelling to initiate an incident report - Correct time frame to collect statement (emphasized, if the injury is confirmed at a later date, investigation must begin at the time resident initially complained of pain and statements collected 72 hours prior. 3)WHAT MEASURES WILL BE PUT IN PLACE OR WHAT SYSTEMIC CHANGES YOU WILL MAKE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR. -The DON /designee will in-service all nurses on a thorough and proper investigation of all incidents to include: -Proper identification of injuries, example, pain, swelling to initiate an incident report - Correct time frame to collect statement (emphasized, if the injury is confirmed at a later date, investigation must begin at the time resident initially complained of pain and statements collected 72 hours prior. -The policy and procedure for investigation of accident and Incident was reviewed, no revision were necessary. 4 )HOW THE CORRECTIVE ACTIONS WILL BE MONITORED TO ENSURED THE DEFICIENT PRACTICE WILL NOT RECUR, IE, WHAT QUALITY ASSURANCE PROGRAM WILL BE PUT INTO PRACTICE. - The DON will ensure that all A/I investigative summaries must be accompanied by a completed accident and incident report. -The Director of nursing/designee will ensure all A/IÆs are completed thoroughly to rule out abuse, neglect or exploitation in timely fashion -The facility initiated an audit tool to be used to audit all A/I weekly x 3 months. -All negative findings will be corrected immediately and findings will be presented to the QA committee quarterly. 5)THE DATE FOR CORRECTION AND THE TITLE OF THE PERSON RESPONSIBLE FOR CORRECTION OF EACH DEFICIENCY. 5. Director Of Nursing/Designee- 03/14/23 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2023
Corrected date: March 14, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY 705) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that each resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for one (Resident #163) of two residents reviewed for Nutrition. Specifically, Resident #163 had a 14% significant weight loss in one month, identified in (MONTH) 2021, which was not addressed by the Registered Dietitian (RD) until (MONTH) 2022. The finding is: The facility's policy titled, Monthly Weight and Vital Sign Policy and Procedure last reviewed on 1/2021 documented that the Nurse would notify the Physician and Dietitian of any 5 pounds (lbs)/5% weight changes. The policy also documented that once weights are completed, they will be given to the Dietitian. The Dietitian will enter the weights into the Electronic Medical Record and document the weight on the monthly weight sheet. The facility's policy titled, Unplanned Significant Weight Changes last reviewed on 11/2021 documented that a significant weight loss is defined as a 5% weight loss in one month or more and a 10% loss in 6 months. The policy also documented that the Dietitian will complete a comprehensive assessment and based on the findings, the Dietitian will determine the need for further interventions. Resident #163 has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance of one person for eating. The resident's height was 70 inches and they weighed 180 pounds. The MDS documented the resident had loss of liquids/solids from mouth when eating or drinking; was holding food in mouth/cheeks or residual food in mouth after meals; and exhibited coughing or choking during meals or when swallowing medications. The quarterly MDS assessment dated [DATE] documented that the resident had a BIMS score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident was totally dependent on one person for eating. The resident's height was 70 inches and they now weighed 150 pounds, a decrease of 30 lbs since the 11/4/2021 MDS assessment. The MDS documented the resident had loss of liquids/solids from mouth when eating or drinking; was holding food in mouth/cheeks or residual food in mouth after meals; and exhibited coughing or choking during meals or when swallowing medications. The MDS also documented that there was a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and that the resident was not on a physician prescribed weight-loss regimen. The resident's Weight Monitoring Report documented that on 10/20/2021 the resident weighed 180 lbs and on 12/10/2021 the resident weighed 158 lbs which indicated a 22 lbs or a 14% significant weight loss in two months. The resident's current diet orders dated 12/22/2021 documented Diet: No Concentrated Sweets (NCS), Food Consistency: Ground (No Bread), and Fluid Consistency: Thin Liquids. The Speech Therapy Progress Note dated 1/12/2022 recommended a diet change from ground solids (no bread) and thin liquids to puree solids and nectar thick liquids secondary to a change in the resident's cognitive status. The resident's diet orders dated 1/12/2022 documented Diet: NCS, Food Consistency: Puree, and Fluid Consistency: Nectar Thickened. The resident's Weight Monitoring Report documented that on 1/14/2022 the resident weighed 150 lbs which indicated an additional 8 lb or 5% significant weight loss in one month. The Speech Therapy Progress Note dated 1/14/2022 at 4:26 PM recommended a diet change from nectar thickened liquids to honey thickened liquids due to an increased aspiration risk. Speech Language Pathologist (SLP) observed excessive coughing post swallow of nectar thick liquids. The resident's diet orders dated 1/14/2022 documented Diet: NCS, Food Consistency: Puree, and Fluid Consistency: Honey Thickened. The Weight Change/Quarterly Nutrition assessment dated [DATE], written by Registered Dietitian (RD) #2, documented that the resident's Current Body Weight (CBW): 150 lbs, Height: 70 inches, Ideal Body Weight Range (IBWr): 149-183 lbs, and the Body Mass Index (BMI): 21.5 (categorized as normal body weight; BMI>20 is desirable given advanced age). The evaluation by RD #2 documented that the resident presented with a weight change of (-30 lbs, -20% loss) x 3 months, and (-30 lbs, -20% loss) x 6 months; weight change (x 3 and 6 months) was clinically significant, unplanned, and undesirable, questioned the accuracy of weighs/weight status and a reweigh for the resident for (MONTH) was currently pending. The weight loss was likely related to the resident's variable oral (po) intake, mechanically altered diet, disease process, [MEDICAL CONDITION], Dementia, and recent positive COVID-19 diagnosis. The Brief Nutrition Note dated 1/17/2022, written by RD #2, documented concerns regarding the resident's weight loss and nutrition status were discussed with the resident's family, food preferences were obtained, and Glucerna shakes (a nutritional supplement) would be provided twice daily to aid in optimizing the resident's intake and weight status. The resident's diet order dated 1/17/2022 documented Supplement: Honey Thickened Glucerna 8 ounces (oz) by mouth twice daily (BID). The 3rd Floor Registered Nurse (RN) #7, Charge Nurse, was interviewed on 1/10/2023 at 3:00 PM and stated that monthly weights are started at the end of each month by the 30th or 31st and finished by the 5th of the following month. RN #7 stated that if there is a weight discrepancy, reweights are done by the 10th of the month. RN #7 stated that the weights are written on a weight worksheet, and they (RN #7) would check if they could find the old weight worksheets for 2021 to see why the resident was not weighed for (MONTH) 2021 and why no reweights had been done to check the accuracy of the weights when the resident had lost 22 lbs between (MONTH) and (MONTH) 2021 and another 8 lbs between (MONTH) 2021 and (MONTH) 2022. RN #7 was re-interviewed on 1/10/2023 at 4:05 PM and stated that they (RN #7) did not see any documentation in the resident's EMR, nor were they (RN #7) able to find any weight worksheets to explain why there was no weight taken for the resident in (MONTH) 2021 and why no reweights were done to address the resident's significant weight loss. RN #7 was re-interviewed again on 1/11/2023 at 10:00 AM and stated that during October, November, and (MONTH) 2021 the RD would enter the weights into the EMR. RN #7 stated that if there is a discrepancy of more than 2 pounds, they (RN #7) would ask for a reweigh. If a significant weight loss was seen, they (RN #7) would notify the Primary Care Physician (PCP) with a phone call and write a progress note in the EMR. RN #7 could not explain why they (RN #7) did not write a progress note regarding the resident's weight loss and notification to the PCP. The facility's current RD (RD #1) was interviewed on 1/11/2023 at 10:45 AM and stated by looking into the resident's EMR, a weight in (MONTH) 2021 was never obtained nor was there a re-weight for the (MONTH) 2021 weight. RD #1 stated there should have been a note written by the RD at that time (RD #2) stating that a reweight was pending and some kind of intervention put into place in (MONTH) of 2021 when the 22 lbs. weight loss was seen. RD #1 stated that the resident's family should have been called first to get food preferences and to tell them (the family) if there was a confirmed weight loss and put an intervention in place first while waiting for a reweigh such as giving a Mighty Shake (a high calorie shake) in between meals at 10:30 AM, 2:30 PM, and 8:30 PM. The facility's previous RD (RD #2) was interviewed on 1/11/2023 at 3:00 PM and stated that if they (RD #2) had known about the weight or seen the significant weight loss in (MONTH) 2021, they (RD #2) would have documented the findings. RD #2 stated that they (RD #2) were in charge of putting all of the weights into the EMR. RD #2 stated that Resident #163's weight of 158 lbs. in (MONTH) of 2021 was a 14% weight loss in two months, which was significant. RD #2 could not say why they (RD #2) missed the resident's initial weight loss in (MONTH) 2021. RD #2 stated that had they (RD #2) seen the resident's weight loss in (MONTH) 2021, they (RD #2) would have discussed meal preferences with resident's family, initiated a supplement, liberalized their (Resident #163) diet if possible, seen if there was anything they (RD #2) could work on with the speech therapist, and start Resident #163 on weekly weights. The Director of Nursing Services (DNS) was interviewed on 1/12/2023 at 10:00 AM and stated that Nursing staff communicates with the PCP when there is a weight loss. The DNS stated that the weight scale should be checked if there was something wrong, maybe the weight scale was not balanced. The DNS stated that a re-weigh for the resident should have been obtained. The DNS stated that the resident should also have been looked at to see how much the resident was eating at meals at the time and the RD should have been notified. The DNS further stated that if there was a change in the resident's weight of plus or minus 5 lbs. in a month, the resident should have been reweighed. 10 NYCRR 415.12(i)(1) | Plan of Correction: ApprovedMarch 3, 2023 1)WHAT CORRECTIVE ACTIONS WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE. -Residents # 163 has been discharged from the facility on 2/9/22. - The nurse manager, CNAÆs and dietician of resident #163 were in-serviced by the DON on procedure on collecting weights, reweights, communication of weight loss and implementation of intervention. 2)HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PARACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN -All residents have the potential to be affected by this deficient practice. -The dietician reviewed all residents weight records and identified all residents with significant weight loss - No other residents were noted with missing weights. -All residents with significant weight loss were reweighed and checked for accuracy. -Moving forward any residents with a weight loss of 5 pounds or more will have a reweight done within 24-48 hours. -The dietician will notify nursing of any significant weight loss and nursing will notify the physician. 3)WHAT MEASURES WILL BE PUT IN PLACE OR WHAT SYSTEMIC CHANGES YOU WILL MAKE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR -The policy and procedure for the unplanned significant weight changes was reviewed and revised. - All nursing, CNAÆs and dietician staff will be in-serviced by the DON/designee on revised policy for unplanned significant weight changes. - A communication tool was formulated, to be utilized by the dietician in notifying nursing of significant weight loss. -Dietician/designee will provide a weekly update for residents triggering for significant weight loss to nursing. -Nursing with notify the physician of all residents with weight loss and implement intervention as needed. 4)HOW THE CORRECTIVE ACTIONS WILL BE MONITORED TO ENSURED THE DEFICIENT PRACTICE WILL NOT RECUR, IE, WHAT QUALITY ASSURANCE PROGRAM WILL BE PUT INTO PRACTICE. -The dietician will monitor that monthly weights are completed by the 10th of each month. - Dietician will review the weight roster and enter weights into EMR and document on monthly weight sheet. - The dietician/designee will audit all residents weight and communicate with nursing the names of residents with significant weight loss weekly x4 weeks, then monthly X 3 months thereafter. -The DON/designee will ensure that physician has addressed weight loss and proper intervention, are put in place, weekly X 4 weeks, then monthly X 3 months thereafter. -All negative findings will be corrected immediately and reported to the quarterly QA committee. 5)THE DATE FOR CORRECTION AND THE TITLE OF THE PERSON RESPONSIBLE FOR CORRECTION OF EACH DEFICIENCY. 5. Dietician /designee will be responsible for this corrective action- 03/14/23. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2023
Corrected date: March 14, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY 723) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #21) of one resident reviewed for Change of Condition. Specifically, Resident #21 was identified with swelling and pain of the right lower extremity beginning on 3/8/2022. The resident continued to participate in Physical Therapy (PT), standing on both lower extremities, and was performing transfers from once surface to another (bed/chair) on the nursing unit daily. The resident was complaining of pain to the right lower extremity during the PT and during transfers. The resident was evaluated by the Physician on 3/8/2022, 3/10/2022 and 3/15/2022. An x-ray of the right lower extremity and Doppler study were ordered on [DATE], seven days after the pain and swelling was first identified. The x-ray results identified a [MEDICAL CONDITION] tibia. The finding is: Resident #21 was admitted with [DIAGNOSES REDACTED]. The 3/10/2022 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident had severely impaired cognitive decision-making skills. The MDS documented the resident required extensive assistance of two staff members for bed mobility and transfers, was non ambulatory and had no falls. The MDS indicated the resident utilizes wheelchair for locomotion when out of bed. A wound care nursing note dated 3/1/2022 at 12:14 PM documented Resident #21 was seen and examined by the wound care/vascular Physician (MD) for bilateral lower extremity discoloration and dry scabs to bilateral lateral feet. Both lower extremities were examined and noted with Varicose veins, chronic [MEDICAL CONDITION] and discolorations at the ankle and dorsum (top) of both feet. There were spider reticular veins and dark dry scabs covering the lateral feet. No open wounds. Dorsalis pedis pulses positive, no [MEDICAL CONDITION], no [MEDICAL CONDITION]. The feet and toes were warm with no leg [MEDICAL CONDITION] present. Impression: chronic [MEDICAL CONDITION], varicose veins and changes of chronic [MEDICAL CONDITION] with healing superficial skin ulcers. Treatment in progress with dry protective dressing and Ace wraps to bilateral lower extremities. A Rehabilitation-Physical Therapy (PT) progress note dated 3/4/2022 documented Resident #21 stood with a rolling walker and one person assistance full weight bearing on both lower extremities. The resident had no pain. A nursing progress note written by Registered Nurse (RN) #1 on 3/8/2022 at 8:32 AM documented Resident #21 was alert and responsive and complained of pain in the right foot. Upon examination right foot had [MEDICAL CONDITION], was warm to touch, and very tender. Pedal pulses were present and equal bilaterally. Physician notified and ordered [MEDICATION NAME] 400 milligram (mg) as a onetime dose and stat (immediate) laboratory blood work. A Physician note (Physician #1) dated 3/8/2022 at 4:39 PM documented Resident #21 had left foot redness, pain, and swelling. The resident had no history of trauma. The resident had been evaluated by a vascular surgeon on 3/2/2022 with no clinical evidence of [MEDICAL CONDITION]. Ace wrap and dry protective dressing ordered for daytime for both lower extremities. Further work-up and prescription as per clinical course. A nursing progress note dated 3/9/2022 at 6:18 AM documented the laboratory blood work results were received and reviewed with the Physician with no new orders obtained. A PT discharge summary dated 3/10/2022 documented Resident #21 stood full weight bearing on both lower extremities for 20 seconds; however, now required maximum assistance of two staff members. The resident was complaining of right lower leg and right foot pain. The discharge summary recommended for the resident to get out of bed daily to the wheelchair, begin Restorative Nursing Program for active assistive range of motion to bilateral upper and lower extremities and a standing program. A nursing note dated 3/10/2022 at 7:53 AM documented Resident #21 was discharged from Occupational Therapy (OT)/PT. Recommendations were to provide a Restorative Nursing Program for Transfers/Standing Program, 20 seconds with extensive assistance of 2 persons using handrails, 6 days per week. A nursing note written by RN #1 dated 3/10/2022 at 2:06 PM documented the resident was alert and responsive. The resident's right foot remains swollen and tender to touch. The Physician was notified and ordered Tylenol 650 mg every 6 hours as needed for pain and to elevate the foot while in bed. A nursing note written by RN #1 dated 3/11/2022 at 2:15 PM documented the resident's right foot remains swollen and tender to touch. Orders were in place for Tylenol 650 mg every 6 hours as needed for pain and to elevate the foot while in bed. Physician #1's note dated 3/11/2022 at 3:55 PM documented the resident continues with right foot pain episodically. The resident was discussed with the RN and was given Tylenol with good results. The assessment/plan for the right foot included Osteo Arthritis (OA). Further adjustments as per clinical course. A nursing note written by the wound RN on 3/15/2022 at 12:02 PM documented Resident #21 was seen and examined by the wound care physician for evaluation of right lower extremity pain and tenderness. The Right ankle and right distal leg were identified with tenderness and warmth compared to the left leg. A nursing note written by RN #1 on 3/15/2022 at 12:41 PM documented resident alert and responsive. Seen today by Wound Care/Vascular Physician. Suggested ordering a right lower extremity Venous Doppler and Physician (#1) was in agreement. A STAT (immediate) portable x-ray was ordered and to be completed today. Physician #1's note dated 3/15/2022 at 3:22 PM documented the resident continues with right foot pain, no history of trauma, diffuse tenderness to the dorsal aspect of the right foot and lateral malleolar area. The plan for the right foot pain was to check x-rays and a Doppler study was already ordered by the vascular surgeon. A nursing note dated 3/15/2022 at 7:56 PM documented the x-ray and venous Doppler results were received and Physician #1 was made aware. X-ray of the right ankle revealed an acute nondisplaced spiral distal tibial fracture. A new order was obtained to transfer the resident to the hospital. A Rehabilitation evaluation dated 3/16/2022, upon the resident's return from the hospital, documented that the resident had a cast in place to the right lower extremity, was non-weight bearing to right lower extremity, and was to follow up with the Orthopedic Surgeon in one week. RN #1 (unit supervisor) was interviewed on 1/10/2023 at 12:20 PM and stated the x-ray was not considered initially because there was no trauma, like an accident or fall, and the pain was treated as arthritic pain. RN #1 stated when the pain persisted the x-ray was ordered. RN #1 stated when the resident was transferred out of bed, the resident would complain about pain to the CNA, and even when the resident was being moved in bed the resident would complain of pain to the CNA. RN #1 stated the CNA reported the pain to me (RN #1) and RN #1 reported it to the doctor. RN #1 stated on 3/15/2022 the wound care physician and the Primary Care Physician discussed Resident #21 and decided to order an x-ray. RN #1 further stated as far as they (RN #1) know transfers were not stopped when the resident complained about pain because there was no Physician's order for non-weight bearing. Review of the CNA Accountability record from 3/8/2022-3/15/2022 revealed that the resident was transferred from bed to chair and chair to bed daily with extensive assistance of two persons. Physician #1 was interviewed on 1/10/2023 at 1:22 PM and stated that an x-ray was not initially ordered because there was not a high index of suspicion of a fracture because there were no falls or accidents, and the suspicion of a fracture was remote. Physician #1 stated in the setting of trauma, an x-ray would be done, but in the absence of trauma, things were done to determine if there was something else going on like a clot, which is more significant. Physician #1 stated an order for [REDACTED]. The current Director of Nursing Services (DNS) was interviewed on 1/10/2023 at 2:20 PM and stated an x-ray should have been ordered initially to rule out a fracture. The DNS stated they (DNS) would have fought with the doctor for an x-ray order because we are all clinicians. The DNS stated transfer status is based on what the Rehabilitation Department (Rehab) assessment indicates, and Rehabilitation did not say to stop transfers after the resident was discharged from therapy. Physician #1 was reinterviewed on 1/11/2023 at 8:23 AM and was asked if a clot was a concern, why was the venous Doppler ordered on [DATE] instead of 3/8/2022 when the pain and swelling started. Physician #1 stated a venous Doppler was not ordered sooner because maybe the pain and swelling were not as accentuated, but as time progressed and the pain and swelling did not resolve, or the pain worsened, that is when the venous Doppler was ordered. The Rehabilitation Director was interviewed on 1/11/2023 at 9:59 AM and stated the 3/10/2022 PT discharge note documented pain in the right lower leg. The Rehabilitation Director stated we did not know what was going on because there was no x-ray and the resident was still able to stand with extensive assist of two persons. The PT note documented that the resident stood for 20 seconds with maximum assistance of two persons. The Rehabilitation Director stated if we notice pain, we report it to nurse and nurse tells the doctor and that Rehabilitation Department does not communicate with the doctor. The Rehabilitation Director stated the pain was probably the reason why therapy was discontinued because the resident's status was not improving, and the resident reached maximum potential. The resident was placed on active assistive range of motion because the resident's pain was inconsistent, and the PT wanted to keep the resident active. The Rehabilitation Director stated we just inform the nurse about the pain by phone call; we do not say what is needed or recommended like an x-ray. Certified Nursing Assistant (CNA) #1 was interviewed on 1/11/2023 at 10:41 AM and stated they (CNA #1) were the one who reported to the nurse that the resident had pain in the right leg CNA #1 stated the resident would wince if you tried to move or touch the resident. CNA # 1 stated we just transferred the resident by having the resident step on the floor and pivot but did not do a standing program. CNA #1 could not recall if the resident complained of pain during the transfer process. PT #1 (treating therapist) and Rehabilitation Director were interviewed concurrently on 1/12/2023 at 10:30 AM. PT #1 stated the resident was not performing that well because of the pain in the right lower leg and kept on refusing to participate. PT #1 stated we did not know what was going on with the right leg. PT #1 stated the resident's pain was not consistent and they (PT #1) had documented in the therapy notes before discharge that the resident had pain. PT #1 stated they (PT #1) recommended a nursing rehab program after discharge because they (PT #1) did not want the resident to stop activities. PT #1 stated that nursing was aware of the pain in the right leg. PT #1 stated they (PT #1) did speak to a nurse on the unit regarding the resident's pain, but PT #1 did not document the conversation and did not remember who the nurse was. PT #1 stated that as long as the resident was able to tolerate the program and there was nothing excruciating, they (PT #1) did not recommend an x-ray to the nurse. 10NYCRR 415.12 | Plan of Correction: ApprovedMarch 3, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1)WHAT CORRECTIVE ACTIONS WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE. -Resident #21 was evaluated by MD on 3/8/22 for pain. -Pain medication was ordered and administered. -A doppler was ordered on [DATE] results negative -X-ray was done on 3/15/22 results positive for fracture and resident was sent to hospital immediately for further management. -Resident returned to facility 3/16/22 after Emergency visit, transfer status changed to hoyer lift with assist of two. -Nurse manager, nurses, CNAÆs and Rehab staff were in-serviced on proper treatment and care of residents with signs and symptoms of injury such as pain and swelling. 2)HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN -All residents have the potential to be affected by the same deficient practice. -All residents with swelling, redness or acute complaints of pain to extremities will be reviewed in morning report daily. -The DON will log all resident identified with swelling, redness or acute complain of pain to extremities daily to ensure that treatment was provided. 3)WHAT MEASURES WILL BE PUT IN PLACE OR WHAT SYSTEMIC CHANGES YOU WILL MAKE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR In-service will be given by DON/designee to all nurses, CNAÆs and rehab staff on procedure to follow after identification of signs of injury and of pain. -All residents will be assessed for pain during rehab. -If pain is identified rehab will communicate with nursing and therapy will be withheld and care plan will be modified, until resident is evaluated by physician. -The nurse will communicate with Physician in reference to pain, and the physician will ensure that appropriate interventions is in place accordance with professional standard of practice. -Rehab will reassess the resident and revise the plan of care for therapy as needed. -The policy and procedure on pain assessment was reviewed and revised. -All nurses, CNAÆs and Rehab staff was in-serviced on the revised policy by the DON/designee. 4 ) HOW THE CORRECTIVE ACTIONS WILL BE MONITORED TO ENSURED THE DEFICIENT PRACTICE WILL NOT RECUR, IE, WHAT QUALITY ASSURANCE PROGRAM WILL BE PUT INTO PRACTICE. -An audit tool was created to identify any residents who complain of pain,swelling and redness daily based on the 24-hour report. -This audit will be conducted by the DON/designee daily x 3 months to ensure that each resident receive treatment and care in accordance with professional standards of practice. -All negative findings will be corrected immediately and reported to the quarterly QA committee. 5)THE DATE FOR CORRECTION AND THE TITLE OF THE PERSON RESPONSIBLE FOR CORRECTION OF EACH DEFICIENCY. 5.Director of Nursing/designee will be responsible to correct this deficiency. 3/14/23 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2023
Corrected date: March 14, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY 705) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that the medical care of each resident was supervised by the Physician including monitoring changes in the resident's medical status. This was identified for one (Resident #163) of two residents reviewed for Nutrition. Specifically, Resident #163 had a 14% significant weight loss in one month, identified in (MONTH) 2021, which was not addressed by their Primary Care Physician (PCP). Resident #163 had an additional 5% significant weight loss in one month, identified in (MONTH) 2022, and there was no documentation from the PCP addressing the resident's significant weight loss in a timely manner. The finding is: The facility's policy titled, Monthly Weight and Vital Sign Policy and Procedure last reviewed on 1/2021 documented that the Nurse would notify the Physician and Dietitian of any 5 pounds (lbs)/5% weight changes. The facility's policy titled, Unplanned Significant Weight Changes last reviewed on 11/2021 documented that a significant weight loss is defined as a 5% weight loss in one month or more and a 10% loss in 6 months. The policy also documented that the Physician should review the weight loss and based on the resident's diagnosis/prognosis, determine if the weight loss is unavoidable. Resident #163 has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance of one person for eating. The resident's height was 70 inches and they weighed 180 pounds. The MDS documented the resident had loss of liquids/solids from mouth when eating or drinking; was holding food in mouth/cheeks or residual food in mouth after meals; and exhibited coughing or choking during meals or when swallowing medications. The quarterly MDS assessment dated [DATE] documented that the resident had a BIMS score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident was totally dependent on one person for eating. The resident's height was 70 inches and they now weighed 150 pounds a decrease of 30 lbs since the 11/4/2021 MDS assessment. The MDS documented the resident had loss of liquids/solids from mouth when eating or drinking; was holding food in mouth/cheeks or residual food in mouth after meals; and exhibited coughing or choking during meals or when swallowing medications. The MDS also documented that there was a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and that the resident was not on a physician prescribed weight-loss regimen. The physician's orders [REDACTED]. The resident's Weight Monitoring Report documented that on 10/20/2021 the resident weighed 180 lbs and on 12/10/2021 the resident weighed 158 lbs which indicated a 22 lbs or a 14% significant weight loss in two months. The Medical Monthly Progress Note dated 12/22/2021, written by the resident's PCP (Physician #2), documented: Weight 180 lbs - No changes - observe only. The resident's current diet orders dated 12/22/2021 documented Diet: No Concentrated Sweets (NCS), Food Consistency: Ground (No Bread), and Fluid Consistency: Thin Liquids. The Speech Therapy Progress Note dated 1/12/2022 recommended a diet change from ground solids (no bread) and thin liquids to puree solids and nectar thick liquids secondary to a change in the resident's cognitive status. The resident's diet orders dated 1/12/2022 documented Diet: NCS, Food Consistency: Puree, and Fluid Consistency: Nectar Thickened. The resident's Weight Monitoring Report documented that on 1/14/2022 the resident weighed 150 lbs which indicated an additional 8 lb or 5% significant weight loss in one month. The Speech Therapy Progress Note dated 1/14/2022 at 4:26 PM recommended a diet change from nectar thickened liquids to honey thickened liquids due to an increased aspiration risk. Speech Language Pathologist (SLP) observed excessive coughing post swallow of nectar thick liquids. The resident's diet orders dated 1/14/2022 documented Diet: NCS, Food Consistency: Puree, and Fluid Consistency: Honey Thickened. The Medical Monthly Progress Note dated 1/14/2022 at 10:14 PM, written by the resident's PCP (Physician #2), documented: Weight 150 lbs - observe only. There was no further documentation in reference to the resident's weight. The Weight Change/Quarterly Nutrition assessment dated [DATE], written by Registered Dietitian (RD #2), documented that the resident's Current Body Weight (CBW): 150 lbs, Height: 70 inches, Ideal Body Weight Range (IBWr): 149-183 lbs, and the Body Mass Index (BMI): 21.5 (categorized as normal body weight; BMI>20 is desirable given advanced age). The evaluation by RD #2 documented that the resident presented with a weight change of (-30 lbs, -20% loss) x 3 months, and (-30 lbs, -20% loss) x 6 months; weight change (x 3 and 6 months) was clinically significant, unplanned, and undesirable, questioned the accuracy of weighs/weight status and a reweigh for the resident for (MONTH) was currently pending. The weight loss was likely related to the resident's variable oral (po) intake, mechanically altered diet, disease process, [MEDICAL CONDITION], Dementia, and recent positive COVID-19 diagnosis The Brief Nutrition Note dated 1/17/2022, written by RD #2, documented concerns regarding the resident's weight loss and nutrition status were discussed with the resident's family, food preferences were obtained, and Glucerna shakes (a nutritional supplement) would be provided twice daily to aid in optimizing the resident's intake and weight status. The resident's diet order dated 1/17/2022 documented Supplement: Honey Thickened Glucerna 8 ounces (oz) by mouth twice daily (BID). The Medical Progress Notes dated 1/17/2022, 1/19/2022, 1/21/2022, and 2/7/2022 written by the resident's PCP (Physician #2) documented that they were asked to see patient by staff for f/u (follow-up) eval (evaluation) with no documented evidence addressing the resident's significant weight loss. The Medical Progress note dated 3/6/2022 written by the resident's PCP (Physician #2) documented that the resident's family had taken the resident to the Emergency Department (ED) on 2/9/2022 for an undisclosed reason. The 3rd Floor Registered Nurse (RN #7) Charge Nurse was interviewed on 1/10/2023 at 3:00 PM and stated that monthly weights are started at the end of each month by the 30th or 31st and finished by the 5th of the following month. RN #7 stated that if there is a weight discrepancy, reweights are done by the 10th of the month. RN #7 stated that the weights are written on a weight worksheet, and they (RN #7) would check if they could find the old weight worksheets for 2021 to see why the resident was not weighed for (MONTH) 2021 and why no reweights had been done to check the accuracy of the weights when the resident had lost 22 lbs between (MONTH) and (MONTH) 2021 and another 8 lbs between (MONTH) 2021 and (MONTH) 2022. RN #7 was re-interviewed on 1/10/2023 at 4:05 PM and stated that they (RN #7) did not see any documentation in the resident's electronic medical record (EMR), nor were they (RN #7) able to find any weight worksheets to explain why there was no weight taken for the resident in (MONTH) 2021 and why no reweights were done to address the resident's significant weight loss. RN #7 was re-interviewed again on 1/11/2023 at 10:00 AM and stated that during October, November, and (MONTH) 2021 the RD would enter the weights into the EMR. RN #7 stated that if there is a discrepancy of more than 2 pounds, they (RN #7) would ask for a reweigh. If a significant weight loss was seen, they (RN #7) would notify the PCP with a phone call and write a progress note in the EMR. RN #7 could not explain why they (RN #7) did not write a progress note regarding the resident's weight loss and notification to the PCP. The facility's current RD (RD #1) was interviewed on 1/11/2023 at 10:45 AM and stated by looking into the resident's EMR, a weight in (MONTH) was never obtained nor was there a re-weight for the (MONTH) weight. RD #1 stated there should have been a note written by the RD at that time (RD #2) stating that a reweight was pending and some kind of intervention put into place in (MONTH) of 2021 when the 22 lb weight loss was seen. RD #1 stated that the resident's family should have been called first to get food preferences and to tell them (the family) if there was a confirmed weight loss and put an intervention in place first while waiting for a reweigh such as giving a Mighty Shake (a high calorie shake) in between meals at 10:30 AM, 2:30 PM, and 8:30 PM. Resident #163's PCP (Physician #2) was interviewed on 1/11/2023 at 1:13 PM and stated that the resident was on Comfort Measures since 7/30/2021 and guessed that was why they (Physician #2) were not too aggressive in treating them (Resident #163) for their weight loss. Physician #2 stated that it was very strange why they (Physician #2) did not acknowledge the resident's significant weight loss in (MONTH) of 2021 and could not explain why they (Physician #2) would just observe the resident's weight in (MONTH) 2022 when the resident had lost 20 lbs or 20% of their weight in 3 months. The Medical Director was interviewed on 1/11/2023 at 2:50 PM and stated that when Physician's document weights, they should refer to the weights in the EMR. The Medical Director stated that if a resident has a significant weight loss, it should be documented that it was discussed with family and in this case, that weight loss was expected because they (the resident) were on Comfort Care. The facility's prior RD (RD #2) was interviewed on 1/11/2023 at 3:00 PM and stated that if they (RD #2) had known about the weight or seen the significant weight loss in (MONTH) 2021, they (RD #2) would have documented. RD #2 stated that they (RD #2) were in charge of putting all of the weights into the EMR. RD #2 stated that Resident #163's weight of 158 lbs in (MONTH) of 2021 was a 14% weight loss in two months, which was significant. RD #2 could not say why they (RD #2) missed the resident's initial weight loss in (MONTH) 2021. The Director of Nursing Services (DNS) was interviewed on 1/12/2023 at 10:00 AM and stated that Nursing staff communicates with the PCP when there is a weight loss. The DNS stated that the weight scale should be checked if there was something wrong, maybe the weight scale was not balanced. The DNS stated that a re-weigh for the resident should have been obtained. The DNS stated that the resident should also have been looked at to see how much the resident was eating at meals at the time and the RD should have been notified. The DNS further stated that if there was a change in the resident's weight of plus or minus 5 lbs in a month, the resident should have been reweighed. 10 NYCRR 415.15(b)(1)(i)(ii) | Plan of Correction: ApprovedMarch 3, 2023 1) WHAT CORRECTIVE ACTIONS WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE. -Residents # 163 has been discharged from the facility on 2/9/22. -Medical Director educated physician assigned to resident #163 on addressing weight loss timely, intervention and documentation of outcome. 2) HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN -All residents have the potential to be affected by this deficient practice. -All residents with significant weight loss will be checked for accuracy and re-weigh as necessary. -Any weight loss of 5 pounds or more will have a reweight done within 24-48 hours. -Notification to the Physician will be made and addressed appropriately. -DON/designee will review the residents medical record to ensure that the physician has addressed the weight loss and interventions are in place. 3)WHAT MEASURES WILL BE PUT IN PLACE OR WHAT SYSTEMIC CHANGES YOU WILL MAKE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR -Policy and procedure on Physician services were reviewed and no changes were necessary. - All physicians will be in-serviced by the Medical Director on addressing weight loss timely, intervention and documentation of outcome. - DON/ designee In-serviced all nursing staff and dietician on weighing procedure and documentation. -Dietician/designee will provide a weekly update utilizing a communication form for weight loss for residents triggering for significant change, to nursing and nursing will inform physician 4)HOW THE CORRECTIVE ACTIONS WILL BE MONITORED TO ENSURED THE DEFICIENT PRACTICE WILL NOT RECUR, IE, WHAT QUALITY ASSURANCE PROGRAM WILL BE PUT INTO PRACTICE. -The dietician/designee will audit all residentÆs weights and communicate with nursing the names of residents with significant weight loss weekly x4 weeks, then monthly X 3 months thereafter. -The DON/designee will ensure that physician has addressed weight loss and proper intervention, are put in place, weekly X 4 weeks, then monthly X 3 months thereafter -All findings negative findings will be corrected immediately and will be reported to the quarterly QA committee. 5)THE DATE FOR CORRECTION AND THE TITLE OF THE PERSON RESPONSIBLE FOR CORRECTION OF EACH DEFICIENCY. 5. Medical Director/designee will be responsible to correct this deficiency-3/14/2 |
Scope: N/A
Severity: N/A
Citation date: January 13, 2023
Corrected date: March 14, 2023
Citation Details Based on record review and staff interviews during the Recertification Survey initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that a Criminal History Record Check (CHRC) 105 Form was submitted within the required 30-day time frame to the New York State Department of Health (NYSDOH) after an employee was terminated. This was identified for one (Employee #6) of six employee records reviewed for CHRC. Specifically, the facility received a negative determination letter from CHRC dated 7/12/2022 for Employee #6 who was hired by the facility on 6/30/2022. Employee #6 was terminated on 7/12/2022, however, the facility did not submit a CHRC 105 Form to the NYSDOH within the required 30 days. The finding is: The Policy titled, New Employee Fingerprinting dated 5/2015 documented under the section Termination: Authorized Person (AP) should access the CHRC termination form from the CHRC Menu and click on Terminate Employees link and click submit. AP has to submit these electronically within 30 days of the individual's termination of employment. A review of Employee #6's file revealed that the facility received a Hold in Abeyance to Provider letter on 7/12/2022; however, there was no documented evidence that a CHRC 105 Form was submitted to the NYSDOH to terminate the employee from the CHRC system. The Staffing Coordinator was interviewed on 1/9/2023 at 11:40 AM and stated that when they (Staffing Coordinator) had received Employee #6's Hold in Abeyance to Provider letter on 7/12/2022, they (Staffing Coordinator) removed Employee #6 from the facility's work schedule and contacted the Agency Employee #6 worked for and informed the Agency that Employee #6 was no longer employed by the facility. Employee #6 was also removed from the payroll list. The Staffing Coordinator stated that they (Staffing Coordinator) should have then immediately terminated Employee #6 from the CHRC system by completing the CHRC 105 Form. The Staffing Coordinator stated that they (Staffing Coordinator) thought they (Staffing Coordinator) had submitted the CHRC 105 Form, but the form was not submitted. The Administrator was interviewed on 1/9/2023 at 12:10 PM and stated that when the negative determination letter was received, and Employee #6 was terminated, the Staffing Coordinator should have immediately submitted the CHRC 105 Form. The Administrator further stated that the CHRC 105 Form must be submitted within 30 days for all terminations. | Plan of Correction: ApprovedMarch 3, 2023 1) WHAT CORRECTIVE ACTIONS WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE. - No residents were affected by this deficient practice. -Employee #6 was terminated -Termination was reported to CHRC 01/9/23 2) HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN -All residents have the potential to be affected by this deficient practice. - Cross reference a current list of employees roster with the CHRC roster to ensure CHRC roster is updated. 3)WHAT MEASURES WILL BE PUT IN PLACE OR WHAT SYSTEMIC CHANGES YOU WILL MAKE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR -All terminated employees will be logged in the Termination Log biweekly by the Staffing Coordinator. -A termination checklist was developed to ensure that all termination notice for each department is sent to the appropriate state agencies and department heads. - The new employee finger printing policy and procedure was reviewed and revised. - All department heads and staffing coordinator were inserviced by the administrator on the revised policy. 4)HOW THE CORRECTIVE ACTIONS WILL BE MONITORED TO ENSURED THE DEFICIENT PRACTICE WILL NOT RECUR, IE, WHAT QUALITY ASSURANCE PROGRAM WILL BE PUT INTO PRACTIC - All department heads will report their terminated employees bi-weekly via termination form to the staffing coordinator. -The Staffing Coordinator will send a report of all terminated employees to CHRC. -The Administrator will conduct a monthly audit x 12 months of all terminations will be done to cross reference with CHRC to ensure timely termination. -All negative findings will be corrected immediately and reported to the quarterly QA committee. 5)THE DATE FOR CORRECTION AND THE TITLE OF THE PERSON RESPONSIBLE FOR CORRECTION OF EACH DEFICIENCY. -The Administrator/designee will be responsible to correct this deficiency - 03/14/23 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2023
Corrected date: March 14, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the Recertification Survey and Abbreviated Survey (NY 893) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not provide a functional environment for one (Resident #263) of one Resident reviewed for Environment. Specifically, when Resident #263 resided on the second floor in a three bedded room. There was insufficient space in the room to accommodate a Mechanical (Hoyer) lift between Resident #44's bed and Resident #263 bed. Resident #263 was asked to get out of bed exit the room when Resident #44 needed to be transferred in and out of bed with Hoyer lift. The finding is: The facility policy entitled Safety Management Plan dated (MONTH) (YEAR) documented that a safe and functional environment of care is essential for delivering high quality of care to all. All staff are responsible for cooperating with all aspects of the Safety Management Program. This includes performing their duties in a safe manner and reporting any and all hazardous conditions. 1 a) Resident #44 has [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderately impaired cognition. Resident #44 required extensive assistance of two persons for bed mobility and transfer. The Physical Therapy (PT) evaluation dated 11/2/2022 documented that Resident #44 required assistance of two persons via mechanical lift for transfers in and out of bed to the wheelchair. 1 b) Resident #263 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #263 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderately impaired cognition. Resident #263 required extensive assistance of two persons for bed mobility and transfer. The facility census documented that Resident #44 occupied the A bed in the three bedded Room from 11/11/22 to 12/20/22. The census also documented that Resident #263 occupied the C bed in the three room [ROOM NUMBER] from 11/16/22 to 12/22/22. Resident #263's family member was interviewed on 1/10/2023 at 10:10 AM and stated Resident #263 was moved to another unit in a private room after readmission from the hospital on [DATE]. Resident #263 had previously resided on the second floor in the three bedded room. The family member stated that the three bedded room was too small for three residents. Whenever the roommate needed to be transferred out of bed with the Hoyer lift, the whole room had to be rearranged. The Certified Nursing Assistant (CNAs) had to move Resident #263's bed to make room for the Hoyer to fit in between the beds. The family member and Resident #263 would have to step out of the room when visiting so that the staff could get to the roommate. The family member stated that they expressed concern to the CNAs and the nurse, but no one did anything about it. The three bedded room was observed on 1/10/2023 at 10:38 AM. The room was L shaped with the A bed located closest to the window. The C bed was parallel to the A bed and was located closest to the room door. The B bed was located on the opposite side of the room. CNA #3 was interviewed on 1/10/2023 at 10:40 AM. CNA #3 stated that they are currently assigned to the three bedded room. CNA #3 stated that it is difficult to get the Hoyer lift into the three bedded room and that whenever they assisted with the Hoyer lift transfer, they had to move the other bed closer to the door. CNA #4, who was dayshift CNA assigned to Resident #263 while the resident was in the three bedded room, was interviewed on 1/11/23 at 9:54 AM and stated that the three bedded room was small. CNA #4 stated that they had to ask Resident #263's family member and Resident #263 to step out of the room whenever they had to get Resident #44 transferred out of bed. Sometimes CNA #4 had to ask Resident #263 to get out of bed so they (CNA #4) can move Resident #263's bed to transfer Resident #44 with the Hoyer lift because the space between the beds is too small to fit the Hoyer lift. The Director of Nursing Services (DNS) was interviewed on 1/12/2023 at 10:25 AM and stated that the resident needs have to be considered when assigning a room. The DNS stated that having a small space for a Hoyer lift is not safe and could cause a resident to fall out of the Hoyer. The DNS stated that the room would have to be re-arranged or a resident who requires a Hoyer lift should be assigned to another room that can fit a Hoyer lift. 10 NYCRR 415.29 | Plan of Correction: ApprovedMarch 3, 2023 1) WHAT CORRECTIVE ACTIONS WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE. -Resident #263 was placed in a private room upon readmission on 1/3/23. -No other residents in the same room required Hoyer lift for transfers and were not affected by this deficient practice. 2) HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTILA TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN -All residents in multi-bedded rooms, needing the assistance of a Hoyer lift for transfers have the potential to be affected by the deficient practice. -An initial audit was conducted on all residents currently using Hoyer lift for transfers, with their room assignment, to ensure that the environment is safe, functional, sanitary and comfortable for residents and staff within that room. -Necessary room change was done for one resident identified from the audit. - Unit managers observed that all other residents in multi-bedded rooms did not have difficultly being transferred, and that transfer did not affect other residents in the room. No room changes were necessary. -Rehab will generate a listing of all residents using Hoyer lift for transfers monthly/as needed, and communicate with nursing to ensure that the environment is safe, functional, sanitary and comfortable for residents and staff within that room. 3)WHAT MEASURES WILL BE PUT IN PLACE OR WHAT SYSTEMIC CHANGES YOU WILL MAKE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR -New policy was formulated on placement for residents requiring Hoyer lift during transfers to ensure the following: ò Admission department will notify Rehab/Nursing if any incoming resident requires a mechanical lift/Hoyer for transfers. ò Rehab/Nursing will confirm that the resident requires the use of a mechanical lift. ò Nursing will communicate with the admissions department to ensure that room assignment is taken into consideration for these residents i.e. not utilizing multiple-bedded rooms with insufficient space to accommodate a mechanical/Hoyer lift. ò For current residents noted with a significant change in transfer status involving the use of a Mechanical /Hoyer lift, Nursing will communicate with the Admissions department and Social Worker to arrange a transfer to an appropriate room for the residents. ò The Social Worker will inform the resident/residentÆs representative of the reason for the room transfer ò All staff will be encouraged to report all hazardous conditions in performing their duties in accordance with safety standards. -DON/designee In-serviced Admission, Nursing, Rehab, Maintenance and Social Service staff on new policy. -Environmental safety rounds will be conducted by Maintenance Director/ Designee to ensure that the environment is safe, functional, sanitary and comfortable for residents and staff within each room. -Admissions department will coordinate with Nursing to ensure that only appropriate residents are assigned to multiple-bedded rooms upon admission. 4)HOW THE CORRECTIVE ACTIONS WILL BE MONITORED TO ENSURED THE DEFICIENT PRACTICE WILL NOT RECUR, IE, WHAT QUALITY ASSURANCE PROGRAM WILL BE PUT INTO PRACTICE -An audit will be conducted by unit manager on 50% of residents using Hoyer lift monthly for 3 months. -All negative findings will be corrected immediately and reported to the quarterly QA committee. 5)THE DATE FOR CORRECTION AND THE TITLE OF THE PERSON RESPONSIBLE FOR CORRECTION OF EACH DEFICIENCY. -The Director of Nursing /designee will be responsible to correct this deficiency |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 27, 2023
Corrected date: April 11, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.1.6 Minimum Construction Requirements. 19.1.6.1 Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.) Life Safety Code Section 19.1.6 and Table 19.1.6.1 limit the height of buildings that are built of unprotected non-combustible construction (i.e., NFPA 220 Type II (000) building construction) to only two stories with a complete automatic sprinkler system. 2012 NFPA 220: 4.1 General. (5000:7.2.1) 4.1.1* Buildings and structures shall be classified according to their type of construction, which shall be based upon one of five basic types of construction designated as Type I, Type II, Type III, Type IV, and Type V, with fire resistance ratings not less than those specified in Table 4.1.1 and Sections 4.3 through 4.6 and with fire resistance ratings meeting the requirements of Chapter 5. (5000:7.2.1.1) Based on observation and staff interview, the facility did not ensure the existing health care occupancy was in accordance with NFPA 101, 2012 edition. Specifically, the steel beams above the ceiling tiles were noted without fire resistive material and the building is 3 stories in height. This was noted on two of three floors, and within the basement of the facility. The findings are: On 1/10/2023 between 9:30 AM and 9:50 AM, during the recertification survey, the building was observed to be three stories and Type II (000) construction. Unprotected steel beams and joists were observed above the drop ceiling in the corridors at the smoke barrier adjacent to room [ROOM NUMBER], at the smoke barrier adjacent to room [ROOM NUMBER], and at the smoke barrier in the basement adjacent to the clean linen room. In an interview on 1/9/23 at 9:55am, the Administrator and the Director of Environmental Services stated that they are not sure what the building construction type is and will look for documentation. No documentation was provided by the survey exit date to verify the building construction type. 2012 NFPA 101: 19.1.6.1 2012 NFPA 220 10NYCRR 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review conducted during a Life Safety Code (LSC) offsite Post Survey Revisit (PSR) from 4/19/23-4/20/23, the facility did not ensure that the building was at least Type II (111) Fire Resistive, Noncombustible construction in accordance with NFPA 101. Specifically, the facility did not provide an approved time limited waiver (TLW) from CMS. Record review revealed the following: Plan of correction (P(NAME)) was reviewed and rejected multiple times: 2.07.2023, 2.23.2023, 2.24.2023, 2.27.2023, 4.07.2023 - P(NAME) rejected, feedback comments included: 1. The K161 P(NAME) - Corrective action for the corridor doors was not indicated within the timeline. The P(NAME) indicated that the corridor doors were scored as 'zero' and were to be corrected. However, detail of what 'work' will occur to correct the doors was missing. Additionally, the door correction was not listed within the milestones/timeline. 2. The supporting document set - Life safety features were not indicated on the floor plans. 4.11.2023 - Facility supplied revised floor plans 3. Documented NYSDOH calls and emails with the facility (regarding citations that would not be corrected within 90 days of survey exit): 4.07.2023 4. No documentation to verify the citation had been corrected to code or equivalency. ---- The facility was cited for the following during the 1/13/2023 recertification survey: 2012 NFPA 101: 19.1.6 Minimum Construction Requirements. 19.1.6.1 Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.) Life Safety Code Section 19.1.6 and Table 19.1.6.1 limit the height of buildings that are built of unprotected non-combustible construction (i.e., NFPA 220 Type II (000) building construction) to only two stories with a complete automatic sprinkler system. 2012 NFPA 220: 4.1 General. (5000:7.2.1) 4.1.1* Buildings and structures shall be classified according to their type of construction, which shall be based upon one of five basic types of construction designated as Type I, Type II, Type III, Type IV, and Type V, with fire resistance ratings not less than those specified in Table 4.1.1 and Sections 4.3 through 4.6 and with fire resistance ratings meeting the requirements of Chapter 5. (5000:7.2.1.1) Based on observation and staff interview, the facility did not ensure the existing health care occupancy was in accordance with NFPA 101, 2012 edition. Specifically, the steel beams above the ceiling tiles were noted without fire resistive material and the building is 3 stories in height. This was noted on two of three floors, and within the basement of the facility. The findings are: On 1/10/2023 between 9:30 AM and 9:50 AM, during the recertification survey, the building was observed to be three stories and Type II (000) construction. Unprotected steel beams and joists were observed above the drop ceiling in the corridors at the smoke barrier adjacent to room [ROOM NUMBER], at the smoke barrier adjacent to room [ROOM NUMBER], and at the smoke barrier in the basement adjacent to the clean linen room. In an interview on 1/9/23 at 9:55am, the Administrator and the Director of Environmental Services stated that they are not sure what the building construction type is and will look for documentation. No documentation was provided by the survey exit date to verify the building construction type. 2012 NFPA 101: 19.1.6.1 2012 NFPA 220 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedApril 27, 2023 Garden Care Center is a 3-story and cellar skilled nursing facility located in the(NAME)Square Section of Nassau County. The building was cited for K-161. The building was cited based on the fact that portions of the existing suspended ceiling systems throughout the building are not fire rated and therefore the buildingÆs steel beams, bar joists and steel deck are not fire protected as required for a 3-story building by Section 19.1.6.2 of NFPA [PHONE NUMBER]. 1.No residents were affected by the deficient practice. 2. All residents have the potential to be affected by the deficient practice. The Medical Director is in agreement there is no additional risk to the residents. 3. The facilityÆs operator has contracted with an architectural firm to assess the citation, perform an FSES analysis and to formulate a plan of action to correct the deficiency. 4a.Based on reviews of original construction drawings and physical on-site observations, it has been determined by the Architect that the building was originally designed to meet Construction Type II (222) of NFPA 220. It was further observed by the Architect that since itÆs original construction in 1972, portions of the existing fire rated ceiling systems were replaced throughout with non-fire rated components. The net result is that the building currently has a Construction Type of Type II (000) which is not permitted for a three story building per 19.1.6.2 of NFPA [PHONE NUMBER]. The Architect has concluded that by replacing the non-compliant components of the existing suspended ceiling systems with a 2-hour fire rated ceiling assembly, (UL G-211) the building will be brought into compliance with 19.1.6.2 of NFPA [PHONE NUMBER]. The Architect has surveyed the entire building and has identified all areas in the building where the cited deficiency occurs. The Architect has prepared an FSES Analysis in support of a Time Limited Waiver Application to correct the cited deficiency. The Architect has also observed that existing smoke resistant corridors doors on floors 1, 2 and 3 do not qualify for a minimum 20-minute fire resistance rating as required by NFPA [PHONE NUMBER], 19.3.6.1(2). This is due to the fact that required fire-label tags are missing at a number of existing doors throughout the facility. Therefore, in addition to the work required to correct the K-161 deficiency, the Facility will replace or modify its existing smoke resistant corridor doors to achieve the minimum required 20-minute fire resistance rating. FSES Parameter #5 (Corridor Doors) has been scored with a value of ôZeroö to reflect the current deficiency. The facility will apply for a time limited waiver to The New York State Health Department within the permitted 60-day timeframe (Completion Date for Waiver submission is (MONTH) 14, 2023). Assuming approval of the Time Limited Waiver Request, the alteration work needed to cure the non-compliance will be completed by 6/15/2025 (after Time Limited Waiver Approval, Corrective Alteration Work will be completed by 6/15/2025). A time limited waiver is required to; allow sufficient time for the existing conditions to be evaluated and a detailed solution to be identified, allow sufficient time for the preparation of related construction drawings; allow time for local building department and fire department approvals, allow sufficient lead time to order and acquire the needed materials, allow sufficient time for the completion of the construction work and finally to allow sufficient time for the scheduling of final inspections and the processing of sign-offs by the local building and fire authorities having jurisdiction. Facility will review Certificate of Need Application requirements (NYSE-CON) and submit Application or Notice as required by the scope of work to be executed under this project. Additionally, a resident safety plan will be submitted by the Facility to the local area office of the New York State Department of Health for approval prior to the start of construction. 4bThe Overall timeline to correct the issues identified on the FSES report is as follows: a.Select Design Professional. Start Date: 2/15/2023. End Date 3/15/2023. Duration: 1 Month b. Evaluation of Deficiency & Recommendation of Corrective Action. Start date: 3/15/2023. End Date: 4/15/2023. Duration: 1 month. c. Preparation of Contract Documents. Start date: 4/15/2023. End Date: 7/15/2023. Duration: 3 months. d. Obtaining Local Permits & Approvals (this serves as notification to the Building Authority Having Jurisdiction). Start date: 7/15/2023. End Date: 10/15/2023. Duration: 3 months. e. Duration of Construction. Start date: 10/15/2023. End Date: 6/15/2025. Duration: 1 year and 8 months. f. Overall Time Limited Waiver Duration. Start date: 2/15/2023. End Date: 6/15/2025. Duration: 2 years and 4 months. 4c Detailed Scope and Phasing is as follows: Construction in resident areas will be done during normal business hours 8:00 a.m. û 5:00 p.m., Monday thru Friday. PHASE 1: Cellar û 10/15/2023 to 3/15/2024 û 5 Months Replacement of all non-compliant suspended ceiling systems with fire rated suspended ceiling systems including fire protection of recessed lights and installation of fire dampers at ceiling air diffusers. Corridors must remain unobstructed at all times so that continuous egress is maintained. No construction materials, tools or debris will be allowed to accumulate in corridors. Where work zones border un-demised occupied space, a 1-hour fire barrier partition will be constructed between the work area and occupied space in accordance with NFPA [PHONE NUMBER], Sections 19.1.1.4.3 and 4.67. Negative pressure exhaust fans with HEPA filtration will be used to limit dust migration in and around work areas. The Facility has contracted with a 3rd Party Testing/Certification Company who will inspect those existing corridor doors that do not currently have riveted metal fire label tags to determine whether these existing doors meet the requirements of NFPA-80 for classification as 1-1/2 Hour, ¾-Hour, or 20 Minute fire rated doors (required fire rating varies based on the location of a given door within the building and the area/room served by that given door). Where a given door meets NFPA requirements for the required fire rating, a riveted metal tag will be affixed to the door stating its NFPA-80 Fire Label Rating. Where a given existing door does not meet the requirements of NFPA-80 for a given fire rating, the Facility will replace such door with an NFPA-80 compliant door with a riveted metal tag affixed stating its NFPA-80 fire rating. This work will be completed in Phase 1. Residents will not have access to the work zones. As only 1 Floor will be renovated at a time, the facility will stage programs and activities in central areas and on other floors to reduce the number of residents on the ôconstruction floorö during construction work hours. PHASE 2: First Floor û 3/15/2024 to 8/15/2024 û 5 Months Replacement of all non-compliant suspended ceiling systems with fire rated suspended ceiling systems including fire protection of recessed lights and installation of fire dampers at ceiling air diffusers. Corridors must remain unobstructed at all times so that continuous egress is maintained. No construction materials, tools or debris will be allowed to accumulate in corridors. Where work zones border un-demised occupied space, a 1-hour fire barrier partition will be constructed between the work area and occupied space in accordance with NFPA [PHONE NUMBER], Sections 19.1.1.4.3 and 4.67. Negative pressure exhaust fans with HEPA filtration will be used to limit dust migration in and around work areas. Residents will not have access to the work zones. As only 1 Floor will be renovated at a time, the facility will stage programs and activities in central areas and on other floors to reduce the number of residents on the ôconstruction floorö during construction work hours. PHASE 3: Second Floor û 8/15/2024 to 1/15/2025 û 5 Months Replacement of all non-compliant suspended ceiling systems with fire rated suspended ceiling systems including fire protection of recessed lights and installation of fire dampers at ceiling air diffusers. Corridors must remain unobstructed at all times so that continuous egress is maintained. No construction materials, tools or debris will be allowed to accumulate in corridors. Where work zones border un-demised occupied space, a 1-hour fire barrier partition will be constructed between the work area and occupied space in accordance with NFPA [PHONE NUMBER], Sections 19.1.1.4.3 and 4.67. Negative pressure exhaust fans with HEPA filtration will be used to limit dust migration in and around work areas. Residents will not have access to the work zones. As only 1 Floor will be renovated at a time, the facility will stage programs and activities in central areas and on other floors to reduce the number of residents on the ôconstruction floorö during construction work hours. PHASE 4: Third Floor û 1/15/2025 to 6/15/2025 û 5 Months Replacement of all non-compliant suspended ceiling systems with fire rated suspended ceiling systems including fire protection of recessed lights and installation of fire dampers at ceiling air diffusers. Corridors must remain unobstructed at all times so that continuous egress is maintained. No construction materials, tools or debris will be allowed to accumulate in corridors. Where work zones border un-demised occupied space, a 1-hour fire barrier partition will be constructed between the work area and occupied space in accordance with NFPA [PHONE NUMBER], Sections 19.1.1.4.3 and 4.67. Negative pressure exhaust fans with HEPA filtration will be used to limit dust migration in and around work areas. Residents will not have access to the work zones. As only 1 Floor will be renovated at a time, the facility will stage programs and activities in central areas and on other floors to reduce the number of residents on the ôconstruction floorö during construction work hours. 5. The facility is fully sprinkled, and hard-wired detectors, connected to a central alarm system, are installed in each resident room and throughout the facility. Interior finishes on walls and ceilings within the means of egress and within all resident rooms are Class A materials. The facility will implement the following additional measures to mitigate the risks to residents and staff: 5a. Conduct additional fire drills (minimum 2 times per month) 5b. Test the fire alarm system more frequently (2 times per week), immediately replacing non-functioning equipment. Testing and modifications to the fire alarm system will be documented. 5c. Conduct daily rounds of the construction areas to ensure that all fire and smoke doors are functioning and not propped open. A written log of daily rounds is to be maintained by the Facility. 5d. Ensure corridors within the construction areas remain unobstructed to allow for evacuation when required. 5e. During construction, facility will perform frequent observations of the work areas (3 times per work day) to monitor resident safety. Throughout all phases of this project the facility will use an interdisciplinary approach to ensure resident safety. All facility department heads and staff will be notified in advance of the project phasing and their respective responsibilities to insure the safety of residents, visitors and staff. The facility has established Safety Officers to act as a liaison between the facility and the contractor. The Safety Officers will evaluate daily, any safety issues or concerns. All staff in the vicinity of the construction areas will be responsible to monitor the area to ensure that residents are not exposed to any hazards. This includes, nurses, CNAÆs, housekeeping staff, and recreation staff. In-service education will be provided to staff prior to the commencement of construction as to what their responsibilities will be. In-service will be provided by the facilityÆs In-Service Coordinator, Administrator, Director of Nursing, and Director of Maintenance to ensure that Staff are properly monitoring residents throughout their daily routines (such in-service training shall be documented). The existing nurse call system will remain completely operational for the duration of the construction project. 6. Notification of Families and Staff The administrator will hold meetings with residents, families and staff regarding the impending construction and how it will affect their daily routines. 7. Signage Appropriate signage will be utilized to delineate the areas of construction. This will ensure that the residents will remain away from the construction areas. 8. Storage of Materials The contractor will store materials in locked storage rooms located in the construction area and in storage containers outside the facility, adjacent to the parking lot. All combustible materials, cleaning fluids, gases, etc. will be removed from the work area at the end of each day and stored in a fire proof cabinet. The facility safety officer and the project superintendent are responsible to monitor that these items are used and stored properly each day. Any concerns of improper use or storage will be addressed immediately with corrective actions implemented by the safety office and the project superintendent. 9. Fire Safety The Director of Maintenance will ensure that a minimum of four (4) additional fire extinguishers will be available in the construction areas at all times. In the event of a disruption of fire sprinkler and/or smoke detector systems during construction, the facility will implement its fire watch protocol. Means of egress within construction ôzonesö will be maintained uninterrupted for the duration of the construction. 10. Disposal of Refuse All construction refuse/debris will be properly placed in a refuse dumpster located outside, adjacent to the building. 11a. Administrator, in conjunction with Director of Maintenance, will meet with contractors to ensure timeliness of dates as reflected in the waiver request. 11b. Administrator will report any updates at the next quarterly QA meeting. 12. The Administrator is responsible for the correction of this deficiency. 13. Insuring the Problem does not Recur: Facility will in-service its Senior Management along with the maintenance staff to make clear that the buildingÆs fire rated suspended ceiling systems are a key element in fire protecting the buildingÆs steel structure and that any modifications to the suspended ceiling systems must be done so as to maintain the fire safety integrity of the ceiling systems per the as-designed UL Fire Rated Assemblies specified by the Architect . In-service training will be documented. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2023
Corrected date: March 2, 2023
Citation Details 2012 NFPA 101:9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 99: 6.3.2.1 Electrical Installation. Installation shall be in accordance with NFPA 70, Nation Electrical Code 2011 NFPA 70:400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure Based on observation and staff interview the facility did not ensure that relocatable power taps were used in accordance with NFPA 70, and that electrical equipment for used for patient care was tested . Specifically, a power strip was noted daisy - chained to a second extension cord. This occurred within the basement of the facility. The findings are: During the Life Safety recertification survey conducted on 1/9/23 to 1/11/23 between the hours of 8:30 AM and 4:30 PM, a tour of the Central Supply Room revealed a power strip was plugged into the wall outlet. The power strip was daisy - chained to an extension cord that was plugged into a computer and electronic devices. In an interview on 1/9/23 at 1:45 PM, the Director of Environmental Services stated they are not allowed to have these extension cords and we will remove them immediately. 2012 NFPA 70: 400.8 10 NYCRR 711.2 (a) (1) | Plan of Correction: ApprovedFebruary 7, 2023 1. No residents were affected by deficient practice. The daisy chained power strip in central supply was removed. 2. All resident have the potential to be affected by this deficient practice. A facility wide audit was done and no other locations have been identified with this deficient practice. 3.An in-service of all office and environmental personnel to ensure that no daisy chaining occurs and proper power strip use. 4. Bi-weekly rounds will be conducted for 2 months. Any findings will be reported to the QA/Safety committee. 5. The director of maintenance/designee will be responsible for this corrective action. action. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2023
Corrected date: February 28, 2023
Citation Details 2012 NFPA 99: 10.5.2.1 Testing Intervals. 2012 NFPA 99: 10.5.2.1.1 The facility shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment. 2012 NFPA 99: 10.5.2.1.2 All patient care-related electrical equipment used in patient care rooms shall be tested in accordance with 10.3.5.4 or 10.3.6 before being put into service for the first time and after any repair or modification that might have compromised electrical safety. 2012 NFPA 99: 10.3 Testing Requirements - Fixed and Portable. 10.3.1* Physical Integrity. The physical integrity of the power cord assembly composed of the power cord, attachment plug, and cord-strain relief shall be confirmed by visual inspection. 10.3.2* Resistance. 10.3.2.1 For appliances that are used in the patient care vicinity, the resistance between the appliance chassis, or any exposed conductive surface of the appliance, and the ground pin of the attachment plug shall be less than 0.50 ohm under the following conditions: (1) The cord shall be flexed at its connection to the attachment plug or connector. (2) The cord shall be flexed at its connection to the strain relief on the chassis. 10.3.2.2 The requirement of 10.3.2.1 shall not apply to accessible metal parts that achieve separation from main parts by double insulation or metallic screening or that are unlikely to become energized (e.g., escutcheons or nameplates, small screws). 10.3.3* Leakage Current Tests. 10.3.3.1 General. 10.3.3.1.1 The requirements in 10.3.3.2 through 10.3.3.4 shall apply to all tests.10.3.1* Physical Integrity. The physical integrity of the power cord assembly composed of the power cord, attachment plug, and cord-strain relief shall be confirmed by visual inspection. 10.3.3.1.2 Tests shall be performed with the power switch ON and OFF. 10.3.3.2 Resistance Test. The resistance tests of 10.3.3.3 shall be conducted before undertaking any leakage current measurements. 10.3.3.3* Techniques of Measurement. The test shall not be made on the load side of an isolated power system or separable isolation transformer. 10.3.3.4* Leakage Current Limits. The leakage current limits in 10.3.4 and 10.3.5 shall be followed. 10.3.4 Leakage Current - Fixed Equipment. 10.3.4.1 Permanently wired appliances in the patient care vicinity shall be tested prior to installation while the equipment is temporarily insulated from ground. 10.3.4.2 The leakage current flowing through the ground conductor of the power supply connection to ground of permanently wired appliances installed in general or critical care areas shall not exceed 10.0 mA(ac or dc) with all grounds lifted. 10.3.5 Touch Current - Portable Equipment. 10.3.5.1* Touch Current Limits. The touch current for cord connected equipment shall not exceed 100 ?A with the ground wire intact (if a ground wire is provided) with normal polarity and shall not exceed 500 ?A with the ground wire disconnected. 10.3.5.2 If multiple devices are connected together and one power cord supplies power, the leakage current shall be measured as an assembly. 10.3.5.3 When multiple devices are connected together and more than one power cord supplies power, the devices shall be separated into groups according to their power supply cord, and the leakage current shall be measured independently for each group as an assembly. 10.3.5.4 Touch Leakage Test Procedure. Measurements shall be made using the circuit, as illustrated in Figure 10.3.5.4, with the appliance ground broken in two modes of appliance operation as follows: (1) Power plug connected normally with the appliance on (2) Power plug connected normally with the appliance off (if equipped with an on/off switch) 10.3.5.4.1 If the appliance has fixed redundant grounding (e.g., permanently fastened to the grounding system), the touch leakage current test shall be conducted with the redundant grounding intact. 10.3.5.4.2 Test shall be made with Switch A in Figure 10.3.5.4 closed. 10.3.6* Lead Leakage Current Tests and Limits - Portable Equipment. 10.3.6.1 The leakage current between all patient leads connected together and ground shall be measured with the power plug connected normally and the device on. 10.3.6.2 An acceptable test configuration shall be as illustrated in Figure 10.3.5.4. 10.3.6.3 The leakage current shall not exceed 100A for ground wire closed and 500 A ac for ground wire open. Based on observation, documentation review, and staff interview during the recertification survey, the facility did not provide evidence, and policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment (PCREE) in accordance with the requirements of chapter 10.3 of 2012NFPA 99 HEALTH CARE FACILITIES CODE. During the Life Safety Code documentation review on 1/10/2023 at 2:15 PM, 4 sit- in style hair dryers were observed in the beauty salon that serve the residents. There was no documented evidence that the sit in style hair dryers were inspected. Additionally, the facility did not provide established policy and procedure for the testing and established testing frequencies for PCREE. At the time of the finding, the Director of Environmental Services stated they have not inspected the hair dryers, and they can perform an in-house inspection. 2012NFPA101 2012NFPA 99 NYCRR 711.2(a) 10 NYCRR 415.29 | Plan of Correction: ApprovedFebruary 9, 2023 1. No residents were affected by deficient practice. 2. All residents who attend beautician services have the potential to be affected by this deficient practice. The salon style hair dryers were inspected with no negative findings. A facility wide audit was done and no other equipment was identified. 3. An in-service of all maintenance personnel will be conducted to ensure that patient care related electrical equipment is properly inspected. A policy was developed to include inspection and frequency of how often patient care related electrical equipment is checked according to code. 4.Patient related equipment is inspected on an annual and as needed basis. Resident personal related items will be checked monthly x 3 months and then quarterly. Any findings will be reported to the QA/Safety committee. 5. The director of maintenance/designee will be responsible for this corrective action. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2023
Corrected date: February 26, 2023
Citation Details 2010 NFPA 110: 5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. 5.6.5.6.1 The remote manual stop station shall be labeled. Based on observation and interview during the Life Safety Code survey on 1/9/23 to 1/11/23, the facility's emergency generator was not equipped with an emergency manual stop station in an area outside of the generator room. This affected one of one emergency generator that provide emergency power to the facility. The finding is: Observation in the Electric Meter Room in the basement of the facility on 1/9/23 at 2:25 PM revealed the emergency generator was located within this room. An emergency manual stop station was installed on the generator. No emergency manual stop station was installed outside of the Electric Meter Room. During an interview at the time of the observation, the Director of Maintenance stated they recently installed an emergency stop button, and that there was no emergency stop button located outside the room. 2012 NFPA 101: 9.1.3.1 2010 NFPA 110: 5.6.5.6, 5.6.5.6.1 10 NYCRR 711.2(a)(1) | Plan of Correction: ApprovedFebruary 7, 2023 1. No residents were affected by deficient practice. 2. All resident have the potential to be affected by this deficient practice. An emergency stop button will be installed outside of the generator room with proper labeling indicating emergency stop button. 3. The maintenance staff will be inserviced on the operation and purpose of the emergency stop button. 4. Upon installation of emergency stop button it will be tested annually to ensure proper function. Any findings will be reported to the QA/Safety committee. 5. The director of maintenance/designee will be responsible for this corrective action. |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 13, 2023
Corrected date: February 28, 2023
Citation Details 2012 NFPA 101: 9.4.6.2 All elevators equipped with fire fighters' emergency operations in accordance with 9.4.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASMEA17.1/CSA B44, Safety Code for Elevators and Escalators. Based on observations, interview, and record review conducted during a Life Safety Code Survey recertification survey on 1/9/2023 to 1/11/2023, the facility failed to properly maintain building service records for two of two elevators. Specifically, no evidence was provided to ensure that elevators that were equipped with firefighter recall service were being tested monthly. The findings are: On 1/9/2023 at 10:40 AM, 2 elevators were observed with fire fighter recall. Record review of the building testing and maintenance logs on 1/10/23 at 10:00 AM, revealed the facility's elevator firefighter recall testing log was not documented on any logs. In an interview on 1/10/2023 at 1:00 PM, the Director of Environmental Services stated the elevators drop to the first floor, and the doors open when the fire alarm goes off. They additionally stated they test them with the fire alarm, but it is not recorded, and they can add it to the fire drill logs. 2012 NFPA 101: 9.4.6.2 10 NYCRR 711.2(a)(1) | Plan of Correction: ApprovedFebruary 7, 2023 1. No residents were affected by deficient practice. 2. All residents have the potential to be affected by this deficient practice. The fire drill logs will now reflect the fire fighter recall for the elevators when a fire drill takes place. 3. The maintenance staff will be inserviced on testing requirements for the fire fighter recall and on the updated fire log. 4. The fire drill logs will show the fire fighter recall operation for the elevators. Any findings will be reported to the QA/Safety committee on quarterly. 5. The director of maintenance/designee will be responsible for this corrective action. |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 13, 2023
Corrected date: February 9, 2023
Citation Details Based on documentation review and staff interview, the facility did not ensure that a formal risk assessment for the building system categories was conducted and documented in accordance with NFPA 99. Specifically, documentation of a risk assessment describing the facility's building system categories was not provided at time of survey. The findings are: During the life safety survey on 1/9/23 to 1/11/23 between the hours of 8:45 AM and 4:30 PM, a review of the facility's maintenance logs revealed that a risk assessment for building system categories was missing. The facility was not able to provide documentation of a building systems risk assessment at time of survey. In an interview on 1/11/23 at 9 AM, the Administrator stated that they will see if they have a risk assessment. No NFPA 99 risk assessment for the building system categories was provided for review. 2012 NFPA 101 2012 NFPA 99: 4.1* 10 NYCRR 711.2 (a) | Plan of Correction: ApprovedFebruary 7, 2023 1. No residents were affected by deficient practice. The NFPA 99 risk assessment was completed by the director of maintenance on 1/20/23. 2. All residents have the potential to be affected by this deficient practice. 3. The maintenance staff will be inserviced on NFPA 99 risk assessment and its annual review. 4. The NFPA 99 risk assessment will be reviewed annually with the EP or as needed. Any findings will be reported to the QA/Safety committee. 5. The director of maintenance/designee will be responsible for this corrective action. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2023
Corrected date: March 2, 2023
Citation Details 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 the hazardous area room doors were self-closing, and positively latching. This occurred within the 1st floor, 2nd floor, and the basement of the facility. The findings are: On 1/9/2023 to 1/11/2023 between the hours of 8:30 AM and 4:30 PM during the Life Safety Code recertification survey the following was observed: 1) On 1/9/2023 at 11:40 AM, the door to the chute in the 2nd floor soiled utility room was tested . The chute door did not properly latch into the frame. 2) On 1/9/2023 at 12:00 PM, the door to the chute in the 1st floor soiled utility room was tested . The chute door did not properly latch into the frame. 3) On 1/9/2023 at 1:45 PM, the laundry room contained 2 self closing doors. When tested , the doors did not latch into their frames. In an interview at the time of the findings, the Director of Environmental Services stated they recently tested the doors and are aware that the chute doors and laundry room doors are not latching, and will adjust them. 2012NFPA101 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedFebruary 7, 2023 1. No residents were affected by deficient practice. 2. All resident have the potential to be affected by this deficient practice. A facility wide audit was done and no other locations have been identified with this deficient practice All chute doors, self-closing or automatic closing doors were identified and repaired. 3. An inservice to ensure that all chute doors, self-closing or automatic closing doors are latching properly was given to maintenance personal. 4. All findings will be monitored by the maintenance director/designee weekly for 3 months and reported to the QA/safety committee. 5. The director of maintenance/designee will be responsible for this corrective action. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2023
Corrected date: February 28, 2023
Citation Details NYCRR 415.29 (j)(6) Waste: (ii) facilities shall manage regulated medical waste in accordance with the provisions of Part 70 of this Title. Section 70-2.2 - Containment and storage 70-2.2 Containment and storage. (g)(3) Regulated medical waste shall not be stored for a period exceeding thirty (30) days, except that a site generating under fifty (50) pounds of regulated medical waste per month and not accepting regulated medical waste for treatment from other facilities, may store waste for a period not exceeding sixty (60) days. 415.29 Physical environment. The nursing home shall be designed, constructed, equipped and maintained to provide a safe, health, functional, sanitary and comfortable environment for residents, personnel and the public. (a) Life safety from fire and other hazards. Based on observation, documentation review and staff interview, the facility did not ensure that the (1) regulated medical waste was stored in accordance with the requirements of Section 70-2.2, and (2) the environment was maintained in a safe and sanitary manner. Specifically, the facility's regulated medical waste (RMW) was stored on the premises for a period exceeding 60 days and Personal Protective Equipment (PPE) was being stored directly on the floor. The findings are: During the recertification survey on 1/6/2023 to 1/11/2023 between the hours of 8:30 AM and 4:30 PM, the following was observed: (1) A review of the medical waste manifest for the last 12 months was conducted. Documentation review of the medical waste pick up receipts from an outside vendor showed the following pick-up dates: 1/13/22, 4/14/22, 7/14/22, 10/13/22. The regulated medical waste was picked up at intervals greater than 60 days. In an interview on 1/11/2023 at 9:55 AM, the Director of Environmental Services stated that the vendor picks up medical waste quarterly. (2) On 01/06/23 at 10:47 AM, the 60-day supply of PPE was observed in a storage building, adjacent to the facility. The PPE consisting of gowns, gloves and masks were being stored in cardboard boxes directly on the floor. In an interview on 01/09/23 at 8:31 AM the Director of Environmental Services stated they did not know the PPE boxes could not be on the floor and are in the process of gathering pallets. (3) On 1/9/23 at 1:45 PM, the laundry room was observed to contain unused diapers in cardboard boxed being stored on the floor. In an interview on 01/09/23 at 1:45PM the laundry aid stated they will pick up the boxes and put on the table. The findings were acknowledged by the Administrator at the exit conference on 1/11/2023 at 11:00 AM. 10 NYCRR 415:29 10 NYCRR, Section 70-2.2(g)(3) 10 NYCRR 711.2 (a)(1) | Plan of Correction: ApprovedFebruary 7, 2023 1. No residents were affected by this deficient practice. 2. All residents have the potential to be affected by this deficient practice. The scheduled for waste pick up has been changed to 60 days. This schedule will be monitored by Director of maintenance. 3. A schedule will be put into place for all outside contracted maintenance services with their frequencies and will be monitored for 120 days. The director of maintenance will monitor all the waste pickups and confirm with the manifests that it did not exceed over 60 days. 4. Any findings will be reported to the QA/Safety committee. 1. No residents were affected by this deficient practice. 2. All resident have the potential to be affected by this deficient practice. A facility wide audit was done and no other locations have been identified with this deficient practice. PPE items that were on the floor both offsite and onsite have corrected. 3.An in-service of all maintenance, housekeeping and laundry personnel will be conducted to ensure that no items are left on the floor. 4. Monthly checks where PPE is stored both onsite and offsite will be conducted for 2 months. 5. Any findings will be reported to the Director of maintenance/designee will be responsible for this corrective action. 1. No residents were affected by this deficient practice. 2. All resident have the potential to be affected by this deficient practice. A facility wide audit was done and no other locations have been identified with this deficient practice. An in-service of all maintenance, housekeeping and laundry personnel will be conducted to ensure that no items are left on the floor. The diapers that were on the floor in the laundry have been removed. 3.An in-service of all maintenance, housekeeping and laundry personnel will be conducted to ensure that no items are left on the floor. 4 Daily rounds will be conducted for 2 months in the laundry area. Any findings will be reported to the QA/Safety committee. 5. The director of maintenance/designee will be responsible for this corrective action. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2023
Corrected date: February 9, 2023
Citation Details 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: 5.3.4* Antifreeze Systems. The freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary. 2011 NFPA 25: 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, documentation review and interview, the facility failed to ensure that the sprinkler system was tested in accordance with NFPA 101, 2012 edition. Specifically, no evidence was provided to verify the antifreeze system was tested , and the 5 year internal inspection of piping was conducted. This occurred for the fire suppression system that serves the facility. The findings are: On 1/9/2023 to 1/11/2023 between the hours of 8:30 AM and 4:30 PM during the Life Safety Code recertification survey the following was noted: 1) Inspection of the elevator motor room revealed the elevator shaft contained an antifreeze fire suppression system. 2) Review of the vendor testing documents for the fire suppression system revealed the 5-year internal inspection of the sprinkler piping was not conducted, and the anti-freeze system had not been tested within the last year. In an interview on 1/10/2023 at approximately 1:00 PM, the Director of Environmental Services stated he was not aware of the pipe inspection and does not believe the testing was done. 2012 NFPA 101 2011 NFPA 25:5, 14.2 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedFebruary 7, 2023 1. No residents were affected by this deficient practice. 2. All residents have the potential to be affected by this deficient practice. The antifreeze annual testing was completed on 1/27/23 and the 5-year internal pipe inspection was completed on 1/27/23. 3. The maintenance staff will be inserviced on testing requirements for the 5 year internal inspection and the annual anti-freeze testing. 4. A schedule will be put into place for all outside contracted maintenance services with their frequencies. This schedule will be monitored by the safety committee/ QAPI committee Quarterly 5. The director of maintenance/designee will be responsible for this corrective action. |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 13, 2023
Corrected date: March 7, 2023
Citation Details (b) Policies and procedures. (Facilities) must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.) At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. Based on staff interview and document review, the facility emergency preparedness manual did not contain policies and procedures that addressed the provision of subsistence needs for staff and patients whether they evacuate or shelter in place. Specifically, there was no information regarding alternate sources of energy to maintain temperatures. This occurred during review of the facilities emergency preparedness manual and could affect all residents. The findings are: On 1/9/2023 to 1/11/2023 between the hours of 8:45 AM and 4:30 PM during the life safety recertification survey, the emergency preparedness manual was reviewed. The manual did not contain policy and procedures regarding alternate source of energy to maintain temperatures. In an interview on 1/9/2022 at 9:55 AM, the Director of Environmental Services stated the PTAC units in the resident rooms and the corridors are not supplied by generator power. The Administrator acknowledged the finding on 1/11/2023 at 11 AM during the exit conference. º483.73(b)(1) | Plan of Correction: ApprovedFebruary 10, 2023 1. No residents were affected by deficient practice. 2. All resident have the potential to be affected by this deficient practice. An emergency agreement has been put into place with our generator vendor to receive a temporary generator to maintain temperatures. The director of maintenance/administrator/designee will ensure that the corrective action is implemented. 3. The staff will be inserviced on the procedure in case the facility loses power and the vendor needs to be contacted to receive a temporary generator. The temporary generator will be hooked up to the proper electrical panels in order to maintain proper temperatures. Upon delivery of the emergency generator, the generator company alongside with the director of maintenance will make sure the temporary generator is operating properly to maintain temperature. 4. The contract will be reviewed on an annual basis/as necessary when updating the emergency preparedness. Any findings will be reported to the QA/Safety committee. 5. This will be monitored by the director of maintenance/designee monthly. |