Manhattanville Health Care Center
May 14, 2018 Complaint Survey

Standard Health Citations

FF11 483.25(k):PAIN MANAGEMENT

REGULATION: §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 14, 2018
Corrected date: July 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (NY 138), the facility did not ensure that a resident's complaint of pain was addressed promptly. This was evident in 1 out of 4 residents sampled (Resident #1). Specifically, Resident #1 complained of pain on 02/08/2018 at 6:15 PM during a transfer from the wheelchair to the bed. Resident #1 was assessed with [REDACTED]. Registered Nurse #1 (RN #1) notified the Nurse Practitioner (NP) at 6:31 PM. The NP ordered [MEDICATION NAME] 300 mg - [MEDICATION NAME] 30 mg tablet (a narcotic medication) by oral route two times a day as needed. This medication was not available and not administered and the NP was not notified to ensure an alternative could be provided. Resident #1 was given [MEDICATION NAME] 100 mg Capsule (a scheduled pain medication) at 10:00 PM, approximately 3 1/2 hours after Resident #1 complained and was assessed with [REDACTED]. The findings include: The facility policy and procedure on Pain Management, with a revised date of 11/2017, states, pain assessment will be completed by the Licensed Nurse upon admission, readmission, significant change, quarterly/change in pain meds, and complaint of pain. The Licensed Nurse completes the Pain Assessment in Sigma using the Pain Assessment Tool (Pain Score Numerical Rating and Wong Baker FACES Pain Rating Scale). Upon completion of the assessment, positive findings of pain will be documented in the nurse's notes, care plan and the 24-hour report. The physician will be notified to establish pain medication measures. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) on 01/16/2018, indicated a Brief Interview for Mental Status (BIMS) score 15/15, associated with intact cognition. Resident #1 required total dependence with two staff assisting with transfer and extensive assistance of two staff with bed mobility. The Accident/Incident Report dated 02/08/2018 at 6:15 PM, documented that Resident#1 reported she was dropped on the floor. The report also documented that when the two CNAs were transferring Resident#1 from the wheelchair to the bed, the resident complained of pain to the right knee. During an assessment by RN #1, Resident #1's right knee was noted with swelling and was painful to touch. Resident#1 rated the pain to the right knee using the Numeric Pain Scale as 9/10. The NP was notified at 6:31 PM. A Nurse's Progress Note by RN#1 dated 02/08/2018 at 8:51 PM, documented that Resident #1 was noted complaining of severe pain to the right knee while she was being transferred from the wheelchair to the bed by two CNAs. The right knee was noted with swelling and the NP was notified with an order for [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. This order was discontinued on 02/08/2018 at 8:27 PM. A physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. There was no documentation that Resident #1 was reassessed for the effectiveness of the scheduled [MEDICATION NAME] that was administered at 10:00 PM. The Medication Administration Record [REDACTED]. A follow up pain assessment documented Resident #1 pain scale as zero. A review of the Control Drug Inventory form dated 02/09/2018, documented that Resident #1 received Tylenol/[MEDICATION NAME] #3 ([MEDICATION NAME] 300 mg-[MEDICATION NAME] 30 mg) at 1:29 AM. A Nurse's Progress Note, by RN #2, dated 02/09/2018 at 10:57 AM documented that Resident #1 complained of pain to her right knee and the NP was made aware. The MAR indicated [REDACTED]. A follow up pain assessment documented Resident #1 pain scale at 3:51 PM was zero. A Medical Progress Note by the NP dated 02/09/2018 at 2:57 PM documented that the NP examined Resident #1 for follow-up knee pain. Resident #1 complained of right knee pain, no swelling noted. The assessment/plan included a STAT x-ray of the right knee and Tylenol #3 given for pain. A physician's orders [REDACTED]. A Nurse's Progress Note by RN #3 dated 02/09/2018 at 5:57 PM, documented Resident #1 complained of pain 4/10 to the right knee. During assessment by RN #2, the resident's right knee was noted with swelling. Resident #1 was seen and evaluated by the NP for right knee pain and swelling. PRN Tylenol was given. The STAT x-ray done and awaiting result. A Medical Progress Note, by the NP, dated 02/09/2018 at 5:51 PM documented x-ray showed questionable fracture. The NP noted that the resident will be transferred to the Hospital to get another x-ray to check if there is fracture and if it is chronic or acute. A Nurse's Progress Note by RN #1 dated 02/09/2018 at 7:15 PM documented that the x-ray to the right knee result came: limited, questionable non-displaced fracture thru tibia inferior to tibial plateau, advise follow-up with bandages removed. The NP was notified with the result of the x-ray and the NP ordered for Resident #1 to be sent to the hospital for x-ray to rule out if chronic or acute fracture. The resident was transferred to the Hospital at 6:50 PM via ambulance. A Nurse's Progress Note dated 02/13/2018 at 9:31 PM documented that Resident #1 was readmitted at 4:35 PM with [DIAGNOSES REDACTED]. The Hospital Discharge Summary dated 02/13/2018 documented that Resident #1's primary [DIAGNOSES REDACTED]. Discharge medication included [MEDICATION NAME]-[MEDICATION NAME] 5 mg-325 mg Tablet, 1 Tablet orally as needed for pain every four hours (a medication containing narcotic). Extended instructions to leg: [MEDICATION NAME]-menthol 15%-10% cream, 1 application topical three times a day as needed for pain. RN #1 was interviewed on 03/08/2018 at 1:38 PM and stated that he assessed Resident #1 on 02/08/2018 on the evening shift. He further stated that Resident #1 complained of right knee pain while she was being transferred from the wheelchair to the bed. He stated that he observed the right knee with swelling and it was painful to the touch. He also stated that he notified the NP and a routine x-ray for the right knee was ordered and pain medication was given to the resident. A follow-up interview was conducted with RN #1 on 05/03/2018 regarding pain medication. He stated that he informed the NP that Resident #1 was complaining of pain to her right knee and that the resident stated that her right knee was dropped to the floor. He stated that he recommended that an x-ray be ordered. He stated that the resident reported pain 9/10 on a scale of 0-10, and that he did not administer the [MEDICATION NAME] 300 mg-[MEDICATION NAME] 30 mg tablet because it ran out. He stated that Resident #1 was on [MEDICATION NAME] which was administered at 10:00 PM. The RN stated that he did not notify the NP that the [MEDICATION NAME] with [MEDICATION NAME] was not available. The [MEDICATION NAME] with [MEDICATION NAME] was ordered at 8:27 PM. He stated that the medication nurse should have notified the NP that the Tylenol with [MEDICATION NAME] ran out. The NP was interviewed on 05/01/2018 at 3:15 PM and stated she saw Resident #1 on 02/09/2018 sometime in the morning (does not remember exact time) and the resident was crying in pain. She stated that she ordered the x-ray STAT (a routine x-ray was ordered on [DATE]). She stated that she received a text message from RN #1 on 02/08/2018 during the evening shift informing her that Resident #1 was complaining of pain in the right ankle. RN#1 wanted to have an x-ray done for the resident and renew the order for [MEDICATION NAME] with [MEDICATION NAME]. She stated that she was not informed that the resident reported that she fell . She stated, had she known, she would have ordered the x-ray STAT on 02/08/2018 or send the resident to the Hospital for evaluation. The Director of Nursing (DNS) was interviewed on 05/14/2018 at 4:16 PM and stated that [MEDICATION NAME] 300 mg-[MEDICATION NAME] 30 mg tablet was not given on the 02/8/2018 because it was unavailable. She stated that the NP should have been notified so the NP could order another pain medication that was available in the facility. 415.12

Plan of Correction: ApprovedJune 7, 2018

I. Immediate Corrective Actions
1. As of 2/9/18, the NP completed the physical assessment, stat X-ray ordered and transferred to SJMC for R knee X-ray and rule out if R Tibia Fx is chronic or acute
2. Pain management completed and care plan updated.
3. Re-inserviced staff and re-viewed P&P Pain Management
4. Disciplinary action served to RNS and RN
II. Identification of Other Residents
1. The facility respectfully states all residents were potentially affected.
2. An in-house audit was conducted to identify all residents on Pain Management to ensure pain medication orders and CCP are resident -centered.
III. Systemic Changes
1. The DNS and the Medical Director on 6/4/18, reviewed the Policy and Procedure on Pain Management and found same to be compliant.
2. The DNS/ Designee implemented staff in-service education for Policy and Procedure on Pain Management.
3. All PMDs/ NPs were given list of residents on pain management for review.
4. Highlights of the Lesson Plan include:
? Assessment to be done on admission, re-admission, significant change/ annually and complaint of pain
? Pre/post pain assessment using Pain Scale Management Rating for verbal residents and Wong Baker FACES rating for non-verbal residents
? Documentation of findings in the nurses? progress notes, 24hr report.
? Notification of MD for positive findings.
? MD review of efficiency of pain management monthly, annually and as needed.
? Availability of Pain Medication Emergency kit.
? Responsibility of nurse to contact MD if pain medication is not available and obtain order for alternate (from e-kit)
IV. Quality Assurance
? Medical Director and DNS will review listing of all residents on Pain Medication, weekly x4 weeks then monthly by x6 months.
? DNS/ ADNS developed an audit tool to monitor pain assessment and management compliance of licensed nurses
? Audit will be done for (4) randomly selected residents weekly x 1month followed by 4 residents monthly x 6 months
? Findings of the audit will be brought to the Quarterly QA Meetings to check compliance and identify any areas of follow-up
V. Responsible Parties
? The Administrator, Medical Director and DNS are responsible to ensure compliance with facility P&P Pain Management

FF11 483.50(b)(1)(i)(ii):RADIOLOGY/OTHER DIAGNOSTIC SERVICES

REGULATION: §483.50(b) Radiology and other diagnostic services. §483.50(b)(1) The facility must provide or obtain radiology and other diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. (i) If the facility provides its own diagnostic services, the services must meet the applicable conditions of participation for hospitals contained in §482.26 of this subchapter. (ii) If the facility does not provide its own diagnostic services, it must have an agreement to obtain these services from a provider or supplier that is approved to provide these services under Medicare.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 14, 2018
Corrected date: July 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F776 Based on interviews and record review conducted during an abbreviated survey (NY 138), the facility did not provide radiology services in a timely manner to meet the needs of a resident. This was evident in 1 out of 4 residents sampled (Resident #1). Specifically, Resident #1 complained of pain to her right knee while she was being transferred from the wheelchair to the bed on 02/08/2018 at 6:15 PM. The Registered Nurse (RN) assessed Resident #1 for reports of right knee pain and observed that the knee was swollen, painful to touch and the resident reported that the pain was 9/10 (Pain Score 0-10 Numerical Rating 10 worst possible pain). The Nurse Practitioner (NP) was notified on 02/08/2018 at 6:31 PM and gave a telephone order for a routine x-ray of the right knee. On the morning of 02/09/2018 (does not recall the exact time), the NP saw the resident for complaints of pain and she ordered a STAT x-ray that was performed at 11:46 AM (14 hours after the initial x-ray was ordered). Resident #1 was transferred to the Hospital for questionable non-displaced fracture on 02/09/2018 at 6:50 PM, approximately 24 hours after the resident was assessed with [REDACTED]. The resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) on 01/16/2018, indicated a Brief Interview for Mental Status (BIMS - used to determine attention, orientation and ability to recall information) score of 15/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment & 12-15 cognitively intact). Resident #1 required total dependence with two staff assisting with transfer and extensive assistance of two staff with bed mobility. The Accident/Incident Report dated 02/08/2018 at 6:15 PM, documented that Resident#1 reported she was dropped on the floor. The report also documented that while being transferred by two CNAs from the wheelchair to the bed, Resident#1 complained of pain to the right knee. During assessment by RN#1, Resident #1's right knee was noted swollen and painful to touch. Resident#1 rated the pain to the right knee using the Numeric Pain Score 9/10. The NP was notified at 6:31 PM. A Nurse's Progress Note by RN #1 dated 02/08/2018 at 8:51 PM documented that Resident #1 was noted complaining of severe pain to the right knee as staff were transferring her from the wheelchair to bed. The right knee was noted with swelling. The NP was notified with an order for [REDACTED]. A Nurse's Progress Note by RN#1 dated 02/08/2018 at 8:52 PM documented that the x-ray was scheduled by the lab to be done on 02/09/2018. There was no documentation that the physician was made aware the x-ray would not be done on 02/09/2018. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The routine x-ray ordered on [DATE] was discontinued. A Medical Progress Note by the NP dated 02/09/2018 at 2:57 PM, documented that the NP saw and examined Resident #1 for follow-up knee pain. The resident complains of right knee pain, no swelling. The assessment/plan included STAT x-ray of the right knee and Tylenol#3 given for pain. A Medical Progress note by the NP dated 02/09/2018 at 5:51 PM, documented x-ray showed questionable fracture. The NP spoke with Resident #1's next of kin (NOK) regarding sending the resident to the hospital to get another x-ray to check if there is fracture and if it is chronic or acute. A Nurse's Progress Note by RN #3 dated 02/09/2018 at 5:57 PM documented that Resident #1 complained of pain 4/10 to the right knee. RN #2 assessed Resident #1 right knee and noted that it was swollen. The NP evaluated Resident #1 pain and swelling. Tylenol was administered and the STAT x-ray was done, awaiting result. The Diagnostic company's x-ray log revealed a STAT x-ray was taken on 02/09/2018 at 11:46 AM and uploaded at 11:52 AM. The result of the STAT x-ray was called in to the facility at 4:52 PM. The results of the right knee x-ray with two views dated 02/09/2018, documented impression of questionable horizontal non-displaced fracture seen through the tibia inferior to tibial plateau. Advise follow-up with bandaged removed. A Nurse's Progress note by RN #1 on 02/09/2018 at 7:15 p.m., documented x-ray result read right knee limited, questionable non-displaced fracture thru tibia inferior to tibial plateau. NP and NOK notified. NP ordered transfer of the resident to the hospital to rule out if fracture chronic or acute. Resident #1 left the faciity on [DATE] at 6:50 PM. The hospital discharge summary dated 02/13/2018, documented the resident's primary [DIAGNOSES REDACTED]. A Nurse's Progress Note by RN #4 dated 02/13/2018, documented that Resident #1 was readmitted at 4:35 PM, with [DIAGNOSES REDACTED]. RN #1 was interviewed via telephone on 03/08/2018 at 1:38 PM., and stated he was the Charge Nurse on 02/08/2018 during the evening shift. RN #1 stated that Resident #1 complained of right knee pain while being transferred by the CNAs from the wheelchair to bed. RN #1 stated that he observed the right knee with swelling and was painful to the touch. RN #1 stated he notified the NP and a routine x-ray for the right knee was ordered and pain medication was given to the resident. A follow-up telephone interview with RN #1 was conducted on 05/03/2018 at 4:00 PM, and he stated he notified the NP a few minutes after he was notified by the CNAs on 02/08/2018 at 6:15 PM. that Resident#1 complained of pain in her right knee while being transferred from the wheelchair to the bed. RN #1 stated he recommended that an x-ray be ordered. He further stated he did not tell the NP that Resident #1 reported she fell because the two CNAS present during the transfer denied the resident fell . The Nurse Practitioner was interviewed via telephone on 05/01/2018 at 3:15 PM, and stated she examined the resident in the morning of 02/9/2018 and saw the resident crying in pain and ordered a STAT x-ray. She stated she received a text message from RN #1 on 02/8/2018 during the evening shift and was informed the resident was complaining of pain in the right ankle. RN #1 recommended to have an x-ray done for the resident and renew order for Tylenol with [MEDICATION NAME]. According to the NP, she was not aware of the alleged fall. She stated that, had she known, she would have ordered the x-ray as STAT or send the resident to the hospital for evaluation. The NP further stated that when the results of the x-ray came, she ordered the resident to be transferred to the hospital for further evaluation, and repeat of x-ray. The Director of Nursing (DNS) was interviewed via telephone on 05/14/2018 at 4:16 PM and stated that the x-ray was initially ordered as a routine because the NP was not aware of the alleged fall. She stated that the RN should have reported the alleged fall to the NP. 415.21

Plan of Correction: ApprovedJune 7, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Actions
1. Upon NP assessment, the routine x-ray order was changed to stat x-ray order.
2. Resident # 1 was transferred to hospital upon receipt of stat x-ray result to rule out chronic vs acute fracture.
3. Involved RNs received in-service and disciplinary action.
4. Resident was readmitted [DATE] and MD reassessed resident.
5. CCP was received and revised as indicated.
II. Identification of Other Residents
1. The facility respectfully states that all residents were potentially affected.
2. A list of all residents with x-ray orders was reviewed.
III. Systemic changes
1. The Medical Director and DNS reviewed P&P for Physician Notification 6/4/18 and found to be compliant.
2. The DNS/ Designee implemented staff in-service education on P&P Physician Notification to all licensed nurses.
3. All MDs/ NPs will review all Radiology/ Diagnostic Services during their monthly visits and as needed.
Highlights of Lesson Plan
In-service ? Physician Notification
? To inform MD/NP of resident?s change in condition that may require change in treatment plan or transfer to hospital including but not limited to
- Accident involving resident which results in injury and/ or has the potential of injury
- Significant change in resident?s physical, mental and psychological status
- A need to alter treatment significantly
-A decision to transfer or discharge resident from facility
-Abnormal laboratory reports
? RN/ Charge nurse identifies the change in condition, and notifies the RN Supervisor and MD/ NP in a timely manner based on assessment
? Medical Director will be contacted if MD/ NP not reachable
? RNS will do complete physical/ mental assessment if charge nurse is LPN
IV. QA
The DNS developed an audit to monitor the facility?s compliance with ensuring timely radiologic services to meet resident?s needs. This audit will be completed for all STAT radiological orders weekly x 4 weeks followed by monthly x 6 mos.
V. Responsible Parties
? The Medical Director and DNS/ Designee are responsible to ensure compliance with facility P&P Physician Notification