Mercy of Northern New York

Based on record review and staff interview conducted during the standard survey, it was determined for 8 of 21 residents (Residents #1, 4, 8, 11, 15, 18, 22, and 23), reviewed for dental care/concerns the facility did not ensure residents received an initial dental evaluation by a dentist or dental hygienist within 7 days of the initial comprehensive resident assessment. Specifically, Residents #1, 4, 8, 11, 15, 18, 22, and 23 did not receive initial dental examinations as required. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The facility's "Dental Consults" policy revised in September of 2011 documented dental assessments and treatment were to be made available to residents on admission, annually, and as ordered by the physician. A dental consultation was to be ordered by the attending physician upon admission, upon request, or upon assessment of the resident's mouth and/or teeth, which indicated the need for dental care.

1) Resident #1 was admitted to the facility on August 4, 2011 with diagnoses including diabetes.

The August 4, 2011 admission physician's orders documented the resident was to have a dental consultation.

The August 4, 2011 admission nursing assessment documented the resident had "few teeth left - teeth he has are rotted."

The comprehensive care plan (CCP), initiated on August 4, 2011, documented the resident had some missing teeth and poor oral care. The resident was to be assisted with oral care by staff.

The August 10, 2011 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and had "obvious or likely cavity or broken natural teeth."

The August 11, 2011 initial registered dietitian's (RD) assessment documented the resident had his own teeth and a few were "rotted." The plan included providing regular consistency foods and monitoring intake.

The August 17, 2011 diet technician's progress note documented the resident had "many missing/broken teeth" and ground hamburgers and ground hot dogs were to be provided.

The CCP, updated September 20, 2011 by the diet technician, documented the resident required a mechanically altered diet related to difficulty chewing. The resident was to be provided with pureed food and the goal was for the resident to tolerate the food consistency provided.

The September 21, 2011 diet technician's progress note documented the resident's diet consistency was changed as a result of poor intake of foods. The plan included monitoring the resident for an improvement in intakes following the diet consistency change.

Review of the medical record at the time of the survey revealed an initial dental evaluation was not completed for the resident.

2) Resident #18 was admitted to the facility with diagnoses including congestive heart failure.

The Initial Nursing Assessment dated July 28, 2011, documented the resident had no natural teeth except for 1 lower front tooth, which was decayed.

The Resident Interdisciplinary Care Plan dated July 28, 2011 documented the resident had 1 tooth that was completely rotted.

The Minimum Data Set (MDS) assessment dated August 2, 2011 documented the resident was cognitively intact, understood other and made themselves understood. The resident required extensive assistance with bed mobility, transfers, dressing, and bathing.

The resident's medical record contained no documented evidence an initial dental evaluation was completed.

3) Resident #8 was admitted to the facility with diagnoses of Alzheimer's dementia and chronic lymphocytic leukemia.

The Initial Nursing Assessment dated July 22, 2011 documented the resident had cavities and broken teeth with upper and lower partial dentures.

The Minimum Data Set (MDS) assessment dated September 12, 2011 documented the resident was cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, and bathing.

Review of the medical record at the time of the survey revealed no documented evidence an initial dental evaluation was completed.

INTERVIEWS:

On September 22, 2011 at 9:16 AM, the Admissions Coordinator (who was responsible for scheduling dental appointments) stated in an interview, residents were required to have annual dental examinations. She stated after someone was admitted, she had a year to schedule their dental appointments. In most cases, residents were seen in less than 1 year after admission. She stated the Ward Clerks notified her when a dental appointment was needed. She did not keep track of when dental appointments were due, she relied on the Ward Clerks to notify her. She stated lately, residents were being placed on waiting lists at local dentists office as there were not many dentists offices in the area taking new patients. She stated nursing told here when a resident had a problem and "we get them in." She was asked for a list of all residents seen by dentists in the last 3 months, those with appointments scheduled in the next 3 months, and those on "waiting lists."

The "Dental Appointments" list provided by the Admissions Coordinator on September 22, 2011, documented Resident #1's name as being on the waiting list with a "?" next to his name. Residents #4, 8, 11, 15, 18, 22, and 23 were not listed as having an appointment scheduled, or as being on a waiting list for an appointment.

On September 22, 2011 at 10:50 AM, the Ward Clerk on the 2 East Unit stated in an interview, a referral sheet was completed if dental services were ordered by the physician and the form was sent to the Administrative Assistant. She stated this was the same process that was followed for appointments with any consultants. The licensed practical nurse (LPN) on the unit, added during the interview, nursing completed the physician appointment request form if nursing found a problem with the resident's teeth when checked on admission the information was then sent to the Admissions Coordinator. The Ward Clerk and the LPN agreed they did not think a dentist came to the facility anymore and residents were sent out to a Dentist. The Ward Clerk kept a copy of all requests for dental consults and, upon reviewing the file, was not able to find a consult for the recent admissions as requested by the surveyor.

On September 22, 2011 at 9:55 AM, the Ward Clerk for the 3 North Unit stated in an interview, she requested dental appointments when they were ordered or a resident was having problems. She stated at this time, she was told the local dentists were not taking new admissions and as a result, she had not been requesting appointments from the Admissions Coordinator. She stated she had Resident #1's paperwork on the unit, and had not sent it to the Admissions Coordinator.

During an interview with the Medical Director on September 22, 2011 at 12:30 PM, he stated he had "very little" involvement with dental at the facility. He stated he was not aware there was a requirement that residents needed to see a dentist or a dental hygienist within 14 days of the initial assessment. When asked if it was routine on admission to order a dental consult, he said he did not know if that was addressed.

During an interview on September 22, 2011 at 3:00 PM with the registered nurse (RN) Manager of the 4 North Unit, she stated there had been issues with dentists in the past. Presently residents were being sent to a different dental practice.

In summary the facility did not ensure residents received an initial dental evaluation by a dentist or dental hygienist within 7 days of the initial comprehensive resident assessment.

10 NYCRR 415.17

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 3 of 9 residents (Residents #9, 10, and 12), reviewed for weight concerns the facility did not ensure residents maintained acceptable parameters of nutritional status. Specifically , for Resident #9 who had an unplanned weight loss, low albumin, and skin breakdown, the facility did not ensure the resident's nutritional needs were reassessed when needed and did not ensure the plan of care contained consistent, accurate information. For Resident #10, the facility did not ensure a resident had a current assessment of nutritional needs; did not ensure the resident's intakes were monitored and evaluated; did not ensure the established weight goal was evaluated for appropriateness; did not ensure the plan of care contained the current plan; and did not ensure the dietary consult ordered was completed. For Resident #12, who exhibited a gradual weight loss there was no documented evidence the resident's plan of care was reassessed for appropriateness to promote increased intake. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #9 had diagnoses including Parkinson's disease, dementia, and a history of congestive heart failure (CHF).

The March 9, 2011, the registered dietitian's (RD) readmission nutrition assessment documented the resident was at low to moderate risk for skin breakdown. The resident lost 10 pounds in 3 months and his nutritional needs were calculated based on his current weight of 170 pounds. The resident was on a mechanical soft, no concentrated sweets (NCS) diet with a 2000 cc (cubic centimeters) fluid restriction. The RD assessed the resident's protein and calorie needs at baseline level for the elderly including 1g/kg (gram per kilogram) of protein per day or 78 g per day. The meal plan included fortified cereal and sugar free shakes for supplements.

The April 6, 2011 diet technician's progress note documented the resident's weekly weight reflected a 7 % loss in 180 days, with the resident's previous 5-day intake "only 47%". Laboratory results from March 9, 2011 documented the resident's albumin level (a measure of protein stores) declined from 4.0 g/dl (grams per deciliter) to 2.8 g/dl, (norm = 3.2-5 g/dl). A swallow evaluation recommended continuing with a mechanical soft diet. The diet technician documented it was difficult to increase the resident's calorie and protein needs with the fluid restriction and added juice with protein powder to the meal plan. There was no documented evidence the diet technician re-assessed the resident's nutritional needs in view of the weight loss and decreased albumin level or assessed the amount of protein provided with the current meal plan.

The comprehensive care plan (CCP), dated April 6, 2011, identified the resident's weight loss and documented the resident "leaves 25% of meals". The plan was to stabilize the resident's weight, the interventions included a NCS diet.

On May 13, 2011, a diet technician's progress note documented the resident's diet consistency was changed to pureed and the resident's weight was 161 pounds, a 9 pound weight loss in 2 months. The resident required more assistance with eating and supplements/fortified foods remained in place.

The CCP dated May 13, 2011 documented the resident's need for a mechanically altered diet related to difficulty chewing with progression of Parkinson's disease. The plan was to provide a pureed diet.

On June 18, 2011, a nursing progress note documented the resident had an unstageable pressure ulcer on his left outer ankle and a a Stage I pressure ulcer on his right outer ankle. A skin integrity flow sheet was initiated on June 18, 2011 for the left ankle open area and the right ankle area. Both forms documented dietary was notified of the areas on June 20, 2011.

A diet technician's progress note dated June 20, 2011, documented a nutrition consult was ordered due to the resident's low albumin and a scabbed area on the left ankle) The resident received fortified cereal, juice with protein powder, 3 shakes a day, and fortified pudding. A request was written to discontinue the resident's fluid restriction so the protein could be increased. LiquaCel (a liquid protein supplement) was recommended and the note specified a nutritional assessment would be completed when the wound team evaluated the resident. There was no documented evidence the resident's nutritional needs were re-assessed when the additional supplements were added to the meal plan.

The CCP documented the resident had a scabbed area on the left ankle on June 20, 2011. The planned interventions included: updating food preferences; providing fortified cereal and pudding, and health shakes; protein powder in juice; LiquaCel daily; intake observed at meal rounds and via consumption records; monitoring weights; and providing assistance with meal completion. There were no dates listed on the CCP and the surveyor was unable to determine when each intervention was initiated.

On June 21, 2011, the RD's quarterly nutrition assessment specified the resident ate 95% at meals and weighed 166 pounds, which was an 11 pound weight loss in 3 months. The 11 pound weight loss was identified as "desirable". The assessment documented the resident had scabbed areas on the left and right ankles and identified the supplements as noted in the June 20, 2011 nutrition note. The resident's nutritional needs were not reassessed in view of the weight loss, low albumin, and pressure ulcer. The RD did not assess whether the current meal plan met the resident's nutritional needs and there was no documented explanation as to why the resident's weight loss was "desired."

The RD's nutrition progress note dated August 23, 2011, documented the area on the resident's left ankle was improving and no changes were made to the plan of care.

On September 7, 2011, nursing documented in a progress note, the resident had a small open area on the left inner ankle and was seen by the wound team.

A Skin Integrity Flow Sheet initiated on September 7, 2011 identified the area on the resident's left inner ankle and documented that dietary was notified.

The resident was observed during breakfast on September 20, 2011 at 8:30 AM. He was being assisted with his pureed meal and was attempting to drink independently from Sippy cups.

There was no further documentation in the resident's medical record by clinical nutrition staff when the record was reviewed on September 21, 2011.

On September 21, 2011 at 3:00 PM, the RD stated in an interview, her review of the resident's meal plan showed they were giving the resident enough calories and protein. She stated there was no reassessment of the resident's nutritional needs since March 2011. She reviewed the quarterly assessment form and stated there was no place to document the resident's assessed needs. When asked about the resident's area that developed on September 7, 2011, the RD stated she was notified about areas when she attended wound rounds and she would reassess the resident "tomorrow" as his quarterly assessment was due. When questioned about the resident's weight loss documented as "desired" in June 2011, the RD stated she did not remember why she wrote that and stated that it "does not make sense." She said the resident was not on a planned weight loss program.

In summary the facility did not ensure the resident maintained acceptable parameters of nutritional status when they:
- did not reassess the the resident's nutritional needs when the resident lost weight, had a decrease in albumin level, and developed pressure ulcers;
- did not develop a plan of care that was clear and free from conflicting information as the CCP identified a goal of stabilizing the resident's weight and the RD's quarterly assessment documented weight loss for the resident was desirable.

2) Resident #10 had diagnoses including dementia and breast cancer.

The April 13, 2011 quarterly diet technician's assessment documented the resident weighed 134 pounds and had gained 6 pounds in 3 months. The resident ate 46% of meals, received fortified foods with meals, and supplements with medication passes. The assessment did not include an assessment of the resident's calorie/protein needs and did not document whether the resident was meeting his assessed nutritional needs.

The April 15, 2011 diet technician's progress note documented the resident had a favorable weight gain. The resident refused Boost (a protein supplement) and fortified pudding were discontinued as the resident refused them. Fortified cereal was provided with the addition of ice cream.

The registered dietitian's (RD) July 5, 2011 quarterly assessment documented the resident weighed 134 pounds, ate 50% of meals, and received fortified foods at meals. There was no assessment of the resident's nutritional needs, the RD did assess the resident's consumption of the fortified foods, and the RD did not specify whether the resident was meeting his nutritional needs.

The comprehensive care plan (CCP), revised in "July 2011," documented the resident was at risk for weight loss and the goal was to promote weight gain towards the usual body weight of 150 pounds. The CCP specified the resident "refuses" fortified cereal/potatoes/pudding, Boost, and Health Shakes (nutritional shakes). There was no documented rationale for providing the resident with fortified foods when he refused them; no documented evidence the RD assessed the resident's weight goal of 150 pounds to determine whether it was an appropriate goal; and no evidence the RD reassessed the resident's nutritional needs in order to promote the 16 pound weight gain to reach the established goal weight.

The July 7, 2011 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and required set-up assistance at meals.

The weight record documented the resident weighed 129 pounds in August 2011 (no date specified). This was a 5 pound (3.7%) loss in 1 month.

The August 4, 2011 nursing progress note documented the resident had a 2.2 cm (centimeters) x 6 cm wound on the breast from cancer that he had for "some time." There was no documented evidence the resident's nutritional needs were assessed in view of the wound.

The August 4, 2011 nurse practitioner's (NP) progress note documented the resident lost 5 pounds in the past month, had poor intake of food, and a dietary consult was ordered to address the weight loss.

The August 4, 2011 RD's progress note documented the resident lost 5 pounds in 1 month and received fortified cereal, fortified potatoes, ice cream, Health Shakes, and Boost. There was no prior documentation in the medical record that the resident received Health Shakes or when they were initiated. Prior documentation in the nutrition progress notes specified the resident's Boost was discontinued in April 2011 and there was no evidence it had been re-started at the time of the RD's note. The RD did not document the resident's acceptance of the supplements/fortified foods, did not reassess the resident's nutritional needs, and did not assess whether the resident met his assessed needs. The plan was for the NP to discuss artificial nutrition/hydration with the resident's health care proxy.

The August 5, 2011 RD's progress note documented "per NP progress note, resident does not want artificial nutrition/hydration."

The CCP, updated on August 23, 2011, documented the resident had an open lesion from breast cancer and received Boost with medication pass 4 times a day. There was no documented evidence the resident received Boost after it was discontinued in April 2011.

The monthly physician's orders dated August 24, 2011 did not include an order for Boost.

The weight record documented the resident weighed 127 pounds in September 2011 (date not specified).

The September 8, 2011 NP's progress note documented the resident lost 3 pounds in a week and a dietary consult was ordered to review the resident's plan of care and monitor weights.

The September 11, 2011 nursing progress note documented the resident had increased dark red drainage from the chest wound. There was no documented evidence a nutritional re-assessment was completed in view of increased drainage from a wound.

There was no documented evidence on the resident's medical record the dietary consult was completed as ordered when reviewed on September 19, 2011.

The resident was observed during lunch on September 19, 2011 between 12:00 PM and 12:20 PM. He consumed bites of turkey and vegetables.

On September 20, 2011, the resident was observed during breakfast at 8:15 AM. He was provided with milk, orange juice, bacon, fortified cereal, scrambled eggs and coffee. The resident was not eating and was seen placing the bacon in a napkin on his lap.

The RD stated in an interview on September 21, 2011 at 3:00 PM, the resident had cancer and refused all supplements, fortified foods, and snacks. She reviewed the progress notes and stated he did receive fortified cereal and ice cream and she did not know if he routinely accepted them. The RD said when she conducted resident assessments, she watched them at 1 meal and asked staff if they accepted the supplements/fortified foods. She stated she thought the diet technician received tracking forms of supplements; she did not know what was on those forms; and she did not know how the diet technician used the information. She stated residents with weight loss were reviewed at weekly weight meetings and she did not know the criteria used by the diet technician to select those residents. She was not aware a dietary consult was ordered on September 8, 2011 and stated either herself or the diet technician could complete the consult.

On September 21, 2011 at 4:15 PM, the diet technician stated residents reviewed at the weekly weight meetings were those with significant weight loss of 5% in 1 month, 7% in 3 months, and 10% in 6 months. Residents whose weight loss was gradual or not significant would not normally be added to the list of residents to be reviewed at the meeting.

In summary for the facility:
- did not ensure a resident with cancer diagnosis, a draining wound, and weight loss had a current assessment of their nutritional needs;
- did not ensure clinical nutrition staff monitored the resident's consumption of supplements and fortified foods;
- did not ensure clinical nutrition staff assessed whether the resident's actual intake met his nutritional needs;
- did not ensure the established weight goal of a 16 pound weight gain was assessed for appropriateness;
- did not ensure the CCP contained the resident's current plan of care; and
- did not ensure the dietary consul ordered by the NP on September 8, 2011, was completed.

3) Resident #12 had diagnoses including Alzheimer's disease and Parkinson's disease.

The nutrition assessment dated February 18, 2011 identified the resident was on a pureed diet and documented the resident had a significant weight loss in 30 days, with a weight of 113 pounds. The resident's caloric needs were calculated to promote weight gain with the addition of 250 calories. The resident's meal consumption was documented as (poor) 25% and the resident received fortified cereal and 2 Cal (a dietary supplement) to supplement her intake. The assessment documented the resident used "plastic for safety", and had a 4.4 % weight loss in 30 days. The assessment noted the resident and accepted Boost Plus (a liquid protein supplement) better than shakes, and was provided with Boost Plus at all meals and "between". The plan included allowing the resident adequate time for meal completion.

The May 12, 2011 quarterly nutrition review documented the resident's weight was 117 pounds and her intake at meals was 25%. The review recorded the resident fed herself, ate slowly and used plastic utensils, (no knife). The resident received fortified cereal at breakfast, Boost at meals, twice between meals and received a supplement (2 Cal) with medication pass.

The monthly weight record for the resident documented the resident was 117 pounds in June, 115 pounds in July, and 114 pounds in August 2011.

The Minimum Data Set (MDS) assessment dated August 4, 2011, documented the resident had moderate cognitive impairment, with poor short and long term memory. The resident's weight was 114 pounds and the resident was on a mechanically altered diet. The resident was identified as wandering daily, and refusing care at times.

The August, 2011 quarterly nutrition review documented the resident's weight was 114 pounds, her intake of solids was 25%. The resident fed herself, ate slowly and used plastic utensils (no knife). There was no documented change in the resident's plan of care. There was no documented rationale for the use of plastic utensils at meals.

The comprehensive care plan (CCP) for nutrition was initiated on February 18, 2011 and reviewed by the interdisciplinary team August (specific date not identified) 2011. The CCP documented a problem of significant weight loss related to the resident leaving 25% of meals, and requiring time for meal completion. The plan included supplements, observation of intake at meal rounds and "via consumption sheets", and monitoring of the resident's weight. There was no documented evidence any changes were made to the CCP since identifying the concern on February 18, 2011. There was no documentation in the CCP of the use of the plastic utensils when it was reviewed on September 12, 2011.

The resident's weight record documented the resident's September weight was 113 pounds.

The resident's meal consumption record for September 1 through 21, 2011 documented the resident's intake of solids at meals was 0 (refused) to 25%, and for 2 of the 60 meals the intake was 50%. The record documented the resident refused between meal snacks at times, the snacks were recorded as refused or 100%.

The resident was observed in the dining room on September 19, 2011 at noon, seated at an overbed table with her pureed meal in front of her, holding a plastic spoon. The resident was not eating and she offered her food to the surveyor. The resident's meal consumption was not recorded for that meal when reviewed, by the surveyor, on September 22, 2011.

On September 20, 2011 at 8:30 AM, the resident was seated in the unit dining room at an overbed table with her meal in front of her and plastic utensils. At 9 AM, the licensed practical nurse (LPN) entered the dining room and told the resident the hairdresser was there. The resident had not eaten her breakfast, the LPN said "if you want you can have applesauce after the hairdresser." The resident had eaten a few bites of the solids and 50% of her drinks.

On September 21, 2011 at 3:00 PM, the registered dietitian (RD) stated in an interview, she was not sure why Resident #12 had plastic utensils, and residents usually had disposable utensils "due to harm to themselves or others". She stated upon her last review, the resident's intake averaged 25% for solids had a fair acceptance of fortified cereal. When asked, she did not state whether other interventions were tried in an attempt to improve the resident's intake. She stated the diet technician compiled the list of residents reviewed at the weekly weight meetings and she did not know the criteria used to select those residents. She did not know if the resident had recently been reviewed at a weekly weight meeting. The RN manager, when asked by the RD, stated the resident was discussed at the weekly meetings for hydration and not for weight. The RD said the diet technician reviewed the consumption records and she (the RD) assessed the resident's intake during meal rounds or when being reviewed for an assessment.

On September 21, 2011 at 4:15 PM, the diet technician stated in an interview residents who had significant weight loss (5% in 1 month, 7% in 3 months, and 10% in 6 months) were reviewed at the weekly wight meetings. The interdisciplinary team did not review residents with gradual weight loss or weight loss that was not significant.

On September 21, 2011 at 5:05 PM, the RN manager and the LPN on the unit were interviewed regarding the resident's use of plastic utensils. They stated the resident was given plastic utensils because she had been agitated at meals and "went after someone." When asked when this occurred, the RN stated "years ago" and the LPN stated the resident continued to be agitated at times. The RN stated the resident ate away from other residents. She was aware the use of plastic utensils was not on the CCP, needed to be added to the CCP, and needed to be reviewed for continued appropriateness.

In summary, the facility did not ensure the resident's plan of care was reassessed for appropriateness to promote increased intake.

10 NYCRR 415.12(i)(1)

Based on observation, record review, and staff interviews conducted during the standard survey, it was determined the facility did not conduct a comprehensive assessment within 14 days after a significant change occurred for 1 sampled resident (Resident #9) with a significant change in physical status. Specifically, for Resident #9 the facility did not complete a comprehensive assessment within 14 days after the resident experienced a significant decline in activities of daily living (ADLs)including a decline in the ambulation, transferring, eating and the developing pressure ulcers.
Findings include:

Resident #9 had diagnoses including Parkinsons disease and dementia.

The Minimum Data Set (MDS) assessment dated March 31, 2011 documented the resident had poor short and long term memory and severe cognitive impairment. The resident was independent in transfers and required "set up help only", for eating and ambulation. The resident required limited assistance of one person for dressing and was frequently incontinent of urine and always incontinent of bowel.

The ADL (activities of daily living) Functional Progress Notes for April 5, 12, 19 and 26, 2011, documented the resident was independent in ambulation, transfers and bed mobility (turning and positioning), and the resident required set up (cut food) assistance for eating.

On May 12, 2011, a physical therapy evaluation was completed as a result of the resident's unsteady gait. At that time, the resident was using a rolling walker and wheelchair as needed. The resident received physical therapy treatment for decreased balance, unsteady gait with rolling walker and decreased transfer skills.

Review of the nursing progress notes documented the following significant changes in the resident's condition:
- On May 21 and 22, 2011, the resident was leaning to the right when in a wheelchair;
- On May 23, 2011, physician orders were received for the resident to see the neurologist as a result of right sided weakness;
- On May 30, 2011, the resident fell out of the wheelchair, was assessed and placed back in the wheelchair; and
- On June 2, 2011, an order was received for the resident to be in a geri-chair.

On June 3, 2011, a physical therapy discharge evaluation documented the resident was unable to medically tolerate therapy. The resident was discharged from the ambulation program with a recommendation for a geri-chair for comfort and positioning.

The ADL Functional Progress Note for June 14, 2011 documented the resident required the assistance of 2 for ambulation and transferring, and the assistance of 1 for bed mobility. The resident required set up and verbal cues for meals, and at times, needed to be fed.

A nursing progress note dated June 18, 2011 documented the resident had skin breakdown on both outer ankles. The resident was documented to be in a geri-chair with soft slippers.

The resident was observed during survey in the geri-recliner on September 20, 2011 in the dining room from 8:15 AM to 8:30 AM being assisted with his meal completion. The resident was also observed at 10:10 AM, and at 5:10 PM on the same date seated upright in the geri-recliner. On September 21, 2011, the resident was observed at 9:35 AM reclined in the geri-recliner in the hallway.

On September 22, 2011, the registered nurse (RN) responsible for the completion of the MDS assessments, was interviewed at 11:40 AM. She stated significant change reviews were identified during the daily morning report. She reviewed her notes related to the resident and stated a significant change review should have been completed as a result of the resident's decline in ADLs.

In summary, the facility did not complete a comprehensive assessment within 14 days after the resident experienced a significant decline in their ADLs, and developed pressure ulcers.

10 NYCRR 415.11(a)(3)(ii)

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 1 of 1 residents (Resident #11), reviewed for antipsychotic medications, the facility did not ensure the resident was free from unnecessary drugs. Specifically, for Resident #11, the facility: did not ensure there was sufficient and specific documentation of the behaviors exhibited by the resident warranting the use of Haldol (an antipsychotic medication); did not develop and implement a plan of care that incorporated non-pharmacological interventions to use before administering Haldol; and did not ensure that a gradual dose reduction was attempted for the use of Haldol. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #11 had diagnoses including dementia with paranoid features.

The physician's admission orders for the resident were dated April 2, 2011, and documented the resident was to receive Haldol 5 milligrams (mg) twice a day for dementia with psychosis.

The resident's Minimum Data Set (MDS) assessment dated April 4, 2011, documented the resident had moderately impaired cognition. There were no behavior concerns were identified.

The "Interdisciplinary Team Meeting Summary" form dated April 12, 2011, documented the resident was alert, pleasantly confused, and enjoyed socializing. The resident had episodes of paranoia noted, which had lessened since admission. There was no behavior plan was identified.

The physician's progress note dated May 20, 2011, documented the resident had a history of dementia with "some" paranoia issues. The resident was on Haldol 0.5 mg twice a day for psychosis. No specific behaviors were identified related to the use of the antipsychotic medication.

The physician's progress note date July 13, 2011, documented the resident had dementia; was a little confused at times; "for the most part is very easy to get along with"; and was not showing any evidence of paranoid features "at this time." The progress note documented the resident had a history of dementia with some behavioral issues and received Haldol twice a day for psychosis. The progress note did not contain documented evidence a gradual dose reduction was attempted for the Haldol.

The resident's Comprehensive Care Plan (CCP) dated September 1, 2011, identified the resident used psychotropic medications for dementia. The goal was for the resident to be on the lowest therapeutic dose of the psychotropic medication (medication not specified). There was no documented evidence that a gradual dose reduction had been attempted for the use of psychotropic medications.

The "Interdisciplinary Resident Care Plan Record", used by the certified nurse aides (CNA) to provide care, dated September 1, 2011, documented the resident was alert, cooperative, pleasant, had a history of paranoia and was agitated at times. The resident's activity preferences included: visits, television, entertainment , rosary, and church. The form did not include techniques for staff to use if the resident became agitated, and did not describe the resident's specific behaviors.

The physician's progress note dated September 8, 2011, documented the resident was on Haldol twice a day for psychosis. The note documented the resident did "not have any evidence of paranoid features at this time but is on Haldol to prevent this". There was no documented evidence a gradual dose reduction was attempted for the use of Haldol.

The "31 Day Behavior Observation Record" for the month of September 2011, completed by the CNAs, did not contain documented evidence the resident exhibited any behaviors when reviewed on September 22, 2011.

Another behavior observation record for September 2011 documented the resident occasionally refused PM care, including her shower on one occasion. There was no description of the behavior and no documentation of interventions attempted.

The resident was observed on September 19, 2011 at 11:00 AM sitting in her room. She informed the surveyor she had not been in the facility very long and talked about the furniture in her room belonging to her. At 12 PM she was observed in the dining room eating half of a sandwich she told the surveyor she had a small appetite and did not mind eating sandwiches.

The resident was observed on September 19, 2011 at 4:45 PM entering the dining room, and on September 20, 2011 at 8:15 AM in the dining room. She was very quiet and polite when observed on both occasions. The resident was observed ambulating down the hallway to dinner on September 21, 2011 and to lunch on September 22, 2011, assisting another through the hallway on both observations.

On September 22, 2011 a CNA on the unit was interviewed at 10:40 AM. She stated the resident's behaviors were generally displayed in the morning during AM care. She stated the resident was better later in the morning, but she thought the resident would not want to go to the dining room without first receiving care. The CNA said she did not think the resident would be allowed to eat breakfast in her room.

At 10:45 AM on September 22, 2011, the RN Manger was interviewed. She stated the resident remained on Haldol because she continued to have episodes of paranoia, exhibited by her being fearful of others coming into her bathroom. The RN stated the resident could have eaten in her own room if she had asked.

The nurse practitioner (NP) was interviewed on September 22, 2011 at 12:00 PM and again at 12:20 PM, as the attending physician was contacted, and was not available until the following week. The NP reviewed the resident's chart and stated Haldol was prescribed to prevent paranoia and there was no evidence a dose reduction was attempted. The NP stated he would have requested a psychiatric evaluation and further assessed the possibility of a dose reduction.

In summary, the facility:
- did not ensure there was sufficient and specific documentation of the behaviors exhibited by the resident warranting the necessity for the use of Haldol;
- did not develop and implement a plan of care that incorporated non-pharmacological interventions to use before administering Haldol; and
- did not ensure that a gradual dose reduction was attempted for the use of Haldol.

10 NYCRR 415.12(l)(1)

Based on record review and staff interview conducted during the standard survey, it was determined for 1 of 24 sampled residents (Resident #4), the facility did not ensure all alleged violations involving mistreatment or neglect were thoroughly investigated. Specifically, on multiple occasions, Resident #4's medication patch was not removed as ordered; the facility did not thoroughly investigate the cause of the medication error, and there was no documented evidence the nurses involved in the incidents needed to be provided or were, provided with remedial training. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #4 was admitted to the facility on June 16, 2011 with diagnoses including congestive heart failure (CHF) and lower extremity edema.

The June 2011 Medication Administration Record (MAR) documented the resident had an order for 0.2 mg (milligrams)/hour Nitropatch (a medication patch used to prevent chest pains) that was to be applied at 8:00 PM and removed at 8:00 AM daily.

The June 19, 2011 nursing progress note written at 8:45 PM, documented the supervisor was called as the evening shift nurse noticed the day shift nurse did not remove the resident's Nitropatch at 8:00 AM as ordered. The physician was contacted and the order was changed.

The June 2011 MAR documented the Nitropatch was not applied on June 19, 2011 and was held until June 20, 2011 at 8:00 PM.

The June 23, 2011 nursing progress note documented at 8:00 PM, when the nurse went to apply a Nitropatch to the resident, she noticed the patch had not been removed as ordered at 8:00 AM that day. The nurse documented "this is now the third time a patch has been found on her when the patch was supposed to be taken off at 8:00 AM." The physician was contacted and an order was obtained to hold the patch until the following evening at 8:00 PM.

The August 4, 2011 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition.

The September 11, 2011 nursing supervisor's progress note documented the unit nurse called her at 8:30 PM as the resident's Nitropatch was not removed as ordered that morning at 8:00 AM. The patch was to be left off until the next evening at 8:00 PM.

Upon request the facility was unable to provide the surveyor with medication error investigations from June 19, 2011 to September 21, 2011.

On September 21, 2011 between 1:45 PM and 2:10 PM, the Director of Nursing (DON) stated in an interview, she was not aware of incidents with the resident's Nitropatch. She stated the facility recently observed all the nurses completing medication administration. The DON was asked to look into the incidents and provide the surveyor with information related to the medication errors and whether the nurses involved had received remedial training on the procedure for transdermal medications.

The facility's "Medication Error Tool Policy" dated November 8, 1999, documented medication errors were to be reported and the nurses who made the errors were to receive progressive discipline depending on the severity and frequency of the medication errors. In most cases, educational counseling was to be provided following a medication error.

The facility's "Administration Topical Nitroglycerin/Pain Preparations" policy dated January 26, 2004, documented the procedure for administering the medications and did not address the process to follow when a patch was found on a resident after it was to be removed.

The DON did not provide the requested information regarding if the nurse had received remedial training for transdermal medications to the surveyor prior to the survey team's exit from the facility.

In summary, on multiple occasions the resident 's medication patch was not removed as ordered; the facility did not thoroughly investigate the cause of the medication error, and there was no documented evidence the nurses involved in the incidents were provided with remedial education.

10 NYCRR 415.4(b)

Based on observations, record review, and staff interviews conducted during the standard survey, it was determined the facility did not ensure 1 of 3 residents (Resident #9), reviewed for pressure ulcers received the necessary care and services to prevent the development of pressure ulcers. Specifically, for Resident #9, when the resident, experienced significant a decline in physical condition, the facility did not ensure the resident did not develop pressure ulcers as the facility did not reassess the resident's risk for developing pressure ulcers and initiate preventive measures in a timely manner; did not ensure a podiatry evaluation was provided as recommended; and did not determine the causative factors in a timely manner to prevent further skin breakdown when the resident developed a pressure ulcer. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #9 had diagnoses including Parkinson's disease and dementia.

The resident's "Pressure Ulcer Risk and Assessment" form dated March 8, 2011, documented the resident was independent with transfers and ambulation. The resident was continent of bowel and bladder, and he did not have pressure ulcers. The risk assessment documented the resident did not require "High Risk Pressure Sore Preventions".

The resident's Minimum Data Set (MDS) assessment dated March 31, 201, documented the resident had severe cognitive impairment, was independent in transfers, and required "set up help only" for ambulation. The resident was assessed as frequently incontinent of urine and always incontinent of bowel. This assessment documented the resident did not have pressure ulcers. The MDS documented the resident was identified at risk for the development of pressure ulcers, and had a pressure reducing device for the bed and chair.

On May 12, 2011, a physical therapy evaluation was completed as a result of the resident's unsteady gait. At this time, the resident was using a rolling walker and wheelchair as needed. The plan was for physical therapy 3 times a week for 4 weeks due to decreased balance, unsteady gait with rolling walker and decreased transfer skills.

On June 2, 2011, the resident's comprehensive care plan (CCP) documented the resident was in a gerichair. There was no documented evidence the resident's risk for skin breakdown was reassessed.

The physical therapy discharge evaluation dated June 3, 2011, documented the resident was unable to medically tolerate therapy and was discharged from the ambulation program, with a recommendation for the geri-chair for comfort and positioning.

The ADL Functional Progress Note for June 14, 2011, documented the resident required the assistance of two for ambulation and transferring, and the assistance of one for bed mobility.

The nursing progress note dated June 18, 2011, documented the resident's ankles were observed "r/t (related to) skin breakdown". The resident's right outer ankle had a "Stage I" that measured 1.5 x 0.9 (no unit of measurement specified). The resident's left outer ankle had a "0.9 x 0.8 unstageable area" (no unit of measurement specified) secondary to "necrotic tissue". The progress note documented the resident was in a gerichair with soft slippers on and there was no "pressure on ankle currently". A call was placed to the physician. There was no documented evidence the resident's risk for skin breakdown was reassessed.

The "Skin Integrity Flow Sheet" form dated June 18, 2011, documented a pressure "Wound/Ulcer" on the resident's right outer ankle. The area was described as a Stage I pressure "Wound/Ulcer" that was red, intact, and measured "1.5 x 0.9" (no unit of measurement specified). Handwritten in under the date "6/18/11" were written the words "per supervisor". The "Skin Integrity Flow Sheet" form documented that the Stage I pressure "Wound/Ulcer" was added to the resident's CCP on June 22 (year unspecified). There was no documented evidence the resident's risk for skin breakdown was reassessed.

The "Skin Integrity Flow Sheet" form dated June 18, 2011, documented a pressure "Wound/Ulcer " on the resident's left outer ankle. The area was described as unstageable and measured 0.9 x 0.8 " (no unit of measurement specified) and pain was associated with the area. Handwritten under the date "6/18/11" were the words"per supervisor", and above the numerical date were the words: "Sheet completed 6/22/11". The "Skin Integrity Flow Sheet" form documented the unstageable pressure "Wound/Ulcer" was added to the resident's CCP on June 22, 2011. There was no documented evidence the resident's risk for skin breakdown was reassessed.

The nursing progress note dated June 19, 2011, documented the resident's left ankle had a scab, and the surrounding area was red. The area was to be assessed by the skin team on June 20, 2011.

A nursing progress note dated June 20, 2011 documented an order was received for the resident to be seen by the podiatrist for consultation and treatment. A nursing progress note later on the same date documented the resident was seen by the podiatrist.

The physician's orders dated June 21, 2011, documented to apply skin prep (a topical protective barrier) to the resident's right outer ankle twice a day for 14 days, and a podiatrist re-evaluation in 2 weeks. There was no documented evidence of a follow-up visit.

Impaired skin integrity was recorded on the resident's CCP on June 22, 2011. The CCP documented the resident had a Stage II pressure ulcer on the left ankle and a Stage I on the right ankle. The plan included: wound care as ordered by the physician; weekly skin rounds by the wound team; weekly skin check turning and positioning the resident every 2 hours; pressure reduction mattress; and boots as ordered. The interventions were not dated and it was not known from reviewing the CCP, when each intervention was initiated.

The "Pressure Ulcer Risk and Assessment" form dated June 22, 2011, documented the resident had an "actual" pressure ulcer, and required "high risk pressure sore preventions". The interventions included turning and positioning every 2 hours, a pressure relieving device for his mattress and cushion, and incontinence care. The assessment did not identify the use of protection for the resident's ankles/heels.

The resident's MDS assessment dated June 23, 2011, documented the resident had severe cognitive impairment. The resident required extensive to total assistance with the activities of daily living. The resident did not ambulate during the assessment period. The MDS documented a clinical assessment was done, and the resident had an unstageable pressure ulcer that measured 1.3 cm (centimeter) x 1.0 cm. The MDS documented a pressure reduction device for the resident's chair and bed, and nutritional/hydration interventions.

The physician's orders dated June 24, 2011, documented "pressure relieving boots" to the resident's feet at all times, except for care and skin inspection.

The Skin Integrity Flow Sheet dated June 18, 2011 - August 3, 2011, documented the area on the resident's ankle was observed weekly.

The nursing progress note dated July 29, 2011, documented the resident's right "upper side of pelvic" skin starting to breakdown "due to" Attends (incontinence product). There was no documented evidence a "Skin Integrity Flow Sheet" form was completed for this area, or a reassessment of the resident's risk for skin breakdown.

On June 29, 2011, the "Skin Integrity Flow Sheet" form documented an unstageable pressure "Wound/Ulcer" on the resident's left outer ankle. The area was described as a scab, that measured "1.3 x 1". A unit of measurement was unspecified.

On August 3, 2011 the Skin Integrity Flow Sheet documented the use of Multi Podus boots, a boot that provided pressure relief to the heel and prevented the resident's foot from rotating outward.

The physician's orders from June 29 - August 24, 2011 documented continued care to the left ankle pressure ulcer with minor changes in the treatment.

The August (date unclear) 2011 physician renewal orders documented cleanse the resident's left outer ankle with normal saline, pat dry, apply skin prep to intact skin, and cover with an Optifoam dressing (a foam dressing, used to promote healing). The order instructed to change the dressing every 3 days, and to use pressure relieving boots on both feet at all times, except for care and skin inspection.

The"Pressure Ulcer Risk and Assessment" form dated August 30, 2011, documented the resident had an "actual" pressure ulcer on his left outer ankle, and required "high risk pressure sore preventions". The interventions included assistance repositioning when the resident was in his geri-chair, a pressure relieving device for his mattress and cushion, and "off loading boots" with a "rotator bar" and incontinence care.

A nursing progress note dated September 7, 2011, documented the resident had a small open area on the left inner ankle and was seen by the wound team.

A "Skin Integrity Flow Sheet" form was initiated on September 7, 2011 identifying a newly developed Stage II area on the resident's left inner ankle. There was no documented evidence an assessment was completed to identify the cause of the new area or that the resident's risk for skin break down was reassessed.

The "Pressure Ulcer Prevention Protocol" policy dated September 8, 2011, documented the pressure ulcer prevention protocol would be implemented by the nursing department for a resident scoring 16 or less on the "Pressure Ulcer Risk Assessment" scale. The policy documented all residents at risk for pressure ulcers, were to have their skin inspected every shift during care "paying particular attention to the bony prominences". Interventions to be implemented, depending on the resident's assessed needs, included providing pillows or foam wedges to keep bony prominences from direct contact (such as knees and ankles).

The physician's order dated September 14, 2011, documented to cleanse the resident's inner and outer ankles with normal saline, pat dry, apply skin prep, covered with a gauze dressing, and wrap with Kerlix twice a day.

The physician's orders dated September 20, 2011, documented to remove the resident's Multi Podus boots when he was in bed, and use an Achilles-ease cushion for off-loading the heels in bed.

The resident was observed during survey in the geri-recliner on September 20, 2011 in the dining room from 8:15 AM to 8:30 AM and at 10:10 AM, and at 5:10 PM in the dining room with no sock on his left foot and the boot in place.

The RN Manager was interviewed at 10:25 AM on September 21, 2011 and stated the resident's sock should have been on both feet under the boot and she did not know why it was not on when observed the previous evening. At 12:35 PM, the RN Manager stated the resident was seen by the podiatrist on June 20, 2011 for cellulitis and there was "no change" resulting from that visit.

The RN Manager was interviewed while reviewing the resident's record with the surveyor on September 21, 2011 between 10:30 AM and 11:30 AM. During the interview/review, the RN stated:
- The resident had a significant decline in his Parkinson's disease, was falling and very shaky. The RN was not sure when this change was first observed;
- In May, there was a change in the resident's medications and it was thought this contributed to the resident's decline;
- The resident was in physical therapy and was discontinued on June 3, 2011 as he was not achieving the goals and the geri-chair was recommended;
- She updated the comprehensive care plan and stated it was her error that the interventions were not dated;
- She thought the podiatry request written on June 20, 2011 was in the wrong resident record and she was going to look into it;
- The skin risk assessments were generally completed on admission, quarterly, and when the resident developed impaired skin; and
- The area on the resident's inner ankle was discovered during the resident's bath on September 7, 2011, and the RN thought it was caused from the resident scratching the area. This was not documented in the resident record.

The Director of Nursing was interviewed by the surveyor on September 21, 2011 at 1:30 PM. She stated a new worksheet was developed this month (September 2011) to assess the cause of any new pressure ulcers. The DON said she was not certain of the exact date the form was initiated. She stated before the new form was implemented the assessed cause of a pressure area should have been in the CCP.

The physical therapist (PT), who attended the wound rounds, was interviewed on September 21, 2011 at 2:00 PM, and stated "heel pillows" were started on the resident the day the first area developed. The PT said the Multi Podus boots were initiated on July 27, 2011. She stated she "guessed" the new area on the inner ankle developed from the resident attempting to kick off the boot. The PT said during wound rounds, the procedure was for the team to discuss the causative factors of any pressure areas and, they would be added the CCP. When asked what was changed so the resident did not develop another area, she stated the physician order was changed on September 20, 2011, so the resident now used an "Achilles-ease" in bed instead of the boots.

In summary, the facility did not ensure the resident did not develop pressure ulcers as they:
- did not reassess the resident's risk for developing pressure ulcers and initiate preventive measures in a timely manner after the resident's activities of daily living (ADLs) declined in regards to continence and ambulation;
- did not follow through on a planned request for a podiatry evaluation; and
- did not determine the causative factors in a timely manner to prevent further skin breakdown when the resident developed a pressure ulcer.

10 NYCRR 415.12 (c)(1)

Based on record review and staff interview conducted during the standard survey, it was determined for 2 of 21 residents reviewed for advanced directives (Residents #4 and #15), the facility did not ensure residents had the right to formulate advance directives. Specifically, for Resident #15, the facility did not execute a do not resuscitate (DNR) order according to law as: the concurring physician did not independently determine the resident's capacity to formulate her own advanced directives; the resident's capacity to formulate her own advanced directives, determined by 2 physicians, conflicted with the facility's assessments of the resident's ability to understand; and there was no documented evidence the resident's known wish to be "full code" (resuscitated)was accurately followed. For Resident #4, the facility did not ensure 2 physician's determined the resident's capacity to understand before a surrogate made advance directive decisions, and did not ensure the resident's primary health care proxy (HCP) made decisions regarding the resident's advanced directives. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #15 was admitted to the facility with diagnoses of Alzheimer's dementia, hypertension, and osteoporosis.

A hospital admission History and Physical dated February 26, 2011, documented "the patient wants to be a full code (CPR, cardiopulmonary resuscitation). ACLS (advanced cardiac life support) protocol discussed and patient freely stated that she wants to be a full code."

On August 17, 2011, the resident's HCP signed a DNR form for the resident documenting the resident lacked decision making capacity.

The admission History and Physical from the attending physician dated August 18, 2011, documented the resident had a DNR code status established.

On August 21, 2011, the attending physician signed a DNR form for Determination of Lack of Capacity. A second, concurring physician signed the same form on August 25, 2011.

The resident's admission Minimum Data Set (MDS) assessment dated August 22, 2011, documented the resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) and was determined to be cognitively intact. The MDS also documented the resident had the ability to express ideas and wants, and the resident was understood and understands with clear comprehension. This assessment conflicted with the primary and secondary physicians determination the resident lacked capacity to understand clearly.

The Initial Assessment and Social History dated August 23, 2011 by the social worker documented the resident "is an alert lady who is able to voice her needs and concerns. She is able to maintain a good level of independence." This assessment conflicted with the primary and secondary physicians determination the resident lacked capacity to understand clearly.

During an interview with the social worker on September 21, 2011 at 3:20 PM, the social worker was asked if she discussed advanced directives with the resident and why the resident was described as lacking capacity. The social worker said she did not think the resident fully understood the concept of DNR. When asked where this would be documented, the social worker said in the medical record. When asked to produce this information, the social worker could not.

During an interview on September 22, 2011 at 12:30 PM with the concurring physician, he was asked if he discussed advanced directives with the resident. He said to be honest, he relied on what the other physician told him. He did not personally determine if the resident fully understood what DNR meant as he did not speak with her.

In summary, the facility did not execute a DNR code status according to law as follows:
- the concurring physician did not independently determine the resident lacked the capacity to formulate her own advanced directives;
- the determination by the physicians that the resident lacked capacity conflicted with the facility's assessments of the resident's ability to understand; and
- there was no documented evidence the resident's known wish for "full code", was accurately followed.

2) Resident #4 was admitted to the facility on June 16, 2011 with diagnoses including congestive heart failure and epilepsy.

Filed in the resident's medical record was a HCP form signed by the the resident on May 8, 2009 documenting the resident designated her son to be her primary HCP, and her daughter to be her alternate HCP.

The June 16, 2011 admission nursing progress note documented the resident was alert and oriented to person and situation only. The resident's daughter was present with her and was her HCP.

The "LTC (long term care) Advance Directive Checklist," signed by the social worker on June 16, 2011, documented the resident's "wishes are written and include" DNR code status and the resident had a HCP.

The "Do Not Resuscitate-Resident Lacking Capacity" form, signed by the social worker and the resident's daughter on June 16, 2011, documented the resident's daughter requested a DNR as that was the resident's "known wishes." The form documented the resident's appointed HCP should be the person to make health care decisions for the resident. There was no documentation on the form regarding utilizing the resident's alternate HCP. There was no documented evidence a physician and/or a concurring physician determined the resident lacked decision-making capacity.

The June 17, 2011 social worker's progress note documented the resident needed assistance with orientation to the facility. The social worker noted DNR paperwork was done on June 16, 2011 and an order was written.

The comprehensive care plan (CCP), updated on July 4, 2011, documented the resident had memory problems, was able to make a choice between 2 options, and was able to follow verbal cues. The CCP did not address the resident's code status.

The July 12, 2011 Minimum Data Set (MDS) assessment documented the resident scored 14 out of 15 on the BIMS (brief interview for mental status) meaning she was cognitively intact.

On September 22, 2011 at 9:00 AM, the Director of Social Services stated in an interview, the resident's unit social worker was not available for an interview. She stated the unit social workers met with residents at the time of admission to ensure the residents understood code status and could make a decision. If residents did not understand the discussion, the social workers would go to their HCP. If a resident or the HCP requested a DNR order, the social worker started the paperwork and the physician would sign the paperwork. This resident's primary HCP lived out of state and that was probably why the facility utilized the alternate HCP. She stated if the alternate HCP lived locally, the facility would utilize that person instead of the primary HCP.

On September 22, 2011 at 9:45 AM, the Director of Social Services stated in a second interview, she could not locate paperwork documenting the physician and a concurring physician determined the resident lacked decision-making capacity. She reviewed the resident's medical record and could not find where the resident's wishes were documented.

On September 22, 2011 at 12:30 PM, the attending physician stated in an interview, he was aware the resident's DNR paperwork was completed by her daughter. He stated the resident's daughter was her primary caretaker and he had always dealt with her. He was not aware the resident appointed her son to be her primary HCP.

In summary the facility:
- did not ensure the physician and a concurring physician determined the resident lacked decision-making capacity before a surrogate was asked to make advance directive decisions; and
- did not ensure the resident's primary HCP made advanced directive decisions as opposed to the resident's alternate HCP.

10 NYCRR 415.3(e)(1)(ii)

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure all the elevators, which travel greater than 25 feet above the ground floor, were equipped with the fire fighters service phase I and/or phase II automatic recall systems, in accordance with ASME/ANSI A17.3. Specifically, the facility's 6 operating elevators lacked fire fighters' service. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEYS OF March 16, 2011, September 17, 2010, March 26, 2010, August 21, 2009, October 28, 2008, and January 16, 2008, November 3, 2006, and October 19, 2005.

Findings include:

The facility had a 3 year waiver granted to complete an upgrade of the 6 operating elevators; the waiver expired September 23, 2007.

During the survey, the facility had 11 elevators; 5 of the 11 elevators no longer were in service; the other 6 elevators remained in use:
- the 2 elevators in the 5 story Madonna Building;
- the west elevator in the 4 story West Building; and
- the 3 elevators in the 4 story East Building.

These 6 elevators lacked fire fighters' service and were identified during the 2006 survey to be machine numbers 202085, 205076, 205084, 205085, 205086, and 336797.

Since all of the currently operating elevators have a travel distance of over 25 feet, the facility is required to comply with the current elevator fire service recall and control requirements.

During an interview on March 14, 2011 at 1:15 PM with the Environmental Services Director, he stated he was unaware of the facility's plans to upgrade the elevators, and he stated residents no longer resided in the Madonna Building.

When the Administrator was interviewed on September 20, 2011 at 9:45 AM. He stated there were no plans to upgrade the elevators. He stated there were no residents currently occupying the Madonna Building, and residents currently did not use the West Building. He stated there was an approved limited review project (#111304) to begin site work this week at a new site, and the certificate of need (CON) project to construct a new building on the new site is on the agenda for final approval in October 2011. In the mean time, their disaster plan included plans to manually bring the elevators to the first floor or floor of non-fire origin during a fire, and staff have been inserviced on this as well as evaluated during the monthly fire drills.

In summary, the facility had not completed the required corrections for the 6 operating elevators, and the 3-year time limited waiver expired in September 2007.

10 NYCRR 415.29(a)(1&2), 711.2(a)(1)
2000 LSC 19.5.3 and 9.4.3.2
ASME A17.3 Existing Elevator Code and Handbook Section 211 Emergency Operation and Signaling

Based upon observations and staff interviews conducted during the standard survey, it was determined that the facility did not ensure that all doors in an exit passageway, smoke barrier, or hazardous area enclosure were held open by devices arranged to automatically close all such doors upon activation of local smoke detection system for smoke barriers on 1 of 5 floors (basement). Specifically, the facility did not ensure that one set of smoke/fire barrier doors located in the basement corridor and one set of fire doors to a hazardous area in the basement (receiving room) that were held open by electromagnetic devices, closed and latched upon release of the doors. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During the building inspection of the basement of the North/South Building on September 20, 2011 between 11:20 AM - 11:53 AM, the following observations were made:
- The set of fire doors to the receiving room was not closed and latched and was not held open by the electromagnetic hold-open devices as designed. Upon further inspection, the self-closing device was missing to one of the doors (west side).
- The set of fire/smoke barriers doors in the exit corridor near the kitchen did not close and latch upon release from the electromagnetic hold-open devices as one door caught upon the clinical coordinating device, preventing the door from closing.

The Director of Maintenance was interviewed on September 20, 2011 at 11:53 AM. He stated the fire doors throughout the facility were on a preventive maintenance schedule and were supposed to be checked every 3 months. He thought that laundry carts may have damaged the set of corridor fire barrier doors near the kitchen. He had no idea how the maintenance staff had not noticed the self-closing device was missing to one of the receiving room doors.

The Director of Maintenance was interviewed on September 22, 2011 at 10:45 AM, and stated he checked the written preventive maintenance log book for fire doors and was surprised to discover there were no written logs kept on the fire doors since 2005. They found the hinges were bent to the set of fire doors near the kitchen by laundry carts.

In summary, the facility did not ensure that one set of smoke/fire barrier doors located in the basement corridor and one set of fire doors to a hazardous area in the basement (receiving room) that were held open by electromagnetic devices, closed and latched upon release of the doors.

2000 LSC 19.2.2.2.6
2000 LSC 7.2.1.8.2