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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2024
Corrected date: N/A
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 12/15/2024 and completed on 12/23/2024, the facility did not ensure each resident received the necessary behavioral health care and services according to the resident's comprehensive assessment and plan of care to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This was identified for one (Resident #93) of four residents reviewed for Choices. Specifically, Resident #93 was not offered behavioral or psychological counseling when the resident expressed feeling down, depressed, and hopeless to Social Worker # 1. Additionally, the Psychiatrist's consultation dated 10/21/2024 recommended providing behavior therapy. Nurse Practioner #1 reviewed the recommendations provided by the Psychiatrist; however, did not agree, disagree, or implement the recommendations. The finding is: The Consultation Policy and Procedure, last reviewed in (MONTH) 2024 documented the Physician will approve any orders they agree with on the consultation. The Physician will document the reason if they disagree with the consultant. Resident #93, who has no known family or designated representative, has [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 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 Minimum Data Set assessment documented Resident #93 was feeling down, depressed, hopeless, had trouble falling or staying asleep, had little energy, felt bad about themselves, and had trouble concentrating on things. The assessment documented Resident #93 received Antipsychotic and Antidepressant medications during the 7-day lookback period. The Level I Preadmission Screening and Resident Review (PASRR) Screen dated 2/29/2024 documented that Resident #93 had a serious mental illness and required a referral for Level II evaluation by the designated mental health review entity. The Preadmission Screening and Resident Review (PASRR) Level II Screen dated 3/12/2024 documented Resident #93 had a [DIAGNOSES REDACTED]. The screen documented the nursing facility was required to provide Resident #93 with a person-centered psychiatric plan of care, ongoing psychiatric consultations, medication management by a Psychiatrist or licensed prescriber, recovery-oriented clinical counseling focused on goal achievement by overcoming mental illness barriers, and therapeutic group interventions. The screen documented Resident #93 would benefit from professional counseling to help process feelings within a supportive setting and help learn healthy coping skills to calm themselves when experiencing difficult emotions. The counseling can effectively address the resident's symptoms which include sadness, worry, and Paranoia (a mental state where a person has an irrational and persistent fear of being harmed or deceived by others). The screen documented Resident #93's symptoms led to the need for ongoing psychiatric care and medication management and it is likely Resident #93's daily life has been impacted by the mental illness. The Psychiatry Consultation dated 10/21/2024 documented the resident felt unhappy, lonely, and had no primary support. Recommendations were for the resident to receive behavior therapy or counseling. The Physician's Consult Review Note dated 10/22/2024, written by Nurse Practitioner #1, documented they reviewed the Psychiatry Consultation dated 10/21/ 2024. Nurse Practitioner #1 rewrote all the recommendations made by the Psychiatrist in the Psychiatry Consultation dated 10/21/2024; however, Nurse Practitioner #1 did not document whether they agreed or disagreed with the recommendations. A review of Resident #93's physician's orders [REDACTED]. The Care Plan Notes (progress note) dated 11/20/2024, written by Social Worker #1, documented the resident displayed or reported the following: Feeling down, depressed, hopeless, tired, or having little energy. Sleep pattern issues: trouble falling asleep or sleeping too much. The resident has a [DIAGNOSES REDACTED]. The was admitted with a Level 2 PASRR evaluation indicating serious mental illness including [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION], Anxiety Disorder, and [MEDICAL CONDITION]. The Care Plan Meeting Progress Note dated 11/20/2024, written by Social Worker #1, documented Resident #93 had no family contact and the resident was not able to represent themselves due to periods of confusion. The Interdisciplinary Team members present for a quarterly care plan meeting were Social Worker #1 and a representative from the Dietary Department. The resident's plan of care was reviewed and all concerns were addressed. The resident would remain in the facility for long-term care. A review of the resident's Electronic Medical Record on 12/17/2024 at 11:30 AM revealed no documented evidence that Resident #93 was referred to behavior therapy or counseling services by the Social Worker. During an interview on 12/17/2024 at 12:30 PM, the assigned Social Worker #1 stated Resident 93's Brief Interview for Mental Status score was 13; however, Resident #93 was not invited to their care plan meeting, because the resident was confused at times. Social Worker #1 stated Resident #93 had reported feeling down, depressed, and hopeless and Social Worker #1 reported the resident's mood to the nursing staff (could not recall who); the nursing staff was supposed to report and obtain physician's orders [REDACTED].#1 stated they did not document their communication with the nursing staff in the resident's medical record. During an interview on 12/17/2024 at 1:50 PM, the Director of Social Services stated after Social Worker #1 asked Nursing staff to obtain a physician's orders [REDACTED].#1 should have documented the conversation and followed through and made sure a physician's orders [REDACTED]. During an interview on 12/17/2024 at 3:20 PM, the Administrator stated Social Worker #1 should have ensured a physician's orders [REDACTED]. During an interview on 12/17/2024 at 5:00 PM, Nurse Practitioner #1 stated they were a remote (does not physically work in the facility) Medical Provider who only reviews the recommendations made by the Psychiatrist. Nurse Practitioner #1 stated they had strict instructions from their Supervisor to not write Physician Orders. Nurse Practitioner #1 stated the in-house Medical Providers are the ones to either agree or disagree with the recommendations made by the Psychiatrist. Nurse Practitioner #1 stated if an in-house Medical Provider agrees with the recommendations made by the Psychiatrist, they would be the one to place the physician's orders [REDACTED]. During an interview on 12/17/2024 at 5:25 PM, the resident's Primary Physician (Primary Physician #1) stated a remote Medical Provider can also enter physician's orders [REDACTED]. Primary Physician #1 stated that a resident can not receive behavioral (Psychological) counseling without a physician's orders [REDACTED].#93 to receive behavioral counseling. During an interview on 12/17/2024 at 6:00 PM, the Medical Director stated that whenever a Medical Provider, either remote or in-house, reviews a Psychiatry Consultation they are to document whether they agree or disagree with the recommendations. The Medical Director stated Nurse Practitioner #1 should have entered a physician's orders [REDACTED]. | Plan of Correction: ApprovedJanuary 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 740 ÔÇ£ Behavioral Health Services The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: a) Resident #93 was seen by the Psychologist on 12/18/2024 to address his feelings of hopelessness and Depression. b) The Attending Physician re-addressed the Psychiatrists recommendations dated 10/22/2024 by placing an order for [REDACTED]. 2024. c) Resident #93 ÔÇ£ The assigned Social Worker addressed the Residents feelings of hopelessness and reports of feeling depressed by providing emotional support on 01/13/ 2025. d) The Social Worker who failed to provide emotional support to Resident #93 and failed to ensure the Resident received Psychology services as recommended by the Psychiatrist received educational disciplinary action on 01/13/ 2025. B) Identification of other Residents having the potential to be affected by the deficient practice: The Medical Director will be responsible for conducting an audit of all recommendations made by the Psychiatrist for the past 6 months, to ensure that all recommendations made are reviewed and implemented if applicable; or that there is documented evidence if the physician disagreed with the recommendation. Any negative findings will be immediately corrected. The Director of Social Work/Designee will be responsible for conducting an audit of all recommendations made by the Psychiatrist for the months of (MONTH) through (MONTH) 2024, to ensure that all recommendations made are reviewed and implemented if applicable by the assigned Social Worker. Any negative findings will be immediately corrected. Persons responsible: Medical Director & Director of Social Work C) Systemic Changes to ensure the deficient practice will not recur: e) The policy and procedure titled ?ôConsultation?Ø was reviewed and found to be in compliance. f) All onsite and offsite attending medical providers will be re-educated on the procedure of: a. Documenting their agreement with a consultants recommendation and implementing the physicians order; or b. Documenting their disagreement and documenting the reason for disagreement. Person responsible: Medical Director g) All Social Workers will be re-educated on the following: a. Residents identified with signs and symptoms of Depression will receive documented emotional support and will be referred to the Psychiatrist and Psychologist for follow up. h) Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Staff Educator D) QA ÔÇ£ Monitor of the deficient practice: The Medical Director will have the responsibility of auditing 10% of Psychiatry consultations monthly to ensure there is documented evidence of the attending physician addressing any recommendations made. Any negative findings will be immediately corrected and reported to the QAPI committee. This audit will be completed monthly x 6 months. The Medical Director is responsible for the correction of this deficiency. The Director of Social Work will have the responsibility of auditing 10% of Residents scheduled weekly for care plan meeting, to ensure that any resident identified as having signs and symptoms of Depression on the MDS 3. 0 is having same addressed by the unit assigned Social Worker. Any negative findings will be immediately corrected and reported to the QAPI committee. This audit will be completed weekly x 3 months, then monthly x 3 months. The Director of Social Work is responsible for the correction of this deficiency. Date of correction: 02/18/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2024
Corrected date: N/A
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 12/15/2024 and completed on 12/23/2024, the facility did not develop and implement an effective discharge planning process that focused on the resident's discharge goals. This was identified for one (Resident #93) of four residents reviewed for Choices. Specifically, Resident #93, a cognitively intact resident with no known family or designated representative, requested a transfer to another nursing facility; however, the facility did not address the resident's request to meet the resident's discharge goals. The finding is: The Discharge Summary and Plan Policy and Procedure last reviewed in (MONTH) 2024 documented that when the facility anticipates a resident's discharge to a private residence, or another nursing care facility, a discharge summary, and the post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and their family. Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, they will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge preferences. If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the decision. Resident #93, who has no known family or designated representative, 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 13, which indicated that the resident had intact cognitive skills for daily decision-making. Section Q0310 A, the resident's overall goal for discharge established during the assessment process was left blank. The Psychiatry Consultation dated 10/21/2024 documented the resident felt unhappy, lonely, and had no primary support. Recommendations included for Social Services to discuss with the resident their nursing home options in Suffolk County and for the resident to receive Behavior Therapy or counseling. The Psychiatry Consultation dated 12/06/2024 documented the resident reported they would like to move to a facility in Suffolk County. The recommendations included but were not limited to providing social work support to discuss nursing home options in Suffolk County as per the resident's request and for the resident to receive Behavior Therapy or counseling. The physician's orders [REDACTED]. A review of the resident's Electronic Medical Record on 12/17/2024 at 11:30 AM revealed no documented evidence that Social Services had discussed discharge planning options with the resident to a nursing home in Suffolk County. During an interview on 12/17/2024 at 12:30 PM, Social Worker #1, who was the resident's assigned Social Worker, stated discharge planning was not their responsibility. The facility has a Discharge Planner, who was also a Social Worker responsible for discharge planning. Social Worker #1 stated they discussed the possibility of the resident being discharged to another nursing home in Suffolk County with the facility's Discharge Planner and they both agreed the resident was not a candidate due to the resident being confused at times. Social Worker #1 stated that they should have documented their discussion with the Discharge Planner. Social Worker #1 stated that they never went to the resident to discuss discharge planning because the resident was confused at times. During an interview on 12/17/2024 at 1:50 PM, the Director of Social Services stated Social Worker #1 should have met with the resident to discuss the options for transferring to another nursing home in Suffolk County. The Director of Social Services stated Social Worker #1 should have also met with the resident to know why they no longer wanted to live in this facility so that their experience in this facility could be a better one. During an interview on 12/17/2024 at 3:10 PM, the Discharge Planner stated if a resident was requesting to transfer to another facility, the resident's Social Worker should speak with the resident, and then relay the information to the Discharge Planner. The Discharge Planner stated they were not aware of the physician's orders [REDACTED]. with Social Worker # 1. The Discharge Planner stated they should have met with the resident to discuss why the resident wanted a transfer to another facility and to facilitate the transfer. During an interview on 12/17/2024 at 3:20 PM, the Administrator stated it is a resident's right to be invited to their care plan meetings. The Administrator stated the physician's orders [REDACTED].#93 should have been followed. During an interview on 12/18/2024 at 10:00 AM, Resident #93 stated before coming to this facility they had lived in a group home. The resident stated they wanted to be placed in a group home in Suffolk County because they thought they could be placed in a facility faster in Suffolk County, but they would be okay being placed in Nassau County as well. 10 NYCRR 415. 11(d)(3) | Plan of Correction: ApprovedJanuary 17, 2025 F 660 ÔÇ£ Discharge Planning Process The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: a) A discharge planning meeting was held on 12/18/2024 with Resident #93 to address his request to be transferred to another facility. Resident is scheduled for discharge on 01/15/ 2025. b) Resident #93 was seen by the Social Worker with no psychological harm noted from this deficient practice. c) The Social Worker who failed to initiate the discharge planning process for Resident #93 received educational disciplinary action on 01/13/ 2025. B) Identification of other Residents having the potential to be affected by the deficient practice: All cognitively intact residents without family or legal representative are at risk for this deficiency. The Director of Social Work will compile a list of all Residents with a BIMS score of 13 ÔÇ£ 15. Utilizing this list, the Social Worker will create an audit tool and interview Residents to determine if they had expressed a desire to be discharged to another facility. Any residents found to have this request, will have a discharge planning meeting to determine the feasibility of facilitating the discharge. The Medical Director will be responsible for conducting an audit of all recommendations made by the Psychiatrist for the past 6 months, to ensure that all recommendations made are reviewed and implemented if applicable; or that there is documented evidence if the physician disagreed with the recommendation. Any negative findings will be immediately corrected. C) Systemic Changes to ensure the deficient practice will not recur: The ?ôDischarge Summary and Plan?Ø policy and procedure with a review date of 01/2025 was reviewed and found to be in compliance. a) All onsite and offsite attending medical providers will be re-educated on the procedure of: a. Documenting their agreement with a consultants recommendation and implementing the physicians order; or b. Documenting their disagreement and documenting the reason for disagreement. All Social Workers responsible for the enforcement of the ?ôDischarge and Summary Plan?Ø policy and procedure will receive re-education regarding this policy. Education will also emphasize the inclusion of residents in all care plan meeting discussions and documentation of discharge meetings held. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Staff Educator D) QA ÔÇ£ Monitor of the deficient practice: The Director of Social Work/Designee will have the responsibility of interviewing 10% of the population of Residents with a BIMS score of 13-15, to ensure their request for discharge (if applicable) was addressed by the assigned Social Worker. Any negative findings will be immediately corrected and results of findings will be reported to the QAPI committee quarterly. This audit will be conducted weekly x 3 months, then monthly x one year. The Director of Social Work is responsible for the correction of this deficiency. Date of correction: 02/18/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 12/15/2024 and completed on 12/23/2024, the facility did not ensure that drug records were in order and accounted for all controlled drugs. This was identified on one (Unit 1 East) of seven units reviewed during the Medication Storage Task. Specifically, the Pharmacy delivered 56 tablets of [MEDICATION NAME] 10 milligrams for Resident #162 on 12/17/2024; however, the Individual Resident's Controlled Substance Record documented that 46 tablets were received. Additionally, on 12/18/2024, the Individual Resident's Controlled Substance Record documented that 41 tablets of [MEDICATION NAME] 10 milligrams were available, although the blister packs contained 50 tablets due to an inaccurate reconciliation of the total medication received from the Pharmacy on 12/17/ 2024. The finding is: The facility policy titled Controlled Substance/Narcotic Management Protocol dated 2/2021 and revised 1/2024 documented that all narcotics will be counted and reconciled at the beginning of every shift with the outgoing and oncoming nurse. Both nurses must sign the controlled substance log attesting to the presence of the narcotic as stated from the previous shift. Any discrepancies in the count must be reported to the unit manager and the nursing supervisor immediately. Staff responsible for narcotic administration will not leave their shift until the narcotic count is reconciled. Resident #162 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented the Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident received a scheduled pain medication regimen and did not have pain within the last 5 days. A Comprehensive Care Plan titled Alteration in Comfort dated 9/7/2023 and revised 2/6/2024 documented interventions including administering medications as ordered, monitoring, and documenting for side effects of pain medications. A physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. Unit 1 East's Medication Storage Room was observed with Licensed Practical Nurse #4 on 12/18/2024 at 1:32 PM. Resident #162's Individual Resident's Controlled Substance Record for [MEDICATION NAME] 10 milligrams documented 46 tablets were received from the Pharmacy on 12/17/ 2024. The Individual Resident's Controlled Substance Record documented that 41 [MEDICATION NAME] 10 milligram tablets were remaining at 6:00 AM on 12/18/ 2024. There were two blister packs of [MEDICATION NAME] 10 milligrams labeled with Resident #162's name. One of the two blister pack labels indicated 26 of 56 tablets were delivered by the Pharmacy. There were 20 tablets present in that blister pack. The second blister pack label indicated that 30 of 56 tablets were delivered by the Pharmacy. There were 30 tablets present in that blister pack for a total of 50 tablets remaining in the two blister packs. During an interview on 12/18/2024 at 1:33 PM, Licensed Practical Nurse #4 stated they prior to today, they were not aware of the observed discrepancy and that they were not the assigned medication nurse for Resident # 162. During an interview on 12/18/2024 at 2:01 PM, Licensed Practical Nurse #5 stated they administered medication to Resident #162 on 12/18/2024 during the day shift. They reconciled the controlled substances for the residents with the outgoing night-shift Licensed Practical Nurse #6 on the morning of 12/18/2024 and did not notice any discrepancy. Licensed Practical Nurse #5 stated the Individual Resident's Controlled Substance Record documented that 46 tablets were received from the Pharmacy; however, the accurate number should have been 56 tablets and no one noticed the discrepancy including themselves. Licensed Practical Nurse #5 further stated they administered a dose of [MEDICATION NAME] to Resident #162 at lunchtime on 12/18/2024 and forgot to update the Individual Resident's Controlled Substance Record. During an interview on 12/18/2024 at 2:34 PM, Licensed Practical Nurse #6 stated they worked the previous night shift from 11:00 PM to 7:00 AM and reconciled the Individual Resident's Controlled Substance Record with Licensed Practical Nurse # 5. Licensed Practical Nurse #6 stated they may have overlooked the number of tablets available. During an interview on 12/18/2024 at 2:49 PM, the Assistant Director of Nursing Services stated the total amount of [MEDICATION NAME] tablets that were received for Resident #162 from the Pharmacy was documented incorrectly. This discrepancy should have been picked up by the unit nurses immediately and the nursing supervisor should have been notified. Licensed Practical Nurse #5 should have updated the controlled substance record at the time of the medication administration. During an interview on 12/18/2024 at 3:53 PM, the Director of Nursing Services stated when a controlled substance is delivered by the Pharmacy, the nursing supervisor and the unit nurse, who receives the controlled substance, must ensure the accuracy of the amount and correctly document the amount on the Individual Resident's Controlled Substance Record for accurate reconciliation. The discrepancy for Resident #162's [MEDICATION NAME] should have been picked up by the unit nurses and reported to the unit supervisor. 10 NYCRR 415. 18(b)(1)(2)(3) | Plan of Correction: ApprovedJanuary 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 755 ÔÇ£ Pharmacy Services The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. Immediate Corrective Action for Resident found to be affected by the deficient practice: a) There was no psychological harm or complaint of pain for Resident #162 as a result of this deficient practice. b) For Resident #162, the narcotic [MEDICATION NAME] 10mg was reconciled to reflect the accurate number of tablets received as 56 tablets on 12/18/ 2024. c) The Licensed Practical Nurse who inaccurately documented the number of [MEDICATION NAME] received from the pharmacy for Resident #162 received an educational counseling dated 12/18/ 2024. d) The Licensed Practical Nurses responsible for reconciling the narcotic count of [MEDICATION NAME] for Resident #162 at beginning and ending of shifts and failed to observe the inaccurate count, received an educational counseling on 12/18/ 2024. e) The Licensed Practical Nurse who failed to immediately reconcile the narcotic count of [MEDICATION NAME] for Resident #162 after medication administration received an educational counseling on 12/18/ 2024. B) Identification of other Residents having the potential to be affected by the deficient practice: All residents on controlled medication have the potential to be affected by the deficient practice. Upon identification of the inaccurate narcotic count for the medication [MEDICATION NAME] for Resident #162 on 12/18/2024, the Nurse Managers conducted an immediate audit of all narcotics on all units to ensure there were no further discrepancies in the number of tablets received and documented. There were no negative findings. The Nurse Managers also conducted an audit on 12/18/2024, reviewing the narcotic book to ensure that licensed nurses were immediately documenting and reconciling the narcotic count after medication administration. There were no negative findings. C) Systemic Changes to ensure the deficient practice will not recur: The facility policy and procedure titled ?ôControlled Substance/ Narcotic Management?Ø was reviewed and found to be in compliance. All Licensed Nurses will be re-educated on the importance of ensuring an accurate narcotic count as well as reconciling the narcotic count immediately after the medication is administered. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Nurse Educator QA ÔÇ£ Monitor of the deficient practice: The Managers and RN Supervisors will be responsible for auditing the narcotic books on a daily basis x 3 weeks then weekly x 3 months to ensure accuracy of narcotic count and timely reconciliation after medication administration. Any negative findings will be immediately corrected and reported to the Assistant Director of Nursing for follow up and report to the QAPI committee. The Assistant Director of Nursing is responsible for the correction of this deficiency. Date of correction: 02/18/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2024
Corrected date: N/A
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 12/15/2024 and completed on 12/23/2024, 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 #93) of four residents reviewed for Choices. Specifically, The Psychiatrist's consultation dated 10/21/2024 included recommendations to explore options with the resident for transfer to another facility of the resident's choice and for the resident to receive behavior therapy and counseling. Nurse Practioner #1 reviewed the recommendations provided by the Psychiatrist; however, did not agree, disagree, or implement the recommendations. The finding is: The Consultation Policy and Procedure, last reviewed in (MONTH) 2024 documented the Physician will approve any orders they agree with on the consultation. The Physician will document the reason if they disagree with the consultant. Resident #93, who has no known family or designated representative, has [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 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 Minimum Data Set assessment documented Resident #93 was feeling down, depressed, hopeless, had trouble falling or staying asleep, had little energy, felt bad about themselves, and had trouble concentrating on things. The assessment documented Resident #93 received Antipsychotic and Antidepressant medications during the 7-day lookback period. The Psychiatry Consultation dated 10/21/2024 documented the resident felt unhappy, lonely, and had no primary support. Recommendations included for Social Services to discuss with the resident their nursing home options in Suffolk County and for the resident to receive behavior therapy or counseling. The Physician's Consult Review Note dated 10/22/2024, written by Nurse Practitioner #1, documented that they reviewed the Psychiatry Consultation dated 10/21/ 2024. Nurse Practitioner #1 rewrote all the recommendations made by the Psychiatrist in the Psychiatry Consultation dated 10/21/2024; however, did not document whether they agreed or disagreed with the recommendations. The physician's orders [REDACTED]. During an interview on 12/17/2024 at 5:00 PM, Nurse Practitioner #1 stated they were a remote (does not physically work in the facility) Medical Provider who only reviews the recommendations made by the Psychiatrist. Nurse Practitioner #1 stated they had strict instructions from their Supervisor to not write Physician Orders. Nurse Practitioner #1 stated the in-house Medical Providers are the ones to either agree or disagree with the recommendations made by the Psychiatrist. Nurse Practitioner #1 stated if an in-house Medical Provider agrees with the recommendations made by the Psychiatrist, they would be the one to place the physician's orders [REDACTED]. During an interview on 12/17/2024 at 5:25 PM, the resident's Primary Physician (Primary Physician #1) stated a remote Medical Provider can also enter physician's orders [REDACTED]. Primary Physician #1 stated that a resident can not receive behavioral (Psychological) counseling without a physician's orders [REDACTED].#93 to receive behavioral counseling. During an interview on 12/17/2024 at 6:00 PM, the Medical Director stated that whenever a Medical Provider, either remote or in-house, reviews a Psychiatry Consultation they are to document whether they agree or disagree with the recommendations. The Medical Director stated that the facility has remote Medical Providers to add an extra layer of supervision so that areas of concern related to the resident's medical care are not missed. The Medical Director stated Nurse Practitioner #1 should have referred the resident to Social Services to discuss their nursing home options in Suffolk County and should have also entered a physician's orders [REDACTED]. During an interview on 12/18/2024 at 10:00 AM, the resident stated they had lived in a group home prior to coming to live in this facility. The resident stated they wanted to be placed in a group home specifically in Suffolk County because they thought they could be placed in a facility faster in Suffolk County. The resident stated they received psychological services when they had lived in their group home and talked about their feelings, and thoughts, and could talk to someone about what was bothering them physically, emotionally, and mentally. 10 NYCRR 415. 15(b)(1)(i)(ii) | Plan of Correction: ApprovedJanuary 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 710 ÔÇ£ Physician Services The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: 1. Resident #93s choice to be transferred to another facility was initiated immediately upon notification and resident transferred to a Suffolk County placement. 2. Evaluation by the Social Worker and the Psychologist revealed no psychological harm sustained by resident as a result of this deficient practice. 3. The Attending Physician re-addressed the Psychiatrists recommendations dated 10/22/2024 by placing an order for [REDACTED]. 2024. 4. The Nurse Practitioner who failed to address the Psychiatrist consult dated 10/21/2024, was re-educated on 12/18/2024 that documented evidence is required in the medical record if there is agreement or disagreement with the consultants recommendation and if in agreement, same must be implemented. B) Identification of other Residents having the potential to be affected by the deficient practice: All residents with a Psychiatry consult have the potential to be affected by the deficient practice. The Medical Director will be responsible for conducting an audit of all recommendations made by the Psychiatrist for the past 6 months, to ensure that all recommendations made are reviewed and implemented if applicable; or that there is documented evidence if the physician disagreed with the recommendation. Any negative findings will be immediately corrected. C) Systemic Changes to ensure the deficient practice will not recur: b) The policy and procedure titled ?ôConsultation?Ø was reviewed and found to be in compliance. c) All onsite and offsite attending medical providers will be re-educated on the procedure of: a. Documenting their agreement with a consultants recommendation and implementing the physicians order; or b. Documenting their disagreement and documenting the reason for disagreement. d) Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Medical Director D) QA ÔÇ£ Monitor of the deficient practice: The Medical Director will have the responsibility of auditing 10% of Psychiatry consultations monthly to ensure there is documented evidence of the attending physician addressing any recommendations made. Any negative findings will be immediately corrected and reported to the QAPI committee. This audit will be completed monthly x 6 months. The Medical Director is responsible for the correction of this deficiency. Date of correction: 02/18/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2024
Corrected date: N/A
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 12/15/2024 and completed on 12/23/2024, the facility did not ensure that each resident had the right to participate in the development and implementation of their person-centered plan of care. This was identified for one (Resident #93) of four residents reviewed for Choices. Specifically, Resident #93, a cognitively intact resident with no known family or designated representative, was not invited to their Comprehensive Care Plan meeting. The finding is: The Care Planning-Interdisciplinary Team Policy and Procedure last reviewed in (MONTH) 2024 documented that the resident, the resident's family, and/or legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of day for the resident and family. The Care Plans, Comprehensive Person-Centered Policy and Procedure last reviewed in (MONTH) 2024, documented that the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care including, but not limited to, the right to participate in the planning process. Resident #93, who has no known family or designated representative, has [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 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 Minimum Data Set assessment documented Resident #93 was feeling down, depressed, hopeless, had trouble falling or staying asleep, had little energy, felt bad about themselves, and had trouble concentrating on things. The assessment documented Resident #93 received Antipsychotic and Antidepressant medications during the 7-day lookback period. The Social Services Progress Note dated 11/18/2024, written by Social Worker #1, documented the resident had no family contact and that the (Comprehensive Care Plan) meeting would convene with the Interdisciplinary Team. The Care Plan Meeting Progress Note dated 11/20/2024, written by Social Worker #1, documented the resident had no family contact and was not able to represent themselves due to periods of confusion. The Interdisciplinary Team members present were Social Worker #1 and a representative from Dietary. It was a quarterly care plan meeting. The resident's plan of care was reviewed and all concerns were addressed. Staff would continue to provide support to the resident, as they remained stable at this time. The resident would remain in the facility for long-term care. During an interview on 12/17/2024 at 12:30 PM, Social Worker #1 stated Resident 93's Brief Interview for Mental Status score was 13 (intact cognition); however, Social Worker #1 did not invite Resident #93 to their care plan meeting that was held on 11/20/2024 because the resident was confused at times. Social Worker #1 stated they should have visited the resident on the day of the care plan meeting to determine the resident's mental status and if the resident was able to participate in their care plan meeting that day. During an interview on 12/17/2024 at 1:50 PM, the Director of Social Services stated Resident #93 should have been invited to their care plan meeting to participate and discuss their wishes. During an interview on 12/17/2024 at 3:20 PM, the Administrator stated it is a resident's right to be invited to their care plan meeting especially if they are cognitively intact. During an interview on 12/18/2024 at 10:00 AM, Resident #93 stated they would like to be invited to participate in their care plan meetings. 10 NYCRR 415. 11(c)(2)(i-iii) | Plan of Correction: ApprovedJanuary 17, 2025 F 553 ÔÇ£ Right to participate In Plan of Care The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: a) An invitation was issued and Resident #93 participated in his person-centered plan of care on 12/18/ 2024. b) The Social Worker who failed to invite Resident #93 to participate in his care plan meeting, received educational disciplinary action on 01/13/ 2025. B) Identification of other Residents having the potential to be affected by the deficient practice: All cognitively intact residents without family or legal representative are at risk for this deficiency. A list was compiled of all current Residents who had a care plan meeting scheduled from the timeframe of (MONTH) 15, 2024 to (MONTH) 31, 2024. Utilizing this list, an audit was created and completed to ensure the Residents and/or their legal representative were invited to participate in their plan of care. Any negative findings were immediately corrected by issuing invitations and convening a care plan meeting. Person responsible: Assigned Unit Social Worker C) Systemic Changes to ensure the deficient practice will not recur: The ?ôCare Planning ÔÇ£ Interdisciplinary Team?Ø policy and procedure with a review date of 01/2025 was reviewed and found to be in compliance. All Social Workers responsible for the enforcement of issuing invitations and facilitating the care planning meetings will be re-educated on the facilitys policy and procedure regarding same. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Staff Educator D) QA ÔÇ£ Monitor of the deficient practice: The Director of Social Work will conduct audits of all residents scheduled for care planning to ensure that Residents and/or their representatives are invited to participate in the care planning process. Any negative findings will be immediately corrected and results of findings will be reported to the QAPI committee quarterly. This audit will be conducted weekly x 3 months then monthly x one year. The Director of Social Work is responsible for the correction of this deficiency. Date of correction: 02/18/2025 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2024
Corrected date: N/A
Citation Details Based on record review and interviews during the Recertification Survey initiated on 12/15/2024 and completed on 12/23/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for seven of seven units reviewed for the Sufficient Nursing Staffing Task. Specifically, 1) a review of the Payroll-Based Journal (PBJ) Staffing Data Report Quarter Three, 2024 (April 1- (MONTH) 30) indicated excessively low weekend staffing and One Star Staffing Rating 2) a review of the daily staffing sheets revealed the facility did not provide sufficient numbers of Certified Nursing Assistants as indicated in the Facility Assessment. This is a repeat deficiency. The finding is: The Payroll-Based Journal Staffing Data Report for Fiscal Year Quarter Three, 2024 (April 1- (MONTH) 30) indicated the facility triggered for excessively low weekend staffing and One Star Staffing Rating. The Facility Assessment, last updated (MONTH) 2024, documented the average daily census was 265-275 residents. The facility consisted of seven resident units. The Facility Assessment indicated staffing plan for the weekends as follows: -Unit 1 East: During the 7:00 AM-3:00 PM Shift there should be three Licensed Practical Nurses and five Certified Nursing Assistants available. During the 3:00 PM-11:00 PM shift there should be two Licensed Practical Nurses and four Certified Nursing Assistants available. During the 11:00 PM-7:00 AM shift there should be two Licensed Practical Nurses and three Certified Nursing Assistants available. -Unit 2 East: During the 7:00 AM-3:00 PM Shift there should be 2. 5 Licensed Practical Nurses and five Certified Nursing Assistants available. During the 3:00 PM-11:00 PM shift there should be 1. 5 Licensed Practical Nurses and four Certified Nursing Assistants available. During the 11:00 PM-7:00 AM shift there should be one Licensed Practical Nurses and two Certified Nursing Assistants available. -Unit 2 West: During the 7:00 AM-3:00 PM Shift there should be 2. 5 Licensed Practical Nurses and five Certified Nursing Assistants available. During the 3:00 PM-11:00 PM shift there should be 1. 5 Licensed Practical Nurses and four Certified Nursing Assistants available. During the 11:00 PM-7:00 AM shift there should be one Licensed Practical Nurses and two Certified Nursing Assistants available. -Unit 3 East: During the 7:00 AM-3:00 PM Shift there should be 2. 5 Licensed Practical Nurses and five Certified Nursing Assistants available. During the 3:00 PM-11:00 PM shift there should be two Licensed Practical Nurses and four Certified Nursing Assistants available. During the 11:00 PM-7:00 AM shift there should be 1. 5 Licensed Practical Nurses and three Certified Nursing Assistants available. Unit 3 West: During the 7:00 AM-3:00 PM Shift there should be 2. 5 Licensed Practical Nurses and five Certified Nursing Assistants available. During the 3:00 PM-11:00 PM shift there should be two Licensed Practical Nurses and four Certified Nursing Assistants available. During the 11:00 PM-7:00 AM shift there should be 1. 5 Licensed Practical Nurses and two Certified Nursing Assistants available. -Unit 4 East: During the 7:00 AM-3:00 PM Shift there should be 2. 5 Licensed Practical Nurses and five Certified Nursing Assistants available. During the 3:00 PM-11:00 PM shift there should be two Licensed Practical Nurses and four Certified Nursing Assistants available. During the 11:00 PM-7:00 AM shift there should be 1. 5 Licensed Practical Nurses and three Certified Nursing Assistants available. -Unit 4 West, the Dementia Unit: During the 7:00 AM-3:00 PM Shift there should be 2. 5 Licensed Practical Nurses and five Certified Nursing Assistants available. During the 3:00 PM-11:00 PM shift there should be two Licensed Practical Nurses and four Certified Nursing Assistants available. During the 11:00 PM-7:00 AM shift there should be 1. 5 Licensed Practical Nurses and three Certified Nursing Assistants available. A review of weekend staffing sheets for (MONTH) 2024 through (MONTH) 2024 and during the Recertification Survey the facility was had low staffing levels based on the numbers specified in the Facility Assessment. The staffing concerns were identified including but not limited to the following: During the 7:00 AM to 3:00 PM Shift: -Unit 1 East had one Licensed Practical Nurse assigned on 4/6/2024, 5/5/2024, 5/12/2024, 6/15/2024, and 6/23/ 2024. -Unit 2 East had one Licensed Practical Nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/15/2024, and 6/23/ 2024. -Unit 2 West had one Licensed Practical Nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, and 6/23/ 2024. -Unit 3 East had one Licensed Practical Nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/15/2024, and 6/23/ 2024. -Unit 3 West had one Licensed Practical Nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/25/2024, 6/1/2024, 6/2/2024, and 6/15/ 2024. -Unit 4 East had one Licensed Practical Nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 5/4/2024, 5/5/2024, 5/11/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/15/2024, and 6/23/ 2024. - Unit 4 west had one Licensed Practical Nurse assigned on 4/6/2024, 4/7/2024, 4/13/2024, 4/14/2024, 5/5/2024, 5/11/2024, 5/12/2024, 5/25/2024, 5/26/2024, 6/1/2024, 6/2/2024, 6/15/2024, and 6/23/ 2024. During the 7:00 AM to 3:00 PM Shift: -Unit 1 East had three Certified Nursing Assistants on 4/14/2024, -Unit 2 East had three Certified Nursing Assistants on 6/9/2024, -Unit 2 West had three Certified Nursing Assistants on 4/7/2024, 4/13/2024, 6/2/2024, 6/8/2024, -Unit 3 West had three Certified Nursing Assistants on 4/28/2024, 6/9/2024, -Unit 4 East had three Certified Nursing Assistants on 4/13/2024, 4/28/2024, 6/2/2024, - Unit 4 west had three Certified Nursing Assistants on 4/6/2024, During an interview on 12/23/2024 at 2:35 PM, the Staffing Coordinator stated the facility has staffing shortage on the weekends for a long time. The Staffing Coordinator stated the facility utilizes one agency; however, the staffing issues have not been resolved. The Staffing Coordinator stated they have informed both the Director of Nursing Services and the Director of Human Resources with no resolution. During an interview on 12/23/2024 at 2:53 PM, the Director of Nursing Services stated they were not familiar with the Payroll-Based Journal or that the facility triggered for the low weekend staffing on the Payroll-Based Journal. The Director of Nursing Services stated the Facility Assessment is updated by them and the Administrator. The Director of Nursing Services acknowledged the facility had staffing concerns on weekends because the facility has not been successful in hiring enough staff for the weekends despite their efforts and has been challenged with a high staffing turnover rate. During an interview on 12/23/2024 at 3:30 PM, the Administrator stated the facility is committed to meeting the staffing levels identified in the Facility Assessment; however, they have been unsuccessful in doing so at this time which because of difficulty in attracting and retaining nursing staff. 10 NYCRR 415. 13(a)(1)(i-iii) | Plan of Correction: ApprovedJanuary 24, 2025 F 725 ÔÇ£ Sufficient Staffing The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: Immediate corrective action of the discrepancy between staffing levels and the facility assessment could not be completed as the staffing levels for the time period of (MONTH) 1, 2024 through (MONTH) 30, 2024 cannot be altered. All Incident reports and grievance logs were reviewed for the time period of (MONTH) 1, 2024 through (MONTH) 30, 2024 to ascertain if there were any reports or grievances as a result of the alleged deficient practice. There were no residents identified as harmed or affected as a result of this deficient practice. B) Identification of other Residents having the potential to be affected by the deficient practice: All residents have the potential to be affected by the deficient practice. An audit tool will be created and a retrospective review (10% audit) will be completed reviewing the staffing levels of licensed nurses and certified nursing assistants for the months of (MONTH) 2024 through (MONTH) 2024 to determine any shifts of excessively low staffing in conjunction with the facility assessment. After identification, all incident reports and grievance logs for the same time period will be reviewed to ascertain if there were any reports or grievances as a result of the alleged deficient practice. The Facility Assessment will be reviewed and adjusted to reflect the actual staffing of the units for licensed nurses and certified nursing assistants. The Director of Nursing in conjunction with the Staff Scheduler will review staff levels weekly prior to the following work week to ensure adequate staffing levels on each unit based on acuity and facility needs. Person responsible: Director of Nursing C) Systemic Changes to ensure the deficient practice will not recur: The facility has implemented the following process in an effort to recruit staff especially Certified Nursing Assistants: - Agency contracts are in place - Staff members are offered overtime - Qualified walk-ins are hired immediately after the interview process with an emphasis towards weekend staffing levels - A full-time recruiter is on staff to assist the facility with staffing needs - The facility is offering sign-on bonus and referral bonus - The facility hosts job fairs and open houses - Staff are offered flexible schedules - The facility has a presence on social media and online advertising Person responsible: Administrator/Designee D) QA ÔÇ£ Monitor of the deficient practice: A 10% audit will be completed monthly x 6 months reviewing the staffing sheets to determine any shifts of excessively low staffing, specifically Certified Nursing Assistants. Any negative findings will be presented to QAPI to determine further discuss specific reasons and corrective measures relative to nursing staffing needs, especially with Certified Nursing Assistants. The Director of Nursing is responsible for the correction of this deficiency. Date of correction: 02/18/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification Survey completed on 12/23/2024, the facility did not ensure that residents received proper assistive devices to maintain hearing abilities. This was identified for one (Resident #59) of two residents reviewed for Communication. Specifically, Resident #59, with highly impaired hearing had a physician's orders [REDACTED]. The facility staff did not recharge the hearing aids consequently Resident #59 was not able to use the hearing aids to effectively communicate with staff and peers. The finding is: The facility's Policy titled Hearing Aid; Rechargeable Type dated 1/2024 documented guidelines including: storing the resident's hearing aids in the charger, away from direct sunlight or very warm temperatures when not in use. Check specific manufacturer's instructions for care of the hearing aid and charger. It is recommended to charge the hearing aids every night. Resident #59 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderately impaired cognition. The Minimum Data Set (MDS) documented the resident had highly impaired hearing and utilized a hearing aid. The physician's orders [REDACTED]. Place the hearing aids in both ears in the Morning (AM). The Medication and Treatment Administration record for (MONTH) 2024 to (MONTH) 2024 did not indicate the resident was provided with their hearing aids every day, and that the hearing aids were recharged as per the physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) for Hearing Deficit/Hearing Loss dated 6/19/2024 and revised on 8/22/2024 documented the resident will wear hearing aids as indicated. The interventions included but were not limited to anticipating resident needs and applying the hearing aid ( left/right) and care of the hearing aids. During an observation on 12/15/2024 at 10:58 AM, Resident#59 was observed sitting in a wheelchair in the hallway without the hearing aids. Resident#59's family member was observed reporting to Registered Nurse #3 that Resident#59 often did not have their hearing aids on. During an interview on 12/15/2024 at 11:10 AM, Resident#59's family member stated they regularly visited the resident and found them without their hearing aids and always notified the staff that the resident did not have their hearing aids on. During an interview on 12/15/2024 at 11:15 AM, Resident #59 stated the staff do not give them their hearing aids often. Resident #59 stated it was difficult to communicate without their hearing aids. During an interview on 12/15/2024 at 11:30 AM, Registered Nurse Unit Manager #3 stated the overnight nurses were supposed to recharge the hearing aids. Licensed Practical Nurse #8, the overnight nurse, forgot to recharge the resident's hearing aids. Registered Nurse Unit Manager#3 stated they realized that the physician's orders [REDACTED].# 59. During an interview on 12/20/2024 at 8:00 AM, Licensed Practical Nurse #8 stated they were the overnight nurse assigned to Resident # 59. Licensed Practical Nurse #8 stated they never recharged Resident #59's hearing aids because the Medication or the Treatment Administration Record did not indicate the physician's orders [REDACTED]. During an interview on 12/20/2024 at 11:00 AM, the Director of Nursing Services stated Resident #59 had a physician's orders [REDACTED]. The Director of Nursing Services stated for some unexplained technical issues, the order for the hearing aids did not get transcribed onto either the Treatment Administration Record or Medication Administration Record. The Director of Nursing Services stated the nurses should have charged the hearing aids and placed the hearing aids on the resident as per the physician's orders [REDACTED]. 415. 12(a)(3)(b)(1-3) | Plan of Correction: ApprovedJanuary 17, 2025 F 685 ÔÇ£ Device to Maintain Hearing The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: a) For Resident #59 ÔÇ£ the hearing aids were immediately charged and inserted for use on 12/15/ 2024. b) The Treatment Administration Record (TAR) was updated to include the application and removal of the hearing aids as well as placing them to charge at hour of sleep. B) Identification of other Residents having the potential to be affected by the deficient practice: All residents with hearing aides have the potential to be affected by this deficient practice. An immediate audit was conducted of all residents utilizing hearing aids to ensure they were charged or in place. There were no negative findings. An audit tool was developed to identify all Residents with a hearing device and type. Utilizing this list, the Unit Manager will ensure the following: a) A physicians order is in place that includes the application, removal and charging of device, if applicable. b) The Treatment Administration Record (TAR) is updated to reflect the physicians order. c) The care plan and CNA task is updated to reflect same. C) Systemic Changes to ensure the deficient practice will not recur: The facilitys policy and procedure titled ?ôHearing Aid: Rechargeable Type?Ø was reviewed and found to be in compliance. All licensed nursing staff will be educated regarding the policy ?ôHearing Aid: Rechargeable Type?Ø, in addition to how to transcribe the order in the Treatment Administration Record. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Staff Educator D) QA ÔÇ£ Monitor of the deficient practice: The Nurse Managers/Designee will have the responsibility of auditing all residents with a rechargeable hearing aid on a daily basis x 1 week; then weekly x 3 months; to ascertain compliance with this policy. Any negative findings will be reported to the Assistant Director of Nursing for follow up and report to the QAPI committee. The Assistant Director of Nursing is responsible for the correction of this deficiency. Date of correction: 02/18/2025 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2024
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 1. 6 Minimum Construction Requirements. 19. 1. 6. 1 Health care occupancies shall be limited to the building construction types specified in Table 19. 1. 6. 1, unless otherwise permitted by 19. 1. 6. 2 through 19. 1. 6. 7. (See 8. 2. 1. ) Life Safety Code Section 19. 1. 6 and Table 19. 1. 6. 1 limit the height of buildings that are built of unprotected non-combustible construction (i.e., NFPA 220 Type II (000) building construction) to only two stories with a complete automatic sprinkler system. 2012 NFPA 220: 4. 1 General. (5000: 7. 2. 1) 4. 1. 1* Buildings and structures shall be classified according to their type of construction, which shall be based upon one of five basic types of construction designated as Type I, Type II, Type III, Type IV, and Type V, with fire resistance ratings not less than those specified in Table 4. 1. 1 and Sections 4. 3 through 4. 6 and with fire resistance ratings meeting the requirements of Chapter 5. (5000: 7. 2. 1. 1) Based on observation and staff interview, during the recertification survey the facility did not ensure that the ceiling assembly was maintained to provide at least a two-hour fire resistance barrier on 4 of 4 resident floors. The findings are: During the Life Safety inspections on 12/16/2024, 12/17/2024 and on 12/18/2024 between 9:00am and 2:30pm the following was noted: On 12/18/2024 at 10:00am, the facility's Life Safety Director provided documentation from a ceiling tile manufacturer indicating that the facility is provided with a UL listed (UL Type FR-83) two-hour fire resistive ceiling tile assembly. Multiple observations during the survey revealed unsealed openings around electrical wires and conduits of the ceiling assemblies within the electrical closets on all the nursing units. In an interview on 12/16/2024 the facility's Life Safety Director stated that all the ceiling openings around the wires and conduits would be sealed with the appropriate fire stopping material. 2012 NFPA 101: 10NYCRR 711. 2(a)(1) 10 NYCRR 415. 29 | Plan of Correction: ApprovedJanuary 17, 2025 K 161 ÔÇ£ Building Construction Type and Height The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: No residents were affected by the deficient practice. The Medical Director is in agreement that there was no additional risk to residents. The facility corrected the deficiency by sealing the openings with fire stopping material around the electrical wires and conduits of the ceiling assemblies within the electrical closets on all nursing units. 01/09/2025 B) Identification of other Residents having the potential to be affected by the deficient practice: All residents have the potential to be affected by the deficient practice. Review of incident reports revealed no issues as a direct effect of the above-mentioned deficiency. A full house audit will be completed to ensure that all ceiling assemblies are free of unsealed openings. Person responsible: Director of Maintenance/ Designee C) Systemic Changes to ensure the deficient practice will not recur: The Nurse Educator will Inservice all facility maintenance staff regarding the following: - all fire rated ceiling tiles and assemblies are to be free of unsealed openings; and - unsealed openings are to be sealed with appropriate fire stopping material. - Education will be verified by posttests or return demonstration to ensure education retention. D) QA ÔÇ£ Monitor of the deficient practice: Audit tool created to inspect ceiling tiles and assemblies for unsealed openings. An audit will be completed monthly to inspect 10% of ceiling tiles and assemblies to ensure areas are free of unsealed openings. Any negative findings will be immediately corrected and presented at QAPI quarterly. Audits will be completed monthly x 6 months. The Director of Maintenance is responsible for the correction of this deficiency. Date of correction: 02/18/2025 |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 23, 2024
Corrected date: N/A
Citation Details 2012 Life Safety Code 101 7. 8 Illumination of Means of Egress. 7. 8. 1. 2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided in 7. 8. 1. 2. 2 7. 9 Emergency Lighting 7. 9. 2. 3* The emergency lighting system shall be arranged to provide required illumination automatically in the event of any interruption of normal lighting due to the following: (1) Failure of a public utility or other outside electrical power supply (2) Openings of a circuit breaker or fuse (3) Manual act(s), including accidental openings of a switch controlling normal lighting facilities. Based on observation and staff interview during the recertification survey, the facility did not ensure that illumination of egress in general resident congregation spaces were installed to prevent manual switch controlling the lighting on 4 of 4 resident floors. The findings are: During the Life Safety inspections on 12/16/2024 and on 12/17/2024 between 9:00am and 2:30pm it was noted that the lighting within resident lounges on all nursing units and in the chapel were controlled by manual light switches that completely turned off all the lights. In an interview on 12/17/2024 at 2:00pm the facility's Life Safety Director stated that the light switches would be reconfigured so that they don't turn off all the lighting in the identified areas. 2012 NFPA 101: 10NYCRR 711. 2(a)(1) 10 NYCRR 415. 29 | Plan of Correction: ApprovedJanuary 17, 2025 K 281 ÔÇ£ Illumination of Means of Egress The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. Immediate Corrective Action for Resident found to be affected by the deficient practice: No residents were affected by the deficient practice. The Medical Director is in agreement that there was no additional risk to residents. The facility corrected the deficiency by reconfiguring the light switches to prevent all lighting being completely turned off within resident lounges on all nursing units and the chapel. 01/17/2025 B) Identification of other Residents having the potential to be affected by the deficient practice: All residents have the potential to be affected by the deficient practice. Review of incident reports revealed no issues as a direct effect of the above-mentioned deficiency. A full house audit will be completed to ensure that other resident congregation spaces have light switches preventing all lighting being turned completely off. Person responsible: Director of Maintenance C) Systemic Changes to ensure the deficient practice will not recur: The Nurse Educator will Inservice all facility maintenance staff that all resident congregant spaces must have lighting that are not controlled by manual switches. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Nurse Educator QA ÔÇ£ Monitor of the deficient practice: Audit tool created to inspect all resident congregant spaces to ensure configuration of light switches to allow illumination of means of egress at all times. This audit will be completed monthly x 3 months and presented to QAPI quarterly. Director of Maintenance is responsible for the correction of this deficiency. Date of correction: 02/18/2025 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2024
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |