Ozanam Hall of Queens Nursing Home Inc
August 11, 2016 Complaint Survey

Standard Health Citations


REGULATION: Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Scope: Isolated
Severity: Actual harm has occurred
Citation date: August 11, 2016
Corrected date: August 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review conducted during an abbreviated survey, the facility did not ensure that a resident received the necessary care and services to attain the highest practicable level of physical well- being. Specifically, the facility did not implement a recommendation of an assistive drinking equipment for 1 of 3 residents sampled for quality of care issues (Resident #1). The Occupational Therapy Assistant (OTA) evaluated Resident # 1 on 10/21/2015 at which time a covered mug was recommended due to the resident's incoordination and spilling of liquids, when attempting to hold a mug with both hands. On 11/4/2015, Resident #1 spilled a cup of hot tea sustaining a 6x8cm burn to the left mid-thigh. The recommendation was not implemented and the resident did not receive the covered mug. Complaint # NY 755 The Findings include: Resident #1 is an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #1 has intact cognition. The Facility's Investigation Summary dated 11/4/2015 documented that the OTA evaluated Resident #1 on 10/21/2015. It was noted that Resident #1 was having difficulty holding a glass to drink juice. The OTA reportedly recommended a covered mug to allow Resident #1 to safely drink through a straw. The OTA reportedly delivered the covered mug to a member of the dietary staff, however the use of a covered mug was not added to the resident meal ticket and the covered mug was not provided for use at mealtime. The investigation further revealed on 11/4/2015, Resident #1 missed-held a cup of hot tea and it spilled on her left mid-thigh. She sustained a reddened area measured 6x8cm. Diagnosis: [REDACTED]. Review of the OTA note dated 10/21/2015 documented Resident #1 has incoordination and spills beverages. The resolution documented please provide a covered mug. The Rehabilitation Nursing Recommendations Form dated 10/21/2015 documented Resident #1 requires a covered mug to promote safe feeding and eating. The FDR Feeding Equipment list dated 10/16/2015 revealed that Resident #1's name was not on the list. There were no other FDR Feeding Equipment list for the month of (MONTH) (YEAR). The Certified Nursing Assistant Assignment Record (CNAAR) for the month of 10/2015 has no documentation for Resident #1 to be provided with a covered mug. The Nursing Progress Note dated 11/4/2015 at 1:30PM documented that Resident #1 is status [REDACTED]. Icepack applied, and order given for polymen to be applied to the affected area. The Medical Doctor Progress Note dated 11/05/2015 documented Resident #1 was assessed for second degree burn measured 8x6cm. The OTA was interviewed on 12/7/2015 at 12:56PM. She stated, on 10/21/2015, she observed Resident #1 with incoordination of her left hand. The Resident was struggling to hold a cup of juice with both hands. The OTA also stated that a recommendation for a covered mug was ordered and she entered the recommendation into the computer. In addition, she stated that she provided the dietary supervisor with the covered mug. The OTA was asked for the name of the dietary supervisor she gave the covered mug to, and she stated that she does not remember. She further stated that the recommendation was also given to the Occupational Therapy Secretary to be added to the feeding list. The Occupational Therapy Secretary was interviewed on 7/5/2016 at 9:50 AM. She stated that she added Resident #1's name and the recommendation for a covered mug to the FDR Feeding Equipment list and placed a copy in the mail box. When the Secretary was asked for the date that she added Resident #1's name and recommendation to the FDR Feeding Equipment list, she stated that she does not remember and that she does not have a copy of the old list. Review of the only FDR Equipment Feeding list dated 10/16/2015 revealed that Resident #1's name was not on the list. The Manager of Food Service was interviewed on 12/7/2015 at 1:18PM. She stated that she does not recall being given a ticket with recommendation for a covered mug for Resident #1. She further stated, if she had been given the recommendation, it would have been entered into the computer. The Registered Nurse that was assigned to Resident #1 was interviewed on 5/2/2016 at 10:00AM. She denied receiving a referral for an assistive device for Resident #1. The Director of Rehabilitation Department was interviewed on 5/9/2016 at 12:30PM. She was asked if any of the Occupational Therapy staff had conducted an observation of the recommended adaptive device for Resident #1 and she stated, Occupational Therapy staff would only observe the resident if they were specifically working with the resident for feeding purposes. The facility revised policy and procedure for adaptive equipment dated 8/2012 documented Nursing, Dieticians and Occupational Therapists will periodically monitor the status of residents using adaptive feeding equipment by observation and report findings to the Quality assurance Committee. 483.25

Plan of Correction: ApprovedAugust 26, 2016

Element I
On 11/4/15 at 11:50 AM resident #1 accidentally spilled hot tea on her left thigh sustaining a second degree burn. A Physician was notified, a treatment was ordered and initiated.
Element II
A. Residents identified as having/needing an assistive feeding device were reviewed to ensure that the type of equipment was noted, that it was available and that it was in use at mealtime.
Completed by: (MONTH) (YEAR)
B. The type of adaptive feeding equipment recommended by the Occupational Therapist was reconciled to with the meal ticket for all Residents requiring adaptive equipment.
Completed by: (MONTH) (YEAR)
Element III
The ?Resident Wellness Task Force?,(Committee members include the Director of Clinical Nutrition, Registered Dieticians, Director of Rehabilitation Services, Director of Food Service, Director and Assistant Director of Nursing, Medical Director, Quality Management and Administration) reviewed and revised Policies and Procedures related to adaptive feeding equipment.
Effective: (MONTH) (YEAR)
A new policy ?Safe Service for Hot Beverages? was developed effective (MONTH) (YEAR).

The ADON/Designee in-serviced all Nursing staff on the policy for Safe Service of Hot Beverages.
Completed by: (MONTH) (YEAR)
The Director of Rehabilitation Services in-serviced all of the Rehab Staff on the policy for Adaptive Feeding Equipment.

Completed by: (MONTH) (YEAR)
The Director of Food Service in-serviced all of the Dietary staff on the policy for Safe Service of Hot Beverages and Adaptive Feeding Equipment.
Completed by: (MONTH) (YEAR)

Element IV
Quality Assurance Activity was initiated for 10% of those residents using adaptive feeding equipment to ensure that all aspects of the new/revised policies and procedures are being followed. Monthly auditing will continue until 100% compliance is achieved. Frequency of auditing will be re-evaluated at that time.
Completed by: (MONTH) (YEAR)
Element V
The Director of Nursing,the Director of Rehabilitation, the Director of Food Service, and the Director of Quality Assurance ensured that the plan of correction was implemented and will be monitored for compliance.
Completed: (MONTH) 24, (YEAR)