Ferncliff Nursing Home Co Inc
September 12, 2017 Certification Survey

Standard Health Citations

FF10 483.25(e)(1)-(3):NO CATHETER, PREVENT UTI, RESTORE BLADDER

REGULATION: (e) Incontinence. (1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. (2)For a resident with urinary incontinence, based on the resident?s comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident?s clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident?s clinical condition demonstrates that catheterization is necessary and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. (3) For a resident with fecal incontinence, based on the resident?s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 12, 2017
Corrected date: November 6, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and interview conducted during a recertification survey, the facility did not ensure that 1 of 3 residents (#38) reviewed for urinary incontinence was provided the necessary services to decrease incidents of urinary incontinence. Specifically, measures were not put into place to assist the resident regain or improve as much bladder function to the extent possible, following decline in urinary continency level. The findings are: Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a comprehensive resident assessment tool) dated 7/27/17 showed that the resident had severe cognitive impairment, was frequently incontinent of urine (defined in MDS as 7 or more episodes of urinary incontinence, but at least one episode of continent voiding in a week), was wheelchair bound, and required extensive assistance of two people in toileting. There was no documented evidence that a care plan to address the decline in urinary incontinence was developed at that time. The resident sustained [REDACTED]. On 8/1/17 a readmission care plan was developed which noted that the resident was incontinent of bowel and bladder. This was consistent with the readmission MDS dated [DATE], which showed that the resident was always incontinent of urine (defined in MDS as no episodes of continent voiding). The care plan did not state specific goal and interventions to attempt to decrease the urinary incontinence. The nurse aide care guide noted that the resident was being toileted and did not indicate frequency and instructions to prompt the resident to void on a specific schedule based on assessment of the resident's assessed voiding pattern. The unit Registered Nurse (RN) manager was interviewed on 9/12/17 at 1:40 PM regarding the lack of interventions to attempt to improve or regain the resident's usual level of urinary continence. The RN unit manager reviewed the care plan and the nurse aide care guide with the surveyor and stated that based on the instruction on the care guide, the aides were to toilet the resident and that the frequency for toileting was not indicated. The Certified Nurse Aide assigned to the resident on the day shift was interviewed on 9/12/17 at 1:47 PM and stated that the resident was not on a toileting schedule that prompted her to void. The MDS Registered Nurse was interviewed on 9/12/17 at 2:05 PM via telephone and stated that based on an incontinence assessment done on 8/3/17 it was determined that the resident's incontinence was related to her to cognition. She further stated that the resident was not a candidate for retraining program but was a candidate for being on a toileting schedule. 415.12(d)(2)

Plan of Correction: ApprovedSeptember 27, 2017

I. Corrective Action for Affected Residents:
For Resident #38
The care plan and nurse aide care guide were updated to reflect the decline in urinary incontinence.
The resident was put on a new toileting schedule.
09/20/17
II. Identify Other Residents Potentially Affected:
All residents that have had a decline in urinary incontinence have the potential to be affected in the same manner.
An audit was completed for all residents that have had a decline in urinary incontinence to ensure that:
1. The care plan reflects the decline in urinary incontinence and
2. Measures were put in place to assist the resident regain or improve as much bladder function to the extent possible, following a decline in urinary continence level.
Any issues identified were immediately corrected.
10/15/17
III. Systemic Changes and Measures to Prevent Recurrence:

The Director of Nursing reviewed the policy/procedure regarding urinary incontinence and determined that no revisions were needed.
All nursing staff were re-educated on the existing urinary incontinence policy/procedure with a focus on ensuring that:
1. The care plan reflects any decline in urinary incontinence.
2. Measures were put in place to assist the resident regain or improve as much bladder function to the extent possible, following a decline in urinary continence level.
10/15/17
IV. QA for Monitoring Corrective Action
The Director of Nursing will develop an audit tool to verify that:
1. The care plan reflects any decline in urinary incontinence and
2. Measures were put in place to assist the resident regain or improve as much bladder function to the extent possible, following a decline in urinary continence level.
Audits will be performed by the Director of Nursing or designee monthly for three months. Any findings noted will be reported immediately to the Administrator and QA Committee for tracking and trending.
Audit findings will be presented to QA committee monthly for three months. The need and frequency of audit will be evaluated thereafter.

11/01/17
Person Responsible - Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:GAS AND VACUUM PIPED SYSTEMS - WARNING SYSTEM

REGULATION: Gas and Vacuum Piped Systems - Warning Systems All master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate Category warning system requirements, as applicable. 5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 12, 2017
Corrected date: November 6, 2017

Citation Details

2012 NFPA 99 Health Care Facilities Code 5.1.9.2 Master Alarms. A master alarm system shall be provided to monitor the operation and condition of the source of supply, the reserve source (if any), and the pressure in the main lines of each medical gas and vacuum piping system. 5.1.9.2.1 The master alarm system shall consist of two or more alarm panels located in at least two separate locations, as follows: (1) One master alarm panel shall be located in the office or work space of the on-site individual responsible for the maintenance of the medical gas vacuum piping systems. (2) In order to ensure continuous surveillance of the medical gas and vacuum systems while the facility is in operation, the second master alarm panel shall be located in an area of continuous observation (e.g., the telephone switchboard, security office, or other continuously staffed location). Based on observation, interview and record review, it was determined that the facility did not ensure that a master alarm panel for the piped in oxygen system was located in an area of continuous observation. This was evidenced by two of two master alarm panels located in areas of continuous operation (an unoccupied mail room on the lobby level and the Director of Plant Operations and Management office). The findings are: On 9/11/17 during the life safety tour of the nursing units conducted between 9:00 AM - 2:00 PM during the recertification survey, it was observed that a piped in oxygen system is installed in the building. The mailroom located in the vicinity of the main lobby was toured at approximately 2:30 PM the same day. At that time, an alarm panel labeled 'Medical Gas Alarm - Normal and Abnormal' was observed to be installed in the room. The room was unoccupied at the time of the tour. Alarms stating Oxygen secondary supply in use and Oxygen reserve in use were indicated under the 'Abnormal' column on the panel. A list provided by the Administrator the next day (9/12/17) confirmed that 18 residents received oxygen via the piped in oxygen system. In an interview at the time of the tour, the Engineering Department staff member accompanying this surveyor stated that the facility is in the process of changing one of the liquid oxygen tanks located in the basement. A tour of the basement liquid oxygen storage room was conducted at 2:40 PM on 9/11/17. The indicator panel in the room confirmed that the left tank was in use (green light indicated), while the 2nd tank was 'low, empty' (red light). In an interview at the time of the observation, the Engineering Department staff member stated that when one tank is low or empty, the second, or reserve tank will automatically take over when the other tank is empty, or low. He also said that the empty tank would be replaced immediately. The oxygen storage room was revisited with the Administrator and the Director of Plant Operations and Management (Engineering) at 4:00 PM on 9/11/17 and the indicator panels were in normal mode, indicating that the left bank was 'ready for use', while the right bank was 'in use'. In an interview at that time, the Director of Plant Operations and Management stated that the Engineering Department orders replacement oxygen tanks three times per week (Monday, Wednesday, and Friday) that are delivered the following day. He further stated that two members of his department that had been trained by him have the responsibility for switching out the tanks. The Director also stated that there is no documentation of the training provided to the staff responsible, or for switching the tanks and checking the alarm panels, as these are everyday routine tasks. The last medical gas system annual testing and inspection report, dated 10/17/2016, was reviewed on 9/12/17 at approximately 2:45 PM, dated 10/17/2016. The report indicated that the master alarm panel for the piped in oxygen system was not located in a . suitable location to ensure continuous observation, an area of 24-hour surveillance. 10NYCRR 711.2(a)(1) 2012 NFPA 101 - 19.3.2.4 2012 NFPA 99 - 5.1.9.2.1

Plan of Correction: ApprovedSeptember 27, 2017

I. Corrective Action for Affected Area
The facility will be eliminating the piped in oxygen system.
10/31/17
II. Identify Other Areas Potentially Affected:
All residents receiving piped in oxygen have the potential to be affected by the facility not having the oxygen main panel in an area monitored 24/7.

III. Systemic Changes and Measure to Prevent Recurrence:
The policy and procedure regarding piped in oxygen was discontinued. A new oxygen use policy was created to note that oxygen is now only provided by concentrators and cylinders.
All resident room oxygen wall regulators will be covered to eliminate possible usage.
10/31/17
All Engineering and licensed Nursing Staff will be educated on the discontinued piped-in oxygen policy and the new oxygen use policy and procedure.
10/15/17

IV. QA Monitoring:
The Director of Support Services will develop an audit tool to verify that Nursing and Engineering staff are adhering to new oxygen use policy. The audit will include random checks of wall regulators to insure that the covers are intact.
Audits will be performed by the Director of Support Services or designee monthly. Any findings noted will be addressed immediately and reported to Administrator and QA Committee for tracking and trending.
Audit findings will be reported to the QA committee monthly for three months. The need and frequency of the audit will be evaluated thereafter.

11/01/17

Person Responsible ? Director of Support Services

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 12, 2017
Corrected date: November 6, 2017

Citation Details

Based on observation and interview, the facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating and were constructed in accordance with 8.3, in that unsealed penetrations, exposed mineral wool, and fire stop material of an unknown rating were noted on 4 of 4 resident sleeping floors examined (floors 2-5). The findings are: On 9/12/2017 during life safety rounds conducted between 12:30 PM and 2:00 PM during the recertification survey, smoke barrier walls were examined on floors 2 - 5 (resident sleeping floors) and the following was noted: 5th floor: - 5B unit, wall above barrier doors into dining room, near room #5023 and barrier doors near room #5026 - One small penetration each noted around white cables. 4th floor: - 4B unit, wall above barrier doors into dining room - One approximately 1 in. diameter penetration noted in the conduit containing blue and white cables, 1 small penetration around 2 blue cables, and exposed mineral wool noted along entire upper edge of wall/ceiling junction. - Wall above barrier doors near room #4046 - Expandable orange foam of an unknown fire rating noted filling penetrations. - Corridor wall above 4th floor Stair 3 exit door - Expandable orange foam of an unknown fire rating filling penetrations in the wall. 3rd floor: - 3B unit, wall above barrier doors into dining room - Exposed mineral wool filling space between wall/ceiling junction. - Barrier wall near room #3027 - 3 small penetrations noted, including around cables. - 3A unit, wall above dining room doors - one unsealed 1 diameter conduit, and yellow foam in place. - 2nd floor: -Wall above barrier doors near room #2062 - penetration measuring approximately 1 by 2 noted around blue cable and string. - Wall above barrier doors near room #2033- missing section of sheetrock measuring approximately 3 by 6. In an interview at 12:30 PM the same day, the Director of Plant Operations and Maintenance stated that a vendor must have installed the cables, which are probably for a speaker or work being done on the staff door fobs. He also stated that the facility only uses red fire stop in block form or caulk form, and that a vendor must have applied the foam. 2012 NFPA 101: 19.3.7.3 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedSeptember 27, 2017

I. Corrective Action for Affected Areas:
The identified areas have been repaired with approved UL fire stop material by the engineering department. These areas include the following locations; above 3A, 3B, 4B, and 5B dining room doors, above barrier doors near 4046, 5026, and above 4th floor Stair 3 exit door, near rooms 2033, 2062, 3027, and 5023
09/29/17
II. Identify Other Areas Potentially Affected:
All smoke barriers have the potential to be affected by facility not ensuring that smoke barrier penetrations were fire stopped.
The Engineering Supervisor and maintenance staff conducted rounds of all other smoke barriers throughout the facility to determine if further penetrations exist. No smoke barrier penetrations were found during their rounds.
09/29/17
III. Systemic Changes and Measures to Prevent Recurrence:
The Director of Support Services will insure that all contracted/maintenance work that involves smoke barriers has been performed to meet Life Safety Code requirements. A work log will be implemented and utilized by the Director of Support Services for verifying any work that may include penetrations. All vendors will sign the facilities Rules and Regulations which includes the section on fire stopping all penetrations created. The Director of Support Services or Designee will visually inspect any penetrations created to insure they were fire stopped appropriately.
10/01/17
The Director of Support Services and Administrator reviewed the policy/procedure regarding smoke barrier penetrations and revised the policy to note the process for inspecting and fire stopping all smoke barrier penetrations. A Monthly Preventive Maintenance (PM) program to inspect, address and correct all new findings immediately will be initiated. This will be performed by the Engineering Department and verified by the Engineering Supervisor. The PM?s will be performed one floor per month on a rotating schedule throughout the facility. PM includes; performing checks for smoke barrier penetrations, and repairing during scheduled frequencies. Engineering will be educated on revised policy
10/01/17
IV. QA for Monitoring Corrective Action
The Director of Support services will develop an audit tool to verify that all penetrations created by vendors during the month were reviewed and inspected to ensure they were properly repaired and fire stopped.
Audits will be performed by the Director of Support Services monthly. Any findings noted will be repaired immediately and reported to the Administrator and QA Committee for tracking and trending.
Audit findings will be presented to QA committee monthly for three months. The need and frequency of audit will be evaluated thereafter.

11/01/17
Person Responsible - Director of Support Services