The Grand Rehabilitation and Nursing at Mohawk
April 1, 2019 Complaint Survey

Standard Health Citations

FF11 483.25:QUALITY OF CARE

REGULATION: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2019
Corrected date: May 1, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated survey (NY 151), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents reviewed for quality of care (Resident #4). Specifically, Resident #4 developed a rash and [MEDICATION NAME] (a steroid) was ordered. The [MEDICATION NAME] was not administered as ordered and the rash worsened and the resident required hospitalization . Findings include: The facility's policy E-prescribing, Transcription, and Order Entry via Point Click Care EMR, revised 1/2019, documented all medication orders were entered by the provider or nurse and after entering an order, the person entering it should check the EMAR (electronic Medication Administration Record) to ensure accuracy of the order entered. Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's cognition was intact per the 12/13/2018 Minimum Data Set (MDS) assessment. The 1/22/2019 nurse practitioner (NP) progress note documented the resident complained of a rash. The NP ordered Cortisone cream twice daily. The 1/29/2019 nurse practitioner (NP) progress note documented the resident had a raised, bumpy rash on her arms, legs, chest, and abdomen. The plan was to discontinue [MEDICATION NAME] (diabetes medication) the resident recently started taking and to start [MEDICATION NAME] (steroid). The 1/29/2019 physician's orders [REDACTED]. - [MEDICATION NAME], 5 milligrams (mg), 1 tablet twice a day starting on 1/30/2019. - [MEDICATION NAME], 5 mg, 1 tablet three times a day for one day on 1/31/2019. - [MEDICATION NAME], 5 mg, 1 tablet four times day on 2/1/2019. - [MEDICATION NAME], 5 mg, 1 tablet 3 times a day for one day on 2/2/2019. The 1/2019 Medication Administration Record (MAR) documented: - On 1/30/2019, licensed practical nurse (LPN) #1 administered the resident 5 mg [MEDICATION NAME] at 7 AM. - The MAR did not document the resident received the 8 PM dose of [MEDICATION NAME] on 1/30/2019. - On 1/31/2019, LPN #2 documented the 12 PM dose of [MEDICATION NAME] was not given and was not available yet from pharmacy. The 1/31/2019 LPN #2's progress note at 2:07 PM, documented the resident was having more discomfort from the rash. Multiple blisters appeared and were ruptured and the NP was to see her. The 1/31/2019 NP progress note documented the resident had worsening itching from a red, raised rash from her fingertips to toes. The resident had some blistering and she never received the [MEDICATION NAME] ordered on [DATE] as it was not sent from the pharmacy. The NP discontinued the prior [MEDICATION NAME] orders and ordered a new [MEDICATION NAME] taper. The 1/31/2019 physician orders [REDACTED]. -discontinue the [MEDICATION NAME] order from 1/29/2019. - [MEDICATION NAME], 40 mg, one dose to start that day. - [MEDICATION NAME], 40 mg once a day for 3 days; 30 mg once a day for 3 days, 20 mg once a day for 3 days, and 10 mg once a day for 3 days. In an interview with the NP on 3/28/2019 at 10:45 AM, she stated when she saw the resident on 1/29/2019, the rash was more diffuse than it was on 1/22/2019 and she thought it could be a reaction to [MEDICATION NAME]. On 1/29/2019, she ordered a [MEDICATION NAME] taper to start on 1/30/2019. On 1/31/2019 she was told the [MEDICATION NAME] had not been given as they had not received it from pharmacy. She stated if the resident had received the [MEDICATION NAME] ordered on [DATE], the rash should have been improved on 1/31/2019, and it was not. On 1/31/2019, the resident had some blistering on her hand, she discontinued the prior [MEDICATION NAME] order, ordered a new [MEDICATION NAME] taper plus an additional 40 mg dose to be given that day. She stated she wanted the resident to have the 40 mg dose that day and the following morning (2/1/2019) so when the physician saw her on 2/1/2019, she would have had two 40 mg doses. The Omnicell (automated medication dispenser) report documented at 8:41 PM on 1/31/2019, registered nurse (RN) #5 removed 40 mg [MEDICATION NAME] from the Omnicell for the resident. The 1/31/2019 at 9:51 PM LPN #4's progress note documented the resident was asking to go to the hospital. She had swelling in her face and redness and blisters all over. The Supervisor was aware and there were new [MEDICATION NAME] orders in place. The 1/31/2019 at 11:15 PM, (RN) #5's progress note documented the resident had increased swelling and a body rash with fluid filled blisters to her thighs and [MEDICATION NAME] 40 mg was given that night. The 2/2019 MAR and Medication Administration Audit Report documented: - The resident had two orders for 40 mg [MEDICATION NAME] to start on 2/1/2019. One was scheduled for 7 AM and the second dose was scheduled for 7:30 AM. - On 2/1/2019, LPN #6 signed for administering three 40 mg doses of [MEDICATION NAME] at 8:23 AM. - On 2/2/2019, LPN #7 signed for administering one 40 mg dose of [MEDICATION NAME] at 7:28 AM and a second 40 mg dose of [MEDICATION NAME] at 7:29 AM. The 2/2/2019 at 12:13 PM, LPN #7's progress note documented the resident had a red rash to her entire body that was bright red and warm to touch. The 2/2/2019 at 9:08 PM, LPN #8's progress note documented the resident was at the emergency room for a head to toe skin rash with blisters that were painful and popping. On 3/18/2019 at 11:05 AM, LPN #2 stated in an interview, the resident developed a rash and the NP ordered [MEDICATION NAME] for the resident. On 1/31/2019, the resident's rash was worse with blisters and the resident was asking to go to the hospital. The resident had [MEDICATION NAME] ordered but when she went to administer it on 1/31/2019, there was no [MEDICATION NAME] for the resident. She checked the MAR and saw that LPN #1 documented he gave one dose of [MEDICATION NAME] on 1/30/2019. She stated she did not know how he could have administered it as there was not any in the medication cart. She stated she noticed this sometime between 10:30 AM and 12 PM on 1/31/2019. She reported this to the Director of Nursing (DON) that day. The NP saw the resident and the resident was told the [MEDICATION NAME] was coming. The resident was upset the rest of the shift and was crying as she wanted to go to the hospital and have the rash looked at. When LPN #2 left the facility for the day on 1/31/2019, the [MEDICATION NAME] had not arrived for the resident. On 3/20/2019 at 1:35 PM, the DON stated in an interview, LPN #2 spoke to her about the [MEDICATION NAME] not being available on 1/31/2019 and she was aware LPN #1 signed as administering it on 1/30/2019. She stated he could have gotten it from the Omnicell, but she did not check to see if he did. She stated she also did not follow up with the nurse on duty at 8 PM on 1/30/2019 to see why the [MEDICATION NAME] was not administered. She stated nurses entered the orders for the medical providers and there were no handwritten records of verbal or telephone orders. She stated in the electronic medical record, there was not a system to check orders for accuracy. On 3/28/2019 at 9 AM, the DON was interviewed a second time and stated she spoke with LPNs #6 and 7 and they both stated although there were duplicate orders for [MEDICATION NAME] on the resident's MAR on 2/1 and 2/2/2019, they did not administer them. She stated she also spoke to LPN #1 and he stated he used another resident's [MEDICATION NAME] at 7 AM on 1/30/2019. She did not know which resident's [MEDICATION NAME] he used and did not verify whether there was discontinued [MEDICATION NAME] available. She stated the reason for the duplicate [MEDICATION NAME] taper order on 2/1/2019 was because on 1/31/2019, RN Supervisor #5 called the physician because the resident had facial swelling and he ordered a [MEDICATION NAME] taper. RN #5 entered that order and did not realize there was a [MEDICATION NAME] taper already ordered to begin on 2/1/2019. She stated RN #5 must not have checked the orders and there was not an alert in the medical record system to let the nurse know when a duplicate order was entered. On 3/28/2019 at 10:10 AM, LPN #6 stated in an interview, on 2/1/2019, she signed for administering three 40 mg doses of [MEDICATION NAME] to the resident at 8:23 AM. She stated she did not think she gave the resident 120 mg as she thought that was a large dose. She stated the orders were confusing, she did not recall what she administered, and she did not clarify the confusing orders with anyone. On 3/28/2019 at 11:15 AM, RN #5 stated in an interview, she had additional notes that were not part of the medical record which she typed up every shift and gave to the Administrator. On the night shift from 1/31/2019 through 2/1/2019, she called the physician and obtained an order for [REDACTED]. She did not know the resident already had an order for [REDACTED]. She sent the resident to the hospital at 4:56 PM on 2/2/2019. Her additional notes documented the resident continued with a full body rash and draining blisters. The local hospital called her back and told her the resident was transferred to a larger medical center in a neighboring city for further evaluation. 10NYCRR415.12

Plan of Correction: ApprovedApril 23, 2019

1. Resident # 4 returned from the hospital on (MONTH) 13, 2019 and has been seen be medical. Resident #4 is doing well medically and participating and progressing in therapy. Resident #4 shows no negative effect from her hospital stay.
LPN # 1 was re-educated for utilizing another resident?s medication and not informing the supervisor that the medication had not been delivered by the pharmacy. He was also re-educated on the policy and procedure for medication administration and informing the supervisor when a medication is not available.
LPN #2 was educated on the policy and procedure for Administering Medications as well as E-Prescribing Transcription, and order entry via PointcClickCare EMR
LPN # 6 is no longer at the facility.
Director of Nursing has reviewed the policy and procedure for Medication Administration and E-prescribing, transcription, and order entry via Point Click Care EMR.
2. The facility respectfully recognizes all residents as having potential to be affected and the facility reviewed all new resident medication orders back to (MONTH) 1, 2019 to ensure accuracy, medications administered per physician order, that there is no duplicate order, and medications were delivered in a timely manner. Any issues identified during the audit was correctly immediately and medical was notified.
3. The policy and procedures for e-prescribing, transcription, and order entry via Point Click Care EMR and medication administration has been reviewed and revised. The Director of Nursing will be responsible to ensure that all licensed and medical staff are educated on both policies. Medication administration reports will be ran to ensure that all medications are administered per policy. Any issue identified, including medications that are not delivered, will be addressed/corrected immediately. The facility will also review all medications ordered from the day prior at morning meeting to ensure that the medications were received by the facility. Any medication that was not received will be addressed by the pharmacy and medical is to be notified.
4. The Director of Nursing will be responsible to ensure compliance with this process by conducting weekly audits for 6 months at which time it may be referred to the Quality Assurance Committee for guidance and any findings will be immediately corrected. The Director of Nursing will be responsible to report the findings at he Quality Assurance Committee Meeting monthly for review and follow up.
5. Director of Nursing
6. May 1, 2019

FF11 483.10(a)(1)(2)(b)(1)(2):RESIDENT RIGHTS/EXERCISE OF RIGHTS

REGULATION: §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2019
Corrected date: May 1, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated survey (NY 648), the facility did not ensure residents could exercise their rights without interference, coercion, or reprisal from the facility for 1 of 5 residents reviewed for resident rights (Resident #1). Specifically, Resident #1 requested to go to the hospital for complaints of chest pain and was told she would have to sign out AMA (against medical advice) and would lose her bed if she went. Findings include: The Discharge Against Medical Advice (AMA) policy dated 3/2018 documented the facility was to ensure family members understood their rights regarding the request for immediate discharge without physician's approval. The procedure documented nursing staff were to inform medical and social work when a resident or representative requested an immediate discharge. The policy did not make reference to signing out AMA to go to the hospital. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's cognition was intact per the 2/12/2019 Minimum Data Set (MDS). Review of the medical record revealed from 1/2019-2/2019, the resident experienced a change in medical condition. She had breast/chest pain for which a breast ultrasound was ordered and was negative; she had shortness of breath and was started on oxygen which she was not previously on; she had [MEDICATION NAME] (diuretic) ordered; she experienced increased anxiety and had a new order for [MEDICATION NAME] (anti-anxiety medication), and she was being treated with [MEDICATION NAME] for a urinary tract infection. A social worker #12 progress note dated 2/21/2019 at 10:43 AM documented she and registered nurse (RN) Supervisor #5 spoke with the resident. The resident complained of chest pain and wanted to go to the hospital. RN Supervisor #5 stated she was told by the Assistant Director of Nursing (ADON) the facility's Medical Director stated if the resident wanted to go to the hospital she would have to sign out against medical advice (AMA). Social worker #12 explained what AMA was to the resident. The resident asked the social worker if she thought the resident was stupid and the resident refused to sign the form. The resident threw RN #5 out of her room and the social worker tried to calm the resident. The social worker called the resident's family member (her appointed health care proxy, HCP) and explained the situation. The family member stated she would call the resident and call the facility back. On 2/21/2019 at 6:30 PM, RN Supervisor #5's progress note documented she was called to the resident's room to speak with the resident and the family. Social worker #12 called the resident's family member (appointed HCP) and explained that another family member was present and encouraging the resident to go to the hospital. RN Supervisor #5 documented The Medical Director was aware of request. If resident leaves she needs to sign AMA. RN #5 and social worker #12 approached the resident about AMA and the resident started screaming at them and threw RN #5 out of the room. On 2/24/2019, the resident was sent to the hospital with radiating chest pain. On 3/15/2019 at 9:55 AM, the resident stated in an interview, a few weeks ago she felt horrible. She had chest pain, was short of breath, and her chest was so tight. They were doing tests at the facility and nothing was helping. She stated she was begging and begging the nurses to send her to the hospital and they would not let her go. She stated when she asked to go they tried to intimidate me and told me I might not have my bed when I was ready to come back. She stated she was scared and I thought I'd be homeless. She stated because of that, she did not sign the AMA paperwork and did not go to the hospital. She stated a few days later she was admitted to the hospital and they found out that she had a fractured rib. On 3/20/2019 at 12:30 PM, the Administrator stated he was out of town when the resident was told she had to sign out AMA if she chose to go to the hospital. He stated he would not have given that directive to staff and it was not the facility's policy to have residents sign out AMA if they wanted to go to the hospital. On 3/28/2019 at 11:15 AM, RN Supervisor #5 stated in an interview, the day the resident wanted to go to the hospital, her family was visiting, and they were encouraging her to go. She stated she spoke to the ADON who told her the resident would need to sign out AMA to go to the hospital. She explained AMA to the resident and told her if she went to the hospital they would not hold her bed. She stated the resident refused to sign out AMA and stayed in the facility. On 3/28/2019 at 12 PM, the ADON stated in an interview, the day the resident wanted to go to the hospital, she was on call and RN Supervisor #5 called her. She stated she reminded RN #5 to notify the Corporate Medical Director prior to sending the resident to the hospital as this was a new facility policy. She stated she did not call the facility's Medical Director or the Corporate Medical Director for RN #5 and did not direct RN #5 to complete AMA paperwork with the resident. On 3/28/2019 at 12:20 PM, social worker #12 stated in an interview, on 2/21/2019, RN Supervisor #5 told her she was going to do AMA paperwork with Resident #1 and she offered to assist. The social worker stated RN #5 told her the ADON instructed RN Supervisor #5 to do AMA paperwork with the resident and this was per the facility's Medical Director. She stated when they went to speak to the resident she was shaking, had chest pains, and was tensing up as they spoke to her. The resident became very upset during the conversation with RN #5 and the social worker stated she tried to help the resident remain calm. The resident did not sign the AMA form and was not sent out that night. 10NYCRR415.3(c)(l)(i)

Plan of Correction: ApprovedApril 23, 2019

1. Resident # 1 returned from the hospital on (MONTH) 13, 2019 and has been seen be medical. Resident #1 is doing well medically and participating and progressing in therapy.
Rn #5 has been educated on the Discharge Policy and the Discharge Against medical Advice Policy.
Social Worker has been educated on the Discharge Policy and the Discharge Against medical Advice Policy.
2. The facility completed a review of all hospital transfers for the past 60 days to identify all residents that were not transferred to the hospital per his/her request, there were no negative outcomes from the deficient practice. Residents that are requesting to be transferred to the hospital, will no longer be required to sign out against medical advice.
3. The facility has reviewed both the policies for Discharge and the Discharge Against Medical Advice. All interdisciplinary staff and medical staff that participate in discharge planning will be educated on the policy, specifically that residents and/or designated representatives will not be required to sign out against medical advice when requesting a transfer to the hospital. The Director of Nursing will be responsible to review all hospital transfers monthly to identify all interventions attempted prior to the transfer and if the transfer was at the request of the resident and/or designated representative and was that request met? The Director of Nursing will also review all hospital transfers to ensure that the resident and/or designated representative were not required to sign out Against Medical Advice.
4. The Director of Nursing/designee will be responsible to ensure compliance to this process as evidenced by completing monthly audits of all hospital discharges and transfers. Audits will be completed monthly for 6 months and the audit will address what interventions the facility did prior do the transfer, the outcome of those interventions, and whether the resident was transferred to the hospital. The audit will also ensure that if the transfer was at the request of the resident and/or the family, that a discharge against medical advice form was not required to be signed. Any issues identified by the audit will be corrected immediately, and the information obtained from the audits will be addressed at the monthly QAPI meeting.
5. Director of Nursing
6. May 1, 2019