Alice Hyde Medical Center

Based on medical record review and staff interview during the standard recertification survey, the facility did not ensure that residents and/or designated representatives were informed, both orally and in writing, about the right to formulate advance directives at the time of admission, and periodically during the resident's stay for eight (#s 2, 19, 26, 38, 39, 45, 51, and 68) of fifteen residents. Specifically, the facility did not operationalize their advance directive policy to ensure accurate documentation on the physician's order. Additionally, the facility did not follow-up to resident discussions on resuscitative status in a timely manner. This resulted in no actual harm with the potential for more than minimal harm that was not immediate jeopardy. This was evidenced by:

1. Resident #2
The resident was admitted to the facility on 6/28/1998 with diagnoses of quadriplegia, chronic obstructive pulmonary disease, and anemia. The Minimum Data Set (MDS) dated 7/28/10 assessed the resident as having intact long term and short term memory and as having independent decision making skills. It also assessed the resident as not having DNR documentation in the medical record.

During the initial unit tour interview on 10/25/10 at 12:30 pm, the surveyor was informed by the Registered Nurse Unit Manager (RNUM) that the resident was of full code/cardiopulmonary resuscitative (CPR) status.

A Plan of Care titled, Identify Presence of Advanced Directives was dated as having been initiated on 7/28/03. It documented that the resident had a Health Care Proxy, but had no documented evidence to show that the resident's resuscitative status was periodically discussed and reviewed by the facility, with the resident to determine if his wish was to remain of full code/cardiopulmonary resuscitative status.

Interdisciplinary Conference Summaries dated 5/12/10, 8/14/10, and 10/27/10 had no documented evidence to show that resuscitative status options had been specifically discussed and reviewed with the resident to determine if his wish to remain a full code/cardiopulmonary resuscitative status continued.

There were no Interdisciplinary Progress Notes in the medical record with documented evidence that resuscitative status options had been discussed and reviewed with the resident to determine if his wish to remain of full code/cardiopulmonary resuscitative status continued.

Routine physician orders dated 6/8/10, 7/1/10, 8/18/10, 9/2/10, and 10/11/10 documented that the resident's DNR status was reviewed and remained the same. There was no documented evidence to correlate with this notation on the routine physician orders to show that resuscitative status options were fully discussed and reviewed by the physician with the resident to determine if his wish to remain of full code/cardiopulmonary resuscitative status continued. Additionally, there were no physician progress notes with documented evidence that resuscitative status options were fully discussed and reviewed by the physician with the resident to determine if his wish to remain of full code/cardiopulmonary resuscitative status continued.

During an interview with the Director of Social Work (DSW) on 10/27/10 at 8:00 am, she stated that she would discuss resuscitative status with resident's and/or designated representatives on admission and on a quarterly basis, thereafter during care conference. She stated that the facility documented their advance directive reviews with residents on a quarterly basis on Interdisciplinary Team Conference Assessments/Notes forms. After review of these forms for this resident, she stated that she could see how there was no documented evidence to show that resuscitative status options had in fact been discussed him on a quarterly basis to determine if his wishes were to remain of full code/cardiopulmonary status continued.

During an interview on 10/27/10 at 3:05 pm with the Director of Nursing (DON), she stated that the order "DNR status reviewed and remains the same" written on routine physician's orders was intended to remind the physicians to review resuscitative status with the residents. The DON further stated that she was not present with the physicians during monthly rounds and was not sure what they exactly stated to the residents regarding resuscitative status, but that this should be documented in their monthly progress notes. She stated she could see how if it was not documented, then they could not prove that resuscitative status was periodically reviewed with the residents by the facility.
2. Resident #38
The resident was admitted on 9/3/10 with diagnoses of rib fracture, pelvic fracture, and right scapula fracture. The MDS dated 9/7/10 assessed the resident as having short term memory problems, intact long term memory and modified independence in decision making in new situations only. It also documented that the resident had no DNR advance directive documented in the medical chart.
During the initial unit tour interview on 10/25/10 at 12:30 pm, the surveyor was informed by the RNUM that the resident was of full code/cardiopulmonary resuscitative status.
A Social Work Admission Note dated 9/3/10 documented that the resident was admitted to the facility on that date. This note had a check list of information provided to the resident, but no documented evidence of advance directive information having been provided to the resident. It was documented that the resident was alert and mostly oriented.
A Plan of Care titled, Identify Presence of Advanced Directives, was dated as having been initiated on 9/3/10. It documented that the resident had a Health Care Proxy. This Plan of Care had no documented evidence to show that the resident's resuscitative status was periodically discussed and reviewed by the facility with the resident to determine if her wish was to remain of full code/cardiopulmonary resuscitative status.

An Admission Interdisciplinary Conference Summary and Interdisciplinary Team Conference Assessment/Notes form dated 9/22/10 had no documented evidence that resuscitative status was specifically discussed and reviewed with the resident to determine if her wish to remain a full code/cardiopulmonary resuscitative status continued.
In an Interdisciplinary Progress Note written by the social worker dated 9/24/10 at 2:20 pm, it was documented that she had a visit with the resident and her family. It then noted that after the resident talked with her two daughters over the weekend, she would then look at signing a DNR/Medical Order for Life Sustaining Treatment (MOLST) the following week. It noted that she was alert and oriented and knew what she wanted for end of life care.
There were no physician progress notes with documented evidence that resuscitative status options were fully discussed and reviewed by the physician with the resident to determine if her wish to remain of full code/cardiopulmonary resuscitative status continued.

There was no documented evidence of timely follow-up having been completed by the facility with the resident regarding her decision about her resuscitative status after the date of 9/24/10 and up to the time of the close of this recertification survey on 10/28/10.
During an interview with the DSW on 10/27/10 at 2:30 pm, she stated she typically would give information to the residents and/or designated representative about advance directives on admission and would then review resident resuscitative status options with the residents and/or designated representatives at the time of the admission care conference and that at quarterly care conferences thereafter. She stated that the facility documented their advance directive reviews with residents first on a form titled, Interdisciplinary Resident/Family Health Education Record and then at the time of admission and quarterly care conferences on a form titled, Interdisciplinary Team Conference Assessments/Notes. After review of these forms for this resident, she stated she had not specifically documented that the resident's full code status and resuscitative status options had been reviewed with her. She stated that she could see how there was no documented evidence to show that resuscitative status options had in fact been discussed her on admission or shortly thereafter to determine if her wishes to remain of full code/cardiopulmonary status continued. She had no explanation as to why this resident's resuscitative status options were not addressed until 9/24/10. She stated that she had yet to follow-up with the resident regarding her decision about her resuscitative status wishes after having discussed such with her on 9/24/10 because the resident's daughter had been unavailable to assist in making the decision.

During an interview on 10/27/10 at 3:05 pm with the DON, she stated that the order for DNR status reviewed and remained the same written on routine physician's orders were intended to remind the physicians to review resuscitative status with the residents. The DON further stated that she was not present with the physicians during monthly rounds and was not sure what they exactly said to the residents regarding resuscitative status, but that this should be documented in their monthly progress notes. She stated she could see how if it was not documented, then they could not prove that resuscitative status was periodically reviewed with the residents by the facility.
3.. Resident #51
The resident was admitted on 6/3/10 with diagnoses of Alzheimer dementia, hypertension and depression. The MDS dated 9/2/10 assessed the resident as having short term and long term memory problems and as having moderately impaired decision making skills.

The Social Work Admission Note dated 6/3/10 did not document that a conversation occurred with the resident and/or designated representative regarding resuscitative status options.

An Interdisciplinary Resident/Family Health Education Record was dated 6/3/10. This record, however, gave no documented evidence that education of advance directives had been completed with the resident and/or designated representative. This record had no documented evidence that resuscitative status options were specifically discussed and reviewed with the resident and/or designated representative to determine if her wish to remain of full code/cardiopulmonary resuscitative status continued.
The plan of care was initiated on 6/3/10 with a target date of 9/11/10 titled, Additional Care Needs was documented to identify the presence of advanced directives. This plan of care had no documented evidence that resuscitative status options were specifically discussed and reviewed with the resident and/or designated representative to determine if her wish to remain of full code/cardiopulmonary resuscitative status continued.
The admission assessment completed on 6/3/10 at 11:29 am by a Registered Nurse (RN) documented the resident did not have advanced directives. There was no documented evidence on this assessment that resuscitative status options were specifically discussed and reviewed with the resident and/or designated representative to determine if her wish to remain of full code/cardiopulmonary resuscitative status continued.

The Interdisciplinary Conference Summary and Team Conference Assessment/Notes forms dated 6/16/10 and 9/8/10 had no documented evidence that resuscitative status options were specifically discussed and reviewed with the resident and/or her designated representative after admission to determine if her wish to remain of full code/cardiopulmonary resuscitative status continued.

The physician orders dated 9/30/10 documented DNR (do not resuscitate ) status reviewed and remains the same. However, there was no documented evidence to correlate with this notation on the routine physician orders to show that resuscitative status options were fully discussed and reviewed by the physician with the resident to determine if her wish to remain of full code/cardiopulmonary resuscitative status continued. Additionally, there were no physician progress notes with documented evidence that resuscitative status options were fully discussed and reviewed by the physician with the resident to determine if her wish to remain of full code/cardiopulmonary resuscitative status continued.

During an interview on 10/27/10 at 2:30 pm with the DSW, when asked who had the initial conversations with responsible parties and or residents regarding advanced directives, she stated the responsibility was hers and that she would then document this in the section of the advanced directives on the interdisciplinary resident/family health education form, which the social worker then stated was blank when shown the document dated 6/3/10. She further stated there was no other place she would document the initial conversation. If the documentation is not there, the DSW stated, there was no way to prove that the conversation had occurred. She stated that any subsequent conversations she would have had would have been documented in the Interdisciplinary Progress Notes. When the social worker was informed that there were no progress notes found in the resident's medical record regarding discussion of resuscitative status options with the resident after admission, she again stated if the documentation was not there, then there was no way to prove that discussion had occurred.

During an interview on 10/27/10 at 3:05 pm with the DON she said the DNR status on the orders was intended to remind the physicians to review resuscitative status with the residents. The DON further stated that she was not with the physicians during rounds and was not sure what they exactly said to the residents regarding resuscitative status, but that this should be documented in their monthly progress notes. She stated she could see how if it was not documented, then they could not prove that resuscitative status was periodically reviewed with the residents by the facility.
10 NYCRR 415.3 (e)(2)(iii)

Resident #s 51, 45 and 68 phase 2 resident reviews

Resident # 51:

The resident was admitted with diagnoses of alzheimer dementia, hypertenion and depression. The MDS dated 9/2/10 assessed the resident as having short and long term memory problems and moderately impaired decision making skills.

The social work admission note dated 6/3/10 documents that the resident has a healthcare proxy and living will, the admission note does not document what, if any, conversation occurred with the resident or residents responsible party regarding advanced directives.

The interdisciplinary resident/family health education record dated 6/3/10 which is completed by the team on admission, has a section for areas adressed regarding reponsiblility of resident in care, rights and advanced directives. This section is blank and not completed.

The patients plan of care initiated 6/3/10 with a target date of 9/11/10 documents in the section titled additional care needs to identify the presence of advanced directives. The interventions are living will and healthcare proxy. The patients plan of care was printed 8/8/10.

The admitting assessment completed on 6/3/10 at 11:29 by an Registered Nurse (RN) documents the resident does not have advanced directives.

The admission interdisciplianary conference summary form and team conference assesment and notes dated 6/16/10 has advanced directives circled yes as topics reviewed. There is no documentation of the discussion or what was reviewed. There is no documentation that advanced directives were discussed with the resident or the residents responsible party.

The quarterly interdisciplinary conference summary form and team conference assessment and notes

The physician orders dated 9/30/10 document DNR (do not resuscitate) status reviewed and remains the same.

Interview with a Registered Nurse regarding the physician orders

Interview with the SW regarding her discussions and documentation of discussion

Interview with the DON and Administrator

Based on observation, medical record review and staff interview, the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 (#1) of three residents reviewed, for falls during a complaint investigation (Case # NY00090032). Specifically, the facility did not follow the resident's Comprehensive Care Plan (CCP) by utilizing a positioning device, for which the resident had not been assessed for. The resident attempted to stand up from a wheelchair with the foot buddy in place and fell. This resulted in no actual harm with the potential for more than minimal harm that was not immediate jeopardy. This was evidenced by:

Resident #1
This resident was admitted to the facility on 3/26/10 with diagnoses of dementia, peripheral neuropathy and osteoporosis. The Minimum Data Set (MDS) dated 6/6/10 assessed that the resident had long and short term memory problems, moderately impaired decision making skills, was able to understand others and to make herself understood. Additionally, it assessed that the resident required the extensive assistance of two staff for transferring and for walking.

The Policy and Procedure titled, Fall Prevention dated 4/8/09 and with a release date of 4/14/09 documented that care plans were to be updated, to include interventions to prevent falls from occurring. Staff were also to monitor for safety issues, and "equipment issues" was listed, as an example.

The Physical Therapy (PT) and Occupational Therapy (OT) notes documented that on 6/17/10, the resident was assessed to have impaired safety awareness.

The Fall Risk Assessment dated 6/23/10, documented that the resident was assessed to be at high risk for falling.

The CCP was reviewed and there was no documented evidence that a foot buddy was to be applied to the resident's wheelchair.

The Risk Management Report (I/A) dated 8/10/10 at 9:20 am, documented that a staff member was walking in the hallway when he heard a resident calling for help. As he entered this resident's room, the resident was noted to lying on the floor on her right side. The resident's wheelchair was also noted to be tipped over onto its right side. The resident had a 7 centimeter (cm) by 3 cm raised hematoma with a 0.5 cm laceration above her right eye, which was treated with first aide. The resident also complained of head, neck, hip and right shoulder pain. A neck immobilizer was placed and the resident was log rolled onto a stretcher and the physician was notified.

A review of the Director of Nursing's (DON) investigation dated 8/10/10 into this fall revealed, that PT #1 found this resident on the floor in her room and that it appeared that the resident had fallen forward and was likely trying to stand up or shift her weight in the wheelchair. The resident was lying on her right side and her legs were up on a foot buddy (a positioning device attached to the foot rests of a wheelchair which created a padded platform) and the foot buddy was attached to the wheelchair foot rests.

A written statement by PT #1 dated 8/10/10 documented that when he entered the resident's room, she was lying on her right side with blood coming from a bump, near her right eye. The resident's legs were tangled in the wheelchair leg rests and her right hand was trapped between her legs and the leg rests of the wheelchair. The wheelchair was tipped forward.

A written statement of an interview with PT #1 conducted by the DON on 8/10/10 documented that when he entered the resident's room, the resident was lying on her right side and both legs were on the foot buddy and that it looked like she had tried to stand or shift her weight when she fell.

In an interview with the DON on 9/2/10 at 10:10 am, she stated that on 8/10/10 the resident had fallen from her wheelchair while attempting to stand or to shift her weight. She stated that at the time of the fall, a foot buddy was not part of this resident's plan of care and should not have been in place. She stated that Certified Nurse Aides (CNAs) were responsible to review the CCP for each resident that they were caring for and that there was no documentation that the foot buddy was to be applied to the leg rests of this resident's wheelchair.

During an interview with the Registered Nurse Manager (RNM) on 9/2/10 at 11:07 am, she stated that this resident had a history of a few falls, in the past couple of months and that she was occasionally impulsive and occasionally attempted to stand on her own. She stated that prior to the fall, she had not been aware that the foot buddy was being used and that it was not part of the plan of care.

During an interview 9/2/10 at 11:15 am with a CNA familiar with this resident's care, she stated that a foot buddy had been used with this resident's wheelchair for at least a week, prior to the resident falling on 8/10/10. She stated that she did not know who had initiated the use of the foot buddy, but that it was kept in her room and when she put the resident in the wheelchair she also applied the foot buddy.

During an interview with PT #1 on 9/2/10 at 11:34 am, he stated that on 8/10/10 he went into this resident's room and found her lying on her right side. Her legs were still on the wheelchair leg rests and the foot buddy was still attached to the leg rests. He stated that the process for applying a foot buddy, to the plan of care would be that PT or OT would be consulted and they would evaluate the need for the foot buddy. PT #1 stated that this resident had not been assessed for a foot buddy and one was never ordered for her from PT or OT.

10NYCRR 415.12(h)(1)

Based on observation and staff interview, it was determined that the automatic sprinkler system was not maintained in reliable operating condition, during the standard recertification survey. 1999 NFPA 13, Standard for the Installation of Sprinkler Systems sets minimum distances from sprinkler deflectors and non-continuous obstructions, such as cubical curtains. Specifically, the sprinkler system in resident rooms on 2 of 2 nursing units were obstructed from reliable operation with cubical curtains that impeded discharge of the system in the event of a fire emergency. This resulted in the potential for more than minimal harm that was not immediate jeopardy. This was evidenced as follows;

During an observation conducted on 10/27/2010 at 8:30 am, it was revealed that cubical curtains in residents rooms;p S-10, S-11, S-14, S-15, S-17, S-19, E-11, E-12, E-15, E-18, and E-19. On the ground floor nursing unit and cubical curtains resident rooms; W-22, W-23, W-24, W-25, W-26, S-24, S-25, S-26, S-29, E-22, E-25, E-26, E-28, N-22, N-24, N-25, N-27, and N-29 were not designed with a \'bd-inch diagonal opening mesh and would not permit the unobstructed discharge of the sprinkler system.

The Director of Maintenance when interviewed on 10/27/2010 at 8:30 am, concurrent with survey observations, acknowledged that the cubical curtains were not designed with a inch diagonal opening mesh.

2000 NFPA 101 19.7.6; 1999 NFPA 13; 1997 NFPA 101 13-7.6; 1996 NFPA 13; 10 NYCRR 415.29, 711.2(a)(1)

Based on record review and staff interview, it was determined that the facility did not test the fire alarm system in accordance with 1999 NFPA 72, National Fire Alarm Code, during the standard recertification survey. Sections 7-2.2 and 7-2.3 require that heat detectors require annual heat tests and/or function tests. 10 of 10 fixed temperature heat detectors located in the nursing home section of the facility, were visually inspected only and not heat tested and/or function tested. This resulted in the potential for more than minimal harm that was not immediate jeopardy. This was evidenced as follows;

Record review of the facility's fire alarm testing records on 10/26/2010 revealed that facility fixed temperature heat detector initiating devices were accorded a visual test only within the past 12 months.

During an interview with the Director of Maintenance on 10/26/2010 at 10:00 am, concurrent with survey record review of the testing records, revealed acknowledgement that the fixed temperature heat detectors located in the nursing home section of the facility were visually inspected only.

2000 NFPA 101: 9.6.1.4; 1999 NFPA 72: 7-2.2, 7-3.2; 1997 NFPA 101: 7-6.1.4; 1996 NFPA 72: 7-2.2, 7-3.2; 10 NYCRR 415.29, 711.2(a)(1)

Based on observation, staff interview, and record review it was determined that the facility did not maintain the integrity of 1 of 1 smoke barriers observed, during the standard recertification survey. 2000 NFPA 101 section 19.3.7.3 requires that smoke barriers shall have a fire resistance rating of not less than 1/2 hour. Section 8.3.6 requires that space between pipes, conduits, cables, wires, air ducts and similar building service equipment passing through smoke barriers shall be filled with a fire rated material that is capable of maintaining the smoke resistance of the smoke barrier. Specifically, the ground floor smoke barrier had multiple unfilled penetrations and sections that were unfinished on one side. This resulted in the potential for more than minimal harm that was not immediate jeopardy. This was evidenced with the following;

Record review of the facility floor plan on 10/27/2010 revealed the locations of the smoke barrier walls.

During the observation of the ground floor smoke barrier on 10/27/2010 at 1:30 pm, a 2 foot by 2 foot section was unfinished in the bathroom in room S-20, a 1 foot by 2 foot section was unfinished in the supply room, and a 3 inch by 3 inch through penetration was unsealed in the corridor.

The Director of Maintenance was interviewed 10/27/2010 at 1:30 pm and, concurrent with survey observations, acknowledged the construction status of the ground floor smoke barrier as noted above.

2000 NFPA 101 19.3.7.3, 8.3; 1997 NFPA 101 13-3.7.3, 6-3; 10 NYCRR 415.29, 711.2(a)(1)