Conesus Lake Nursing Home

Based on observations, staff interviews, and record reviews, it was determined that for 3 of 13 residents reviewed for accidents the facility did not provide adequate assistance devices to prevent accidents. The issue involved residents who were transported in wheelchairs without footrests which allowed their feet to slide across the floor. This resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy for Residents #15, #16,and #17, and was evidenced by the following:

1. Resident #17 has diagnoses including Alzheimer's dementia. A 3/27/09 PT evaluation included wheelchair use with footrests. A 10/25/10 Physical Therapy (PT) Annual Screen documented the resident is nonambulatory and uses a geriatric chair for positioning and comfort. The 5/2/11 updated Certified Nursing Assistant (CNA) Resident Specific Assignment sheet included the resident was nonambulatory, required a Hoyer lift for transfers, and was out of bed to a geri chair.

On 5/16/11 at 10:15 a.m. Resident #17 was observed being wheeled from her room to the bathing suite on a shower chair by a CNA. The resident had no shoes or socks on, and her right foot was dragging along the floor causing the great toe to bend back slightly. The resident was wheeled approximately 30 feet before a Licensed Practical Nurse stopped the CNA and pulled out the chair's footrest for the resident to rest her feet on.

In an interview on 5/17/11 at 2:30 p.m., the Physical Therapist stated that Resident #17 cannot lift her legs and should be in a geriatric chair or a chair with legs/footrests for all transports.

2. Resident #15 has diagnoses including Alzheimer's dementia. A 10/12/10 PT annual screen documented the resident is independent with wheelchair mobility but dependent for specific destinations.

On 5/16/11 at 10:20 a.m. and again at 12:45 p.m., the resident was observed being wheeled from the dining room to the bathing room toilet (approximately 20 feet) and then from the dining room to the activity room (approximately 40 feet) via wheelchair without footrests by different staff members. Both times the resident's feet could be heard dragging along the floor. At no time was the resident asked to raise her feet.

In an interview on 5/17/11 at 2:30 p.m., the Physical Therapist stated that Resident #15 self propels and can lift her legs. Staff should remind her to do so when they push her. Her feet should not touch the floor, and if so, they should apply footrests.

3. Resident #16 has diagnoses including dementia. In a 4/25/11 PT monthly note it was documented that a wheelchair is currently the primary mode of locomotion and that the resident can hold her feet up for transportation.

On 5/16/11 at 1:40 p.m., Resident #16 was observed being transferred from the front door sitting area to the activity room (approximately 75 feet) via wheelchair without footrests by a staff member. Both feet could be heard dragging along the floor. At no time was the resident asked to raise her feet.

In an interview on 5/17/11 at 2:30 p.m., the Physical Therapist stated that Resident #16 can lift her feet but has limited capacity and should have footrests in a bag on the back of her wheelchair to be used if she is dragging her feet.

In an observation on 5/18/11 at 10:30 a.m., Resident #16 was sitting in her wheelchair in the dining room with no footrests on and both feet were resting on the ground.

During an interview on 5/18/11 at 8:15 a.m., the Registered Nurse stated that she expects staff to ask residents to raise their feet when transporting. If they do not, they should apply the footrests.

When interviewed on 5/18/11 at 10:45 a.m., the Director of Nursing stated that the facility does not have a policy regarding footrests.

[10 NYCRR 415.12(a)(1)(i-v)]

Based on observations, record reviews, and staff interviews, it was determined that for one of three residents reviewed for Activities of Daily Living, the facility did not provide the necessary services to maintain and/or improve ambulation. Specifically, Resident #4 did not receive assistance with ambulation as care planned. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #4 was admitted on 1/12/10 with diagnoses including dementia. The 1/4/11 Physical Therapy recommendations, the 2/8/11 Nursing Care Plan, and the undated Certified Resident specific assignment sheet all revealed that staff were to ambulate the resident twice daily 115 feet with rolling walker with one assist and to follow with wheelchair.

The Restorative Sheets for April 2011 revealed ambulation twice daily with rolling walker and one assist and was not signed off as done on 19 of 60 opportunities for the month of April. For May 2011 15 of 32 opportunities were not signed off or circled as not done for May 2011.

During an observation of morning care on 5/16/11 at 12:05 p.m., the resident was given incontinence care and then transferred to a wheelchair for transportation to lunch. When asked by the surveyor at this time if the resident was able to walk, the Certified Nursing Assistant (CNA) #1 replied that the resident was not able to walk anymore.

When interviewed on 5/17/11 at 10:15 a.m., CNA #2 (who said she was the resident's regular aide) stated that the resident does walk, but she will only take a few steps. She added that she has not walked her today, but she would try it later this afternoon.

During an observation of ambulation on 5/17/11 at 1:45 p.m., CNA #2 and CNA #3 attempted to ambulate the resident, who was only able to take three steps before her legs started to give out and sat down in a wheelchair. CNA #2 stated at this time that she can usually go further but has not for awhile now. She added that the resident was sleepy today.

When interviewed on 5/17/11 at 2:30 p.m., the Physical Therapist (PT) stated that Resident #4 should be walked twice daily as care planned. If the resident is unable to do this on a consistent basis, she would expect the CNAs to inform the wing nurse so the resident can be re-evaluated, and that she expects a new referral for any decline so the resident can be re-evaluated.

On 5/18/11 at 10:00 a.m., the PT stated that she did re-evaluate Resident #4, and while she was able to walk better than yesterday, she was weaker and had to use a platform walker, which was a decline for her. The PT added that she was putting her back on therapy to avoid any further decline and was adding the platform walker to the care plan for safety.

When interviewed on 5/18/11 at 8:15 a.m., the Registered Nurse/Nurse Coordinator stated that she expects all residents to be ambulated according to their care plan, and if unable to do so, she expects the CNAs to inform the nurses so the resident can be re-evaluated. She added that she was not aware of Resident #4's difficulty walking. She also said if a task is not signed off, she assumes it was not done.

[10 NYCRR 415.12(a)(1)(i-v)]

Based on observations staff interviews, and record reviews, it was determined that the facility did not provide pharmaceutical services to assure that narcotics were stored according to federal regulations. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

The medication room was inspected on 5/16/11 at 7:20 a.m. The medication refrigerator was locked and required a key to be opened. When the Licensed Practical Nurse (LPN) opened the refrigerator, a metal narcotic box containing two vials of Ativan (an anti anxiety narcotic) could be removed from the refrigerator.

When interviewed on 5/18/11 at 11:00 a.m. via telephone, the pharmacy consultant stated that he comes to the facility every month to review chart records but does not inspect the medication room or the refrigerator. He added that the nurses take care of that. When asked if he knew that the refrigerator contained a removable narcotic box which contained Ativan, he stated that he was not aware of that but knows that this issue is a problem in facilities. He added that it sounded like the box is not as secure as it should be and that he would talk to someone at the facility about the box.

When interviewed on 5/18/11 at 11:30 a.m., the Director of Nursing stated that she was unaware if there was a facility policy regarding the pharmacist inspecting the medication room and refrigerator.

Review of the facility's current Policy and Procedure for Accounting for Narcotic Medications revealed that there was no procedure for the pharmacist to inspect the medication room and refrigerator.

[10 NYCRR 415.18(a)]

Based on observation, staff interviews, and record review, it was determined that the facility did not provide for the safe and secure storage of medications. The issue concerned controlled substances that were not securely stored with a double locked system. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

The medication room was inspected on 5/16/11 at 7:20 a.m. The medication refrigerator was locked with an attached lock and key. The thin metal narcotic box was locked with a numbered plastic lock which needed to be cut off to open the box. Licensed Practical Nurse (LPN) #1 removed the box from the refrigerator and placed it on the counter. When opened, the box contained two vials of Ativan (an anti anxiety narcotic).

When interviewed on 5/18/11 at 11:30 a.m., the Director of Nursing said she was not sure if there was a facility policy for the storage of narcotics.

[10 NYCRR 415.18(d)]

Based on record reviews and staff interviews, it was determined that for two of seven residents reviewed for professional standards, the facility did not provide care and services that met professional standards of quality. The issue involved lab work not obtained as ordered for Residents #3 and #10. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

1. Resident #10 has diagnoses including hypothyroidism. A 4/15/11 physician (MD) order included a Thyroid Stimulating Hormone (TSH), a blood test to determine thyroid level, to be drawn with next lab draw. Review of the medical record revealed that the resident had a Vitamin B12 blood test drawn on 4/19/11. There was no documentation to indicate a thyroid test had been drawn on 4/19/11 or at anytime after.

An interview with the Director of Nursing (DON) on 5/17/11 at 11:30 a.m. revealed that she had called the lab and discovered that the TSH had been missed, as the last TSH test in the system was on 2/15/11. She added that the resident did not have another test ordered but she would inform the MD and have it drawn as soon as possible.

During an interview with the Registered Nurse/Nurse Coordinator on 5/17/11 at 1:25 p.m., she stated that routine labs are ordered by the night shift nurse, and one time orders are ordered by the charge nurse or the nurse taking off the orders. She added that a phlebotomy log sheet is filled out, and the nurse fills out the lab slip. She also said that the resident's lab order was on the log sheet, but she did not know why it was not done.

In an interview on 5/18/11 at 9:00 a.m., the DON produced a lab slip, dated 4/19/11, that documented that the TSH was ordered by the nurse so she felt the lab must have missed it. When asked if the facility had discovered the missing lab work, she stated they did not.

2. Resident #3 has diagnoses including diabetes. The 4/28/11 MD orders include a Hemoglobin A1c test, a blood test to check diabetes, to be drawn every six months in March and September. Review of the medical record did not reveal any lab work indicating a Hemoglobin A1c level.

In an interview on 5/16/11 at 2:30 p.m., the DON stated that she checked with the lab, and the resident's last Hemoglobin A1c level was drawn on 11/2/10 and that the resident's every six month labs were done in March, but the Hemoglobin A1c level was missed. She added that there was nothing ordered for this resident to be drawn until September, but she would inform the MD and have it drawn as soon as possible.

[10 NYCRR 415.11(c)(3)(i)]

Based on observations conducted during the Life Safety Code Survey, it was determined that the facility did not properly enclose a hazardous area. The issues were related to openings in walls and non-compliant door features. This affected one (center) of three smoke compartments, resulting in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

Observations on 5/16/11 at 1:13 p.m. revealed the kitchen was not properly separated from the egress corridor and contains a natural gas range and griddle (fuel fired heating appliance). The following was observed:

1. There are two pass through windows from the kitchen to the main dining room that measured 34 x 31 inches and 30 x 25 inches. Each opening had a wooden hinged door that was held in the open position by white string attached to the door and a wall mounted metal tie-off. Staff were observed to use these openings to pass through meal trays and return used dishes.

2. The doors that separate the main dining room from the egress hallway were also held in the open position by magnetic catch devices that would allow these doors to become selfclosing only when pulled. Additionally, these two doors latched into each other and not the door frame. Because the main dining room is connected to the kitchen via the pass through windows, the room must comply with the door and separation requirements for hazardous areas.

3. Additionally, the door to the kitchen opens to an exit hallway near the basement stairwell. This door did not automatically release with activation of the fire alarm system and only became selfclosing when pulled.

The Director of Environmental Services immediately contacted the fire alarm system contractor, who on 5/17/11 installed electro-magnetic release devices on the kitchen and dining room doors, which release with activation of the fire alarm system.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); 2000 NFPA 101: 19.2.2.2.6, 7.2.1.8.2]

Based on observations conducted during the Life Safety Code Survey, it was determined that the facility did not provide compliant exit lighting. The issue was related to exit lighting that was controlled by a switch. This affected one of one basement, and resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

Observation on 5/16/11 at 9:20 a.m. revealed the hallway lighting in the basement was controlled by a switch located on the wall next to the boiler room. When switched to the off position, all lights in the hall turned off leaving only the natural light of surrounding windows. Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. The Director of Environmental Services immediately re-wired the system so that the toggle switch did not control the lighting.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); 2000 NFPA 101: 19 .2.8, 7.8.1.2]