St Johns Health Care Corporation
February 15, 2017 Complaint Survey

Standard Health Citations

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 15, 2017
Corrected date: April 27, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during an Abbreviated Survey (complaints #NY 364, #NY 653, #NY 247, and #NY 445), completed on 2/15/17, it was determined that for 1 of 6 residents reviewed for care plan implementation related to accidents and 1 of 19 residents reviewed for care plan implementation related to abuse, neglect, and mistreatment, the facility did not provide services in accordance with the written plan of care. Specifically, Resident #25's call bell was out of reach and the floor mat was not in use, and Resident #26 was not wearing arm protectors. This is evidenced by the following: 1. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment, dated 2/7/17, documented that the resident has severe impairment of cognitive function, does not ambulate, and requires extensive assist of staff for dressing and transfers. The Nursing Care Plan, dated as last revised on 2/6/17, includes that the resident has a potential to fall related to advancing dementia, unsteady gait secondary to a left foot amputation, and a history of falls. Approaches to prevent falls include, but are not limited to, bring the resident to the nursing area when out of bed, to lock the wheelchair brakes when in her wheelchair, to assist to a recliner (legs elevated) or bed after meals as desired, a tilt in space wheelchair when out of bed, and when sitting at the dining room table magazines to look at as accepted. Additionally, under pressure ulcers it includes to encourage the use of arm protectors as accepted due to behaviors of hitting the table and chairs with her arms. Review of Incident and Accident Reports for the past month included the following: a. On 1/12/17, the resident was found on the floor in her room, having fallen out of her wheelchair, sustaining a bump on the forehead. The investigation/follow-up summary concluded that the resident fell face first out of her wheelchair. A tilt and space wheelchair was obtained to decrease the resident leaning forward and falling out, and to encourage naps in recliner or bed after meals as resident accepts. b. On 1/30/17, the resident was noted to have a reddish purple bruise on her left wrist with [DIAGNOSES REDACTED] (redness of the skin often caused by an injury) measuring 5 centimeters (cm) x 3 cm of unknown cause. The resident was nonverbal and unable to report how it happened. A summary, dated 1/31/17, includes that the resident has a history of being combative with care and banging her hands on the table repeatedly. The resident's care plan was under review for safety and protection from injury. The care plan was revised on 2/6/17 following this incident to apply arm protectors as accepted. c. On 2/10/17, the resident sustained [REDACTED]. There is no documentation regarding arm protectors in the investigation or any witness statement. During an observation on 2/7/17, from 10:15 a.m. to 11:00 a.m. (after breakfast), the resident was in the dining room, in a tilt in space wheelchair that was not reclined, brakes were not locked, and the resident was pushing away from the table back and forth several feet repeatedly. There was not consistent supervision in the dining room throughout the observation. There were no magazines (or anything) on the table for the resident to engage in, and she was not wearing arm protectors leaving both wrists bare. When observed on 2/15/17 at 1:00 p.m., the resident was again sitting at a dining room table calmly visiting with family. She was not wearing arm protectors. Interviews conducted on 2/7/17 included the following: a. At 10:20 a.m., at 11:00 a.m., and again on 2/15/17 at 12:50 p.m., the Registered Nurse/Neighborhood Administrator (RN/NA) stated that the resident bangs her hands/arms on the table when agitated. She said the resident should wear arm protectors as she will allow. She said that the resident's brakes looked locked, but they were not fully engaged and should have been. She said that the arm protectors were ordered on [DATE] and are not available yet. The RN/NA said she was on vacation the week before and no one ordered the arm protectors after the 1/30/17 incident. She said that she expects staff to follow the care plan (i.e., move to a recliner and give her something to hold or do). She said if the resident becomes agitated or refuses, she should be notified. At that time, the resident's brakes were locked and she was given a stuffed animal to hold to decrease agitation. When observed on 2/15/17 without arm protectors, the RN/NA stated that the resident did have them after the first incident but now they cannot be found and she has to reorder them. She said the facility keeps the arm protectors in stock and can get them within a day. She said the resident should have the arm protectors. The RN/NA said the resident probably would not have obtained a skin tear (2/10/17) if she had the arm protectors in place. b. At 10:35 a.m., the Certified Nursing Assistant (CNA) stated that she did not have any arm protectors to put on the resident. The CNA added that the resident does not refuse care but can get agitated with cares sometimes and needs to be calmed down. When asked if the resident got agitated that day, the CNA stated, No. The CNA said she was not aware that the resident's brakes were unlocked. She does not know why the resident was left in the dining room (as opposed to moving to a recliner after meals). 2. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS Assessment, dated 2/6/17, documented that the resident has moderately impaired cognitive function, requires extensive assist of staff for toileting and transfers, and has a history of falls. The Nursing Care Plan, dated 10/21/16, includes that the resident has a potential for falls. Approaches include, but are not limited to, keeping the bed in a low locked position, and placing a floor mat next to the bed while the resident is sleeping was added on 12/23/16. Review of Incident/Accident Reports, dated 11/11/16, 11/18/16, and 12/23/16, revealed that the resident slipped or rolled out of bed onto the floor. On the 12/23/16 incident the resident sustained [REDACTED]. In an observation on 2/6/17 at 2:10 p.m., the resident was sitting in her room in a wheelchair. The nursing call bell was under the bed several feet away. The resident stated that she is supposed to use the call bell when she has to use the toilet but cannot find it. The resident was very soft spoken and there was no staff in the hallway or in the nearby living room at that time. The surveyor stayed with the resident approximately 10 minutes until a staff member walked by. When interviewed at that time, the Licensed Practical Nurse stated that the resident will use her call bell but she could not reach it on the floor and added that all the staff were at an emergency. When observed on 2/15/17 at 10:30 a.m., the resident was in bed, the bed was elevated approximately 4 feet from the floor, and the floor mat was leaning against the wall. The resident's call bell was along the top of the mattress, well out of the resident's reach. When asked if she could find her call bell, the resident stated, No, I haven't been able to find it this morning. When notified and interviewed at that time, the CNA stated that the resident will call when she is ready to get up or when she has to use the toilet. The CNA observed the call bell and stated the resident could not reach the call bell but she could yell. When interviewed on 2/15/17 at 10:45 a.m., the Registered Nurse Leader stated that the call bell should be in reach at all times, and that the fall mat should be down anytime the resident is in bed. (10 NYCRR 415.11(c)(3)(ii))

Plan of Correction: ApprovedMarch 6, 2017

1. The call bell was placed in reach and the floor mat was placed on the floor for Resident #25. The arm protectors were placed on Resident #26. Responsible: Assistant Director of Nursing
2. All kardexes and care plans were reviewed for floor mats and arm protectors. A full house audit was completed to assure that they were in use for those who require them. A full house audit was completed on call bells being within reach. Responsible: Assistant Director of Nursing
3. The policy and procedure for Nursing Care Planning was reviewed and revised. A new system of kardex use was instituted as of 3/1/16. The Standards of Care were reviewed for call light placement. All nursing staff are being inserviced on the use of assistive devices as required, and on call light placement being within reach of the residents. Responsible: Assistant Director of Nursing
4. Audits of the use of floor mats and arm protectors as indicated on the kardex will continue to be completed monthly. Audits of call light placement will be completed monthly. Audit results are reported to the QAPI committee for review and follow up if indicated. Responsible: Assistant Director of Nursing