NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 29, 2025
Corrected date: March 17, 2025
Citation Details Based on Document review and staff interview, the facility did not conduct any drills to test emergency preparedness. The findings include: During document review on 3/4/25, between 10: 00 am and 12:00 pm, the facility's emergency preparedness policy and procedures did not include documentation of emergency drills conducted within the last 12 months. The Director of Maintenance stated that no drills were conducted during this time. | Plan of Correction: ApprovedFebruary 11, 2025 F689: Free of Accidents, Hazards, Supervision, Devices I. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 had a pain assessment completed on 1/31/25 which indicated he did not have any pain. Resident #1 receives a pain screen completed every shift and has PRN APAP ordered that can be administered if needed. Resident #3 is non-ambulatory, requires extensive assistance from staff for ADL care/mobility (since last readmission on 12/17/24), and is no longer an elopement risk. His elopement assessment was updated on 1/31/25, along with his comprehensive care plan to reflect the changes in his medical status and low elopement risk. II. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the same deficient practice. Specific to resident #1, a work call was placed to Otis to have the elevator sensors inspected and cleaned, which was completed on 1/15/ 2025. House-wide education is in progress for all staff on reporting accidents and incidents through the appropriate chain of command, ensuring notification is made to the highest-level supervisor in the facility. Nursing Supervisors have been re-educated to immediately notify the Director of Support Services, or designee, via phone and email if an accident/incident occurs involving equipment that is not maintained by nursing. Specific to resident #3, all locked housekeeping closet doors have been checked, with no other striker plates found to be loose or otherwise malfunctioning, which could lead to recurrence. III. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? Routine maintenance/cleaning of the elevator sensors have been added to the Otis monthly preventative maintenance schedule. Incident and Accident Reports (I&As) are discussed the business day following the occurrence during the Interdisciplinary Team (IDT) morning meeting/clinical meeting. This ensures that follow-up has been communicated and completed. The Director of Nursing Services will complete an audit weekly for 12 weeks of all I&As to ensure no follow-up is omitted or missed during the IDT's review. Results will be presented to the QAPI committee monthly. The Director of Support Services, or designee will conduct audits twice daily to ensure locked housekeeping closets are secure and no other striker plates were loose, malfunctioning, or presented danger to residents. These audits will be completed for a period of at least 90 days post incident, seven days a week. Results will be presented to the QAPI committee monthly. Education is in progress with all nursing staff on Incident & Accident notification process for significant occurrences. This training will also be included in new care member orientation for all new staff. IV. How will corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? Results of the locked housekeeping door audit and the I&A audit are given to the Director of Support Services and Director of Nursing Services, respectively, for review, and are also presented to the QAPI committee monthly. The QAPI committee will determine when substantial compliance has been achieved, and when the audits can be discontinued, frequency changed, or if they should continue as currently scheduled. V. The date for correction and the title of the person responsible for correction of each deficiency? Date Certain - 3/17/2025 Person Responsible - Director of Support Services |