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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2023
Corrected date: May 26, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and the Abbreviated Survey (NY 955) initiated on 3/22/2023 and completed on 3/30/2023 the facility did not ensure that a Baseline Care Plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care was developed within 48 hours of admission. This was identified for one (Resident #276) of four residents reviewed for Pressure Ulcer (PU). Specifically, Resident #276 was admitted with a Sacral PU on 12/16/2022. A Baseline care plan for the Sacral Pressure Ulcer was not completed within 48 hours as required. The finding is: The facility's Baseline Care Plan policy reviewed 1/2023 documented to assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. Resident #276 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a short-term memory problem and was moderately impaired for daily decision making. The resident required total assistance of two staff members for bed mobility and was frequently incontinent of bowel. The resident had an indwelling Foley catheter. The MDS further documented the resident was at risk for developing PU and had one unhealed Stage III PU that was present on admission. The Baseline Care Plan dated 12/16/2022 was blank under the Skin Concern section. A Nursing Admission assessment dated [DATE] documented the resident had redness to both heels and had a Stage IV PU to the Sacrum that measured 5 centimeters (cm) x 4.5 cm. A wound care initial evaluation completed on 12/22/2022 reassessed to wound as a Stage III PU. A Comprehensive Care Plan (CCP) dated 12/26/2022 documented the resident had a Stage III Sacral PU. Interventions included but were not limited to apply skin treatment as per the physician's orders [REDACTED]. Registered Nurse (RN) #7, who completed the admission assessment, was interviewed on 3/28/2023 at 1:24 PM. RN #7 stated when a resident is admitted or readmitted to the facility, a head-to-toe body check is completed during the assessment. RN #7 stated after completing the assessment an admission note should be documented and a care plan should be initiated. RN #7 stated they should have completed the Baseline Care Plan; however, the care plan can be completed within twenty-four hours after admission and that any RN on the unit can review and complete the care plan. RN #1, who was the 7:00 AM - 3:00 PM RN Supervisor at the time the resident was readmitted , was interviewed on 3/30/2023 at 9:55 AM. RN #1 stated on admission or readmission, the RN that completes the admission assessment also initiates the Baseline Care Plan. RN #1 stated if the admission RN was unable to complete the care plan, they (RN #1) should follow up and complete the care plan the next day. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 6:32 PM. The DNS stated that the admission RN should have completed the Baseline Care Plan; however, if the admission RN was unable to complete the Baseline Care Plan, then the RN Supervisor should have completed the Baseline Care Plan the following day. 10 NYCRR 415.11 | Plan of Correction: ApprovedApril 23, 2023 1. Corrective action for the resident effective: Resident 276 was discharged from the facility prior to the time of the Statement of Deficiencies. 2. How to identify other residents having the potential to be affected by the same deficient practice: The facility reviewed all baseline care plans of all new admissions within the last 30 days to assure all clinical assessments were identified. Corrections were made as needed. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Medical Director, Director of Nursing and Administrator reviewed the policy and procedure on base line care plans. No changes in the policy and procedure were made. The In-service Educator re-educated Rn #7 and RN # 1 on the baseline care plan. The In-service Educator re-educated the licensed nursing staff on the baseline care plan process to include all assessments. Clinical team will review their dedicated assessment on the baseline care plan for new admissions during the morning meeting to make sure all appropriate assessments are included. 4. How the corrective monitored to ensure the deficient practice will not recur: The Director of Nursing or designee will conduct weekly audits of 10% new admitted resident's records for competed baseline care plan for four weeks, bi-weekly audits for one month, and then monthly for two months to ensure compliance. Results will be reported to the monthly QAPI Committee meeting. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2023
Corrected date: May 26, 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 3/22/2023 and completed on 3/30/2023, the facility did not ensure that high protein supplements were provided as ordered by a Physician. This was identified for one (Resident #128) of four residents reviewed for Nutrition. Specifically, Resident #128 was assessed by the Registered Dietician (RD) on 10/13/2022 with recommendations to provide LPS (liquid protein supplement) and then again on 12/17/2022 with recommendation to provide LPS and Juven (a powdered protein supplement) to aid in wound healing. A physician's orders [REDACTED]. There was no documented evidence in the Medication Administration Record [REDACTED]. The finding is: The facility's policy titled, Enteral (tube) Nutrition last reviewed on 1/2022 documented that the Dietitian will monitor residents who are receiving enteral feedings and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. The facility's policy titled, Nutrition and Hydration to Maintain Skin Integrity last reviewed on 1/2023 documented that the healing of acute (e.g., postoperative) and chronic (e.g., pressure ulcers) wounds requires enough protein and calories so that the body will not use lean body mass for energy and wound repair. The policy also documented that the recommended protein levels for a resident with wounds or at risk of developing wounds is approximately 1.2 - 1.5 grams (gm) of protein per kilogram (kg) of body weight. Resident #128 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 10 which indicated the resident had moderately impaired cognitive skills for daily decision making. The resident was totally dependent on one person for eating. The resident's height was 68 inches and the resident weighed 140 pounds (lbs). The resident received 51% or more of their total calories through tube feeding. The Dietary Progress Note dated 10/13/2022, written by RD #2, documented that the resident's Current Body Weight (CBW) was 145.8 lbs on 10/11/2022 and that the resident had a Stage 4 sacral pressure ulcer. The Plan recommended a change in the tube feeding amount and flow rate and also suggested liquid protein supplement (LPS) 30 milliliter (ml) via Percutaneous Endoscopic Gastrostomy (PEG) tube twice daily (BID) which would provide the resident with an additional 200 kilo calories (kcal) and 30 gms protein per day to help meet the resident's increased protein needs related to wound healing. The physician's orders [REDACTED]. There was no documented evidence in the resident's Electronic Medical Record (EMR) that the LPS was ordered as suggested by RD #2. The Nutrition Wound Note dated 12/17/2022, written by RD #1, documented that the resident had a Stage 4 sacral pressure ulcer, current size measuring 5.5 centimeters (cm) x 5.5 cm x 2 cm. The note documented that protein supplementation of LPS by mouth (po) BID was recommended to provide the resident with an extra 200 kcal and 30 gms of protein per day and Juven (a high protein powder) was recommended to provide the resident with an extra 180 kcal and 33 gms of protein per day. The physician's orders [REDACTED]. Review of the resident's (MONTH) 2022 Monthly Medication Administration Record [REDACTED]. Review of the resident's (MONTH) 2023 Monthly MAR indicated [REDACTED]. Review of the resident's (MONTH) 2023 Monthly MAR indicated [REDACTED]. RD #2 was interviewed on 3/28/2023 at 11:35 AM and stated that when they (RD #2) assessed the resident on 10/13/2022, they (RD #2) adjusted the resident's tube feeding and recommended that the resident receive the LPS twice daily due to the resident's increased protein needs related to wound healing. RD #2 was re-interviewed on 3/29/2023 at 10:10 AM and stated that when they (RD #2) stated that they (RD #2) had no idea why the order for the LPS was not obtained in (MONTH) 2022 when they (RD #2) had first recommended LPS because the resident had increased protein needs due to a Stage 4 sacral pressure ulcer. RD #2 stated that the LPS order was not obtained until 12/17/2022. RD #2 further stated they (RD #2) could not explain why the resident did not receive the LPS until 1/22/2023 after the physician's orders [REDACTED]. RD #1 was interviewed on 3/29/2023 at 11:10 AM and stated that when completing the Nutrition Wound Note on 12/17/2022, they (RD #1) made a request for the resident to receive the two high protein supplements because the tube feeding was not providing enough protein to promote wound healing. RD #1 stated that they (RD #1) put both orders into the computer on 12/17/2022 for the LPS and the Juven. RD #1 further stated they (RD #1) had no idea why the resident did not receive the LPS for the first time until 1/22/2023 and the Juven for the first time on 2/2/2023. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 2:40 PM and stated that the RDs are responsible to place the dietary supplement orders into the computer and then Nursing confirms the order. The DNS stated that Nurses are responsible to notify the Physician of the RD's recommendation. The DNS stated that if there were no signatures on the MAR, there was no evidence that LPS or Juven were administered to Resident #128 in the month of (MONTH) 2022. The DNS stated LPS was first administered on 1/22/2023 as evidenced by the staff signature on the MAR. The DNS stated that the first time the Juven was administered was on 2/2/2023 as evidenced by the staff signature on the MAR. 10 NYCRR 415.11(c)(1) | Plan of Correction: ApprovedApril 23, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Corrective action for the resident effective: Resident # 128 medical record was reviewed, resident continues to receive protein supplement, her body weight is stable, and her sacral pressure ulcer is improving. The nurses involved received educational counseling regarding documentation of supplements. 2. How to identify other residents having the potential to be affected by the same deficient practice: The facility reviewed and updated, if necessary, all residents receiving supplements to assure the facility was following the physician orders. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Medical Director, Director of Nursing and Administrator reviewed the policy and procedure on Comprehensive Care Plan and Enteral nutrition. No changes in the policy and procedure were made. The In-service Educator re-educated the licensed nursing staff and dietician on following physician orders. During weekly weight and nutrition meeting, the Dietitian will review the new recommendations for supplements to ensure physician orders [REDACTED]. 4. How the corrective monitored to ensure the deficient practice will not recur: The Dietitian will conduct weekly audits of physician order [REDACTED]. Then 10% records will be reviewed Bi-weekly for one month, and then 5% records will be reviewed monthly for two months in order to ensure compliance. Results will be reported to the monthly QAPI Committe meeting. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2023
Corrected date: May 26, 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 3/22/2023 and completed on 3/30/2023, the facility did not ensure that Physician Responses (actions) documented on Monthly Medication Regimen Reviews (MRR) were carried out to address irregularities identified by the Pharmacist. This was identified for two (Resident #7 and Resident #109) of five residents reviewed for Unnecessary Medications. Specifically, 1) a Psychiatric Consult was requested for Resident #7 by the Physician in (MONTH) 2023, in response to the MRR dated 2/11/2023; however, no Physician's Order was documented in the resident's Electronic Medical Record (EMR). A Psychiatric Consult was not completed until 3/27/2023 after a subsequent MRR was completed on 3/7/2023 and the physician again recommended a Psychiatry Consult. 2) Resident #109 was seen by the Pharmacy Consultant on 2/21/2023 who recommended a Gradual Dose Reduction (GDR) for [MEDICATION NAME] (an antipsychotic medication) from 0.5 milligrams (mg) daily to 0.25 mg daily on the Medication Regimen Review (MRR). The physician agreed with the recommendation; however, the GDR was not initiated until the resident was seen by the Psychiatry Services on 3/27/2023. The finding is: The facility's undated policy titled, Drug Regimen Review-Monthly documented that the Consultant Pharmacist shall review the medical record of each resident and perform a Drug Regimen review at least once each calendar month. The Consultant Pharmacist shall identify, document and report possible medication irregularities for review and action by the Attending Physician, where appropriate. The attending Physician or licensed designee shall respond to the Drug Regimen Review within 7-14 days or more promptly, whenever possible. 1) Resident #7 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 10 which indicated that the resident had moderately impaired cognitive skills for daily decision making. The MDS also documented that the resident received antipsychotic and antidepressant medications during the last 7 days. The original Physician's Order dated 5/14/2020 and last renewed on 1/31/2023 documented to administer [MEDICATION NAME] (an antipsychotic medication) oral tablet (tab) 2 milligrams (mg) - give 1 tab by mouth (po) at hour of sleep (HS) for [MEDICAL CONDITION]. The original Physician's Order dated 9/1/2022 and last renewed on 1/31/2023 documented to administer [MEDICATION NAME] M-tab dispersible 1 mg, give 1 tab po once daily related for [MEDICAL CONDITION]. The MRR dated 2/11/2023 documented the resident was currently receiving [MEDICATION NAME] ([MEDICATION NAME]). The Consultant Pharmacist documented they were unable to locate recent documentation of current need/effect, absence or presence of side effects, and ability or lack of ability to taper current dose in the chart. Under the Physician/Prescriber Response the resident's Physician checked the box indicating,Agree; Will do. On the MRR the Physician wrote to obtain a Psychiatry Consult and signed the MRR, however, did not date the MRR. There was no Physician's Order for a Psychiatry Consult in response to the MRR in (MONTH) 2023. The MRR dated 3/7/2023 documented the resident was currently receiving [MEDICATION NAME] ([MEDICATION NAME]) with a [DIAGNOSES REDACTED]. Please evaluate current use, consider either adding a progress note to support the diagnosis, changing the diagnosis, or gradual dose reductions and discontinuing [MEDICATION NAME], if appropriate. Under the Physician/Prescriber Response, obtained by the Registered Nurse (RN #6) Supervisor dated 3/21/2023, the resident's physician agreed with the recommendations and gave a verbal order for a Psychiatric Consult. Review of the resident's EMR revealed that the Physician's Order for a Psychiatric Consult was not entered into the EMR until 3/27/2023. The Nursing Progress Note dated 3/27/2023, written by RN #6, documented that a verbal order from Physician #1 was obtained for a psychiatric referral for review of medications for the purpose of a possible gradual dose reduction (GDR). RN #6 was interviewed on 3/28/2023 at 4:55 PM and stated that when they (RN #6) got the verbal telephone order from Physician #1 on 3/21/2023, they (RN #6) did not put the Physician's Order into the computer until 3/27/2023 because they (RN #6) knew that the Psychiatric Nurse Practitioner (NP) was on vacation and not was returning until 3/27/2023 when the Psychiatry Consult was completed. Physician #1 was interviewed on 3/28/2023 at 5:00 PM and stated they expected the Psychiatry Consult order to be documented in the EMR after they (Physician #1) gave the verbal order on 2/11/2023. Physician #1 stated that a Psychiatry Consult should have been obtained when the Pharmacy Consultant first made the recommendations on 2/11/2023. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 3:10 PM and stated that there may not have been a rush to put the Physician's Order into the computer to have the resident seen by the Psychiatrist in (MONTH) of 2023 because the facility did not have a Psychiatrist back then. The DNS further stated that the Physician's Order should have been put into the resident's EMR on the day the telephone order was obtained on 3/21/2023, but it would not have changed the outcome because the Psychiatric NP was not coming back from vacation until 3/27/2023. 10 NYCRR 415.18(c)(2) 2) Resident #109 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severely impaired cognition. A Physician's order dated 1/28/2023 documented to administer [MEDICATION NAME] 0.5 mg daily. The MRR dated 2/21/2023 documented a recommendation for a GDR of [MEDICATION NAME] 0.5 mg to [MEDICATION NAME] 0.25 mg. The physician agreed and recommended a Psychiatric Consultation. The psychiatric evaluation dated 3/27/2023 documented to attempt a trial GDR of [MEDICATION NAME] Oral tablet 0.5 mg to [MEDICATION NAME] Oral Tablet 0.25 mg daily. The Nursing Progress Note dated 3/28/2023 documented that Resident #109 was seen by the Psychiatrist and a physician's order was obtained to decrease [MEDICATION NAME] from 0.5 mg daily to 0.25 mg daily. Registered Nurse (RN) Supervisor #1 was interviewed on 3/28/2023 at 3:11 PM and stated the Psychiatrist was on vacation and the Medical Director had to cover for the Psychiatrist. The RN Supervisor is unsure why the recommendation for a Psychiatric consultation was conducted on 3/27/2023, over a month after the order was recommended by the physician. The RN Supervisor was unable to find the consultation order in the medical record. RN Supervisor stated they were responsible to place the order for the Psychiatry consult in the EMR and must have forgotten to do so. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 2:50 PM and stated that when a consultation of any kind is recommended, the Physician's order is placed immediately in the EMR. The Psychiatrist was on vacation until 3/27/2023 and no one was assuming the responsibilities of the Psychiatrist while they were away. The DNS stated that if the physician determined the Psychiatric consultation was needed, there should have been an order in place on 2/21/2023. 10 NYCRR 415.18(c)(2) | Plan of Correction: ApprovedApril 23, 2023 1. Corrective action for the resident effective: Resident #7 was seen by the psychiatrist on 3/27/23. Resident #109 had a GDR initiated on 3/27/23. 2. How to identify other residents having the potential to be affected by the same deficient practice: The facility Medical Director reviewed the Drug Regimen Review for the last 30 days to make sure all recommendations were address by the attending physician. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Medical Director, Director of Nursing and Administrator reviewed the policy and procedure on Drug Regimen Review. No changes in the policy and procedure were made. The Medical Director educated the attending physicians on the facility policy for Drug Regimen Review. The In-service Educator re-educated the licensed nursing staff on the facility policy for Drug Regimen Review. 4. How the corrective monitored to ensure the deficient practice will not recur: The pharmacy consultant will provide a monthly report to the Medical Director and the Director of Nursing on monthly compliance with recommendations. The Medical Director and Director of Nursing will meet monthly to review report and compliance. The Director of Nursing or designee will ensure compliance with any outstanding recommendations given by the Pharmacy Consultant. The results of the review will be shared the Attending Physicians during the Medical Board meeting. The Director of Nursing/designee will report results at the monthly QAPI Committee meeting. |
Scope: Isolated
Severity: Actual harm has occurred
Citation date: March 30, 2023
Corrected date: May 26, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the Recertification Survey and Abbreviated Survey (NY 185) initiated on 3/22/2023 and completed on 3/30/2023, the facility did not ensure each resident was free from abuse, neglect, misappropriation of resident property, and exploitation. This was identified for one (Resident #140) of two residents reviewed for Resident-to-Resident Abuse. Specifically, on 11/8/2022, Resident #326, with intact cognition, verbalized that they are going to hit Resident #140 if the resident went to their room again. Soon after the verbal threat, Resident #326 went to Resident #140's room and was observed hitting Resident #140 in the head. Subsequently, Resident #140 was transferred to the hospital and was diagnosed with [REDACTED]. This resulted in actual harm to Resident #140 that is not Immediate Jeopardy. The finding is: The facility's policy titled, Abuse Prevention Program/Abuse and Neglect-Clinical Protocol/Abuse Investigation and Reporting, last reviewed 1/2023, documented that residents have a right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility defined Physical abuse as the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse includes but is not limited to such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, slapping, kicking, pinching, and burning. Resident #326 (aggressor) was admitted with [DIAGNOSES REDACTED]. The 8/19/2022 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS documented that the resident had verbal behavioral symptoms directed toward others and required extensive assistance for bed mobility and transfers. Walking did not occur, and the resident utilized a wheelchair for mobility. The Comprehensive Care Plan (CCP) for Resident #326 titled, Behavior Problems effective 8/12/2022 documented that the resident had behaviors of increased agitation, yelling and was verbally abusive to staff and others, physically abusive toward staff, and was socially inappropriate. A 9/6/2022 entry documented that the resident was overheard talking to a friend on the phone about an incident in another facility and what they would do at the other facility with a gun. Interventions were put in place including close supervision. A Psychiatry consult for Resident #326 dated 9/6/2022 documented [DIAGNOSES REDACTED]. The resident was noted with a worsening condition and with mood instability. Recommendations included Quetiapine (an antipsychotic medication) 50 milligrams (mg) twice a day. A review of Resident #326's progress notes from (MONTH) 2022 to (MONTH) 2022 revealed on 8/11/2022 Resident #326 made a threat to hit staff. Other documented behaviors in progress notes included agitation, yelling, verbally abusive, harmful to self and others, erratic, voicing suicidal and homicidal ideation, physically aggressive, cursing, disruptive to the whole unit, and slamming the nursing station desk for narcotics (controlled substance). A nursing progress note for Resident #326, written by Licensed Practical Nurse (LPN) #4 (charge nurse), dated 11/8/2022 documented LPN #4 was informed by Certified Nursing Assistant (CNA) #1 that the resident stated, If (Resident #140) goes into my room again, I am going to punch (Resident #140) out. Resident #326 repeated the same statement to LPN #4. LPN #4 notified the nursing supervisor. The nursing progress note documented that CNA #1 yelled out for assistance because Resident #326 was going into Resident #140's room. LPN #4 ran down the hall and saw Resident #326 standing over and punching Resident #140 with a closed fist. LPN #4 jumped in between the two residents and screamed, and then Resident #326 stopped punching Resident #140. Staff responded and a physician was notified. Resident #326 left the unit with the ambulette attendants and three police officers. Resident #326 returned to the facility on [DATE]. A Social Work note for Resident #326 dated 11/9/2022 documented a 30-day transfer-discharge notice issued to Resident #326 due to the resident being a danger to other residents. A review of admission transfer and discharge (ADT) data revealed that Residents #140 and #326 resided across the hallway from each other. Resident #140 (victim) was admitted with [DIAGNOSES REDACTED]. The 10/2/2022 Significant Change MDS assessment documented a BIMS score of 4, indicating the resident had severely impaired cognition. The MDS documented that the resident sometimes understands and is sometimes understood. The MDS documented no mood or behavioral issues. The MDS documented that the resident required limited assistance for transfers and walking. A CCP titled Abuse Prevention for Resident #140 dated 10/26/2022 documented that the resident was at risk for victimization related to the [DIAGNOSES REDACTED]. A nursing progress note for Resident #140 dated 11/4/2022 documented the resident was observed going into other resident rooms and eating from their food trays. Resident #140 was redirected whenever this behavior was observed. A nursing progress note, written by Registered Nurse (RN) #6, for Resident #140 dated 11/8/2022 documented that at 5:30 PM Resident #140 was assaulted by another resident (Resident #326). Resident #326 left their room and went into Resident #140's room and started punching Resident #140 in the head several times for no reason. Resident #140 was assessed for injury; some swelling was noted. Due to Resident #140's scalp deformity, RN #6 was unable to assess the injury. Physician #4 was made aware of the incident and ordered to transfer Resident #140 to the hospital for head injury evaluation. A nursing progress note dated 11/9/2022 documented that RN #4 spoke to the emergency room physician, resident had a Computerized Tomography (CT-a diagnostic imaging exam) scan of the head which indicated a non-displaced left orbital (eye) wall fracture. Due to Resident #140's anatomy of the skull, the resident needed to follow up in a few weeks with an orthopedic surgeon to determine if surgical intervention was needed. Resident #140 was admitted to the hospital. A review of Resident #140's medical record revealed no documented evidence that a follow-up with an Orthopedic Surgeon was completed to determine if surgical intervention is needed. Resident #140 was readmitted back to the facility on [DATE] and relocated to a different unit. A physician's orders [REDACTED].#140 on every 15-minute monitoring due to Resident #140's wandering behavior into other resident rooms. A CCP for Resident #140 titled Resident-to-Resident Altercation, effective 6/27/2022, documented the resident is a potential victim related to the inability to protect self and inability to walk away from an abuser. A review of the Accident and Incident (A/I) report dated 11/8/2022 at 5:30 PM documented that when Resident #140 was lying in their bed, Resident #326 entered the room and began punching Resident #140 on their head. Resident #326 said they did not want Resident #140 coming into their room and taking their food. The A/I investigation dated 11/8/2022 documented there was no reasonable cause to believe any resident abuse, neglect, or mistreatment occurred. On 3/22/2023 at 1:40 PM Resident #140 was observed lying in bed. The resident was awake; however, spoke minimally. The resident appeared calm and comfortable. The resident's skull appeared deformed and enlarged. During an interview with LPN #4 on 3/24/2023 at 11:47 AM, they stated after they went to speak to Resident #326, LPN #4 went back to the nursing station to call the nursing supervisor and that was when CNA #1 alerted them that Resident #326 was observed wheeling themselves into Resident #140's room. LPN #4 stated they ran down the hallway to intervene and witnessed Resident #326 punching Resident #140 in the head. LPN #4 stated Resident #140 had behaviors of wandering into other resident rooms. LPN #4 stated they were not aware of any incidents between the two residents prior to 11/8/2022. During an interview with CNA #1 on 3/24/2023 at 11:56 AM, they stated they were the assigned CNA for Resident #140 on 11/8/2022. CNA #1 stated Resident #140 always wandered and was on every 15-minute check. CNA #1 stated on 11/8/2022 they were completing room checks and saw Resident #140 sleeping in bed. CNA #1 then went into Resident #326's room, who was lying in bed, and told the CNA that they were going to hit Resident #140 because Resident #140 comes into their room and takes stuff. CNA #1 stated at that point CNA #1 left the room and informed LPN #4. CNA #1 stated they were in the hallway when they saw Resident #326 wheeling into Resident #140's room, CNA #1 yelled for help, and LPN #4 responded. There was no documented evidence provided by the facility that every 15-minute monitoring was being completed for Resident #140 on or prior to 11/8/2022. During an interview with Physician #4 on 3/28/2023 at 9:55 AM, they stated the resident has a [DIAGNOSES REDACTED] (enlargement or overgrowth) skull due to Paget's Disease (bone disease). The physician did not recall if Resident #140 went out for a follow-up appointment regarding the [MEDICAL CONDITION] lateral orbit wall. Physician #4 stated Resident #326 was a very aggressive individual, staff provided a lot of redirection to the residents but the redirection cannot be performed 100% of the time. During an interview with the Director of Nursing Services (DNS) on 3/28/2023 at 12:02 PM, they stated Resident #326 went to seek Resident #140; the altercation was not in response to Resident #140 going into Resident #326's room again. The DNS stated that after 11/4/2022 when there was documentation that Resident #140 was wandering and seeking food, the resident was given snacks and monitored when in the hallway. The DNS stated they were not able to provide documented evidence of the hallway monitoring. The DNS stated that every-15-minute monitoring requires a physician's orders [REDACTED]. The DNS further stated that the 15-minute monitoring would not be documented without a physician's orders [REDACTED]. The Medical Director was interviewed on 3/29/2023 at 11:55 AM. The Medical Director stated Resident #140 sustained a mild fracture because of the incident. The Medical Director stated that the fracture would heal on its own and that a referral to the Orthopedic Surgeon was not warranted. 10 NYCRR 415.4(b)(1)(i) | Plan of Correction: ApprovedApril 23, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective action for the resident effective: Once the Statement of Deficiency was received the facility The facility contracted with a consultant and convened itís QAPI committee to examine the deficiencies cited. QAPI team (Consisting of the Administrator and Department Heads) and the Consultant completed an assessment of causative factors as well as a root cause analysis that may have contributed to the citation. Resident #326 no longer resides at the facility. At the time of the incident the facility notified the police and reported the incident to the department of Health. An Accident and Incident report was initiated. How to identify other resident having potential to be affected by the same deficient practice: The facility respectfully submits that all residents have the potential to be affected by the deficient practice. An audit was undertaken, based on the comprehensive care plan, for all residents with known wandering behavior and verbal disruptive behaviors with a look back for the last 30 days. If any deficient practice is noted, it will be reported to the administrator and Director of Nursing and corrected immediately. All new or re-admissions with a history of wandering behaviors and verbal disruptive history will be audited on admission and appropriate interventions will be implemented if necessary. What measures will be in place or what systemic changes to ensure that the deficient practice will not recur? The Medical Director, Director of Nursing and Administrator reviewed the following policies and procedures: ï ìAbuse Prevention Program/Abuse and Neglect-Clinical Protocol/Abuse Investigation and Reporting,î reviewed 1/2023, which documents that residents have a right to be free from abuse, neglect, misappropriation of resident property, and exploitation. ï ìUnmanageable Residents,î reviewed 1/2023, which documents Each resident will be provided with a safe place of residence ï ìBehavioral Assessment, Intervention and Monitoring,î reviewed 1/2023 which documents As part of the initial assessment, the nursing staff and Attending Physician will identify individuals with a history of impaired cognition, altered behavior, or mental illness (e.g., [MEDICAL CONDITION] disorder or [MEDICAL CONDITION]). ï ìResident to Resident Altercations,î reviewed 1/2023 which was modified to include ìIf necessary, in the event of a verbal threat or imminent potential for harm, staff will remain with one of the residents and request help from surrounding staff to report to the supervisor and assist with protecting the resident.î The In-service Educator will re-educate all employees on the following policies. ï ìAbuse Prevention Program/Abuse and Neglect-Clinical Protocol/Abuse Investigation and Reporting,î reviewed 1/2023 ï ìUnmanageable Residents,î reviewed 1/2023 ï ìBehavioral Assessment, Intervention and Monitoring,î reviewed 1/2023 ï ìResident to Resident Altercations,î reviewed 1/2023 which was modified to include ìIf necessary, in the event of a verbal threat or imminent potential for harm, staff will remain with one of the residents and request help from surrounding staff to report to the supervisor and assist with protecting the resident.î The clinical staff will review the 24-hour report to identify any changes in a residentís wandering behavior and/or verbal disruptive behaviors which will be discussed during the morning meeting and appropriate interventions will be implemented if necessary. How the corrective monitored to ensure the deficient practice will not recur: The Director of Social Work or designee will conduct audits of 10% of residents with wandering behaviors and/or verbally disruptive behaviors weekly for four weeks then bi-weekly for one month, and then monthly for two months to ensure compliance. New admissions and re-admissions residents with a history of wandering behaviors and/or verbally disruptive behaviors will be evaluated daily for the first seven days of admission by the clinical staff; Then they will be evaluated weekly then weekly for 4 weeks, appropriate interventions will be implemented if necessary. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2023
Corrected date: May 26, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 3/22/2023 and completed on 3/30/2023 the facility did not ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified for one (Resident #24) of one resident reviewed for Hydration. Specifically, Resident #24 was observed with Intravenous (IV) hydration fluid infusing via an IV port. The IV bag was not labeled with the resident's name nor the date and time the IV fluid was hung. The finding is: The facility Intravenous Administration of Fluid and Electrolytes policy and procedure reviewed 1/2023 documented for continuous therapy, mark solution container with label that states when the bag was started and approximate time of completion. The policy documented to always use a label or tape (never write directly on the bag with ink or marker). Resident #24 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 8 which indicated the resident had moderately impaired cognition. A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) for Hydration dated 2/19/2023 documented the resident was at risk for fluid and electrolyte imbalance related to the use of Diuretics. Interventions included to encourage the resident to drink if not contraindicated, to monitor laboratory results and report abnormal findings to the Physician, and to monitor vital signs as needed to identify signs and symptoms of electrolyte imbalance/ Hypovolemia (such as weak pulse, [MEDICAL CONDITION] temperature elevation and Orthostatic [MEDICAL CONDITION]) and report to the Physician. The CCP was not updated to include interventions related to IV use. During a tour conducted on 3/23/2023 at 10:38 AM on the 2 North nursing unit Resident #24 was observed out of bed in a reclining chair in the hallway. IV [MEDICATION NAME] Normal Saline was observed infusing via a right-hand IV port and there was no label observed on the IV fluid bag. Licensed Practical Nurse (LPN) #2, the medication nurse, was interviewed on 3/23/2023 at 10:38 AM and stated that the Registered Nurse (RN) Supervisor that started the IV line should have labeled the IV bag with the resident's name, date, and time the fluid was hung. RN #6, the 7:00 AM - 3:00 PM Nursing Supervisor, was interviewed on 3/30/2023 at 10:31 AM. RN #6 stated there should have been a label on the IV fluid bag. The RN who hung the IV fluid bag should have labeled the IV bag. RN #6 stated the receiving shift RN Supervisor, or the LPN medication nurse could have labeled the IV bag with the resident's name, date, and time the fluid was hung. An interview was conducted on 3/30/2023 at 1:30 PM with the Director of Nursing Services (DNS). The DNS stated that the IV bag should have been labeled with the date and time. 10NYCRR 415.18(d) | Plan of Correction: ApprovedApril 23, 2023 1. Corrective action for the resident effective: Resident #24 IV bag was properly labeled by the licensed nurse immediately after the issue was identified. The nurse involved received education counseling regarding labeling of IV bags for infusion. 2. How to identify other residents having the potential to be affected by the same deficient practice: The facility inspected all residents with IV bags to determine each bag was properly labeled. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Medical Director, Director of Nursing and Administrator reviewed the policy and procedure on IV medication. No changes in the policy and procedure were made. The In-service Educator re-educated the licensed nursing staff on the proper labeling of IV bags. The RN Supervisor on each shift will check all IVs during rounds to ensure proper labeling is in places. 4. How the corrective monitored to ensure the deficient practice will not recur: Unit Managers or designee will round 3 times per week to ensure that the IV bags are labelled properly. The results of the audit will be presented to the Director of Nursing/designee. This audit will be done weekly three times a week for one month; followed by b-weekly for one month and the monthly for 2 months. Corrections will be made if appropriate and all finding will be reported by the Director of Nursing or designee to the monthly QAPI Committe meeting. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2023
Corrected date: May 26, 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 (Complaint #NY 569) initiated on 3/22/2023 and completed on 3/30/2023, the facility did not obtain laboratory services to meet the needs of its residents. This was evident for one (Resident #226) of four residents reviewed for Nutrition. Specifically, Resident #226 had physician's orders [REDACTED]. The finding is: The facility's policy titled, Lab and Diagnostic Test Results - Clinical Protocol last revised in (MONTH) 2023 documented that the Physician will identify and order diagnostic and laboratory testing based on diagnostic and monitoring needs. Resident #226 has [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated that the resident had moderately impaired cognitive skills for daily decision making. The resident required limited assistance of one person for, toilet use and was occasionally incontinent of urine. The physician's orders [REDACTED]. A blood specimen reported on 12/12/2022 revealed that the resident had a high white blood cell (WBC) count of 15.56 (reference range 3.98-10.04). The physician's orders [REDACTED]. A blood specimen reported on 12/15/2022 revealed that the resident had a high WBC level of 14.78 (reference range 3.98-10.04). The physician's orders [REDACTED]. The Nursing Progress Note dated 12/16/2022, written by Licensed Practical Nurse (LPN) #5, documented that the laboratory called and stated that the resident's urine sample could not be found and therefore the Culture and Sensitivity (C & S) could not be completed. Review of the resident's Electronic Medical Record (EMR) revealed no other attempts were made to obtain a urine sample for the resident prior to the resident's discharge on 12/30/2022. LPN #5 was unavailable for interview. Registered Nurse (RN) #1, Supervisor, was interviewed on 3/30/2023 at 10:45 AM and stated that LPN #5 should have just tried to obtain another urine sample after they (LPN #5) were notified by the laboratory that the resident's urine sample was missing. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 2:50 PM and stated that LPN #5 should have notified the RN Supervisor and the Physician when the resident's urine sample was lost and should have attempted to collect another urine sample. 10 NYCRR 415.20 | Plan of Correction: ApprovedApril 23, 2023 1. Corrective action for the resident effective: Resident #226 lab was ordered and obtained. The nurse involved is no longer employed by the facility. 2. How to identify other residents having the potential to be affected by the same deficient practice: The facility will review lab orders for all the residents received in the last 30 days to ensure the lab was drawn. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Medical Director, Director of Nursing and Administrator reviewed the policy and procedure on lab collection. No changes in the policy and procedure were made. The In-service Educator re-educated the licensed nursing staff on the policy and procedure for lab collations per Phyician orders. The Unit Manager or designee will review the lab orders weekly to ensure that all orders have had a collection taken. 4. How the corrective monitored to ensure the deficient practice will not recur: Every week for one month, the Unit Manger or designee will audit 10% residents records that have had labs ordered to ensure the collection was taken. Subsequently, every other week for one month, and monthly for 2 months. The manager will report to the monthly QAPI meeting. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2023
Corrected date: May 26, 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 the Abbreviated Survey (NY 955) initiated on 3/22/2023 and completed on 3/30/2023 the facility did not ensure that each resident representative was notified timely when there was a change in the resident's condition and a need to commence a new form of treatment was identified. This was identified for one (Resident #276) of two residents reviewed for notification of change. Specifically, Resident #276 was identified with significant weight loss of twenty-nine pounds in last six months and received intravenous fluids due to poor oral intake. The facility staff did not notify the resident's family in a timely manner of the resident's poor oral intake, significant weight loss, and administration of the Intravenous (IV) fluids in response to the poor oral intake. The finding is: The facility's policy and procedure titled; Acute Condition Changes Clinical Protocol last reviewed 1/2023 did not address notification to the resident's representative when there is a significant change in the resident's condition. Resident #276 was admitted with [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a short-term memory problem and was moderately impaired for daily decision making. The MDS documented the resident was at risk for developing Pressure Ulcer (PU) and had one unhealed Stage III PU that was present on admission. A Dietitian assessment dated [DATE] documented the resident consumed 50% - 75% of meals with supervision. The note documented the resident had a significant weight loss of twenty-nine pounds(lbs.) / 10.5 percent (%) over the past six months. The etiology was likely due to a combination of acute Gastrointestinal (GI) issues, [DIAGNOSES REDACTED]. A Nursing progress note dated 11/20/2022 documented the resident was alert and responsive to all stimuli. The resident's appetite was poor this tour and the resident consumed 25% of supper and 100% of fluids. IV fluid continues to the left arm with no signs and symptoms of infiltration. The note did not document that the resident's family was notified of the initiation of the IV fluids. A Nurses note dated 11/22/2022 documented the resident completed the second round of IV fluids on 11/20/2022 and the Physician ordered IV D5.33% ([MEDICATION NAME]) NS for 3 days and to hold [MEDICATION NAME] (Diuretics) for 3 days. The note did not document that the resident's family was notified of the initiation of the IV fluids. A Nutrition Significant Change assessment dated [DATE] documented the resident was status [REDACTED]. Currently the resident was started on IV hydration for 3 days, and calorie count was requested by the Physician. A Nurses note dated 11/30/22 documented the resident was alert and responsive to all stimuli. IV fluids D5.1/2% NS on going at 70 cc an hour. The resident was on a 3-day calorie count due to poor appetite. The note did not document that the resident's family was notified of the initiation of the IV fluids or decreased oral intake. A review of the progress notes from 11/2022 to 12/2022 lacked documented evidence that the resident's representative was notified regarding the resident's poor po intake, weight loss, and need for IV hydration. Dietitian #2 was interviewed on 3/28/2022 at 11:22 AM. Dietitian #2 stated when there is an acute change in weight that they (Dietitian #2) would notify nursing, the Physician, and the resident's family. Dietitian #2 stated Resident #276 had a significant unplanned weight loss over a six-month period due to multiple comorbidities including poor oral intake. Dietitian #2 stated that they did not notify the family of the weight changes. RN #1 was interviewed on 3/30/2023 at 9:27 AM and stated that when Resident #276's condition changed and warranted a change in the plan of care such as initiation of intravenous fluids, the resident's family should have been notified. RN #1 stated after they had reviewed the progress notes, that there was no documented evidence that the family was notified of the changes in the resident's condition. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 1:20 PM. The DNS stated that the nursing staff should have notified Resident #276's family when the IV hydration was initiated as an intervention in response to the resident's poor oral intake. The dietician should have updated the resident's family regarding the resident's significant weight changes and deterioration in the oral intake status. The DNS stated they expected the facility staff to document in the resident's medical record that the resident's family was notified of the changes in the resident's clinical status. Physician #3 was interviewed on 3/30/2023 at 3:45 PM. Physician #3 stated that any significant alteration in the resident's treatments, including starting a new form of treatment such as administration of Intravenous fluids, the resident's family must be informed. 10 NYCRR 415.3(f)(2)(ii)(c) | Plan of Correction: ApprovedApril 23, 2023 1. Corrective action for the resident effective: Resident # 276 was discharged from the facility prior to the time of the Statement of Deficiencies. 2. How to identify other residents having the potential to be affected by the same deficient practice: The facility reviewed all current residents to identify any residents with a nutritional significant change. Each resident was identified, reviewed and communication was provided to the resident's family/responsible party of the change in condition. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Medical Director, Director of Nursing and Administrator reviewed the policy and procedure on change of condition. No changes in the policy and procedure were made. The In-service Educator re-educated the licensed nursing staff and dietician on the change of condition policy and procedure, and the importance to communicate and document in the resident's electronic medical record the resident change in condition to the family/responsible party. The clinical staff will meet during the facility morning meeting and review the 24-hour report to identify any change in the condition of the resident, and to verify the family/responsible party was notified. 4. How the corrective monitored to ensure the deficient practice will not recur: The Director of Nursing/designee will conduct weekly audits of 10% residents' records with change in condition for four weeks, bi-weekly audits for one month and then monthly for two months to ensure the responsible party was notified. Results will be reported to the monthly QAPI committee meeting. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2023
Corrected date: May 26, 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 3/22/2023 and completed on 3/30/2023, the facility did not ensure that the resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for one (Resident #128) of four residents reviewed for Nutrition. Specifically, Resident #128 was not provided the adequate amount of protein via tube feeding that was needed for wound healing, as assessed and recommended by the Registered Dietician (RD). The finding is: The facility's policy titled, Enteral (tube) Nutrition last reviewed on 1/2022 documented that the Dietitian will monitor residents who are receiving enteral feedings and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. The facility's policy titled, Nutrition and Hydration to Maintain Skin Integrity last reviewed on 1/2023 documented that the healing of acute (e.g., postoperative) and chronic (e.g., pressure ulcers) wounds requires enough protein and calories so that the body will not use lean body mass for energy and wound repair. The policy also documented that the recommended protein levels for a resident with wounds or at risk of developing wounds is approximately 1.2 - 1.5 grams (gm) of protein per kilogram (kg) of body weight. Resident #128 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 10 which indicated the resident had moderately impaired cognitive skills for daily decision making. The resident was totally dependent on one person for eating. The resident's height was 68 inches and the resident weighed 140 pounds. The resident received 51% or more of their total calories through tube feeding. The physician's orders [REDACTED]. The Initial Wound Round Evaluation Progress Note dated 9/1/2022 documented that the resident had a Stage 4 sacral pressure wound measuring 9.5 centimeter (cm) x 14.2 cm x 2.3 cm; 40% granulation (newly formed healthy tissue); 60% necrotic (dead tissue), no exudate (drainage). The resident's weight dated 9/8/2022 documented the resident's weight as 130.6 pounds (lbs). The Nutrition Assessment completed on 9/9/2022, by Registered Dietitian (RD) #3, documented that the resident's weight was 130.6 lbs. The resident's daily caloric needs were documented as 1475-1770 kilo calories (kcal) based on 25-30 kcal/kg of the resident's current body weight (CBW) and that their daily protein needs were 60 gms of protein based on 1 gm/kg of the resident's current body weight. The resident's tube feeding order was documented as [MEDICATION NAME] 1.5 600 cc/day and that the resident had a Stage 4 sacral pressure ulcer. There was no documented evidence that RD #3 had calculated that the resident's current tube feeding was only providing 900 kcals and 38.4 gms of protein per day; rather than the 1475-1770 kcal and 60 gms of protein calculated in the nutritional assessment. The physician's orders [REDACTED]. The Dietary Progress Note dated 10/13/2022, written by RD #2, documented that the resident's CBW was 145.8 lbs on 10/11/2022 and that the resident had a Stage 4 sacral pressure ulcer. The resident's estimated nutrient needs based on ideal body weight (IBW) of 63.6 kg (140 lbs) was 1590-1908 kcal (25-30 kcal/kg) and 76-95 gms of protein (1.2-1.5 gms protein/kg). The note also documented that the resident's current tube feeding order was [MEDICATION NAME] 1.5 1040 milliliter (ml-which is the equivalent to cc) at 65 ml/hour x 16 hours which provided the resident with 1560 kcal and 66 gms protein daily. The Plan documented in this progress note to suggest [MEDICATION NAME] 1.5 1000 ml at 50 ml/hour x 20 hours which would provide the resident with 1500 kcal and 63.8 gms of protein daily. The Plan also suggested liquid protein supplement (LPS) 30 ml via PEG twice daily (BID) which would provide the resident with an additional 200 kcal and 30 gms protein per day to help meet the resident's increased protein needs related to wound healing. The physician's orders [REDACTED]. There was no documented evidence in the resident's EMR that the LPS was ordered as suggested by RD #2. The physician's orders [REDACTED]. The Nutrition Wound Note dated 12/17/2022, written by RD #1, documented that the resident had a Stage 4 sacral pressure ulcer, current size measuring 5.5 cm x 5.5 cm x 2 cm. The note documented that protein supplementation of LPS by mouth (po) BID was recommended to provide the resident with an extra 200 kcal and 30 gms of protein per day and Juven (a high protein powder) was recommended to provide the resident with an extra 180 kcal and 33 gms of protein per day. The physician's orders [REDACTED]. Review of the resident's (MONTH) 2022 Monthly Medication Administration Record [REDACTED]. Review of the resident's (MONTH) 2023 Monthly MAR indicated [REDACTED]. Review of the resident's (MONTH) 2023 Monthly MAR indicated [REDACTED]. RD #3 was not available for interview. RD #2 was interviewed on 3/28/2023 at 11:35 AM and stated that when they (RD #2) assessed the resident on 10/13/2022, they (RD #2) adjusted the resident's tube feeding and recommended that the resident receive the LPS twice daily due to the resident's increased protein needs related to wound healing. RD #2 was re-interviewed on 3/29/2023 at 10:10 AM and stated that when they (RD #2) make a recommendation, they enter the order themselves into the EMR and then there is a pending sign off notification that nursing and the physician has to also sign. RD #2 believed that they (RD #2) had entered the request into the computer on 10/13/2022 after making the recommendation for the resident to receive LPS twice daily. RD #2 stated that they (RD #2) had no idea why the order for the LPS was not obtained in (MONTH) 2022 when they (RD #2) had first recommended LPS because the resident had increased protein needs due to a Stage 4 sacral pressure ulcer. RD #2 stated that the LPS order was not obtained until 12/17/2022. RD #2 further stated they (RD #2) could not explain why the resident did not receive the LPS until 1/22/2023 after the physician's orders [REDACTED]. RD #1 was interviewed on 3/29/2023 at 11:10 AM and stated that when completing the Nutrition Wound Note on 12/17/2022, they (RD #1) made a request for the resident to receive the two high protein supplements because the tube feeding was not providing enough protein to promote wound healing. RD #1 stated that they (RD #1) put both orders into the computer on 12/17/2022 for the LPS and the Juven. RD #1 further stated they (RD #1) had no idea why the resident did not receive the LPS for the first time until 1/22/2023 and the Juven for the first time on 2/2/2023. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 2:40 PM and stated that the RDs are responsible to place the dietary supplement orders into the computer and then Nursing confirms the order. The DNS stated that Nurses are responsible to notify the Physician of the RD's recommendation. The DNS stated that if there were no signatures on the MAR, there was no evidence that LPS or Juven were administered to Resident #128 in the month of (MONTH) 2022. The DNS stated LPS was first administered on 1/22/2023 as evidenced by the staff signature on the MAR. The DNS stated that the first time the Juven was administered was on 2/2/2023 as evidenced by the staff signature on the MAR. 10 NYCRR 415.12(i)(1) | Plan of Correction: ApprovedApril 23, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Corrective action for the resident effective: Resident # 128 medical record was reviewed, resident continues to receive nutritional enteral feeding and protein supplement, her body weight is stable, and her sacral pressure ulcer is improving. The Dietician # 3 that had calculated the protein and enteral feeding needs is no longer employed by the facility. 2. How to identify other residents having the potential to be affected by the same deficient practice: The facility reviewed all tube feed residents to assure that each one was receiving proper nutritional needs for the resident. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Medical Director, Director of Nursing, Dietician and Administrator reviewed the policy and procedure on Enteral nutrition. No changes in the policy and procedure were made. The In-service Educator re-educated the dietician on facility policy on Enteral Nutrition. During weekly nutrition and weight meeting, the Dietician will review new enteral feeding recommendations and physician orders [REDACTED]. 4. How the corrective monitored to ensure the deficient practice will not recur: The Dietician will audit 10% residents' records weekly for one month to ensure residents are receiving their proper nutritional needs. Then 10% resident records bi-weekly for one month, then 10% records per month for 2 months. Corrections will be made if appropriate and all findings will be reported to the facility Quality Assurance meeting by the Dietician. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2023
Corrected date: May 26, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure it provided pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. This was identified for two (Resident #47 and #98) of four residents observed during medication pass. Specifically, on [DATE], 1) Resident #47 did not receive the scheduled [MEDICATION NAME] (a medication for Hypertension) dose; and 2) Resident #98 did not receive the scheduled [MEDICATION NAME] ([MEDICATION NAME]-prescribed for [MEDICAL CONDITION]) dose during the medication pass observation. The medications were not available for administration because the medications were not re-ordered in a timely manner from the pharmacy. The finding is: The facility's undated policy titled, Prescribing and Ordering of Medications documented the facility will communicate any medication reorders, changes, or discontinuation to the pharmacy in accordance with pharmacy guidelines and state/federal regulations, thus ensuring a standardized process of communication. Communication may be transmitted through verbal, written, or electronic orders. All orders must clearly be communicated to the pharmacy by the facility. 1) Resident #47 was admitted with [DIAGNOSES REDACTED]. The [DATE] Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 6, indicating the resident had severe cognitive impairment. A physician's orders [REDACTED]. A medication pass observation on [DATE] at 8:58 AM for Resident #47 was conducted. The medications were being administered by Registered Nurse (RN) #1, who was the RN Supervisor. RN #1 stated they (RN #1) were conducting the medication pass because the scheduled medication nurse called out. RN #1 stated Resident #47 was due to receive [MEDICATION NAME] 20 mg tablet at 9 AM and they (RN #1) were unable to find the blister-pack for the [MEDICATION NAME] 20 mg tablet. RN #1 was re-interviewed on [DATE] at 11:19 AM and stated they (RN #1) had searched everywhere for the [MEDICATION NAME] 20 mg tablet blister-pack but were unable to find the medication. RN #1 stated they (RN #1) will call the pharmacy to re-order the medication. Review of the (MONTH) 2023 Medication Administration Record [REDACTED]. Pharmacist #1 was interviewed on [DATE] at 8:31 AM and stated the last refill request for Resident #47's [MEDICATION NAME] prior to [DATE] was on [DATE]. Pharmacist #1 stated the new refill request for [MEDICATION NAME] came in from RN #1 on [DATE] at 3:19 PM. Pharmacist #1 stated the facility must request re-orders through the Electronic Medication Record (EMR) or through a phone call, the pharmacy do not just refill the medications. RN #1 was re-interviewed on [DATE] at 9:43 AM and stated the [MEDICATION NAME] was delivered very late on [DATE]. RN #1 stated the [MEDICATION NAME] 20 mg is in the emergency box (E-Box), but they (RN #1) did not use it. RN #1 stated they did not notify the doctor regarding the missing [MEDICATION NAME] until today ([DATE]). The Director of Nursing Services (DNS) was interviewed on [DATE] at 9:05 AM and stated if the medication supply is getting low, the nurses should call the pharmacy to re-order the medication at least ,[DATE] days before the medication runs out. 2) Resident #98 was admitted with [DIAGNOSES REDACTED]. The [DATE] Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severe cognitive impairment. The MDS documented the resident was receiving [MEDICAL CONDITION] medications. A physician's orders [REDACTED]. A medication pass observation on [DATE] at 9:09 AM for Resident #98 was conducted. The medications were being administered by Licensed Practical Nurse (LPN) #2. A blister-pack for [MEDICATION NAME] contained [MEDICATION NAME] tablets. The blister-pack had a label indicate [MEDICATION NAME] was delivered on [DATE]. LPN #2 did not administer [MEDICATION NAME] for Resident #98 and stated that the blister-pack was expired because the blister-pack was only good for one month. LPN #2 stated they (LPN #2) had re-ordered the medication two days ago on [DATE] and the medication has not yet arrived from the pharmacy. Review of the (MONTH) 2023 Medication Administration Record [REDACTED]. Pharmacist #1 was interviewed on [DATE] at 8:31 AM and stated the Pharmacy had a re-order request for Resident #98's [MEDICATION NAME] on [DATE], which was delivered on [DATE]. Pharmacist #1 stated the (MONTH) re-order request for Resident #98's [MEDICATION NAME] was made by LPN #2 on [DATE] at 9:30 AM. The Director of Nursing Services (DNS) was interviewed on [DATE] at 9:05 AM and stated if the medication supply is getting low, the nurses should call the Pharmacy to re-order the medication at least ,[DATE] days before the medication runs out. 10 NYCRR 415.18(a) | Plan of Correction: ApprovedApril 23, 2023 1. Corrective action for the resident effective: Resident #47 and # 98 received their medication from the pharmacy. The nurses involved were re-educated on the policy and procedure for ordering medication. 2. How to identify other residents having the potential to be affected by the same deficient practice: All residents' medications were checked to ensure sufficient quantity on hand and reorder if needed. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Medical Director, Director of Nursing and Administrator reviewed the policy and procedure on ordering medication. No changes were made. The In-service Educator re-educated the licensed nursing staff on facility policy and procedure for ordering of medications. 4. How the corrective monitored to ensure the deficient practice will not recur: The Unit Manager or designee will conduct a weekly audit of 10% randomly selected medications to ensure enough supply or re-order was completed timely for one month; 10% randomly medication will be audited bi-weekly for one month; 5% randomly selected medications will be audited monthly for two months. Significant findings will be shared with the Director of Nursing. The Director of Nursing/designee will report audit results at the monthly QAPI Committee meeting. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2023
Corrected date: May 26, 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 3/22/2023 and completed on 3/30/2023, the facility did not ensure that each resident received food that accommodates resident preferences and receive appealing options of similar nutritive values to residents who chose not to eat food that is initially served or who request a defend meal choice. This was identified for two (Resident #46 and Resident #76) during the Dining Observation task for one of three dining rooms. Specifically, during the Dining Observation Task on the second floor, Resident #46 and Resident #76 verbalized they were not made aware or offered the alternate meal for lunch on 3/24/2023. The finding is: The facility's Policy and Procedure on Food Preferences, last revised 1/2023 documented that upon admission, the resident's food preferences will be taken by the Dietician or nursing staff. Staff, assisted by the Physician, will identify any nutritional issues and dietary recommendations that may conflict with a resident's food preferences. The Food Service Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. During the second-floor dining room observation task on 3/24/2023 at 2:00 PM, Resident #46 and #76 verbalized a complaint that they did not know there was an alternate meal available for lunch specifically a bacon, lettuce, and tomato sandwich. Resident #46 and #76 stated they were not offered a menu that included an alternate meal choice. 1) Resident #46 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognition. The physician's orders [REDACTED].#46 documented to provide a regular consistency diet with thin liquids, no added salt diet, gluten free, and no wheat products. 2) Resident #76 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognition. The physician's orders [REDACTED].#76 documented to provide a regular consistency diet with thin liquids, and no concentrated sugars. The Food Service Director was interviewed on 3/27/2023 at 1:45 PM and stated there is a 10 AM Certified Nursing Assistant (CNA) who is responsible to collect the resident's food preference cards every day; however, the food preference cards have not been collected consistently over the last two months. The Food Service Director stated that they have made the Nursing Supervisors and the Director of Nursing Services (DNS) aware. The Food Service Director stated that the Dietician did an in-service education training with the CNAs about two months ago, but nothing has changed. The Dietician was interviewed on 3/29/2023 at 11:14 AM and stated that Resident #76 is on a non-concentrated sugar diet and Resident #46 is on a no added salt (NAS) diet. When collecting preference cards, the 10 AM CNAs are responsible to go to all alert residents and ask what they want for lunch and dinner, including the main meal and the alternative meals. An in-service education was provided to the CNAs on all floors to remind them about collecting preference cards before mealtime. The Dietician stated they made the Assistant Director of Nursing Services and the DNS aware of the issue regarding the CNAs not collecting the resident's food preference cards approximately two weeks ago. The second floor Registered Nurse (RN) Supervisor was interviewed on 3/30/2023 at 9:26 AM and stated a 10 AM CNA is not always available and when this occurs, the unit CNAs are responsible to collect the meal preference cards. This leads to preference cards not being done correctly or being forgotten. This is a building-wide issue, not just a second-floor issue. The 10 AM Certified Nurse Assistant (CNA) #4 on 2 South was interviewed on 3/30/2023 at 10:40 AM and stated that one of their responsibilities is to collect lunch and dinner preference cards from the residents. The CNA will print the cards, go to each room, tell the residents the main and alternate options for meals, and bring the preference cards to the kitchen. CNA #4 stated they were pulled to work on Unit 2 North and then were sent for a transportation run. CNA #4 stated they were not aware of any issues related to Resident #46 and #76 meal preferences. The 10 AM CNA #5 for 2 North was interviewed on 3/30/2023 at 12:00 PM and stated they did work on 2 South on 3/24/2023. CNA #5 stated they did not recall any resident complaining about not knowing about the alternate meals. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 1:12 PM and stated that food preference issues are only brought to their attention if there is a major issue and there has not been a recent time where meal preferences were an issue brought to their attention. There was an in-service education about preference card collection, but the DNS was unsure of the exact date. The responsibility of collecting preference cards is assigned to the 10 AM CNA. If a 10 AM CNA was unavailable, another CNA would be assigned. 10 NYCRR 415.14(d)(4) | Plan of Correction: ApprovedMay 9, 2023 1. Corrective action for the resident effective: Residents #76 and #46 were provide with alternative menus for them to select their meals. 2. How to identify other residents having the potential to be affected by the same deficient practice: The Dietician and Recreation Director spoke to each resident and informed them that there are alternate food choices that can be selected for the meal. At the monthly Resident Council meeting the Director of Recreation informed the council that there are alternate food choices and the process to obtain the alternate. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Medical Director, Director of Nursing, Dietician, Food Service Director and Administrator reviewed the policy and procedure on meal preferences and choice. The policy will be modified to include the collection of the meal preferences to include the dietician and recreation department. The In-service Educator educated the nursing staff, recreation staff and dietary staff on the meal selection process. The Dietary Department will post the weekly menu on each floor including the alternate meal selections. There will be extra menus provided in each dining room for the residents to review. weekly the recreation staff and dietician will approach the residents and offer the meal sections for the week. Daily announcements of the meal and alternate will be announced over the intercom system. The selection will be provided to the dietary department for them to provide the selected menu choice. The process was discussed with the Resident Council and will continue to be monitored at the Council meeting. 4. How the corrective monitored to ensure the deficient practice will not recur: The dietician will complete an audit on residents' meal choices. The dietician will discuss her findings during morning meeting. This audit will be done weekly three times a week for one month; followed bi-month for one month then quarterly for 6 months. Corrections will be made if appropriate and all findings will be reported to the facility Quality Assurance meeting by the dietician. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2023
Corrected date: May 26, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification initiated on 3/22/2023 and completed on 3/30/2023, 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 #7) of four residents reviewed for Nutrition. Specifically, Resident #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's Physician did not monitor the resident's blood work timely to evaluate the progression of the disease and need for treatment. The finding is: The facility's policy titled Diabetes - Clinical Protocol last reviewed on 2/2023 documented that the Physician will follow up on any acute episodes associated with a significant change in blood sugars or deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. Resident #7 with [DIAGNOSES REDACTED]. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated that the resident had moderately impaired cognitive skills for daily decision making. One of the resident's Active [DIAGNOSES REDACTED]. Review of the resident's Electronic Medical Record (EMR) revealed the following Comprehensive Metabolic Panel (CMP) Glucose results: -1/24/2022 Glucose high 250 milligram/deciliter (mg/dl) (reference range 65-99 mg/dl)mg/dl -9/12/2022 Glucose high 385 mg/dl Review of the medical record revealed that Resident #7 was not receiving medication to manage the [DIAGNOSES REDACTED]. The Medical Doctor (MD) Monthly Progress Note dated 10/1/2022, written by Physician #1, documented under Diagnostic Tests - Glucose 385 non fasting. Review of the resident's EMR revealed the following CMP glucose result: 11/16/2022 Glucose high 345 mg/dl. The Nursing Progress Note dated 11/17/2022 documented that the blood test results were available, and the Glucose level was 350 mg/dl. Physician #1 was made aware and ordered to repeat the Glucose level tomorrow. Review of the resident's EMR revealed the following CMP Glucose result: 11/18/2022 Glucose high 319 mg/dl. The 11/18/2022 Medical Progress Note, written by Physician #1, documented that the resident's laboratory reports were reviewed, and a random Glucose level was 345 mg/dl. The Physician documented to start [MEDICATION NAME] (oral medication to treat DM) and to check the resident's hemoglobin A1c (HgbA1c- blood test to determine the blood glucose levels over 2-3month period). The physician's orders [REDACTED]. The laboratory report dated 11/21/2022 documented a Glucose level of 297 mg/dl (high) and HgbA1c 13.5%, high (reference range 4.8-5.6%). The 11/26/2022 MD Monthly Progress Note dated 11/26/2022, written by Physician #1, documented that the resident was found to have DM. and was started on [MEDICATION NAME]. The Note also documented that the resident's blood Glucose level was 297 mg/dl and their HgbA1c was 13.6%. The resident's Physician (Physician #1) was interviewed on 3/30/2023 at 11:30 AM and stated that when the resident first had a very high glucose level in (MONTH) 2022, they (Physician #1) were not concerned because the blood glucose level was not a fasting blood glucose test. Physician #1 stated that the resident's DM was controlled by diet for a long time, but that they (Physician #1) should have ordered a HgbA1c for the resident a few times a year to monitor their DM. Physician #1 stated that they (Physician #1) were not sure why they (Physician #1) had not ordered a HgbA1c after the CMP glucose result on 11/16/2022 when the resident's Glucose was 345 mg/dl and they (Physician #1) should have. Physician #1 stated that the resident's diabetes was not well controlled and that they (Physician #1) take responsibility for that and will now have the resident's HgbA1c checked twice a year. Physician #1 also stated that they (Physician #1) did not know why the resident's Glucose level was not checked for almost a year between (MONTH) 2022 and (MONTH) 2022 and that it should have been checked more often since the resident's Glucose was on the high side in (MONTH) 2022. The Medical Director (Physician #2) was interviewed on 3/30/2023 at 6:10 PM and stated that the resident's HgbA1c should have been checked yearly or every other year as a standard of practice for someone having a [DIAGNOSES REDACTED]. 10 NYCRR 415.15(b)(1)(i)(ii) | Plan of Correction: ApprovedApril 23, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Corrective action for the resident effective: Resident #7 medical record was reviewed by the attending physician and no new orders were obtained. 2. How to identify other residents having the potential to be affected by the same deficient practice: The facility reviewed all current diabetic residents HgbA1c results. At the direction of the facility Medical Director, any diabetic resident with an HgbA1c lab test past ninety days will have repeat lab work. The results will be reviewed with the attending physician. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Medical Director, Director of Nursing and Administrator reviewed the policy and procedure on physician orders [REDACTED]. All non-diabetic [DIAGNOSES REDACTED]. The facility Medical Director will in-service all attending physicians and extenders on policy modification. The Medical Director will educate Physician #1 on the importance to review the resident's HgbA1c on a quarterly basis. The In-service Educator will educate all licensed nursing staff on policy modifications. 4. How the corrective monitored to ensure the deficient practice will not recur: The Medical Director will conduct a weekly audit of 10% of the diabetic patients to determine the HgbA1c is ordered and review findings with attending physician. Then 10% resident records bi-weekly for one month, then 5% records per month for 2 months. Findings will be reported to the facility QAPI Committe meeting by the Medical Director/designee. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2023
Corrected date: May 26, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 3/22/2023 and completed on 3/30/2023 the facility did not ensure that all residents were free of any significant medication errors. This was identified for two (Resident #8, and Resident #114) of two residents reviewed for choices. Specifically, both residents did not receive their medications as ordered by the Physician. On 3/22/2023 Resident #8 complained that they received all their 9:00 AM medications at 11:00 AM, and Resident #114 did not receive the 9:00 AM Buprenorphine HCl-[MEDICATION NAME] (treatment of [REDACTED]. The finding is: 1). Resident #8 was admitted with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had intact cognition. The resident had no behavior problems and received Antidepressant, Antianxiety, Anticoagulant, and Opioid medication during the assessment period. Resident #8 was interviewed on 3/23/2023 at 12:58 PM. The resident stated that on 3/22/2023 they received all their 9:00 AM medications late. A physician's orders [REDACTED]. -[MEDICATION NAME] HCl oral tablet 5 milligrams (mg). Give 1 tablet by mouth every 12 hours related to Pain; -Eliquis (Anticoagulant) oral tablet 5 mg. Give 1 tablet by mouth two times a day related to Acute Embolism and [MEDICAL CONDITION] of lower extremity. -[MEDICATION NAME] oral tablet 20 mg. Give 1 tablet by mouth three times a day for Muscle [DIAGNOSES REDACTED]. -[MEDICATION NAME] oral tablet 4 mg. Give 1 tablet by mouth three times a day for Muscle [DIAGNOSES REDACTED]. -[MEDICATION NAME] oral tablet 1 mg. Give 1 tablet by mouth two times a day related to [MEDICAL CONDITION] Disorder, Current Episode of Depression, Panic Disorder, and Anxiety. A Review of the Medication Administration Audit Report (timed stamp) dated 3/27/2023 documented Resident #8 received all 9:00 AM medications at 10:57 AM -11:00 AM on 3/22/2023. LPN #6 was re-interviewed on 3/29/2023 at 10:46 AM. LPN #6 stated that they came into work at 9 AM on 3/22/2023 and that as soon as they arrived in the facility, they (LPN #6) immediately went to their assigned unit. LPN #6 stated that it was a busy morning, and all the residents were waiting and asking for their medications at the same time; the medication pass had not started, the finger sticks were not completed and that was why they were running late with the medication pass. Physician #3 was interviewed on 3/30/2023 at 6:45 PM. The Physician #3 stated that the resident should not have receive their medications late. Physician #3 stated that currently the resident's main concern is pain and that it was important to administer the pain medication on time and the goal is for the resident to be comfortable. Physician #3 stated that the expectation would be that all residents receive their medication timely. 2) Resident #114 was admitted with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 11 which indicated moderate cognitive impairment. The resident had no behavior problems. A physician's orders [REDACTED]. Continue to use this medication until the tablet form is added to the medication record. A physician's orders [REDACTED]. Give 2 tablet sublingually every 12 hours for medication for Opioid Dependency. Resident #114 was observed on 3/22/2023 at 11:30 AM speaking loudly and was visibly upset. The resident stated that they did not receive their special medication that they should have received at 9:00 AM. The resident stated that they were told the medication was not on the unit and the Registered Nurse (RN) Supervisor was following up. A review of the Medication Administration Audit Report (timed stamp) dated 3/27/2023 documented Resident #114 received their 9:00 AM Buprenorphine HCl-[MEDICATION NAME] films Sublingual 2-0.5 mg at 12:02 PM on 3/22/2023. Licensed Practical Nurse (LPN) #6, the 7:00 AM - 3:00 PM medication nurse, was interviewed on 3/22/2023 at 11:33 AM. LPN #6 stated the resident did not receive their Buprenorphine HCl-[MEDICATION NAME] HCl medication because they (LPN #6) were unable to find the resident's medication. LPN #6 stated that the RN Supervisor was made aware and was currently following up. RN #6, who was the 7:00 AM - 3:00 PM RN Supervisor, was interviewed on 3/28/2023 at 5:02 PM. RN #6 stated that on 3/22/2023 they checked the narcotic cabinet and found the resident's medication. LPN #6 was re-interviewed on 3/29/2023 at 10:46 AM. LPN #6 stated that they came into work at 9 AM on 3/22/2023 and that as soon as they arrived in the facility, they (LPN #6) immediately went to their assigned unit. LPN #6 stated that it was a busy morning, and all the residents were waiting and asking for their medications at the same time; the medication pass had not started, the finger sticks were not completed and that was why they were running late with the medication pass. LPN #6 stated the initial order for Resident #114's Buprenorphine HCl-[MEDICATION NAME] HCl medication was a Sublingual Film and they (LPN #6) had looked for the medication in the narcotic cabinet and could not find the medication. The Director of Nursing Services (DNS) was interviewed on 3/30/2023 at 3:30 PM and stated the shift RN Supervisor should have covered the unit until a medication nurse arrived. The DNS stated that they were not made aware that the residents received their medications late. The DNS further stated the expectation is for the residents to receive their medications timely. The window for medication administration is one hour before to one hour after the physician prescribed time. 10 NYCRR 415.12(m)(2) | Plan of Correction: ApprovedApril 23, 2023 1. Corrective action for the resident effective: Resident #8 and 114 medication was reviewed by the attending physician and no recommendations were made. Nurses involved were counseled on completing medication administration as per guidelines. 2. How to identify other residents having the potential to be affected by the same deficient practice: The facility reviewed the medication administration time for each resident in the last 30 days to make sure the medication was provided to the resident on time. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Medical Director, Director of Nursing and Administrator reviewed the policy and procedure on medication administration. No changes in the policy and procedure were made. The In-service Educator re-educated the licensed nursing staff on the facility policy and procedure for medication and administration and timeliness of completion. 4. How the corrective monitored to ensure the deficient practice will not recur: The Unit manager or designee will conduct a weekly audit of 10% randomly selected resident to review medication administration time for one month; 10% randomly selected residents will be audited bi-weekly for one month; 5% randomly selected medication will be audited monthly for two months. Significant findings will be shared with the Director of Nursing. The Director of Nursing will report audit results at the monthly QAPI Committee meeting. |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 31, 2023
Corrected date: April 20, 2023
Citation Details 2012NFPA99: 6.5.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches. 6.5.4.1.1.1 Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenance parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 6.4.1.1.10 and 6.4.3.1. 2012NFPA101: 9.1.3.1 Emergency generators and standby power systems shall be installed, tested , and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2010 NFPA110: 8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established. 8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available. 8.3.4.1 The permanent record shall include the following: (1) The date of the maintenance report (2) Identification of the servicing personnel (3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced (4) Testing of any repair for the time as recommended by the manufacturer 8.3.5* Transfer switches shall be subjected to a maintenance and testing program that includes all of the following operations: (1) Checking of connections (2) Inspection or testing for evidence of overheating and excessive contact erosion (3) Removal of dust and dirt (4) Replacement of contacts when required 8.3.7* Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications. 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. 2010NFPA 110: 8.4 Operational Inspection and Testing. 8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 8.4.2.4 Spark-ignited generator sets shall be exercised at least once a month with the available EPSS load for 30 minutes or until the water temperature and the oil pressure have stabilized. 8.4.6 Transfer switches shall be operated monthly 8.4.9* Level 1 EPSS shall be tested at least once within every 36 months. Based on documentation review and staff interview conducted during the life safety recertification survey, the facility failed to ensure that the generator was inspected and testing in accordance with NFPA99, NFPA 101 and NFPA 110. Specifically, it could not be determined if the (1) generator monthly load test was conducted for a minimum of 30 minutes, (2) transfer switch was tested and (3) the transfer from normal to emergency power occurred within 10 seconds. This occurred for the generator that serves the essential electrical system for the facility. The findings are: On 3/31/2023 at 9:15 AM documentation review of the facility emergency generator test log revealed the following: 1) The emergency generator test document included the column Time. There was one recorded time entered for each column listed. The document did not contain a start and end time, to ensure the generator was being test for the minimum amount of time 2) No evidence was included in the emergency generator test document to ensure the automatic transfer switch was being maintained and inspected as required by NFPA 110, Section 8.3.5. 3) No evidence was included in the emergency generator test document to ensure the transfer of power from normal power to emergency power occurred within 10 seconds. On 3/31/2023 at 2:30 PM with the Director of Maintenance and the Administrator acknowledged the findings. 2012 NFPA 99:6.5.4.1.1 2012 NFPA 101: 9.1.3.1 2010 NFPA 110: 5.6, 8.3, 8.4 10 NYCRR 711.2(a)(1) | Plan of Correction: ApprovedMay 3, 2023 1. Corrective action for the resident effective: There was no specific resident identified in the Statement of Deficiencies. 2. How to identify other residents having the potential to be affected by the same deficient practice: The generator is in a non-resident area and no other residents are affected. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Maintenance Director will modify the emergency generator test log to include the start and end time of the test; The automatic transfer switch was being maintained and inspected and the time of the transfer of power to emergency power, occurred within 10 seconds. 4. How the corrective monitored to ensure the deficient practice will not recur: The Maintenance Director will share the log with the Administrator for compliance. The Maintenance Director will be responsible to ensure the corrective action is implemented. The Maintenance Director will share the results of the log during the facility Quality Assurance meeting. |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 31, 2023
Corrected date: May 23, 2023
Citation Details 2012 NFPA 101 Life Safety Code 9.4.2.2 Except as modified herein, existing elevators, escalators, dumbwaiters, and moving walks shall be in accordance with the requirement of ASME A 17.3, Safety Code for Existing Elevators and Escalators. 9.4.2.3 Elevators in accordance with ASME A 17.7 /CSA B44.7, Performance Based Safety Code for elevators and Escalators, shall be deemed to comply with ASME A 17.1 /CSA B44, Safety Code for Elevators and Escalators, or ASME A 17.3, Safety Code for Existing Elevators and Escalators. 2007 ASME A 17.1 Safety Code for Elevators and Escalators 2.8.1 Equipment Allowed Only machinery and equipment used directly in connection with the elevator shall be permitted in elevator hoist ways, machinery spaces, machine rooms, control spaces, and control rooms. 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, staff interview, and record review conducted during a Life Safety Code recertification survey on 3/30/2023 to 3/31/2023, the facility failed to properly maintain building service records for two of two passenger elevators. Specifically, no evidence was provided to ensure that elevators equipped with firefighter recall service, were being tested monthly. The findings are: On 3/30/2023 at 10:35 AM, 2 elevators were observed with fire fighter recall. Record review of the building testing and maintenance logs on 3/31/23 at 9:30 AM, revealed the facility's elevator firefighter recall test was not documented on the elevator vendor testing logs. In an interview on 3/31/2023 at 11:58 AM, the Director of Maintenance stated the elevators drop to the first floor and the doors open, when the fire alarm goes off. They further stated they have a vendor who comes in to test the elevator monthly and will request documentation. They further stated they are not aware if the elevator vendor tests the fire fighter recall monthly. 2012 NFPA 101: 9.4.6.2 10 NYCRR 711.2(a)(1) | Plan of Correction: ApprovedMay 3, 2023 1. Corrective action for the resident effective: There was no specific resident identified in the Statement of Deficiencies. The Maintenace Director contacted the elevator company and requested them to show evidence during their monthly reports that the fire recall was tested . 2. How to identify other residents having the potential to be affected by the same deficient practice: The Maintenance Director tested the fire alarm system and observed the elevator fire recall was working properly. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Maintenance Director will meet with the elevator service vendor and discuss the findings identified in the Statement of deficiencies. The vendor's monthly report will document the firefighter recall test performed. The Maintenance Director will monitor the vendor's inspections to assure compliance. If the report does not include fire recall, then the facility will request the vendor to complete a new updated report to include testing of the fire recall. 4. How the corrective monitored to ensure the deficient practice will not recur: As part of the on-going preventive maintenance the Maintenance Director will create a log that will show the elevator inspections to include fire recall testing. The Maintenance Director will be responsible to ensure the corrective action is implemented. The Maintenance Director will report all findings to the facility Quality Assurance meeting. |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 31, 2023
Corrected date: May 12, 2023
Citation Details 2012NFPA101: 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. Based on documentation review and staff interview conducted during the life safety recertification survey, the facility failed to ensure that fire drills were conducted at different locations across each shift. This occurred for the fire drills conducted (MONTH) 2022 to (MONTH) 2023. The findings are: On 3/31/2023 at 10:00 AM the fire drill records were reviewed. The document titled Fire Drill Report indicated the date of drill, time of drill, code and the location of the alarm. The fire drill reports from (MONTH) 2022, (MONTH) 2022, (MONTH) 2022, (MONTH) 2022, (MONTH) 2023, (MONTH) 2023, and (MONTH) 2023 indicated location of alarm: Lobby. The fire drill locations were not conducted at varying locations and conditions to test and evaluate the efficiency, knowledge and response of staff. The findings were acknowledged by the Director of Maintenance and the Administrator on 3/31/2023 at 2:30 PM. 2012 NFPA 101:19:7.1.4 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedMay 3, 2023 1. Corrective action for the resident effective: There was no specific resident identified in the Statement of Deficiencies. The Maintenance Director will conduct next month fire drill in a different location within the facility. 2. How to identify other residents having the potential to be affected by the same deficient practice: Fire Drill are conducted quarterly on each shift to ensure familiarity of the staff in the event of a fire. The Maintenance Director will conduct fire drills at varying locations throughout the facility. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Administrator and Maintenance Director reviewed the monthly fire drill process. Each month the drills will be held in a different location within the building. The area will be rotated within the basement, first, second and third floor. These drills will include residents' areas and non-resident areas. The Maintenance Director will create a log showing the location and time of each monthly drill. 4. How the corrective monitored to ensure the deficient practice will not recur: This log will be shared with the Administrator for compliance. The Administrator/designee will be responsible to ensure the corrective action is implemented. Corrections will ensure compliance The log will be part of the facility preventive Maintenance program. The Maintenance Director/designee will share the log at the facility QAPI Committee meeting. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2023
Corrected date: April 20, 2023
Citation Details 2012 NFPA 99: 11.3.4 Signs 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING Based on observation and staff interview conducted during the life safety recertification survey, the facility failed to provide oxygen storage rooms with the appropriate signage required by NFPA 99, 2012 edition. This occurred on the roof and the 3rd floor within the facility. The findings were: On 3/30/2023 between the hours of 9:00 AM and 4:30 PM a tour of the facility revealed the oxygen storage room on the roof, and the oxygen storage room on the 3rd floor, lacked the required signage indicating CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING In an interview on 3/30/2023 at 11:35 AM, the Director of Maintenance stated they will replace the oxygen storage room sign immediately. 2012 NFPA 99: 1.3.4 10 NYCRR 711.2(a)(1) | Plan of Correction: ApprovedMay 3, 2023 1. Corrective action for the resident effective: There was no specific resident identified in the Statement of Deficiencies. The Maintenance Director added signage on the oxygen storage room to say CAUTION: OXYIDIZING GAS(ES) STORED WITHIN NO SMOKING: 2. How to identify other residents having the potential to be affected by the same deficient practice: The Maintenance Director inspected the facility and there are no additional storage room that needed signage. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Maintenance Director replaced the oxygen storage sign to include the proper language. The Maintenance Director will create a audit that will be part of the facility preventive maintenance program. This audit will be done to assure that oxygen storage room has the proper signage on the door. 4. How the corrective monitored to ensure the deficient practice will not recur: The maintenance staff will complete the audit three times a week for one month; followed by bi-month for one month then quarterly for 6 months. The Maintenance Director will be responsible to ensure the corrective action is implemented. The Maintenance Director will report the results to the facility Quality Assurance meeting. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2023
Corrected date: April 19, 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, doors to hazardous areas were not self-closing or positively latching, when tested . This occurred in the basement of the facility. The findings are: On 3/30/2023 between the hours of 9:00 AM and 4:30 PM during the recertification survey, doors to hazardous areas were not self- closing or positively latching when tested . 1) The Dietary Storage room door did not self-close, or latch into its frame when tested . The room contained food storage and the door would not close due to a metal storage rack placed in front of the door. 2) The Kitchen door located adjacent to the smoke barrier doors by the elevator bank, did not self-close and latch into its' frame when tested . In an interview on 3/30/2023 at 11:15 AM, the Director of Maintenance stated they will fix the storage room door right away. 2012 NFPA 101: 19.3.2.1 10 NYCRR 711.2(a)(1) | Plan of Correction: ApprovedMay 3, 2023 1. Corrective action for the resident effective: There was no specific resident identified in the Statement of Deficiencies. The Maintenance Director immediately removed the metal storage rack so the door would close properly. The kitchen door was immediately adjusted so it would close properly. 2. How to identify other residents having the potential to be affected by the same deficient practice: The maintenance department inspected the doors in hazardous areas to assure all the doors closed properly and are free from any obstructions. Repairs were made if needed. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Housekeeping Director and Maintenance Director re-educated the housekeeping dietary and maintenance staff on the importance of making sure the doors to hazardous areas are able to self-close with no obstruction. The Maintenance Director will create an audit tool that will be part of the facility preventive maintenance program. This audit will be done to assure that all doors in hazardous areas are able to self-close. 4. How the corrective monitored to ensure the deficient practice will not recur: This audit completed by the Maintenance Director/designee will be done weekly three times a week for one month; followed by bi-month for one month then quarterly for 6 months. Corrections will be made if appropriate. The Maintenance Director will be responsible to ensure the corrective action is implemented. and all findings will be reported to the facility Quality Assurance meeting. |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 31, 2023
Corrected date: May 25, 2023
Citation Details 2012NFPA101: 19.5.2 Heating, Ventilating, and Air-Conditioning. 19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications, unless otherwise modified by 19.5.2.2 9.2 Heating, Ventilating, and Air-Conditioning. 9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service 2012 NFPA 90A: 5.4.8.1 5.4.8 Maintenance. 5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives 2010 NFPA 80 Standard for Fire Doors and Other Opening Protectives Chapter 19 Installation, Testing and Maintenance of Fire Dampers 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where frequency shall be every 6 years. 19.3.4 Documentation. All inspections and testing shall be documented, indicating the location of the fire damper, date (s) of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. Based on observation, documentation review and staff interview conducted during the life safety recertification survey, it was determined that the heating, ventilating, and air conditioning (HVAC) system was not maintained in accordance with NFPA 80. This was evidenced by the lack of documentation that the fire dampers installed were inspected and tested every 4 years. The findings are: During the recertification survey on 3/30/2023 at 9:45 AM the facility's fire / smoke damper log was requested. A letter was provided for review from an outside fire protection services vendor indicating the Fire Damper Fusible Links throughout the bathroom ductwork were cleaned and inspected on (MONTH) (YEAR). These dampers were found to be in good working order. An additional document from the same vendor titled Customer Detail indicated Code: Links, Description: Fusible Links, Quantity: 100, Inspection: 3/2022, Comment: A/C Vents. The documentation provided did not indicate the location of the fire damper, date of inspection, name of inspector, deficiencies discovered, and space to indicate when and how the deficiencies were corrected. In an interview on 3/31/2022 at 11:58 AM, the Director of Maitnenace stated the a vendor does the fusible links and will check the records. The Director of Maintenance and the Administrator acknowledge the finding at the exit conference on 3/31/2023 at 2:30 PM. 2012 NFPA 101: 19.5.2.1, 9.2 2012 NFPA 90A: 5.4.8.1 2010 NFPA 80: 19.3.4, 19.4.1.1 10 NYCRR 711.2 (a)(1) | Plan of Correction: ApprovedMay 3, 2023 1. Corrective action for the resident effective: There was no specific resident identified in the Statement of Deficiencies. The Maintenance Director contacted the fire protection services vendor and requested a detail report on the fire dampers that was done on 3/2022 to include location of the fire damper, date of inspection, name of the inspector, deficiencies discovered if any and how were they corrected. 2. How to identify other residents having the potential to be affected by the same deficient practice: Each resident at the facility may have the potential to be affected be the deficient practice. The vendor has been contacted to have his report include the required information. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The maintenance department will be in-serviced on the testing requirements for the fire dampers and what is required to be on the report; to include the location of the dampers, date of inspection, name of inspector, deficiencies discovered and a space to indicate when and how the deficiencies were corrected. The Maintenance Director will meet with the fire protection service company and discuss the findings identified in the Statement of deficiencies. The vendor's report will include the items identified. If the report is incomplete, then the facility will request the vendor to complete a new updated report to include the items mentioned. The Maintenance Director will review future inspections to assure that the required items are listed properly. 4. How the corrective monitored to ensure the deficient practice will not recur: As part of the on-going preventive maintenance the Maintenance Director will create a log that will list all of the required items to be in the vendor report to ensure compliance. The Maintenance Director will be responsible to ensure the corrective action is implemented. The Maintenance Director will report all findings to the facility Quality Assurance meeting. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2023
Corrected date: April 27, 2023
Citation Details 2012 NFPA 101: 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 7.1.10.1 General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Based on observation and staff interview, during the Life Safety recertification survey on 3/30/2023 to 3/31/2023, the facility failed to ensure that means of egress was continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This occurred in the basement and on the roof of the facility. The findings were: On 3/30/2023 at 10:40 AM, storage of combustibles such as a storage cabinet containing linens, a metal shelving unit containing clean linens, 4 blue carts containing linens, and 4 (50) Gallon paper shredding containers was observed in the corridor in the basement. On 3/30/2023 at 11:46 AM, storage of combustibles such as cardboard boxes and ladders were observed on the roof landing adjacent to the elevator. The corridor is used as a path of egress, to the exit stairwell. In an interview on 3/30/2023 at 10:40 AM, the Director of Housekeeping stated they store the clean linens there for daily use, and staff pull linen from there, as needed. 2012 NFPA 101: 7.1.10.1, 19.2.1 10 NYCRR 711.2(a)(1) | Plan of Correction: ApprovedMay 3, 2023 1. Corrective action for the resident effective: There was no specific resident identified in the Statement of Deficiencies. The Housekeeping Director immediately relocated the linen carts and shredding containers from the corridor in the basement and the Maintenance Director removed the boxes and ladders from the roof landing. 2. How to identify other residents having the potential to be affected by the same deficient practice: The basement and roof corridor are not near any resident rooms or common area. The Maintenance Director inspected the corridor and exit stairwell to make sure the area was free of any obstruction in order to have a clear path of egress. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Housekeeping Director and Maintenance Director re-educated the housekeeping and maintenance staff on the importance of keeping the path of egress cleared in all corridors and exit stairwells. The Maintenance Director will create an audit tool that will be part of the facility preventive maintenance program. This audit will be done to assure the path of egress and stairwells are free of any obstruction. 4. How the corrective monitored to ensure the deficient practice will not recur: This audit, completed by the Maintenace Director/designee will be done weekly three times a week for one month; followed by bi-month for one month then quarterly for 6 months. The Maintenance Director will be responsible to ensure the corrective action is implemented. Corrections will be made if appropriate. The Maintenance and all findings will be reported to the facility Quality Assurance meeting. |
Scope: N/A
Severity: N/A
Citation date: March 31, 2023
Corrected date: April 18, 2023
Citation Details 415.29 Physical environment. The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel, and the public. (a) Life safety from fire and other hazards. (1) Buildings and equipment shall be maintained and operated so as to prevent fire and other hazards to personal safety. Based on observation and staff interview conducted during the life safety recertification survey, the facility did not ensure the labeling machine in the clean linen area was operated in a safe manner. This occurred in the basement of the facility. The findings are: On 3/30/2023 at approximately 10:10 AM, a tour of the housekeeping storage area in the basement revealed an iron-on labeling machine, that was left in the on position and unattended. The temperature reading on the labeling machine indicated 354 degrees Fahrenheit. The labeling machine was hot when the surveyor placed their hand near the machine. Four cotton towels were placed on the lower portion of machine, which is utilized to imprint the label onto, from the hot iron when depressed by a staff worker. A sign was placed above the machine indicating the machine should be turned off, when not utilizing the machine. No staff members were in the vicinity of the labeling machine at the time of the observation. In an interview at the time of the observation the Director of Housekeeping stated the machine does not close properly so staff use the towels to prop the clothes up onto, so the labels will stick to the clothes. They further stated that staff might have just walked away to deliver clothes. 415.29 (a) | Plan of Correction: ApprovedMay 3, 2023 1. Corrective action for the resident effective: There were no residents identified in the Statement of Deficiencies. The labeling machine was immediately turned off by the Housekeeping Director. The housekeeping employee was re-educated on the importance of not leaving the machine unattended while in use. 2. How to identify other residents having the potential to be affected by the same deficient practice: The labeling area is in the basement is not near any resident rooms or common area. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Administrator and Housekeeping Director reviewed the policy and procedure on the use of the labeling machine. There were no changes in procedure. The Housekeeping Director re-educated the housekeeping staff on the use of the labeling machine and the importance to make sure the machine is turned off when the employee leaves the machine during and after use. The manufacture of the machine was contacted, and the maintenance department was able to repair the machine, so it closed properly. The maintenance department will install a digital timer on the machine to automatically turn off after use. 4. How the corrective monitored to ensure the deficient practice will not recur: The Director of Housekeeping will create a log to record each time the machine is in use. This log will show the times the machine is turned on and off and that the machine is functional working properly. The log will be signed by the person using the machine that the machine is turned off. The Housekeeping Director will review the log as part of his daily rounds to ensure the labeling machine was used and functioning in the correct manner. The Housekeeping Director will be responsible for ensuring the corrective action is implemented. The Housekeeping Director will report the log activity to monthly QAPI Committee meeting. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2023
Corrected date: May 10, 2023
Citation Details 2012 NFPA101:19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posting with the international symbol for no smoking. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. Based on observation and staff interview, the facility did not provide the outdoor smoking area with the provisions listed under NFPA 101, 19.7.4. This occurred in the outdoor smoking area. The findings are: On 3/30/2023 between the hours of 9:00 AM and 4:30 PM, the outdoor smoking area was observed to contain a plastic cigarette butt receptacle. The area did not contain an ashtray of safe design and a metal container with a self-closing cover device to empty ashes. In an interview on 3/30/2023 at 2:30 PM, the Director of Maintenance stated they have the receptacle in the area, it contains a metal bin at the bottom, for the ashes to fall into. They further stated they can purchase an ashtray of safe design. 2012 NFPA 101:19.7.4 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedMay 3, 2023 1. Corrective action for the resident effective: There was no specific resident identified in the Statement of Deficiencies. The ashtray provided will be replaced to include an ashtray of safe design, a metal container with a self-closing cover to empty ashes. 2. How to identify other residents having the potential to be affected by the same deficient practice: The residents who smoke have the potential to be affected by the deficient practice. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The facility smoking policy and procedure will be updated to include the required ashtray to include a safe design, metal container with a self-closing cover device to empty ashes. The housekeeping, maintenance and recreation department will be in-serviced on the new ashtray and monitoring procedures. The facility will purchase a metal container ashtray with a self-closing cover device. The Housekeeping Director/designee will monitor the ashtray. The Housekeeping Director will report any issues with the ashtray during morning meeting. If need be, corrections to the ashtray will be made. 4. How the corrective monitored to ensure the deficient practice will not recur: The Housekeeping Director will be responsible to ensure the corrective action is implemented. The Housekeeping Director will report the any issues that needed to be corrected at the facility Quality Assurance meeting. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2023
Corrected date: May 24, 2023
Citation Details K353 s/s=E 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: 5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance 2011 NFPA 25: 5.2.1.1* Sprinklers shall be inspected from the floor level annually. 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5) *Loading (6) Painting unless painted by the sprinkler manufacturer 2011 NFPA25: 5.3 Testing. 5.3.1* Sprinklers. 5.3.3 Waterflow Alarm Devices. 5.3.3.1 Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 2011NFPA25: 13.2.5*. A main drain test shall be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves. (See also 13.3.3.4.) 13.2.5.1 In systems where the sole water supply is through a backflow preventer and/or pressure reducing valves, the main drain test of at least one system downstream of the device shall be conducted on a quarterly basis. 2012NFPA101: 9.7 Automatic Sprinklers and Other Extinguishing Equipment. 9.7.1 Automatic Sprinklers. 9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems 2010 NFPA 13: 8.5.5.2* Obstructions to Sprinkler Discharge Pattern Development. 8.5.5.2.1 Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.5.5.2. 2010 NFPA 13: 8.5.6* Clearance to Storage. 8.5.6.1* Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or 8.5.6.5 are met, the clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater Based on observation, staff interview and record review, the facility did not maintain sprinklers in accordance with NFPA 25, 2011 Edition. Specifically, storage was observed within 18 inches of the deflector, escutcheon and cover plates were missing, and quarterly inspections were not completed. This occurred for the sprinkler system that serves the entire facility. The findings are: On 3/30/2023 to 3/31/2023 between the hours of 9 AM and 4:30PM during the life safety recertification, the following was observed: 1) In the Rabbi Room, the closet contained storage of metal bins within 18 inches of the sprinkler deflector. 2) In the maintenance shop, storage of cardboard boxes was observed within 18 inches of the sprinkler deflector. 3) In the Medical Record room, a light fixture was installed on the ceiling and within 18 inches of the sprinkler deflector. 4) Escutcheons and cover plates were missing from sprinklers on the 1st floor corridor, at the nurse station and within the clean linen room. 5) The most recent quarterly test report was conducted by the sprinkler vendor on 11/18/2022. The quarterly test was due 2/18/2023. In an interview on 3/30/2023 at 10:30 AM, the Director of Maintenance stated they will move the boxes right away and can install a different light fixture to not block the sprinkler. In an interview on 3/31/2023 at 2:30PM, the Director of Maintenance stated the sprinkler company is coming in to install the cover plates and conduct the quarterly test. 2012NFPA101 2011NFPA 25 10 NYCRR 711.2(a)(1) | Plan of Correction: ApprovedMay 3, 2023 1. Corrective action for the resident effective: There was no specific resident identified in the Statement of Deficiencies. The Maintenance Director immediately relocated the items in the Rabbi Room and maintenance shop so that no items were within 18 inches of the sprinkler deflector. The light fixture in the medical record room was removed and a new light fixture was added so not be within 18 inches of the sprinkler deflector. The sprinkler vendor will replace the escutcheons and plate covers that were missing on the 1st floor corridor, at the nursing station and within the clean linen room as identified on the Statement of Deficiencies. The sprinkler vendor has been contacted to complete the quarterly test of the sprinkler system. 2. How to identify other residents having the potential to be affected by the same deficient practice: The maintenance department inspected the facility to ensure that no obstacles are within 18 inches of the sprinkler deflectors throughout the facility. The maintenance department inspected the facility to ensure that there are no light fixtures installed on the ceiling within 18 inches of the sprinkler deflectors. The Maintenance Director contacted the sprinkler vendor, to do a compete audit of the facility and replace any missing escutcheons and cover plates throughout the building. The sprinkler vendor will complete the required quarterly test of the sprinkler system. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Housekeeping Director and Maintenance Director re-educated the housekeeping, dietary, medical record and maintenance staff on not storing items within 18 inches of the sprinkler deflector. The Maintenace staff will be in-serviced on not installing any fixture within 18 inches of the sprinkler deflector. The Maintenance Director contacted the sprinkler vendor to inspect the facility for any missing escutcheons and cover plates. This will be part of the vendor's quarterly test. The Maintenance Director will create an audit tool as part of the preventive maintenance program. This audit will be done to assure that no items are stored within 18 inches of the sprinkler deflector, no light fixtures are installed within 18 inches of the sprinkler deflectors and that there are no escutcheons and cover plates missing. If any items are identified, they will be corrected. 4. How the corrective monitored to ensure the deficient practice will not recur: The Director of Maintenance/designee will conduct this audit three times a week for one month; followed by bi-month for one month then quarterly for 6 months. Corrections will be made if appropriate. The Maintenance Director will be responsible to ensure the corrective action is implemented. The Maintenance Director will report all findings to the facility Quality Assurance meeting. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2023
Corrected date: April 20, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101 Existing Health Care 19.3.7.6 Openings in smoke barriers shall be protected using one of the following methods: (1) Fire-rated glazing (2) Wired glass panels in steel frames (3) Doors, such as 134 in. (44 mm) thick, solid-bonded wood core doors (4) Construction that resists fire for a minimum of 20 minutes. 2012NFPA:101 8.5.4 Opening Protectives. 8.5.4.1* Doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be without louvers or grilles. The clearance under the bottom of a new door shall be a maximum of 3?4 in. (19 mm). Based on observation and staff interview, the facility failed to ensure that smoke barrier doors were maintained. Specifically, smoke barrier doors were not smoke tight. This occurred on 2 of 3 floors within the facility. The findings are: On 3/30/2023 between the hours of 9 AM and 4:30 PM during the Life Safety recertification survey, the following was observed. On the 3rd floor, the smoke barrier located adjacent to the Dental Services Room was observed to contain a gap around the doorknob, on both sides of the smoke barrier door. Light could be seen from one side of the door, through, to the other side. On the 2nd floor, the smoke barrier located adjacent to room [ROOM NUMBER] was observed to contain a gap around the doorknob, on both sides of the smoke barrier door. Light could be seen from one side of the door, through, to the other side. In an interview at the time of the observations, the Director of Maintenace stated they will adjust the doorknobs right away. 2012 NFPA 101: 8.5.4.1, 19.3.7.6, 10 NYCRR 711.2(a)(1) | Plan of Correction: ApprovedMay 17, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Corrective action for the resident effective: There was no specific resident identified in the Statement of Deficiencies. The Maintenance Director immediately repaired the gap around the doorknob adjacent to the Dental Service Room and on both sides of the smoke barrier door to maintain the smoke barrier. The smoke barrier adjacent to room [ROOM NUMBER] was repaired to maintain the smoke barrier. 2. How to identify other residents having the potential to be affected by the same deficient practice: The maintenance department inspected the doors throughout the facility to make sure the smoke barrier doors are maintained. Repairs were made if needed. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Maintenance Director re-educated the maintenance staff on the importance of making sure that all smoke barrier doors have no gab around the doorknobs. The Maintenance Director will create an audit tool that will be part of the facility preventive maintenance program. This audit will be done to assure that all smoke doors do not have any gaps in them. 4. How the corrective monitored to ensure the deficient practice will not recur: The Maintenance Director/designee will audit all doorknobs on the fire doors for gaps three times a week for one month; followed by bi-month for one month then quarterly for 6 months. Corrections will be made if appropriate. The Maintenance Director will be responsible to ensure the corrective action is implemented. and all findings will be reported to the facility Quality Assurance meeting. |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 31, 2023
Corrected date: May 15, 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 3/30/2023 to 3/31/2023 between the hours of 9 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 an alternate source of energy to maintain temperatures. In an interview on 3/30/2023 at 9:45 AM, the Administrator stated that the facility heat and air conditioning is not on generator power. In an interview on 3/31/2023 at 2:30 PM, the Administrator stated they have additional methods of providing heat in the building but will have to look into addressing air conditioning. ß483.73(b)(1) | Plan of Correction: ApprovedMay 17, 2023 1. Corrective action for the resident effective: The facility utilizes HVAC equipment to maintain temperatures for our residents between 71-81 degrees Fahrenheit. If the ambient temperatures move out of the desires range, the facility will contact the outside vendor within 4 hours of loss of temperature range. The vendor will mobilize to the facility external cooling or heating with their own backup generator energy source. 2. How to identify other residents having the potential to be affected by the same deficient practice: Each resident at the facility may have the potential to be affected be the deficient practice. The facility has air conditioning throughout the facility. They have two sources of air conditioning; each resident room is supplied with wall air conditioning units and throughout the hallways on each floor are wall units. Each supply air conditioning within the building. 3. What measures will be put in place or what systemic changes to ensure that the deficient practice will not recur? The Administrator and Maintenance Director reviewed and updated the emergency preparedness policy and procedure for alternate air conditioning if needed. The Maintenace Director will monitor the tempered air of the facility as part of the preventive maintenance program. The facility utilizes HVAC equipment to maintain temperatures for our residents between 71-81 degrees Fahrenheit. In the event of loss of power, we have made arrangement with an outside vendor to provide external cooling or heating with their own backup generator energy source. If the facility believes the loss of power will continue over an extended period of time, and that the ambient temperatures will move outside of the desire range, the facility will contact and arrange for outside vendor within 4 hours of loss of temperature range. Per the vendor, it takes approximately two hours to mobilize the equipment and an additional hour to install. Tempered air will be piped into the communal dining rooms, to create a large cooling areas, and is designed to flow into corridors and residents' rooms over the next several hours, conditioning the entire floor. This will be utilized on every unit that needs supplemental HVAC. The emergency preparedness policy and procedure were updated to reflect this. The Maintenance Director will educate the maintenance and housekeeping staff of the new policy. This policy will be part of the annual emergency preparedness training to all staff. 4. How the corrective monitored to ensure the deficient practice will not recur: The Maintenance Director will monitor the temperature of the facility in the event there is loss of power. The emergency preparedness policy and procedure will be implemented. The policy will be reviewed annually and updated as needed. In the event of loss of power, the Maintenance Director will complete an action plan that will be shared at the QAPI Committee meeting. |