Blossom South Nursing and Rehabilitation Center

Based on observation, record review, and staff interviews conducted during an Abbreviated Survey (complaint #NY00085936) completed on 5/26/10, it was determined that for two of two residents, the facility did not provide sufficient staffing to ensure that resident care was provided in accordance with individual care plans. The issues involved lack of assistance for toileting and transfers for Resident #1, and showering for Resident #3. This resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

1. During the initial tour of the facility's "B" wing on 5/24/10 at 8:15 a.m., the Licensed Practical Nurse (LPN) reported that there were 56 residents of 58 potential residents living on the unit that day. The LPN said the unit was staffed with four Certified Nursing Assistants (CNAs) and two LPNs, which included herself. This information matched the staffing documented on the staffing board on the unit.

Resident #1 was admitted to the facility on 3/25/08 with diagnoses including right hemiparesis (weakness), aphasia, and depression. The 1/25/10 Comprehensive Care Plan (CCP) for activities of daily living (ADLs) includes the assistance of two for toilet use. The January 2010 CCP for continence of bowel and bladder directs staff to check and change the resident every two to three hours, and to transfer with two assist. The current CNA ADL sheet revealed that the resident uses a urinal and briefs, and needs a two-person assist with transfers.

During a continuous observation made on 5/24/10 from 8:20 a.m. - 11:45 a.m., the resident was seated in his wheelchair in his room. There was a urinal on the windowsill out of his reach. When asked at 8:55 a.m. how long the resident had been in the wheelchair, the assigned CNA responded that the resident had been in the wheelchair since 7:00 a.m. and that she was providing cares for 15 residents. The resident remained in his wheelchair until 11:30 a.m., a total of 4.5 hours. The CNA positioned the resident in the wheelchair and attempted to lift/transfer him. She was unable to, repositioned his legs, and then pivot transferred him to the bed, using his pants to lift. The resident's left hip was not on the bed when he was sat down, and the CNA quickly moved so he would not fall, to roll him all the way on to the bed. She checked the resident's brief, stating, "You're dry." As the CNA proceeded to retape the resident's brief, the resident stopped her, moaned, and placed his hand over his bladder. The CNA asked if he wanted the urinal, and he indicated that he did.

When interviewed on 5/24/10 at 11:40 a.m., the CNA said that she was aware that the resident should have a two-person assist with transfer. The CNA said there was no one else on the unit to help her, so she did it by herself and that she was late getting to the resident because of the lack of staffing.

When asked about the resident's transfer status on 5/24/10 at 11:50 a.m., the Registered Nurse Manager (RNM) responded that the resident needs a two person assist with transfer. The RNM added that the usual staffing for this unit is four CNAs, sometimes five, so she has been helping staff.

When interviewed on 5/24/10 at 11:25 a.m., another CNA assigned to the unit stated that she does the best that she can. Her assignment included the 16 residents that live in Rooms #10 through #17.

2. During tour of the "B" unit on 5/25/10 at 8:10 a.m., the staffing board revealed five CNAs scheduled. When interviewed at this time, the RNM said they floated one of the CNAs from the "A" unit because someone had called in. When interviewed on 5/25/10 at 8:10 a.m., the unit secretary said that the current census was 56 residents.

Resident #3 has diagnoses including depression and venous stasis ulcers. The current CNA ADL sheet includes that the resident is to receive a shower on Tuesdays.

When observed on 5/25/10 at 9:07 a.m., the resident was up in her wheelchair, dressed, and was wearing makeup. She complained to the surveyor that she had not had her shower and she was supposed to have one. She began to yell that this always happens. A CNA told the resident that her assigned CNA was busy feeding residents and the resident replied that was not true, she saw the CNA getting another resident dressed. The CNA then told the resident that her assigned CNA has to get that resident dressed for an appointment, and she would find out what time her shower would be done. The CNA left.

When observed on 5/25/10 at 9:11 a.m., the resident again came to the surveyor and began yelling that she was not receiving her shower, this always happens and she doesn't get the shower. The LPN intervened and told the resident she would find out what time her shower would be. She returned and said it would be at 10:00 a.m. When interviewed on 5/25/10 at 12:40 p.m., the assigned CNA said she could not get to the resident's shower because she was so busy, but someone else did do it. When interviewed on 5/25/10 at 12:44 p.m., the resident said she did get a shower, but if the surveyor was not there it would not have been done.

When interviewed on 5/25/10 between 12:45 p.m. and 1:30 p.m., the RNM and the Administrator both said they were aware of the lack of adequate staffing to meet resident needs.

[10 NYCRR 415.13(a)(1)(i)(ii)]

Based on observations, record review, and resident and staff interviews conducted during an Abbreviated Survey (complaint #NY00085936) completed on 5/26/10, it was determined that for two of two residents reviewed for activities of daily living, the facility did not provide the necessary services to prevent a decline in activities of daily living. The issues involved a lack of toileting assistance for Resident #1 and a lack of prescribed therapy treatments for Resident #2. 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:

1. Resident #1 was admitted to the facility on 3/25/08 with diagnoses including right hemiparesis (weakness), aphasia, and depression.

The 4/22/08 Nursing Comprehensive Assessment revealed that the resident is frequently incontinent of bowel and bladder. Neurology Stroke Clinic notes, dated 6/11/08 and 5/18/09, both revealed that the resident is continent.

The Incontinence Assessmentdated 1/10/10, revealed that the resident does ask to use the bathroom but does need to be physically assisted to a bathroom and with personal hygiene cares. This assessment also emphasized the need to communicate this care plan to all staff and identified that it is the facility's policy to toilet all residents upon rising, before and after meals, mid-afternoon, and before bed.

The 1/25/10 Comprehensive Care Plan (CCP) for Activities of Daily Living (ADL) includes the assistance of two for toilet use. The January 2010 CCP for Continence of Bowel and Bladder directs staff to check and change the resident every two to three hours. The current Certified Nursing Assistant (CNA) ADL sheet shows the resident uses the urinal and briefs.

The 3/26/10 Minimum Data Set (MDS) Assessment revealed that the resident makes decisions independently, is incontinent of bowel and bladder, and uses no appliances.

On 5/24/10 a prescription, dated 4/6/10 (to be used when the resident is discharged), for a 3:1 (free-standing or over the toilet) commode was located in front of the medical record.

A continuous observation was made on 5/24/10 from 8:20 a.m. to 11:45 a.m. There was no commode in the room. A urinal sat on the windowsill. When interviewed at 8:55 a.m., the assigned CNA said that the resident had been seated in the wheelchair since 7:00 a.m. The resident remained in his wheelchair until 11:30 a.m. for a total of 4.5 hours, at which time the assigned CNA checked the resident's brief, stating, "You're dry." She proceeded to retape the resident's brief. The resident stopped her, moaned, and pointed to his bladder. The CNA asked if he wanted the urinal, and he indicated yes.

During interviews on 5/24/10 between 11:25 a.m. and 11:40 a.m., a CNA who regularly cares for the resident and the assigned CNA both stated that they check and change this resident and have not ever seen a commode in his room. The assigned CNA said she was late for providing cares for this resident because of staffing.

When interviewed on 5/24/10 at 9:05 a.m. and 2:15 p.m., the resident indicated that he has not been asked if he would like to use a commode or to sit on the toilet. He also said he would have used a commode if provided and is only asked sometimes if he would like to use the urinal.

When interviewed on 5/24/10 at 11:50 a.m., the Registered Nurse Manager (RNM) said the resident is incontinent, checked, and changed. She then added that he should be toileted and that he has never asked to go to the toilet.

2. Resident #2 has diagnoses including a 2/2/10 total hip replacement and dementia.

A nursing note, dated 3/30/10 at 11:58 p.m., documented that the resident was found on the floor after rolling out of bed. A nursing note, dated 4/2/10, documented that when the resident was found on the floor next to the bed, the physician was notified. On 4/2/10 the physician ordered a Physical and Occupational Therapy evaluation for transfers and ambulation. There is no documented evidence in the medical record that these evaluations were done.

The 4/14/10 MDS Assessment and the 5/13/10 CCP for ADLs both show that the resident requires the assistance of two for transfers.

The resident was observed on 5/25/10 at 8:36 a.m., seated in a gerichair in the hall. He moved further forward, and sat up straight. The Licensed Practical Nurse (LPN) asked the resident if he wanted to stand up. He replied, "Yes." The LPN said, "You can't stand up." The LPN put on a hall fan and elevated the resident's feet and left. At 10:47 a.m., the CNA and RNM took the resident into the bathroom. The CNA and RNM held the resident underneath each arm. The resident did not straighten his legs or bear any weight. When transferring the resident back from the toilet, again the CNA and RNM had the weight of the resident underneath his arms. He did not bear any weight and did not straighten his legs. The surveyor pushed the geri chair underneath the resident's buttocks to prevent him from being lowered to the floor. The RNM commented that it is not usually this bad, and she would need to put in a referral for PT to evaluate the resident. When interviewed at this time, the CNA said the resident does usually stand better.

When interviewed on 5/25/10 at 11:13 a.m., the Physical Therapist said she did not receive any referral from 4/2/10 asking for an evaluation; they would have the sheet in the file. She also said there is no Occupational Therapist right now, and the request for PT/OT would be on the safe sheet.

In interviews on 5/25/10 at 11:32 a.m. and 12:22 p.m., the RNM said the referral sheet was sent because the order was co-signed by three nurses including her. She also said they do not keep a copy of the referral sheet.

[10 NYCRR 415.12(a)(1)(ii)(iii)]

Based on observation, record review and staff interviews conducted during an Abbreviated Survey (complaint #NY00085936) completed on 5/26/10, it was determined that for two of two residents reviewed for accidents, the facility did not provide adequate supervision and assistance devices to prevent accidents. Issues included an unsafe transfer for Resident #1, a chair alarm not in place and lack of effective care plan changes for Resident #2. 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 #1 has diagnoses including right hemiparesis (paralysis). The 1/25/10 Comprehensive Care Plan for Activities of Daily Living (ADLs), the 3/26/10 Minimum Data Set (MDS) Assessment, and the current Certified Nursing Assistant (CNA) ADL sheet, all show that the resident needs the assistance of two people for transfers.

During an observation of a transfer on 5/24/10 at 11:30 a.m., the assigned CNA positioned the resident in the wheelchair and attempted to lift/transfer him. She was unable to, repositioned his legs, and then pivot transferred him to the bed, using his pants to lift. The resident's left hip was not on the bed when he was sat down, and the CNA quickly moved so he would not fall, to roll him all the way onto the bed. When asked at 11:40 a.m. how the resident is usually transferred, the CNA reported that the resident should have two people to assist with transfers; however, there was no one else working on the unit to ask for help so she did this by herself. When asked at 11:50 a.m. how the resident transfers, the Registered Nurse Manager (RNM) verified that the resident needs two people to assist with a transfer.

2. Resident #2 has diagnoses including dementia and was readmitted to the facility on 2/3/10 following a total hip replacement for a fractured hip. Interventions documented in the 9/21/09 Comprehensive Care Plan (CCP) for falls include a call bell at bedside. No alarms were in use at this time. The 2/3/10 Fall Risk Assessment described the resident at high risk for falls, as evidenced by falls in the past three months, need for assistance to ambulate, and balance problems. The 2/13/10 MDS Assessment revealed that the resident's cognitive skills for daily decision making were assessed as poor, requiring cues and supervision to make decisions.

The resident fell nine times between 2/4/10 and 4/2/10, (2/4, 2/5, 3/5, 3/14, 3/19, 3/25, twice on 3/30, and 4/2/10), and at least five of these falls occurred between 6:00 p.m. to 11:30 p.m. when the resident was trying to get into bed or reach a bathroom.

Examples included, but are not limited to:

a) A nursing note, dated 3/19/10, revealed that at 6:30 p.m. the resident was found on the floor, on his back, by the bed with an alarm sounding attempting to put himself to bed. The resident will be kept at the nursing station until he goes to bed for the evening.

b) A nursing note, dated 3/30/10 at 8:43 a.m., revealed that the resident attempted to self ambulate twice, was found on the floor by his bed, and said he was reaching for the urinal when he rolled out of bed. The I/A Report on this date added that the resident fell at 11:30 p.m., continues with risk taking behaviors, and had an alarm on. Root cause is listed as risk taking behaviors, and preventative measures were to keep urinal at bedside.

c) A nursing note, dated 4/2/10, includes the resident was found on the floor next to the bed. There is no I/A Report for this incident.

The resident's CCP for falls, updated on 5/13/10, includes bed/chair alarm, check/change resident every 2-3 hours, will occasionally ask for the urinal, and has the toileting schedule crossed out. The current CNA sheet includes offer urinal and bedpan, bed/chair alarms, toileting schedule, high visible area, and urinal at bedside.

When continuously observed on 5/25/10 between 8:15 a.m. - 10:47 a.m., the resident was seated in the hall in a gerichair. No chair alarm was seen, but a grey wire coming out of the bottom of the chair and hanging underneath the chair with the end on the floor was visible. There was no urinal in the room at 8:30 a.m. On 5/25/10 at 10:47 a.m., the hanging wire was pointed out to the RNM. She said it was the chair alarm and showed the surveyor the bare wires that had been pulled out. When interviewed at 10:47 a.m., the CNA said sometimes the resident is toileted and sometimes checked and changed. When interviewed at 12:45 p.m., the RNM said she had not made changes to the care plan because the resident had everything in place when he came back from the hospital - bed/chair alarms, and he is by the nursing station, he tries to get out of bed at night, and often when she comes in he is already at the nursing station, he keeps trying to stand up and he cannot. She was not aware that most of the falls occurred during the evening shift.

[10 NYCRR 415.12(h)(2)]

Based on record review and staff interviews conducted during an Abbreviated Survey (complaint #NY00084709) completed on 5/26/10, it was determined that for one of two residents reviewed for incidents, the facility did not report an incident nor thoroughly investigate two incidents to rule out abuse, neglect, or mistreatment for Resident #2. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #2 was readmitted to the facility on 2/3/10 after a total hip replacement for a left femoral neck fracture and has diagnoses including dementia and seizure disorder. The 3/12/09 Comprehensive Care Plan for Activities of Daily Living revealed that the resident walks in the corridor with the assistance of one. The 11/9/09 Minimum Data Set Assessment revealed that the resident walks in the corridor with supervision and one person physical assist.

A nursing note, a physician note, and an Incident/Accident Report (I/A), all dated 1/29/10, revealed that the resident fell while ambulating independently after having his eyes dilated by the ophthalmologist. The nurse documented that the resident's left leg was at a 90 degree angle and could not be moved without pain. The physician noted his determination that the resident needed to be seen at the hospital to rule out a fracture. The I/A Report concluded that the fall was preventable as the care plan was not followed. The I/A Report also revealed that the Department of Health was not notified of the incident and did not list the reason for not reporting.

A nursing note, dated 3/19/10, revealed that the resident was observed on the floor, on his back, by his bed. An alarm was sounding, and the resident said he was going to put himself to bed. There is no investigative report to rule out abuse/neglect for this incident.

A nursing note, dated 4/2/10, revealed that the resident's alarm was going off and he was found on the floor next to the bed. There is no investigative report to rule out abuse/neglect for this incident.

During an interview on 5/25/10 at 12:45 p.m., the Registered Nurse Manager stated that the ophthalmologist brings an assistant to assist with resident services. Staff at the facility transport residents to the solarium to be examined. When the opthalmologist has completed the services for one resident, he moves that resident to another area and brings up the next resident to be seen. Facility staff learn when the resident is ready to return to the unit by checking with, or receiving a call, from the opthamalogist's assistant. She added that all the I/A Reports for this resident had been turned into the Director of Nursing (DON).

When asked on 5/25/10 at 12:20 p.m. and again at 1:00 p.m. for the I/A Reports for 3/19/10 and 4/2/10, the DON stated that she did not have any for this resident for those dates. She also said there were no other places these I/A Reports would be.

[10 NYCRR 415.4(b)(3)]

Based on record review and staff interviews conducted during an Abbreviated Survey (complaint #NY00085936) completed on 5/26/10, it was determined that for three of three residents reviewed for professional standards, the facility did not provide services that met professional standards of quality. Issues included blood glucose levels (BG) that were not checked, and lack of timely transcription of a physician's order for dental services for Resident #1 and pacemaker checks that were not done for Resident #2. 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 #1 has diagnoses including diabetes and aphasia. The 1/6/10 Minimum Data Set Assessment revealed that the resident was cognitively intact and could make independent decisions. The physician orders for August 2009 through February 2010 included Lantus (insulin) every evening. There were no prescribed BG checks. The Medication Administration Records (MAR) for this time period revealed that Lantus insulin was administered every evening.

A nursing note, dated 2/28/10, revealed that the nurse was called into the resident's room by the significant other because the resident was sweaty and acting unusual. The significant other asked the nurse to check the resident's BG. The BG when checked was 50. After orange juice and Glucagon were given, the BG increased to 65. The physician was notified at that time, saw the resident, and documented that the resident had a hypoglycemic reaction with drowsiness and sweating at 8:35 p.m. with BG of 50. The physician gave the resident glucose gel twice and an injection of Glucagon, fruit juice with 12 packets of sugar. The resident's BG increased to 122, and he was more alert. Physician orders for 2/28/10 include to check the resident's BG every 4 hours for 12 hours and then four times a day. A decrease in the Lantus insulin was also ordered.

When interviewed on 5/21/10 at 8:25 a.m., the significant other said the facility did not know the resident was a diabetic and had not been checking his BGs. She stated that she had gone to the facility in the evening, and the resident was sweating and drowsy. She checked his BG (she is diabetic too) and it was 50, so she called the nurse and told her.

When interviewed on 5/24/10 at 10:40 a.m. and 10:55 a.m., the physician said he did not know why BGs were not being checked prior to this episode. He also said he would still check BG, at least weekly, if a resident was on insulin and BG were stable. In an interview at 11:50 a.m., the Registered Nurse Manager (RNM) said she would not question the physician or check a resident's BG if there was no order.

Additionally, an 11/12/09 Speech Therapy progress note revealed that on 11/11/09 the resident complained of pain in the lower front sulcus (oral cavity), while chewing and swallowing. Upon examination a dark area was present.

A nursing note, dated 11/13/09, revealed that the resident complained of mouth pain while pointing to his lower jaw and that the resident's name was added to the list of residents to receive dental services the next week. On that day, the physician ordered a dental appointment to check for gum inflammation and pyorrhea (deep pockets with discharge of pus). There is no documented evidence of when this order was transcribed.

A nursing note, dated 11/15/09, documented the resident's complaint of a tooth ache and the presence of a black spot on the last tooth in the right side of the resident's bottom jaw. On that date the physician ordered Ibuprofen for pain.

A dental services note, dated 11/16/09, revealed that the resident described his tooth pain on a scale of 1-10 as a 10 and that an emergency dental appointment request was initiated. A dental services note, dated 11/17/10, revealed that when the dental hygienist saw the resident, the dentist was scheduled to evaluate the resident's tooth pain. The dentist's note, dated 11/18/09, revealed that a periodontal abscess was identified as the source of the pain. The dentist prescribed antibiotics for 14 days and noted that the abscess should resolve with this treatment.

During interviews completed on 5/24/10 between 10:55 a.m. and 2:21 p.m., the Licensed Practical Nurse (previous NM) said she did not call the dental office until 11/16/09. She stated that she transcribed the orders on 11/15/09 and may have noticed then that the 11/13/09 order for the dental appointment had not been transcribed. Also, the RNM said the resident should have been seen by the dentist sooner.

2. Resident #2 has diagnoses including arrhythmia. A 12/28/09 consult note signed by a Nurse Practitioner (NP) revealed that the resident has complete heart block. The NP checked the pacemaker functioning during this visit and noted that it was functioning normally. The NP's plan was to have the resident's pacemaker checked with phone checks every two months, and follow-up in the office in six months. The facility's physician noted acknowledgement that the pacemaker phone checks and follow-up were planned. There was no documented evidence that these pacemaker checks were done.

In an interview on 5/25/10 at 9:32 a.m., the unit secretary stated that nurses schedule and record pacemaker checks. At 11:32 a.m., the RNM said she did not know this resident had a pacemaker, or if the resident was getting any pacemaker checks. The RNM stated that for residents who have pacemakers, she would contact the cardiology office and tell the secretary when the next pacemaker check should be, so it could be written on the calendar. She would document in the progress notes the date/time of the pacemaker checks.

When interviewed on 5/26/10 at 9:09 a.m., the Licensed Practical Nurse (previous NM) said she was not aware this resident had a pacemaker or that the resident needed pacemaker checks. She reported that if a check is needed, she would bring the resident to the phone for the check. She would know to do this by looking at the date on the calendar.

[10 NYCRR 415.11]