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Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: March 31, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Recertification Survey conducted from 03/24/2025 to 03/31/2025, the facility did not develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet each resident's medical, nursing, mental, and psychosocial needs. This was evident in 2 of 2 residents reviewed out of 35 total sampled residents. Specifically, 1. ) Resident #27, who was on palliative care and had been receiving pain medications, had no care plan developed to address pain management and palliative care. 2. ) Resident #123, who had a [DIAGNOSES REDACTED]. The findings are : The facility policy titled Comprehensive Care Plan with a revision date of 12/2023 documented it is the policy of the facility that all residents will have a comprehensive care plan completed in accordance with Federal and State requirements. The comprehensive care plan include measurable objectives and timetable to meet the resident's medical, nursing, and psychosocial needs that are identified from the comprehensive assessment, it will be started immediately upon admission and completed within seven days after the completion of the comprehensive assessment. Care plan will be reviewed and revised as needed by a team of qualified persons and minimally after each assessment or reassessment. 1. Resident #27 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident #27 had severely impaired cognition, unable to walk, and was completely dependent on staff for dressing, transfer, bed mobility, and was spoon fed by staff during meals. During an observation on 03/25/2025 at 12:05 PM, Resident #27 stated they have pain. The physician's orders [REDACTED].#27 was on Palliative Care, on Tylenol 325 milligram 2 tablets every 6 hours as needed for low back pain and to apply [MEDICATION NAME] 1% gel twice a day and as needed for low back pain. A medical note dated 03/05/2025 documented that Resident #27 was seen for monthly assessment and physical examination, resident was on Tylenol and [MEDICATION NAME] gel for pain to both knee. A palliative care visit note dated 03/31/2025 documented Resident #27 was seen on 03/21/2025 with no complaint of pain or discomfort, consumed lunch with a fair appetite. Will visit the resident again on the next palliative care visit. A review of Resident #27's comprehensive care plans had no documented evidence that care plans for palliative care and pain management was developed. 2. Resident #123 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident #123 had intact cognition and required maximal assistance in dressing, eating, transfer, and toileting. A physician's orders [REDACTED]. A review of Resident #123's comprehensive care plans had no documented evidence that a care plan to address Resident #123's [DIAGNOSES REDACTED]. On 03/31/2025, Registered Nurse #4 was interviewed and stated it is the nurse supervisors' responsibility to initiate the care plans on admission. They stated it is the Registered Nurses' responsibility to update the care plans. On 03/28/2025 at 12:30 PM, Registered Nurse #5, who was the nursing supervisor, was interviewed and stated they checked the medical record and found no care plans developed for Resident #27 on pain management and palliative care. Registered Nurse #5 stated Resident #123 had no care plan developed for diabetes. They stated care plans are initiated by the admitting Registered Nurse and that it is every nurse's responsibility to initiate and complete the care plans. 10 NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedApril 24, 2025 The facility recognizes the importance of accurate and timely completion of all Minimum Data Set (MDS) assessments, as per regulatory standards and our internal policy titled Minimum Data Set 3. 0 (last reviewed 10/2024). Upon review of the discrepancy regarding Resident #358's discharge status, the following corrective and preventive measures have been implemented: 1. Immediate Correction: The MDS for Resident #358 has been corrected on 3/31/2025 to reflect the accurate discharge destination to home on 03/03/ 2025. 2. Staff Re-education: The MDS Coordinator received immediate re-education regarding proper discharge coding procedures and the importance of cross-referencing interdisciplinary documentation. 3. Ongoing Compliance: As part of our Quality Assurance and Performance Improvement (QAPI) program, the Director of MDS will audit five (5) discharge assessments every 4 weeks for 6 months to ensure accurate coding of discharge location and identify any additional training needs. The facility remains committed to maintaining compliance with all applicable federal and state regulations and ensuring accurate resident assessments to support appropriate care planning and transitions. Please consider this letter as our formal acknowledgment and assurance that corrective actions have been taken to address the cited concern. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2025
Corrected date: May 29, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 03/24/2025 to 03/31/2025, the facility did not ensure that services provided meet professional standards of quality. This was evident for 1 (Resident #320) of 3 residents observed during Medication Administration. Specifically, 1) Licensed Practical Nurse #3 was observed administering the medication [MEDICATION NAME] 50 mg-500 mg 1 tablet by mouth at 10:05 AM, however, review of the Medication Administration Record [REDACTED]#318 to Resident #320 instead of [MEDICATION NAME] Silver 0. 4 mg-300 mcg 250 mcg 1 tablet by mouth as ordered by the physician. The findings are: Resident #320 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #320 had intact cognition and required supervision when performing Activities of Daily Living. The Physician order [REDACTED]. 4 mg-300 mcg 250 mcg tablet, give 1 tablet by oral route once daily at 10:00 AM. On 03/26/2025 at 10:05 AM, during the Medication Administration task, Licensed Practical Nurse #3 administered [MEDICATION NAME] 50 mg-500 mg tablet 1 tablet by mouth and [MEDICATION NAME] Silver Ultra Men's 300 mcg-60 mcg-600mcg-300 mcg 1 tablet by mouth to Resident # 320. The Medication Administration Record [REDACTED]. Review of the Physician orders [REDACTED].#320 was prescribed [MEDICATION NAME] Silver 0. 4 mg-300 mcg 250 mcg tablet,1 tablet by oral route once daily at 10:00 AM but received [MEDICATION NAME] Silver Ultra Men's 300 mcg-60 mcg-600-mcg-300 mcg 1 tablet by mouth instead. On 03/26/2025 at 10:15 AM, an interview was conducted with Licensed Practical Nurse #3 who stated that they signed for [MEDICATION NAME] 50 mg-500 mg tablet 1 tablet by oral route for Resident #320 when they started work this morning around 7:00 AM but they did not administer it at that time. Licensed Practical Nurse #3 also stated that they sometimes sign off medications early and hope to administer them later as many residents receive their medication at 10:00 AM and prefer to receive them all at the same time. Licensed Practical Nurse #3 further stated that they wanted to give Resident #320 all their medications together. During a follow-up interview on 03/26/2025 at 10:30 AM, Licensed Practical Nurse #3 stated that, during the Medication Administration, they did not see the medication [MEDICATION NAME] Silver 0. 4 mg-300 mcg-250 mcg dispensed for Resident #320, so they went to look for it among the extra medications located at the bottom of the medication cart. Licensed Practical Nurse #3 also stated that they just selected another [MEDICATION NAME] medication, but they did not realize that the [MEDICATION NAME] blister pack they picked belonged to another resident (Resident #318). On 03/31/25 10:10 AM, an interview was conducted with Registered Nurse #5, a unit supervisor who stated that all medication nurses are taught the five rights of medication administration. Registered Nurse #5 also stated that the [MEDICATION NAME] for Resident #320 was in the medication cabinet but is listed under another name which Licensed Practical Nurse #3 was not familiar with. Registered Nurse #5 further stated that signing for a medication that had not yet been administered to the resident is not acceptable practice On 03/31/25 at 11:00 AM, an interview was conducted with the Medical Director who stated that the [MEDICATION NAME] could be administered at any time during the morning. The Medical Director also stated that they believed the [MEDICATION NAME] being entered for administration at 8:00 AM was an error because the medication would not have any interaction with other medications if administered at 10:00 AM. The Medical Director concluded that the nursing staff should not sign off medication they have not administered. On 03/31/25 at 11:30 AM, a further interview was conducted with the Medical Director who stated that the facility has a standard [MEDICATION NAME] preparation that they use for residents. The Medical Director also stated that sometimes residents come from the hospital with a different order, or their respective provider required a different dosage of [MEDICATION NAME], so an individual order would be written, and the pharmacy would supply them individually because of the different strengths. On 03/31/25 at 12:00 PM, an interview was conducted with the Director of Nursing who stated that all nursing staff were in-serviced annually and as needed for medication administration competency. The Director of Nursing stated that the Licensed Practical Nurse #3 had received medication administration competency training, and there were no concerns with their performance at that time. 10 NYCRR 415. 11(c)(3)(i) | Plan of Correction: ApprovedJune 18, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** P(NAME) F656 I. Immediate Corrective Action: Resident # 27 1) On 3/31/25 the IDT Team developed a CCP for Palliative care and pain management. 2) On 4/2/2025 the resident was reassessed by Nurse Practitioner and the total plan of care including pain management and palliative care was reviewed 3) On 4/17/2025 the SW and RNS met with the resident's family to review the current plan of care for pain management and palliative care and the resident's family verbalized satisfaction with the plan. 4) On 4/1/2025 the DON provided the SW responsible for initiating the palliative care CCP with education and counseling. Resident # 123 1) On 3/28/2025 the IDT Team developed a CCP for Diabetes. 2) On 3/28/25 the resident was reassessed by Nurse Practitioner and the total plan of care including diabetic management was reviewed. 3) On 3/31/2025 the DON issued an educational counseling to the Admitting RN for not initiating the diabetic management CCP. II. Identification of Others: 1) The facility respectfully states that all residents could potentially be affected. 2) A report will be generated from the EMR- Sigma care to determine which residents have orders for Palliative care. This list will be utilized by the SW in conjunction with the RNS to ensure all residents with palliative care have an individualized care plan. Any issues will be immediately corrected. 3) A report will be generated from the EMR-Sigma care to determine which residents have pain management medication orders. This list will be utilized by the RNS to ensure all residents have an individualized pain management care plan. Any issues will be immediately corrected 4) A report will be generated from the EMR-Sigma care for all residents with diabetes. This list will be utilized by the RNS to ensure all residents with diabetes have an individualized care plan. Any issues will be immediately corrected. III. Systemic Changes: 1) The DNS and members of the IDT reviewed the P/P on Comprehensive Care Planning and found same to be compliant. 2) All RNs, MDS Coordinators, and IDT Team members will be inserviced by the In-service Coordinator. Highlights of the lesson plan include: ??? The responsibility to develop and implement a care plan that describes all of the following with emphasis on palliative care, pain management and diabetes; a. Resident goals and desired outcomes; b. The care/services that will be furnished so that the resident can attain or maintain his/her highest practicable physical, mental, and psychosocial well-being; c. Resident's medical, nursing, physical, mental, and psychosocial needs, and preferences, and how the facility will assist in meeting these needs and preferences. ??? The specific CCP's that each member of the IDT is responsible for initiating. ??? The responsibility of all members of the IDT to initiate or update CCP's for changes in the residents' care plan that are addressed at the morning QA Meeting. ??? The responsibility of the IDT to review each resident's physician orders [REDACTED]. IV. Quality Assurance: 1) The DON developed an audit tool to ensure that all care plans are developed, implemented, and reviewed, including goals and interventions after each care plan meeting. 2) The DON/Designee will review 8 randomly selected residents weekly x 4weeks followed by 8 residents each month including new admission x 6 months. 3) Any findings regarding CCP implementation will be reviewed at the monthly QA meeting for follow-up. 4) Findings will be reported quarterly to QA Committee to track compliance and monitor sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025-Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2025
Corrected date: May 29, 2025
Citation Details None | Plan of Correction: ApprovedJune 18, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F759 I. Immediate Corrective Action: 1) On 3/26/25 Resident # 320 was assessed by the MD/NP and no adverse effects of receiving late administration of [MEDICATION NAME] and the administration of a different type of [MEDICATION NAME] were noted. 2) On 3/26/25 a medication error report was developed by the DON for this incident and shared with Pharmacy Consultant and Medical Director 3) On 4/1/25 the DON issued a disciplinary action for LPN# 3 responsible for the medication error. 4) On 4/1/25 a Medication competency was conducted by the RNS for LPN # 3. II. Identification of Others: 1) The facility respectfully states that all residents were potentially affected. 2) The DON conducted a meeting with the Medical Director and Pharmacy consultant to review any medication errors in the past 3 months to assess Facility medication error rate. No medication errors were reported. III. Systemic Changes: The DON, Medical Director and Administrator in conjunction with the Pharmacy Consultant reviewed the Facility policies/procedures for medication administration and found same to be compliant. The P/P will be inserviced to all Licensed Medication nurses by the Inservice Coordinator. The Lesson plan will focus on: ??? Standard for safe medication practices: The Rights of Medication Administration that include: ??? Right patient, ??? Right drug, ??? Right dose, ??? Right route, ??? Right time, ??? Right reason, ??? Right Monitoring (including vital signs and observation for side effects), ??? Right documentation, ??? Right patient education, ??? Right evaluation and ??? Right to refuse. ??? Types of Medication Errors ??? Medication Documentation and communication. IV. Quality Assurance 1) The DON will develop an audit tool to monitor compliance with ensuring compliance with standards of practice for Medication Administration. 2) The audit will be done by the DON/Designee on 4 randomly selected medication nurses on random shifts weekly x 4 weeks, followed by 4 randomly selected medication nurses monthly x 6 months. 3) All Nurses will continue to have a Medication Competency upon hire and annually completed by the Inservice Coordinator /Designee 4) Results from the audit will be brought to the Quarterly QA Meeting to monitor compliance and track sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025-Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2025
Corrected date: May 29, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the Recertification Survey conducted from 03/24/2025 to 03/31/2025, the facility did not ensure that the Minimum Data Set assessment accurately reflected a resident's status. This was evident in 1 (Resident #358) of 38 total sampled residents. Specifically, Resident #358's Minimum Data Set assessment did not accurately reflect their discharge status. The findings are: The facility policy titled Minimum Data Set 3. 0 with a reviewed date of 10/2024 documented the facility is to ensure accurate and timely completion of Minimum Data Set assessments for all residents. Resident #358 had [DIAGNOSES REDACTED]. The discharge Minimum Data Set assessment dated [DATE] documented Resident #358 was discharged to an acute hospital. A nursing note dated 03/03/2025 documented Resident #358 was discharged home in stable condition and that Resident #358 left the unit accompanied by their family at 10:35 AM. A social services note dated 03/04/2025 documented Resident #358 was discharged home on 03/03/ 2025. On 03/31/2025 at 10:46 AM, Registered Nurse #2 was interviewed and stated Resident #358 was a resident on their unit. Registered Nurse #2 also stated Resident #358 was discharged home on 03/03/ 2025. On 03/31/2025 at 11:31 AM, the Minimum Data Set Coordinator was interviewed and stated they completed the discharge Minimum (MDS) data set [DATE] for Resident # 358. They stated Resident #358 was discharged home and it was an error when they coded Resident #358 as discharged to an acute hospital. 10 NYCRR 415. 11(b) | Plan of Correction: ApprovedApril 25, 2025 P(NAME): F609 I. Immediate Corrective Actions: Resident # 230 1) On readmission 05/21/2024 the resident was reassessed by the physician and total plan of care was reviewed. 2) On 6/11/24 the IDT Team reviewed and revised the resident plan of care including Falls risk and interventions, family agreeable with plan of care. 3) The RNS reviewed and updated the CNAAR to include any new interventions. II. Identification of Others: 1) The facility states that all residents were potentially affected. 2) All incidents and accidents for the preceding 30 days were reviewed to ensure that any incidents involving injuries of unknown origin, alleged, or actual abuse were reported to NYSDOH. No other issues were identified. III. Systemic Changes: 1) The Policy and Procedure for Abuse Prevention was reviewed by the Administrator in conjunction with the Director of Nursing (DON) and Medical Director and is in compliance. 2) Inservice education will be provided by the Inservice Coordinator for all Direct Care staff including Licensed nurses, CNAs, Social Workers, and IDT Team members on the reporting requirements related to reporting violations involving injuries of unknown origin and actual or alleged abuse to the NYSDOH. 3) Highlights of the Lesson Plan include: ??? The facility staff must report all alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property, immediately to the Administrator/ DON. ??? Upon notification the DON/Administrator must report alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property immediately to the NYS DOH ??? As per CMS 42CRF 483. 12(c) the reporting definition immediately is defined as: 1. 2 hours if the alleged violation involves abuse or results in serious bodily injury. 2. 24 hours if the alleged violation does not involve abuse and does not result in serious injury. ??? As per Federal regulation 483. 12(b)(5) all reasonable suspicions of crimes and/or suspicious Incidents resulting in serious bodily injury must be reported to the local law enforcement within two hours. ??? Any reasonable suspicion of a crime not resulting in serious injury must be reported to law enforcement within 24 hours. ??? The Facility procedure for Staff to notify Administrator/DON immediately of any incidents involving alleged abuse or serious injuries immediately 24hrs day/7 days weekly and the responsibility of the DON or Administrator/ designee to report to NYS DOH to comply with reporting requirements. IV. Quality Assurance: 1) An audit tool was developed to monitor the facility's compliance with ensuring that all incidents and accidents are investigated, and any injuries of unknown origin or abuse are reported timely as per NYS DOH and Federal reporting guidelines. 2) All Accident and Incidents will be audited by DON weekly x 6 months. Any identified issues will be immediately addressed and shared at morning report 3) Findings will be reviewed at Monthly QA Meeting to monitor sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025-Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2025
Corrected date: May 29, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure that the medication error rate was not less than 5 percent. This was evident for 2 of 28 medications given during the Medication Administration task. Specifically, 1) Licensed Practical Nurse #3 was observed administering the medication [MEDICATION NAME] 50 mg-500 mg 1 tablet by mouth at 10:05 AM, however, review of the Medication Administration Record [REDACTED]#318 to Resident #320 instead of [MEDICATION NAME] Silver 0. 4 mg-300 mcg 250 mcg 1 tablet by mouth as ordered by the physician which resulted in a medication error rate of 7. 14%. The findings are: The facility policy titled Medication Administration, dated 01/2019 documented the following that it is the policy of the facility to ensure that nurses administer medications correctly and on a timely manner. The policy also documented that medication administered shall be charted immediately after administration. The policy further documented that the medication supplied for one resident shall not be administered to another resident. Borrowing one resident's medication for another resident is not permitted. Resident #320 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #320 had intact cognition and required supervision when performing Activities of Daily Living. The Physician order [REDACTED]. 4 mg-300 mcg 250 mcg tablet, give 1 tablet by oral route once daily at 10:00 AM. On 03/26/2025 at 10:05 AM, during the Medication Administration task, Licensed Practical Nurse #3 administered [MEDICATION NAME] 50 mg-500 mg tablet 1 tablet by mouth and [MEDICATION NAME] Silver Ultra Men's 300 mcg-60 mcg-600mcg-300 mcg 1 tablet by mouth to Resident # 320. The Medication Administration Record [REDACTED]. Review of the Physician orders [REDACTED].#320 was prescribed [MEDICATION NAME] Silver 0. 4 mg-300 mcg 250 mcg tablet,1 tablet by oral route once daily at 10:00 AM but received [MEDICATION NAME] Silver Ultra Men's 300 mcg-60 mcg-600-mcg-300 mcg 1 tablet by mouth instead. This resulted in an error rate of 7. 14%. On 03/26/2025 at 10:15 AM, an interview was conducted with Licensed Practical Nurse #3 who stated that they signed for [MEDICATION NAME] 50 mg-500 mg tablet 1 tablet by oral route for Resident #320 when they started work this morning around 7:00 AM but they did not administer it at that time. Licensed Practical Nurse #3 also stated that they sometimes sign off medications early and hope to administer them later as many residents receive their medication at 10:00 AM and prefer to receive them all at the same time. Licensed Practical Nurse #3 further stated that they wanted to give Resident #320 all their medications together. During a follow-up interview on 03/26/2025 at 10:30 AM, Licensed Practical Nurse #3 stated that, during the Medication Administration, they did not see [MEDICATION NAME] Silver 0. 4 mg-300 mcg-250 mcg dispensed for Resident #320, so they went to look for it among the extra medications located at the bottom of the medication cart. Licensed Practical Nurse #3 also stated that they just selected another [MEDICATION NAME] medication, but they did not realize that the [MEDICATION NAME] blister pack they picked belonged to another resident (Resident #318). On 03/31/25 10:10 AM, an interview was conducted with Registered Nurse #5, a unit supervisor who stated that all medication nurses are taught the five rights of medication administration. Registered Nurse #5 also stated that the [MEDICATION NAME] for Resident #320 was in the medication cabinet but is listed under another name which Licensed Practical Nurse #3 was not familiar with. Registered Nurse #5 further stated that signing for a medication that had not yet been administered to the resident is not acceptable practice On 03/31/25 at 11:00 AM, an interview was conducted with the Medical Director who stated that the [MEDICATION NAME] could be administered at any time during the morning. The Medical Director also stated that they believed the [MEDICATION NAME] being entered for administration at 8:00 AM was an error because the medication would not have any interaction with other medications if administered at 10:00 AM. The Medical Director concluded that the nursing staff should not sign off medication they have not administered. On 03/31/25 at 11:30 AM, a further interview was conducted with the Medical Director who stated that the facility has a standard [MEDICATION NAME] preparation that they use for residents. The Medical Director also stated that sometimes residents come from the hospital with a different order, or their respective provider required a different dosage of [MEDICATION NAME], so an individual order would be written, and the pharmacy would supply them individually because of the different strengths. On 03/31/25 at 12:00 PM, an interview was conducted with the Director of Nursing who stated that all nursing staff were in-serviced annually and as needed for medication administration competency. The Director of Nursing stated that the Licensed Practical Nurse #3 had received medication administration competency training, and there were no concerns with their performance at that time. 10 NYCRR 415. 12(m)(1) | Plan of Correction: ApprovedJune 18, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F658 I. Immediate Corrective Action: 1) On 3/26/2025 Resident # 320 was assessed by the MD/NP and no adverse effects of receiving late administration of [MEDICATION NAME] and the administration of a different type of [MEDICATION NAME] were noted. 2) On 03/26/25 a medication error report was developed by the DON for this incident and shared with Pharmacy Consultant and Medical Director 3) On 4/1/25 the DON issued a disciplinary action for LPN# 3 responsible for the medication error. 4) On 4/1/25 a Medication competency was conducted by the RNS for LPN # 3. II. Identification of Others: 1) The DON obtained a printout from the EMR for all residents scheduled to receive medications prior to the daily standard 10 am medication time. This list will be utilized by Unit RNS' and DON to conduct unit rounds to determine if residents are receiving medication timely and accurately. Any issues will be immediately corrected 2) The DON obtained a list of all residents receiving [MEDICATION NAME]. This list will be utilized by the DON and Medical Director to ensure appropriately prescribed [MEDICATION NAME] vitamin doses are ordered and received. Any issues will be immediately corrected. III. Systemic Changes: 1) The DON, Medical Director and Administrator in conjunction with the Pharmacy Consultant reviewed the Facility policies/procedures for medication administration and found same to be compliant. The P/P will be in serviced to all Licensed Medication nurses by the Inservice Coordinator. The Lesson plan will focus on: ??? Standard for safe medication practices: The Rights of Medication Administration that include: ??? Right patient, ??? Right drug, ??? Right dose, ??? Right route, ??? Right time, ??? Right reason, ??? Right Monitoring (including vital signs and observation for side effects), ??? Right documentation, ??? Right patient education, ??? Right evaluation and ??? Right to refuse. Types of Medication Errors Medication Documentation and communication. IV. Quality Assurance: 1) The DON will develop an audit tool to monitor compliance with ensuring compliance with standards of practice for Medication Administration. 2) The audit will be done by the DON/Designee on 4 randomly selected medication nurses on random shifts weekly x 4 weeks, followed by 4 randomly selected medication nurses monthly x 6 months. 3) All Nurses will continue to have a Medication Competency upon hire and annually completed by the Inservice Coordinator /Designee 4) Results from the audit will be brought to the Quarterly QA Meeting to monitor compliance and track sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025-Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 28, 2025
Corrected date: May 25, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 28, 2025
Corrected date: May 20, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 28, 2025
Corrected date: April 29, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 28, 2025
Corrected date: May 12, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews during the abbreviated survey (NY 925) the facility did not develop and implement a comprehensive person-centered care plan to meet the resident's medical and nursing needs for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 exhibited frequent exit-seeking behaviors, there were no documented interventions to address their behaviors, the resident exited the building and was found in the parking lot. Findings include: The facility policy, Comprehensive Care Plans, reviewed 3/24/2022 documented: - the facility would provide an individualized, interdisciplinary plan of care for all residents that was appropriate to the residents' needs, strengths, results of diagnostic testing, limitations, and goals. - The plan of care shall be individualized, based on diagnosis, resident assessment, and personal goals of the resident and their family. - The planning of care, treatment, and services shall include care planning based on data collected from assessments with integration of those findings into the care planning process. The facility policy, Elopement/Wandering Risk, revised 3/20/2024 documented: - An assessment will be completed by the Charge Nurse/designee and elopement/unsafe wandering risk will be determined. - Upon completion of the Elopement/Wandering Risk Assessment, the Charge Nurse/designee will initiate/update the Elopement/Wandering Risk Care Plan based upon information/risk factors identified and interventions will be implemented as appropriate. - If a resident is considered high risk for elopement/unsafe wandering, initially and upon change in physical status, a care plan must be initiated with documented interventions. Resident #1 had [DIAGNOSES REDACTED]. The 4/4/2024 Admission Minimum Data Set assessment documented the resident had moderate cognitive impairment and did not exhibit wandering behaviors. The Comprehensive Care Plan initiated 3/31/2024 documented: - the resident had impaired cognitive function related to the disease process, [MEDICAL CONDITION], and impaired decision making. Interventions included: simple, structured activities; consistent routine; monitor, document, and report changes in cognition, decision-making, and general awareness; and the resident required supervision with decision-making. - the resident had an activities of daily living self-care performance deficit related to confusion, dementia, and impaired balance. Interventions included supervision for walking with a 4-wheeled walker, walking 5 feet with two turns, supervision and contact guard assistance. - the resident was at risk for falls related to confusion, gait/balance problems, and lack of safety awareness. The resident had falls on 4/5/2024, 4/25/2024, 5/7/2024, and 5/9/ 2024. Interventions included: safety reminders, anticipate needs, encouragement to participate in activities, and appropriate footwear. The 4/1/2024 Wandering Risk Evaluation completed by Registered Nurse #5 documented the resident was forgetful/had a short attention span, was admitted within the last month, had a caregiver or staff change, was independent with mobility and use of a cane/walker, and took antidepressants and narcotics. The last section Elopement Risk (known wandering, history of wandering, follows visitors out, opens exit doors, exit seeking, potential to learn door codes, or resident is not at risk for unsafe wandering) had no options checked. The risk score was documented as 6 and moderate risk for wandering. The evaluation did not include parameters for interventions based on the score. There were no documented interventions in the Comprehensive Care Plan related to wandering or exit-seeking from 4/1/2024-5/11/ 2024. The 5/11/2024 Incident Report completed by Licensed Practical Nurse Supervisor #1 documented: - at approximately 5:50 PM, an alarm indicated a door was opened. The alarm panel indicated one of the side doors on the C-wing was opened. - Registered Nurse Supervisor #1 went to Resident #1's room, the resident's wheeled walker was in the room, the resident was not in the room. - The Predisposing Situation Factors included use of a walker and wandering. - A certified nurse aide (unnamed) alerted Licensed Practical Nurse Supervisor #1 that Resident #1 was in the visitor parking lot, leaning against a car. During a telephone interview on 8/19/2024 at 6:30 PM Certified Nurse Aide #2 stated since the resident was admitted (end of 3/2024), they frequently exhibited exit-seeking behaviors. Their behaviors included getting their coat, saying they were leaving, and going to the front and side doors. They were unaware of any specific interventions and was instructed to redirect the resident. During an interview on 8/20/2024 at 10:35 AM Licensed Practical Nurse #18 stated since the resident was admitted they wandered in and out of rooms, the halls, and sometimes went to doors, and the reception area. The resident verbalized all the time they wanted to get their truck, go to work, or go see their brother. The resident would approach the emergency exit doors and looked like they were reading the signs on the door (which says if door held for 15 seconds, it would release). The resident had triggered the door alarm by pushing the bar before 5/11/ 2024. The exit-seeking behaviors were discussed multiple times at shift reports. They were not certain if the resident had a wander alert device in place prior to 5/11/ 2024. During an interview on 8/20/2024 at 10:47 AM the Activities Director stated since the resident was admitted , they exhibited exit-seeking behaviors. The resident said things such as they had to get out of there, had to get their truck, go to work, they had to get their brother, and would ask where to get out. The resident went to the doors, sometimes saying they were looking for their spouse. Staff redirected them by offering walks, snacks, or distracting them with conversation. At times it was not difficult to redirect the resident, other times, it required more persuasion. Prior to the resident's elopement on 5/11/2024, they had participated in meetings where the resident's exit-seeking was discussed as related to their confusion. They were unaware of any specific interventions or if the resident had a wander alert device at the time. During an interview on 8/30/2024 at 11:31 AM, Licensed Practical Nurse Unit Manager #17 stated they were responsible for care plans. The interdisciplinary team reviewed them to ensure needed areas were addressed. Updates and revisions were done based on changes in status and new interventions needed. A Wandering Risk Evaluation result of moderate risk meant the resident was actively wandering the building without active attempts to leave and the resident should be care planned for the behavior. Specific interventions would be discussed with the interdisciplinary team. The resident began exit-seeking and wandering close to their admission. The resident wandered about the facility and made verbal statements about leaving. They stated they were unsure of the reason there was no care plan for the resident's wandering behaviors. 10NYCRR 415. 11(c)(1) | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 28, 2025
Corrected date: May 20, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 28, 2025
Corrected date: May 23, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |